Inspection on 30/06/08 for Tarn House

This inspection was carried out on 30th June 2008.

CSCI found this care home to be providing an Adequate service.

The inspector found no outstanding requirements from the previous inspection report, but made 4 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Tarn House 02/06/09

Tarn House 30/08/07

Tarn House 26/06/06

Tarn House 24/11/05

Tarn House 23/06/05

Tarn House 05/01/05

Tarn House 13/09/04

Similar services:

Ruskin Lodge

Clover House

Dystlegh Grange

The Good Companions

Cuerden Grange Rest Home

Springfield Cottage

Parkside

Park Lodge

Extracts from inspection reports are licensed from CQC, this page was updated on 28/09/2008.

CARE HOME ADULTS 18-65 Tarn House Mill Lane Walney Barrow in Furness Cumbria LA14 3XX Lead Inspector Ray Mowat Key Unannounced Inspection 30th June 2008 08:30 Tarn House DS0000036626.V366137.R01.S.doc Version 5.2 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Tarn House DS0000036626.V366137.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Tarn House DS0000036626.V366137.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Tarn House Address Mill Lane Walney Barrow in Furness Cumbria LA14 3XX 01229 471798 01229 470125 Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) www.cumbriacare.org.uk Cumbria Care Mrs Bernadette Eileen Calldine Care Home 14 Category(ies) of Learning disability (14), Physical disability (3) registration, with number of places Tarn House DS0000036626.V366137.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category/ies of service only: Care home only - Code PC to service users of the following gender: Either whose primary care needs on admission to the home are within the following categories: Learning disability - Code LD (maximum number of places: 14) Physical disability - Code PD (maximum number of places: 3) The maximum number of service users who can be accommodated is: 14 Date of last inspection 30th August 2007 Brief Description of the Service: Tarn House is a care home providing personal care and accommodation for fourteen adults with learning and or physical disabilities. The home is owned by Cumbria County Council and managed by Cumbria Care, an independent business unit of the County Council. It is situated in a residential area of Walney Island and is close to local amenities and a local bus route that services the island and the nearby town of Barrow-in-Furness. The Home is on two storeys and is divided into four distinct units. These are called hill view, sea view, Greenland’s and Beachwood. Three of the rooms are used for short-term respite care. Each of the units has a lounge and a separate kitchen with dining area. All the bedrooms are single occupancy, some of which are fully accessible for people with physical disabilities. To the rear of the building are two fenced garden areas with seating. To the front of the building are open plan garden areas and a large car park, which is shared with the adjoining day service. The scale of charges for the home varies according to people assessed needs and are agreed on admission, with additional charges agreed on an individual basis for personal sundry expenses. The home makes relevant information available to residents in an accessible Tarn House DS0000036626.V366137.R01.S.doc Version 5.2 Page 5 format. Tarn House DS0000036626.V366137.R01.S.doc Version 5.2 Page 6 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 1 star. This means the people who use this service experience adequate quality outcomes. This inspection visit took place over one day. We (Commission for Social Care Inspection, CSCI) spent time with people living in the home and talking to them about their experiences. We also met with the manager and the staff on duty and looked at records relating to the running of the home and how people like to be supported to live their lives. We also sent out surveys as part of this inspection to get feedback from people living in the home, staff and other professionals involved with the home. Before the visit the manager completed an Annual Quality Assurance Assessment, which provided information about all aspects of the running of the home. This included a self-assessment against the National Minimum Standards (NMS) recording what the home does well, what has improved and plans for the future. It also included information about policies and procedures, health and safety and information about the people living and working there. What the service does well: The home always make sure they know people’s needs and preferences before they move into the home. They work closely with Social Workers and families to find out important information about them such as how they like to live their lives and what support they will need. This is written in a person centred support plan so that all the staff know what to do. They also work closely with other agencies such as the behaviour intervention team, community nurse team, speech therapist, psychiatrists and psychologists. Support plans and other information is regularly reviewed to make sure it is up to date and accurate. Some information is recorded in an, ‘easy read format’, using pictures and symbols to make it easier for people to understand. Staff know people well and support them to do the things they want to do when they want to do them. People are involved in making decisions about their lives and how the home is run. The diverse needs of the people living in the home are recorded making sure their individual wishes, needs and beliefs are supported. For example one person has identified that they want staff of the same gender to provide personal care. Tarn House DS0000036626.V366137.R01.S.doc Version 5.2 Page 7 People have busy social lives and enjoy going out in the local community and meeting up with their family and friends. Relevant risk assessments that support an independent lifestyle whilst safeguarding people are in place to support and guide staff. These related to both in house and community activities and these were also kept under review on a regular basis. People and their representatives are asked on a regular basis about what they want and if they are happy with the service to make sure they have the opportunity to pursue their interests and lead a fulfilling lifestyle of their choice. What has improved since the last inspection? The manager meets with the social workers to discuss compatibility issues for people on short respite breaks and on permanent placements, which makes sure their stay is enjoyable and they are safe. One flat has been improved to meet the needs of the person who lives there, with new flooring being fitted, new furniture provided and decoration completed. People have been consulted in how they like to have their medication administered and this is recorded in the support plans. In addition local medications procedures have been improved following errors that have been made. Person centred support plans have continued to develop for people, with staff now more confident in using support plans. Transport arrangements have improved with all the people living in the home having their own bus pass and accessible transport being arranged for people with a physical disability. Some people with staff support have been involved with decorating their own lounge and kitchen and enjoyed participating in this. The manager is completing monthly health and safety checklist to maintain a safe and comfortable home environment. Staff skills for working with people with challenging behaviour have improved with other agencies supporting staff and providing training regarding specific strategies to support an individual. Tarn House DS0000036626.V366137.R01.S.doc Version 5.2 Page 8 What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Tarn House DS0000036626.V366137.R01.S.doc Version 5.2 Page 9 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Tarn House DS0000036626.V366137.R01.S.doc Version 5.2 Page 10 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 3,. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. There are sound systems in place to ensure people’s needs are assessed on an ongoing basis and the home will meet their needs and aspirations. EVIDENCE: The home’s statement of purpose and service user guide should be updated, as changes occur to ensure all the information is up to date and accurate. The current versions being used are not up to date. The documents are displayed in the home and made available to existing and new residents. Information for people who use the service is provided in easy read formats using symbols to support the typed text making it more accessible to people. An easy read summary of the last key inspection and an easy read version of the complaints procedure were displayed on the notice board in the hallway. Each service user on admission to the home require a social worker assessment, this assessment is a base line for the development of the person centred support plan. Information is obtained from all relevant people to support this. If the person is moving into the home on a permanent basis the manager or supervisor would meet with the service user and their family/carer on several occasions to complete a pre-admission document and appropriate risk assessments. Tarn House DS0000036626.V366137.R01.S.doc Version 5.2 Page 11 Based on the Social Work assessments the home develop person centred support plans which are very detailed and ensure individual needs are assessed and personalised support plans developed that provide people with the support they need to achieve their goals and lead an independent lifestyle. These are kept under review ensuring needs are assessed on an ongoing basis and the service respond to these changes in need. When specialist needs are identified the home are making appropriate referrals to other professionals and agencies to enable people to access appropriate services. This has included the home working closely with the behaviour intervention team, community nurse team, speech therapist, psychiatrists and psychologists. Interventions are well documented and specific strategies are developed to guide staff and support good practice. Tarn House DS0000036626.V366137.R01.S.doc Version 5.2 Page 12 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7, 8, 9. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. People’s individual needs who live permanently in the home are well documented, respite service users records need to be regularly reviewed and updated to ensure their well being and safety are maintained. EVIDENCE: Person centred support plans are being developed for all the people who live in the home on a permanent basis. They record in detail relevant information about a person’s past, their family and relationships and what is important to them to lead a fulfilling and independent lifestyle. This includes a wide range of information from health and personal care needs, how people communicate, spiritual and cultural needs and individual needs and aspirations. Daily care notes are recorded and specific staff are allocated as key workers to closely monitor a person’s needs and well being. Monthly reviews of support plans are also completed to make sure any changes are documented and actions taken as required. A good example of this was the completion of a ‘pathway to independence assessment’, which was completed to support a person to look Tarn House DS0000036626.V366137.R01.S.doc Version 5.2 Page 13 at alternative accommodation that would better suit their needs. This person centred approach helps staff to identify the diverse needs of the people living in the home making sure their individual wishes, needs and beliefs are supported. For example one person has identified that they want staff of the same gender to provide personal care. All the files examined contained relevant risk assessments that support an independent lifestyle whilst safeguarding people. These related to both in house and community activities and were kept under review on a regular basis. Based on our observations and discussions with people during this inspection people are involved in all aspects of home life. This could be cleaning their rooms, planning menus or going out shopping. Staff are aware of the need to take on an ‘enabling role’ with people and to offer choices at all times. How people communicate their needs and preferences are well documented, which ensures people with limited verbal communication are able to control their lives and make decisions. Staff were skilled at communicating with people using Makaton sign language, hand gestures and verbal prompts when talking to and supporting people with tasks. We observed one person who used to good effect a range of hand gestures, head movement, verbal noises and facial gestures to effectively communicate their needs to staff, which the staff were able to understand and respond to. All the people using the home for short term respite care had a care plan in place, however it was not clear if this was up to date or accurate or if the person had agreed to it. Assessments and care plans for people on short term respite care need to be reviewed more frequently and should be signed, dated and agreed with the service user or their representative. The manager is aware of this shortfall and explained that a supervisor and care staff have been identified to take a lead role in ensuring short term respite care plans are kept up to date, however staff shortages have impacted on their ability to complete this task. Tarn House DS0000036626.V366137.R01.S.doc Version 5.2 Page 14 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 11, 12, 13, 14, 15, 16, 17. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Although fluctuating staffing levels have sometimes limited the opportunities for people to access the local community, people are enjoying a full and active lifestyle with appropriate support from staff. EVIDENCE: People living in the home are leading very varied and independent lifestyles. Some people enjoy and appear to benefit from attending a local day service on a full or part time basis that provides them with opportunities for personal growth and development. This includes having the opportunity to take part in a range of vocational, educational and leisure activities. Other people choose to ‘do their own thing’ are do not attend a structured day service. This level of choice is good practice and enables people to pursue their own lifestyle. Other good examples of the home listening to people is recently a group of people expressed an interest in swimming on a regular basis, which staff are now Tarn House DS0000036626.V366137.R01.S.doc Version 5.2 Page 15 planning. Some people were not happy with the reception on their televisions so a digital Ariel is now in place and digital set top boxes have been purchased to increase people’s options. Staff have a good awareness of people’s diverse needs recently arranging accessible transport for a group of people to enable them to attend a regular social club. One person we spoke to talked about the weekly activities they enjoy, which included attending a local church social club and a ‘contact lunch’, also organised by the church, where they are able to meet with people from the local community. People talked about holidays they had been on or that they were planning for this year, this included a trip to Euro Disney, which they were obviously looking forward to. Some people talked about weekend activities they had enjoyed which included watching the local carnival, going out for lunch and having a day trip with their family. The previous week a small group had visited the local wildlife park. It was evident from our discussions people are enjoying full and active lives with appropriate support from staff, however there was evidence that when staffing levels are low this impacts negatively on the range of activities the home can support. Menus were displayed in each unit and are planned with people on a weekly basis with the people living there. Staff then support people to go out and buy the food required. Some people are able to get involved in the preparation of meals including making their own packed lunch. The menus provided a varied and nutritional range of food with health eating encouraged. Bowls of fresh fruit were available in all the units. Each unit has a kitchen/dining area where people can get together for meals making it a relaxed social occasion where they can enjoy a chat. Tarn House DS0000036626.V366137.R01.S.doc Version 5.2 Page 16 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19, 20 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Good systems are in place to ensure individual personal and healthcare needs are being met. EVIDENCE: All the care plan files examined during this inspection contained detailed information relating to people’s personal and healthcare needs. This included a record of all health interventions and appointments including specialist input and support as well as a record of day to day support. The home works closely with a number of other agencies and health professionals to ensure the varied individual needs of people living in the home are being responded to appropriately. Individual strategies that guide and support good practice and a consistent approach from staff have been developed and are kept under review. These include behaviour strategies, risk assessments and strategies to support different activities. One of the agencies provided specific training for staff to enable them to meet the needs of an individual service user who has autism and challenging behaviour. It has been invaluable in ensuring a Tarn House DS0000036626.V366137.R01.S.doc Version 5.2 Page 17 structured and consistent approach that is crucial to this person. Key workers take a lead role and work closely with the supervisory team to monitor people’s needs and record relevant information. Staff are knowledgeable about people’s idiosyncrasies and personal preferences and work hard to promote their independence. People are supported to pursue their interests and lead a life that reflects their own personality. Medication records examined were up to date and accurate and were sufficient to support staff in the safe handling and administration of people’s medication. Policies and procedures were in place to guide and support good practice and relevant staff receive appropriate training. Actions have been taken since recent medication administration errors occurred to prevent a reoccurrence and competency of staff has been assessed. Tarn House DS0000036626.V366137.R01.S.doc Version 5.2 Page 18 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22, 23. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Adult protection training and the reporting of incidents need to be strengthened to ensure the safety of people living in the home. EVIDENCE: There is an easy read version of the complaints policy and procedure displayed in the home and is also included in the service user guide making it accessible to people living in the home and their representatives. Feedback from people we met with and who completed surveys say they know how to complain and who to complain to. There has been one formal complaint since the last inspection, which was fully investigated with the involvement of other agencies and family representatives. The complaint was satisfactorily resolved with appropriate actions agreed to prevent a reoccurrence. There have also been two adult protection concerns raised, which were appropriately referred to the local authority team. Strategy meetings and investigations took place with the home ensuring people were supported and safeguarded throughout the process. Only one of the referrals was notified to the Commission due to the manager misinterpreting the procedures. The home should ensure all adult protection referrals are reported under regulation 37. Tarn House DS0000036626.V366137.R01.S.doc Version 5.2 Page 19 Appropriate security checks are completed on all new staff including Criminal Record Bureau checks, POVA first checks and two references, this ensures that staff are suitable for the role and people using the service are safeguarded. Currently there is a high number of staff who have not completed up to date training in relation to adult protection, identifying and reporting abuse. The manager is aware of this shortfall and is planning future training events for staff. It is recommended all staff complete the adult protection training and it is refreshed on a regular basis. Tarn House DS0000036626.V366137.R01.S.doc Version 5.2 Page 20 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 25, 26, 27, 28, 29, 30. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Although the majority of the decoration and furnishing of the home is satisfactory, the issues raised that are not being addressed by the organisation detract from the ambience of the home and give it an institutional feel. EVIDENCE: Despite good practice recommendations being made at the last inspection there is still grey insulating foam held on with black tape being used to cover water pipes and industrial style metal radiator guards in place throughout the home. The National Minimum Standards state, homes should provide a “comfortable and homely environment” in a “style and ambience that reflect the home’s purpose with fittings that are domestic, unobtrusive and ordinary as is compatible with fulfilling their purpose”. The homes own service user guide supports this stance stating, “the home will be decorated to an appropriate domestic standard”. The aforementioned grey foam and metal radiator guards are neither homely, unobtrusive or of an appropriate domestic standard. Tarn House DS0000036626.V366137.R01.S.doc Version 5.2 Page 21 In the seaview flat the grey foam has been removed and was not covering the pipes, which is an obvious hazard. These pipes must be protected with a more permanent solution to stop the covering being easily removed. The organisations accommodation manager recently completed a condition survey, however this was not yet available. Routine maintenance and decoration has been taking place with old built in wardrobes being replaced with more modern alternatives. People are involved in choosing their furniture and decoration and rooms were very personalised to individual’s tastes. Bedrooms and bathrooms were suitably equipped with aids and adaptations to support and promote people’s independence with high/low beds and baths, shower chairs, tracking hoists and mobile hoists. The garden area was improved last year and people have been involved in looking after the plants as well as enjoying relaxing in the garden with friends. The fire escape to the rear of the home is now rusting and although has been assessed as being structurally sound it is starting to look unsightly and is in need of remedial action. All areas of the home were clean and hygienic with domestic staff in place to maintain the cleanliness of the home. Tarn House DS0000036626.V366137.R01.S.doc Version 5.2 Page 22 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 33, 34, 35, 36. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Staff shortages and inconsistent levels of training have impacted negatively on people’s quality of life. EVIDENCE: Based on feedback from staff surveys, discussions with care staff and the manager and our observations, staff shortages have at times had a negative impact on the quality of the service, which is reflected in the following quotes. • • • “Supporting people to go out socialising and maintaining a community presence has been affected by staff shortages”. “People who are more able have been left with minimal support”. “Staff shortages have affected the morale of staff and made meeting the needs of service users hard at times”. Recruitment is ongoing and some new staff have been appointed which will improve this situation. However the manager must ensure suitable numbers of Tarn House DS0000036626.V366137.R01.S.doc Version 5.2 Page 23 staff are available at all times to meet the needs of the people living in the home. The organisation has robust recruitment policies and procedures in place ensuring all staff are safe and suitable for their role. All new staff complete the LDAF (Learning Disability Award Framework) induction and foundation. They also confirmed they were given a “good introduction to the home and the people living there”. We examined staff training records, which reflected an inconsistent level of training and refresher training being provided. The manager described how training needs are identified and passed onto the organisations central training unit who in turn organise relevant courses. The home must develop a more robust and effective system to monitor training needs and ensure suitable training is provided. We examined staff records and spoke to staff who confirmed that they receive appropriate supervision. The manager provides supervision for the supervisory team who then support the care staff. All the staff spoken to said management were “approachable and anything can be discussed”. Another person said, “There is a good team ethos we get good support from the manager”. Tarn House DS0000036626.V366137.R01.S.doc Version 5.2 Page 24 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 38, 39, 42. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The manager and supervisory team provide good leadership and support to staff to make sure the home is run in the best interests of the people living there. EVIDENCE: The manager of the home ensures the people living there are included in all aspects of home life and decisions are made in their best interests. People feel safe and well supported by the manager and staff. The care staff also talked about “good support and leadership” confirming that “people’s needs and preferences are a priority and that they had a good understanding of them”. The service sends out customer satisfaction surveys to people living in the home, families, carers and other relevant stakeholders. An action plan is then developed from the comments and feedback identifying how the home will Tarn House DS0000036626.V366137.R01.S.doc Version 5.2 Page 25 respond. This was displayed on the notice board in the foyer area. The action plan forms part of the home’s local business plan and links to the staff team appraisal. The manager explained how further consultation was planned to try to get more detail about peoples views. Link workers will take a lead role in providing emotional support to people and making sure their views and preferences are known and recorded. Designated staff complete routine health and safety checks. This includes water temperatures, fridge and freezer temperatures and fire checks, with fire equipment recently checked and serviced, which all helps to maintain a safe environment. Cleaning fluids were found in three areas of the home and they were not securely stored. Although they were immediately removed the home is required to review their practice in relation to the handling of COSHH substances to make sure they are securely stored at all times. Tarn House DS0000036626.V366137.R01.S.doc Version 5.2 Page 26 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 2 3 3 3 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 2 ENVIRONMENT Standard No Score 24 2 25 3 26 3 27 3 28 3 29 3 30 3 STAFFING Standard No Score 31 X 32 3 33 2 34 3 35 2 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 3 3 X LIFESTYLES Standard No Score 11 3 12 3 13 3 14 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 3 3 3 X X 2 X Tarn House DS0000036626.V366137.R01.S.doc Version 5.2 Page 27 No Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard YA24 Regulation 13(4)a Requirement Hot water pipes must be securely protected to make sure the home as far as reasonably practicable is free from hazards to the safety of the people living there. The manager must ensure suitable numbers of staff are available at all times to meet the needs of the people living in the home. Staff must receive training appropriate to the work they are to perform. COSHH substances must be securely stored at all times. Timescale for action 01/09/08 2 YA33 18(1)a 01/09/08 3 4 YA35 YA42 18(1) c (i) 13(4) a 01/10/08 07/07/08 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard YA1 Good Practice Recommendations The statement of purpose and service user guide should be reviewed and updated regularly or as changes occur. DS0000036626.V366137.R01.S.doc Version 5.2 Page 28 Tarn House 2 YA6 3 4 5 YA23 YA23 YA24 Assessments and care plans for people on short term respite care need to be reviewed more frequently and should be signed, dated and agreed with the service user or their representative. The home should ensure all adult protection referrals are notified to the Commission for Social Care Inspection. All staff should complete adult protection training to enable them to recognise and report incidents effectively. Metal radiator guards should be replaced with something that is homely, unobtrusive and of an appropriate domestic standard. Tarn House DS0000036626.V366137.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection Regional Contact Team Unit 1, 3rd Floor Tustin Court Port Way Preston PR2 2YQ National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries.northwest@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Tarn House DS0000036626.V366137.R01.S.doc Version 5.2 Page 30 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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