Inspection on 18/11/08 for Tavistock Square (17)

This inspection was carried out on 18th November 2008.

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

The inspector found no outstanding requirements from the previous inspection report, but made 1 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Tavistock Square (17) 09/01/08

Tavistock Square (17) 07/12/06

Tavistock Square (17) 23/11/05

Tavistock Square (17) 30/06/05

Tavistock Square (17) 25/01/05

Tavistock Square (17) 02/08/04

Tavistock Square (17) 17/03/04

Similar services:

22 Sandown Road

The Highlands

Dilston College Of Further Education

West View House

Prince Bishop Court

Park View (15)

Craigmore House

1 Lanark Close

Extracts from inspection reports are licensed from CQC, this page was updated on 09/02/2009.

CARE HOME ADULTS 18-65 Tavistock Square (17) Silksworth Sunderland SR3 1DZ Lead Inspector Andrea Goodall Key Unannounced Inspection 18th November 2008 10:00 Tavistock Square (17) DS0000015736.V373221.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 Tavistock Square (17) DS0000015736.V373221.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. Tavistock Square (17) DS0000015736.V373221.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Tavistock Square (17) Address Silksworth Sunderland SR3 1DZ 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) 0191 523 8250 0191 523 9724 Northumberland, Tyne & Wear NHS Trust manager post vacant Care Home 6 Category(ies) of Learning disability (6) registration, with number of places Tavistock Square (17) DS0000015736.V373221.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 9th January 2008 Brief Description of the Service: The home at 17 Tavistock Square provides accommodation for 6 people with a learning disability. The home is a modern, purpose-built bungalow with level access at the 2 front entrances and good access around all areas for people with physical disabilities. It is sited in a cul-de-sac of similar modern housing and is set back with a large driveway and large back garden. The home provides personal care and is owned and operated by Northumberland, Tyne & Wear NHS Trust. The bungalow provides 6 good-sized bedrooms, 2 lounges, 2 dining rooms, 2 bathrooms and an activities room. The home is within easy walking distance of various local shops, clubs, health centre and a church. It is also a short drive from main supermarkets and leisure clubs. Tavistock Square (17) DS0000015736.V373221.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 2 star. This means the people who use this service experience good quality outcomes. Before the visit: We looked at: • information we have received since the last visit on 9th January 2008 • how the service dealt with any complaints & concerns since the last visit • any changes to how the home is run • the provider’s view of how well they care for people in their annual quality assessment form (called an AQAA) • the views of other people such as relatives and professionals The Visit: An unannounced visit was made on 18th November 2008. During the visit we: • talked with people who use the service and staff • joined residents for a meal and looked at how staff support the people who live here • looked at information about the people who use the service & how well their needs are met • looked at other records which must be kept • checked that staff had the knowledge, skills & training to meet the needs of the people they care for • looked around parts of the building to make sure it was clean, safe & comfortable • checked what improvements had been made since the last We have reviewed our practice when making requirements, to improve national consistency. Some requirements from previous inspection reports may have been deleted or carried forward into this report as recommendations – but only when it is considered that people who use services are not being put at significant risk of harm. In future, if a requirement is repeated, it is likely that enforcement action will be taken. What the service does well: Before people move in, the home makes sure that it will be the right place for them to live. If they need different help, staff help them to find a different place. Tavistock Square (17) DS0000015736.V373221.R01.S.doc Version 5.2 Page 6 The care plan records are good so that all staff know exactly how to help people in the right way. People can choose to spend time in any part of their house and be alone if they want. The bungalow is brightly decorated and comfortable. People have chosen to paint their bedrooms in the colours that they like. All the rooms are nice. Staff have good training so they know how to help people and how to keep them safe. What has improved since the last inspection? 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. Tavistock Square (17) DS0000015736.V373221.R01.S.doc Version 5.2 Page 7 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 Tavistock Square (17) DS0000015736.V373221.R01.S.doc Version 5.2 Page 8 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): 2 and 4. People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to the service. People have a full assessment of their needs before they move here so that they can be sure that the home at 17, Tavistock Square can meet their needs. EVIDENCE: Since the last inspection there have been some changes to the people who live here. One person who has significant physical disabilities has moved to another home where they are now able to engage in more activities. One new resident has moved to the home. Before people move here a full assessment of their needs is carried out by health and social care professionals. It is good practice that the new resident and family had lots of visits to the home. Before the new resident moved in their bedroom was redecorated in colours that their family chose. The home acknowledges any change in needs of the people who live here. The home holds on-going reviews, with other professional where necessary, to ensure that it can continue to support any change in a residents needs. For example, one resident has been in hospital for about a year due their increase Tavistock Square (17) DS0000015736.V373221.R01.S.doc Version 5.2 Page 9 in behavioural needs. Their needs are being re-assessed to see if they require an alternative placement. Tavistock Square (17) DS0000015736.V373221.R01.S.doc Version 5.2 Page 10 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 and 9. People who use the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to the service. Overall care records are satisfactory, but a new resident’s records do not reflect their new arrangements so staff are not fully guided in their support needs. EVIDENCE: Support plans are records that are used by all care services to show what sort of help each person needs and how staff will provide that care. There are support plans in place for each resident living here. In most cases these provide good details of each residents needs and goals, and how staff should support them. Tavistock Square (17) DS0000015736.V373221.R01.S.doc Version 5.2 Page 11 However the support plans for the person who moved here two months ago all refer to their previous home. Those records indicate that their care needs and goals have not been reviewed since February or April 2008. Residents have some daily opportunities to make their own decisions and choices, such as what to wear, and where to spend time in the home. People can show their choice from options that are given to them. There are some choices that can be offered in pictorial form such as menus. However the severity of their disabilities means that they may find it difficult to express other choices. It is good practice that staff are now developing easy-read and pictorial books about what people like to do, how they communicate, what they like to eat, and how they express their dislikes. These are very person-centred and informative books for new and current staff. It is also good practice that the home arranged for an independent advocate to support a resident who was moving to another home to make sure his decisions and choices were promoted. There are risk assessment records in place for activities that may involve an element of manageable risk. For example horse riding, using mouthwash, and bathing. These include clear guidelines about how the risks can be minimised. However the risk assessments for a new resident have not been reviewed since they moved to this home. These risk assessments indicate that the person can be present in the kitchen with staff. However this is not the case at Tavistock Square so the risk assessment is incorrect and this could be confusing for new or bank staff. Also staff and relatives discussed a period where a resident’s play equipment had been removed from them for a few weeks after it had been used during an incident with another resident. There had been no risk assessment put into place about this matter. The staff confirmed that the resident has since been given their equipment back. Tavistock Square (17) DS0000015736.V373221.R01.S.doc Version 5.2 Page 12 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): 12, 13, 14, 15, 16 and 17. People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to the service. People have improving opportunities to engage in activities and their rights are respected. EVIDENCE: At the last inspection people had very limited opportunities to engage in any leisure activities due to the shortfall in staff support. However this is improving as staffing levels are now back up to minimum levels, and one person with significant mobility needs has moved to another home. Another resident with significant support needs is still in hospital. This allows the three staff on duty to manage the house and support people to go out. However the home still has a vacant post for an Activities Enabler. This means that support staff mainly Tavistock Square (17) DS0000015736.V373221.R01.S.doc Version 5.2 Page 13 have to take people out in small groups rather than on an individual one-toone basis. On the day of this visit the staff made sure everyone had a chance to go out in the home vehicle, even if it was just for a drive to another home or to pop into shops. It was clear from records and discussions that staff are reviewing the programme of activities to try to ensure that everyone living here has better opportunities to go out. Two people attend a day centre for part of the week and so staff are looking at how they can arrange activities for the other residents on those days. Current activities outside the home include swimming, trampolining, cinema, walks out and shopping trips. Staff are also looking at new activities such as cycling and aromatherapy. Some people have had some evening activities for example one person goes to a weekly ice-hockey event, and another person has been to a couple of music concerts at the Newcastle Arena. However there are only two staff on duty from 6pm so any evening activities would have to be planned well in advance so that the staff rota could support this. The people who live here are supported to use local community facilities such as shops, pubs, health centres and local transport. The bungalow is sited in a modern estate in a former mining village. As part of their activities budget people can also go on holiday once a year, but records showed that only two people have gone on holiday, together, this year. House Meeting minutes indicated that other people had not been offered the opportunity to have a holiday because they may move to alternative accommodation in the future. However that could take some time to arrange. Staff stated that one person had chosen to use their holiday budget to go to concerts instead. Residents right to lead their own lifestyle within the house is respected. One person prefers to spend most of their free time in the activities room listening to music and this is respected. All the residents can spend time in their rooms whenever they want. At the time of this visit there were clearly good relations between staff and residents. Although the people who live here have very limited verbal skills, they enjoyed engaging with staff and there was relaxed and good-humoured connection between residents and staff. One person mainly goes with staff to do the weekly grocery shopping, but everyone has some opportunities to go shopping both for personal items and for groceries. The menus are designed around residents’ known preferences (and these are also recorded in individual care plans). There is a photo-menu Tavistock Square (17) DS0000015736.V373221.R01.S.doc Version 5.2 Page 14 book although people rarely use this, as most staff are familiar with peoples’ likes and there are always alternatives made for people to choose from. The home has 2 small dining rooms in either side of the kitchen. Both dining rooms offer a comfortable, pleasant environment for residents and staff to dine together. Residents seem to enjoy their meals in the house, and this mealtime was a relaxed, unhurried social occasion. People also enjoy occasional meals out and one person described his favourite pub meal. Tavistock Square (17) DS0000015736.V373221.R01.S.doc Version 5.2 Page 15 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 and 20. People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to the service. Overall people receive satisfactory support so that their personal care needs are met. EVIDENCE: All of the people who live here need some support with personal care to varying degrees. For example most people need support with bathing or dressing, and prompts for personal grooming. All support is carried out in the privacy of a residents own bedrooms or bathrooms. At this time there is only one male staff on the team so the four men who live here do not often have the choice of gender-appropriate support. It is good that people can choose their own daily routines. For example, one person likes a lie-in then a shower later in the morning and this is respected. Other people get up at whatever time they wake up (unless they are attending day centres). Tavistock Square (17) DS0000015736.V373221.R01.S.doc Version 5.2 Page 16 Everyone can get around their home independently but three people now use wheelchairs for longer distances when they are out of the home so they would need one-to-one support for this. There are clear health care records which show that the home supports people to access health care services for example physiotherapists, GP, opticians, and chiropodists. The health care records also show the well-being of each resident. In the records examined one person had experienced a period of declining meals and of vomiting. Health care services were contacted twice and samples were carried out. However there were no weight records in this person’s file at the time of this inspection. None of the people who live here have been assessed as able to manage their own medication. All staff who administer medication have had training in Safe Handling of Medication. Medication is managed by the home using a standard monitored dosage system. This means most medication is delivered by a pharmacist to the home in blister packs. The storage and administration of medication is appropriate. The medication records (MARs) are printed by the pharmacist to show the prescribed medication and dosage times of each person. However some new medication had to be handwritten by staff on to the MARs. One medication had been misspelt and another did not state that it was to be given ‘as and when required’ rather than at every dosage time. One medication is an anti-anxiety medication that is to be given when someone becomes agitated. There are good guidelines about this in the person’s care file, however it would take staff some time to find this amongst all the other information. Tavistock Square (17) DS0000015736.V373221.R01.S.doc Version 5.2 Page 17 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 and 23. People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to the service. The home’s procedures and staff training make sure that people are protected from abuse. EVIDENCE: The Trust has a booklet, Tell Us, for people who use its services. This describes the complaints procedure in easy language for people with a learning disability. Residents are also asked if they are happy or unhappy with anything at the monthly Residents’ Meetings. Due to the severity of their communication needs, most of the people who live here use gestures, noises and behaviourisms to show their dissatisfaction. Long-standing staff have built up a very good understanding of different residents likes, dislikes and communication needs. For newer staff there are some guidelines in each resident’s support plan about to recognise if a resident is unhappy with a situation. There has been one complaint about the service since the last inspection and this is being looked into. All staff have had updated training in Safeguarding Adults procedures so they all know how to report suspected abuse. Tavistock Square (17) DS0000015736.V373221.R01.S.doc Version 5.2 Page 18 All staff receive training in physical interventions, so that they can safely support the challenging behaviour of one resident. Staff receive annual training in this area. There is clear guidance to show how and when staff should intervene to support someone with their behaviour. Tavistock Square (17) DS0000015736.V373221.R01.S.doc Version 5.2 Page 19 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): People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to the service. People here live in a homely, comfortable and safe environment so they enjoy a good standard of accommodation. EVIDENCE: This bungalow offers a good standard of accommodation for the people who live here. Overall, the home is modern, bright, well furnished, contemporary and cheerful. People make good use of all areas of the home as they wish, including spending time in their own rooms or in the different lounges and activities rooms. Some people were keen to show off their bedrooms, which have been decorated in colours that they have chosen themselves. New sofas and a new big-screen tv have been also been provided in one lounge. Tavistock Square (17) DS0000015736.V373221.R01.S.doc Version 5.2 Page 20 Since the last inspection the home has been provided with a new central heating boiler, which seems to have resolved the longstanding problems with heating in this home. The home was warm, comfortable and clean during this visit. Laundry and cleaning is carried out by support staff and residents are encouraged to be as involved in these tasks as they can or want to be, though few people are. At this time the home is awaiting a new washing machine so laundry was being carried out at other care homes in the area. Tavistock Square (17) DS0000015736.V373221.R01.S.doc Version 5.2 Page 21 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, 34 and 35. People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to the service. Overall the home provides suitable, competent well trained staff in adequate numbers to meet the main needs of the people who live here. EVIDENCE: The staff team currently consists of a manager, a deputy manager and 12 support staff. The staffing levels have returned to the minimum since the last inspection so there is adequate support available for the people who live here. At this time the staff rota allows for 3 support staff on duty from 8am to 6pm, and two staff on duty for the evening and night. An additional staff is arranged for a weekly evening event for one resident. The Trust now operates a ‘bank’ system which means the home now has better arrangements to cover gaps in the rota, for example due to sick leave. The home endeavours to use the same ‘bank’ staff to cover these gaps in order to provide some continuity of care for the people who live here. Tavistock Square (17) DS0000015736.V373221.R01.S.doc Version 5.2 Page 22 There have been some changes to the staff team, as previous staff have left the home and three staff from other homes have transferred to Tavistock Square. There have been no new employees. There remains a vacant Activities Enabler post. The manager and staff commented on the difficulties in attracting applicants to this post as the Trust is currently only employing new starters on a “temporary contract”. Staff commented on the continuing uncertainty of the future of the Trust’s care homes, but they felt that the service at Tavistock Square was “safe”. There is an individual learning plan for each member of staff that identifies any training that they need. The home also has a good record of all training courses already attended by each staff. Recent training for staff has included safeguarding adults, values and attitudes, and management of aggression. One staff said, “The training we get is excellent. It’s the best training programme I’ve known of any organisation I’ve worked for.” Tavistock Square (17) DS0000015736.V373221.R01.S.doc Version 5.2 Page 23 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, 39 and 42. People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to the service. Overall the home is run in a satisfactory way that promotes the welfare of the people who live here. EVIDENCE: The current manager has been responsible for the operations of this home for about one year. An application for registration had not been received from the manager so a letter has been sent by CSCI outlining the legal requirement for the home to have a registered manager. (Since this inspection an application for registration has been received and is being processed.) The manager is a registered nurse and has achieved NVQ level 4 in management. These are suitable qualification for a manager of a care service. Tavistock Square (17) DS0000015736.V373221.R01.S.doc Version 5.2 Page 24 However in discussions staff and relatives felt that there are still some uncertainties about the future management of the home as they were under the impression that there would be more changes to the management next year. The Trust uses a number of quality monitoring tools to audit the service at this home. These include monthly visits by a representative of the Trust to the home to check on its operations, and to talk with residents and staff for their views. The views of residents are sought about the service they receive, where their capabilities allow, at Residents’ Meetings and through their individual annual reviews. Staff receive mandatory training in health & safety matters on an annual basis through the Trust. Staff carry out sleep-in duties overnight and in-house fire instruction is carried out and recorded every 3 months. The records of safety checks that were examined were up to date and in good order. Tavistock Square (17) DS0000015736.V373221.R01.S.doc Version 5.2 Page 25 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 X 2 3 3 X 4 3 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 3 28 X 29 X 30 3 STAFFING Standard No Score 31 x 32 2 33 x 34 3 35 3 36 x CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 X 2 X LIFESTYLES Standard No Score 11 X 12 2 13 3 14 2 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 X 2 X 3 X X 3 X Tavistock Square (17) DS0000015736.V373221.R01.S.doc Version 5.2 Page 26 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 YA9 Regulation 13(4) Requirement Risk assessments for new residents must be up to date and applicable to this home. This is to ensure that all staff have current guidance about how to support people with activities that incur risk. Timescale for action 01/01/09 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. 2. 3. 4. Refer to Standard YA6 YA12 YA14 YA20 Good Practice Recommendations The support plans of a new resident should be reviewed to make sure that these are up to date and applicable to this home. Staff should continue to develop an activities programme that allows equal opportunities for each person to engage in leisure activities. All of the people who live here should be offered the opportunity for a holiday or alternatives (such as day trips) to suit their individual preferences. Staff should ensure that handwritten, transcribed information about incoming medications exactly matches DS0000015736.V373221.R01.S.doc Version 5.2 Page 27 Tavistock Square (17) 5. 6. YA33 YA33 7. YA37 the prescription e.g. dosage times and name of medication. Also it would be better if a copy of the guidelines about when to give ‘as and when’ anti-anxiety medication is also kept in the MARs file so that staff have instant access to this. The vacant post of Activities Enabler should be covered to ensure that people have sufficient opportunities to engage in activities both within and outside the home. The provider should consider how the staff team can achieve an appropriate gender mix, in order to reflect the gender mix of residents and to meet the support preferences of all residents. The application for a registered manager should continue so that the home has a registered manager in place. Tavistock Square (17) DS0000015736.V373221.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection North Eastern Region St Nicholas Building St Nicholas Street Newcastle Upon Tyne NE1 1NB National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@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. 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