Inspection on 09/01/08 for Tavistock Square (17)

This inspection was carried out on 9th January 2008.

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

The inspector found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 6 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Tavistock Square (17) 18/11/08

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 09/07/2008.

CARE HOME ADULTS 18-65 Tavistock Square (17) Silksworth Sunderland SR3 1DZ Lead Inspector Miss Andrea Goodall Unannounced Inspection 9th January 2008 10:00 Tavistock Square (17) DS0000015736.V357637.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.V357637.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.V357637.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 vacant Care Home 6 Category(ies) of Learning disability (6) registration, with number of places Tavistock Square (17) DS0000015736.V357637.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: None Date of last inspection 7th December 2006 Brief Description of the Service: The home at 17 Tavistock Square provides accommodation for 6 people with a learning disability, one of whom also has physical disabilities and uses a wheelchair. 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. The fee for a placement at 17 Tavistock Square is £1,159.38 a week. The people who live here each contribute £62.35 a week towards the fee. Tavistock Square (17) DS0000015736.V357637.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 1 star. This means the people who use this service experience adequate quality outcomes. Before the visit: We looked at: • information we have received since the last visit on 7th December 2006 • 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 • the views of people who use the service & their relatives, staff & other professionals The Visit: An unannounced visit was made on 9th January, 2007. During the visit we: • talked with people who use the service, and with staff • 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 visit We told the staff what we found. 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. The care plan records are very good so that all staff know exactly how to help people in the right way. The home uses pictures to help people make choices about what they would like to do and what they would like to eat. People can choose to spend time alone if they want. Tavistock Square (17) DS0000015736.V357637.R01.S.doc Version 5.2 Page 6 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.V357637.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.V357637.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): 1, 2 and 5. People who use the service experience good quality outcomes in this area. Overall people receive good information and 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. We have made this judgement using a range of evidence, including a visit to the service. EVIDENCE: The home has developed an informative Service Users Guide for potential new residents and their representatives. The document is descriptive and includes pictorial information to support people’s communication needs. Most people could not understand the information without help, so some parts of it are explained. It is clear from past placements here, that all prospective residents would have as many chances as they wanted or needed to visit the home, before deciding whether they would like to move here. Four residents have lived here since the home opened several years ago. Tavistock Square (17) DS0000015736.V357637.R01.S.doc Version 5.2 Page 9 The other 2 residents have moved to the home over the past couple of years. For all the people who live here, a full assessment of their needs was carried out by health and social care professionals before they moved to the home. It is good practice that 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 a few months due their increase in behavioural needs. Their needs are being re-assessed to see if they require an alternative placement. All the residents have a copy of a Residents Agreement, which tells people about the terms and conditions of their residence here. The agreement is written in plain English and pictorial symbols. Due to the severity of their disabilities, residents could not understand this contract without help. However some residents have signed the agreement, even though they do not understand the information. The Residents’ Agreements have been sent to relatives or representatives where these exist. However two residents have no relatives or other independent representation. The home continues to seek out advocacy services, but there have been no advocates for those two people for many years. Tavistock Square (17) DS0000015736.V357637.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 good quality outcomes in this area. Support planning systems are very good, so that staff work consistently to support residents with their individual needs and goals. We have made this judgement using a range of evidence, including a visit to the service. EVIDENCE: There are support plans in place for each resident. These include very good details of each residents needs and goals. The support plans clearly guide staff as to how to support each person with their long-term needs, such as communication, activities and personal hygiene. It is good practice that staff create new support plans for any changes in need. There is also a monthly summary that provides a general overview of each resident’s well-being, activities and behaviour. Following the last inspection these now include residents’ own expressed short-term goals. For example, Tavistock Square (17) DS0000015736.V357637.R01.S.doc Version 5.2 Page 11 one person would like to try swimming for the first time. The monthly summary outlines her progress towards that goal. The care plans have some information in pictorial form to help residents understand their own records, and to remind staff that the records belong to the residents. There is also a note at the front of each persons files that states whether or not they are able to be involved in their own care plans. For example, there is a record of one person sitting with staff to join in discussions about his support plan. 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. However the severity of their disabilities means that they may find it difficult to express choices. Since the last inspection, pictures are now being used to support residents to express their own menu choices, and activity timetables are in also in picture format. Residents have monthly meetings where they are encouraged to be involved in group decisions. Since the last inspection these meetings are now recorded so that it can be clearly seen whether they participated, whether any suggestions or decisions were made, and whether these were acted on. There are risk assessments in place for activities that may involve an element of manageable risk. For example horse riding, using mouthwash, and helping in the kitchen. There are clear guidelines about how these risks can be minimised. Two people use wheelchairs when they are out of the home because of their poor mobility. Staff stated that wheelchair straps are used to protect them from falling from the wheelchairs. However there are still no risk assessments to show the justification for using these restrictive straps. (This was mentioned at the last inspection.) Tavistock Square (17) DS0000015736.V357637.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, 15, 16 and 17 People who use the service experience good quality outcomes in this area. Overall residents have improved opportunities to make decisions about their daily lifestyle so their rights to individuality, choice and privacy are respected. We have made this judgement using a range of evidence, including a visit to the service. EVIDENCE: Two people have structured daytime occupations outside the home, as they attend a day centre 3 days a week. Two other people have at least one regular activity a week, such as horse-riding or trampolining, as well as community activities such as shopping. The remaining person dislikes crowds or busy places and has shown by their behaviour that they do not like to go out. Most activities are provided in the local community. All staff support residents with activities and the home also has an ‘enabler’ staff who has specific role in helping people to access activities, both in and out of the home. Tavistock Square (17) DS0000015736.V357637.R01.S.doc Version 5.2 Page 13 One person needs lots of attention and diversion or they can become angry and aggressive. As a result this person goes out on lots of activities with staff in order to support their behavioural needs. However this can be to the detriment of other residents as there are not sufficient staff to provide them all with the same opportunities for activities. It was clear from records that staff try to find new activities for residents to broaden their choices and experiences. These have included activity centres, and drama groups. It is also good practice that residents have been supported to buy their own computer for different CD games and activities which staff stated they enjoy. However at this time only a couple of staff are confident about helping with the computer, which might limit residents’ use of it. 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. In this way, residents are supported to be part of the local community. Residents right to lead their own lifestyle is respected. One person prefers his own company and expresses his choice, through behaviour, to spend much of his time in a quiet lounge. Staff support him to do this, whilst still offering alternative choices and activities. Residents are also encouraged to make their own choices and decisions, for example holiday destinations, décor for bedrooms, and clothes. It is good practice that residents are now supported to be more involved in designing the monthly menus. Staff have developed pictures books of menu choices, which residents use at the monthly meetings to give their suggestions for the next month’s menus. These are then set out, with alternative choices, on a pictorial menu sheet. Residents are then asked verbally which of the choices they would like at each meal, for example today’s’ lunch was a choice of two soups, macaroni cheese, or sandwiches. None of the residents are involved in preparing meals due to the severity of their disability or risks due to their behaviour when in the kitchen (and there are risk assessment about this). The home has 2 small dining rooms in either side of the kitchen. Both dining rooms offer a comfortable, pleasant environment for residents to dine in. One person chooses to dine alone in a quiet lounge and this is respected. Residents seem to enjoy their meals in the house, and one person was also able to describe his favourite pub meal. Tavistock Square (17) DS0000015736.V357637.R01.S.doc Version 5.2 Page 14 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. Residents receive personal support in the right way so their physical, emotional, and health care needs are met. We have made this judgement using a range of evidence, including a visit to the service. EVIDENCE: All of the people who live here need some support with personal care to varying degrees. One person has a severe physical disability and needs full physical support of staff. The home provides suitable equipment for this and there is a comprehensive moving & assisting plan for staff to follow. Other residents 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. Tavistock Square (17) DS0000015736.V357637.R01.S.doc Version 5.2 Page 15 Following several changes to the staff group there are only two male support staff, who are both night staff. In this way there are no male daytime support staff to provide gender-appropriate care of the men who live here. Staff commented that at least one male resident prefer male staff support, but this is currently not being met. There are clear health care records which show that the home ensures that residents have access to the right health care services when required. For example, physiotherapists, opticians, chiropodists, psychiatrists and annual medication reviews. None of the people who live here have been assessed as able to manage their own medication. Medication is managed by the home using a standard monitored dosage system. This means most medication is delivered to the home in blister packs. The storage and administration of medication is appropriate. All staff who administer medication have had training in Safe Handling of Medication. However the list of which staff are designated to do this is now out of date, following several staff changes. Tavistock Square (17) DS0000015736.V357637.R01.S.doc Version 5.2 Page 16 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. The home’s procedures and staff training make sure that people are protected from abuse. We have made this judgement using a range of evidence, including a visit to the service. 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. Staff have built up a very good understanding of different residents likes, dislikes and communication needs. For newer staff there are also clear guidelines in each resident’s support plan about how each person’s shows if they are happy or unhappy. In this way staff are able to recognise if a resident is unhappy with a situation. Staff were able to describe such occasions, and how they would support a resident is they showed displeasure or dissatisfaction with a situation. There is a complaints file that includes good guidance for staff. There have been no recorded complaints since the last inspection. Tavistock Square (17) DS0000015736.V357637.R01.S.doc Version 5.2 Page 17 Over the last year all staff have had updated training in Safeguarding Adults procedures so they all know how to report suspected abuse. Since the last inspection all staff (except the new manager) have had 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. There are also clear records to show when and why this has been necessary. The people who live here are entitled to a number of disability allowances that support their active lifestyles. All their allowances are directly debited into their own individual banks accounts. Their contribution to the weekly residential fee is then directly debited to the Trust. Due to their disabilities, the residents have little or no understanding of the value or concept of money, so this is securely stored for them. All records relating to residents finances are in good order, and include receipts for any transactions made by them or on their behalf. In this way residents’ monies continue to be safely managed on their behalf. Tavistock Square (17) DS0000015736.V357637.R01.S.doc Version 5.2 Page 18 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 and 30. People who use the service experience adequate quality outcomes in this area. Residents live in a homely, comfortable and safe environment, but the inadequate heating system means that it is often not warm enough for the people who live here. We have made this judgement using a range of evidence, including a visit to the service. 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. Since the last inspection the dining room has been fitted with good quality, oak-effect flooring. People were keen to show off their bedrooms, which have been decorated (or are planned to be redecorated) in colours that they have chosen themselves. Tavistock Square (17) DS0000015736.V357637.R01.S.doc Version 5.2 Page 19 Most areas of the bungalow are well maintained. However for several years the heating system has been periodically faulty. The heating system has again been broken for the last couple of weeks over the Christmas period, despite a number of visits by plumbers. During this inspection visit most rooms were being heated by a number of small portable heaters, but these have to be removed at night as residents could burn themselves. A new electric shower has had to be fitted (next to the existing shower) so that residents can have a wash. An emersion heater supplies hot water to sinks, and dishes are washed by a dishwasher so that at least hygiene standards can be maintained. However these are short-term remedies to a long-standing problem that may only be resolved by the provision of a new heating system. Staff are responsible for housekeeping and some residents are encouraged to be involved in cleaning their own bedrooms, is they choose to. All areas of the home that were viewed were clean, although some extractor fans were becoming furred up which could present a fire hazard. All staff have had training in Infection Control. Tavistock Square (17) DS0000015736.V357637.R01.S.doc Version 5.2 Page 20 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): 33, 34 and 35. People who use the service experience adequate quality outcomes in this area. The home provides competent, well-trained staff but not always in sufficient numbers to ensure that the needs and choices of residents are met. We have made this judgement using a range of evidence, including a visit to the service. EVIDENCE: The minimum staffing levels for the service at Tavistock Square is 3 support staff on duty from 8am-8pm, and 2 night–time staff (one of whom is on waking duty). There is also a full-time enabler’ staff for 5 days a week whose role is to support residents with activities. However it was clear from the staff rota that, due to staff sickness, this level of staffing is not being achieved. The staff team currently has a 33 shortfall due to sickness and secondments. The remaining staff are unable to cover all these gaps and there are no relief or bank staff arrangements within the Trust to support this situation. As a result there are several occasions where there Tavistock Square (17) DS0000015736.V357637.R01.S.doc Version 5.2 Page 21 have been only two staff on duty, mainly during afternoons and week-ends. It is at these times that residents are at home and require the greatest support. This situation is compounded by the fact that one resident has severe physical disabilities and epilepsy, and requires the presence of two staff in the house at all times for health & safety. This means that none of the other residents can be supported to leave the house when there are only two staff on duty. This severely restricts their lifestyle and choices, and the lack of outside activities can significantly affect the behavioural needs of one resident. Due to this inadequate staffing situation, there have been occasions, particularly at week-ends, where staff have put a resident with epilepsy to bed (for his safety) so that one member of staff can take some residents out. This level of staffing is unacceptable as it severely impinges on the lifestyle, dignity and choices of all of the people who live here. Following several changes to the staff group there are now only two male support staff, who are both night staff. In this way there are no male daytime support staff to provide gender-appropriate care of the men who live here. Staff commented that at least one male resident prefers male staff support, but this is currently not being met. Since the last inspection 6 staff have left, and 2 further staff started then left in the same period. (This represents more than half of the staff team and such a high staff turnover could compromise the continuity of care of the people who live here.) Another staff is on secondment at another placement, but their hours have not been covered. There have been 4 new staff start work here. The Trust operates robust recruitment and selection procedures that includes all necessary checks and clearances, to make sure that only suitable staff are employed. However most changes to the staff team are the result of staff being transferred to, or from, other care homes operated by the Trust. Staff stated that they have “good” opportunities for training. There is an individual learning plan for each member of staff that identifies any training that they need. The home also has a record of all training courses already attended by each staff. Tavistock Square (17) DS0000015736.V357637.R01.S.doc Version 5.2 Page 22 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 adequate quality outcomes in this area. Management changes and low staffing levels means that the service has not been run well enough, so people do not always get enough support in a consistent way. We have made this judgement using a range of evidence, including a visit to the service. EVIDENCE: The previous registered manager transferred to another care home in summer 2007. There have been two subsequent changes to the management of this Tavistock Square (17) DS0000015736.V357637.R01.S.doc Version 5.2 Page 23 small home in the past few months. The Provider did not inform CSCI about either change of management at the time of those changes. The current manager has been in post here for a few weeks. She has been transferred here from a similar small home operated by the Trust. She has many years experience in health and social care of people with a learning disability, and has been a registered manager of another service. In this way she is a suitable person to manage the service at Tavistock Square, but is currently not registered as the manager of this home. During discussions, staff commented very positively on the current manager’s attitude, competence, and management style. However the significant number of changes have made staff rather uncertain about the future management of the home and felt that even the current arrangements are still “temporary”. 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. However there have only been 5 recorded visits in the past 12 months. The views of residents are sought about the service they receive, where capabilities allow, at Residents’ Meetings and through their individual annual reviews. Some time ago the Trust designed a questionnaire that uses pictures and easy language to support the communication needs of the people who live here. However, the questionnaires have not yet been used. Residents would not be able to complete them without support, and two people have no relatives or independent representation. 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.V357637.R01.S.doc Version 5.2 Page 24 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 3 2 3 3 X 4 X 5 2 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 2 25 x 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 X 33 2 34 2 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 4 3 X 2 X LIFESTYLES Standard No Score 11 x 12 2 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 2 X 2 X X 3 X Tavistock Square (17) DS0000015736.V357637.R01.S.doc Version 5.2 Page 25 YES 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 YA5 Regulation 12(2) Requirement The Provider must ensure that there is independent advocacy or representation arrangements for those residents without relatives. This is to ensure that they have impartial support with contracts and agreements about the service they receive. (Previous timescale 01/02/06 and 01/02/07 not met.) Risk assessments must be in place for the use of wheelchair straps for some people. This is to demonstrate the reasons for this restrictive equipment. (Previous timescale of 01/02/07 not met.) 3. YA24 23(2)(c) & The faulty heating system must (p) be replaced. This is to ensure that the people who live here have a suitable standard of heating in their home at all times. The Provider must ensure that there are sufficient staff on duty, DS0000015736.V357637.R01.S.doc Timescale for action 01/03/08 2. YA9 13(7) 01/03/08 01/03/08 4. YA33 18(1)(a) 01/02/08 Page 26 Tavistock Square (17) Version 5.2 including relief arrangements, at all times to meet the needs of all of the people who live here. This is to ensure that people’s right to support with personal and social care needs is not restricted. The Provider must inform CSCI about any changes to the management arrangements of this service. This is to ensure CSCI is aware of who is managing the service and that the person is ‘fit’ to be in charge. The Provider should carry out Regulation 26 visits at least monthly. This is to ensure that the Provider is fully aware of the reports of the home’s operations. 5. YA37 39 01/02/08 6. YA39 26 01/03/08 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. 2. 3. 4. 5. Refer to Standard YA7 YA12 YA20 YA30 YA33 Good Practice Recommendations The home should continue to expand on the use of communication aids, such as photographs and pictures, to support residents to make their own informed choices. All staff should be supported to learn how to help residents with their computer so that they can use it whenever they wish. The list of staff designated as responsible for the administration of medication should be brought up-to-date so that it includes ‘new’ staff. Extractor fans need periodic cleaning to ensure that they do not become furred up. The provider should consider how the staff team can achieve an appropriate gender mix, in order to reflect the DS0000015736.V357637.R01.S.doc Version 5.2 Page 27 Tavistock Square (17) 6. YA39 gender mix of residents and to meet the support preferences of all residents. Residents should be supported by relatives or independent advocates to complete the Trusts questionnaires that are intended to review the service. Tavistock Square (17) DS0000015736.V357637.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection 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. Extracts may not be used or reproduced without the express permission of CSCI Tavistock Square (17) DS0000015736.V357637.R01.S.doc Version 5.2 Page 29 - 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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