Inspection on 22/10/08 for Tillson House

This inspection was carried out on 22nd October 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

Tillson House 11/01/07

Tillson House 17/08/05

Tillson House 10/05/05

Tillson House 27/01/05

Tillson House 05/07/04

Tillson House 23/03/04

Similar services:

Hillside

Applegarth

Trevayler Residential Care Home

122 Scorer Street

Byars Care Home

St Marys Nursing Home

Jubilee Villa Care Home

Bramble Lodge

Extracts from inspection reports are licensed from CQC, this page was updated on 17/12/2008.

Inspecting for better lives Key inspection report Care homes for older people Name: Address: Tillson House Bradgate Drive Coalville Leicestershire LE67 4HF     The quality rating for this care home is:   two star good service A quality rating is our assessment of how well a care home, agency or scheme is meeting the needs of the people who use it. We give a quality rating following a full assessment of the service. We call this a ‘key’ inspection. Lead inspector: Linda Clarke     Date: 2 2 1 0 2 0 0 8 This is a report of an inspection where we looked at how well this care home is meeting the needs of people who use it. There is a summary of what we think this service does well, what they have improved on and, where it applies, what they need to do better. We use the national minimum standards to describe the outcomes that people should experience. National minimum standards are written by the Department of Health for each type of care service. After the summary there is more detail about our findings. The following table explains what you will see under each outcome area. Outcome area (for example Choice of home) These are the outcomes that people staying in care homes should experience. the things that people have said are important to them: They reflect This box tells you the outcomes that we will always inspect against when we do a key inspection. This box tells you any additional outcomes that we may inspect against when we do a key inspection. This is what people staying in this care home experience: Judgement: This box tells you our opinion of what we have looked at in this outcome area. We will say whether it is excellent, good, adequate or poor. Evidence: This box describes the information we used to come to our judgement. Copies of the National Minimum Standards – Care Homes for Older People can be found at www.dh.gov.uk or bought from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop 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 Our duty to regulate social care services is set out in the Care Standards Act 2000. Care Homes for Older People Page 2 of 30 Reader Information Document Purpose Author Audience Further copies from Copyright Inspection report CSCI General public 0870 240 7535 (telephone order line) Copyright © (2008) Commission for Social Care Inspection (CSCI). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CSCI copyright, with the title and date of publication of the document specified. www.csci.org.uk Internet address Care Homes for Older People Page 3 of 30 Information about the care home Name of care home: Address: Tillson House Bradgate Drive Coalville Leicestershire LE67 4HF 01530832793 F/P01530832793 Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): Name of registered manager (if applicable) Lorraine Lee Welham Type of registration: Number of places registered: Leicestershire County Council Social Services care home 40 Conditions of registration: Category(ies) : Number of places (if applicable): Under 65 dementia learning disability mental disorder, excluding learning disability or dementia old age, not falling within any other category physical disability sensory impairment Additional conditions: The maximum number of service users who can be accommodated is: 40 The registered person may provide the following category 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: Sensory Impairment, over 65 years of age SI(E) - 4 Dementia - DE - 8 Physical Disability, over 65 years of age PD(E) - 12 Learning Disability, over 65 years of age LD(E) - 4 Dementia, over 65 years of age DE(E) - 24 Old age, not falling into any other category Care Homes for Older People Page 4 of 30 Over 65 24 4 6 40 12 4 8 4 8 0 8 4 OP - 40 Mental Disorder, excluding Learning Disability or Dementia over 65 years of age MD(E) - 6 Sensory Impairment SI - 4 Physical Disability PD 8 Learning Disability LD - 4 Mental Disorder, excluding Learning Disability or Dementia MD - 8 Date of last inspection Brief description of the care home Tillson House is a residential care home providing personal care and accommodation for up to forty older persons. Tillson House is fully accessible, with communal areas and bedrooms being located on both floors. Accommodation is provided over two floors with access between floors being via stairs or a passenger lift. The forty single bedrooms are without en-suite facilities. The Garden, with seating areas, mature plants and trees, is accessible to residents. Tillson House also has a respite facility offering accommodation for up to eight individuals with Dementia. The facility, called Beacon Villa is self contained within the home. Owned by Leicestershire County Council Social Services Department Tillson House is situated close to the town centre of Coalville, offering all local amenities and is accessible by private or public transport. Care Homes for Older People Page 5 of 30 Summary This is an overview of what we found during the inspection. The quality rating for this care home is: Our judgement for each outcome: two star good service Choice of home Health and personal care Daily life and social activities Complaints and protection Environment Staffing Management and administration peterchart Poor Adequate Good Excellent How we did our inspection: We as it appears throughout the Inspection Report refers to The Commission for Social Care Inspection. We did this Key Inspection with an expert by experience who spoke to people who are using this service. An expert by experience is a person who either has a shared experience of using or understands how people in this service communicate. They visited the service with us to help us get a picture of what it is like to live in or use the service. This is important because the views and experiences of people who use services are central to help us make a judgement about the quality of care. The expert by experience spent their time in Beacon Villa, which is a respite facility Care Homes for Older People Page 6 of 30 for people with Dementia. They met with eight residents, and spoke with staff and a relative of someone staying in the unit. The inspection process consisted of pre-planning the inspection, which included reviewing the Annual Quality Assurance Assessment (AQAA), which is a selfassessment tool completed by a representative of the service, reviewing previous Inspection Reports, and any information we have received. The unannounced site visit commenced on the 22nd October 2008, and took place between 09:30 and 17:15. The focus of the inspection is based upon the outcomes for people who use the service. The method of inspection was case tracking. This involved identifying people with varying levels of care needs and looking at how these are being met by the staff at Tillson House. Four people accessing services were selected. Discussions were held with two people chose, along with four other people living at the Home, and visiting relatives. Staff members were spoke with along with the Registered Manager. In addition the expert by experience spoke with people staying in and visiting Beacon Villa. What the care home does well: What has improved since the last inspection? What they could do better: Information available to people thinking of or already staying at Tillson House could be improved, to enhance peoples understanding, by providing information in a format which is easier to understand. Information held in care plans could be expanded upon, where decisions are made by people living at the home, and supporting health care professionals to change the way in which a person lives their day to day lives. The range of activities provided, particularly for those people with additional needs such as Dementia could be improved and tailored to ensure that everyone has the opportunity to take part in worth while pursuits which are part of their care plan. Care Homes for Older People Page 8 of 30 The expert by experience wrote in their report I feel that care staff probably tried their best to do activities, but needed more ideas. If you want to know what action the person responsible for this care home is taking following this report, you can contact them using the details set out on page 4. The report of this inspection is available from our website www.csci.org.uk. You can get printed copies from enquiries@csci.gsi.gov.uk or by telephoning our order line –0870 240 7535. Care Homes for Older People Page 9 of 30 Details of our findings Contents Choice of home (standards 1 - 6) Health and personal care (standards 7 - 11) Daily life and social activities (standards 12 - 15) Complaints and protection (standards 16 - 18) Environment (standards 19 - 26) Staffing (standards 27 - 30) Management and administration (standards 31 - 38) Outstanding statutory requirements Requirements and recommendations from this inspection Care Homes for Older People Page 10 of 30 Choice of home These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People are confident that the care home can support them. This is because there is an accurate assessment of their needs that they, or people close to them, have been involved in. This tells the home all about them and the support they need. People who stay at the home only for intermediate care, have a clear assessment that includes a plan on what they hope for and want to achieve when they return home. People can decide whether the care home can meet their support and accommodation needs. This is because they, or people close to them, have been able to visit the home and have got full, clear, accurate and up to date information about the home. If they decide to stay in the home they know about their rights and responsibilities because there is an easy to understand contract or statement of terms and conditions between them and the care home that includes how much they will pay and what the home provides for the money. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Tillson House enables people who require residential care to make an informed decision as to whether the home is appropriate to their needs by providing information about the service it provides and through its assessment process. Evidence: We wanted to look at the information provided to people who use the service to find out whether it was detailed and answered all their questions, and to find out how the service passed on the information. We spoke with people who live at Tillson House and individuals who were visiting relatives on the day of our visit, all said they had been given information about the home, in some instances before they moved in, whilst others received information when they arrived at the home. Information available about the home and services has not been developed with the needs of individuals in mind, it is available in a printed format, but has not considered that those with a sensory impairment may benefit from the information being provided in larger print, or Care Homes for Older People Page 11 of 30 Evidence: that the use of photographs may provide an easier reference guide. We looked at the records of four people living at Tillson House, and found that individuals had had their needs assessed by a Social Worker, before moving into the home, this enables the Registered Manager to look at the information provided and decide whether their needs can be met by the staff and facilities at the home. The Registered Manager told us that they allocate a member of staff to support someone when they move into the home, to help them to settle in and show them around the home and answer any queries they have. Tillson House has a separate facility which provides respite care to people with Dementia, the expert by experience spent time with those in residence. Care Homes for Older People Page 12 of 30 Health and personal care These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People’s health, personal and social care needs are met. The home has a plan of care that the person, or someone close to them, has been involved in making. If they take medicine, they manage it themselves if they can. If they cannot manage their medicine, the care home supports them with it, in a safe way. People’s right to privacy is respected and the support they get from staff is given in a way that maintains their dignity. If people are approaching the end of their life, the care home will respect their choices and help them feel comfortable and secure. They, and people close to them, are reassured that their death will be handled with sensitivity, dignity and respect, and take account of their spiritual and cultural wishes. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The health and personal care that people receive is based on their individual needs, choices and expectations of care, and the principles of respect, dignity and privacy are put into practise. Evidence: We wanted to find out how the health and personal care needs of people living at the home were met. We spoke with people living at the home, and observed the care and support provided by staff, we also looked at the care plans and records of four people. The expert by experience who spent time in Beacon Villa, made the following observations and comments in their report. I observed that there was a notice board which gave the day, date and name of the staff member on duty in large clear letters, in addition there was a large clock which showed the day and date, which was there to help reduce confusion of the people staying at the home. I was told that residents are asked when they want to go to bed and to get up, to try to promote their independence. Residents arrive with a care plan, unless admitted as an emergency. Care Homes for Older People Page 13 of 30 Evidence: Staff find this useful, but would like more information about the lives of residents, some families provide this, it is more difficult to get to know their background, as the residents are not there permanently. A relative came to take a resident home, the relative said he was very happy with the care. His father had been in Beacon Villa once before, recently. I noted that one gentleman had not had a shave that day. However, later, the member of staff was talking to him about having a shave later. The staff member explained to me that he does not like to have a shave in the morning but he will have it at night. At the moment, there is a lady in residence, whose first language is not English, the member of staff tried to recall some words in their first language to use with her. When we asked people about the care they receive they told us staff are very obliging and knowledgeable. Whilst someone else said the care is good, Ive been here a few months and settled well. Whilst a relative told us I think very highly of this place, because of the care and cleanliness, efficiency and homely atmosphere, Id recommend it to anyone. Care plans begin by providing information about a persons life before moving into the home, this includes information about their work and family life, hobbies and interests, and significant events and dates. The information helps staff to develop a care plan which is tailored to support an individuals lifestyle and enables staff to support people in a sensitive and understanding manner. Care plans record the care and support individuals need, and the role of staff in providing the support. Peoples wishes and expectations of care are recorded along with information as to how they wish to be cared for. Care plans detail the abilities of people so that staff can continue to promote and maintain the independence of those living at the home. Records we looked at showed us that people living at the home have access to a range of health care professionals, and that additional areas of care are assessed to ensure that people receive the care and support they need. Tillson House supports people in conjunction with health care professionals to remain at the home if they so wish to in the final stages of their life, enabling people to die with dignity in the home and reduce unnecessary hospital admissions. We spoke with one person and their relative who told us that they were comforted by the thought that they could remain within the home, and receive nursing care and support, as going into hospital caused them anxiety and stress. We observed the interaction between people living at the home and staff throughout the visit, there was good rapport and friendly banter. Staff were sensitive to the needs Care Homes for Older People Page 14 of 30 Evidence: and wishes of people, and supported them in receiving care and support in a manner they preferred. We looked at the medication and medication records of four people, and found them to be in good order, recent changes to legislation mean that the Registered Manager needs to check that the way in which it stores and manages Controlled Drugs is satisfactory. Care plans we looked at stated that staff are responsible for the management of individuals medication. Assessments and care plans need to detail the wishes and choices of people with regards to the management of their medication, to ensure that peoples independence is promoted. Care Homes for Older People Page 15 of 30 Daily life and social activities These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: Each person is treated as an individual and the care home is responsive to his or her race, culture, religion, age, disability, gender and sexual orientation. They are part of their local community. The care home supports people to follow personal interests and activities. People are able to keep in touch with family, friends and representatives. They are as independent as they can be, lead their chosen lifestyle and have the opportunity to make the most of their abilities. People have nutritious and attractive meals and snacks, at a time and place to suit them. There are no additional outcomes. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Opportunities are available for people to engage in activities, but these are not far ranging and are dependent upon the availability of staff to provide them. Tillson House provides a wholesome and varied diet. Evidence: We wanted to find out about how people spend their day, and how the staff working at the home support people to make decisions and stay in contact with relatives and friends, we did this by observing people throughout the day, talking with people living at the home and by looking at the care plans and records of four people. The expert by experience who spent time in Beacon Villa, made the following observations and comments in their report. There was a television, which was showing Daniel ODonnell shows the whole time I was there. Staff said the ladies liked it, but no one seemed to be actually watching. After lunch, a gentleman and lady joined in singing along. In the afternoon, a resident had been standing looking out of the doors, the staff member took him out with her when she went to hang out some washing. It enabled him to have a short walk, some fresh air and it was something that would happen naturally at home. As I was leaving, a member of staff came to play dominoes Care Homes for Older People Page 16 of 30 Evidence: with two gentlemen, staff told me that in the afternoons residents do craft work, jigsaws, play ball games, listen to CDs and some staff manicure nails, and give ladies facials. Occasionally an entertainer comes in to play the accordion. A member of staff told me that a gentleman would be going to the day centre that he visits regularly when at home, to maintain his routine as far as possible, which seemed a good idea. Tillson House has a relaxed atmosphere, with people getting up and spending time where they choose to, for some this meant staying in their bedroom, whilst others sat in one of the three lounges in the home. We sat with several people in the morning who were listening and watching a video of Daniel ODonnell, some sang a long to the songs whilst others tapped their feet. One person told us I dont like joining in or sitting in the lounges, but prefer to say in my bedroom, I like to listen to talking books and enjoy listening to Radio Leicester. I have a telephone in my room so i can speak with family and friends. Someone else told us When Im well enough I go and listen to the accordionist who visits and take part in the sing-a-long, I also like to join in the Church Service. We saw photographs of a trip to Twycross Zoo in the Summer, and a group of people out for lunch in a Public House. People we spoke with told us about some of the activities organised, which included a film night with popcorn, and fish and chip evenings. Two people we sat with at lunchtime were making plans for Christmas. Tillson House has a computer which is located in a lounge/dining room on the first floor, the computer has internet access, and has a large mouse and keyboard to enable people to use it, the Registered Manager said that they were going to have a web-cam so that people living at the home could have visual contact with family and friends, particularly for those people who have relatives who live overseas. We sat and joined in the lunchtime meal with a group of people in the dining room, and asked them what they thought about the food provided. One person said you cant fault it, always plenty of choice and variety. People who required support from staff received it, and peoples individual needs as detailed within care plans were met by the staff. The dining experience was unhurried and relaxed, and people sat talking to each other and sharing jokes. The expert by experience who spent time in Beacon Villa, made the following comments and observations in their report. One member of staff was in Beacon Villa most of the time, with other staff coming into provide help. The member of staff was always attentive to the residents, for instance, at lunchtime, when they were feeding the lady having day-care, the staff member also kept an eye on other residents to see if they were alright. Tablecloths and linen serviettes were used for lunch, main meals are cooked in the main kitchen, however Beacon Villa has its own domestic kitchen. A Care Homes for Older People Page 17 of 30 Evidence: resident told me the food is always good. Residents are asked what they want the next day from a menu, there are always two options and a vegetarian option. Care Homes for Older People Page 18 of 30 Complaints and protection These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: If people have concerns with their care, they or people close to them know how to complain. Any concern is looked into and action taken to put things right. The care home safeguards people from abuse and neglect and takes action to follow up any allegations. People’s legal rights are protected, including being able to vote in elections. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People living at Tillson House are able to express their concerns, and have access to a complaints procedure, and are protected from abuse by a supportive and knowledgeable staff team. Evidence: We wanted to find out how the staff of Tillson House promote the safety and welfare of people who use the service, written information supplied by the Registered Manager before our visit told us about the policies and procedures staff have to follow, to safeguard vulnerable people. Newly appointed staff undertake a period of induction which takes place over three months, and includes training as to their roles and responsibilities in ensuring people in their care live a life free of abuse. The expert by experience who spent time in Beacon Villa, made the following observations and comments in their report. In a residents bedroom, in a drawer, he had a care pack giving information about Tillson House, complaints procedure etc. We looked at the record of complaints received by Tillson House in the last 12 months, this included three concerns which were dealt with and recorded by the Registered Manager, we have not received any concerns or complaints in the last 12 months. We spoke with people living at the home and asked them if they knew who to speak Care Homes for Older People Page 19 of 30 Evidence: with if they were unhappy or wished to complain, some people said they would speak with the Manager, whilst others said they would speak to a relative. One relative said Id speak with the Manager, but the need to complain has never arisen. Information about how to complain is displayed within the home, but needs updating to reflect current contact details, including information about advocacy services. We spoke with staff and looked at records to find out about the training care staff receive, all staff receive training which promotes the safety and welfare of people, including training on reporting concerns or complaints expressed to them. Care Homes for Older People Page 20 of 30 Environment These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People stay in a safe and well-maintained home that is homely, clean, pleasant and hygienic. People stay in a home that has enough space and facilities for them to lead the life they choose and to meet their needs. The home makes sure they have the right specialist equipment that encourages and promotes their independence. Their room feels like their own, it is comfortable and they feel safe when they use it. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Tillson House provides, a comfortable and homely environment, which is well maintained. Evidence: We had a tour of Tillson House, including Beacon Villa which provides respite care for people with Dementia. All communal areas of the home were decorated to a high standard, and provide people with light and airy rooms in which to relax. The decor of Beacon Villa has been undertaken after researching how colours and patterns can support those with Dementia in moving around independently in unfamiliar surroundings and reducing their level of confusion and disorientation. Further improvements with regards to bathing facilities are planned for the near future. Tillson House has a lounge on the ground floor, which overlooks the front of the home and its gardens, whilst a small lounge to the rear of the home gives access to a courtyard, with tables and seating and potted flowers which in turns leads into a large and well kept garden with mature trees, plants and shrubs. The ground floor also provides the main dining room of the home, which includes a licensed bar. The first floor provides two lounge/diners, one for people who live in the home who wish to smoke. These rooms are also used by people who choose not to go downstairs and eat in the main dining room. Care Homes for Older People Page 21 of 30 Evidence: Bathing, shower and toilet facilities are located on the ground and first floor as are the bedrooms. Access to the first floor is via a stairwell or passenger lift. We looked at some of the bathing facilities and bedrooms of people who live at the home, all were decorated to a good standard, and bedrooms had been personalised with the belongings of people living at the home. The expert by experience who spent time in Beacon Villa, made the following comments and observations in their report. Beacon Villa is a secure unit. There were alarms on the fire doors leading to the Villa garden. This pleasant garden has a level paved surface. There were seats, a table and pots of flowers. The garden area is fenced off with trellis. The unit has large windows overlooking the gardens, so it was very light and bright. The lounge/dining room area was decorated mainly in blue. There were comfortable arms chairs, small coffee tables, dining table and chairs, and various units, which made it feel very homely. The rooms and small lounge were decorated in red and cream. The bedrooms I saw were very clean and adequately furnished. The full name of the residents were written in large clear letters on the door. Some personal items, eg photographs of family, were seen. In one room, there was a notice board, which had a note on it for a resident telling him that he is there for a short stay and that his family know where he is. The unit has its own laundry and kitchen. Care Homes for Older People Page 22 of 30 Staffing These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have safe and appropriate support as there are enough competent staff on duty at all times. They have confidence in the staff at the home because checks have been done to make sure that they are suitable to care for them. Their needs are met and they are cared for by staff who get the relevant training and support from their managers. There are no additional outcomes. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People who live at Tillson House are supported by staff who have undergone a robust recruitment process and are supervised, and are experienced and trained, and who are employed in sufficient numbers to meet their personal care needs. Evidence: We wanted to find out how staff were recruited and whether the recruitment of staff promoted the health and well-being of people who use the service. We looked at the records of some staff and found that they had undergone a robust recruitment process, which included an interview, the seeking of two satisfactory written references and a check as to a persons suitability to work with vulnerable people, which includes finding out if they have a criminal record. This means all staff have had a Criminal Record Bureau (CRB) disclosure. Information provided to us by the Registered Manager before our site visit states that all members of care staff have a National Vocational Qualification (NVQ) in Care, and that staff receive training in various topics which are directly related to their role in providing care and support, including topics related to health and safety. Training received by staff includes report writing, fire awareness, conflict resolution and manging challenging behaviour, food hygiene, medication training and training in dementia awareness. Care Homes for Older People Page 23 of 30 Evidence: The Registered Manager also provided us with information about staffing levels, in the morning five care staff are on duty, whilst in the afternoon and evening their are four, and two night staff on duty during the night, their is always a Manager on site twentyfour hours a day providing support and direction to staff. We observed staff throughout the day and found that there were sufficient staff to meet the needs of people living at the home, call bells were responded to promptly, and staff wore pagers so that they knew when people need assistance. We spoke with staff who were satisfied with the training they received, and said that the training contributed to the quality of care people in the home receive, as it enables them to have good understanding of how conditions such as Dementia affect people. Staff were able to talk about how they supported people with Dementia using the different techniques learnt in training. Care Homes for Older People Page 24 of 30 Management and administration These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have confidence in the care home because it is led and managed appropriately. People control their own money and choose how they spend it. If they or someone close to them cannot manage their money, it is managed by the care home in their best interests. The environment is safe for people and staff because appropriate health and safety practices are carried out. People get the right support from the care home because the manager runs it appropriately with an open approach that makes them feel valued and respected. The people staying at the home are safeguarded because it follows clear financial and accounting procedures, keeps records appropriately and ensures their staff understand the way things should be done. They get the right care because the staff are supervised and supported by their managers. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The management of Tillson House encourages people who live at the home, their relatives and its staff to share their views to ensure that the home is run in the best interests of people who receive a service. Evidence: The Registered Manager of Tillson House, Lorraine Welham has worked at the home for many years, and has gained a National Vocational Qualification (NVQ) at level 4 and has attained the Registered Managers Award. We looked at the training record of the Registered Manager and found that they have undertaken training in conflict resolution and managing challenging behaviour, attended conferences and training on the care of people with Dementia, along with other training which enables her to effectively and efficiently oversee and manage the day to day running of the home. Throughout the day we saw people who live at the home, staff, visitors and professional visitors approach the Registered Manager, who was able to deal with all Care Homes for Older People Page 25 of 30 Evidence: queries effectively, conversations Ms Welham had with us throughout the day demonstrated that the Registered Manager is knowledgeable about the needs of people living at the home, and that her management approach is positive and inclusive taking on board the wishes and views of everyone. Questionnaires are sent out to people who use the service, their relatives and supporting health and social care professionals, these are audited and used to develop and improve the service. We looked at the most recent quality assurance report, which detailed that people who receive a service and others involved in their care are happy with the level of care provided. Staff meetings take place, and staff we spoke with said that they do receive supervisions and performance reviews, the frequency of supervisions was varied, but staff did feel that they received sufficient support from the Management Team. Information the Registered Manager supplied prior to the site visit details the regular maintenance of equipment and systems in the home, including heating and electrical systems along with fire fighting equipments and systems. Care Homes for Older People Page 26 of 30 Are there any outstanding requirements from the last inspection? Yes £ No R Outstanding statutory requirements These are requirements that were set at the previous inspection, but have still not been met. They say what the registered person had to do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards No. Standard Regulation Requirement Timescale for action Care Homes for Older People Page 27 of 30 Requirements and recommendations from this inspection: Immediate requirements: These are immediate requirements that were set on the day we visited this care home. The registered person had to meet these within 48 hours. No. Standard Regulation Requirement Timescale for action Statutory requirements These requirements set out what the registered person must do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The registered person(s) must do this within the timescales we have set. No. Standard Regulation Requirement Timescale for action 1 9 13 The Registered Manager to establish whether the cabinet which stores Controlled Drugs at Tillson House complies with the Misuse of Drugs (Safe Custody) Regulations 1973. If it is found current storage facilities do not meet the regulations then a storage system, which does comply with the Misuse of Drugs (Safe Custody) Regulation 1973 is to be purchased and installed. To ensure the safe storage of Controlled Drugs 23/01/2009 Recommendations These recommendations are taken from the best practice described in the National Minimum Standards and the registered person(s) should consider them as a way of improving their service. No. Refer to Standard Good Practice Recommendations 1 1 The format of information provided to people who use the services of Tillson House should take into account the needs of people who use the service, and be produced to encourage and enable individuals to have a greater Care Homes for Older People Page 28 of 30 understanding of its contents by the use of large print, signs, symbols and photographs. 2 7 Information about the care people receive including any restrictions need to be transparent. Care plans to include information where restrictions are in place with regards to an individuals lifestyle and provide the rationale, process, role of staff and names of those signed up to the agreement including the person receiving care. The robust system for the receipt, managing and disposal of Controlled Drugs to be supported by the purchase and use of a Controlled Drug Register. A review to be undertaken as to the range, suitability and frequency of activities available to people with specific needs such as Dementia, by seeking advice from specialist organisations, and reviewing how person centred activities could be introduced. The complaints procedure to be reviewed and distributed and to include contact details of advocacy services, and be produced in a format which considers the needs of people who use its services by the use of large print, photographs and symbols. 3 9 4 12 5 16 Care Homes for Older People Page 29 of 30 Helpline: 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 We want people to be able to access this information. If you would like a summary in a different format or language please contact our helpline or go to our website. Copyright © (2008) Commission for Social Care Inspection (CSCI). 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