Inspection on 24/05/07 for Tower House II Residential Home

This inspection was carried out on 24th May 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Tower House II Residential Home 06/11/09

Tower House II Residential Home 03/06/09

Tower House II Residential Home 28/07/08

Similar services:

Henry Nihill House

Birchwood

The Infirmary

Orchard House Nursing Home

St Josephs Rest Home

Red Court Nursing Home

Spinney (The)

Queen Elizabeth House

Extracts from inspection reports are licensed from CQC, this page was updated on 09/07/2008.

CARE HOMES FOR OLDER PEOPLE Tower House II Residential Home 11 Tower Road Willesden London NW10 2HP Lead Inspector Mr Ram Sooriah Key Unannounced Inspection 24th May 2007 10:00 X10015.doc Version 1.40 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 Tower House II Residential Home DS0000068639.V341311.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 Older People. 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. Tower House II Residential Home DS0000068639.V341311.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Tower House II Residential Home Address 11 Tower Road Willesden London NW10 2HP 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) 020 8621 4742 Mrs Mary Mundy Mrs Rosalia Daracan Care Home 3 Category(ies) of Old age, not falling within any other category registration, with number (3) of places Tower House II Residential Home DS0000068639.V341311.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. That only service users who are able to ascend and descend the stairs to the ground floor without the assistance of staff, may be accommodated on the first floor. Date of last inspection Brief Description of the Service: Tower House II is located in Tower Road off Pound Lane in Willesden. It is easily accessible by cars and public transport. Buses serve Pound Lane and the home is about five minutes walk from the bus stop. There is a small parking area in front of the home for about 2 cars. Parking on the road is for residents only. The home was registered on the 11th January 2007 for three elderly residents of mixed gender who require personal care. It consists of a semi-detached House. There is a kitchen, lounge/dining area and a bedroom on the ground floor and two bedrooms and a bathroom on the first floor. All bedrooms are ensuite with a toilet and washbasin. There are pleasant garden/patio areas in front of the home and at the back which are very well maintained. The first floor is reached by a set of stairs and at the time of the inspection, the residents accommodated on the first floor were able to negotiate the stairs. Tower House II is own by Ms Mary Mundy. She has another care home next to Tower House II at number 9 and 10. There are a lot of interactions between the two homes as they are next to each other and Ms Mundy is able to offer very good support to Rosalia Daracan, the registered manager of Tower II. The home charges £560 weekly and also accommodates residents who are publicly funded. They do not have to pay a top-up. There were 3 residents in the home at the time of the inspection. Tower House II Residential Home DS0000068639.V341311.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This is the first key inspection for the service as it was first registered in January 2007. The inspection was unannounced and started at about 10:00 and finished at about 15:30. During the course of the inspection I spoke to 2 residents, the manager and the proprietor. I also toured some of the premises, looked at a sample of records, observed lunchtime and interactions of residents with staff. I would like to thank the residents for talking to me and for making me feel welcome into the home and the proprietor, manager and the staff for their support and cooperation during the inspection. What the service does well: What has improved since the last inspection? What they could do better: The service users’ guide must contain information about the range of fees charged by the home and the contract/statement of terms and conditions must be made clearer and more specific. Tower House II Residential Home DS0000068639.V341311.R01.S.doc Version 5.2 Page 6 The assessment of the needs of residents must be reviewed regularly or when the needs of residents change. Care plans could be more specific to the needs of individual residents and must be agreed where possible with the residents or their relatives. In cases where this is not possible a note must be made to this effect. Risk assessment must be more comprehensive in order to include all the activities that residents are engaged in and which can carry a degree of risk. These must be reviewed monthly or at intervals as indicated on the risk assessments. Care plans must include some information about the thoughts and aspirations of residents for the future and any wishes and instructions that they have for end of life care and death. Any spillages of urine or other matter should be clean without delay to prevent the build up of odours in the home. Not all members of staff were up to date with statutory training such as in fire training, food hygiene and manual handling. This is required to ensure that they are fully trained to meet the needs of the residents. A training and development plan will ensure a planned and consistent approach to training. Staff must also have supervision six times a year or once every two months as a minimum. Staff have not had training on safeguarding adults. This is required to ensure the safety of residents and to raise staff’s awareness of abuse issues. The manager must have an NVQ level 4 in care and must achieve the registered manager’s award. This may raise her awareness of her legal responsibilities as the registered manager of the service. Health and safety issues were generally dealt with appropriately but a few issues were noted. There must be a risk assessment in cases where residents have access to windows which can be fully opened, as they do not have restrainers. The use of window restrainers must be considered as a control measure. Emergency lights must be tested monthly. 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. Tower House II Residential Home DS0000068639.V341311.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR 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) Scoring of Outcomes Statutory Requirements Identified During the Inspection Tower House II Residential Home DS0000068639.V341311.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1-4 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents and their relatives receive information about the service before deciding if they want to live in the home. The quality of the information in the contract/statement of terms and conditions was slightly lacking. Residents’ needs are assessed prior to a place being offered to the residents to ensure that the home is able to meet the needs of the residents. EVIDENCE: The home has updated its service users’ guide since that document was required for the registration of the home. Copies were available in the bedrooms of residents. The proprietor stated that the service users’ guide does not yet contain information about the range of fees that are charged and information about what they cover. This is required according to recent legislation. Tower House II Residential Home DS0000068639.V341311.R01.S.doc Version 5.2 Page 9 Contracts/statements of the terms and conditions of the placement is offered to all residents. These covered most of the topics as detailed in standard 2.1. I was however noted that the contracts/statements of terms and conditions needed to be revised as they at times were not that specific. For example a contract in the front mentioned that it is a contract between the resident, local authority, which placed the resident, and the home, when it should be a contract between the home and the resident. Clarification was also required for aspects such as charging full fees for absences, fees charged after the death of residents, notice periods etc… The residents who were admitted to the home have been visited by the proprietor who had carried out an assessment of needs to determine if the home was suitable for the residents. This was confirmed by one of the resident. There was also evidence that the assessments/care plans of the funding authorities were sent to the home to provide information about the needs of the prospective residents. The pre-admission assessment was in the main appropriately completed to provide information about the needs of the residents. The proprietor stated that residents or their relatives were invited to visit the home, to meet staff and other residents and to ask questions. I noted that the two residents present in the home at the time of the inspection were comfortable in the home and that their needs were being met. Members of staff knew them very well and the residents also knew members of staff. The two residents accommodated on the first floor were able to climb the stairs to their bedrooms. Tower House II Residential Home DS0000068639.V341311.R01.S.doc Version 5.2 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7-11 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Care plans are not individualised and comprehensive enough to address all the needs of residents. The home supports residents with their healthcare needs. The management of medicines is of a good standard and ensures the safety of residents. Care plans do not include information about the end of life care of residents and their fears for the future as a result these needs may not be met should they arise. EVIDENCE: The care plans for the three residents in the home were inspected. Each care plan was kept in the bedroom of the relevant resident, and as such was available to the resident if he/she wanted to read his/her care plan. There was however little evidence in the care records to show that the residents have agreed to the care plans and risk assessments. Tower House II Residential Home DS0000068639.V341311.R01.S.doc Version 5.2 Page 11 The care plans were in good order. While a preadmission assessment of needs is carried out routinely for each resident, these are not reviewed and updated as required by legislation. A resident who has been in the home for about 2 years has not had his needs’ assessment reviewed or updated. A number of risks assessments were in place to address the safety of residents. These included manual handling, pressure sore and falls risk assessments and a nutritional assessment. It was noted that these were not always reviewed monthly, particularly for those residents whose needs are likely to change because of their health condition. There were other risk assessments, which were based on individual behaviour and lifestyle of residents but the standard of this risk assessment process was variable. One resident with a particular behaviour had a care plan/risk assessment addressing that behaviour but another resident who was involved in gardening and who at times goes out in the local community did not have a risk assessment addressing these issues. Care plans were also not individualised enough. There has been an attempt to introduce pre-printed care plans for specific problems such as communication but these were not individualised to each resident’s needs. One resident with a cognitive problem was given a care plan about communication for someone who has sustained a stroke. All residents presented as clean and appropriately dressed and groomed. Members of staff related to them appropriately and consulted them about their choices. It was however noted that the clothes of some residents were not always ironed as properly as they should have been. Records showed that residents were seen by the GP, dentist, optician and chiropodist and other healthcare professionals as required. The manager stated that the home keeps good links with healthcare professionals in the community and that the home is well supported by them. Staff were clear that they would contact the GP or the relevant healthcare professionals if they has concerns about a resident. The proprietor stated that the health and medication of residents are reviewed by the GP. One resident had a care plan for losing weight. It was however noted that her weight was not being monitored on a monthly basis or more often if that was required. I looked at medicines management in the home. The residents in the home were on few medicines and overall there were appropriate records for the management of medicines. Medicines were kept safely in a locked area. The proprietor stated that all members of staff who administer medicines have had medication training and have been assessed as competent by her. Tower House II Residential Home DS0000068639.V341311.R01.S.doc Version 5.2 Page 12 Care plans of residents contained little information about the fears for the future and aspirations of the residents and any wishes and instructions with regards to their future, end of life care and death. The proprietor stated residents could stay in the home as long as the needs of the residents are being met in the home, but due to restrictions posed by the layout of the home, residents may need to move to other care homes providing nursing, should residents develop nursing care needs. Tower House II Residential Home DS0000068639.V341311.R01.S.doc Version 5.2 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12-15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Social and leisure activities are provided to residents but it is not clear if these are according to the needs of the residents because the care records with regards to this aspect of care was lacking. A variety of nutritious meals are provided in sufficient quantity to residents to meet their nutritional needs. EVIDENCE: The assessment of needs contained little information about the background of residents and their social and recreational needs. Care plans were also lacking with regards to addressing this aspect of the care of residents. During the inspection, I observed that the residents were engaged in the things that they enjoyed and wanted to do. One resident was engaged in gardening and another sat outside enjoying the warm weather. However, the things that residents enjoy doing are not always included in their care records and within a risk assessment context particularly if residents are involved in some activities where there is some risk of harm. Tower House II Residential Home DS0000068639.V341311.R01.S.doc Version 5.2 Page 14 The residents are also involved in the local community to a certain extent. One resident enjoys going to the day centre and another enjoys going out for walks. The manager said that one of the residents does his own shopping and that other residents can go for walks with members of staff. The proprietor reported that people who live in the home are free to practice their faith. She added that the representatives from the Roman Catholic Church and the Pentecostal Church come nearly every week into the home. There has been an attempt by the home to address the religious needs of residents in the care records, but the plan of care was broad and not specific enough about the action to take to meet the needs of the residents. For example it says that residents should be given access to spiritual support but does not identify the individual spiritual support that each resident wants or needs. The home has a four weekly menu. Copies of the menu were available on the dining table for the information of residents. I observed lunch being served. Lunch should have consisted of beef stroganoff but there was fish instead. I was informed that the residents wanted fish and therefore the beef was not prepared. One of the residents confirmed that he wanted fish and did not want beef. There was also mixed vegetables and rice for lunch. Fresh fruits are provided in the home for the convenience of residents. It was noted that on the day of the inspection the meals were prepared in Tower House 1, so I briefly inspected the kitchen in Tower House 1. It was clean and tidy. The home keeps individual records about the meals of residents. This is good practice. Tower House II Residential Home DS0000068639.V341311.R01.S.doc Version 5.2 Page 15 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Whilst the proprietor and staff take complaints and allegations of abuse seriously, they have not yet had training on safeguarding adult to raise awareness about abuse, the prevention of abuse and the action that need to be taken in cases where there are allegations and suspicions of abuse. EVIDENCE: The complaint procedure was available in the service users’ guide and also on a poster in the foyer of the home. A resident said that he would approach the manager or the proprietor if there was something with which he was not happy about. Staff were also clear that they needed to report to the proprietor any concerns that residents might raise with them. The home has not had any complaints. A policy to deal with allegations of abuse and the safeguarding adult policy and procedures of Brent was available in the home. While the proprietor was clear about what needed to be done in cases where there have been allegations or suspicions of abuse it was however noted that the manager and the proprietor have not yet had training on safeguarding adults. Care staff have also not had this training. It is therefore required that the manager makes arrangement for herself and all her staff to attend this training as soon as possible. Tower House II Residential Home DS0000068639.V341311.R01.S.doc Version 5.2 Page 16 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19,24 and 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is located in a good position in the local community and provides a homely and pleasant environment for residents. EVIDENCE: The home is situated in a residential area of Willesden and is close to local amenities and shops. There is off-street parking for about 2 cars in front of the home. The building is in good condition and the front area is maintained to a good standard. Plants and patio areas have been used to make the front of the home attractive and inviting. The back of the home is equally well maintained and residents have the opportunity to benefit from these when they sit outside or take walks in the garden/lawn. The proprietor is commended for her Tower House II Residential Home DS0000068639.V341311.R01.S.doc Version 5.2 Page 17 commitment to improve the environment of the home for the benefit of residents. The ground floor has a kitchen area and a dining/lounge area. These were well decorated and appropriately furnished. Residents also have the opportunity to use the facilities in Tower House I, which is next door to the home. Bedrooms of residents were clean and well decorated. They were all en-suite. There was evidence that residents were encouraged to personalise their bedrooms. There were photographs, pictures and personal items that residents brought from their previous homes. Residents also had keys to their bedrooms. There was a slight odour in one of the bedrooms and the proprietor stated that the cleaner was going to shampoo the room. It is recommended that shampooing of the room take place as soon as there has been a spillage to prevent the build-up of odours. The proprietor stated that most of the laundering of clothes, including bed linen and residents clothes is done by an outside company and that the home only has a small facility for emergency washing. Tower House II Residential Home DS0000068639.V341311.R01.S.doc Version 5.2 Page 18 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27-30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Staff are provided in adequate numbers to meet the needs of the residents. Members of staff receive some training but not all of them are up to date with statutory training. As a result the quality of the service may not be fully optimised. EVIDENCE: The manager and another member of staff were on duty on the day of the inspection. The member of staff had accompanied one of the residents to the day centre. The proprietor stated that there are normally two members of staff during the day. She clarified that she is also on the premises or in Tower House 1 most of the time and will attend to any issues if necessary. At night there is one waking member of staff. The proprietor informed the inspector that there are four members of staff who tend to work in Tower House II and that when there is a shortage of staff, staff from Tower House 1 cover the home or staff from an agency is used. The same agency is used most times and the proprietor stated that there are procedures in place for the checking of CRB checks of the members of staff sent by the agency. Tower House II Residential Home DS0000068639.V341311.R01.S.doc Version 5.2 Page 19 Two personnel files were inspected. One set of records contained only one reference and the other set of records did not have an application form at the time of the inspection. I was later sent the second reference for one of the employee and the application form for the second employee, which according to the proprietor were misplaced. There were records to show that new members of staff have had an induction in the home. The proprietor stated that the home now uses the common induction standards from Skills for Care, the training organisation for the social care sector. It was noted that staff do not always receive supervision six times a year or once every two months as a minimum. There was evidence of some training taking place in the home but current records show that not all members of staff had received updates in statutory training. For example it was not clear if all members of staff were up to date with fire training, manual handling, food hygiene and health and safety. Records however suggested that most of the four members of staff who work in the home were qualified to at least NVQ level 2 in care. The home did not yet have a training and development plan for staff. Tower House II Residential Home DS0000068639.V341311.R01.S.doc Version 5.2 Page 20 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. 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 and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31,33, 35,36 and 38 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The management of the home is supportive of residents in the home, but it seems that the manager does not fully appreciate her legal responsibilities with regards to running a care home. The quality management system is not yet fully operational to enable the organisation carry out its own quality assessment. Staff are not supported with regular supervision. Health and safety of residents is generally maintained with few issues identified which needed addressing. EVIDENCE: The manager has been registered at the same time as the home was registered. She has an NVQ 2 qualification in care and is still to gain the Tower House II Residential Home DS0000068639.V341311.R01.S.doc Version 5.2 Page 21 Registered Managers Award and an NVQ level 4 in care. She gets very good support from the proprietor and at times it seems that she does not fully understand her legal position with regards to running a care home as a registered manager. Completion of the relevant training may raise her awareness of her responsibilities. The home plans to carry out yearly satisfaction surveys as per the quality procedure of the organisation. The proprietor stated that she was in the process of developing an audit tool as part of the quality management system. This was not in place yet but the inspector noted the commitment of the proprietor to provide a good service. There was a development plan for the organisation, which included the two homes, belonging to the provider but not specifically to Tower II. There were no minutes of staff or residents meetings available in the home at the time of the inspection. There was a staff meeting planned for the day after the inspection and minutes of this meeting were forwarded to the inspector. I was informed that the home does not look after the personal money of the residents. The relatives of the residents or the local authorities placing the residents are responsible for this role. In one case a resident was responsible for managing his finances with the support of his relatives and the home. Personnel records and conversation with members of staff show that staff do not always receive supervision six times a year or once every two months to support them and to raise issues while working in the home. The home carries out weekly fire detector checks, monthly fire drills and daily health and safety checks. The emergency lights test was not being carried out monthly as required. A fire risk assessment and a fire emergency plan were available in the home. An electrical wiring certificate, PAT testing certificate and a gas safety certificate were also available for inspection. While touring the premises it was noted that windows from the first floor did not have restrainers. It is required that appropriate risk assessments be carried out with regard to access to these windows by residents and to ensure the safety of the residents. Tower House II Residential Home DS0000068639.V341311.R01.S.doc Version 5.2 Page 22 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 2 2 3 3 X x HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 3 10 3 11 2 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 3 X X X X 3 X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 2 X 3 2 X 2 Tower House II Residential Home DS0000068639.V341311.R01.S.doc Version 5.2 Page 23 Are there any outstanding requirements from the last inspection? N/A 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 OP1 Regulation 5 Requirement The service users’ guide must contain information about the range of fees charged by the home and what is covered in the fees. The contract/statement of terms and conditions must be reviewed to make it clearer and more transparent (see text). All risk assessments must be reviewed at least monthly or at intervals indicated in the risk assessment. Care plans and risk assessments must be signed and agreed with residents/representatives whenever possible. Care plans must be clear with regard to the action to take to meet the needs of the residents. There must be comprehensive risk assessments for residents when they are involved in specific activities, which may pose some risks. All residents must be weighed monthly or more often if required. Care plans must address the DS0000068639.V341311.R01.S.doc Timescale for action 15/08/07 2 OP2 5 15/08/07 3 OP7 15(2)(b) 15/07/07 4 5 OP7 OP7 15(1) 13(4)(b) 15/07/07 15/07/07 6 7 OP8 OP11 12(1) 15(1,2) 15/07/07 15/08/07 Page 24 Tower House II Residential Home Version 5.2 8 OP12 16(2) (m,n) 9 10 OP18 OP30 13(6) 18(1)(c) 11 OP31 10(3) 12 13 14 OP33 OP36 OP38 24 18(2) 13(4) 15 OP38 13(4) aspirations and future of residents as well as any wishes and instructions with regards to end of life care and death. The social and recreational needs of residents must be fully assessed. The proprietor must consider the formulation of a life history or a biography for each individual resident. The proprietor must ensure that all members of staff are trained in safeguarding adults. The home must have a training and development plan and all staff must have regular updates in statutory training such as fire training, food hygiene and manual handling. The manager must have an NVQ level 4 in care and must achieve the registered manager’s award as soon as possible. The home must have in place a fully working quality management system. Care staff must be supervised at a minimum of six times a year or once every two months A risk assessment must be carried out with regards to the access of residents to windows which can be fully opened. Control measures such as window restrainers must be in place in cases where risks have been identified. Emergency lights must be tested at least monthly. 15/08/07 31/08/07 15/08/07 31/05/08 31/08/07 31/07/07 15/07/07 15/07/07 Tower House II Residential Home DS0000068639.V341311.R01.S.doc Version 5.2 Page 25 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 Refer to Standard OP10 OP26 Good Practice Recommendations The clothes of residents should be ironed to a good standard. It is recommended that shampooing of the area where there has been a spillage take place as soon as possible to prevent the build-up of odours. Residents’ meetings and staff meetings must be arranged at the frequency as detailed in the home’s policies and procedures. 3 OP33 Tower House II Residential Home DS0000068639.V341311.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Harrow Area office Fourth Floor Aspect Gate 166 College Road Harrow HA1 1BH 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 Tower House II Residential Home DS0000068639.V341311.R01.S.doc Version 5.2 Page 27 - 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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