Inspection on 28/12/07 for Tranquility House

This inspection was carried out on 28th December 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 found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Tranquility House 20/11/08

Tranquility House 15/12/06

Tranquility House 20/02/06

Tranquility House 27/10/05

Tranquility House 26/01/05

Tranquility House 17/08/04

Similar services:

Springfield House

Sutton Lodge Nursing Home

The Shelley

St Helier`s Residential Hotel

St Joseph`s

Ridgemount

Wingham Court

Old Hastings House

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

CARE HOMES FOR OLDER PEOPLE Tranquility House 39 Cheriton Gardens Folkestone Kent CT20 2AS Lead Inspector Mary Cochrane Key Unannounced Inspection 28th December 2007 10:15 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 Tranquility House DS0000036015.V353198.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. Tranquility House DS0000036015.V353198.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Tranquility House Address 39 Cheriton Gardens Folkestone Kent CT20 2AS 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) 01303 244049 TINAWRATTEN@AOL.COM Mrs T.Wratten Post Vacant Care Home 20 Category(ies) of Dementia - over 65 years of age (1), Old age, registration, with number not falling within any other category (19) of places Tranquility House DS0000036015.V353198.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. Service users with DE(E) to be restricted to 1 (one) whose DOB are 11/01/1921. 17th September 2007 Date of last inspection Brief Description of the Service: Tranquillity House is a large detached premises offering accommodation over four floors for up to 20 Service Users over the age of 65, requiring residential care. The home is located within the town of Folkestone and all local amenities are within easy reach (main train and bus stations being 5 minutes walk away). There are 12 single and 4 shared bedrooms available. None of the bedrooms have en-suite facilities but all have a wash hand basin, call systems, and are well furnished. Residents are encouraged to bring personal possessions to furnish their bedroom. The home has adequate storage space to enable residents who wish to fully furnish their room themselves to do so. A shaft lift provides access to all upper floors. Communal areas comprise of a main lounge, a reading / quite area, a large dining room and spacious conservatory. The property has a secluded, small back garden is accessible for wheel chairs. There is a private parking area at the side of the house. The owner of the home is in charge of the day-to-day running of the home and is in the process of applying to the CSCI to become the registered manager. Fees for this service range between £1,248.00 and £1,820.00 per month with additional charges for hairdressing, chiropody, aromatherapy and newspapers. The most recent CSCI report is available on request from the home. Tranquility House DS0000036015.V353198.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The Commission has since the 1st April 2006, developed the way it undertakes its inspection of care services. This inspection of the service was an unannounced “Key Inspection”. The inspection started at 10.15 a.m. and lasted for six hours. It was a thorough look at how well the service is doing. All the key standards were looked at during the visit. The inspection process consisted of information collected before and during the visit to the home. There was one-to-one discussion with residents, staff and visiting professionals Interactions, care interventions and activities were observed. Individual support plans, risk assessments, selected policies, medication procedures, and training programmes were also looked at and discussed. The CSCI did not receive the required completed questionnaire from the home in time for the information to be used in the report. Tranquillity House is registered to provide care for 20 older people. At the time of the inspection there were 18 residents living at the home. The homes owner/manager was on duty and was available all day to assist in the inspection process. The residents and the staff were helpful and cooperative throughout the visit. In September 2007 a safeguarding adults alert was raised at the home. A multi –disciplinary meeting was held to discuss the issues and the action that needed to be taken. This prompted the CSCI to undertake a random inspection on 19th September ’07. Following this 3 requirements and 2 recommendations were made. The home has worked actively with out-side agencies to improve the care given to the residents. Visiting professionals have reported an improvement in care practises. At the time of writing the report the alert remains open. Prior to the visit surveys were sent to service users, families, and care managers. The comments on the surveys returned to us were all positive. One relative commented the home provides a friendly, family atmosphere. A resident said ‘ I am very happy here. I am well looked after’. A person who visits the home regularly said ‘I would say the home is a very happy one. It is a pleasure to visit there’. Tranquility House DS0000036015.V353198.R01.S.doc Version 5.2 Page 6 A request for an improvement plan will be made on publication of the report. This will tell us how the home plans to meet the shortfalls and will include timescales. What the service does well: What has improved since the last inspection? There have been improvements since the last inspection and there was evidence to support that the home is moving in the right direction, but there is still some way to go before all the National Minimum Standards are met. The owner/manager now makes sure that only residents who meet the registration requirements of the service can come and live at home. She also ensures that there are enough staff with the necessary skills on duty to meet the needs of the residents. Planning care and identifying risks for people living in the home has improved but there is still some way to go to ensure that the care is delivered effectively and efficiently in a way that suits and benefits each individual resident. The staff have received more training to ensure they are developing the knowledge and skills to meet the needs of the residents and keep them as safe as possible. Training needs to continue. The homes environment continues to improve to provide a comfortable, safe homely place for people to live in. Tranquility House DS0000036015.V353198.R01.S.doc Version 5.2 Page 7 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 Tranquility House DS0000036015.V353198.R01.S.doc Version 5.2 Page 8 contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Tranquility House DS0000036015.V353198.R01.S.doc Version 5.2 Page 9 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 Tranquility House DS0000036015.V353198.R01.S.doc Version 5.2 Page 10 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): 1,2 and 3. Standard 6 does not apply. People who use the service experience poor outcomes in this area Prospective service users receive sufficient information to enable them to make an informed choice about living at the home. They cannot be sure that a full assessment of their needs will be undertaken prior to arriving at the home. Residents do not know what they will get for the fees that they pay and they don’t know if their places at the home are protected. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The service has a statement of purpose, which sets out the aims and objectives of the home and includes a service users guide, which provides information about the home and the care that is on offer. The guide is Tranquility House DS0000036015.V353198.R01.S.doc Version 5.2 Page 11 available in a standard format. Both the statement of purpose and the service users guide need to be up-dated to reflect the present situation in the home. At the time of the visit there was no evidence to show that people had received an initial assessment of their care needsprior to coming to live at the home. The files of two most recent admissions to home were looked at. The owner /manager told us that she does go visit people either in hospital or at their homes to make sure the service will be able to look after them appropriately, however she does not document this. There were no care management assessments available but some care management care plans were seen. The manager needs to make sure that thorough assessments are in place prior to people coming to live at the home. This will ensure that all aspects of care and support for individuals have been looked at and considered. This will allow the service to make the decision as to whether or not they can offer the care needed. The manager needs to make sure that the assessment is used as starting point for developing an individual plan of care. The manager told us that since the random inspection in September’07 all the residents at the home have been re-assessed by the home and the local care management team. The outcome of these re-assessments was that the home could meet the needs of the residents living there. At the time of the visit there was no evidence to show that residents are provided with a statement of terms and conditions /contract with the home. Each residents needs to have contract in place, which is signed by them or a representative and the manager. This will ensure that people places are protected and they know what they will receive for the fee they pay. Tranquility House DS0000036015.V353198.R01.S.doc Version 5.2 Page 12 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): 7,8,9 and 10. People who use the service experience adequate outcomes in this area Residents cannot be sure that all their needs will be identified and met and that all risks are minimised. Action needs to be taken to ensure that the homes medication policies and procedures fully protect the safety of residents. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Five care plans was looked at during the visit and shortfalls were identified in different areas of the care planning system. Some of the plans are of a reasonable standard and contained the information and guidance for staff to meet the needs of the residents. The plans seen gave good guidance on how to deliver personal care to the residents. However others were not up-dated to Tranquility House DS0000036015.V353198.R01.S.doc Version 5.2 Page 13 reflect the changing needs of the people living at the home. For example some people have diabetes and this was recognised in their care plans. However there was no individual information on what staff should if the persons blood sugar became too high or too low. When asked staff knew did know what action they had to take, but this does need to be documented. A specialist nurse had visited another resident but there was nothing documented about the outcome of the visit and the care plan had not been updated to reflect the changes in the care and support needed. Daily records are kept but they do not give a clear picture about how residents spent their time and do not relate to the individual care plans. There are some risk assessments in place but these need to be further developed more individualised to ensure that all risks have been identified and kept to a minimum. The home does need to develop a more person centred approach to care. Key working needs to be developed and promoted. At present care needs are met in a task orientated way. Plans focussed on what residents could not do instead of promoting independence and self-esteem. The manager does make sure that all the health care needs of the residents are met. Each resident is registered with a local G.P. and any area of concern related to health is referred to the G.P. Since the adult protection alert there has been a significant increase in contact with the local community teams. The home now has daily contact with the district nursing team and good relationships are developing. Visiting professionals said that the home is improving and they are contacted promptly if they are any concerns or if staff need any advise about the residents. Specialist intervention is presently being further enhanced by the introduction of a community team who work specifically with residential homes in the area. They will work pro-actively along side the staff and residents to improve support and care given to the people who live at the home. The residents have regular appointments with opticians, a chiropodist and dentists. A medication round was observed during the visit. Medication was stored and dispensed safely to residents and all medication administered was signed for. To make sure that medication is administered as safely as possible all staff who administer medication need to have received have received appropriate training. It was evidenced that some staff administering medication have only had in-house training. Staff must have recognised medication training before they give medication to residents. The manager was going to take immediate steps to address this. Formal medication has been booked for 21st January ’08. The home also needs to keep a list of signatures for staff who are trained to dispense the medication and there also need to be system in place to check staff competencies on a regular basis. Tranquility House DS0000036015.V353198.R01.S.doc Version 5.2 Page 14 It was seen that some medications had been hand written on the dispensing sheets. They had not been signed or dated. It needs to be ensured that all hand written entries are dated and signed by 2 people. Through observation and from talking to the residents and staff there was evidence to show that privacy and dignity is up-held. Residents are well dressed in clothing appropriate for the season and appeared well kept. Staff were observed assisting the residents in a caring and supportive manner and were seen treating them with respect and understanding. Some members of staff were observed demonstrating good body language and communication skills when interacting with the residents. Members of staff spoken to confirmed an understanding and commitment to caring for older people. Tranquility House DS0000036015.V353198.R01.S.doc Version 5.2 Page 15 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): 12,13,14 and 15. People who use the service experience good outcomes in this area The home does provide the residents with some opportunities and facilities that enable them to maintain an appropriate and fulfilling lifestyle in and outside the home. Family links are encouraged and maintained wherever possible. The home provides nutritious and varied meals for the residents. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home does provide activities for residents. These include various board games, bingo, dominoes and skittles. The home also arranges for musical entertainers to visit the home. There is music and movement, aromatherapy and a hand massager, which is included in the homes fees. In the better weather staff take residents out on a regular basis. The manager said that she wants to be able to take more people out more often. The staff need to make sure that they document what activities the residents do on daily basis and whether they were enjoyed or not. At the moment records relating to activities and how residents spend their time are sparse. Tranquility House DS0000036015.V353198.R01.S.doc Version 5.2 Page 16 One person said ‘ I would like to go out more, but it depends on how many staff are around’. Relatives are made to feel welcome at the home at all reasonable times and no restrictions are imposed. Residents are able to receive their visitors in the privacy of their own rooms or in the communal areas. The people at the home felt that they are able to have some choice in regards to their day-to-day lives. Examples given were that they could get up and go to bed when they liked. They could choose what to eat and where to eat their meals, if they wanted a bath. Generally they felt happy with the choices they are offered. One person had requested to move to a different home for personal reasons. This request had been actioned and the move was imminent. The home employs 3 cooks to work throughout the week. The menu is planned over a 4 week period. The home provides a varied menu ensuring the residents receive a nutritious and balanced diet. Soft foods are served in separate portions. The staff keep a record of meals and who has chosen what. If any dietary concerns have been highlighted about any individual then in detailed intake records are maintained and G.P’s consulted. A lunchtime meal was observed, this was relaxed and unhurried with residents able to take their time to enjoy the food. Staff were observed assisting residents to eat in a respectful way. Residents said that the food was very good and there was always plenty. They said they could have drinks or snacks whenever they wanted. Special diets are catered for. It was noted that fridge temperatures are not been taken daily. The manager need to make sure that this is done to ensure that food is stored at the correct temperature and ensure the safety of the residents. Tranquility House DS0000036015.V353198.R01.S.doc Version 5.2 Page 17 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 People who use the service experience good outcomes in this area Residents and their relatives can be confident that their concerns and complaints will be listened to and acted on. There are systems in place, which protect residents from abuse. This judgement has been made using available evidence including a visit to this service. Residents and their relatives can be confident that their concerns and complaints will be listened to and acted on. There are systems in place, which protect residents from abuse. EVIDENCE: The home has a complaints procedure, which meets the national minimum standards. At the time of the visit there was no complaints procedure on display in the home. The complaints procedure needs to be prominently displayed so that residents and staff are aware of how to make a complaint. When asked residents and staff where aware of what to do if they wished to make a complaint .The owner/manager told us that complaints are taken seriously and acted on. Tranquility House DS0000036015.V353198.R01.S.doc Version 5.2 Page 18 The owner raised a safe guarding adults at the home in September 2007. Meetings have taken place with the service and the involved agencies. The service has been active in dealing with the alert and has made changes to ensure the safety and well being of all the residents. Improvement plans and action plans have been developed and at the time of the visit are being implemented and actioned. The home has improved its practises. The majority of staff have received up-to date training in safe guarding adults and were able to explain how they would protect the people living at the home. Professionals involved in the alert said that he home is slowly improving and moving in the right direction. It is hoped that with the extra support and input they are now receiving from community services the improvements will speed up. The safeguarding adults alert remains open on the home. The home will continue to receive regular checks from the adult protection team to monitor their progress. Tranquility House DS0000036015.V353198.R01.S.doc Version 5.2 Page 19 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 and 26. People who use the service experience good outcomes in this area The service continues to improve and maintain the environment to provide people with a comfortable homely and safe place to live. On the whole the residents benefit from a clean and pleasant environment This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home is spread over four floors with a security door keypad on each floor for safety. Access to all floors for residents is via a lift. The owner said that since they bought the property five years ago they have improved the environment considerably. A partial tour of the building was undertaken. Tranquility House DS0000036015.V353198.R01.S.doc Version 5.2 Page 20 The property is well maintained with comfortable furniture. Bedrooms are personalised and reflect the interests and lifestyles of individuals. There are two lounges, a dining room and a large conservatory leading to a secure garden area. The service does need to show that they have a planned maintenance and renewal programme for the ongoing up- keep and improvements within the home. The owner /manager is aware of the work that needs to be done. At the time of the visit the home smelt fresh and clean. There are the facilities available in all the appropriate areas for hand washing and the home has the appropriate facilities for the disposal of clinical waste. The home has a laundry room and soiled laundry is transported correctly in red bags and washed at the appropriate temperatures. Tranquility House DS0000036015.V353198.R01.S.doc Version 5.2 Page 21 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): 27,28,29 and 30. People who use the service experience adequate outcomes in this area This judgement has been made using available evidence including a visit to this service. The staff have a good understanding of the residents and positive relationships have been formed. Staff training needs to be further developed to ensure that all he needs of the residents are met. Recruitment policies and procedures need to be adhered to ensure the service users are fully protected. EVIDENCE: The manager informed the CSCI that staffing levels are reviewed regularly and reflect the dependency levels of residents. There is usually 5 staff on duty in the morning, 4 in the afternoon and 2 at night. This was reflected in the duty rota. Residents said that there are always staff around when you need them. During the visit staff were available to attend to residents promptly. No- one was seen to be kept waiting. Call bells were responded to quickly. Staff said the amount of training available has increased over the past few months and they were able to demonstrate their knowledge on different aspects of care. The mangement do need to develop ways to check staff Tranquility House DS0000036015.V353198.R01.S.doc Version 5.2 Page 22 competencies after they have received training. The service employs 17 members of staff. 5 staff have achieved NVQ level 2 or above and 5 more have started the course. At the time of the visit the home had not yet reached the recommended 50 of staff trained to NVQ level 2 or above. There are gaps in mandatory training. The manager is aware of this shortfall and has organised a lot of training for the new year. If all goes to plan everyone will be up to date by the end of March ’08. . The staff also need to receive more specialist training to ensure that they have the skills knowledge and capabilities to care effectively, positively and safely for the residents at the home. Some specialist training is also planned for the new year. The manager does need to develop a training matrix so gaps can be identified quickly. The training needs to be on-going and planned well in advance. There was evidence to show that all new members of staff receive an induction into the home and have an induction training programe inplace. Staff said, ‘the training I receive is very relevant to my work. All staff receive opportunities and training’. The staff reported that they feel valued by the management. They said that they are listened to and any ideas or concerns are acted on. The manager informed us that staff files have recently been audited and reorganised. The home now has a system in place to check that the files contain all the necessary information. Five staff files were looked at. 3 of the files contained most of the required information on the staff to ensure the safety of the residents. However the files of two new staff who had only just started at the home lacked the rnecessary 2 references and safety checks . The manager said that she had difficulty obtaining these as the staff are from overseas. She stated the new staff were working with one to one supervision and would not be allowed to work alone until all checks had been obtained. The manager does need to make sure that all information is obtained before staff start work at the home. All applications must contain a full employment history and any gaps explored at interview. Evidence of this needs to be kept on file. All files must also contain an up- to-date photograph of the member of staff. Tranquility House DS0000036015.V353198.R01.S.doc Version 5.2 Page 23 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): 31,33,34, 35 and 38 People who use the service experience adequate outcomes in this area Residents live in a home that is well managed. Developing a quality assurance quality systems will help service users to air their views and will help the home to measure its success in meeting their aims and objectives. Residents can be assured that their monies will be kept safe. The home protects the safety of residents and staff. This judgement has been made using available evidence including a visit to this service. Tranquility House DS0000036015.V353198.R01.S.doc Version 5.2 Page 24 EVIDENCE: The owner of the service has now applied to become the registered manager of the home and is waiting for her application to be processed with the CSCI. Since actively taking over the role of manager and following the shortfalls highlighted following the safe guarding adults Mrs. Wratten has worked hard to improve the service and met the National Minimum Standards. She is aware of the amount of work that needs to be done. Other people involved with the service who visit regularly have noted improvements and feel that the home is now slowly moving in the right direction. With the help and support the home is receiving from professionals progress should now be quicker. The service needs to develop and implement a quality assurance programme and quality assurance systems need to be developed. Regular audits need to take place. Questionnaires need to be circulated to residents, relatives and other stakeholders so their opinions and views about the service are sought and considered. All the information needs to be collated and the strengths and weaknesses of the home identified. From this information the home needs to improve the service it provides to the residents. This will ensure that the aims and objectives written in the statement of purpose are being met. Financial procedures have been reviewed to safeguard resident’s monies and robust procedures are in place to make sure that the resident’s monies are as safe as possible. The home provides a safe environment for people to live in and staff to work in. Good working practices ensure the home is free of hazards. The service has an induction programme and staff are presently being updated with mandatory training. Gaps have been identified in training and it needs to be ensured that training is on going and up-dated as required. Policies are in place to strengthen safe practices. The home has informed us that all the relevant checks and inspection of equipment and system have been undertaken. An accident book is maintained. All fire checks are done. Water temperatures are taken and comply with regulations. Tranquility House DS0000036015.V353198.R01.S.doc Version 5.2 Page 25 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for 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 1 1 X X X HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 3 3 3 X X X X X 3 STAFFING Standard No Score 27 3 28 2 29 2 30 1 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 3 1 X 3 X X 3 Tranquility House DS0000036015.V353198.R01.S.doc Version 5.2 Page 26 Are there any outstanding requirements from the last inspection? YES 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 OP2 Regulation 5(b)(c) Requirement Timescale for action 31/03/08 2 OP3 15 3. OP7 15 Each resident needs to be provided with a terms and conditions of residency/contract when they move into the home All residents need to have a full 31/03/08 and thorough assessment undertaken prior to them coming to live at the home. This will then form the basis of a care plan. (Outstanding requirement from previous random inspection. Timescale 17/11/07 not met) The manager develops and 30/04/08 agrees with all residents user/representative an individual support/care plan, which includes all the health, social and personal care required, describing the services and facilities to be provided by the home, and how these services will meet current and changing needs and aspirations. The plan needs to be implemented and updated to reflect the changing needs of the residents. Daily records need to contain Tranquility House DS0000036015.V353198.R01.S.doc Version 5.2 Page 27 4. OP9 13(2) relevant information about the day of the residents and written in a format that is easy to follow. All staff need to receive appropriate training before administering medication. Competencies need to be checked regularly. A list of staff signatures who administer medication needs to be maintained. All hand written entries need to dated and signed by 2 people. 31/01/08 5. OP29 19(4) (c) All staff employed by the home need to have 2 references and safety checks in place before they start working at the home All full employment history needs to be obtained and any gaps explored. 31/01/08 6 OP30 18(1)(a) (c) 7. OP33 24(1)(a) (b),(2)(3) Staff files need to contain an upto date photograph Training needs to be up to date 31/03/08 and on going for all staff members. The home needs to provide specialist training for the staff to ensure that staff are suitably, qualified competent and experienced to meet the needs of the residents and undertake their role effectively and safely Effective quality assurance and 30/06/08 quality monitoring systems, based on seeking the views of service users, are in place to measure success in meeting the aims, objectives and the statement of purpose of the home. Tranquility House DS0000036015.V353198.R01.S.doc Version 5.2 Page 28 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 2 3 4 Refer to Standard OP1 OP16 OP22 OP31 Good Practice Recommendations The statement of purpose and service users guide needs to be up-dated to reflect the present situation at the home. The service needs to make sure that people have easy access to the complaints procedure and a copy is prominently display in the home. 50 of staff need to achieve NVQ level2 or above. The manager of the home needs to register with the CSCI. Tranquility House DS0000036015.V353198.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection Maidstone Local Office The Oast Hermitage Court Hermitage Lane Maidstone ME16 9NT 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 Tranquility House DS0000036015.V353198.R01.S.doc Version 5.2 Page 30 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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