CARE HOME ADULTS 18-65
Tweezle Twigg 3 Campden Road South Croydon Surrey CR2 7EQ Lead Inspector
Claire Taylor Unannounced Inspection 22 December 2005 12:15p Tweezle Twigg DS0000025863.V273780.R01.S.doc Version 5.0 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 Tweezle Twigg DS0000025863.V273780.R01.S.doc Version 5.0 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Tweezle Twigg DS0000025863.V273780.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION
Name of service Tweezle Twigg Address 3 Campden Road South Croydon Surrey CR2 7EQ 020 8680 1219 020 8667 1232 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) Tamarind Care Limited Miss Jocelyn Gillam Care Home 10 Category(ies) of Learning disability (10) registration, with number of places Tweezle Twigg DS0000025863.V273780.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION
Conditions of registration: 1. A variation has been granted to allow three specified service users over the age of 65 to be accommodated on condition that any of them will have to be moved to alternative accommodation if they become too physically or mentally frail and/or require nursing care. 11th July 2005 Date of last inspection Brief Description of the Service: Tweezle Twigg is a large family house situated in South Croydon, not far from a bus route and about ten minutes walk from South Croydon rail station. There is parking space to the front of the house (enough to accommodate the homes minibus) while visitors can park in the street directly outside. The house provides accommodation for up to ten adults with learning disabilities. All bedrooms are single occupancy, and are spread over three floors (including the ground). A passenger lift serves all floors. Toilet facilities are available on all floors, with bathing facilities on the ground and first floors. There is a pleasant lounge, a separate dining room, and a well laid out kitchen. There is a large well-maintained garden to the rear of the home. Three of the current eight occupants are aged over 65 (and a variation has been granted), while the remainder are in their 50s. The General Manager described how they would hope to provide service users with a home for life - as existing residents moved into the older person category then further variations would be sought, while any new residents would not be under the age of 40. Tweezle Twigg DS0000025863.V273780.R01.S.doc Version 5.0 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This was the home’s second inspection for the year, was unannounced, took place over an afternoon and lasted four hours. This inspection focused upon the requirements and recommendations made, and those key standards which were not assessed, by the last inspection. The reader is therefore referred to the July 2005 report should they require any further information. On this occasion, seven service users were in the home and there were three vacancies. One service user has moved on since the last inspection and there have been no new admissions to the home. Time was spent meeting with the service users, talking to two senior staff and the manager, Jocelyn Gillam who came to the home and facilitated most of the inspection. Various records were checked and a brief walk round the premises took place. All those who contributed to the inspection process are thanked for their time. What the service does well: What has improved since the last inspection?
The manager and staff have shown commitment and dedication to improve standards in the home and this is reflected by the significant reduction in the number of requirements and recommendations over the last twelve months. Fourteen of the previous eighteen requirements have been addressed. This includes two that were outstanding from 2003. I.e. Training for staff on disability and anti racism issues has been achieved and the garden path has been extended to enable wheelchair users better access. Staff have now completed training on the protection of vulnerable adults meaning that they have a better understanding of adult protection issues and what action must be taken to keep service users safe. The manager has achieved the required NVQ level 4 management qualification and is working towards the Registered Manager’s Award. The health, safety and welfare of people living and working
Tweezle Twigg DS0000025863.V273780.R01.S.doc Version 5.0 Page 6 in the home are better safeguarded. Staff have completed or updated their training in moving and handling, fire safety and infection control as previously required and the local fire authority has carried out a fire safety inspection on the premises. Record keeping has improved in some areas. I.e. Notifiable events such as service users accidents or incidents are now being reported to the Commission. Further improvements to the environment have taken place including the replacement of dining tables and chairs and the redecoration of the dining room. A new tumble drier has been purchased which has improved the home’s capacity to cope with the large amounts of laundry generated. Broken furniture items have been removed from the rear garden and the scaffolding taken down following the replacement of various window frames. A quality assurance plan has been put in place to demonstrate how the home appraises its care practices through the views of service users, relatives and other relevant parties. Annual job appraisals for staff have been completed meaning that individual work performance is better monitored and career development needs can be addressed. What they could do better:
Service users still lack opportunity to participate in social activities in the wider community although it is acknowledged that the home was in the process of recruiting another driver. A number of care plans detailed that some individuals enjoy outings and they should therefore be provided with the resources to achieve these identified goals/needs. The carpet in bedroom 8 must be replaced with a more suitable flooring that meets the service user’s needs. While safety practices within the home are generally of a good standard, the premises must be properly risk assessed for hazards to further safeguard the well being of the people who live and work in the home. The placing authority (Croydon) had not undertaken a review of one service user’s needs and this must be addressed. Although it is acknowledged that the manager has made efforts to arrange a meeting in conjunction with the placing authority, the home has a responsibility to ensure that a review of service users needs is undertaken at least six monthly. When a new service user is admitted, the home must also ensure that an appropriate review meeting is held following the person’s trial stay period. This is essential in order to evaluate whether individual needs can continue to be met. Written contracts still need to be provided to each service user to ensure that individuals are aware of their rights and responsibilities to live in the home and likewise, the home’s duty of care. To further ensure that service users’ rights and best interests are safeguarded, the proprietors must ensure that unannounced visits are carried out monthly and a report is made of each visit. Regulation 26 of the Care Standards Act requires this and copies of these monthly reports must be sent to the Commission. Two good practice areas for the home to consider are repeated from the last inspection. I.e. Service users care plans could be developed further for those who have limited communication. Pictures and photos should be included to make them more accessible and meaningful to individuals. Secondly, training that is specific to the needs of the service users has yet to be arranged for staff. I.e. on communication methods for people with profound learning disabilities.
Tweezle Twigg DS0000025863.V273780.R01.S.doc Version 5.0 Page 7 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. Tweezle Twigg DS0000025863.V273780.R01.S.doc Version 5.0 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS
Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Tweezle Twigg DS0000025863.V273780.R01.S.doc Version 5.0 Page 9 Choice of Home
The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 2 and 5 Detailed assessments are completed to ensure that the home can meet the needs of prospective service users. Written contracts still need to be provided to each service user to ensure that service users are aware of their rights and responsibilities to live in the home and likewise, the home’s duty of care (its terms and conditions). EVIDENCE: The same group of service users have lived at Tweezle Twigg for a number of years. The home ‘s needs assessment plan is detailed and covers all areas to ensure that any new service user’s needs would be fully assessed prior to their admission. This covers all aspects of the person’s life, including strengths, social and cultural needs and psychological needs. Copies of these assessments were on file for the four files sampled as well as detailed needs assessments completed by their placing authorities. I.e. undertaken by their care managers. The last admission of a ‘new’ service user to the home was approximately one year ago. A review meeting had still not been held for the service user following their admission and this must be addressed. This has been discussed further under “individual needs and choices”. A blank copy of the home’s contract was seen and clearly outlines the terms and conditions of occupancy. Each service user needs to be provided with a completed copy however and the requirement is therefore repeated. Tweezle Twigg DS0000025863.V273780.R01.S.doc Version 5.0 Page 10 Tweezle Twigg DS0000025863.V273780.R01.S.doc Version 5.0 Page 11 Individual Needs and Choices
The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 and 9 Care plans for service users are generally well maintained although reviews need to be carried out more frequently to evaluate whether the home is meeting a person’s assessed needs. Service users are provided with the necessary support to take risks so that independence is maximised as far as possible. EVIDENCE: Files sampled contained comprehensive documentation relating to each service user. Informative action plans outline what service users can do independently and when they require support from staff. Daily records of care directly relate to the assessed needs and goal plans identified in the service user plan. One good practice area for the home to consider is repeated from the last inspection. I.e. Service users care plans could be developed further to enable some people who have differing methods of communication to be more involved in the development and review of the plans. Pictures and photos should be included to make them more accessible and meaningful to individuals. Overall, plans were being reviewed on a six monthly basis and involved relatives and other professionals such as care managers. Documentation regarding the service users’ needs was generally up to date and well maintained although one service user is now due a review meeting to
Tweezle Twigg DS0000025863.V273780.R01.S.doc Version 5.0 Page 12 ensure that any changing needs are identified and addressed. The last documented meeting was held in October 2004 when the service user was first admitted. There were no records to demonstrate that the placing authority (Croydon) had undertaken a review following the trial stay period. This is important as it provides the service user and relative if appropriate, with assurance that the home can continue to meet their needs. It is acknowledged that the manager has made efforts to arrange a review meeting in conjunction with the placing authority. The home has a responsibility however to ensure that a review of service users needs is undertaken at least six monthly. Whilst the ability of most of the service users to make informed choices is limited, staff nevertheless try to consult them on everyday decisions that affect them. Care plans and records reflected this. Relevant risk assessments, matched to individual needs are in place for all the service users. A risk assessment tells the staff how to make sure that each of the service users is kept safe from anything that might harm them. Examples seen included personal hygiene, eating, mobility and accessing the local community. The previous requirement concerning the locking of the front had been addressed. The manager had completed a risk assessment and implemented a locked door policy. Tweezle Twigg DS0000025863.V273780.R01.S.doc Version 5.0 Page 13 Lifestyle
The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 13, 15 and 16 Generally, the service users are supported in making choices and undertaking activities that they enjoy. The home is still failing to provide service users with opportunities to access the local community however. Appropriate contact between service users and their families and friends is encouraged to help them maintain relationships. Standards 12 and 17 were assessed as met at the July 2005 inspection. EVIDENCE: The majority of service users at Tweezle Twigg have highly dependent needs including physical disabilities and limited communication abilities. Staff therefore tend to organise activities based upon what service users are known to enjoy and benefit from. Care plans contained detailed information about each service user’s preferred activities and their likes and dislikes. Activity charts are completed daily and records showed that service users participate in art and craft activities and are provided with music, television, videos and beauty treatments. Recent events have included a Christmas party for the service users and their respective families and friends. An aromatherapist visits the home on a regular basis. Four of the current service users attend two local day centres for two to three days a week. The last inspection report
Tweezle Twigg DS0000025863.V273780.R01.S.doc Version 5.0 Page 14 highlighted that access to the local community is somewhat limited as the home did not have enough drivers to meet the transport needs of the service users. The manager reported that the home has recently recruited another driver subject to clearance of probationary checks. As opportunities to take service users out on community outings remains limited, the former requirement still stands. A number of care plans detailed that some individuals enjoy outings and they should therefore be provided with the resources to achieve these identified goals/needs. Records showed that family, friends and guests are welcome at the home and that the manager maintains very good communication links with the service users’ respective families. None of the people who live at Tweezle Twigg had visitors on the day of inspection but one service user spoken to stated that they saw their family member regularly. Staff were observed talking to the service users in a respectful and appropriate manner. Tweezle Twigg DS0000025863.V273780.R01.S.doc Version 5.0 Page 15 Personal and Healthcare Support
The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19 and 20 Suitable arrangements are in place to ensure that service users’ health care needs are identified, planned for and met. The home’s systems regarding medication are well organised to ensure the safety and consistent treatment and support for each service user. Standard 18 was assessed as met at the July 2005 inspection. EVIDENCE: Information relating to personal and healthcare needs including both routine and one off health interventions were well recorded. Care plans and specific strategies identify individual and specialist needs, which also reflect any changing needs. Detailed records were in place and involvement with specialist services highlighted where necessary. E.g. regular medication reviews and physiotherapy services for some individuals. Service users are supported to attend regular health checks, outpatient appointments and other medical appointments as required. The continence advisor has links with the home and access to other NHS facilities is available. Care plans include details of GP involvement as well as Consultant, dental, chiropodist, optician and district nurses. There are hoists and handrails in place to assist with meeting the needs of service users who have physical disabilities. Records confirmed that the staff team have received training on moving and handling techniques. Tweezle Twigg DS0000025863.V273780.R01.S.doc Version 5.0 Page 16 Medication is stored appropriately within a locked cabinet and adequate staff have undertaken training to administer medication. The registered manager and three senior staff are also trained to administer insulin for one service user. Records for the receipt and safe disposal of medication and administration records were up to date and accounted for. As previously recommended, guidelines for one service user’s “as required” medication have been revised to provide clearer instructions on their use. Tweezle Twigg DS0000025863.V273780.R01.S.doc Version 5.0 Page 17 Concerns, Complaints and Protection
The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23 Improvements for dealing with complaints have been made so that service users and their relatives can be confident that their views will be listened to and acted upon. Staff have now completed training on adult protection issues meaning that they have a better understanding of preventing abuse and service users are more fully protected. EVIDENCE: There are robust policies and procedures in place regarding complaints and the protection of vulnerable adults. Previous requirements relating to these two standards have been addressed. I.e. records showed that the manager had written to all the service users relatives and representatives and provided them with a copy of the home’s complaints procedure. The home also now has a logbook which serves as a better means for recording concerns and defining how the home takes action to address them. Since the last inspection, all care staff have received training in Adult Protection/ Abuse Awareness. This means that people who work in the home have developed a better understanding of adult protection issues and what action must be taken to keep service users safe. Tweezle Twigg DS0000025863.V273780.R01.S.doc Version 5.0 Page 18 Environment
The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 26 and 30 Improvements have been made to the premises and environment since the last inspection meaning that service users are provided with a more homely, safe and pleasing environment in which to live. Bedrooms are overall designed and furnished to meet service users needs and reflect their personal preferences and interests. One service user’s bedroom carpet is in need of replacement however. EVIDENCE: The home has worked hard to address previous requirements concerning the premises and good progress has been made with regards to scheduled refurbishment plans. I.e. The garden path has been extended to enable wheelchair users better access. Dining tables and chairs have been replaced and the dining room redecorated. As previously required, broken furniture items and two old mattresses had been removed although some other items for disposal were being stored in the rear garden. The manager explained that this was in hand as the scaffolding had only recently been taken down following the replacement of various window frames. A larger tumble drier has been purchased which has improved the home’s capacity to cope with the large amounts of laundry generated. As required at the last inspection, a fire safety inspection has been carried out by the London fire and emergency planning authority (September 2005).
Tweezle Twigg DS0000025863.V273780.R01.S.doc Version 5.0 Page 19 Records showed that the manager had addressed some of the requirements set including regular testing of emergency lighting and the completion of a fire risk assessment for the premises. Fire action notices were also displayed throughout the building as required. The manager advised that the home was awaiting a follow up visit from the fire authority to confirm that the premises have fully complied with the required actions. Four of the bedrooms were viewed with the permission of the service users concerned. They appeared comfortably furnished and service users have the equipment and aids required for staff to meet their needs e.g. hoists, rails and adapted chairs for those who have physical disabilities. Decorated to a high standard, rooms have been personalised to reflect service users individuality and personal choice. One outstanding requirement is that the carpet in bedroom 8 needs replacing due to an unpleasant odour. This must be addressed and a more suitable flooring provided that meets the needs of the service user. Aside from this, the home continues to maintain good hygiene practices and has systems in place to control the spread of infection. Tweezle Twigg DS0000025863.V273780.R01.S.doc Version 5.0 Page 20 Staffing
The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34, 35 and 36 Service users benefit from a competent and knowledgeable staff team who have a range of experiences, and an understanding of the needs of people with both learning and physical disabilities. Procedures for the recruitment of staff are robust and provide safeguards for people living in the home. Training and supervision for staff has improved resulting in a more skilled workforce to meet the service users needs and home’s aims and objectives. Standards 31 and 33 were assessed as met at the July 2005 inspection. EVIDENCE: Positively, the staff team remain unchanged and since the last inspection, one new staff has been appointed subject to the completion of satisfactory checks. The manager explained that she was awaiting the return of the CRB / POVA check before they can start. Various staff files were sampled including documentation for the prospective employee. Record keeping remains well organised and files contained all the required documentation to evidence staff fitness to work with this service user group as well as legislative checks. Service users appeared comfortable and well cared for, and staff members have clearly established positive and cooperative relationships with each individual. Observations showed that staff respect service users’ individuality as well as demonstrate an understanding of their specific needs. Staff training required at the last inspection has taken place. Certificates showed that training has been achieved in adult protection issues and disability and antiTweezle Twigg DS0000025863.V273780.R01.S.doc Version 5.0 Page 21 racism training. Further training is still recommended however, that is specific to the needs of the service users. I.e. for staff to develop a better understanding/ refresh their knowledge on communicating with people who have profound learning disabilities. Records confirmed that staff continue to have regular formal supervision and as previously required, the manager has completed yearly appraisals with the staff. These sessions are used to identify what the member of staff does well, what they need to improve upon and what training they may need. Tweezle Twigg DS0000025863.V273780.R01.S.doc Version 5.0 Page 22 Conduct and Management of the Home
The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39, 41 and 42 The home is well run with a clear and open style of a management. Record keeping is generally well managed to ensure that service users’ rights and best interests are safeguarded although monthly visits need to be undertaken by the registered provider. Overall, health and safety practices are well observed. To ensure unnecessary risks to the health and safety of the service users and staff are identified, and so far as reasonably possible eliminated, risk assessments of the premises needs to be undertaken. EVIDENCE: The manager has gained vast experience in working with people who have learning disabilities and began employment as a support worker at Tweezle Twigg over eight years ago. She achieved promotion and has been in post as the registered manager for the last three years. Miss Gillam has attained the NVQ level 4 management qualification in September of this year and explained that she is currently undertaking the Registered Managers Award. Discussions and observation revealed that she is clearly familiar with the needs of the service users and continues to demonstrate good management practice. Staff
Tweezle Twigg DS0000025863.V273780.R01.S.doc Version 5.0 Page 23 in the home have a positive opinion of the manager and gave encouraging comments about her leadership and management style. Service users therefore benefit from a well run home. Records showed that good progress has been made with regards to health and safety training for staff. Through self-learning development packs, some staff have completed training in moving and handling, food hygiene and infection control. Plans are in place for other staff to complete such training. Accurate records are kept for accident and incident reporting. As required at the last inspection, the home now keeps the Commission appropriately informed of any accidents or incidents that affect the service users well being. One shortfall was identified in that the registered provider needs to undertake monthly visits as required by Regulation 26 of the Care Standards Act. Records showed that these visits are not being carried out at the required frequency and this must be addressed. Fire drills are organised at regular intervals and fire alarms and equipment had been checked in August 05. Other maintenance and servicing records were checked at the last inspection and all up to date. An outstanding requirement is that the manager must ensure that environmental hazards around the home have been risk assessed to safeguard the welfare of the service users and minimise the risk of injury. Tweezle Twigg DS0000025863.V273780.R01.S.doc Version 5.0 Page 24 SCORING OF OUTCOMES
This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from:
4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable
CHOICE OF HOME CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score X 3 X X 2 Standard No 22 23 Score 3 3 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 2 3 X 3 X Standard No 24 25 26 27 28 29 30
STAFFING Score 3 X 2 X X X 3 LIFESTYLES Standard No Score 11 X 12 X 13 2 14 X 15 3 16 3 17 Standard No 31 32 33 34 35 36 Score X 3 X 3 3 3 CONDUCT AND MANAGEMENT OF THE HOME X PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21
Tweezle Twigg Score X 3 3 X Standard No 37 38 39 40 41 42 43 Score 3 X 3 X 2 2 X DS0000025863.V273780.R01.S.doc Version 5.0 Page 25 Are there any outstanding requirements from the last inspection? Yes- 4 STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard YA5 Regulation 5(1b&c) Requirement Timescale for action 31/01/06 2. YA4 14(1)(d) (2)(a) 3. YA6 14(1)(d) (2)(a) 15 4. YA13 12(3) 16(2m) Each service user must be provided with a copy of the homes contract. (Timescale of 30.9.05 not met) The home must ensure that an 28/02/06 appropriate review meeting is held following the admission of a new service user. Minutes of the meeting need to be documented and provided for the service user and any other relevant parties. (Timescale of 30.9.05 not met) That an appropriate review 31/01/06 meeting is held for service user J.H. involving the appropriate care manager to ensure that any changing needs are assessed and actioned. The proprietor and those 31/03/06 responsible for the homes management must ensure that service users are enabled to participate in activities outside of the home. Allocation of staff (drivers) needs to be organised in better fashion to enable service users to participate in community outings. (Now outstanding from September
DS0000025863.V273780.R01.S.doc Version 5.0 Page 26 Tweezle Twigg 2004) 5. YA26 16(2 c,k) The flooring in bedroom 8 needs 28/02/06 to be replaced due to the unpleasant odour. (Timescale of 30.9.05 not met) The proprietors must ensure that 31/01/06 Regulation 26 visits are carried out monthly and a report made of each visit. This report must be made available to the manager and a copy sent to the Commission. The manager must ensure that 31/01/06 risk assessments concerning safe working practices are carried out, recorded and regularly reviewed. (Now outstanding from September 2004) 6. YA41 26 7. YA42 13(4) 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. Refer to Standard YA35 Good Practice Recommendations Further training should be organised that is specific to the needs of the service users. i.e. on communication methods for people with profound learning disabilities. (Repeated from July 2005 inspection) Some service users cannot use verbal communication and the home should therefore consider ways to improve its communication methods for these particular individuals. I.e. service user plans written in a format that they can understand. E.g. pictorial, audio or graphic. (Repeated from July 2005 inspection) 2. YA6 Tweezle Twigg DS0000025863.V273780.R01.S.doc Version 5.0 Page 27 Commission for Social Care Inspection Croydon, Sutton & Kingston Office 8th Floor Grosvenor House 125 High Street Croydon CR0 9XP National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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