Inspection on 05/11/07 for Tree Tops

This inspection was carried out on 5th November 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. These are things the inspector asked to be changed, but found they had not done. The inspector also made 14 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Tree Tops 23/01/09

Tree Tops 03/08/06

Tree Tops 22/12/05

Tree Tops 11/07/05

Tree Tops 24/01/05

Tree Tops 09/09/04

Similar services:

Ashlong House

Norbury Crescent (30)

Edenvale

Wadham Avenue

Chatsworth Care - Dawson House

Cowden Road, 52 - 54

Chatsworth Care - Tudor Lodge

Foxley Lane (121a)

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

CARE HOME ADULTS 18-65 Tweezle Twigg 3 Campden Road South Croydon Surrey CR2 7EQ Lead Inspector Barry Khabbazi Key Unannounced Inspection 5th November 2007 08:30 Tweezle Twigg DS0000025863.V353886.R01.S.doc Version 5.2 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Tweezle Twigg DS0000025863.V353886.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Tweezle Twigg DS0000025863.V353886.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Tweezle Twigg Address 3 Campden Road South Croydon Surrey CR2 7EQ 020 8680 1219 020 8667 1232 jocelyngillam@gmail.co.uk 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.V353886.R01.S.doc Version 5.2 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. 3rd August 2006 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 for which a variation has been granted. More detailed information about the services provided at Tweezle Twigg can be found in the home’s Statement of Purpose and Service User Guide - copies of these documents can be obtained directly from the home. Fees charged range from £700.00. Tweezle Twigg DS0000025863.V353886.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This home has recently changed ownership. The new owners have demonstrated a commitment to meeting all outstanding requirements, raising standards, and promoting good practice. In addition a new manager had just started on the day of this inspection. The new manager has expressed a commitment to address the numerous requirements inherited, although it should be noted that these requirements therefore do not necessarily reflect on the new manager’s performance. I am therefore confident that the new manager will address the shortfalls identified in this report, in a timely fashion, and with the full support of the new providers. To assist the home to prioritise the relatively high number of requirements, those that are more urgent have been highlighted as priority requirements. The key Standards identified throughout this report were all assessed at this inspection. Additional non key Standards were also examined where shortfalls were identified under those Standards. During this inspection, breakfast and staff interaction with the service users was observed. The new manager was interviewed. The manager from the organisations other home was also interviewed in her current supporting role to the new manager. Records, care plans and the building were examined, as were the residents’ bedrooms. The service users said they were happy at the home and liked their rooms and the food at the home. There was a calm and relaxed atmosphere in the home and the staff were seen to treat the service users with kindness and respect. Tweezle Twigg DS0000025863.V353886.R01.S.doc Version 5.2 Page 6 What the service does well: What has improved since the last inspection? The home has maintained staffing at previously agreed levels unless the Commission is notified and agrees. This ensures adequate staffing. Service users now have access to some documents in a format that is accessible to them, for example there is a new pictorial menu and a pictorial complaints procedure. The registered person has arranged for the home to be assessed by an Occupational Therapist for any aids or adaptations that would assist them. The home now has regular meetings for staff. This improves staff supervision and communication. All staff who assist with bathing now complete training from an accredited trainer before using the bath hoist with service users. Hot water temperature checks on all hand basins, baths and showers are now carried out on a regular basis with records maintained. Tweezle Twigg DS0000025863.V353886.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 contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Tweezle Twigg DS0000025863.V353886.R01.S.doc Version 5.2 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.V353886.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standard 2. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Prospective service users’ needs are assessed before they start at the home to ensure that all needs are known. EVIDENCE: There had been no new service users since the last inspection to enable this standard to be re-assessed. However, the newest service user’s file were examined at the 2006 inspection and these contained the care management assessment and care plan as required by this Standard. In addition the home has completed its own assessment of need. This Standard will therefore remain met until it can be re-assessed. Tweezle Twigg DS0000025863.V353886.R01.S.doc Version 5.2 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 6, 7, and 9. Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. Plans of care are not available for all the service users, are not accessible to them and changing needs are not all regularly updated. This is needed to help staff know all a service users needs and how they are to be met. Service users are supported to make decisions about their lives. Risk assessments are not available for all restraints and do not contain all the information required. Including this information could reduce unnecessary restrictions of liberty for the service users. Tweezle Twigg DS0000025863.V353886.R01.S.doc Version 5.2 Page 11 EVIDENCE: The last inspection report contained the following requirement: Care plans must be in a format that is accessible to the individual residents and include the resident’s preferences for how care is carried out. The home was able to demonstrate that this process had started but had not concluded yet. The requirement will remain until fully met. Care plans were not available for all service users. Even if they were in the building somewhere, the fact that management could not find one means that its purpose of identifying needs and how they are to be met, could not be achieved. In addition records of reviews indicated that only annual reviews were occurring where six monthly reviews are required. The following two new requirements are set to address this shortfall: 1, Care plans must be available for all service users and contain all the elements required under Standard 6. 2, Care plans must be reviewed on a 6 monthly basis {monthly for those over 65} and be updated with any changes identified. The service users are offered the opportunity to participate in the day to day running of the home and to contribute to the development and review of policies and services through increasingly accessible documentation including pictorial versions{see Standard 40}, regular house meetings and individual discussions with their key workers, and involvement in the annual development plan for the home {see Standard 39}. General risk assessments are available but some service user specific individual risk assessments were not. For example risk assessments for the use of cot sides were not available. This comes under the risk assessment needed for a pre-planned restraint. These must also specifically address any other options explored and demonstrate that as other options were not suitable, the risk assessed restraint is therefore the last resort in protecting the resident. The following requirement is now set to address this shortfall: For any pre-planned restrictions of liberty or pre-planned restraints {and specifically cot sides}, risk assessments must be produced. These must also contain all the information required under Standard 9.4, and in particular, details of how training and other options have been explored. Tweezle Twigg DS0000025863.V353886.R01.S.doc Version 5.2 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards; 12 13, 15, 16, and 17. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents do not always have the opportunity to be part of the local community and be able to take part in appropriate activities. Improving this area promotes inclusion and quality of life. Residents are supported in maintaining appropriate relationships, so that their social lives are maximised within chosen boundaries. Residents’ rights are respected and responsibilities recognised. The food provided is sufficient in quantity, and it is sufficiently nutritious, which is important to ensure good health. Tweezle Twigg DS0000025863.V353886.R01.S.doc Version 5.2 Page 13 EVIDENCE: The last inspection report contained the following two requirements: 1, The home must provide a wider range of social and leisure activities that meet the needs and preferences of the service users. 2, The proprietor and those 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. Although some improvement was recognised, a resident was asked if the number of activities and outings had increased and she said, not really. In addition the new manager said more outings were still needed at the weekends and that a recruitment round was now occurring to obtain more staff who can drive. Both requirements are therefore not fully met and remain in force. The home supports the service users to maintain links with their families and friends through a flexible visiting policy, and by ensuring relatives are always invited to reviews and social events where appropriate. Visitors can be seen in communal areas or the service users’ rooms. Service users have the opportunity to make friends who do not necessarily have their disability, through community use. Staff have information and health training to support service users in making appropriate and informed decisions where they wish to develop close relationships, and they would ensure that this was mutually welcomed. Evidence was provided to confirm that where this is not welcomed or appropriate, staff do take appropriate action to protect the service user. The daily routines and house rules do generally promote independence and choice. Meals, for example, can be taken where and when service users want, and they go to bed and get up when they want. This is done within the context of enabling service users to attend appointments and other commitments. Staff were observed to talk to the service users in a respectful manner. The menu is varied and includes alternatives if service users want something different. Additional snacks and drinks are available at any time. The menu at the home has been to be put into a pictorial format suitable for the people living at the home. The menu was examined and found to be reasonably nutritiously balanced. Tweezle Twigg DS0000025863.V353886.R01.S.doc Version 5.2 Page 14 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 18, 19, and 20. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Personal care is usually carried out in a way that residents prefer so that dignity and choice are maintained. Residents’ physical health needs are met by this home. This ensures that the residents’ physical health is well maintained and therefore the quality of life experienced is also maximised. Residents’ medication is well managed but not all staff have had approved and accredited medication administration training to promote safer medication administration. EVIDENCE: Personal care is usually carried out in a way that residents prefer although a requirement under the care planning Standard 6 remains unmet and therefore also has a slightly negative effect on this Standard. That requirement includes the need for care plans to record the service users preferences for how their care is carried out. Tweezle Twigg DS0000025863.V353886.R01.S.doc Version 5.2 Page 15 The registered person has arranged for the home to be assessed by an Occupational Therapist for any aids or adaptations that would assist them. Encouragement, guidance and support with personal care is provided to service users where required. Personal care is provided in private, and timings of this are also flexible, for example residents can have a bath when they are not booked in for this. The home has been promoting regular health checks. Service users are supported to attend outpatient appointments and other medical appointments as required. All service users have regular medical reviews, which are conducted in private in their own rooms. District nurses and other healthcare professionals attend when required. Evidence was seen of regular and accurate monitoring of service users’ health. The service users are registered with a local G.P and have regular check ups. A record of all appointments and check ups is kept. The service users’ health is discussed at the reviews. There are procedures and a lockable space in service users’ rooms to facilitate self-medication if appropriate. Medication and M.A.R. sheets are kept in a locked metal cabinet. The home has a policy for the administration of medication, most staff who administer medication have been trained and are required to check the possible side effects of any medication. A British National Formulary is available to facilitate this. The manager carries out their own spot checks to ensure the procedure is adhered to. There was no record of the service users’ consent to medication. The following recommendation is set to address this: Written consent to medication should be sought. Although most staff have had approved and accredited medication administration training, one staff member said that the only medication training they had been provided with was from the previous manager. This member of staff is not administering medication until the proper training has been acquired. The following new requirement is now set to address this shortfall: All staff who administer medication, must have approved and accredited medication administration training. Tweezle Twigg DS0000025863.V353886.R01.S.doc Version 5.2 Page 16 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 22 and 23. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents feel their views are listened to and acted upon. On the whole this home manages complaints well and there had been no complaints since the last inspection. The home’s policies and procedures relevant to this Standard generally facilitate protecting service users from abuse. EVIDENCE: There had been no official complaints from service users or relatives since the last inspection. The home has a complaints procedure that meets all the elements of this Standard including a minimum response time of less than 28 days, details of the Commission, and the complaints policy is now also available in more accessible pictorial format. All the protection related polices are in place. The home does have a copy of the placing authority’s adult protection procedures, a Restraint Policy including appropriate recording mechanisms. The home has a Whistle Blowing Policy, a Gifts Policy and the Wills Policy does preclude staff from being involved in the making of, or benefiting from residents’ wills. Tweezle Twigg DS0000025863.V353886.R01.S.doc Version 5.2 Page 17 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards, 24, and, 30. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The building, rooms and furniture generally meet the residents’ needs and provide a comfortable and safe environment which promotes independence. The home is generally hygienic and clean, homely and comfortable. This environment therefore facilitates the residents’ health and emotional wellbeing. EVIDENCE: Tweezle Twigg is situated in South Croydon. There is parking space to the front of the house and unrestricted parking in the street directly outside. The house provides accommodation for up to ten adults. 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 lounge, a separate dining room, and a kitchen. There is a well-maintained garden to the rear of the home. Tweezle Twigg DS0000025863.V353886.R01.S.doc Version 5.2 Page 18 At the time of the inspection the premises were decorated in an appropriate style and reasonably maintained with maintenance records kept. The furniture is domestic in nature. The grounds were observed to be well kept and reasonably accessible to the current service user group. There was suitable lighting and ventilation. Doors are sufficiently wide. Automatic fire door closing devises are present on fire doors. The building was clean and tidy and was generally free of offensive odours. The home has specific policies covering the disposal of clinical waste, control of infection, use of cleaning materials, storage and preparation of food, and dealing with spillages. Protective clothing was observed to be present. Laundry facilities have easily cleanable non-permeable floors and walls. Washing machines had appropriate programmes over 65 degrees to control risk of infection and a sluicing cycle. Tweezle Twigg DS0000025863.V353886.R01.S.doc Version 5.2 Page 19 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standard 32, 34, 35, and 36. Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. The home has exceeded the 50 of staff who are required to have a NVQ2 Qualification. This provides a well qualified staff group. The home’s recruitment procedures need to be tightened up to better protect the residents through rigorous staff vetting. Staff do not receive induction and foundation training to ensure that they are appropriately trained. Staff do not receive regular supervision to ensure they are well supervised. EVIDENCE: The home has exceeded the 50 of staff who are required to have a NVQ2 Qualification. This provides a well qualified staff group. Tweezle Twigg DS0000025863.V353886.R01.S.doc Version 5.2 Page 20 The last inspection report continued the following requirement: The home must maintain staffing at previously agreed levels unless the Commission is notified and agrees. Written notification has been received and approved. This requirement is currently met. The last inspection report continued the following requirement: The home must provide a six weeks induction, and a 6 months foundation training programme, that must both fully meet National Training Organisation specifications and standards. The documentation for this had been acquired but not fully implemented yet. The requirement remains until fully implemented. The last inspection report continued the following requirement: The registered provider must ensure that all documentation required in Schedule 2 of the National Minimum Standards and regulations is obtained for all staff members and retained in the home. At the last inspection only staff photos were still required. However at this inspection a number of other files were examined and additional documents were missing. For example, proof of identification and references. As some confusion regarding location of these documents may have occurred during the change of manager, no further action regarding this deterioration of this Standard will occur at this time. However, this is a key protection Standard, and further action may be taken if not addressed by the next inspection. This requirement remains in force. The last inspection report continued the following requirement: The registered manager must ensure that each member of staff has formal documented supervision at least six times per year. Unmet from previous inspection. With the changing of manager, there had been no time to implement this requirement fully. The requirement therefore will remain in force. Tweezle Twigg DS0000025863.V353886.R01.S.doc Version 5.2 Page 21 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 37, 39, 40, and 42. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Service users benefit from a well run home with an experienced and qualified manager. However, the manager still needs to complete one of the required qualifications. The home’s quality assurance system involves the residents and relatives, but needs to be developed to provide feedback to them, and to allow them to be fully involved in improvements and measure improvements in the home for themselves. Service users rights and interests are promoted by the home’s policies and procedures, but some of these need to be written in a more accessible format for the service users. Although the home generally promotes the health and safety of the residents, more diligence is needed in retention of safety check records. Tweezle Twigg DS0000025863.V353886.R01.S.doc Version 5.2 Page 22 EVIDENCE: The new home manager has over 10 years relevant experience in this field. The new home manager has a number of qualifications including the required NVQ4 in care. The only remaining required qualification is a NVQ4 or equivalent in management. The new manager is starting the registered managers award which meets the management qualification requirement needed. The following requirement is now set to clarify this: The registered manager must be qualified to NVQ Level 4 in Management and Care. There is a quality assurance system, which involves service users. The quality assurance tools include the complaints system, service user meetings, provider inspection visits, user satisfaction surveys. All that is now needed is for a system of feedback and review of quality to be set up for the residents. This could be done by producing a written account of the quality assurance data in the form of an annual development plan, and providing a meeting to feed back to the residents. To clarify the remaining elements needed the following requirement is made: The home must pull together its Quality Assurance tools into a system that makes the service users central to the process. The home must also ensure that there is annual development plan that is open to the service users, to allow measurement of achievement in improving quality, and include the service users in this process. The last inspection report contained the following requirement: Service users must have access to relevant policies and procedures, and in an accessible format. Pictorial menus and a pictorial complaints procedure have been devised. To reflect the progress made the requirement will be currently seen as met and the following recommendation set: The home should continue to develop Service users must access to relevant policies and procedures, and in an accessible format. For example, access to files, and money management policies. All of the health and safety policies and procedures relevant to Standard 42 were seen to be present. Fire Safety, First Aid, Food Hygiene, Infection Control, and Handling and Disposal of Clinical Waste policies are all also included in staff induction. All of the procedures and testing of systems required in Standard 42 were also present except for the Portable Appliance Testing certificate and the gas safety certificate. The gas board want to make some changes to the exterior supply which is effecting the acquisition of the gas safety certificate. The following requirement therefore remains: The registered provider must ensure that the home’s overall gas safety is checked and certified. The following new requirement is now set: The portable appliance testing results must be sent into the Commission. Tweezle Twigg DS0000025863.V353886.R01.S.doc Version 5.2 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 x 2 3 3 x 4 x 5 x INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 x 26 x 27 x 28 x 29 x 30 3 STAFFING Standard No Score 31 x 32 4 33 x 34 1 35 1 36 1 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 1 3 x 2 x LIFESTYLES Standard No Score 11 x 12 2 13 2 14 x 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 2 3 2 x 2 x 2 3 x 2 x Tweezle Twigg DS0000025863.V353886.R01.S.doc Version 5.2 Page 24 yes Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard YA6 Regulation 15[1] Requirement Timescale for action 01/01/08 2. YA6 12[2] 12[3] 12[4]a 15[2]b 3. YA6 4. YA9 13(7) 5. YA12 12(1 3)16(2 Care plans must be available for all service users and contain all the elements required under Standard 6. Priority requirement. Care plans must be in a format that is accessible to the individual residents and include the resident’s preferences for how care is carried out. Care plans must be reviewed on a 6 monthly basis {monthly for those over 65} and be updated with any changes identified. Priority requirement. For any pre-planned restrictions of liberty or preplanned restraints {and specifically cot sides}, risk assessments must be produced. These must also contain all the information required under Standard 9.4, and in particular, details of how training and other options have been explored. Priority requirement. The home must provide a wider m,n) range of social and leisure DS0000025863.V353886.R01.S.doc 01/08/08 01/04/08 01/01/08 01/08/08 Tweezle Twigg Version 5.2 Page 25 6. YA13 12(3) 16(2m) 7. YA20 13[2] 8. YA34 13 (4 c)18(1) Sch. 2 & 4(6) 9. YA35 18(1)(c) 195b 10 YA36 18(1a)(2) 11. YA37 9[2] i activities that meet the needs and preferences of the service users.{Unmet from previous inspection} The proprietor and those 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.{Unmet from previous inspection} All staff who administer medication, must have approved and accredited medication administration training. Priority requirement. The registered provider must ensure that all documentation required in Schedule 2 of the National Minimum Standards and regulations is obtained for all staff members and retained in the home. {Unmet from previous inspection} Priority requirement. The home must provide a six weeks induction, and a 6 months foundation training programme, that must both fully meet National Training Organisation specifications and standards. The registered manager must ensure that each member of staff has formal documented supervision at least six times per year. Unmet from previous inspection. Time-scale extended. Priority requirement. The registered manager must DS0000025863.V353886.R01.S.doc 01/08/08 01/01/08 01/01/08 01/04/08 01/01/08 01/08/08 Page 26 Tweezle Twigg Version 5.2 12 YA39 24,1,2,3 13 YA42 12(1a) 14 YA42 12(1a) be qualified to NVQ Level 4 in Management and Care. The home must pull together its Quality Assurance tools into a system that makes the service users central to the process. The home must also ensure that there is annual development plan that is open to the service users, to allow measurement of achievement in improving quality, and include the service users in this process. The registered provider must ensure that the home’s overall gas safety is checked and certified. Partly met from previous inspection. Time-scale extended. Priority requirement. The portable appliance testing results must be sent into the Commission Priority requirement. 01/08/08 01/01/08 01/01/08 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2 3 Refer to Standard YA33 YA20 YA40 Good Practice Recommendations The homes agency staff should sign to confirm when they have completed their induction. Written consent to medication should be sought. The home should continue to develop service users access to relevant policies and procedures, and in an accessible format. For example, access to files, and money management policies. Tweezle Twigg DS0000025863.V353886.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Croydon, Sutton & Kingston Office 8th Floor Grosvenor House 125 High Street Croydon CR0 9XP 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 Tweezle Twigg DS0000025863.V353886.R01.S.doc Version 5.2 Page 28 - 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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