Inspection on 25/07/07 for Tudor House - Pangbourne

This inspection was carried out on 25th July 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. 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 no outstanding requirements from the previous inspection report, but made 7 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Tudor House - Pangbourne 26/05/06

Tudor House - Pangbourne 20/12/05

Tudor House - Pangbourne 19/07/05

Tudor House - Pangbourne 30/11/04

Tudor House - Pangbourne 25/08/04

Tudor House - Pangbourne 27/02/04

Similar services:

Flint House

Hillview Farm

Dalewood Respite Care

Orchard,The

REACH Upton Court Road

The Cotswold Home

Fairways

Treloar College

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

CARE HOME ADULTS 18-65 Tudor House - Pangbourne Farm Lane Maidenhatch Pangbourne Berkshire RG8 8HP Lead Inspector Robert Dawes Unannounced Inspection 25th July 2007 11:00 Tudor House - Pangbourne DS0000011174.V342283.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 Tudor House - Pangbourne DS0000011174.V342283.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. Tudor House - Pangbourne DS0000011174.V342283.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Tudor House - Pangbourne Address Farm Lane Maidenhatch Pangbourne Berkshire RG8 8HP 0118 974 5030 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) TACT UK Ltd Ms Cynthia Vickery Care Home 6 Category(ies) of Learning disability (6), Physical disability (6) registration, with number of places Tudor House - Pangbourne DS0000011174.V342283.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 26th May 2006 Brief Description of the Service: Tudor House is a large detached house, surrounded by farmland, situated approximately three miles from Pangbourne village. The nearest bus stop is two miles away and Reading and Newbury, approximately six miles away, provide a comprehensive range of amenities. Tudor House provides accommodation and care for up to six residents, aged between eighteen and sixty-five years of age, who have a learning disability and some of whom also, have a physical disability. Fees range from £1348.44 to £1567.44 per week. Tudor House - Pangbourne DS0000011174.V342283.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was a routine unannounced site visit, which took place during the day on the 25th July 2007. The Annual Quality Assurance Assessment, four residents surveys, one care manager’s survey and two relatives’ surveys were returned to the inspector before the site visit. These, together with the site visit, were the main sources of information for the key inspection. During the site visit the inspector interviewed the manager and two members of staff; spoke with two residents; toured the premises; looked at records; case tracked; and observed the interaction between residents and staff. Three outcome groups were judged to be good and five to be adequate. Seven requirements and four recommendations were made. What the service does well: What has improved since the last inspection? What they could do better: Follow the safeguarding younger adults procedures; record the administration of medication accurately; keep all areas of the home clean and hygienic; ensure the self-closing mechanisms shut all the fire doors completely; address Tudor House - Pangbourne DS0000011174.V342283.R01.S.doc Version 5.2 Page 6 the numerous examples of decoration, maintenance and renewal issues that have been identified; review the home’s fire risk assessment; ensure sufficient staff receive medication training; develop a complaints procedure for residents in a user friendly format; incorporate the Learning Disability Award Framework into the induction/foundation training programme; and undertake more detailed Regulation 26 visits. The manager also wants to change the care plans into person centred formats; introduce health action plans for residents; and send more staff on sexuality training. 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. Tudor House - Pangbourne DS0000011174.V342283.R01.S.doc Version 5.2 Page 7 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 Tudor House - Pangbourne DS0000011174.V342283.R01.S.doc Version 5.2 Page 8 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): 2. People who use the service experience good quality outcomes in this area. Prospective residents’ individual aspirations and needs are assessed. This judgement has been made using available evidence including a visit to this service. EVIDENCE: A full assessment was undertaken before the most recent resident was admitted to the home. Tudor House - Pangbourne DS0000011174.V342283.R01.S.doc Version 5.2 Page 9 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): 6, 7 and 9. People who use the service experience good quality outcomes in this area. Residents have individual care plans reflecting their diverse needs; are enabled to make decisions about their lives; and lead as independent a lifestyle as possible. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Individual plans of care are available for all residents and they contain all the information that is specific to their personal care and social care needs. The care plans are regularly reviewed. The manager intends to change the care plans into person centred formats. Each resident has a key worker of his/her own choosing. In response to the question in the care manager’s survey ‘does the care service provide support for individuals to live the life they choose wherever possible?’ the care manager replied ‘always’. In response to the question in the relatives’ survey ‘does the care service support people to live the life they choose?’ the relatives replied ‘usually’. Tudor House - Pangbourne DS0000011174.V342283.R01.S.doc Version 5.2 Page 10 In response to the question in the residents’ survey ‘do you make decisions about what you do each day?’ 4 replied ‘always’ and 1 replied ‘sometimes’; in response to the question ‘can you do what you want to do during the day, evening and at weekends?’ all the residents replied ‘yes’. Residents get up and go to bed when they wish; choose the menu for the week; purchase their own clothes; choose activities; and decide where they would like to go on holiday. Residents said ‘ staff ask me what I want to do’, ‘I have choice in the home and ‘staff ask your views’. The majority of residents have very limited capabilities but they are encouraged and enabled to be as independent as possible. Appropriate risk assessments are in place. Tudor House - Pangbourne DS0000011174.V342283.R01.S.doc Version 5.2 Page 11 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): 12, 13, 15, 16 and 17. People who use the service experience good quality outcomes in this area. Residents take part in a range of appropriate activities which reflect their diverse needs; they participate in the local community and are enabled to keep in touch with their families and friends; their rights are respected and responsibilities recognised in their daily lives; and are offered a healthy diet and enjoy their meals. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Each resident has an individual schedule of weekly events. Activities in the community include accessing day centres where residents can improve their numeracy, literacy and computer skills; music sessions; trampolining; gardening; going shopping; and having meals and drinks in pubs and cafes. Three residents are in supported paid employment. There is a range of activities for residents in house, including reading, playing pool, art and craft, painting, daily living skills, and cooking. None attend a church service in the community but it would be arranged if any resident requested to attend. A local vicar visits the home occasionally. Tudor House - Pangbourne DS0000011174.V342283.R01.S.doc Version 5.2 Page 12 A resident who has budgies in his room said he likes the activities on offer. In response to the questions in the relatives’ survey ‘does the care home help your relative to keep in touch with you?’ and ‘are you kept up to date with important issues affecting your relative?’ both relatives replied ‘usually’. Staff will transport the residents to their family homes. One resident visits a friend in another home when it can be arranged. Residents were observed to have unrestricted movement around the home. Residents can choose to be alone. Residents help with simple tasks around the house such as cleaning their rooms and doing the laundry. All residents have the opportunity to vote and can have keys to their rooms. In response to the question in the care manager’s survey ‘does the care service respect individuals’ privacy and dignity?’ the care manager replied ‘always’. In response t the question in the residents’ survey ‘do the staff treat you well?’ all replied ‘always’. In response to the question ‘do the carers listen and act on what you say?’ 3 residents replied ‘always’ and 1 replied ‘sometimes’. Staff were observed to treat staff respectfully and patiently. Residents said that they enjoy the meals; they have enough to eat and are given a variety of options if they are offered food that they do not want. Residents’ likes and dislikes are catered for and the menu showed a nutritious and well balanced diet is provided. Tudor House - Pangbourne DS0000011174.V342283.R01.S.doc Version 5.2 Page 13 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): 18, 19 and 20. People who use the service experience adequate quality outcomes in this area. Residents receive personal support in the way they prefer and require; and their physical and emotional health needs are well met. The home has appropriate medication policies and procedures but the recording in the MAR sheets was poor and a discrepancy was found between the number of tablets in stock and the number recorded. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Residents get up and go to bed when they wish, choose what they wear, and where possible choose the member of staff they wish to accompany them out of the home. Guidelines covering all aspects of the service users’ personal support needs were seen. Specialist support is provided as required i.e. speech therapy, physiotherapy and occupational therapy. In response to the question in the relatives’ questionnaire ‘does the care home give the support or care to your relative that you expect or agreed?’ the relative replied ‘usually’. The diverse needs of the service users are addressed on an individual basis. Tudor House - Pangbourne DS0000011174.V342283.R01.S.doc Version 5.2 Page 14 All the files contained appropriate monitoring charts, records of appointments and behavioural guidelines, which showed the residents’ physical and emotional health are being well monitored, responded to appropriately and any problems are being promptly addressed. Residents are encouraged to exercise by going for walks, having individual exercise programmes or using exercise bikes. Health professionals, such as psychiatrists and psychologists, are involved when necessary. In response to the question in the care manager’s survey ‘are individuals’ health care needs properly monitored and attended to by the care service?’ the care manager replied ‘always’. None of the service users self-administer their medication except one resident when on antibiotics. Self-medication guidelines are in place. No controlled drugs are on the premises. Appropriate medication policies and procedures are in place, including for the administration of PRN medication. A pharmacist visits the home once a year to inspect the storage, administration, recording and disposal of the medication. In response to the question in the care manager’s survey ‘does the care service support individuals to administer their own medication or manage it correctly where this is not possible?’ the care manager replied ‘always’. No record of any staff trained in administering medication was seen. Gaps were found in the administration records. An error was found in the running record of a resident’s medication and on further examination the number of tablets in stock was seven less than recorded on the MAR sheet. Tudor House - Pangbourne DS0000011174.V342283.R01.S.doc Version 5.2 Page 15 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): 22 and 23. People who use the service experience adequate quality outcomes in this area. Residents feel their views are listened to and acted on. Staff have received safeguarding younger adults training and appropriate procedures are in place. However the organisation did not follow these procedures when an allegation of abuse against a resident was made. This judgement has been made using available evidence including a visit to this service. EVIDENCE: There is a comprehensive complaints procedure in place but no complaints procedure in a user-friendly format for residents. The majority of residents have very limited verbal skills and would find it difficult to complain directly. Staff observe behaviour to determine if a resident is unhappy. Residents are invited to staff meetings so that any concerns may be raised. No complaints to the Commission have been made since the last inspection. One complaint has been made to the home since the last inspection. This was responded to appropriately. In response to the question in the relatives’ survey ‘do you know how to make a complaint?’ the relatives replied ‘yes’. In response to questions in the care manager’s survey, ‘has the care service responded appropriately if you or a person using the service have raised any concerns? the care manager replied ‘always’. In response to the questions in the residents survey, ‘do you know who to speak to if you are not happy?’ and ‘do you know how to make a complaint?’ all four residents replied ‘yes’. Tudor House - Pangbourne DS0000011174.V342283.R01.S.doc Version 5.2 Page 16 A safeguarding younger adults’ policy, a challenging behaviour policy and a physical intervention policy are in place. Staff have received training in safeguarding younger adults and non-physical intervention. Staff spoken to were clear about protection issues and responding to challenging behaviour ensuring respect and dignity. No allegations of abuse have been made to the Commission since the last inspection. The commission was not informed of a recent allegation by a resident to the organisation that a member of staff shouted and hit another resident. The organisation has started an internal inquiry but not informed outside agencies as laid down by the safeguarding younger adults procedures. All the residents have individual bank accounts. Four residents withdraw money themselves. The manager and one other sign to withdraw money on behalf of two residents. Personal money, up to £24, is kept for residents in individual wallets in the safe. A member of staff from the head office audits the personal money records once a year. The manager audits the records on a regular basis. Residents, who are able, look after small amounts of personal money themselves. Tudor House - Pangbourne DS0000011174.V342283.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): 24 and 30. People who use the service experience adequate quality outcomes in this area. The home is spacious and many areas have been decorated in the last year. However there were numerous examples of decoration, maintenance and renewal issues that need addressing. The home was generally clean and hygienic but cobwebs and spiders were observed in several corners of a resident’s bedroom. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home is spacious, accessible to all residents and during the last year, two bedrooms, the lounge, dining room, kitchen and utility room have been decorated. However there were numerous examples of decoration, maintenance and renewal issues that need to be addressed i.e. the skirting boards in the dining room and bathroom need painting; several bedrooms need decorating; some rooms had holes in walls where shelves used to be fitted which need filling and painting; door locks were broken and needed repairing; several of the curtains were torn and broken from their runners; there was a noticeable gap between the lino and the toilet in the upstairs Tudor House - Pangbourne DS0000011174.V342283.R01.S.doc Version 5.2 Page 18 bathroom; a large stain in the lounge carpet; a dining room chair cover was torn; a curtain left off the vinyl strip; the ceiling in the upstairs bathroom is badly stained; a small area of bare plaster in a resident’s bedroom needs painting; the surrounds of a resident’s door needs repairing; several doors are badly marked and need painting; and the back of the building needs clearing and cleaning up. It is acknowledged that the behaviour of one resident can be destructive but it does not account for all the issues listed. Where this resident is responsible a more robust response should be made, as it is not acceptable for the other residents to live in a poorly maintained environment. The home was generally clean, hygienic and free of offensive odours except for one resident’s bedroom where cobwebs and spiders were seen in several corners of his room. In response to the question in the residents’ survey ‘is the home fresh and clean?’ all four residents replied ‘yes’. Tudor House - Pangbourne DS0000011174.V342283.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): 32, 33, 34 and 35. People who use the service experience adequate quality outcomes in this area. An effective, competent and qualified staff team generally support the residents fairly, equally, without discrimination and in a caring manner. The one exception was a member of staff who made no effort to interact with residents when in the lounge. The home operates a thorough recruitment procedure. Staff receive a broad range of training which would be improved if Learning Disability Award Framework training was incorporated in the induction/foundation training programme and staff received medication training. This judgement has been made using available evidence including a visit to this service. EVIDENCE: 53 of the care staff have a NVQ 2 or above in care. In response to the questions in the care manager’s survey ‘do the service’s manager and staff have the right skills and experience to support individuals’ social and health care needs?’ and ‘does the care service respond to the different needs of individual people?’ the care manager replied ‘usually’. The care manager commented ‘the service user I have placed at Tudor House has severe learning disabilities, autism and challenging behaviour. They manage Tudor House - Pangbourne DS0000011174.V342283.R01.S.doc Version 5.2 Page 20 his care extremely well and in a very gentle caring manner. They are encouraging his independence skills’. In response to the questions in the relatives’ survey ‘do you feel that the care home meets the needs of your relative?’, ‘does the care staff have the right skills and experience to look after people properly?’ and ‘does the care service meet the different needs of the people?’ the relative replied ‘usually’. Staff interviewed demonstrated a sound knowledge of the residents’ disabilities and needs Residents interviewed said ‘staff on the whole are OK’, ‘I like all the staff’ and ‘staff are very good’. One member of staff was observed sitting in the lounge watching the TV with two other residents but making no attempt to interact with them. There is a good ratio of staff to residents. Three care staff are on duty from 7.30 am to 10.00 pm with an extra member of staff on duty between 9.00am to 4.30pm. Bank staff will be on duty if the need arises i.e. if residents go out to activities in the community. One member of staff is on duty at night with back up from a ‘sleep in’ care staff. Staff sickness is low. Records showed the organisation complies with the recruitment regulations. All new staff undertake an induction training programme. All staff have received basic training and training in key areas of their work except in administering medication where no evidence of appropriate training taking place could be found. Refresher training of key areas of work takes place. Other courses that staff have attended have been autism, report writing, values and principles, communication and recording, and sexuality. The manager is planning to send the majority of her staff on the sexuality training course. Staff said they considered training equipped them to undertake their work The Learning Disability Award Framework training is not incorporated into the induction/foundation training programme. Tudor House - Pangbourne DS0000011174.V342283.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): 37, 39 and 42. People who use the service experience adequate quality outcomes in this area. The manager is qualified, competent and experienced to run the home; a quality assurance and quality monitoring system is in place which needs improving; and the health, safety and welfare of residents are promoted and protected except for the fire doors of which several do not close properly. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The registered manager is qualified, competent and experienced to run the home. She has been the manager for the past six years. The manager undertakes periodic training to maintain and update her knowledge and skills. Staff described the manager as supportive, approachable and clear in how she wants the clients cared for. Tudor House - Pangbourne DS0000011174.V342283.R01.S.doc Version 5.2 Page 22 Satisfaction questionnaires were sent out to residents, relatives and care managers in June 2006. The manager plans to make the questionnaire more user friendly. An annual development plan has been produced which identifies areas that need addressing to improve the quality of care for the residents. Monthly staff meetings take place where residents are invited to part of the meeting. Regulation 26 visits take place but they need to be more detailed to cover all the standards in the course of a year. Records showed all health and safety checks and inspections are up to date and completed as required. Necessary health and safety policies and procedures are in place. The manager undertakes a monthly health and safety audit of the home. The home’s fire risk assessment has not been reviewed since 2005. All the service users’ files contained appropriate risk assessments and had been reviewed regularly. All the staff have received the necessary health and safety training including first aid. Several of the automatic closure mechanisms failed to shut the fire doors completely. Tudor House - Pangbourne DS0000011174.V342283.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 2 ENVIRONMENT Standard No Score 24 2 25 X 26 X 27 X 28 X 29 X 30 2 STAFFING Standard No Score 31 X 32 3 33 3 34 3 35 2 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 X 3 X 3 X X 2 X Tudor House - Pangbourne DS0000011174.V342283.R01.S.doc Version 5.2 Page 24 No 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 YA20 Regulation 13 (2) Requirement Undertake an audit of the medication to determine why the number in stock does not match the number recorded for a particular resident’s medication. When medication is administered to residents it must be clearly recorded, to ensure that they receive the correct levels of medication. Inform the CSCI of the recent alleged abuse of a resident and comply with the safeguarding younger adults procedures. A maintenance programme must address the numerous examples of decoration, maintenance and renewal issues that have been identified in order for residents to live in a pleasant environment. All areas of the home must be kept clean and hygienic. Sufficient staff receive medication training to ensure DS0000011174.V342283.R01.S.doc Timescale for action 25/07/07 2 YA20 13 (2) 25/07/07 3 YA23 37 25/07/07 4 YA24 23 30/09/07 5 6 YA30 YA35 23 (2)(d) 18(c)(1) 27/07/07 30/09/07 Tudor House - Pangbourne Version 5.2 Page 25 medication is administered and recorded correctly. 7 YA42 23 (4) Ensure self-closing mechanisms shut all the fire doors completely to protect the residents in the event of a fire. 25/07/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 2 Refer to Standard YA22 YA35 Good Practice Recommendations Develop a complaints procedure for residents in a user friendly format. Incorporate the Learning Disability Award Framework into the induction/foundation training programme to provide staff with knowledge about learning disabilities at an early stage of their employment. Regulation 26 visits should be more detailed and cover all the standards over the course of a year. The home’s fire risk assessment should be reviewed to bring it up to date. 3 4 YA39 YA42 Tudor House - Pangbourne DS0000011174.V342283.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Oxford Office Burgner House 4630 Kingsgate Oxford Business Park South Cowley, Oxford OX4 2SU 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 Tudor House - Pangbourne DS0000011174.V342283.R01.S.doc Version 5.2 Page 27 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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