Inspection on 12/07/07 for Tynron

This inspection was carried out on 12th 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 5 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Tynron 20/04/06

Tynron 28/10/05

Tynron 19/05/05

Tynron 09/11/04

Tynron 22/04/04

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 Tynron Church Road Purley Surrey CR8 3QQ Lead Inspector James O`Hara Key Unannounced Inspection 12th July 2007 9:30am Tynron DS0000007213.V345580.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 Tynron DS0000007213.V345580.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. Tynron DS0000007213.V345580.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Tynron Address Church Road Purley Surrey CR8 3QQ 020 8763 0208 020 8763 0962 r.balgobin@sabp.nhs.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) Surrey and Borders Partnership NHS Trust Post Vacant Care Home 11 Category(ies) of Learning disability (11) registration, with number of places Tynron DS0000007213.V345580.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 20th April 2006 Brief Description of the Service: Tynron is a large detached house situated in a quite residential road in Purley. It is within walking distance of local shops and transport links. Tyron provides residential care for ten adults with Learning Disabilities some of who also have physical disabilities and/or epilepsy. The home also has one respite bed. It is owned, managed, and staffed by the Surrey and Borders NHS Trust, a specialist health provider for people with learning disabilities. The home currently has ten people in residence. There are nine single bedrooms, one of which is used for respite provision and one double bedroom. The bedrooms are decorated to suit the individual tastes of people who use the service. The home provides spacious accommodation comprising of a large kitchen diner, a communal living and dining room and a large pleasant garden to the rear. The home has its own transport. Tynron DS0000007213.V345580.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This key unannounced site visit was carried out between 9:30am and 12:30pm on a Thursday morning/afternoon. Methods of inspection included a tour of the premises, observation of contact between staff and people who use the service and discussion with the home manager. Records examined included the homes Statement of Purpose and Service Users Guide, care plans, person centred plans, risk assessments, complaints, adult protection, training, medication, and health and safety. Requirements and recommendations from previous inspections were also discussed with the home manager. What the service does well: The home provides people and their representatives with the information they need so that they can make an informed decision about whether or not to use the service. People have comprehensive care plans and support plans that include information on their needs and personal goals. They have individual risk assessments and risk management strategies in place so that they can participate in activities in the home and in the community in a safe manner. People are offered a varied programme of social and leisure activities that reflects their individual interests. A number of comment cards were returned to the Commission as feedback from people and their relatives. One person who lives at the home commented that he had never made a compliant and he enjoyed the food. One relative commented that their daughter comes home most weekends, that they knew who to speak to if they were not happy and that staff always treat them well. An advocate & friend of a person living at the home commented that the home creates a good atmosphere and it is always warm and friendly when she visits. The home has appropriate quality monitoring systems in place so that the views of people and their representatives are considered about the running of the home. Tynron DS0000007213.V345580.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: There were six requirements set at the last key inspection. All of the requirements have been met. As a result of this inspection there are five new requirements and five recommendations. The home could take more care so as to ensure that food past their best before date is not offered to people. The home could make sure that all staffing records are in place for all members of staff employed in the home. The home could contact the Speech and Language Therapy Department for advice on improving communication. The home could make sure that all people who use the service have their needs/placement assessed by their placing authority. The home could make sure that the living area is arranged so that everyone can see the television, if they wish, and remove the broken television and other furniture from the premises. The home should not use the dining room as an office and confidential information should not be on display in communal areas. The home should contact the local pharmacist for advice on medication. The inspector would like to thank the people who use the service, the staff and the home manager for their support in the inspection process. Tynron DS0000007213.V345580.R01.S.doc Version 5.2 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. The summary of this inspection report can be made available in other formats on request. Tynron DS0000007213.V345580.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 Tynron DS0000007213.V345580.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): 1, 2 and 3. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home provides people who plan to use the service and their representatives with the information they need so that they can make an informed decision about whether or not to use the service. The homes admission procedure ensures that people would have a thorough assessment of their needs and aspirations before they move in. EVIDENCE: As required at the last inspection the home manager has updated the information in the Statement of Purpose and Service Users Guide to reflect the current arrangements at the home. The home manager stated that all of the people who use the service have a personal copy of the Service Users Guide in their rooms. No new people have moved into the home since the last inspection. The Surrey and Borders NHS Trust has an Admission Procedure, that states that people are only admitted to the home once a full assessment has been completed by an appropriate person (usually a care manager) and sent to the Tynron DS0000007213.V345580.R01.S.doc Version 5.2 Page 10 home, along with any other information about the persons needs. The person’s family is also involved, if it is appropriate. Tynron DS0000007213.V345580.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 and 9. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People who use the service have person centred plans that include information on their needs, likes and dislikes. People have individual risk assessments and risk management strategies in place so that they can participate in activities in the home and in the community in a safe manner. EVIDENCE: It was reported at the last key inspection, 24th April 2006, that two people shared the same bedroom. One of these people was very clear that he wanted to have his own room and repeated this wish several times during the inspection. A requirement was set that the home manager supply the Commission for Social Care Inspection with a written plan outlining how this person would have a single bedroom. This was to include a time scale for action. Tynron DS0000007213.V345580.R01.S.doc Version 5.2 Page 12 During today’s visit the same person repeated his wish to move out of the home to a house by the sea were he could have his own bedroom. The home manager produced evidence that this issue had been raised with his care manager, his advocate and senior managers at the Surrey and Borders NHS Trust. The person had been offered the opportunity to move into the homes respite room but stated that he wanted to move out of the home. The home manager stated that the person also had an opportunity to move to another home but after an overnight stay decided against it. The home manager provided evidence that this person has been assessed by a supported living service for a possible move. The home manager also produced evidence that a care manager from this person’s placing authority had telephoned the home to state that he had been placed on a waiting list to be re housed. The advocate and friend of the person wishing to move from the home completed a comment card and returned to the Commission as feedback. She was concerned that her friend has not been moved into his own room as yet. The advocate was contacted by phone on the day of the inspection. She stated that the home had supported her friend very well over the many years that he has lived there but that he had expressed a wish to move and it appeared to be a long drawn out process. She also explained that her friend had visited a psychologist a number of years ago and the psychologist indicated in a letter that her friend would not understand the concept of moving. She agreed that she would forward this information to the home manager. It is recommended that the home manager contact the person who wishes to move’s care manager to refer him onto an Independent Mental Capacity Advocate. It is recommended that the home manager arrange a multi disciplinary meeting in order to establish if moving the person from the home would be in his best interests. Two peoples personal files were selected at random and examined. One person had an Essential Lifestyle Plan, reviewed September 2006; this included a communication profile, what matters to me, things that I enjoy, my dreams and a relationship circle. The other person had a Person Centred Plan that included good information on their needs and personal goals. It was noted that one person had not had her needs assessed by her placing authority. The home manager could not comment on when she last had an Tynron DS0000007213.V345580.R01.S.doc Version 5.2 Page 13 assessment as there was no record of one in her file. The home manager stated that some other people have not had their needs assessed for some time. The home manager must ensure that all people who use the service have their needs/placement assessed by their placing authority. Both people had health action plans indicating what was required to keep them healthy and safe. I.e. appointments to various health care professionals such as opticians, General Practitioner, chiropodist and dentists. Both people had individual risk assessments and risk management strategies in place so that they can participate in activities in the home and in the community in a safe manner. These risk assessments had been reviewed at regular intervals. The home manager provided evidence of regular monthly residents meetings. People decide what activities they want to do or trips they want to go on and what they like to eat. The home manager stated that it was difficult to find out what people like as some people have difficulties with communication. It is recommended that the home manager contact the Speech and Language Therapy Department for advice on Total Communication. Tynron DS0000007213.V345580.R01.S.doc Version 5.2 Page 14 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. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People are offered a varied programme of social and leisure activities that reflects their individual interests. Appropriate arrangements are made so that people have regular contact with their friends and families. Dietary needs are well catered for and well-balanced, nutritional meals, based on personal preferences are being prepared and offered to people who use the service. However the home should take more care so as to ensure that food past their best before date is not offered to people. EVIDENCE: A number of comment cards were returned to the Commission as feedback from people who use the service and their relatives. One person who lives at Tynron DS0000007213.V345580.R01.S.doc Version 5.2 Page 15 the home commented that he had never made a compliant and he enjoyed the food. One relative completed a comment card on behalf of a person living at the home, they commented that their relative comes home most weekends, that they knew who to speak to if they were not happy and that staff always treat them well. An advocate & friend of a person living at the home commented on how the home manager and key worker responded in meeting her friend’s need when he attended his mother’s funeral was excellent. She also commented that they create a good atmosphere and it is always warm and friendly when she visits. The home manager confirmed that some people visit family and at weekends some people stay with their relatives. Visitors can be seen in any of the homes communal areas as well as people’s bedrooms. People have a weekly activity timetable in their individual files. There is a strong emphasis on people accessing the community, people attend local leisure facilities, parks, cafes, cinema, pubs, theatres, libraries, bowling alley and go shopping. People also attend clubs such as the Mencap Club and the Beautiful Blue Octopus Club. People have the opportunity to attend religious services if they wish. People have an annual holiday; the home manager stated that people were currently planning to go on holiday in September. The destination was to be discussed at the next residents meeting. The home is fairly close to a local bus route and has its own transport. The home manager stated that even though people get to go out when they wish there are too few drivers and sometimes the staff team is stretched. People attend Cherry Orchard and Geoffrey Harris House day centres. Some people attend activities such as trampoline, cycling, community awareness, art, woodwork, aromatherapy, dancing, football and cookery sessions at Wallington Girls College. The home manager stated that six people had recently gone to see Joseph and His Multi Coloured Dream Coat at the Fairfield’s Hall in Croydon. Six people spent a day in Eastbourne the day previous to the inspection. Menus at the home are based on people’s likes and dislikes and health needs are taken into consideration when planning meals. The menus also include ethnic options and are checked by the Surrey and Borders NHS Trust dietician for nutritional balance. Tynron DS0000007213.V345580.R01.S.doc Version 5.2 Page 16 During an inspection of the fridge it was observed that two jars of horseradish sauce had passed their use by date. The home manager threw these away. It was evident that all other food was fresh and included a date when it had been opened however the home manager agreed that the home could take more care to check for food past their best before date. The home manager must ensure that regular checks take place in the home so that food past their best before date is not offered to the people. Tynron DS0000007213.V345580.R01.S.doc Version 5.2 Page 17 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. Quality in this outcome area is good. This judgement has been made using all the available evidence including a site visit to this service. The arrangements for meeting the health care needs of people who use the service are good and people receive personal support in the way they prefer. EVIDENCE: All of the people who use the service are registered with a local General Practitioner. People are able to access community health facilities such as opticians, chiropodist and district nurses as required. Some people have been diagnosed with epilepsy. The home manager produced an epilepsy care plan for each person diagnosed with epilepsy. The care plan included a description of typical seizures, guidance for staff to follow i.e. when to call an ambulance, a rectal diazepam treatment plan and a seizure chart. All people diagnosed with epilepsy are regularly monitored by the Neurology Department at the local Hospital. The home manager provided evidence that all staff has had training on epilepsy and the administration of rectal diazepam. Tynron DS0000007213.V345580.R01.S.doc Version 5.2 Page 18 There are guidelines in place for staff to follow in order to offer consistent support to one person so that she can eat safely and there are guidelines in place to support another person with challenging behaviour. Medication is stored in a locked cabinet in the kitchen/dining room. Medication administration records checked on the day of the inspection were up to date and accurate. The medication file included a list of staff competent to administer medication and sample signatures, medication profiles and photos of people who use the service, peoples up to date medication reviews, peoples consent for staff to administer medication and PRN guidelines. Two peoples personal files examined included health action plans indicating what was required to keep them healthy and safe. I.e. appointments to various health care professionals such as opticians, General Practitioner, chiropodist and dentists. The home manager stated that the local pharmacist has visited the home to offer advice on medication however the last visit was in April 2005. It is recommended that the home manager contact the local pharmacist for advice on medication. The Surrey and Borders NHS Trust provide training courses in health care matters such as manual handling and medication courses to ensure that care staff are trained and accredited to meet the health care needs of people who use the service. A record of medication/health care training attended by the staff team is kept on the medication file. Tynron DS0000007213.V345580.R01.S.doc Version 5.2 Page 19 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. Quality in this outcome area is good. This judgement has been made using all the available evidence including a site visit to this service. The home has an appropriate complaints procedure. The home has suitable vulnerable adult protection and abuse prevention measures in place to ensure that people are so far as reasonable practicable protected from abuse. EVIDENCE: The home has an appropriate complaints procedure. The home manager stated that there had been no complaints raised with the home since the last inspection. The complaints procedure is also in a symbol format for the benefit of some people who use the service. The home had a copy of Croydon Councils Protection of Vulnerable Adults Procedure on site. The home manager provided evidence that all staff has had training on adult protection. The home manager stated that the Trust was in the process of reviewing its policy and procedures. The Surrey and Borders NHS Trust has a Whistle Blowing Policy. It is recommended that the Surrey and Borders NHS Trusts new Whistle Blowing Policy be discussed with staff at the next team meeting. Tynron DS0000007213.V345580.R01.S.doc Version 5.2 Page 20 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. Quality in this outcome area is good. This judgement has been made using all the available evidence including a site visit to this service. The home is suitable to meet the needs of the people who live there, comfortable and in reasonable decorative order. However staff are using the dining area to carry out administrative work, this should be eliminated. The home was clean and free from offensive odours throughout. EVIDENCE: The home has a driveway to the front of the building and a pleasant garden to the rear of the house. There are sufficient numbers of bathrooms and toilet facilities situated throughout the home. People’s bedrooms have been personalised and decorated to reflect their individual taste. The home has appropriate laundry facilities separate from the kitchen and the preparation of food. The washing machine is capable of washing clothes at high temperatures, which helps with the control of infections. There is a locked cupboard for the Control of Substances Hazardous to Health products. Tynron DS0000007213.V345580.R01.S.doc Version 5.2 Page 21 A first aid box and a fire blanket are situated in the kitchen. Coloured chopping boards and knives were seen in the kitchen. There are fire extinguishers throughout the house. As required at the last inspection the communal lounge has been redecorated. It was noted that the living room was divided into two areas. The home manager stated that some people sat in the main area and some people sat in an area partitioned by a settee. It was agreed that these people might find it difficult to see the television. The home manager stated that there was a broken television and some other furniture that needed to be removed from this area; the home manager agreed that this area was a bit cluttered. It is recommended that the home manager arrange the living room so that everyone can see the television, if they wish, and remove the broken television and other furniture from the premises. There are two dining tables in the kitchen/dining room. It was observed that the kitchen/dining room had adverts for various activities some people’s photographs and paintings. However there was copies of Surrey and Borders NHS Trust policy and procedures, adult protection advice, the human rights act, health care commission enquiries and weekly activity charts hung on the wall and pinned to notice boards along with numerous other pieces of information. There were guidelines for supporting one person with safe eating pinned on a notice board. A number of files were also on one of the dining tables. The home manager stated that staff normally brought these from the office in the morning and returned them back when they had finished with them. The home manager was reminded that this was the people who use the service dining room but it looked like an office and was used as such. The home manager must ensure that the dining room is used only for its stated purpose. Confidential information must not be on display in communal areas, paperwork/files must be placed in the office and staff must not use the dining room as an office. Tynron DS0000007213.V345580.R01.S.doc Version 5.2 Page 22 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, 34, 35 and 36. Quality in this outcome area is good. This judgement has been made using all the available evidence including a site visit to this service. The homes procedures for the recruitment of staff appear to be robust and provide the necessary safeguards to ensure that so far as reasonably practicable people who use the service are not placed at risk of harm or abuse. Staff at the home receives regular training and supervision so as to ensure that people who use the service benefit from having a consistent approach to their needs. EVIDENCE: The home manager stated that one new member of staff had started working at the home since the last inspection. The home manager stated that this member of staff had completed all the appropriate checks and had all documentation as required in schedule 2 of the Care Homes Regulations however he had not picked her file up from the Surrey and Borders NHS Trust head office. The home manager must inform the Commission when the new member of staffs personnel file is available in the home for inspection. Tynron DS0000007213.V345580.R01.S.doc Version 5.2 Page 23 The home manager stated that the Commission has seen all other staffs Criminal Records Bureau Checks at previous inspection. The home manager stated that three members of staff have completed NVQ level 2 in care and two members of staff started NVQ level 2 in care in June 2007. The home has two care team leaders and both are Registered Learning Disability Nurse’s. Two staff training records were sampled at random, both indicated that staff has attended training on adult protection, epilepsy, fire safety lecture, food hygiene, moving and handling, first aid, health and safety, medication training, health action planning and person centred planning. The home manager stated that all other staff had received a similar level of training however some staff still requires training on health and safety, first aid and food hygiene and he had plans to arrange training on communication. It was required at the last key inspection that the home manager ensures that all staff working at the home has regular supervision sessions and an annual appraisal. The home manager provided evidence that all staff is receiving regular formal supervision and all staff are receiving an annual appraisal, the Trusts “Knowledge Skills Framework”. The atmosphere in the home is friendly and people spoken to were complimentary about the staff and management team. The staff team were observed to treat people with dignity and respect. Tynron DS0000007213.V345580.R01.S.doc Version 5.2 Page 24 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. Quality in this outcome area is good. This judgement has been made using all the available evidence including a site visit to this service. The home appears to be well run and well managed. Appropriate quality assurance and quality monitoring systems are in place so that the views of people and their representatives are considered about the running of the home. EVIDENCE: The home manager is Registered Learning Disability Nurse. He has completed a Certificate in Management Studies and Units RM1 and RM2, which equate to the Registered Managers Award. As required at the last inspection the home manager has applied to the Commission for Social Care Inspection to be the registered manager for the home. The Commission is currently assessing his application. Tynron DS0000007213.V345580.R01.S.doc Version 5.2 Page 25 Copies of monthly Regulation 26 Visit reports were available in the home for inspection. The home manager explained that the Regulation 26 Visit reports now included a section that identified if institutional practices, ideas or behaviours were observed during the visit. This was so that these practices could be eliminated. The home manager was advised that it is no longer a requirement that copies of Regulation 26 Visit reports be sent to the Commission however the home should make the reports available for inspection. The home manager provided evidence that people who use the service had completed questionnaires in order that they could feedback about the service. The home manager stated that he used the feedback to improve the service. The home manager stated that he was due to send questionnaires to people’s relatives. The Surrey and Borders NHS Trust had developed a new assessment “The Cornwall Assessment”. The home manager stated that he had completed “The Cornwall Assessment” for the home and handed it to the Trust. He stated that the assessment highlighted areas where the home might improve and included an action plan. A requirement was set at the last key inspection that the home manager must ensure regular fire drills are undertaken and recorded. The home manager provided evidence that fire drills are taking place on a regular three monthly basis. There is evidence that the fire alarm system is checked on a regular weekly basis. All staff attended an annual fire safety lecture 27/02/07 and the homes fire safety risk assessment was completed on the same day, the home manager carried out a three monthly fire safety audit on the 18/06/07. The home manager produced a Landlords Gas Safety Certificate 23/02/07 and stated that Portable Appliance Testing and legionellas testing had been carried out this year but could not produce any certificates as evidence. The home manager must forward copies of the legionellas testing and Portable Appliance Testing Certificate’s to the Commission. Tynron DS0000007213.V345580.R01.S.doc Version 5.2 Page 26 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 3 2 3 3 3 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 2 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 3 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 4 14 4 15 3 16 3 17 2 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 3 X 3 X X 2 X Tynron DS0000007213.V345580.R01.S.doc Version 5.2 Page 27 Are there any outstanding requirements from the last inspection? No. 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 14 (2) a & b. Requirement The home manager must ensure that all people who use the service have their needs/placement assessed by their placing authority. The home manager must ensure that regular checks take place in the home so that food past their best before date is not offered to the people. The home manager must ensure that the dining room is used only for its stated purpose. Confidential information must not be on display in communal areas, paperwork/files must be placed in the office and staff must not use the dining room as an office. The home manager must inform the Commission when the new member of staffs personnel file is available in the home for inspection. The home manager must forward copies of the legionellas testing and Portable Appliance Testing Certificate’s to the Commission. Timescale for action 31/10/07 2. YA17 13 (3) 13/07/07 3. YA24 12 (4) a 13/07/07 4. YA34 19 (1) 31/08/07 5. YA42 13 (4) a 31/08/07 Tynron DS0000007213.V345580.R01.S.doc Version 5.2 Page 28 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. 3. Refer to Standard YA6 YA20 YA24 Good Practice Recommendations It is recommended that the home manager contact the Speech and Language Therapy Department for advice on Total Communication. It is recommended that the home manager contact the local pharmacist for advice on medication. It is recommended that the home manager arrange the living area so that all of the people who use the service can see the television, if they wish, and remove the broken television and other furniture from the premises. It is recommended that the home manager contact the person who wishes to move’s care manager to refer him onto an Independent Mental Capacity Advocate. It is recommended that the home manager arrange a multi disciplinary meeting in order to establish if moving the person from the home would be in his best interests. 4. 5. YA6 YA6 Tynron DS0000007213.V345580.R01.S.doc Version 5.2 Page 29 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. 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