CARE HOME ADULTS 18-65
Tyrwhitt House Oaklawn Road Leatherhead Surrey KT22 0BX Lead Inspector
Lisa Johnson Unannounced Inspection 11th May 2006 8: 55 Tyrwhitt House DS0000013365.V293709.R01.S.doc Version 5.1 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 Tyrwhitt House DS0000013365.V293709.R01.S.doc Version 5.1 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. Tyrwhitt House DS0000013365.V293709.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION
Name of service Tyrwhitt House Address Oaklawn Road Leatherhead Surrey KT22 0BX 01372 841630 01372 841631 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) Ex Services Mental Welfare Society Mr Anthony John Letford Care Home 30 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (30) of places Tyrwhitt House DS0000013365.V293709.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION
Conditions of registration: Date of last inspection 6th September 2005 Brief Description of the Service: Tyrwhitt is a large Victorian house near Leatherhead. The home caters for exservicemen and women with a mental health need, primarily post traumatic stress disorder. The home is set in extensive grounds and has ample car parking. There are 30 single bedrooms, kitchen, servery, dining room, a main lounge, smoking room and an equipped activities department. The name of the registered provider is the Ex-Services Mental Welfare Society. Tyrwhitt House DS0000013365.V293709.R01.S.doc Version 5.1 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This was the first key inspection carried out in 2006/2007. Mrs. L Johnson Regulation Inspector carried out the unannounced inspection, which took place over eight hours. Mr. A. Letford the registered manager represented the establishment. Two additional inspections have been completed since the last key inspection to monitor requirements that had been made. Copies of these reports are available by contacting the Surrey Commission for Social Care Inspection office A full tour of the premises was undertaken and care plans, staff files and policies and procedures were sampled. The inspector spoke to five service users and five members of staff in the home. The inspector would like to thank the service users and staff for their hospitality and cooperation during this inspection What the service does well:
The service provides an open, relaxed and friendly atmosphere. A wide and varied range of therapeutic, recreational and social activities is available which meets the needs and preferences of individuals. The inspector spoke to service users to gain their views on the service and comments received included “ I give this service ten out of ten”. “The staff are approachable and supportive”. “I would recommend this facility”. “It’s a good place and I look forward to my visits here”. Service users spoken to confirm that they are supported consulted and involved about their treatment programmes. Service users were asked about the quality of the meals and responses included “ You can make choices”. “The food is good”. Tyrwhitt House DS0000013365.V293709.R01.S.doc Version 5.1 Page 6 What has improved since the last inspection? What they could do better:
Since the previous inspection issues pertaining to the medication policies and procedures in the home were raised as a concern with two additional inspections being undertaken by the Commission for Social Care pharmacy inspector. The home has made improvements in its medication handling, however it was of concern that the revised medication procedure has not been signed by staff to confirm that they have read this document and that more detailed risk assessments for service users who self medicate have not been completed. An immediate requirement was made that this work is completed to ensure that the health, welfare and safety of service users is protected by the homes medication policies and procedures. The registered manager had made arrangements for staff to receive training in safeguarding adults, however this training was cancelled outside of the manager’s control and new dates have been arranged. A further requirement was made that a local safeguarding adults procedure is introduced which still remains unmet. These issues must be completed to ensure that service users are safeguarded from abuse. A further requirement was made that the refurbishment of the outstanding bedrooms is completed to ensure that service users have comfortable rooms to stay in and a shower curtain should be replaced in one bathroom. Although the service was found to be clean during this inspection a previous requirement was made that the showers must be cleaned twice a day the cleaning schedule does not indicate that this being completed. A further requirement was made that this information is documented to ensure that service users have clean and hygienic showers to use.
Tyrwhitt House DS0000013365.V293709.R01.S.doc Version 5.1 Page 7 A requirement was made that the registered manager should ensure that at least fifty percent of care staff have completed national vocational qualifications (Level 2) this standard has not been achieved. This is to ensure that service users are supported by qualified staff to promote their health and wellbeing. Staff training including fire prevention and food hygiene must be undertaken as a number of staff have not received recent up to date training. Staff must also receive training in infection control. A requirement was made that this training must be completed and that the training schedule is kept up-to-date. Staff spoken stated that they had received induction, however written records were not maintained on personal files to confirm this and a requirement was made this information is made available. A further recommendation was made that that copies of staff training certificates are maintained on individual’s files to confirm attendance. A previous requirement has not been met that all staff must receive formal supervision sessions at least six times a year and the original timescale has not been met and a further requirement was made to include both nursing and care staff. Two health and safety issues were identified. There were some gaps in the daily records for monitoring fridge temperatures. A ladder was found obstructing the staircase in the cellar, which was immediately responded to by the registered manager. However it is required that regular monitoring continues takes place of the cellar to ensure that walkways are free from obstructions. The registered manager must ensure that all staff complete regular up-to-date mandatory training. This is to ensure that the health, wellbeing and safety of service users is protected. 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. Tyrwhitt House DS0000013365.V293709.R01.S.doc Version 5.1 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 Tyrwhitt House DS0000013365.V293709.R01.S.doc Version 5.1 Page 9 Choice of Home
The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1&2 Quality in this outcome area is good. This judgement has been made using available evidence including a visit. The home is able to demonstrate that service users are provided with adequate information so that they are able to make an informed choice about the suitability of the service as a place to stay. The home is able to demonstrate that pre admission assessments are completed prior to admission. EVIDENCE: The service provides a Statement of Purpose and service user guide which details the aims and objectives of the service and the facilities and services it is able to offer. The inspector spoke to one individual who said, “This is my first time here, “I have been provided with plenty of information about the service” Three files were sampled which concluded pre-admission assessments are being completed prior to service users admission. These are carried out by the ex-services welfare society with further nursing needs assessments being completed. Tyrwhitt House DS0000013365.V293709.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7 & 9 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Each service user is provided with an individual care plan, which details the individual’s health, personal, emotional and social needs. Further work is required in ensuring that plans are signed by staff and service users to ensure that they are fully involved in the process. The home is able demonstrate that service users are able to make decisions about their lives with support when needed. EVIDENCE: Three care plans were sampled which were detailed and comprehensive. The inspector spoke with two key workers who stated that they carry out interviews with individuals each time they attend the service. The care plan is revisited and any changes are added. This was confirmed by service users spoken to who stated that any decisions made are carried out in consultation
Tyrwhitt House DS0000013365.V293709.R01.S.doc Version 5.1 Page 11 with them and it was evident that service users are provided with detailed information about the services and therapies on offer to provide support. However a requirement was made that staff completing the care plan should sign the document, as there were still some gaps in staff signatures. There were also some gaps where service users have not signed to confirm that they have agreed to their plan and a further requirement was made that this is completed to ensure that service users are fully involved in the process. Detailed risk assessments are completed, however further work needs to be undertaken in respect of individuals who self medicate. Tyrwhitt House DS0000013365.V293709.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14,16 & 17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users take part in fulfilling activities and access the local community. Service users engage in a range of leisure activities and are supported to exercise choice. Service users are offered a well balanced diet. EVIDENCE: The service provides a wide range of recreational, therapeutic and social activities. During the inspection a number of service users were attending occupational therapy, which provides activities for example art, painting, metal work, writing therapy. The service provides group work, relaxation therapy, counselling, and trauma therapy. A social activities programme was displayed on the notice board with a variety of activities on offer if service users wish to attend which include swimming, boat trips and visits to historical sites or alternatively service users are able to choose their own activities which meets their individual preferences. Service users spoken to expressed positive comments about the activities available. One person said “ I go out on my bike to the shops”. Another individual said, “ There is plenty to do here”. Tyrwhitt House DS0000013365.V293709.R01.S.doc Version 5.1 Page 13 Positive relationships were seen between staff and service users. Service users are provided with keys for their rooms and their privacy is respected and a number of individuals were observed choosing to relax in the gardens A The inspector spoke to the chef and a two weekly menu is in place. Choices are accommodated if individuals do not like the main meal they can choose alternatives such as salads and omelettes for lunch. The meal at lunchtime was a good quality and nutritious and fruit and yoghurts were made available. At the previous inspection a number of comments were received about the quality and quantity of the meals. However during this inspection all service users were satisfied with the meals on offer. A feedback book has been introduced for service users to comment about the meals Tyrwhitt House DS0000013365.V293709.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19, 20 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The service is able to demonstrate that service users receive treatment and` support in the way they prefer. The physical and health needs of individuals are assessed and interventions and treatments are implemented to address them. Further work is required in ensuring that service users are safely protected by the homes medication administration policies and procedures. EVIDENCE: Each service user has a treatment plan, which is discussed, with each individual on admission to the home. There is a multi disciplinary approach to care and service users have access to a range of health professionals for example occupational therapy, relaxation therapy, counselling, anger and anxiety management, trauma therapy and group work. Service users complete health questionnaires and emotional needs risk assessments are undertaken. The homes medication administration systems were examined and these showed that the home has made some improvements in their handling of medication. The medication charts now included reconciling the information on medication labels with that provided by the service users own doctor.
Tyrwhitt House DS0000013365.V293709.R01.S.doc Version 5.1 Page 15 Photographs were available of individuals with their records. Two staff signatures were present for checking the medication stock on admission. A majority of the service users take their own medication and permission slips signed by service users were available. Records were maintained of medication returned to service users at the end of their stay. The homely remedies list had been updated and authorized by the local GP. The medication procedures for the home had been reviewed. However a requirement was made that staff must sign that they have read the procedures and it was concerning to note that this requirement has not been met since the previous inspections. For individuals who self medicate this decision is recorded in their notes and is based on an emotional needs risk assessment, interviews and history. However a further work is required for a separate detailed assessment to be completed for the self administration of medication to ensure that the health, welfare and safety of service users is protected by the homes medication policies and procedures. Tyrwhitt House DS0000013365.V293709.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home is able to demonstrate that there is an accessible complaints procedure in place. Further work is required to ensure that all staff receive training in safeguarding adults and to produce a local policy to ensure that service users are protected from abuse. EVIDENCE: A complaints procedure is in place and the service has received three complaints since the previous key inspection, which the inspector examined and it was concluded that complaints are, responded two effectively. Service users spoke positively of the care and support that they receive for example “ I give this place ten out of ten”. “ This is a good place the staff understand my needs and I look forward to my visits here”. The local authority safeguarding adult’s procedure and whistle blowing policy were available. A previous requirement had been made that all staff must complete up-to-date training in the safeguarding adults and a local policy to be implemented which makes reference to the local authority procedures. The manager was able to show evidence to the inspector that staff had been booked on to course, which had been cancelled outside of his control. It was concerning to note that that the original requirement should have been met on 6.12.05 and was brought forward to the 14.4.06. The manager told the inspector that a new date had been booked and was able to show evidence for this. Further requirements were made that all staff receive training in safeguarding adults and that the introduction of a local safeguarding adult
Tyrwhitt House DS0000013365.V293709.R01.S.doc Version 5.1 Page 17 policy must be introduced within the timescale set to ensure that service users are protected from abuse. Tyrwhitt House DS0000013365.V293709.R01.S.doc Version 5.1 Page 18 Environment
The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 25 & 30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home is able to demonstrate that progress has been made in improving the communal areas of the home, but further work is required to ensure that the outstanding refurbishment programme is completed in all bedrooms to ensure service users have pleasant and comfortable rooms to stay in. The home is clean and hygienic but the home needs to ensure that the cleanliness of the showers is maintained. EVIDENCE: The home has made improvements in the refurbishment of the home. A number of carpets have been replaced and the smoking room has been redecorated and new armchairs acquired. Large gardens are available which are pleasant and well maintained. Bed mattresses have been replaced and there is currently ongoing programme for refurbishment of bedrooms and a further requirement was made that this work is completed to ensure that service users have pleasant, comfortable rooms to stay in and it is required that a shower curtain is replaced in one bathroom Tyrwhitt House DS0000013365.V293709.R01.S.doc Version 5.1 Page 19 The home was clean and hygienic and separate laundry facilities are available. A cleaning schedule is in place, which is on display recording what times cleaning takes place. However due to past problems with the cleanliness in the shower rooms which service users had raised a previous requirement had been made that these areas are cleaned twice a day and records sampled did not indicate that this was happening. A further requirement was made that the showers must be cleaned twice a day to ensure that service users have pleasant, clean and hygienic facilities to use. Tyrwhitt House DS0000013365.V293709.R01.S.doc Version 5.1 Page 20 Staffing
The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32,34,35 & 36 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. There was room for improvement in respect of the staffing arrangements for example; the registered manager should ensure that at least fifty percent of staff have completed National Vocational Qualifications. Two references on staff files must be made available. Accurate staff training schedules must be maintained. Staff should receive up to date training in fire prevention, food hygiene and infection control. This is to ensure that the health, wellbeing and safety of service users is protected. EVIDENCE: The staff training schedule was sampled which confirmed that two staff have completed National Vocational Qualifications (Levels two and three) with three other staff completing the programme. A requirement was made that the registered manager must ensure that at least fifty percent of care staff must complete National Vocational Qualifications. This is to ensure that service users are supported by suitable and qualified staff to promote their health and wellbeing. The staff-training schedule was examined and dates were recorded for mandatory training including fire, first aid, manual handling, and food hygiene. One persons training record was sampled and it was clear that food hygiene
Tyrwhitt House DS0000013365.V293709.R01.S.doc Version 5.1 Page 21 training had not been received for a number of years which was confirmed by his training certificates maintained on his file. The registered manager informed the inspector that manual handling training was taking place soon. Fire training should be updated and there was no evidence recorded to state that staff have received training in infection control. Staff receive induction training, however copies of these were not available on some staff files. A requirement was made that an accurate record must be obtained for all staff training completed and that all staff receive regular mandatory training to ensure that the health, welfare and safety of service users is protected by appropriately trained staff. It is also strongly recommended that copies of staff training certificates be maintained on individual’s records. Three staff personal files were sampled and it was evident that police checks are carried out and the personnel officer confirmed that protection of vulnerable adults first checks were completed prior to staff commencing employment. However not all files contained two written references. A requirement was made that the registered manager must ensure that two written references are obtained to ensure that service users are protected by the homes recruitments policies and procedures. The inspector discussed with two members of staff about the arrangements for their formal supervision. It was confirmed that they attend fortnightly group supervision. A further individual supervision takes place, which is conducted by an external facilitator. However a previous requirement for all staff to receive formal, documented supervision has still not been met and this is to include both nursing and care staff. A further requirement was made staff must receive formal supervision at least six times a year within the timescale set. Tyrwhitt House DS0000013365.V293709.R01.S.doc Version 5.1 Page 22 Conduct and Management of the Home
The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39, 40 & 42 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The registered manager has the appropriate qualifications and experience to manage the home. The home is able to demonstrate that the financial interests of service users are protected. The home has made progress in ensuring that quality assurance systems are in place. Two health and safety issues need to be addressed to ensure the health, welfare and safety of service users is protected. EVIDENCE: The registered manager is a qualified nurse who holds management qualifications and has undertaken training and development. An open approach was observed in the home. The responsible individual carries out monthly quality visits (regulation 26) and copies of the report are made available to the Commission for Social Care Inspection. Service users have the opportunity to complete exit questionnaires at the end of their stay. Service user meetings are held and minutes were
Tyrwhitt House DS0000013365.V293709.R01.S.doc Version 5.1 Page 23 sampled. A feedback book is in place for service users to record their comments about the quality of the meals. The inspector spoke to the service research assistant who has commenced a pilot project in respect of feedback questionnaires. A sample copy was supplied to the inspector and the outcome of the questionnaire is expected in June. A recommendation was made that the outcomes of the questionnaire are made available to the Commission for Social Care Inspection. Some service users have chosen to let the service look after their monies and property while they are staying in the service. Records sampled were recorded and maintained appropriately with both staff and service users signing in and out with a secure safe available. During a tour of the premises it was evident that that walkways had been cleared of rubbish however a ladder was found stored obstructing the staircase and the manager immediately responded to this issue. However previous requirements were made in respect of items stored in the cellar therefore this requirement remains outstanding. A number of health and safety records were sampled including fire equipment checks, health and safety audits, water checks and accident records which were completed appropriately. However there were occasional gaps in daily fridge temperature records and the registered manager must ensure that all mandatory training is kept up to date including food hygiene, fire prevention and infection control to ensure that the health, welfare and safety of service users is protected. Tyrwhitt House DS0000013365.V293709.R01.S.doc Version 5.1 Page 24 SCORING OF OUTCOMES
This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from:
4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable
CHOICE OF HOME Standard No Score 1 3 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 3 25 2 26 X 27 X 28 X 29 X 30 2 STAFFING Standard No Score 31 X 32 2 33 X 34 2 35 2 36 2 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 X 2 X LIFESTYLES Standard No Score 11 3 12 3 13 3 14 3 15 X 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 X 3 X 3 3 X 2 X Tyrwhitt House DS0000013365.V293709.R01.S.doc Version 5.1 Page 25 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)(2) Requirement The registered person must ensure that service users agree and sign their individual plan. Timescale for action 11/06/06 2 YA6 13(2) 3. YA23 13(6) a) The registered person 11/05/06 must ensure that the medication administration policy is read and signed by all staff. b) Detailed risk assessments must be completed for all individuals who self medicate. The registered person must 11/07/06 ensure that all staff receive up to date training in safeguarding adults and to complete a local policy that includes reference to the local authority safeguarding adults procedures. (Previous requirement 14/4/06 not met). a) The registered persons must ensure that the cleanliness of the home is regularly reviewed and in particular the showers which due to frequent use must be cleaned at least twice daily. (Previous
DS0000013365.V293709.R01.S.doc 4. YA30 23 (2)(d) 11/08/06 Tyrwhitt House Version 5.1 Page 26 requirement not met) b) A shower curtain must be replaced in one bathroom. C) The redecoration and replacement of carpets must be completed in all bedrooms. A schedule of the planned dates for completion of this programme must be supplied to the commission for Social Care Inspection. 5 YA32 18(1)(a) The registered person must ensure that at least fifty percent of care staff have gained National Vocational Qualifications (Level 2 or above). The registered person must ensure that all staff files contain two written references. a) All new staff must receive induction training and written records must be maintained on personal files. b) An accurate training schedule must be updated to include all training and development completed. C) All staff who are involved with food handling must receive up to date training in food hygiene. All staff must receive up to date training in fire and infection control. The registered person must ensure that that all staff have recorded formal supervision at least six times a year (previous requirement 14/4/06 not met) Regular monitoring must take place to ensure that the walkways in the cellar are free
DS0000013365.V293709.R01.S.doc 11/08/06 6 7 YA34 YA35 19(4)(5) Schedule2 18 (1)(a) 11/07/06 11/07/06 8 YA36 18(2) 06/07/06 9 YA34 23(4)(a) 11/05/06 Tyrwhitt House Version 5.1 Page 27 from obstructions. 10 YA42 16(2)(j) The registered person must ensure that the temperature of the fridge is recorded daily. 11/05/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard YA35 Good Practice Recommendations It is strongly recommended that the registered person should maintain copies of staff training certificates on their individual files. It is recommended that the registered manager should consider making the outcome of the service users questionnaire available to the Commission for Social Care Inspection. 2. YA39 Tyrwhitt House DS0000013365.V293709.R01.S.doc Version 5.1 Page 28 Commission for Social Care Inspection Surrey Area Office The Wharf Abbey Mill Business Park Eashing Surrey GU7 2QN National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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