Inspection on 24/09/07 for Tyrwhitt House

This inspection was carried out on 24th September 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 8 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Tyrwhitt House 11/12/08

Tyrwhitt House 11/12/07

Tyrwhitt House 11/05/06

Tyrwhitt House 06/09/05

Tyrwhitt House 06/05/05

Tyrwhitt House 09/11/04

Tyrwhitt House 27/05/04

Similar services:

1 Marten Road

Daubeney House

Three Gables

Aldwick House

49 Glendale

The Springs Community

Crossways Community

Belle Vue Country House

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

CARE HOME ADULTS 18-65 Tyrwhitt House Oaklawn Road Leatherhead Surrey KT22 0BX Lead Inspector Kenneth Dunn Unannounced Inspection 24th September 2007 10:00 DS0000013365.V345453.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 DS0000013365.V345453.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. DS0000013365.V345453.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Tyrwhitt House Address Oaklawn Road Leatherhead Surrey KT22 0BX 01372 841634 01372 841601 cmth@combatstress.org.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) 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 DS0000013365.V345453.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 8th September 2006 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. Fees for the service range from £53,320.00 to £75,000.00 per annum. DS0000013365.V345453.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This site visit was unannounced and took place over five hours. Mr. Kenneth Dunn, Regulation Inspector, undertook the site visit on behalf of the CSCI. The registered manager represented the establishment. A full tour of the premises took place. Discussions with people who use the service (veterans) and staff were held informally and formally to canvass their experiences of the home. An annual quality assurance assessment (AQAA) was supplied to the home by CSCI, and this was completed and returned. Information from the AQAA will be referred to in this report. The AQAA states that the home has policies and procedures to promote equality and diversity and all staff have received training, to increase their knowledge and awareness of these issues. The final report takes into account detailed information provided by the registered provider, Annual Quality Assurance Assessment (AQAA), returned surveys (next of kin, medical professionals, care manger and any other interested representatives of the residents) in addition any information that the CSCI has received about the service since the last inspection will also be used to complete this report. The Commission for Social Care Inspection would like to thank the veterans, relatives, manager and staff for their hospitality, assistance and co-operation with this inspection. What the service does well: Tyrwhitt House provides an opportunity for the veterans who receive respite care from the service to live in an environment that is open, relaxed and is describe as having a “friendly atmosphere”. The inspector spoke to veterans who were being admitted to for respite and two further veterans to gain their views on their experience of using the service. They spoke very favourably about the staff and the approachability they found from everyone at the service. The service provides a wide and varied range of therapeutic, recreational and social activities. The activities are designed specifically to meet the needs and aspirations of the available veterans. The care plans are fully user focused and are designed around the needs and preferences of individuals. DS0000013365.V345453.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. DS0000013365.V345453.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 DS0000013365.V345453.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): Standard 2 was assessed during this visit. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. All veterans are assessed using multidisciplinary assessments in order to allow the manager and the clinical team to identify and respond to their needs and aspirations. EVIDENCE: The inspector sampled four files, which concluded pre-admission assessments are being completed prior to the admission of the veterans. The assessments are community based and multidisciplinary; they are carried out by a team of professionals GP’s, Community Physiatrist Nurses and ex-services welfare societies with further nursing needs assessments being completed by the inhouse team at Tyrwhitt’s House. DS0000013365.V345453.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): Standards 6, 7and 9 were assessed during this visit. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The individual plans are clear and comprehensive including details of needs and goals of the veterans. The plans incorporate known or indicated preferences and choices, and include in depth risk assessments. EVIDENCE: Four care plans were sampled during the visit; they were detailed and comprehensive and offered a rounded picture of the individual who owned the documents. The inspector spoke with members of the nursing staff who confirmed that they conduct extensive discussions with the veterans as the come back to the service or attend it for the first time. The care plans were described by one charge nurse as being fluid and are subject to multiple changes during the course of the veterans stay at Tyrwhitt House. Inline with a requirement for the previous site visit by the CSCI (11th of May 2006), all staff completing the care plan now sign the document and complete a tick box contained on file stating that this has been done. In addition the DS0000013365.V345453.R01.S.doc Version 5.2 Page 10 veterans are encouraged to sign the agreed plan to confirm that they have agreed with the provision within the document. The inspector sampled a series of detailed and in depth risk assessments, completed by the staff on every aspect of the care and support offered to individuals during their stay at the service. DS0000013365.V345453.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): Standards 12, 13, 15, 16 and 17 were assessed during this visit. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The veterans have opportunities for personal development and to take part in appropriate activities within the service and in the local community. They are supported and enabled to maintain and develop appropriate personal and family relationships. Systems are in place to ensure that their rights are respected. Arrangements are in place to ensure that a balanced diet is offered by the service. EVIDENCE: The veterans are provided with a range of recreational, therapeutic and social activities. The service has developed a series of therapies to encourage and enable the veterans to engage with the rehabilitation offered at Tyrwhitt House. The veterans can join relaxation therapy, counselling, and trauma therapy groups to asset them to re-intrograte into their local communities. In addition to the therapeutic activities the service also encourages the veterans to participate in a number of social activities. A programme of DS0000013365.V345453.R01.S.doc Version 5.2 Page 12 activities was displayed on the veteran’s notice board and included swimming, boat trips and visits to historical sites. A member of the care team informed the inspector that the veterans have the right to opt for an alternative programme that meets their own individual preferences. The inspector witnessed positive relationships between staff and the veterans and they appeared genuinely happy to interact with one and other. The inspector was informed that a two weekly menu was in place however if a veteran does not wish to have the meals offered they could choose alternatives. The dining room, however, does not offer a pleasant environment for the veterans to sit and enjoy their meals. The inspector was informed that due to subsidence in the bay window in the dining room there has had to be considerable building work undertaken by the service. The ongoing work has been going on for some considerable time and a completion date must be set. For further information please refer to page 20 of this report. DS0000013365.V345453.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): Standards 18, 19, and 20 were assessed during this visit. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Personal support is good enabling the veterans to receive personal support in the way they prefer and require. Access to healthcare is good ensuring the physical and emotional needs of individuals are met. The arrangement for the storage and administration medications has been strengthened. EVIDENCE: The service is dedicated to promoting and reinforcing the independence of veterans and to maximise their privacy and dignity. The staff develop a treatment plan in conjunction with each individual at the point of admission to the home. There is a multi disciplinary approach to care and the veterans have access to a range of health professionals for example occupational therapy, relaxation therapy, counselling, anger and anxiety management, trauma therapy and group work. The veterans are supported to complete a DS0000013365.V345453.R01.S.doc Version 5.2 Page 14 full health questionnaire and emotional needs risk assessments are undertaken. During a discussions one veteran commented to the inspector that ‘‘rehabilitation is hard work’’ and also stated that ‘‘I had a psychiatric review to help me with my recovery’’, and that “the staff here (Tyrwhitt House) help me get sorted”. The service has reinforced their medication policy and the charge nurse have developed a series of risk assessment for all veterans who self medicate, in addition the staff clearly state why a person is deemed not suitable to self medicate. DS0000013365.V345453.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): Standards 22 and 23 were assessed during this visit. Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. The service has a fully accessible complaints procedure in place. However the recording of complaints requires to be improved and staff training in safeguarding adults still remains an issue. EVIDENCE: A full set of policies and procedures are in place to ensure that any complaints received will be treated uniformly and within a set time and framework. The completed AQAA stated that the service has received 9 complaints in the last 12 months, 7 of which were resolved within 28 days, 4 complaints were upheld and 1 complaint is awaiting a final outcome. However the inspector was unable to substantiate the AQAA on the day of the site visit due to the way the service stores this data. The organisation employs a member of staff to collate and analyse complaints; on the day of the site visit this person was on leave, as a result the manager could not locate the log. A previous requirement had been made that all staff must complete up-to-date training in the safeguarding adults. At the time of this site visit 8 members of the care team had still not undertaken any form of safeguarding training and the manger was unable to verify if any of the ancillary staff (sectaries, cook, cleaners, handyperson or driver) had either undertaken the courses or had been considered as candidates for the course. The manager stated that their has been problem in accessing training but this has been an on going issue since the original requirement should have been met on 6.12.05 and again 14.4.06 and was brought forward on the last inspection to the 11/07/06. DS0000013365.V345453.R01.S.doc Version 5.2 Page 16 Failure to comply with these may result in CSCI seeking legal advice, if these continue to remain unmet. DS0000013365.V345453.R01.S.doc Version 5.2 Page 17 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 24 and 30 were assessed during this visit. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The service is still in the process of ongoing refurbishment work. The general environment of the service is institutional and requires further work to make it homely. The service is relatively clean and hygienic but the home needs to ensure that the cleanliness of the communal showers, bathrooms and toilets is improved. EVIDENCE: The service has a set of security gates; to gain access to the site a veteran or a visitor must firstly work out how to gain entry to the grounds. Not only did the inspector have difficulty gaining access but also he witnessed couriers and deliverymen struggling to get on site. In addition two veterans commented on the frustration they felt when the intercom from the front gate went straight onto an answering machine and they were left waiting until someone finished one call and answered their call to allow them entry. DS0000013365.V345453.R01.S.doc Version 5.2 Page 18 The service has two bedroom wings; the bedrooms are of a suitable size and met the needs of the veterans during their respite stay at the service. However, one wing is showing considerable signs of heavy use; in several areas paint was pealing from the walls and the bedrooms are becoming rather tatty. In addition bathroom and a shower facilities in this wing were being used to store unwanted items of furniture and cleaning utensils. The overall cleanliness of the service is good however during the tour of the premises it was apparent that the communal bathing, shower and toilet facilities were only receiving light cleaning; heavy stains and mildew was common in all these areas. During the tour of the service the inspector found the PM section on the cleaning schedule on one wing had been completed by 12 noon and these areas did not look as if they had been cleaned recently. The carpets throughout the building were stained and in particular the main entrance was heavily stained and marked. The inspector was concerned about the use of donation signs on each bedroom door on both wings. The donation signs stated the name of the benefactor or organisation of the room stressing the charitable nature of the veterans stay at Tyrwhitt House. The possibility of relocating the signs was discussed with the manager and it was recommended that an alternative method of acknowledging a donation would be more appropriate and less obtrusive. The dining room has been in the state of disrepair for some considerable time; a temporary wall and window had to be erected as an interim measure after subsidence was found in the bay window, which was subsequently demolished and the temporary measures put in place. The dining room has a very institutional air about it because of the works being carried out does not offer the veterans a satisfactory place to eat. In addition a further consequence of the works being undertaken in the dining room is that the veterans were being served their meals in a general corridor and then going into the dining room to eat. This was discussed with the manager and a requirement was made for a completion date to be agreed and set and that the CSCI be notified of this agreement. DS0000013365.V345453.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): Standards 32, 34 and 35 were assessed during this visit. Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. All interactions observed between the staff and veterans evidenced a high degree of respect and skill. However training in all mandatory areas has remained an issue. EVIDENCE: The staff on duty demonstrated a good understanding of the needs of the veterans. The staff appeared respectful in dealing with issue that were presented to them and the inspector witnessed a good overall rapport between them. Training has continued to be an issue at the service and a review of the staff training matrix indicated that there are still considerable gaps in the mandatory requirements of care and ancillary staff. Gaps were identified in Basic First Aid, Manual Handling, Food Hygiene and Safeguarding Adults. The training matrix also confirmed that only three members of the care and DS0000013365.V345453.R01.S.doc Version 5.2 Page 20 ancillary staff have completed or are currently participating in a National Vocational Qualifications at either level 2 or 3. The inspector sampled four personal files they contained all the relevant documents as detailed in Schedule 2 of The Care Homes Regulations 2001. All staff has had a criminal record bureau (CRB) check and Protection of Vulnerable Adult (POVA) check prior to starting work in the home. It was apparent that the service operates a two file system the first files sampled by the inspector had a series of gaps identified and it was only when the inspector went to another department that the complete files were sampled. However in both sets of files the inspector found gaps in the employment histories in three of the four files sampled. A requirement was made that the registered manager must ensure that all gaps in the employment histories of current and potential staff must be explained and the reasons recorded on the individuals files. The service has reviewed and updated its supervision policies and procedures (the current addition dated March 2007). The policy is based upon the National Minimum Standards, and establishes the protocols for all staff to receive a minimum of six supervision sessions in one calendar year. The manager confirmed that the service is undertaking supervision of all staff on a regular bases. Clinical supervision and professional updates are offered to nursing and therapy teams. DS0000013365.V345453.R01.S.doc Version 5.2 Page 21 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 37, 39 and 42 were assessed during this visit. Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. The management approach in the service provides an open, positive and inclusive atmosphere. The service has a quality assurance and monitoring system in place. There is a however failings in the service in respect to the health and safety and protection of the veterans. EVIDENCE: The registered manager is a qualified nurse who holds relevant management qualifications and has undertaken further training and development to support him in his role as manager. The inspector observed an open approach to the management of the service and in the day-to-day dealings with the veterans and staff. DS0000013365.V345453.R01.S.doc Version 5.2 Page 22 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. The organisation employees a Quality Director who has the responsibility to collate all information about the service in relation to the care and outcome offered to the veterans during their stay at Tyrwhitt House. To achieve a clear picture of the quality of the service the veterans have the opportunity to complete exit questionnaires at the end of their stay, to allow them to highlight areas of poor practice environmental issues and any positive outcomes from their stay at Tyrwhitt House. In addition to the exit questionnaires the veterans are also encouraged to participate in the regular service meetings the minutes were sampled. Substances hazardous to health (COSHH) were stored securely and appropriately. Health and safety checks are completed and recorded regularly which were sampled including fire prevention records, fridge and water temperatures. However, during the tour of the premises a number of health and safety issues were observed and could be a potential risk to the veterans and staff. The door to the cellar was left jammed open directly accessing a flight of stairs and in the kitchen the inspector found a used mop and bucket left in the food preparation area, a loaf of bread under a work top sitting on a bag of potatoes and a quantity of dirty rags left on top of vegetables. In addition to the health and safety issues identified during the visit the failure to comply with requirements pertaining to the safety of the veterans is a serious issue. DS0000013365.V345453.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 2 23 1 ENVIRONMENT Standard No Score 24 2 25 3 26 X 27 X 28 X 29 X 30 2 STAFFING Standard No Score 31 X 32 2 33 X 34 2 35 1 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 2 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 3 X 2 X X 1 X DS0000013365.V345453.R01.S.doc Version 5.2 Page 24 Are there any outstanding requirements from the last inspection? Yes 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 YA23 Regulation 13(6) Requirement The registered person must ensure that all staff receives up to date training in safeguarding adults and to complete a local policy that includes reference to the local authority safeguarding adults procedures. (Previous requirements 14/04/06 and 11/07/06 not met). The registered person must provide the commission with details on how the service plans to ensure that 50 of staff are trained or are undertaking National Vocational Qualifications (Level 2 or above). Previous requirement 08/03/07 not met. The registered person must ensure that all gaps of employment on staff application forms are explored and detailed. The registered person must ensure that all staff working at the service receive all mandatory training. The redecoration and replacement of carpets must be completed. A schedule of the planned dates for completion of this programme must be DS0000013365.V345453.R01.S.doc Timescale for action 10/11/07 2. YA32 18(1)(a) 08/01/08 3. YA34 19(4)(5) Schedule2 13(6) 11/10/07 4. YA35 11/10/07 5. YA26 23(2)(d) 12/12/07 Version 5.2 Page 25 6. OP30 23 7. YA39 24 8 YA42 13(3-6) supplied to the Commission for Social Care Inspection. The registered person must 08/10/07 ensure that all communal facilities and rooms are fit for purpose. Specifically the on going reconstruction work in the dining room, and the storage of items of furniture and equipment in the bathrooms. All relevant documents for the 08/10/07 purpose of quality assurance must be fully available at all times. The registered person must 08/10/07 ensure that the health and welfare of the people who use this service are not compromised by poor cleaning practises, meals being served in corridors, staff failing to close doors to restricted areas. 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 YA24 Good Practice Recommendations It is strongly recommended that the registered person seek an alternative way of displaying thanks to the generous commitment of groups and organisations for their and support to Tyrwhitt House It is recommended that the registered manager should consider reviewing the means of access to the service from the main road. 2. YA24 DS0000013365.V345453.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 DS0000013365.V345453.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. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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