Care Home: Tredegar Care Home

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What the care home does well There is a dedicated team of staff who care for the residents and who treat them with dignity and respect their privacy. Visitors commented, "The staff are wonderful", and "I could not praise the staff enough". Residents receive a varied and balanced diet, and visitors are welcome to join them for meals. A visitor commented, "I could have joined him for Christmas lunch if I had wanted to". Residents are given choices in all aspects of their lives and are encouraged to personalise their own rooms to make them more homely. A variety of activities are on offer and special occasions are celebrated, e.g. Birthdays, Christmas, Easter, Mothering Sunday, Valentines Day. The home is well managed and has robust Quality Assurance systems in place to gain the views of their stakeholders and to keep regular audits of the quality of care provided. General comments from visitors included, "I think its wonderful", "He is happy here", "She is safe here", "We are very pleased with the place", and "I would give it a good recommendation". What has improved since the last inspection? The requirements on the last report have been met. The home now has protocols in place for tissue viability. Proof of identification and a photograph is on each staff members file, and mandatory training is now up to date. The home were able to obtain some grant funding and with the money have purchased a summer house and two raised planting areas for residents to be able to do some gardening. They have also purchased a computer for the residents to use. CARE HOMES FOR OLDER PEOPLE Tredegar Care Home 13 Upper Avenue Eastbourne East Sussex BN21 3UY Lead Inspector Chris Woolf Unannounced Inspection 12th March 2008 08:50 X10015.doc Version 1.40 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 Tredegar Care Home DS0000014069.V361032.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 Older People. 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. Tredegar Care Home DS0000014069.V361032.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Tredegar Care Home Address 13 Upper Avenue Eastbourne East Sussex BN21 3UY 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) 01323-412808 01323 731119 tredegar@new-meronden.co.uk New Century Care (Eastbourne) Limited Sandra Barnes Care Home 26 Category(ies) of Old age, not falling within any other category registration, with number (26) of places Tredegar Care Home DS0000014069.V361032.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. Service users should be aged 65 and over on admission. A maximum of 26 service users may be accommodated at any one time. 12th July 2006 Date of last inspection Brief Description of the Service: Tredegar is a detached property, which has been converted and adapted as a care home in Eastbourne. It is owned by New Century Care Ltd and provides nursing and personal care for up to 26 residents of an older age. Tredegar is arranged over three floors with a shaft lift providing access to all floors. There are five double bedrooms, two of which have en-suite facilities and sixteen single rooms, nine with en-suites. The home has hoists and bath hoists, and there are grab rails and disability aids in the bathrooms and toilets. Two lounges and a dining room provide communal space and there is access to a garden with a seating area. At the front of the home, there is a parking area for several cars. The home is situated within walking distance of the main town, mainline railway station and main bus routes. The seafront and a large park area are approximately a mile away. Prospective residents or their representatives are welcomed to view the premises, discuss their needs with the Registered Manager and to spend time with the staff and residents. The current fees for the service at the time of the visit range from £485.00 to £720.00 per week. Information on the Home’s services and the CSCI reports for prospective service users will be detailed in the Statement of Purpose and Service User Guide. The e-mail address of the home is tredegar@newmeronden.co.uk Tredegar Care Home DS0000014069.V361032.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 2 star. This means the people who use this service experience good quality outcomes. The information for this report has been gained from information passed on to the Commission prior to the inspection and a site visit to the home. The site visit was unannounced. This means that neither the staff nor the residents knew that we (the Commission) were going to visit. The visit lasted for 7 hours. During the site visit we talked with a number of residents, 4 visitors, the staff on duty, and the deputy manager. The Area Manager was present for the majority of the day and the Operations Director was present for a while in the morning. The Registered Manager was on leave at the time of the site visit but the Deputy Manager gave us all of the assistance we needed. We had a tour of the building. We observed the interactions between staff and residents. We saw the lunchtime meal being served. We also looked at a variety of records including care plans, staff files, complaints records, menus, activities records, medication records, and a selection of records relating to health and safety What the service does well: There is a dedicated team of staff who care for the residents and who treat them with dignity and respect their privacy. Visitors commented, “The staff are wonderful”, and “I could not praise the staff enough”. Residents receive a varied and balanced diet, and visitors are welcome to join them for meals. A visitor commented, “I could have joined him for Christmas lunch if I had wanted to”. Residents are given choices in all aspects of their lives and are encouraged to personalise their own rooms to make them more homely. A variety of activities are on offer and special occasions are celebrated, e.g. Birthdays, Christmas, Easter, Mothering Sunday, Valentines Day. The home is well managed and has robust Quality Assurance systems in place to gain the views of their stakeholders and to keep regular audits of the quality of care provided. Tredegar Care Home DS0000014069.V361032.R01.S.doc Version 5.2 Page 6 General comments from visitors included, “I think its wonderful”, “He is happy here”, “She is safe here”, “We are very pleased with the place”, and “I would give it a good recommendation”. 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. Tredegar Care Home DS0000014069.V361032.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Tredegar Care Home DS0000014069.V361032.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 3, & 4. Standard 6 is not applicable in this home Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Prospective residents can be confident that their needs will be assessed, and that they will not be admitted to the home unless the home is happy they can meet these needs EVIDENCE: The manager visits all prospective residents either in their current home or in hospital to carry out an in depth pre-admission assessment. This assessment covers the physical and mental health and personal care needs, as well as any cultural or diversity needs. A resident said, “Someone came to see me at the hospital”. A visitor commented, “The manager came out and saw her to do an assessment”. When a prospective resident is being ‘care managed’ by Social Tredegar Care Home DS0000014069.V361032.R01.S.doc Version 5.2 Page 9 Services a copy of the joint assessment is also obtained. The assessment enables the resident and the home to be sure that any assessed needs are able to be met by the home. Prospective residents and/or their representatives are welcome to visit the home to find out what facilities are available. A resident commented, “My daughter looked around”. All prospective residents are given a copy of the homes Statement of Purpose and Service User Guide to ensure they have sufficient information for them to make an informed choice about entering the home. The first month of any admission is classed as a trial period. This home does not offer Intermediate Care. Intermediate care is a specialised service with dedicated accommodation and intense rehabilitation aimed at enabling residents to return to their own homes. Tredegar Care Home DS0000014069.V361032.R01.S.doc Version 5.2 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9, & 10 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Resident’s health and personal care needs are recorded in their care plans and are met by the home, supported by a multi-disciplinary health care team. Residents are treated with dignity and their right to privacy is respected. EVIDENCE: A person centred care plan is drawn up by the home for each resident. The care plan is based on the pre-admission assessment and includes physical and mental health needs as well as social, cultural, spiritual and sexual needs. Care plans are regularly updated to reflect any changes in these needs. One care plan for a recent resident, seen on the day of the site visit, did not have all of the assessments completed. Some of the care plans did not have the resident’s wishes regarding actions to be taken at the time of their death Tredegar Care Home DS0000014069.V361032.R01.S.doc Version 5.2 Page 11 completed. This could result in additional trauma for the families at the time of death. A requirement is made that all assessment should be completed as soon as possible after admission including the residents wishes around procedures at the time of their death. The registered nurses in the home, supported by the senior carers and care staff, ensure that the assessed health and personal care needs of each resident are met. There was a requirement on the last report that the home should introduce a protocol with regard to pressure sores. This protocol is now in place. At the time of the inspection site visit there were no residents suffering with pressure sores. Nutritional screening is undertaken for each resident on admission and weights are recorded monthly. When necessary action is taken to address and significant variations. The residents have access to a variety of health care professionals and all contact with health professionals is recorded in the residents care plan. A resident said, “The care is good”. Visitors commented, “They certainly seem to care about the people here”, “They are really good with him, they have even got him walking”, “As soon as she came in here her panic attacks stopped”, and “The care is very good”. The trained nurses deal with the medication in the home. There are clear policies and procedures on the handling of medication and these include a homely remedies policy. The recording of receipt, administration and disposal of drugs is sufficient to allow an audit trail to be undertaken. A resident said, “The staff give me my tablets and I take them”. Residents in the home are treated with dignity and their right to privacy is upheld. A resident commented, “The staff treat me with dignity”. Where residents share a room privacy curtains are provided to enable personal care to be carried out in private. There had been some problems over resident’s clothes going missing when sent for laundry. The home have now introduced a policy that all clothes are to be labelled to avoid this possibility. Tredegar Care Home DS0000014069.V361032.R01.S.doc Version 5.2 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, & 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents have choices in all aspects of their daily life. Activities are available to meet their social needs; they are encouraged to maintain contact with family and friends; and they receive a nutritious and balanced diet. EVIDENCE: An activities coordinator is employed by the home for 4 days each week. On the days when she is not on duty the care staff assist residents with activities. Activities include 1:1 sessions as well as group sessions. Residents commented, “I choose not to join in the activities, I am not that sort of person”, and “I like my knitting, I knit these then someone sews them up to make blankets to send to Africa”. Visitors commented, “They have quizzes and bingo”, “They have bar-b-ques in the summer”, and “He used to take part and enjoy the activities. He cant do so much these days, but they do play board games with him 1:1”. The activities coordinator often takes people out Tredegar Care Home DS0000014069.V361032.R01.S.doc Version 5.2 Page 13 in the garden and sometimes takes 2 or 3 at a time further afield. Some of the residents are looking forward to being able to do some gardening now that two raised garden beds have been provided which are accessible to residents who cant bend down or who are in wheelchairs. In addition to the normal inhouse activities there are parties for special occasions such as Easter, Valentines Day, and Mothering Sunday. Visiting entertainers are brought in regularly. Visitors said, “They have entertainers in quite regularly, they had a lovely pantomime at Christmas”, “They make a big thing of Valentines day, everyone has a card, and family are invited in”, and “We were here on Mothers day, it was excellent, entertainment, food, drinks”. A company that do physical motivation for the elderly visit the home 3 monthly and details of their next planned visit was on display in the hallway. The home is currently making arrangements for a mini bus to take residents out for outings once the weather improves. A newsletter, produced alternate months, has been introduced to keep residents and their families informed about what is going on in the home. The home was able to obtain some grant funding and as well as purchasing the new summerhouse they have also purchased a computer for the residents to use. Resident’s cultural and religious needs are supported by the home. At present all of the clients are Christian but other denominations would be welcomed as long as the home could meet their needs. The home holds a Holy Communion service twice a month and each Sunday a church service or visits to the church are arranged for those who wish to participate. Visitors are made welcome in the home and there is no restriction of visiting times. Visitors commented, “We vary the times we come, we are always made very welcome and offered a cup of tea. There are no restrictions on visiting”, and “They are always here for me as well as for him”. Residents have choice in all aspects of their daily lives. They or their representatives deal with their financial affairs. The home has details of independent advocates available for any resident who may require this service. Residents are able to bring some of their own personal possessions into the home to personalise their own space. Residents receive a varied and balanced diet with choices at all meals. Residents said, “I like the food, its very tasty”, and “The food is fine, there is always a choice for lunch and tea”. The majority of food is fresh cooked on the premises using fresh meat and vegetables. Fresh fruit is always available on request. Residents’ likes and dislikes are recorded and used to help develop the menus. One member of staff goes round each day to check the menu choices for the day. Tredegar Care Home DS0000014069.V361032.R01.S.doc Version 5.2 Page 14 A glass of sherry is offered to residents who wish to take advantage of the offer each Sunday. The home intends to put corkboards up in each resident’s bedroom to display the weekly menu and activities on offer. All kitchen staff have attended nutrition training and the head chef teaches food hygiene to staff from the group. Visitors commented, “I have never heard her complain about the food”, “They monitor what mum eats and drinks”, and “The food is wonderful. He loves his food and they get a good choice”. Tredegar Care Home DS0000014069.V361032.R01.S.doc Version 5.2 Page 15 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16, & 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents can be confident that their concerns and complaints will be listened to and acted upon and that they will be protected from abuse. EVIDENCE: The home has a clear and accessible complaints procedure and a copy is on display in the hallway. Since the last inspection there have been 2 complaints recorded. Both were satisfactorily resolved within the agreed timescales. A visitor commented, “When we have mentioned anything its sorted immediately”. Residents living in the home are protected from abuse. No new member of staff is employed until a satisfactory check of the Protection of Vulnerable Adults (POVA) Register has been received. All staff have basic POVA training during their induction and this is followed by a more depth session at a later date. There was one adult protection incident investigated since the last inspection, no evidence was found, and the allegation was not substantiated. Tredegar Care Home DS0000014069.V361032.R01.S.doc Version 5.2 Page 16 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 24, & 26 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents live in a home which is in need of some redecoration to make it homely; but it is clean, and has bedrooms personalised to meet residents needs EVIDENCE: Tredegar is a detached property situated in a residential part of Eastbourne. It is within easy access of the shops and the railway station. Although there are steps to the main front door there is an alternative entrance at the side available for wheelchairs or those with mobility problems. One visitor commented, “Occasionally at weekends they don’t hear the door bell”. Tredegar Care Home DS0000014069.V361032.R01.S.doc Version 5.2 Page 17 This was discussed with the Area Manager and Deputy Manager and they agreed to investigate an alternative system where the doorbell could be heard from all areas of the home. The communal areas, which consist of 2 lounges and a dining room, are light, airy and are appropriately furnished. The home is in the process of replacing all lamps and shades throughout the home. They are also intending to replace all light bulbs with energy saving bulbs. It was noted that some of the décor in the home is beginning to look ‘tired’ and worn. A requirement has been added that the home should produce a plan of maintenance and decoration needed with timescales for action. A copy of this plan should be submitted to us. The home has a very pleasant garden area at the rear. The garden can be accessed by wheelchairs or less mobile residents by ramped access. There are tables and chairs for residents to enjoy the fresh air and sunshine and a new summerhouse and raised planters have been obtained with grant funding. Residents are now looking forward to the better weather to make use of these new facilities. Off road car parking is available in front of the house and the driveway has recently been repaired. Accommodation in the home is arranged over 3 floors and a shaft lift provides access to all floors. The home has 16 single and 5 double bedrooms, some, although not all have en suite facilities. A resident commented, “I’ve got my own toilet”. All rooms have lockable drawer facilities and are fitted with nurse call system and smoke detectors. Rooms used for double occupancy have privacy curtains to ensure that personal care tasks can be carried out in private. Residents are able to bring in their own ‘bits and pieces’ to personalise their rooms. Residents commented, “I brought in my own bed, it’s a special one”, and “It’s a nice room”. The home has suitable infection control procedures in place. The laundry is fitted with 2 washing machines with appropriate programmes to meet disinfection standards. Sufficient personal protective equipment is provided for staff to use. Hand washing facilities and provided in all of the necessary areas. The domestic staff keep the home clean and reasonably free from odours. Visitors commented, “Its nice and clean”, “There are rarely any nasty smells, only if someone has just had an accident”, and “Its kept clean”. Tredegar Care Home DS0000014069.V361032.R01.S.doc Version 5.2 Page 18 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29, & 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. A dedicated staff team who have been trained to meet their needs care for residents. EVIDENCE: There is a registered nurse on duty in the home at all times. Senior care assistants, care assistants, domestics, and catering staff, support the nurse. Currently 6 of the 14 care staff are trained to NVQ level 2 or above with a further 7 doing this training. In addition 1 has already completed and a further 2 are doing level 3; and 1 is doing her Registered Managers Award. Staff said, “I did NVQ 2 at College and I am starting NVQ 3 here” The home has robust recruitment procedures in place. No new member of staff is employed to work in the home until a Criminal Records Bureau enhanced disclosure has been submitted; and a satisfactory check of the Protection of Vulnerable Adults register and 2 satisfactory references have been obtained. Tredegar Care Home DS0000014069.V361032.R01.S.doc Version 5.2 Page 19 All new staff receive induction training to skills for care specifications. The trained nurses undertake regular training to maintain their professional qualifications and status. The majority of training for the care and ancillary staff is done in house. Staff are either up to date or booked to attend the mandatory training subjects, POVA, and Dementia care. 12 staff have received ‘vision’ training in the past year and 8 have recently attended a course on ‘treating adult malnutrition in the community’. Staff said, “I did training in eye care”, “I did the POVA course”, and “I did a nutrition course”. Residents comments about staff included, “They are very kind and thorough”, and “The staff are very nice”. Visitors said, “They are very helpful”, “They are all very good”, and “Always more than helpful”. General comments from staff included, “Everyone is welcoming and lovely to talk to, the staff are a good team”, and “I enjoy working here, my 7 years speak for themselves”. Tredegar Care Home DS0000014069.V361032.R01.S.doc Version 5.2 Page 20 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. 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 and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35, & 38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is run in the best interests of the residents. The health, safety and welfare of residents and staff is protected. EVIDENCE: The Registered Manager of the home is a first level registered nurse who has worked in the care of the elderly for 29 years. She has attained the Registered Managers Award. A Deputy Manager who is NVQ qualified and who has also worked in the field for several years supports her. There are clear Tredegar Care Home DS0000014069.V361032.R01.S.doc Version 5.2 Page 21 lines of accountability within the home and within the Group as a whole. On the day of the site visit the Registered Manager was on leave but the Deputy Manager gave us all of the help we needed. The group’s Operations Manager visited the home in the morning of the visit and the Area Manager was present for the majority of the day. Visitors commented, “Its well run”, and “The management is good”. Staff confirmed that they get support from the management. The home has good quality assurance systems in place. Questionnaires are sent to residents, families, and staff and the results are published with a copy placed in the hallway for all to see. Meetings with residents and their families are held regularly. A comprehensive list of regular audits is now in place. Resident’s families or representatives deal with their financial affairs. The chiropodist deals directly with the resident’s families. The hairdresser is paid out of the homes petty cash and then reimbursed by the families. The health, safety and welfare of residents and staff is protected. All staff receive the necessary training in the mandatory health and safety related subjects. Accident, fire, and safety records checked were all up to date. Tredegar Care Home DS0000014069.V361032.R01.S.doc Version 5.2 Page 22 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People 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 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 3 3 X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 1 X X X X 3 X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 3 Tredegar Care Home DS0000014069.V361032.R01.S.doc Version 5.2 Page 23 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 OP9 Regulation 15 (1) Requirement Timescale for action 31/05/08 2 OP19 23 (2) (b & d) All assessment in care plans should be completed as soon as possible after admission; including details of the resident’s wishes around procedures at the time of their death. The home should produce a plan 16/06/08 of decorating and maintenance needed, together with timescales for action; and a copy of the plan should be submitted to the Commission RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Tredegar Care Home DS0000014069.V361032.R01.S.doc Version 5.2 Page 24 Commission for Social Care Inspection Maidstone Office The Oast Hermitage Court Hermitage Lane Maidstone ME16 9NT 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 Tredegar Care Home DS0000014069.V361032.R01.S.doc Version 5.2 Page 25 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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