Care Home: Tynron

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What the care home does well Good information is available to people about the home. The needs of people planning to use the service are fully assessed prior to admission to the home to make sure that they can be met. Person centred plans and care plans generally give good information about the support needs of the residents. Risk plans are completed to help people live as independently as they can. People are offered a varied programme of social and leisure activities that reflects their individual interests. Appropriate arrangements are made so that people have regular contact with their friends and families. Dietary needs are well catered for. Medication is well managed. The home has a clear complaints procedure that is accessible to the residents. People live in a clean, comfortable and homely environment.Good Health and Safety arrangements are in place. People told us "I like living here, the staff are nice to me" and "I like the food, my room is good". What has improved since the last inspection? People who use the service have had review meetings that were attended by a care manager from their placing authority. All of the people who use the service have person centred plans. Confidential information was not on display in communal areas, paperwork/files have been placed in the office. 50% of the staff team has completed a National Vocational Qualification. A pharmacist has visited the home to offer advice on medication. People are attending an increased number of activities in the community. People have been supported to browse the Internet so that they can choose holiday`s day trips and activities. The fire panel and the gas boiler have been replaced. The manager has been registered with the Commission for Social Care Inspection to run the home. CARE HOME ADULTS 18-65 Tynron Church Road Purley Surrey CR8 3QQ Lead Inspector James O`Hara Key Unannounced Inspection 23rd September 2008 09:10 Tynron DS0000007213.V371488.R01.S.doc Version 5.2 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Tynron DS0000007213.V371488.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Tynron DS0000007213.V371488.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Tynron Address Church Road Purley Surrey CR8 3QQ 020 8763 0208 020 8763 0962 r.balgobin@sabp.nhs.uk Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Surrey and Borders Partnership NHS Trust Rajendranath Balgobin Care Home 11 Category(ies) of Learning disability (11) registration, with number of places Tynron DS0000007213.V371488.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category of service only: Care Home Only (CRH - PC) to service users of the following gender: Either whose primary care needs on admission to the home are within the following categories: 2. Learning disability - Code LD The maximum number of service users who can be accommodated is: 11 12th July 2007 Date of last inspection Brief Description of the Service: Tynron is a large detached house situated in a quite residential road in Purley. It is within walking distance of local shops and transport links. Tyron provides residential care for ten adults with Learning Disabilities some of who also have physical disabilities and/or epilepsy. The home also has one respite bed. It is owned, managed, and staffed by the Surrey and Borders NHS Trust, a specialist health provider for people with learning disabilities. The home currently has eight people in residence. There are nine single bedrooms, one of which is used for respite provision and one double bedroom. The bedrooms are decorated to suit the individual tastes of people who use the service. The home provides spacious accommodation comprising of a large kitchen diner, a communal living and dining room and a large pleasant garden to the rear. The home has its own transport. Tynron DS0000007213.V371488.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. We spent four and a half hours at the home and talked with three residents and the shift leader. The registered manager was contacted by phone the day after the inspection. Records and documents looked at included the Statement of Purpose, Service Users Guide, care plans, medication, people who use the service support guidelines, staff files, training records and health and safety records. Information was taken from a number of surveys returned to the Commission from people who use the service. The home completed an Annual Quality Assurance Assessment (AQAA) to tell us about the service provided, how it makes sure of good outcomes for the people using it and any planned developments. What the service does well: Good information is available to people about the home. The needs of people planning to use the service are fully assessed prior to admission to the home to make sure that they can be met. Person centred plans and care plans generally give good information about the support needs of the residents. Risk plans are completed to help people live as independently as they can. People are offered a varied programme of social and leisure activities that reflects their individual interests. Appropriate arrangements are made so that people have regular contact with their friends and families. Dietary needs are well catered for. Medication is well managed. The home has a clear complaints procedure that is accessible to the residents. People live in a clean, comfortable and homely environment. Tynron DS0000007213.V371488.R01.S.doc Version 5.2 Page 6 Good Health and Safety arrangements are in place. People told us “I like living here, the staff are nice to me” and “I like the food, my room is good”. What has improved since the last inspection? What they could do better: Staff could attend training on challenging behaviours and Autism so that they can offer a consistent approach to people’s physical and emotional health care needs. The current guidelines in place to support people with their physical and emotional health care needs should be kept under regular review. Staff training on food hygiene and first aid should be updated. More full time staff could be recruited so that the home can deliver a consistent approach to meeting people’s needs. The homes fire alarm system should be checked on a regular weekly basis. We would like to thank the residents, the shift leader, staff on shift and the registered manager for their support over the course of the inspection. Please contact the provider for advice of actions taken in response to this Tynron DS0000007213.V371488.R01.S.doc Version 5.2 Page 7 inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Tynron DS0000007213.V371488.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Tynron DS0000007213.V371488.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1 and 2. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People planning to use the service have good information about the home and they can be sure that the home can meet their needs because their needs are fully assessed before they move in. EVIDENCE: The home has a Statement of Purpose and a Service Users Guide, which clearly outline the nature, aims and objectives of the service. People who use the service have a personal copy of the Service Users Guide in their rooms. No new people have moved into the home since the last inspection. The shift leader told us that one person moved out of the home last year and one person sadly passed away in March this year. The Surrey and Borders NHS Trust has an Admission Procedure, that states that people are only admitted to the home once a full assessment has been completed by an appropriate person (usually a care manager) and sent to the home, along with any other information about the persons needs. The person’s family is also involved, if it is appropriate. The current fee charged for a placement at the home is £1,144.74 per week. Tynron DS0000007213.V371488.R01.S.doc Version 5.2 Page 10 Tynron DS0000007213.V371488.R01.S.doc Version 5.2 Page 11 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 and 9. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents have care plans and person centred plans that include information on their needs, likes and dislikes. Risk plans are completed so that people can live as independently as possible. EVIDENCE: A requirement was set at the last key inspection that the home manager must ensure that all people who use the service have their needs/placement assessed by their placing authority. Five peoples files were examined at random, all had review meetings that were attended by a care manager from their placing authority. All of the people who use the service have person centred plans. These had been completed using words and pictures. Person Centred Plans included good information on their needs and personal goals. These included a Tynron DS0000007213.V371488.R01.S.doc Version 5.2 Page 12 communication profile, things that matter most, things that matter next and things I enjoy. The files also included an individual weekly plan of activities. People had individual risk assessments and risk management strategies in place so that they can participate in activities in the home and in the community in a safe manner. These risk assessments had been reviewed at regular intervals. It was recommended at the last inspection that the home manager contact the person who wishes to move’s care manager to refer him onto an Independent Mental Capacity Advocate, it was also recommended that the home manager arrange a multi disciplinary meeting in order to establish if moving the person from the home would be in his best interests. The registered manager told us that advocates from Croydon Advocacy Partners have been involved in assessments and meetings in relation to this persons capacity to make decisions about moving to another placement. The registered manager told us that this person has been allocated a new care manager and he and his care manager are actively looking at other placements in the Croydon area more suited to his needs. One person who uses the respite service is working with his care manager, family and the community nurse to find another placement. The Commission, the registered manager, care manager and the community nurse has recently attended strategy/review meetings to consider his current support arrangements and future a placement. Tynron DS0000007213.V371488.R01.S.doc Version 5.2 Page 13 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15, 16 and 17. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents can be sure that their social and leisure needs are met because they are offered a varied programme of activities that reflects their individual interests. Appropriate arrangements are made so that residents can have regular contact with their friends and families. EVIDENCE: The registered manager told us in the AQAA that people who use the service have been attending an increased number of activities in the community as well as using their bus passes to travel on public transport. People have been supported to browse the Internet so that they can choose holiday’s day trips and activities. People have accessed more community activities according to their choice such as days out to London, Longleat Safari Park, Brighton, Tynron DS0000007213.V371488.R01.S.doc Version 5.2 Page 14 Heavers Castle, Blue Bell Steam Railway, shows at the theatre and regular meals out. People who use the service have an individual weekly plan of activities. There is a strong emphasis on people accessing the community, people attend local leisure facilities, parks, cafes, cinema, pubs, theatres, libraries, bowling alley and go shopping. People also attend clubs such as the Mencap Club and the Beautiful Blue Octopus Club. People have the opportunity to attend religious services if they wish. Some people attend Geoffrey Harris House day centre. Some people attend activities such as trampoline, cycling, community awareness, art, woodwork, aromatherapy, dancing, football and cookery sessions. The home has two mini buses. The shift leader told us that people are always out and about in the local community. On the day of the inspection three people had gone cycling, and one person had gone to Geoffrey Harris House. The shift leader told us that one person was going to football and three people were going to cooking classes later that day. Three people were getting ready to go on holiday to Disney Land Paris the day after this inspection. The shift leader provided evidence of regular monthly residents meetings. These included pictures of the residents and their comments. Topics discussed at the August meeting included birthday parties, holidays, planning to see Cliff Richards, Mama Mia, a residents comments about a magician who visited the home and a residents comments about helping in the kitchen. Some people visit family and at weekends some people stay with their relatives. Visitors can be seen in any of the homes communal areas as well as people’s bedrooms. Menus at the home are based on people’s likes and dislikes and health needs are taken into consideration when planning meals. The menus also include ethnic options and are checked by the Surrey and Borders NHS Trust dietician for nutritional balance. It was recommended that the home manager contact the Speech and Language Therapy Department for advice on Total Communication. The registered manager told us that one person had been referred to the Speech and Language Therapy Department. They visited the home and developed a communication system for that person. However this person has since moved out of the home. The registered manager told us that the home has used what was learned from the referral to develop communication with other people who use the service. A requirement was set at the last key inspection that home manager must ensure that regular checks take place in the home so that food past their best before date is not offered to the people. Tynron DS0000007213.V371488.R01.S.doc Version 5.2 Page 15 The fridge was examined; all foodstuffs had been labelled on the day of opening. None of the food in the fridge had past its best before date. The home had a visit from an environmental health officer; a number of recommendations were made. The shift leader told us that all of the recommendations had been addressed. Tynron DS0000007213.V371488.R01.S.doc Version 5.2 Page 16 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18,19 and 20 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents can be sure that their health care needs are met because medication is well managed by the home and they have good access to appropriate healthcare professionals. EVIDENCE: All of the people who use the service are registered with a local General Practitioner. All had health action plans indicating what was required to keep them healthy and safe. I.e. appointments to various health care professionals such as opticians, General Practitioner, chiropodist and dentists. A record of people’s appointments is recorded at the home. Some people have been diagnosed with epilepsy. The shift leader produced an epilepsy care plan for each person diagnosed with epilepsy. The care plan included a description of typical seizures, guidance for staff to follow i.e. when to call an ambulance, a rectal diazepam treatment plan and a seizure chart. All staff has had training on epilepsy and the administration of rectal diazepam. Tynron DS0000007213.V371488.R01.S.doc Version 5.2 Page 17 There are guidelines in place for staff to follow in order to offer consistent support to one person to eat safely and there are guidelines in place to support some people with challenging and self-injurious behaviours. However some of these guidelines had not been reviewed for some time. It is recommended that current guidelines in place to support people with their physical and emotional health care needs be kept under regular review. The registered manager told us that some staff had attended training on challenging behaviours but that this was some time ago. So that the staff team can offer a consistent approach to peoples physical and emotional health care needs the registered manager must ensure that all staff attends training or refresher training on challenging behaviours. The registered manager told us that one person has been diagnosed with Autism however there no evidence that staff had attended training on Autism. So that the staff team can offer a consistent approach to peoples physical and emotional health care needs the registered manager must ensure that all staff attends training on Autism. Medication is stored in a locked cabinet in the kitchen/dining room. Medication administration records checked on the day of the inspection were up to date and accurate. The medication file included a list of staff competent to administer medication and sample signatures, medication profiles and photos of people who use the service, peoples up to date medication reviews, peoples consent for staff to administer medication and PRN guidelines. A pharmacist has visited the home on 28th of September 2007 to offer advice on medication a report from this visit was located in the medication cabinet. The Surrey and Borders NHS Trust provide training courses in health care matters such as manual handling and medication courses to ensure that care staff are trained and accredited to meet the health care needs of people who use the service. A record of medication/health care training attended by the staff team is kept on the medication file. Tynron DS0000007213.V371488.R01.S.doc Version 5.2 Page 18 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23. People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People who use the service can be sure that their complaints and concerns are listened to because the home has a clear complaints procedure. People who use the service can be sure that they are protected from harm and abuse because the home has policies in place for safeguarding adults and staff has completed training on adult protection. EVIDENCE: The home has an appropriate complaints procedure. The complaints procedure is also in a symbol format for the benefit of some people who use the service. The homes complaints record book indicated that there had been no complaints raised with the home since the last inspection. A number of comment cards were returned to the Commission as feedback from people who use the service. Two people indicated that they did not know how to make a compliant. It is recommended that the registered manager discuss the complaints procedure with all of the residents. The home had a copy of Croydon Councils Protection of Vulnerable Adults Procedure on site. Staff training records indicated that all staff has had training on adult protection. Tynron DS0000007213.V371488.R01.S.doc Version 5.2 Page 19 The Surrey and Borders NHS Trust has a Whistle Blowing policy and a Respect for all at Work policy. Tynron DS0000007213.V371488.R01.S.doc Version 5.2 Page 20 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24 and 30. People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home is well maintained so that residents can live in a clean, comfortable, homely and safe environment. EVIDENCE: The home has a driveway to the front of the building and a pleasant garden to the rear of the house. There are sufficient numbers of bathrooms and toilet facilities situated throughout the home. People’s bedrooms have been personalised and decorated to reflect their individual taste. A requirement was set at the last key inspection that the home manager must ensure that the dining room is used only for its stated purpose. Confidential information must not be on display in communal areas, paperwork/files must be placed in the office and staff must not use the dining room as an office. Tynron DS0000007213.V371488.R01.S.doc Version 5.2 Page 21 No confidential information was on display in communal areas, paperwork/files have been placed in the office. The home has appropriate laundry facilities separate from the kitchen and the preparation of food. The washing machine is capable of washing clothes at high temperatures, which helps with the control of infections. There is a locked cupboard for the Control of Substances Hazardous to Health products. A first aid box and a fire blanket are situated in the kitchen. Coloured chopping boards and knives were seen in the kitchen. There are fire extinguishers throughout the house. The registered manager told us in the AQAA that the fire panel and gas boiler have been replaced. There are plans to redecorate the dining area and hallway and replace carpets in the office; lounge and hallway, there are also plans to improve the appearance of people’s bedrooms. The home was clean and tidy and free from offensive odours on the day of the inspection. Tynron DS0000007213.V371488.R01.S.doc Version 5.2 Page 22 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34, 35 and 36. People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People who use the service can be sure that they are safe because there are enough staff on duty at all times. They can have confidence in the staff because checks have been done to make sure that they are suitable to care for them. EVIDENCE: A requirement was set at the last key inspection that the home manager must inform the Commission when the new member of staffs personnel file is available in the home for inspection. The registered manager was not present on the day of the inspection so it was not possible to view staff’s personnel files. The registered manager confirmed in an e-mail to the Commission that Criminal Record Checks and written references had been obtained for all staff and was available in the home for inspection. The Commission has seen all other staffs Criminal Records Bureau Checks at previous inspections. Tynron DS0000007213.V371488.R01.S.doc Version 5.2 Page 23 Staff training records showed that staff had attended training on fire safety, food hygiene, moving and handling, adult protection, health and safety, first aid, epilepsy, medication and health action planning. However some staff requires refresher training on food hygiene and first aid. It is recommended that the registered manager ensure that staff training on food hygiene and first aid is updated. The registered manager told us the AQAA that 50 of the staff team has completed a National Vocational Qualification. The registered manager told us that the home uses regular agency and bank staff; some of the bank staff is former staff at the home. The registered manager told us that agency and bank staff attends training and receive regular supervision. Records shows that staff meetings are held on a regular monthly basis and all staff receive an annual appraisal and regular formal supervision. The atmosphere in the home pleasant and the staff team were observed to treat people with dignity and respect. Tynron DS0000007213.V371488.R01.S.doc Version 5.2 Page 24 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 and 42. People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Residents can be sure that their needs are met and wishes are taken into consideration because the home is well managed. The residents can be sure that hey are protected from harm because good health and safety arrangements are in place. EVIDENCE: The home manager is Registered Learning Disability Nurse. He has completed a Certificate in Management Studies and Units RM1 and RM2, which equate to the Registered Managers Award. Since the last inspection he has been registered with the Commission for Social Care Inspection to run the home. Tynron DS0000007213.V371488.R01.S.doc Version 5.2 Page 25 The registered manager told us in the AQAA that day-to-day management at the home is operated within an open positive and inclusive atmosphere. Staff confirmed that the manager has an open door policy. A number of comment cards were returned to the Commission as feedback from people who use the service. All indicated that staff had supported them to complete the form and none made written comments about the service however people ticked boxes indicating that they can make decisions about what they do each day, they can do what they want to do, that the home is fresh and clean and staff treat them well and listen and act on what they say. One resident told us “I like living here, the staff are nice to me” another resident told us “I like the food, my room is good”. One resident told us “I want to move out of this place I have been here a long time, the staff here are good to me and its nice but I want to move to another place”. The shift leader produced evidence that people who use the service and their relatives had been sent questionnaires in order that they could feedback about the service. Feedback from the questionnaire is used the to improve the service. Copies of monthly Regulation 26 Visit reports were available in the home for inspection. A requirement was set at the last key inspection that the home manager must forward copies of the legionellas testing and Portable Appliance Testing Certificate’s to the Commission. The shift leader produced evidence that the Surrey and Borders NHS Trust maintenance department had checked the homes water systems and portable appliances. All staff attended an annual fire safety lecture and the home has a fire safety risk assessment in place, the registered manager carries out three monthly fire safety audits. A full fire evacuation took place on the 15/08/08. Records show that the fire alarm system is being checked on a regular weekly basis however there was a gap between the 6th and the 20th of September when the system was not checked. The registered manager must ensure that the homes fire alarm system is checked on a regular weekly basis. Tynron DS0000007213.V371488.R01.S.doc Version 5.2 Page 26 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 3 2 3 3 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 3 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 3 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 3 X 3 X X 3 X Tynron DS0000007213.V371488.R01.S.doc Version 5.2 Page 27 No. Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard YA19 Regulation 18 (1) c Requirement Timescale for action 31/12/08 2. YA19 18 (1) c 3. YA42 23 (4) c So that the staff team can offer a consistent approach to peoples physical and emotional health care needs the registered manager must ensure that all staff attends training or refresher training on challenging behaviours. So that the staff team can offer 31/12/08 a consistent approach to peoples physical and emotional health care needs the registered manager must ensure that all staff attends training on Autism. The registered manager must 27/09/08 ensure that the homes fire alarm system is checked on a regular weekly basis. 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. Tynron Refer to Standard YA19 Good Practice Recommendations It is recommended that current guidelines in place to DS0000007213.V371488.R01.S.doc Version 5.2 Page 28 2. 3. YA22 YA32 support people with their physical and emotional health care needs be kept under regular review. It is recommended that the registered manager discuss the complaints procedure with all of the residents. It is recommended that the registered manager ensure that staff training on food hygiene and first aid is updated. Tynron DS0000007213.V371488.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection London Regional Office 4th Floor Caledonia House 223 Pentonville Road London N1 9NG 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 Tynron DS0000007213.V371488.R01.S.doc Version 5.2 Page 30 - 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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