Inspection on 15/08/07 for Tanfield House

This inspection was carried out on 15th August 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 9 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Tanfield House 08/09/06

Tanfield House 27/10/05

Tanfield House 24/05/05

Tanfield House 02/12/04

Tanfield House 28/06/04

Tanfield House 11/02/04

Similar services:

Townley Road, 2-3

Foxley Lane (121a)

Tudor Lodge

Stacey Street Nursing Home

Delrose House Ltd

Clovelly House Residential Home Ltd

Abbey Road [53]

Cherry Tree House

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

CARE HOME ADULTS 18-65 Tanfield House 80 Randall Avenue Neasden London NW2 7SS Lead Inspector Julie Schofield Key Unannounced Inspection 15th August 2007 09:20 Tanfield House DS0000036103.V342938.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 Tanfield House DS0000036103.V342938.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. Tanfield House DS0000036103.V342938.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Tanfield House Address 80 Randall Avenue Neasden London NW2 7SS 020 8452 6616 020 8830 5826 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) Mrs Lucille Rabor Amanda Rabor Care Home 5 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (5) of places Tanfield House DS0000036103.V342938.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: Tanfield House (80 Randall Ave) is situated on the corner of Randall Avenue and Tanfield Avenue and is close to the shops in Neasden. Tanfield Avenue is on a bus route and it is relatively close to the North Circular Road. The nearest underground station is Neasden. It is a large semi-detached house with a small garden at the front of the house and a garden at the rear of the property. The garage at the side of the house has been converted into an office for the nursing agency that is also operated by the company. There is parking space available on the street outside the house. The home is registered for 5 adults with mental health problems and there are bedrooms on both the ground and first floor with bathing and toilet facilities on both floors. Communal space is situated on the ground floor and consists of a lounge and a separate open plan kitchen /dining area. There is a small office/sleeping in facility on the first floor and an office on the ground floor. At the time of the inspection there were no vacancies. The registered manager of Tanfield House is also the registered manager of Jude House, which is also situated in Randall Avenue. Details of the fees charged may be obtained from the home, on request. Tanfield House DS0000036103.V342938.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection took place on a Wednesday in August. The inspection started at 9.20 am and finished at 4.35 pm. During the inspection a site visit took place, records and policies and procedures were examined, case tracking was carried out, discussions with the registered manager, the general manager for the company, the assistant manager of the home, members of staff and a resident took place and the preparation of a meal was observed. The Inspector would like to thank everyone for their assistance and for the comments that they gave as part of the inspection. What the service does well: What has improved since the last inspection? During the previous inspection in September 2006 13 statutory requirements were identified and 8 of these are now met: The home is following the advice given by the Environmental Health officer regarding the practice of cooking a meal in one care home and then carrying the cooked food over to another care home, close by. The work surface in the kitchen and the cracked wash hand basin in the kitchen have been replaced. Tanfield House DS0000036103.V342938.R01.S.doc Version 5.2 Page 6 The records of the administration of medication to residents were up to date and complete. The cracked windowpane in the first floor bedroom window has been replaced. The toilet door on the first floor is lockable. Staff have now received training in infection control procedures. It is now possible to see the total hours worked per week by members of staff working shifts in more than 1 Randall care home. The home has set up a programme of individual supervision sessions for staff to be held on a regular basis and recorded. What they could do better: Nine statutory requirements were identified during this inspection. Four were outstanding from a previous inspection(s). One requirement had also been identified during a previous inspection but the timescale for compliance has been extended because without any new admissions the home has been unable to demonstrate that its pre-admission procedure has been amended. The preadmission records need to include the reactions of other residents, views of members of staff on duty and comments made by the prospective resident during visits to the home to demonstrate that the compatibility of the new person has been tested. All staff administering medication must receive training from an accredited trainer and that the content of the course gives staff the depth of knowledge necessary to support residents. The complaints book must include details of the investigation, outcome and feedback to the complainant to demonstrate that complaints are listened to and acted upon. Carpets in the home must be in a good condition to maintain pleasant and comfortable surroundings. The rota demonstrates that there are sufficient staff on duty at all times to support residents. The hours worked by the manager, on site and totalling a minimum of 17.5, must be recorded on the rota to demonstrate that staff and residents have the opportunity to benefit from her guidance, support and supervision. Each member of staff must have an enhanced CRB disclosure, naming the company as the employer, prior to commencing work or work under close supervision, with a pova first check, pending the return of the CRB disclosure. Each member of staff must have a reference taken from their most recent employer. Tanfield House DS0000036103.V342938.R01.S.doc Version 5.2 Page 7 Feedback obtained from quality assurance systems needs to be used to plan and develop services so that changing needs of residents are recognised and met. 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. Tanfield House DS0000036103.V342938.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 Tanfield House DS0000036103.V342938.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): 2,4 People who use this service experience good outcomes in this area. A comprehensive assessment of the needs of the resident, prior to admission to the home, enables the home to determine whether a service tailored to the individual needs of the resident can be provided. A programme of preadmission visits to the home enables the prospective resident to sample life in the home and to decide whether the service provided is acceptable. A record of the content of these visits must be kept so that the home can demonstrate that the needs of the prospective resident are compatible with those of existing residents. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home has an admission procedure, although no new resident has been admitted to the home for over a year. If a referral is made the manager will carry out a comprehensive assessment of the needs of the prospective resident. This information would be in addition to the information provided by the placing authority, which would include a copy of their needs assessment for the prospective resident. On the basis of all this information the manager is able to determine whether the home can provide a service that would meet the needs of the resident. Tanfield House DS0000036103.V342938.R01.S.doc Version 5.2 Page 10 The pre-admission procedure for the home includes a programme of visits to the home by the prospective resident. A record of the dates that visits take place is kept on the resident’s case file. A statutory requirement was identified during the previous inspection in September 2006 that the reactions of other residents, views of members of staff on duty and comments made by the prospective resident during the preadmission visits to the home are recorded. As no new residents have been admitted to the home since this requirement was made the timescale for compliance has been extended. Tanfield House DS0000036103.V342938.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, 9 People who use this service experience good outcomes in this area. Comprehensive care plans have been drawn up for each resident so that the service provided can meet the individual needs of the resident. The home is able to demonstrate that changes in the needs of residents are identified and addressed through a system of regular review meetings. The resident’s right to make decisions about their life in the home is respected. Responsible risk taking contributes towards the resident leading an independent lifestyle. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Three case files were examined. It was noted that each contained a care plan that focuses on the mental health problems of the resident. There were also care plans covering personal care needs and general health needs. Monthly evaluations are carried out and it was noted that these were up to date. There were also daily plans for support worker in respect of the care and support Tanfield House DS0000036103.V342938.R01.S.doc Version 5.2 Page 12 needed by the resident. There was evidence that regular CPA meetings took place. There were also regular review meetings convened by the home and placement reviews by the funding authority. None of the residents receive support from advocacy services although they may receive assistance and support from a member of their family. No one from the company is an appointee for any resident as each resident has control over their finances. However the home will help a resident if the resident is having problems with their benefits etc. Each file contained risk assessments, tailored to the individual needs of the residents. The hazard was stated, identified risks listed, a risk rating was awarded and the action to be taken was specified. Risk assessments covered areas including financial abuse while in the community, the risk of assault while in the community, not taking medication and gambling. Risk assessments were subject to regular evaluations, which were up to date. Tanfield House DS0000036103.V342938.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, 14, 15, 16, 17 People who use this service experience good outcomes in this area. Using community resources gives residents the opportunity to enjoy an interesting and purposeful lifestyle. With staff support, residents are encouraged to maintain contact with their families and to enjoy fulfilling relationships. Residents are encouraged to make decisions and their wishes are respected. Residents are offered a varied and wholesome diet, which meets their religious and cultural needs. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Residents follow their own individual lifestyles although they are encouraged to keep regular hours and to get some exercise by going out to do their personal shopping etc. Residents choose whether they want to attend drop in centres etc and although they had been attending a local centre at the time of the last inspection attendance has decreased. On the day of the inspection one of the Tanfield House DS0000036103.V342938.R01.S.doc Version 5.2 Page 14 residents said that he had attended the drop in centre earlier in the day. One of the residents did attend college for 3 months to do a course for builders and another resident does some voluntary work occasionally. One of the five residents had been preparing for supported living and is due to leave the home within 2 weeks of the date of the inspection. An OT runs group and 1:1 sessions in the home and in the community for residents on 2 days per week. Sessions include working with computers, arts and crafts, cookery, shopping and outings. Residents use community facilities and resources including the cinema, shops, the library, pubs, the mosque or the church. All of the residents travel independently in the community. The names of residents are entered on the electoral roll and they vote if they wish, either in person or by using a postal ballot. Within the home residents are able to choose whether they want to socialise with other residents or whether they want to take part in any activities. Residents do sit together and talk with each other. They also watch television in the lounge or they can watch television or listen to music in their rooms. There are board games and cards if they wish to play a game. The home encourages residents to maintain contact with their family members and some residents go to visit their families, occasionally staying with them overnight. Family members also visit residents at Tanfield House and a resident can entertain visitors in their room or sit with them in the lounge. If visiting is difficult due to distance, contact can also be maintained by telephone calls. Residents are encouraged to take part in the domestic routines in the home and each resident is expected to keep their own room clean and tidy and to do their laundry. Some of the residents will help with the preparation of a meal, after encouragement and motivation by the members of staff on duty. The resident that is ready to move into more independent living sometimes cooks a meal for themselves and another resident also likes to shop for themselves and prepare a meal. A resident that is partially sighted and enjoys making a cooked breakfast, does so under supervision. The home has a no smoking policy within the building and it was noted that residents observed this and went into the garden when they wished to smoke. A resident said that his privacy was respected when he is in his room and that his right to choose what he does during the day is respected. Two statutory requirements were made during the previous inspection in September 2006. The first was that confirmation of the advice received from the Environmental Health Officer (EHO) regarding cooking meals in one of the company’s care homes to take to another of its care homes must be obtained. In January 2007 the EHO contacted the Inspector and summarised the advice given. During the inspection the Inspector spoke with the Assistant Manager Tanfield House DS0000036103.V342938.R01.S.doc Version 5.2 Page 15 and asked what arrangements were now in place for carrying the food from one home to another. It was noted that the arrangements followed the advice of the EHO and so the requirement is now met. The second requirement was that the work surface in the kitchen must be repaired or replaced and that the cracked wash hand basin in the kitchen must be replaced. Replacement of these items has now taken place and the requirements are met. During the inspection the preparation of a meal was observed. The member of staff was preparing fish, rice and peas and vegetables. There are individual menu sheets for each resident with space to record what the resident consumes. Residents are offered a cooked meal in the evening and a lighter meal at lunchtime. Choice is available and the menus include food to meet the cultural needs of the residents. Halal meat is used in the home, as one of the residents is Muslim. A resident said that the meals served in the home are good. Tanfield House DS0000036103.V342938.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, 20 People who use this service experience good outcomes in this area. Discreet and caring support is given to residents by staff so that the privacy and dignity of the resident is respected. The health and well being of residents is promoted through regular health care checks and appointments. Residents’ general health and well being is promoted by staff that assist residents to take prescribed medication in accordance with the instructions of the resident’s GP and psychiatrist. Accredited training for staff would assure residents of the competence of staff in dealing with medication. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Residents are self -caring and no direct assistance is required with personal care tasks. Sometimes staff may need to prompt a resident so that they maintain a clean and tidy appearance and this is carried out discreetly and with regard to the feelings of the resident. The manager said that staff iron one of the residents’ clothes, as they are unable to do this for themselves. The staff Tanfield House DS0000036103.V342938.R01.S.doc Version 5.2 Page 17 team consists of male and female members of staff and includes African and African-Caribbean staff. The current residents are African and AfricanCaribbean men. The home provides each resident with the support of an occupational therapist that visits the home twice a week. The home has a system of key working. One of the residents has been recently diagnosed as a diabetic and an appointment has been arranged for him with the dietician. It was noted that a record of the weight of residents is kept on a monthly basis, provided that the resident wishes to be weighed. There was evidence on the case files of access to health care services in the community including the GP, the psychiatrist, the optician and the dentist. Residents had an annual medical check up and their medication was reviewed on a regular basis. A statutory requirement was identified during the previous inspection in September 2006 that the records of the administration of medication to residents are up to date and complete. Records were inspected and it was noted that they were complete and up to date so the requirement is now met. The storage of medication was safe. Medication is administered from weekly disposable dossette boxes. Three residents have dossette boxes. One resident uses inhalers only and the fifth resident is refusing to take medication. The GP and the psychiatrist are aware of this. Although all members of staff administering medication have received training it is not accredited and the record of the content of the training given does not demonstrate that staff are given a basic knowledge of how medicines are used and how to recognise and deal with problems in use. Tanfield House DS0000036103.V342938.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, 23 People who use this service experience adequate outcomes in this area. Residents are aware of their right to complain if the care that they receive is not satisfactory. Comprehensive complaints records would assure complainants that matters have been investigated and remedial action taken. An adult protection policy and protection of vulnerable adults training for staff contribute towards the safety of residents but recruitment practices need to protect the safety and welfare of residents. This judgement has been made using available evidence including a visit to this service. EVIDENCE: A complaints procedure is in place in the home. A copy is placed in the service user guide and this document is given to each resident, as part of the admission procedure. There is also a copy on the back of the residents’ bedroom doors and on display in the kitchen. The procedure includes contact details for the Commission for Social Care Inspection. The complaints record book was examined and it was noted that a resident had made 1 complaint, since the last inspection. This had been resolved. A neighbour has raised concerns about noise levels, occurring late at night and in the early hours of the morning, on several occasions since the last inspection and although meetings had taken place with the neighbour or a letter had been sent this was not always recorded. It was noted during the inspection that residents were accustomed to an “open door” policy with the managers and that they were also able to discuss their concerns, at any time, with members of staff on duty. Tanfield House DS0000036103.V342938.R01.S.doc Version 5.2 Page 19 Previously residents have confirmed that if there was anything that they were not satisfied with they felt able to speak to someone in the home and mentioned the name of the registered manager. The home prefers to deal with matters before complaints develop and has a system of meetings, which are recorded, taking place between the resident and manager and/or key worker. A protection of vulnerable adults procedure is in place. The manager said that no allegations or incidents have been recorded since the last inspection. There was evidence on the staff files that protection of vulnerable adults training had taken place. During a discussion with the assistant manager he confirmed that he had undertaken training in adult protection procedures and was aware of his duty to report any disclosures of abuse to the manager. A refresher course for members of staff took place in July 2007 and certificates of attendance were on the staff files examined. External training has been booked for all staff on the next course to be run by the local authority. The home has also purchased a training video. Two new members of staff were working in the home without a povafirst check, pending the return of an enhanced CRB disclosure. (See Standard 34). Tanfield House DS0000036103.V342938.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, 30 People who use this service experience good outcomes in this area. Residents live in a home, which is comfortably furnished and provides a pleasing environment for residents to relax in and enjoy. Good standards of cleanliness provide residents with hygienic surroundings. This judgement has been made using available evidence including a visit to this service. EVIDENCE: A statutory requirement was identified during the inspection in September 2006 that the damaged windowpane in one of the first floor windows at the back of the house is replaced. It was noted during the inspection that the windowpane had been replaced and so the requirement is now met. A partial site inspection took place as residents locked their bedroom doors when they left the home. It was noted that although the home was decorated and furnished in a “homely” manner the carpet on the stairs was worn and in need of replacement. A statutory requirement was identified during the inspection Tanfield House DS0000036103.V342938.R01.S.doc Version 5.2 Page 21 in September 2006 that the toilet door on the first floor must be lockable. It was noted during the inspection that a working lock was in place and so the requirement is now met. A resident said that they were satisfied with their room and with the communal areas in the home. A statutory requirement was identified during the previous inspection that all staff receive training in infection control procedures and a training session took place in June 2007. This requirement is now met. It was noted during the inspection that all areas of the home inspected were clean and tidy and free from offensive odours. Laundry facilities are sited on the ground floor and consist of 2 washing machines and a tumble drier. Using the laundry does not involve walking through any area where food is stored, prepared or consumed. The manager confirmed that the home does not service incontinent laundry. Tanfield House DS0000036103.V342938.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, 33, 34, 35, 36 People who use this service experience adequate outcomes in this area. Residents benefit from a service provided by carers that have demonstrated their skills and understanding through NVQ training. The rota failed to demonstrate that there are sufficient staff on duty to support the residents and to meet their needs or that the manager’s hours spent on site are sufficient to supervise staff and to monitor the standard of care. Recruitment practices compromise the safety and well-being of residents. The training programme for staff and individual supervision sessions encourage good working practices. This judgement has been made using available evidence including a visit to this service. EVIDENCE: A discussion took place with the manager regarding the progress made towards achieving the target of 50 of staff working in the home holding an NVQ level 2 or 3 qualification or equivalent. Checking the names of staff recorded on the rota (12) it was noted that 1 member of staff has the NVQ level 3, 6 staff have the NVQ level 2, 3 staff are qualified nurses, 1 member of staff has successfully completed 2 of a 3 year nursing qualification and 1 Tanfield House DS0000036103.V342938.R01.S.doc Version 5.2 Page 23 member of staff is part way through their RMN training. The home has exceeded the target and is to be commended. A copy of the rota for the 14th to the 20th August was supplied. The manager said that during the early shift and during the late shift there were 2 members of staff are on duty and at night there is 1 member of staff, on waking night duties. Three statutory requirements were identified during the previous inspection in September 2007. The first was that the rota must demonstrate that there are sufficient staff on duty at all times. This requirement has now been made during 3 previous inspections. It was noted that there was only 1 member of staff recorded on the rota for Friday 17/8 from 8 am to 1pm, on Saturday 18/8 from 8am to 1pm, on Sunday 19/8 from 8am to 3pm and on Monday 20/8 from 8am to 3pm. Only 1 member of staff is recorded on the rota for Tuesday 14/8 from 3pm to 8pm, on Sunday 19/8 from 3pm to 8pm and on Monday 20/8 from 3pm to 8pm. This requirement therefore remains outstanding. The second requirement was that the hours worked on site by the manager must be recorded on the rota and must be a minimum of 17.5 hours per week, as the manager is now the manager of 2 care homes. It was noted that these hours are not recorded on the rota as the manager is recorded only as a “senior on call”. Therefore this requirement remains outstanding. The third requirement was that when a carer works in more than one of the company’s care homes during the week there must be a record of the total weekly hours worked. This requirement has now been made during 2 previous inspections. As the home has a copy of the rota for each of the 4 care homes within the company it is possible to calculate the total weekly hours worked. The requirement is therefore met. Five staff files were examined. A statutory requirement was identified during the previous inspection that each member of staff must have an enhanced CRB disclosure naming the company as the employer and that applications are made for any staff without a valid CRB disclosure. It was noted that 2 files (belonged to carers that had recently been appointed) contained an enhanced CRB disclosure that had been obtained from a previous employer. Although the manger said that an application for a new CRB disclosure had been made neither file contained a povafirst check. The advice given by the Inspector was confirmed in an immediate requirement letter that was sent to the home. Files contained 2 satisfactory references and it was noted that where a member of staff had supplied references addressed “to whom it may concern” the home had sent reference request letters to ensure the validity of the information. However it was also noted that a member of staff did not list the most recent employer as a referee and a reference had not been sent to the care home where they had been working. Each file contained proof of identity and evidence of leave to remain and to work, if required. Tanfield House DS0000036103.V342938.R01.S.doc Version 5.2 Page 24 There is an induction training package for new members of staff and this was seen on the staff files examined. Staff files included training profiles. There was evidence on staff files of attendance certificates for infection control, manual handling, food hygiene, first aid, protection of vulnerable adults and fire safety training. Staff have also undertaken training in mental health issues. There is a training plan for the home and this includes listing a course of training, deciding who needs this training and within what timescale, who can provide the course, the cost, how the effectiveness of the training is to be evaluated and the progress made. A statutory requirement was made during the previous inspection that each member of staff receives supervision on a 1 to1 basis, at least every 2 months, and that the sessions are recorded. The manager confirmed that the home has now set up a programme of regular supervision sessions for staff and that the general manager will have responsibility for clinical supervision, team building and communication. This requirement is now met. Tanfield House DS0000036103.V342938.R01.S.doc Version 5.2 Page 25 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. 42 People who use this service experience adequate outcomes in this area. The registered manager continues to develop her knowledge through further training and this contributes towards understanding the needs of residents and staff. However the support that staff and residents require has been compromised by not responding to requirements for tasks to be carried out within the timescales allocated. Incorporating information obtained through quality assurance systems into the planning and development of the service would ensure that it continues to meet the needs of the residents. Training in safe working practice topics enables members of staff to safeguard the health, safety and welfare of the residents. Regular servicing and checking of equipment used in the home ensures that all items are in working order and safe to use. This judgement has been made using available evidence including a visit to this service. Tanfield House DS0000036103.V342938.R01.S.doc Version 5.2 Page 26 EVIDENCE: The registered manager has completed her Registered Manager’s Award and has shown evidence of this on a previous inspection. Since the last inspection she has attended Sector Skills Council’s management training. She is currently studying part time for a degree in psychology and said that she has now completed two thirds of the course. Since the last inspection she has become the registered manager of another care home in Randall Ave and an assistant manager post has been created in each of the 2 care homes to help her with the management role. In addition a post of general manager for the company has been appointed to support all of the 4 care homes that it operates. It is of concern that a number of statutory requirements (4) identified during previous inspections remain outstanding, particularly as they affect the supervision of staff, responding to the changing needs of residents, supporting residents and keeping residents safe. A statutory requirement was identified during the previous inspection in September 2006 that the feedback from quality assurance systems is used to plan and to develop the service and to formulate the annual development plan for the home. This requirement has now been made during 2 previous inspections. The manager said that it is difficult to hold residents meetings because residents may choose to go out instead of attending a meeting. Therefore feedback is obtained on a 1:1 basis, either with the manager, deputy manager or key worker. A new survey form is being drawn up to be used in the home and a copy was available. The home already has a form that is used to review the assessment process. A survey form will also be offered to professional visitors to the home. Three residents have already completed the new form. Progress has been made in respect of obtaining feedback from quality assurance systems and this part of the requirement is met but until the information is used in the planning and development of the service the second part of the requirement remains outstanding. There was evidence in the training records that staff have received training in safe working practice topics. There were valid certificates for the servicing/checking of the fire extinguishers, the fire alarms and emergency lighting, the Landlord’s Gas Safety Record, the portable electrical appliances and the electrical installation. Tanfield House DS0000036103.V342938.R01.S.doc Version 5.2 Page 27 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 2 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 2 23 2 ENVIRONMENT Standard No Score 24 2 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 4 33 1 34 1 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 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 X 2 X 2 X X 3 X Tanfield House DS0000036103.V342938.R01.S.doc Version 5.2 Page 28 YES Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard YA4 Regulation 12(3) Requirement The registered person must ensure that the preadmission process records the reactions of other residents, views of members of staff on duty and comments made by the prospective resident during visits to the home to demonstrate that the compatibility of the new person has been tested. The registered person must ensure that all staff administering medication are trained by an accredited trainer and that the content of the course gives staff the depth of knowledge necessary to support residents. The registered person must ensure that the complaints book includes details of the investigation, outcome and feedback to the complainant to assure people that their DS0000036103.V342938.R01.S.doc Timescale for action 01/12/07 2 YA20 13(2) 01/12/07 3 YA22 22(3),(4) 01/10/07 Tanfield House Version 5.2 Page 29 4 YA24 16(2) 5 YA33 18(1) 6 YA33 17(1)S4(7) &18(2) 7 YA34 19(1) complaints are listened to and acted upon. The registered person must ensure that carpets in the home are in a good condition so that residents are assured of pleasant and comfortable surroundings. The registered person must ensure that the rota demonstrates that there are sufficient staff on duty at all times to support residents. (Previous timescale of 01 August 2005, the 1st December 2005 and the 1st October 2006 not met). The registered person must ensure that the hours that she works on site (a minimum of 17.5 hours) are recorded on the rota to demonstrate that staff and residents have the opportunity to benefit from her guidance, support and supervision. (Previous timescale of the 1st October 2006 not met). The registered person must ensure that each member of staff has an enhanced CRB disclosure, naming the company as the employer, prior to commencing work or works under close supervision, with a pova first check, pending the return of the CRB disclosure so that unsuitable persons do not work in the home. 01/12/08 01/10/07 01/10/07 25/08/07 Tanfield House DS0000036103.V342938.R01.S.doc Version 5.2 Page 30 8 YA34 19(1) 9 YA39 24(2) (Previous timescale of the 1st December 2006). The registered person must ensure that references are taken from the most recent employer so that unsuitable persons do not work in the home. The registered person must ensure that feedback obtained from quality assurance systems is used to plan and develop services so that changing needs of residents are recognised and met. (Previous timescale of the 1st January and the 1st December 2006 not met). 01/10/07 01/01/08 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 1. YA28 That the fruit is removed from the grass, on which it has fallen. That all risk assessments on file are reviewed when the care plan is reviewed. That the programme of annual staff appraisals is completed by the end of November 2006. That the manager contacts the company that checked the DS0000036103.V342938.R01.S.doc Version 5.2 Page 31 2. YA9 3. 4. YA36 YA42 Tanfield House electrical installation in the home and establishes when the next inspection of the system is due. Tanfield House DS0000036103.V342938.R01.S.doc Version 5.2 Page 32 Commission for Social Care Inspection Harrow Area office Fourth Floor Aspect Gate 166 College Road Harrow HA1 1BH 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 Tanfield House DS0000036103.V342938.R01.S.doc Version 5.2 Page 33 - 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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