Inspection on 26/01/06 for Tansley House

This inspection was carried out on 26th January 2006.

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 but made no statutory requirements on the home.

Other inspections for this house

Tansley House 17/11/08

Tansley House 03/12/07

Tansley House 06/12/06

Tansley House 23/08/05

Tansley House 03/03/05

Tansley House 27/09/04

Tansley House 17/09/03

Similar services:

Byars Care Home

St Marys Nursing Home

Bramble Lodge

Parkmanor Residential Home

Thornham Grove

Hunter`s Lodge

London Road Neurological and Specialist Care Unit

Carlton Care Home

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

CARE HOMES FOR OLDER PEOPLE Tansley House Church Street Tansley Matlock Derbyshire DE4 5FE Lead Inspector Angela Kennedy Unannounced Inspection 26th January 2006 10:00 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 Tansley House DS0000020103.V279625.R01.S.doc Version 5.1 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for 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. Tansley House DS0000020103.V279625.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Tansley House Address Church Street Tansley Matlock Derbyshire DE4 5FE (01629) 580404 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) Mr Alan Baranowski Mr Steve Lomax, Mrs Janet Baranowski Beverley Sarah Windle Care Home 20 Category(ies) of Old age, not falling within any other category registration, with number (20) of places Tansley House DS0000020103.V279625.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. Plus Three (3) Day Care Places Date of last inspection 23rd August 2005 Brief Description of the Service: Tansley House is a well-established care home registered for 20 elderly residents who require personal care only. The home provides pleasant homely accommodation in 18 single rooms and one shared room. In practice the home usually accommodates 19 residents with the shared room being used if required by a married couple. There is a choice of lounges, a separate dining area and use of the garden. The home is situated in the centre of Tansley village. Tansley House DS0000020103.V279625.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection was unannounced and was conducted over an approximate period of three and a half hours. During the inspection a tour of the building was undertaken, 6 residents were spoken with and two care staff. Several documents were seen, including two staff files and three residents’ files (as part of the case tracking process which helps to determine that the residents individual needs are being met). An assessment of previous requirements left at the last inspection was also undertaken, to determine if the home complies with requirements and regulations. As the manager was not on duty at the beginning of the inspection the person in charge of the shift was available to answer any question and provide documents as required. A discussion with the proprietor of the home was undertaken via the telephone and the manager of the home was available for the last two hours of the inspection. What the service does well: Tansley House provides care to their residents in a clean, comfortable and homely environment. The residents spoke highly of the standard of care provided and the friendly, approachable and kind attitudes of the staff team. All of the residents spoken with were very positive regarding the standards of meals provided. Examination of the menus and discussion with one of the cooks demonstrated that residents were consulted regularly regarding their opinions of the choice of meals available, this demonstrates that residents are empowered to make decisions and choices that suit their preferences. Staff training has been greatly developed and includes training that is specific in meeting the needs of residents. The homes redecoration programme continues to be ongoing and evidence of redecoration was seen. Tansley House DS0000020103.V279625.R01.S.doc Version 5.1 Page 6 What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Tansley House DS0000020103.V279625.R01.S.doc Version 5.1 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 Tansley House DS0000020103.V279625.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): EVIDENCE: Standards 1 – 5 not assessed at this inspection. Tansley House DS0000020103.V279625.R01.S.doc Version 5.1 Page 9 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7,9,11 Residents personal and social care needs are met within their individual care plans. Residents’ wishes concerning terminal illness, care and arrangements after death require further development. EVIDENCE: Of the residents files seen assessments were in place that looked at residents personal and social care needs, these were detailed and included areas within: tissue viability, mobility including moving and handling, and nutrition. However no specific risk assessment regarding the risk of falls was seen with the mobility assessment examined. Development of these assessments would provide further reassurance that residents’ safety is monitored at all times. Daily records were maintained and visits from professionals, such as visits from the doctor were recorded. Residents’ personal likes and dislikes, hobbies and interests were also included within the residents’ files seen. Tansley House DS0000020103.V279625.R01.S.doc Version 5.1 Page 10 Very positive comments were received from all the residents spoken with regarding the kind and friendly approach of the staff team. One of the residents stated that activities were available, but many of the residents chose to decline them. This demonstrates that residents have control over the way they spend their daily lives. An assessment of the previous requirements and recommendations left at the last inspection was undertaken, this included Standard 9, which looked at the recording and safekeeping of temazepam (a schedule 3 controlled drug). The manager of the home stated that Temazepam is now prescribed in blister packs following advice from the homes local pharmacist but confirmed that the home does not store or record temazepam as a controlled drug. Policies and procedures were in place regarding handling the dying and death of residents and were robust in detail this included policies on; ‘Dying (care of residents)’, ‘funeral arrangements’ and ‘helping others cope’. Within residents’ files care plans were seen regarding funeral arrangements, however further care plans need to be developed that look at resident’s wishes regarding the care and support given to them during terminal illness/dying, to ensure the individual retains maximum control. Tansley House DS0000020103.V279625.R01.S.doc Version 5.1 Page 11 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 15 Residents receive a wholesome diet that is subject to their individual preference and needs. EVIDENCE: The menus were seen and offered a four-week rotating menu that was varied in choice. Two cooks are employed at Tansley house, and worked opposite shifts to cover the catering requirements of the home. Both of the cooks had completed their food hygiene course, which was up to date, and both had undertaken a course in nutrition and in Health and Safety. One of the cooks who had worked at the home for nearly 11 years was spoken with, and confirmed that should a resident not desire the choices available on the menus, an alternative meal of their choice would be prepared for them. Breakfasts during the week consisted of a choice of cereals and scrambled egg on toast, and although a full cooked breakfast was not available, mixed grills were often available at lunch times. The cook said that the majority of residents preferred porridge at breakfast time. Tansley House DS0000020103.V279625.R01.S.doc Version 5.1 Page 12 The cook also stated that the residents were regularly consulted regarding their preference of meals, and this information was then included on the menus. Six of the residents were spoken with during the inspection and all said that the meals at the home were very good, and confirmed that; additional meal options were available if required, and that the cooks regularly consulted them regarding their preference of meals. The kitchen floor that had required attention due to a damaged floor covering has now been repaired. This was a requirement at the last inspection and has now been met. There are no fly screens fitted to the kitchen window, as required by the environmental health officer’s report of March 2004. The proprietor discussed his reservations with this requirement. However once this requirement has been met it will further demonstrate that the home endeavours to maintain high standards of hygiene. Tansley House DS0000020103.V279625.R01.S.doc Version 5.1 Page 13 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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): EVIDENCE: Standards 16- 18 were not assessed at this inspection. Tansley House DS0000020103.V279625.R01.S.doc Version 5.1 Page 14 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19,21,24,26 Residents have sufficient toilet and washing facilities and their private accommodation reflects their individual tastes. Risks to residents are identified to enable action to be taken to ensure residents’ safety is maintained. The home was clean, although standards of hygiene could be further developed. EVIDENCE: A requirement was left at previous inspection that risk assessments be undertaken on radiators to ensure the surface temperatures were maintained at a low temperature, to avoid the risk of heat injury to residents. This work has now been undertaken by the proprietor of the home and radiator covers purchased. However these covers have not as yet been fitted to the radiators, but the proprietor confirmed that this work was due to commence in the near future. During a tour of the building the toilets and bathrooms were seen and found to be satisfactory. However it was noted that soap bars were used within the toilets seen and hand towels rather than paper towels were used. To avoid the Tansley House DS0000020103.V279625.R01.S.doc Version 5.1 Page 15 possibility of cross-infection the manager should consider the use of liquid soap in preference to soap bars, and if hand towels are to be used these should be changed regularly. Some resident’s bedrooms were seen and found to be clean and tastefully decorated and contained all the required furnishings and equipment. Of the rooms seen all had either en-suite facilities or a wash hand basin. All rooms seen reflected the individuality of each resident, in their tastes and preferences of décor and style. Not all bedrooms seen had locks on the doors, however the manager stated that should a resident who did not have a lock on their bedroom door require one, then this would be fitted for them. The manager must ensure that this information is documented within the homes statement of purpose and service user guide and a record made in the resident’s file that determines the resident’s preference in this area. Residents spoken with stated that they were happy with their private accommodation, and confirmed that they were able to bring their own personal possessions into the home with them, such as television sets, radios, etc. The home was clean in appearance and the general standard of hygiene was good. An assessment of requirements left at the last inspection was undertaken, and this included the requirement that was left regarding the provision at the home for a sluice or sluicing facility. The washing machines were seen and did not incorporate a sluice programme; the sink was also seen within the laundry area. The manager stated that the sink provided within the laundry area was not sufficient for use as a sluice and stated that one of the washing machines was not working satisfactorily and required replacing. It was suggested that this machine could therefore be replaced with a washer that incorporated a sluice programme, which would then ensure that this requirement is met and would further demonstrate that hygiene and control of infection standards are met by the home. Tansley House DS0000020103.V279625.R01.S.doc Version 5.1 Page 16 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 29, Residents are protected by the recruitment practices of the home. EVIDENCE: Two staff files were examined and in general the homes recruitment practices were found to be satisfactory. An assessment of requirements left at the last inspection was undertaken, this included the requirement that all documentation identified in Schedule 4 must be available on staff files. Of the staff files seen this information was present. Also seen on the staff files examined was the Criminal Records Bureau number, which demonstrates that the home has undertaken a police check on all staff employed. The Criminal Records Bureau certificates were not available to see, it was stated by the manager that only the proprietor of the home had access to these. No written references were seen on the staff files examined. This was discussed with the manager, who stated that no staff had been employed at the home in the last two years but confirmed that she was aware that two satisfactory written references are required prior to employing new staff at the home and any gaps in employment history are explored. Tansley House DS0000020103.V279625.R01.S.doc Version 5.1 Page 17 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 33,38 Resident’s views were actively sought within the home to ensure their best interests are met, and the health and safety of residents and staff is protected by the homes policies, procedures and practices. EVIDENCE: The residents spoken with confirmed that the staff team regularly consult with them regarding the care provided at the home. This included meal choices and activities both inside of the home and within the community. Evidence of residents’ interests and hobbies was seen within the residents’ files and staff confirmed that residents were encouraged to maintain their interests and hobbies. Residents meetings were also held every 6 months and the minute of these meetings was seen. Tansley House DS0000020103.V279625.R01.S.doc Version 5.1 Page 18 The health and safety records of the home were examined and found to be satisfactory, this included; staff training files that demonstrated that the relevant training had been undertaken and was up to date this included, moving and handling, fire safety, food hygiene and first aid. Records were also seen regarding Gas Safety, Water Temperature Checks, risk of Legionella check, Derbyshire Fire and Rescue check and Fire Alarm Inspection Certificate. The homes accident/ incident book was seen and found to be satisfactory. Records regarding the maintenance of electrical systems and equipment were not available to inspect, however the proprietor stated that copies of these would be sent through the post to the CSCI. Tansley House DS0000020103.V279625.R01.S.doc Version 5.1 Page 19 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 X X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 X 9 3 10 X 11 2 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 X 14 X 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 X 17 X 18 X 2 X 3 X X 3 X 2 STAFFING Standard No Score 27 X 28 X 29 2 30 X MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X X 3 X X X X 3 Tansley House DS0000020103.V279625.R01.S.doc Version 5.1 Page 20 Are there any outstanding requirements from the last inspection? YES STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard 11 Regulation 12 (2) (3) Requirement Development of care plans should be undertaken that look at residents wishes regarding the care and support given to them during terminal illness/dying to ensure the resident retains maximum control. The home must ensure that matters identified by the Environmental Health Officer are attended to. Covers must be provided on radiators as identified in the risk assessment undertaken to ensure residents safety The home should provide a sluice or sluicing washer. Two written references are obtained before appointing new staff and any gaps in employment history explored. Timescale for action 30/04/06 2 15 16 (2) (j) 31/03/06 3 19 13(4)(c) 31/03/06 4 5 26 29 23 (2)(k) Sch 2 (5) 30/04/06 01/03/06 Tansley House DS0000020103.V279625.R01.S.doc Version 5.1 Page 21 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 Refer to Standard 9 Good Practice Recommendations Controlled drugs, such as Temazepam are stored in a controlled drugs cupboard, meeting the requirements of the misuse of Drugs (safe custody) Regulations 1973, and a record kept of receipt, administration and disposal within a controlled drugs register. The manager should keep under review her systems of staff supervision and seek to meet the frequency levels within the National Minimum Standards. (This standard was not assessed on this inspection) 2 36 Tansley House DS0000020103.V279625.R01.S.doc Version 5.1 Page 22 Commission for Social Care Inspection Derbyshire Area Office Cardinal Square Nottingham Road Derby DE1 3QT National Enquiry Line: 0845 015 0120 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 Tansley House DS0000020103.V279625.R01.S.doc Version 5.1 Page 23 - 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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