Inspection on 29/09/05 for Tarry Hill

This inspection was carried out on 29th September 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. 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 no outstanding requirements from the previous inspection report, but made 4 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Tarry Hill 01/10/08

Tarry Hill 04/10/06

Tarry Hill 20/02/06

Tarry Hill 09/03/05

Tarry Hill 06/10/04

Tarry Hill 17/03/04

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

CARE HOME ADULTS 18-65 Tarry Hill 3/7 Cale Road The Flat New Mills Derbyshire SK12 4LW Lead Inspector Sue Richards Unannounced Inspection 29th September 2005 09:30 Tarry Hill DS0000055430.V255552.R01.S.doc Version 5.0 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 Tarry Hill DS0000055430.V255552.R01.S.doc Version 5.0 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. Tarry Hill DS0000055430.V255552.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Tarry Hill Address 3/7 Cale Road The Flat New Mills Derbyshire SK12 4LW 01663 746440 01663 744915 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) Active Care Partnerships Limited Mrs Lisa-Marie Joan Lovatt Care Home 15 Category(ies) of Learning disability (15) registration, with number of places Tarry Hill DS0000055430.V255552.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 9th March 2005 Brief Description of the Service: Tarry Hill provides personal care for younger adults with learning disabilities. The home was initially registered by Derbyshire County Council Social Services under the Registered Homes Act 1984, transferring under the Care Standards Act 2000 in 2002. It comprises of no 3 Cale Road, which is a three bedroom semi-detached house, no 7 Cale Road, which is a ten bedded house and The Flat, which is located on the first floor buildings extension of no 10. All are located on the same site, with a central office, which is a prefabricated building located within the grounds. There are separate garden areas with seating provided for each house. The home lies on the north east outskirts of New Mills in the High Peak close to a main bus route and within easy access of local shops and amenities. Each house has its own dedicated lounge and dining space for service users together with bathroom and toilet facilities. No 3 and the Flat have domestic type kitchen each have a domestic washing machine for laundry items. No 7 has a large central kitchen, which some service users can access under supervision and a small separate laundry room. There is a separate bedroom in the Flat and also in No 3 for the purposes of staff sleep-in facilities. However, there is no dedicated staff room or separate washing facility for those staff. The registered manager has the support of a team of care and hotel services staff and also receives external management support via Active care Partnerships Ltd. Activities are organised for service users in accordance with their individually assessed educational, social and occupational activity needs. Tarry Hill DS0000055430.V255552.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspect focused on the inspection of the environment, the home’s staffing and managements systems and its arrangements and position in relation to complaints and adult protection. What the service does well: What has improved since the last inspection? The registered provider has continued with the upgrading, repair and renewal of the home and complied with agreed registration conditions. Outstanding core training has been provided for staff and specialist input and advice has been secured for the home in relation to the specialist needs of those service users with autism. Confirmation of staffs’ employment status in respect of their fitness are provided in the home (previously held centrally). Tarry Hill DS0000055430.V255552.R01.S.doc Version 5.0 Page 6 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. Tarry Hill DS0000055430.V255552.R01.S.doc Version 5.0 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Tarry Hill DS0000055430.V255552.R01.S.doc Version 5.0 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): The standards in this section were not assessed on this occasion. EVIDENCE: Tarry Hill DS0000055430.V255552.R01.S.doc Version 5.0 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): The standards in this section were not assessed on this occasion. EVIDENCE: Tarry Hill DS0000055430.V255552.R01.S.doc Version 5.0 Page 10 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): The standards in this section were not assessed on this occasion. EVIDENCE: Tarry Hill DS0000055430.V255552.R01.S.doc Version 5.0 Page 11 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): The standards in this section were not assessed on this occasion. EVIDENCE: Tarry Hill DS0000055430.V255552.R01.S.doc Version 5.0 Page 12 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 & 23 There is a satisfactory system and arrangements in place to enable service users and their representatives to raise any concerns they may have and also to complain. There were recognised management systems and arrangements in place to promote the protection of service users in the home. Although the investigation of the recent complaint has been formerly closed under adult protection procedures, it was agreed via those procedures that there are a number of identified operational issues, which require further action by management. EVIDENCE: The complaints procedure for the home was openly displayed on service user notice boards and strategies used to enable complaints and concerns to be raised were discussed with the manager and staff. The complaints record was also examined. This detailed all concerns and complaints received, action taken and outcomes. There had been one complaint made since the previous inspection, reported and recently investigated via adult protection procedures, led by Stockport Social Services. The Inspector attended the resolution meeting of this on the morning of the inspection. This was held at the home. The home’s records were also examined in respect of this. Tarry Hill DS0000055430.V255552.R01.S.doc Version 5.0 Page 13 Staff training records kept included details of individual staff’s access to company training in relation to the protection of vulnerable adults. The Manager and deputy planned to attend Derbyshire County Council’s joint agency training in relation to adult protection procedures. The arrangements for staff training and instruction in regarding dealing with violence and aggression/challenging behaviours of service user were also examined. This included discussions with the manager and staff and inspection of staff training and induction records. Written policy guidance was available for staff in respect of internal procedures to follow in the event of any suspicion or allegation of the abuse of any service user and also the Department of Health’s ‘No Secrets’ document. Staff spoken with was familiar with these. Tarry Hill DS0000055430.V255552.R01.S.doc Version 5.0 Page 14 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 25, 26, 27, 28, 29 & 20 Given that the home was initially registered some years ago under the Registered Homes Act and as such does not completely lend itself to the client group accommodated, the current registered providers have invested in terms of a fair amount of upgrading, repair and renewal of the premises. However, there are areas where further development and renewal would ensure that the environment fully meets the needs of existing and potential service users. EVIDENCE: The Inspector carried out a full tour of the home and its facilities. Areas seen were clean and odour free and generally well maintained. The bedrooms of a number of service users inspected. These were generally reasonably well decorated and furnished. However, many windows frames were rotten and in need of replacement. The grounds were untidy and unkempt in some areas. Areas of upgrading and renewal, which were former conditions of the home’s registration, have been complied with since the previous inspection. However, soft furnishings still required replacement in the lounge in ‘The Flat’ and kitchen floor covering was still to be laid to No 3. The manager advised that these had been ordered. Tarry Hill DS0000055430.V255552.R01.S.doc Version 5.0 Page 15 The laundry room to no 7 is very cramped, with area for linen circulation/storage of dirty linen. Open laundry bins were left outside the laundry in the narrow corridor leading to service users bedrooms. There is no walk in shower provision, which some service users would like to have access to ion no 7. Concerns were raised by staff in relation to the lack of dedicated washing facilities for them when undertaking sleep-ins for which they currently share service users facilities and also that there is no separate dedicated staff room for time out/breaks. Tarry Hill DS0000055430.V255552.R01.S.doc Version 5.0 Page 16 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 32, 33, 34, 35 & 36 There were generally satisfactory systems and arrangements in place to ensure that staff were properly recruited, trained and supported and to potentially enable them to carry out their roles for the benefit of service users accommodated. However, the efficacy of the arrangements for night staffing, the considerable number of hours per week that some staff work and how these two issues may impact on service users requires further management review. EVIDENCE: The Inspector held discussions with the manager and individual staff about their roles and responsibilities, the main aims of the home, what the home does well and what could be improved and also the training and support they receive. Job descriptions were also examined for each staff group. Details of staff employed were provided by the manager, together with copies of staff duty rotas, which were also seen displayed in each ‘house.’ Duty rotas examined were based on a core rolling rota with additional hours provided each day (planned a week in advance) to ensure that service users received the additional support they required at the times they required it. Tarry Hill DS0000055430.V255552.R01.S.doc Version 5.0 Page 17 A recent complaint investigated initially under adult protection procedures, had identified and agreed a number of areas, which require further assessment by management. These included the organisation of care on night duty and also key responsibilities/expectations of sleep in staff and all staffs’ understanding of those responsibilities, for the purposes of night duty. Some staff had been working in excess of 60 and 70 hours per week. There were differences in opinion as to the efficacy of this. Records of staff turnover were examined and also the personal/individual records of two new staff starters in relation to their recruitment, induction, supervision and training. These were satisfactory and in accordance with company policy. Central training records were also examined and discussions were held with the manager and staff about the arrangements for and access to training – including core training, NVQs and that related to the specific conditions of service users. Tarry Hill DS0000055430.V255552.R01.S.doc Version 5.0 Page 18 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 38, 39, 40, 41, 42 & 43. The home is well managed and run, within an established management framework and there are key systems, policies and procedures in place, which are there to assist staff in supporting and promoting the health, safety and best interests of service users. EVIDENCE: The registered manager has been in post for a number of years. Details of training undertaken by her have been provided and her job description examined. The Inspector discussed with her and with staff the strategies employed in relation to ensuring a clear direction for the home. These included service aims and objectives, recognised methods for consultation with staff, service users and their representatives and quality monitoring systems. The home is currently working towards achieving Investors in People Award and had Tarry Hill DS0000055430.V255552.R01.S.doc Version 5.0 Page 19 recently been the subject of a diagnostic audit in respect of this with an action plan provided. A number of the home’s policies and procedures were examined in relation to the National Minimum Standards assessed during the inspection process. These were standardised company policies reflective of the home’s service provision and recognised guidance with review dates recorded. Staff spoken with was conversant with a number of key policies, which the Inspector discussed with them. They also confirmed they were able to access these all operational policies and procedures. However, the complaint resolution meeting held under joint agency adult protection procedures (see Complaints section of this report) agreed that a management review of staff responsibilities regarding the home’s accident and incident reporting procedures was necessary. A number of records, which are required by legislation, to be kept in the home, were examined during the inspection process. These included: Staff recruitment and training records Duty rotas Complaints records Reports of the monthly visits to the home by the registered provider representative. Fire procedure and maintenance records. Records were seen to be properly stored. Staff spoken with confirmed the arrangements for access to core health and safety training as described under the Staffing section of this report. Tarry Hill DS0000055430.V255552.R01.S.doc Version 5.0 Page 20 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score X X X X X Standard No 22 23 Score 3 3 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score X X X X X Standard No 24 25 26 27 28 29 30 STAFFING Score 2 3 3 3 2 2 2 LIFESTYLES Standard No Score 11 X 12 X 13 X 14 X 15 X 16 X 17 Standard No 31 32 33 34 35 36 Score 2 3 2 3 3 3 CONDUCT AND MANAGEMENT OF THE HOME X PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Tarry Hill Score X X X X Standard No 37 38 39 40 41 42 43 Score 3 3 3 2 3 3 3 DS0000055430.V255552.R01.S.doc Version 5.0 Page 21 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 OP22 Regulation 22 Requirement The registered manager must ensure that with regard to the recent complaint investigated initially under adult protection procedures, that The complainant is informed of any further action to be taken as a result of the agreed management review and The Commission is also notified in writing of the outcome. The premises of the care home must be kept in a state of good repair (both internally and externally) – in this instance Review of window frames, with replacement to be undertaken as required. Upgrading and better maintenance of the grounds. The registered persons must ensure that as far as is reasonably practicable, that at all times the staffing arrangements are appropriate for the health and welfare of service users. (This relates DS0000055430.V255552.R01.S.doc Timescale for action 31/10/05 2 YA24 23 31/03/05 3 YA31 18 31/10/05 Tarry Hill Version 5.0 Page 22 specifically to the efficacy of the arrangements for night staffing and the considerable number of hours that some staff work per week, which require review). 4 YA40 13 The registered person must ensure that any risks to service users health and safety are identified and as far as possible eliminated. In this instance a review of staff’s understanding of the accident and incident reporting procedures must be undertaken to ensure that staff are conversant with their responsibilities. (Reference complaint). 31/10/05 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 2 3 4 Refer to Standard YA30 YA27 YA28 YA31 Good Practice Recommendations Laundry bins containing dirty laundry should not be left out in the corridor outside the laundry, which is an access corridor to service users bedrooms. The registered provider should consider providing a separate walk in shower facility for service users in no 7. The registered provider should consider possible solutions to the lack of a dedicated washing facility for staff who sleep-in and also the lack of a dedicated staff room. The registered manager should ensure that staff are clear as to their roles and responsibilities with regard to the working arrangements for night staff who sleep in. Tarry Hill DS0000055430.V255552.R01.S.doc Version 5.0 Page 23 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 Tarry Hill DS0000055430.V255552.R01.S.doc Version 5.0 Page 24 - 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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