Inspection on 04/10/06 for Tarry Hill

This inspection was carried out on 4th October 2006.

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 20/02/06

Tarry Hill 29/09/05

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 Key Unannounced Inspection 3rd October 2006 09:30 Tarry Hill DS0000055430.V304796.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 Tarry Hill DS0000055430.V304796.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. Tarry Hill DS0000055430.V304796.R01.S.doc Version 5.2 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 Ltd Mrs Lisa-Marie Joan Lovatt Care Home 15 Category(ies) of Learning disability (15) registration, with number of places Tarry Hill DS0000055430.V304796.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 20th February 2006 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. The home lies on the northeast 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. At the time of the inspection extensive building work had commenced in respect of the phased redevelopment of the site, which aims to provide purpose built accommodation for service users accommodated. The current scale of charges is £1025.00 per week per resident with additional charges of £15.00 per hour for specified one to one care outside the basic contract. Tarry Hill DS0000055430.V304796.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. At the time of the inspection there were 15 service users accommodated, including one in receipt of respite care. Case tracking was used as part of the methodology for the inspection. This involved the random sampling of a number of service users, whose care and the services they received, was examined in more depth. This included discussions with them and also staff involved in their care, the examination of their care and associated records and inspection of their private and communal accommodation. There was no relatives or representatives visiting the home at the time of the inspection. What the service does well: What has improved since the last inspection? The arrangements to enable service users to engage in social, occupational and educational activities of their choice are developing well. Tarry Hill DS0000055430.V304796.R01.S.doc Version 5.2 Page 6 Recent improvements in the menu planning and changes in the way in which residents are to being consulted about these should improve quality and choice to service users satisfaction. Building works have commenced for the total redevelopment of the home and site with the aim of providing more suitable purpose built accommodation for existing and prospective service users. 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.V304796.R01.S.doc Version 5.2 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.V304796.R01.S.doc Version 5.2 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): 2&3 Quality outcome in this area is good. This judgement has been made using evidence available, including a site visit to the home. Service users individual aspirations and needs are effectively assessed and accounted for. EVIDENCE: Case tracking was undertaken for two service users most recently admitted to the home. Discussions were held with those service users about their needs and how they were agreed and discussed with them and how they were met. Both of those service users felt that their needs were being reasonably well met, although one service user who was admitted in August was not yet allocated a named key worker and expressed some frustrations about this. The recorded needs assessment information for each of those service users was examined. These were comprehensive and detailed potential restrictions on choices and freedoms based on their individual specialist needs, which were discussed with those service users. Families and carers interests were also accounted for. There were no service users accommodated with diverse cultural or religious needs. Tarry Hill DS0000055430.V304796.R01.S.doc Version 5.2 Page 9 Individual discussions were held with staff regarding the needs of those service users case tracked and about their experience and training and arrangements for the organisation and delivery of their car and staff training records were also examined. Staff is conversant with service users needs and demonstrated the provision of relevant skill mix on the day of the inspection. The manager advised of the home’s policy regarding the allocation of key workers, which was satisfactory. The manager advised that contacts had recently been established with Peak and Dales Advocacy Services who had provided a workshop in the home in September 2006. From this it had been agreed that monthly open door sessions would be provided for service users at the home, with a view to providing individual advocacy in accordance with service users own requests. There is a named service user who has agreed to act as a named link with the service. Since the previous inspection one service user had been appropriately assisted and supported to find suitable accommodation in accordance with changes in their assessed needs. Tarry Hill DS0000055430.V304796.R01.S.doc Version 5.2 Page 10 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): 6, 7 & 9 Quality outcome in this area is good. This judgement has been made using evidence available, including a site visit to the home. The home’s risk management strategies ensure that service users are effectively supported and empowered to make decisions about their planned care in accordance with their individual rights and risk assessed needs. EVIDENCE: Discussions were held with service users case tracked about their care plans, which they had access to and said that they were agreed with them. Those care plans were examined. They were formulated in accordance with individual’s risk assessed needs and had satisfactory arrangements for their reviews. Care plans also included clear and detailed written procedures in respect of dealing with and managing individual’s potential aggression. These reflected recognised practise and guidance in relation to dealing with and managing violence and aggression. The involvement of significant professionals outside the home and families and representatives was accounted for with each service user. Tarry Hill DS0000055430.V304796.R01.S.doc Version 5.2 Page 11 Discussions were held with service users about how made decisions about their lives and also with the staff caring for them. These included aspects of their care relating to daily living preferences, relationships and contacts and also finances. Limitations to individuals’ rights were clearly recorded via their care plans and accounted for in accordance with a recognised approach to risk assessment and management. Tarry Hill DS0000055430.V304796.R01.S.doc Version 5.2 Page 12 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): 11,12, 13, 14, 15, 16 & 17 Quality outcome in this area is good. This judgement has been made using evidence available, including a site visit to the home. The arrangements to enable service users to engage in social, occupational and educational activities are developing well. Sufficient nutrition is provided for residents and the improvements in menu planning and consultation with residents about these should improve quality and choice to service users satisfaction. EVIDENCE: Discussions were held with service users about the arrangements for them to engage in social, educational and occupational activities, to maintain links with the local community and their families and friends and also their daily living arrangements and rights. Discussions were also held with the manager and staff about these. These were satisfactory, with access to community links/activities continuing to develop, although one service user expressed frustration about their recent lack of access to a chosen weekly leisure pursuit outside the home. This was discussed with the manager, who was not aware of this matter and agreed to clarify matters. Again any restrictions on Tarry Hill DS0000055430.V304796.R01.S.doc Version 5.2 Page 13 individual’s choices and freedoms were well accounted for within their written care plans. An activities co-ordinator had been employed on a part time basis since the previous inspection. Residents were engaged in various group projects, including an allotment, with links forged with the volunteer centre via the Allotment Society, a church grounds renovation project, a healthy eating project and an eco-friendly/recycling project. Groups consisted of a head/link person with service users and staff. A communications group has also been established since the previous inspection looking at all aspects of communication in and outside the home, including contacts with external agencies and is working towards accreditation with the National Autistic Society. Discussions were also held with residents about their daily living responsibilities and any housekeeping tasks they engaged in, which were in accordance with their individual capacities and risk assessed needs, which were clearly recorded in their written plans. Sample dinner menus were provided by way of the pre-inspection questionnaire. These provided a balanced and nutritious diet, with a choice of two dishes provided for the main meal and a set pudding. However, the choice of dishes provided an alternative recipe only for one main ingredient. Residents and staff advised that breakfasts were flexible as were lunches according to individual’s activities and choices. Some residents felt there could be improvements with the dinner choice. The manager and one resident advised of the health eating project and the planned changes to menu planning by more actively involving residents. Progress with this will be assessed at the next inspection for this service. A number of residents were in for lunch during the inspection eating various light meals, which they said they had chosen. Tarry Hill DS0000055430.V304796.R01.S.doc Version 5.2 Page 14 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): 18, 19 & 20 Quality outcome in this area is good. This judgement has been made using evidence available, including a site visit to the home. Residents’ preferences in terms of their personal and health care support are met in accordance with the home’s assessment policy and individual risk management strategies. EVIDENCE: Discussions were held with service users case tracked about their health care needs and how these were met. Discussions were also held with staff and the manager and records examined in respect of these, including health care plans. These were satisfactory. Discussions were also held with service users and staff about the arrangements for personal support, including the allocation of named key workers for each resident. These were satisfactory. The arrangements for the management and administration of service users medicines were also examined, which for the most part were in accordance with the homes policy guidance and also recognised practise. However, the list of staff signatures for those responsible for administering medicines was not completed, with many signatures requiring to be recorded. Also on occasions Tarry Hill DS0000055430.V304796.R01.S.doc Version 5.2 Page 15 where staff responsible was hand writing the medicines instructions onto the medicines administration record (MAR) sheet they were not signing and dating the written instruction and there was no countersignature of a witnessing staff member. Tarry Hill DS0000055430.V304796.R01.S.doc Version 5.2 Page 16 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): Quality outcome in this area is good. This judgement has been made using evidence available, including a site visit to the home. The views of service users and their representatives are listened to and acted on and there are suitable systems and arrangements in place to promote the protection of any service user from abuse, neglect and harm. EVIDENCE: Service users spoken with said they were comfortable raising any concerns or complaints they may have and knew how they would do this. There is a written complaints procedure in place for the home and suitable information is provided on service user notice boards. Records of complaints were examined and discussed with the manager. There had been three complaints raised since the previous inspection. Two of those were made via external sources and were investigated via joint agency adult protection procedures in accordance with the home’s operational procedures. One of those was not upheld and the other was partially upheld. The third complaint was an internal complaint from a staff member and was also upheld. Full and satisfactory information was provided in respect of these, including detailed written reports of investigations undertaken, the outcome of those investigations and action taken as result as appropriate. There is clear and comprehensive policy guidance in place for staff in respect of dealing with potential violence and aggression by any service user. There are suitable arrangements to ensure that all staff undertaken recognised training in Tarry Hill DS0000055430.V304796.R01.S.doc Version 5.2 Page 17 non-physical and physical interventions in relation to dealing with violence and aggression. There are also named staff holding a recognised qualification to enable them to train staff in this area and suitable arrangements for updates and refreshers for both the trainers and other staff. Staff spoken with was conversant with their responsibilities in respect of recognising and preventing abuse, dealing with complaints and dealing with violence and aggression from any service user. Tarry Hill DS0000055430.V304796.R01.S.doc Version 5.2 Page 18 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 & 30 Quality outcome in this area is adequate. This judgement has been made using evidence available, including a site visit to the home. Residents live in a homely and comfortable environment, which is being totally redeveloped in consultation with service users and their representatives. EVIDENCE: The private and communal accommodation of service users case tracked was inspected. All areas seen were well maintained, clean and reasonably well furnished and decorated. Central service areas were also inspected. All areas seen were clean and reasonably well equipped. Previous inspection reports have detailed the fact that the home was initially registered many years ago under the Registered Homes Act 1984, transferring under the Care Standards Act 2000 in July 2002. As such it does not effectively lend itself to the client group accommodated. The registered provider took over the home over 2 years ago and invested considerably in the redecoration, repair and renewal of the fabric of the home and had subsequently developed plans for the total redevelopment of the home and Tarry Hill DS0000055430.V304796.R01.S.doc Version 5.2 Page 19 site. Phased building works have now commenced in respect of these plans, which are to provide purpose built accommodation for existing and prospective service users. Since the inspection, a discussion has been held with the manager regarding the need to ensure that the registered provider liaises fully with the Central Registrations and Compliance Team of the Commission in respect of the registration of the development. The manager agreed to discuss this with external management and the responsible individual. Service users and their representatives are engaged and informed in respect of the development and there are clear written care plans in place for individual service users whose safety and psychological/emotional conditions may be affected by the changes/works being undertaken, for example those with a range of spectrum disorders, such as autism. Tarry Hill DS0000055430.V304796.R01.S.doc Version 5.2 Page 20 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): 32, 34 & 35 Quality outcome in this area is adequate. This judgement has been made using evidence available, including a site visit to the home. Service users are well supported with their needs met by the number and skills of staff caring for them. However, not always obtaining two full written references for each staff member compromises the otherwise effective recruitment practises employed by the home, which may be a potential risk to service users. EVIDENCE: Discussions were held with the manager and individual staff about the arrangements for their recruitment, induction, training and the arrangements for their deployment and supervision. Staff was conversant with their roles in accordance with their individual skills. They described their work with enthusiasm and said that the arrangements for and access to training were very good. Records were examined in relation to the above. These were properly maintained. Tarry Hill DS0000055430.V304796.R01.S.doc Version 5.2 Page 21 The home operates an equal opportunities policy in respect of staff recruitment and selection, with mechanisms for monitoring the efficacy of this. Staff deployment is organised on the basis of a rolling rota, with additional/overtime hours applied to accommodate staff leave. Staff is consulted about these arrangements. The rolling rota as it currently stands provides for ten care staff for the morning shift, with two additional staff providing one to one care and support from 8am to 11am and 10 am to 4 pm (Monday to Friday). This accords with the daily living arrangements and activities undertaken by individual residents. Thirteen care staff is provided for the afternoon shift with thirteen care staff throughout the day at weekends. Night cover consists of four waking staff and one sleep-in. At the time of the inspection there were 15 service users accommodated (including one for respite care only). There are a total of 46 staff employed in the home, with individual variances in the total hours worked. Out of those, a total of fifteen staff had achieved NVQ level 2 and three had achieved NVQ level 3. A total of fifteen were either registered to commenced or were undertaking NVQ level 2 with two the same for NVQ level 3. There were four foreign nationals employed with two undertaking NVQ level 2 included in the above numbers. The other two were still working through their induction/foundation programme. Discussions were held with one of those, who described a satisfactory induction process. Staff spoken with also described the recruitment process undertaken by each of them. The personnel records for four of them were examined. One of those contained only one written reference and another had one written reference and one verbal reference recorded. Details of staff turnover were also provided. Staff said they had regular meetings and also received one to one supervision at regular intervals. Minutes of meetings and records regarding individual supervision were provided. Tarry Hill DS0000055430.V304796.R01.S.doc Version 5.2 Page 22 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, 39, 41 & 42 Quality outcome in this area is good. This judgement has been made using evidence available, including a site visit to the home. The home is well managed and run in the best interests of service users accommodated. On the whole, effective operational systems and policy guidance underpin safe practise and promotes the health, safety and welfare of service users. EVIDENCE: Discussions were held with the manager about her own training and development and the management systems in the home. These were satisfactory. The company operates a formal system of quality assurance in the home. Details of this were provided and discussed. Comprehensive and regular systems audits are undertaken and there are formal arrangements for regular and periodic consultation with service users and their representatives, Tarry Hill DS0000055430.V304796.R01.S.doc Version 5.2 Page 23 including more recently outside stakeholders, with satisfaction surveys collated by head office. Both inform the development plans for the home and suitable information is provided for service users and their representatives as a result of these. A representative of the registered provider visits the home on a monthly basis in order to assess the quality of care and service provision and reports of those visits are provided. A number of records, which are required to be kept in the home, were examined during the inspection. These are referred to under the relevant sections of this report. On the whole, these were generally well maintained and were safely and securely stored and accessible to service users as able, although some omissions of record were identified in respect of medicines administration records and staff records. Details of the arrangements to ensure staffs’ safe working practises were provided by the manager and records examined in relation to these. Discussions were also held with staff regarding the same. These were satisfactory. Information regarding the annual and routine maintenance of equipment and systems in the home were provided by way of the preinspection questionnaire and were satisfactory. Records of accidents/incidents were examined and the home’s policy guidance and practise in respect of the reporting and recording of these were discussed with staff. These were in accordance with requirements and staff spoken with was conversant with these. Tarry Hill DS0000055430.V304796.R01.S.doc Version 5.2 Page 24 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 3 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 2 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 2 35 3 36 X 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 3 12 3 13 3 14 3 15 3 16 3 17 2 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 X 3 X 3 X 2 3 X Tarry Hill DS0000055430.V304796.R01.S.doc Version 5.2 Page 25 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 YA20 Regulation 13, 17 Timescale for action In respect of medicines records a 04/11/06 full list of staff specimen signatures must be maintained for all staff responsible for the administration of medicines in the home. In respect of medicines 04/11/06 administration records, on the occasion where it is necessary to hand write medicines instructions onto the MAR sheet, the instruction(s) must be signed and dated by the staff member writing them and countersigned by a witnessing staff member. The registered persons must 05/10/06 continue to ensure that service users health and safety is promoted and maintained whilst the redevelopment of the home is being undertaken. Staff records must be maintained 30/11/06 in accordance with Schedule 2 of the Care Homes Regulations 2001. In this instance two written references relating to each staff employed must be obtained. Requirement 2. YA20 13 3. YA24 13 4. YA34 17 Tarry Hill DS0000055430.V304796.R01.S.doc Version 5.2 Page 26 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 YA24 Good Practice Recommendations If they have not already done so, the registered persons should ensure liaison with the Central Registrations and Compliance Team of the Commission in respect of the commencement of the building works for the planned phased total redevelopment of the site Tarry Hill DS0000055430.V304796.R01.S.doc Version 5.2 Page 27 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.V304796.R01.S.doc Version 5.2 Page 28 - 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. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!