Inspection on 26/09/06 for Tye Green Lodge

This inspection was carried out on 26th September 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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Similar services:

Claremont House

Oak Ridge

Sun Court Nursing Home

Ashville House

Bramley Avenue (73)

Bilney Hall

Hill Barn

Mabbs Hall Nursing Home

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

CARE HOMES FOR OLDER PEOPLE Tye Green Lodge Yorkes Tye Green Village Harlow Essex CM18 6QR Lead Inspector Sara Naylor-Wild Key Unannounced Inspection 10:30 26 September 2006 th 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 Tye Green Lodge DS0000064980.V295924.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 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. Tye Green Lodge DS0000064980.V295924.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Tye Green Lodge Address Yorkes Tye Green Village Harlow Essex CM18 6QR 01279 770500 01279 770577 tye@quantumcare.co.uk www.quantumcare.co.uk Quantum Care Limited 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) Vacant Care Home 60 Category(ies) of Dementia - over 65 years of age (60), Old age, registration, with number not falling within any other category (60), of places Physical disability over 65 years of age (60) Tye Green Lodge DS0000064980.V295924.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 4. Persons of either sex, aged 65 years and over, who require care by reason of old age only (not to exceed 60 persons) Persons of either sex, aged 65 years and over, who require care by reason of dementia (not to exceed 60 persons) Persons of either sex, aged 65 years and over, who require care by reason of a physical disability (not to exceed 60 persons) The total number of residents accommodated in the home must not exceed 60 persons N/A Date of last inspection Brief Description of the Service: Tye Green Lodge is a Care Home for Older People located on the edge of Harlow in a residential suburb known as Tye Green Village. As well as the large town centre facilities accessible via public transport, there are local shops and pubs within walking distance of the home. The building was purpose built to provide accommodation for 60 older people in four units. Each unit has a self-contained kitchen, dining and living area, with corridors leading to bedrooms, bathrooms and toilets leading off. The bedrooms are single and have en-suite shower rooms. Additional facilities include a treatment room, hairdresser’s salon, two communal lounges and visitor’s room. There are secured landscaped gardens with pathways and seating located around the building. The service caters for residents requiring support due to physical frailty and residents with a diagnosis of dementia. The ranges of fees charged by the service are between £520 and £625 per week. There are additional charges for hairdressing, chiropody and outings and entertainment. This information was provided to the Commission by the provider in September 2006. Tye Green Lodge DS0000064980.V295924.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced key inspection visit is the first conducted at Tye Green Lodge since its registration with the Commission. The visit concluded the information gathering carried out by the Commission in order to form a judgement about the services performance against the Care Homes Regulations 2001 and National Minimum Standards for Older people. The information used included; collating responses to residents and relatives surveys, reading documentation such as care plans, incident and accident forms, Providers monthly reports and speaking to service users, visiting health professionals, relatives, staff and the managers of the home. The visit was conducted over two dates in order to facilitate the full process and the last visit took place on 2nd November 2006. During the period since the registration of the service, the then registered manager had resigned and the Deputy manager Melanie Kinsey had been acting up to the position. At the time of the second visit the interviews for the post had been carried out and the Deputy manager was successfully appointed to the post. The organisation will then need to present an application to the Commission for Ms Kemsley registration until such time the Registered Manager’s position is recorded as vacant by the Commission. What the service does well: What has improved since the last inspection? Tye Green Lodge DS0000064980.V295924.R01.S.doc Version 5.2 Page 6 This is the services first inspection and therefore there are not improvements to be noted. However the inspector had visited the building previously as part of the registration process for the service and was pleased to see the bare bones of the building now being fully utilised and personalised by the residents living there. 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. Tye Green Lodge DS0000064980.V295924.R01.S.doc Version 5.2 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 Tye Green Lodge DS0000064980.V295924.R01.S.doc Version 5.2 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): 1, 2, 3, 4, 5 and 6 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Prospective residents and their families are aware of the services provided at Tye Green Lodge and the service identifies how it will need to best support the service user following admission. EVIDENCE: The organisation has produced an introductory pamphlet and Residents guide that provides any prospective residents and their family with information about the service provided at Tye Green Lodge. The residents and family members spoken with were aware of the publication and found it useful in selecting the home. Residents also recalled visiting the home prior to deciding whether to agree to admission. This was offered to them by the service and included tours of the home by themselves or relatives as well as longer visits. A sample of residents’ needs assessments was taken as part of the case tracking exercise. The files sampled contained a both a social care Tye Green Lodge DS0000064980.V295924.R01.S.doc Version 5.2 Page 9 assessments and an independent assessment carried out by the service that was incorporated in the plan of care. The assessment was designed to gain information about the residents’ abilities, needs and aspirations. When fully completed this would provide a person centred holistic view of the service user and enable the service to understand how they should best support the individual and whether these needs could be catered for. Unfortunately the quality of the completion of this document varied and as such did not always fulfil this objective. The need to ensure that staff collected information in a way that gave as full a picture as possible was discussed with the manager. Residents were given contracts or terms and conditions to agree and sign as part of their admission process. For those residents with dementia, family members or representatives fulfilled this role. The service does not provide an intermediate care service, although there is provision for respite care. Tye Green Lodge DS0000064980.V295924.R01.S.doc Version 5.2 Page 10 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, 8, 9, 10 and 11 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users can expect staff to support them in meeting their needs and preferences. Service users can expect their care plans to identify how staff support them EVIDENCE: All residents have a care plan that contains information in respect of how to meet their daily needs and any associated risks in providing support. The care plans of 8 residents were sampled during the inspection visit, and included a selection from each of the units. These plans contained some variation in the way they were set out, and the manager explained that a recent change in the way care plans were formatted had been introduced across the home and they were in the process of updating all the records. The newer version of the document was more succinct with less bulk to the way the information was recorded. The document contained a mixture of assessment information and instruction to staff in how to meet the identified needs in sections of an individual’s daily life such as mobility, life history, interests, personal care etc. Significantly the manager and staff reported that Tye Green Lodge DS0000064980.V295924.R01.S.doc Version 5.2 Page 11 they found it easier to use the tool than the previous format. However, the quality of the information in the completed care plans varied, and in some cases the information was too basic to provide a good insight into how staff should provide an individual care in a person centred focused service. The manager was aware of the variations and understood the developments needed to provide a better quality of information in care planning. Records of health care were maintained and issues such as diet, weight and continence were regularly monitored to ensure that suitable levels of support were offered. Health professional’s visits were recorded along with their outcomes. Risk assessments were present on the files and included issues such as moving and handling, mobility and falls and access to outdoor spaces. The risks such as falls are audited regularly and the information used to inform both individual risk assessments and general practice in the home. Medication administration is managed appropriately. The service uses a monitored dosage system to dispense medication, and staff are trained in the administration of medication using this system. Medication is stored in locked wheeled cabinets within cupboards on each unit. Additionally a controlled drugs cupboard is situated in the manager’s office with a logbook there are quality checks of the administration documentation carried out three times a day by a shift manager to ensure consistent practice by staff. Additionally the PRN medications such as pain control etc are dispensed by a shift manager, to minimise the possibility of staff making mistakes in recording. Observation of staff carrying out the medication round during the inspection demonstrated a good understanding of the principles of safe handling and administration. The service demonstrates its attitude to the treatment of residents with respect and dignity in a number of ways. These include a person centred approach to providing support to service users. The Inspectors conversations with residents included discussing how staff ensured they were treated with respect and dignity. Residents were adamant that the staff carried out their duties in a way that upheld these rights. Examples given included that staff knocked on doors and that staff did not rush them but supported them at their own pace. Staff also demonstrated in their discussions with the inspector that they understood how individuals support needs varied and how they continued to offer choice to meet the individual’s ability. Tye Green Lodge DS0000064980.V295924.R01.S.doc Version 5.2 Page 12 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): 12, 13, 14 & 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users can expect their daily life to include periods of activity and occupation. EVIDENCE: The service employs an activities co-ordinator who is responsible for sourcing, organising and recording regular large scale activities and events such as karaoke sessions, craft workshops and on the day of the inspection a birds of prey demonstration and talk. Care staff are encouraged to take part in these sessions and to carry out smaller activities on the units with service users. The observation of the inspector on the visits was that this happened at a varied pace with some staff interacting in tabletop games, singing etc, whilst others tended to sit away from service users. The manager reported that a recent dementia care mapping event had provided evidence of more staff interaction than they had previously been assessed, although agreed that there was always room to improve this area. Care plans included information about residents’ life history and interests to assist staff in identifying activities they have an interest in. Two staff members had recently created a shop in the home with a stock of small items such as sweets, cards and toiletries. Residents are invited to select Tye Green Lodge DS0000064980.V295924.R01.S.doc Version 5.2 Page 13 items as they wish. Residents who hold their own monies paid for items themselves, however, those residents whose monies are managed by the home had their names and the total cost of the items they purchased added to a bill that was passed to the administrator for deduction from their account. The inspector observed that one service user in this situation found the arrangement confusing and a little distressing and repeatedly asked staff how she should pay. This was discussed with the manager and she was asked to consider whether the fact that there was not a full transaction detracted from the experience for the service user and how this could be addressed by the service. Residents and their relatives surveyed and spoken with during the inspection reported that they services visiting policy was sufficiently liberal to encourage visits, whilst providing residents with control over who they invited and when. The residents’ wishes in respect of terminal illness and death were recorded in care plans. This is an important aspect of care provision and demonstrates that the service is committed to residents’ involvement in care planning. Staff had attended courses relating to terminal care and death, giving them some insight into the issues they would need to consider at this time. Although meals are prepared and cooked centrally in the main kitchen the ingredients for the meal are transported in heated trolleys to the individual units and staff plate meals according to residents preferences. A menu is available with choices to residents and their selections are given to the catering staff in advance. The manager discussed the user of visual aids to assist residents with dementia in exercising their choices at mealtimes. Discussions with residents identified some difficulties in catering for a large and diverse group of residents that meant that the meals were not always prepared to their taste, although they acknowledged that they were provided with a choice and had discussed their views at the homes forum. The manager and catering manger should continue to consider how they could achieve maximum satisfaction in this area. Tye Green Lodge DS0000064980.V295924.R01.S.doc Version 5.2 Page 14 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): 16 & 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents can be confidant that the service will listen to their concerns and that any issue brought to the attention of the manager and dealt with appropriately. EVIDENCE: The service has a complaints policy that sets out a stepped procedure for residents to raise concerns. The residents and their families spoken with were aware of the complaints procedures and their rights to make their views known to the manager, or a staff member they trusted. The service recorded complaints at various levels of seriousness in a log and included the findings of any investigation as part of this record. Additionally the service has commenced dementia care mapping exercises to gain a greater insight into how the way in which staff deliver support to the residents with dementia is received. This tool charts the reactions residents’ display to staff interaction and stimulus. This demonstrated a respect for residents’ views to improve the quality of the service provision. The Protection of Vulnerable adults policy provides a framework for the recognition of the elements of abuse and how the service will respond to allegations. This meets the good practice set out in “ No Secrets “ and the Essex Vulnerable Adults Guidance. The staff have details of whistle blowing policy as part of their induction and receive training in recognising abuse. Tye Green Lodge DS0000064980.V295924.R01.S.doc Version 5.2 Page 15 These policies have been tested out with witnesses reporting an allegation of abuse. The service demonstrated an appropriate response to the report and instigated a POVA referral to Essex County Council in a timely manner. Tye Green Lodge DS0000064980.V295924.R01.S.doc Version 5.2 Page 16 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, 20, 21, 22, 23, 24, 25 & 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents independent access to the facilities the premises offer is supported by the design of the building. EVIDENCE: The building was purposely designed to accommodate the needs of older people, and therefore benefits from facilities such as wheelchair access to communal and personal rooms. As well as communal space in each unit made up of a lounge diner and kitchen area; there is a communal lounge on each floor linking the two units and numerous seating areas around the corridors. There is access to the enclosed gardens and outdoor seating from the ground floor lounges, and the garden has a paved pathway and patio areas to provide stable footing. Tye Green Lodge DS0000064980.V295924.R01.S.doc Version 5.2 Page 17 As well as the en-suite showers there are a bathroom with assisted baths, sink and toilet in each unit and separate toilet facilities. The residents are individually assessed for mobility and pressure care equipment, including hoists and slings required for moving and handling. Other equipment is provided such as bath hoists and communal wheelchairs by the service. All bedrooms are single rooms and have equipment and furnishings to the National Minimum Standards such as en-suite shower rooms with, lockable facilities and bedroom door locks. Bedrooms each had a different colour scheme and residents had personalised their rooms with family photos, pictures, mementos and ornaments. Each room is equipped with a nurse call system for residents to call staff for assistance. The home appeared clean and no offensive odours were detected in any part of the building. The home has macerator units for the disposal of continence waste and each unit has a sluice room. Staff are equipped with protective clothing including uniforms, disposable gloves and aprons. Clinical waste such as dressings and syringes are disposed of safely. There is infection control policy and staff have undertaken some training in health and safety issues although there is not specific infection control training documented on staff files. : An application to vary the use of the existing visitors room to enable respite residents to stay in this accommodation was considered at the site visit to the home. The room provides the same level of facilities as other residents’ rooms and in fact was only different in the title given to the use of the room. Tye Green Lodge DS0000064980.V295924.R01.S.doc Version 5.2 Page 18 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): 27, 28, 29 and 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents can be confident that the numbers and skills of staff will meet their needs and expectations. EVIDENCE: Staffing levels have been calculated using a needs based calculation tool, and provides two care staff on each unit during the waking day with additional staff supporting such as Care Team Manager, Activity co-ordinator, housekeepers, catering staff and administrative staff. The arrangements appeared to support residents’ needs well, and provided staff with opportunities to spend time with residents in activities that were not purely care task based. The skill levels of the staff group varied, although all staff had undergone an induction programme based on the Skills for Care standards, that provided the mandatory training elements and a basic knowledge of care issues such as dementia, continence management etc. The ongoing training programme provided by the organisation included progressive levels of dementia care training from induction, intermediate and the Certificate in Dementia Care. There is also progress of staff through NVQ levels, care planning training and quality care. The breadth of training should be developed to ensure that issues provided in response to residents assessed needs and staff skill deficits identified from supervision are included in the programme. Tye Green Lodge DS0000064980.V295924.R01.S.doc Version 5.2 Page 19 The robustness of the recruitment process operated by the organisation was evaluated through sampling staff records. The files examined contained all documents listed in the Care Homes Regulations 2001 required to protect service users, such as a full application form that provides details of the individuals employment history, two references, proof of identity and criminal records checks. These checks and measures assist the service in deterring applicants who are unsuitable to work with vulnerable persons, and therefore provides confidence in the suitability of appointed staff. Tye Green Lodge DS0000064980.V295924.R01.S.doc Version 5.2 Page 20 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): 31, 33, 35, 36 and 38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The records and administration of the service support the safety and wellbeing of residents. EVIDENCE: As previously stated the registered managers post was vacant at the time of the first visit to the home, although be the date of the concluding visit the interviews for the post had taken place and the Deputy manger was successfully appointed. The post of manager is required by the Care Standards Regulations 2002 must be registered with the Commission for Social Care Inspection, and requires the post holder to submit an application and have their fitness to operate a care service assessed by the Commission. Tye Green Lodge DS0000064980.V295924.R01.S.doc Version 5.2 Page 21 A number of initiatives are used by the service in understanding and responding to the quality of care provided in the home. These include; Monthly responsible individual visits and reports as a requirement of the Care Standards Regulations 2002. These demonstrate an ongoing assessment by the organisation of the services performance and an ongoing dialogue in response to identified issues arising from these reviews. Other initiatives included home forums for residents to discuss issues and Dementia care mapping to understand how residents with some cognitive impairments demonstrate their feelings about the service they receive. The service does not generally assist residents to manage their finances, however they do support some residents in managing small amounts of monies deposited by relatives or advocates to purchase such items as visiting the hairdresser, chiropodist, buying newspapers and toiletries. The documents and systems operated to safe guard these monies was assessed by the inspector at this visit. Monies are collectively held in the homes safe with individual accounts containing details of all transactions recorded. The systems are audited externally through the organisations accountants on a regular basis and the access to the monies is restricted. Residents are able to have access to monies on request. The manager was asked how residents were assessed to determine why the right to hold monies was removed. In particular the ability to retain some small change for purchases at the homes shop was discussed. As there was not any clear definition of this the manager was asked to give a greater consideration to the issue. The staff files sampled during the inspection contained records of one to one line management supervision, carried out on a bi monthly basis. However there had been some breaks in the frequency of the sessions in some cases and this was attributed to the period affected by the resignation of the previous manager and Care team managers and the additional pressures this placed on the management team. The manager was aware of the omissions and provided detail of how this would be addressed. Documents relating to the maintenance and safety of equipment and supplies such as electric, gas and moving and handling equipment were examined during the visit. These were all present and within timescale of an annual inspection programme. The fire safety logs were examined and contained records of fire safety checks as well as staff training and fire drills undertaken to a satisfactory standard. The accident records were also seen and a discussion was held with the operations manager and the homes manager in respect of how accidents were recorded and monitored. They provided the inspector with monthly audit records and how any issues arising from this are translated into the residents care plan. Tye Green Lodge DS0000064980.V295924.R01.S.doc Version 5.2 Page 22 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 3 3 3 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 3 3 3 3 3 3 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 3 X 3 2 X 3 Tye Green Lodge DS0000064980.V295924.R01.S.doc Version 5.2 Page 23 Are there any outstanding requirements from the last inspection? N/A 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. Standard Regulation Requirement Timescale for action 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 Refer to Standard OP7 OP12 OP19 Good Practice Recommendations The registered person should ensure that the quality of care plan information supports all aspects of residents’ needs, strengths and wishes. The registered person should ensure that the residents rights to hold their own monies is only restricted following a risk assessment process. The registered person should ensure that the environment provides the maximum benefit to resident in its décor and signage according to updated good practice in dementia care. The registered person should ensure that an application for registration is made by the manager of the service to the Commission. The registered person should ensure that staff receive consistent and regular supervision with line managers. 4 5 OP31 OP36 Tye Green Lodge DS0000064980.V295924.R01.S.doc Version 5.2 Page 24 Commission for Social Care Inspection Colchester Local Office 1st Floor, Fairfax House Causton Road Colchester Essex CO1 1RJ 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 Tye Green Lodge DS0000064980.V295924.R01.S.doc Version 5.2 Page 25 - 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!