Inspection on 10/02/06 for Tynefield Court

This inspection was carried out on 10th February 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 17 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Tynefield Court 29/08/08

Tynefield Court 18/10/07

Tynefield Court 13/02/07

Tynefield Court 29/09/05

Tynefield Court 08/12/04

Tynefield Court 16/06/04

Tynefield Court 10/03/04

Similar services:

Byars Care Home

St Marys Nursing Home

Bramble Lodge

Parkmanor Residential Home

Thornham Grove

Hunter`s Lodge

London Road Neurological and Specialist Care Unit

Carlton Care Home

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

CARE HOME MIXED CATEGORY MAJORITY ADULTS 18-65 Tynefield Court Blakeley Lane Egginton Road Etwall Derby DE65 6NQ Lead Inspector Jo Wright Unannounced Inspection 10th February 2006 11:00 Tynefield Court DS0000002169.V283145.R01.S.doc Version 5.1 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 Tynefield Court DS0000002169.V283145.R01.S.doc Version 5.1 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People and 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. Tynefield Court DS0000002169.V283145.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Tynefield Court Address Blakeley Lane Egginton Road Etwall Derby DE65 6NQ 01283 732030 01283 734550 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) Tynefield Care Limited Mrs Shirley Hall Care Home 40 Category(ies) of Old age, not falling within any other category registration, with number (13), Physical disability (27) of places Tynefield Court DS0000002169.V283145.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 27 places for younger PD aged 18 years and over included in the total above 13 places for OP aged 65 years and over included in the above total Date of last inspection 29th September 2005 Brief Description of the Service: Tynefield Court Care Home is a 40 bedded home that provides both nursing and personal care. The home cares for older people, as well as young adults with physical disabilities. The home is purpose built and residents accommodation is located in three single storey wings, with central communal areas. The home has 36 single and 2 shared rooms. A total of 27 rooms have ensuite facilities., 10 of which also have ensuite showers. Tynefield Court Care Home is located outside the village of Etwall. The site also accommodates a children’s nursery and a number of bungalows for independent living. Tynefield Court DS0000002169.V283145.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection and the duration of the visit was approximately 4.5 hours. Discussions were held with two residents and with staff during the inspection. Records such as care plans (as part of the case tracking process, which is used to help determine how the home meets the needs of individual residents) were not examined in depth during this inspection. Other records such as medication records and personal finance records were examined. An assessment was made with respect to the requirements made at the last inspection of this service. What the service does well: What has improved since the last inspection? What they could do better: Ongoing efforts need to be made to ensure that staff receive formal supervision on a regular basis. Although staff receive induction and foundation training, the staff team need to be trained to the required level of National Vocational Qualifications. Tynefield Court DS0000002169.V283145.R01.S.doc Version 5.1 Page 6 The qualified staff need to improve their practice in relation to the administration of medication. Residents must receive their medication as prescribed. Systems need to be in place to obtain the required supplies of medication for residents, so that medication prescribed for one resident is not used for another resident. 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. Tynefield Court DS0000002169.V283145.R01.S.doc Version 5.1 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home Individual Needs and Choices Lifestyle Personal and Healthcare Support Concerns, Complaints and Protection Environment Staffing Conduct of Management of the Home Scoring of Outcomes Statutory Requirements Identified During the Inspection Adults 18 – 65 (Standards 1–5) (Standards 6-10) (Standards 11–17) (Standards 18-21) (Standards 22–23) (Standards 24–30) (Standards 31–36) (Standards 37-43) Older People (Standards 1–5) (Standards 7, 14, 33 & 37) (Standards 10, 12, 13 & 15) (Standards 8-11) (Standards 16-18 & 35) (Standards 19-26) (Standards 27-30 & 36) (Standards 31-34, 37 & 38) Tynefield Court DS0000002169.V283145.R01.S.doc Version 5.1 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 (Adults 18 – 65) and Standards 1 – 5 (Older People) are: 1. 2. 3. Prospective service users have the information they need to make an informed choice about where to live. (OP NMS 1) Prospective users’ individual aspirations and needs are assessed. No service user moves into the home without having been assured that these will be met. (OP NMS 3) Prospective service users’ know that the home that they choose will meet their needs and aspirations. Service Users and their representatives know that the home they enter will meet their needs. (OP NMS 4) Prospective service users’ have an opportunity to visit and “test drive” the home. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. (OP NMS 5) Each service user has an individual written contract or statement of terms and conditions with the home. Each service user has a written contract/statement of terms and conditions with the home. (OP NMS 2) 4. 5. The Commission considers Standard 2 (Adults 18-65) and Standards 3 and 6 (Older People) the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): EVIDENCE: These standards were not assessed during this inspection. Tynefield Court DS0000002169.V283145.R01.S.doc Version 5.1 Page 9 Individual Needs and Choices The intended outcomes for Standards 6-10 (Adults 18-65) and Standards 7, 14, 33 & 37 (Older People) are: 6. Service users know their assessed and changing needs and personal goals are reflected in their Individual Plan. The Service Users health, personal and social care needs are set out in an individual plan of care. (OP NMS 7) Service users make decisions about their lives with assistance as needed. Service Users are helped to exercise choice and control over their lives. (OP NMS 14) Service users are consulted on, and participate in, all aspects of life at the home. The home is run in the best interests of service users. (OP NMS 33) Service users are supported to take risks as part of an independent lifestyle. The service users health, personal and social care needs are set out in an individual plan of care. (OP NMS 7) Service users know that the information about them is handled appropriately and that their confidences are kept. Service Users rights and best interests are safeguarded by the home’s record keeping, policies and procedures. (OP NMS 37) 7. 8. 9. 10. The Commission considers Standards 6, 7 and 9 (Adults 18-65) and Standards 7, 14, and 33 (Older People) the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): EVIDENCE: These standards were not assessed during this inspection. Tynefield Court DS0000002169.V283145.R01.S.doc Version 5.1 Page 10 Lifestyle The intended outcomes for Standards 11 - 17 (Adults 18-65) and Standards 10, 12, 13 & 15 (Older People) are: 11. Service users have opportunities for personal development. 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. (OP NMS 12) Service users are able to take part in age, peer and culturally appropriate activities. 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. (OP NMS 12) Service users are part of the local community. Service users maintain contact with family/ friends/ representatives and the local community as they wish. (OP NMS 13) Service users engage in appropriate leisure activities. 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. (OP NMS 12) Service users have appropriate personal, family and sexual relationships and maintain contact with family/friends/representatives and the local community as they wish. (OP NMS 13) Service users’ rights are respected and responsibilities recognised in their daily lives. Service users feel they are treated with respect and their right to privacy is upheld. (OP NMS 10) Service users are offered a (wholesome appealing balanced) healthy diet and enjoy their meals and mealtimes. Service users receive a wholesome appeaing balanced diet in pleasing surroundings at times convenient to them. (OP NMS 15) 12. 13. 14. 15. 16. 17. The Commission considers standards 12, 13, 15, 16 and 17 (Adults 1865) and Standards 10, 12, 13 and 15 (Older People) the 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, 16 and 17 (Adults 18-65) and 10, 12, 13 and 15 (Older People) People living at the home were supported as individuals to socialise and access to local community. Friendships and family contacts were encouraged and maintained as appropriate. However, staff practice did not always support that residents were always treated with respect and their dignity upheld. Tynefield Court DS0000002169.V283145.R01.S.doc Version 5.1 Page 11 EVIDENCE: Comments from residents and staff and observation during the inspection confirmed that the routines within the home were flexible. Staff were observed providing support and assistance as required, whilst encouraging independence. Residents made good use of the communal areas as well as their bedrooms. Residents stated that generally staff respected their privacy and dignity. However, staff were observed entering a bedroom without knocking, mainly because the member of staff was carrying a tray of hot drinks, and two other staff did not clearly explain to a resident what they were going to do before they did it, ie standing up from the chair and walking to the ensuite. Residents were observed socialising with each other in communal areas and in their bedrooms. Residents spoken with confirmed that visitors were welcome at any time, and that they were encouraged to maintain links with their friends and families. This information was well recorded in the files. Several residents living at Tynefield Court make good use of motorised scooters to access the amenities in the local village. There was evidence to support that in house entertainment was being organised. Those residents spoken with did comment that there were very few organised activities. However, when asked directly what activities they would like, they commented that they were satisfied with the arranged activities and watching the television. The home continues to provide movement to music sessions, and residents commented that they enjoy these. A tour of the kitchen was undertaken as part of this inspection. Catering staff demonstrated good knowledge about individual residents needs and special diets. Records demonstrated that residents were offered a choice and variety of meals, and observation of the mealtime supported this. Levels and storage of food stocks were satisfactory. Environmental Health inspected the home on 20.12.05 and the requirement made in the report had been addressed. Residents made good use of the dining rooms, although a number of residents prefer to stay in their rooms. A number of residents require staff support at meal times. However, it was observed that not all staff provided this in a discreet and relaxed manner. One number of staff was observed assisting two residents at the same time, and referring to residents inappropriately, using terms such as ‘good lad’ and ‘sweetheart’. This was discussed with the person in charge at the time of the inspection. Tynefield Court DS0000002169.V283145.R01.S.doc Version 5.1 Page 12 Personal and Healthcare Support The intended outcomes for Standards 18 – 21 (Adults 18-65) and Standards 8 – 11 (Older People) are: 18. 19. 20. Service users receive personal support in the way they prefer and require. Service users feel they are treated with respect and their right to privacy is upheld. (OP NMS 10) Service users’ physical and emotional health needs are met. Service users’ health care needs are fully met. (OP NMS 8) 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. Service users, where appropriate, are responsible for their own medication and are protected by the home’s policies and procedures for dealing with medicines. (OP NMS 9) The ageing, illness and death of a service user are handled with respect and as the individual would wish. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. (OP NMS 11) 21. The Commission considers Standards 18, 19 and 20 (Adults 18-65) and Standards 8, 9 and 10 (Older People) 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 (Adults 18-65) and 8 and 11 (Older People) The home has failed to improve their procedures for administering medication, placing residents at risk of harm. EVIDENCE: Residents files were not looked at in depth during this inspection. A requirement was made in the last inspection report that all residents with an identified need must have a continence assessment completed. A random sample of care plans were looked at, and continence assessments had not been completed for those residents with an identified need. This was discussed with the person in charge, who confirmed that these assessments had not been introduced. It was also noted that residents wishes at the time of severe illness or post death were not always recorded. This has been an outstanding requirement since April 2004. Tynefield Court DS0000002169.V283145.R01.S.doc Version 5.1 Page 13 A review of medication was undertaken to assess compliance with the requirements made in the last inspection report. Little progress had been made towards compliance. Although systems were in place for the management of medication, staff used these inconsistently. On a number of occasions medication had been given and not signed for, or signed for and not given. Although systems were in place of checking medication on receipt, this information was not always recorded. The actual amount of medication given for variable doses was not being recorded. It was noted that prescribed medication was being shared. This practice has been noted on the last two inspections, and is not acceptable and must stop. Not all residents had a supply of medication as detailed on the medication chart available in the home. Handwritten entries were not always checked and countered signed by a second member of staff. The dosage of a medication for two different residents had been changed. The GP who authorised this change and the date it occurred had not been recorded on the medication chart. Medication was stored appropriately. Systems were in place for the recording and destruction of medication. However, it was noted that medication had been left with one resident in the dining room, to take when they were ready. Staff must observe residents taking their medication and then sign the medication record, and not leave medication with a resident. Six full sharps containers were present in the treatment room. It was not clear why these had not been disposed off. Tynefield Court DS0000002169.V283145.R01.S.doc Version 5.1 Page 14 Concerns, Complaints and Protection The intended outcomes for Standards 22-23 (Adults 18-65) and Standards 16-18 & 35 (Older People) are: 22. 23. Service users feel their views are listened to and acted on. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted on. (OP NMS 16) Service users’ are protected from abuse, neglect and self-harm. Service users legal rights are protected. (OP NMS 17) Also Service users are protected from abuse. (OP NMS 18) Also Service users financial interests are safeguarded. (OP NMS 35) The Commission considers Standards 22-23 (Adults 18-65) and Standards 16-18 and 35 (Older People) 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 and 23 (Young Adults) and 16, 18 and 35 (Older People) The home has a satisfactory complaints system with some evidence that residents feel that their views are listened to and acted upon. People living in the home were protected through staff training and written policies and procedures. EVIDENCE: Those residents spoken with commented that they were able to raise concerns with any member of staff and were confident that any issues would be dealt with. One resident commented that ‘all staff were approachable’ and there were ‘no complaints’. The Commission has not received any complaints about the care and services provided at Tynefield Court since the last inspection. Discussion with several members of staff indicated that they had received training on the protection of vulnerable adults procedure. The required policies and procedures were in place at the time of the last inspection. No referrals have been made through the local authority Protection of Vulnerable Adults procedures since the last inspection. Money was kept in safe keeping for a number of people living at the home. The person in charge at the time of this inspection did not have access to the Tynefield Court DS0000002169.V283145.R01.S.doc Version 5.1 Page 15 personal monies. Individual records were maintained, and receipts kept. However, it was not clear from the records whether residents received their personal allowance every two weeks as provided, or in which bank account the money was kept prior to being paid to the resident. Tynefield Court DS0000002169.V283145.R01.S.doc Version 5.1 Page 16 Environment The intended outcomes for Standards 24 – 30 (Adults 18-65) and Standards 19-26 (Older People) are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users live in a safe, well-maintained environment (OP NMS 19) Also Service users live in safe, comfortable surroundings. (OP NMS 25) Service users’ bedrooms suit their needs and lifestyles. Service users own rooms suit their needs. (OP NMS 23) Service users’ bedrooms promote their independence. Service users live in safe, comfortable bedrooms with their own possessions around them. (OP NMS 24) Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Service users have sufficient and suitable lavatories and washing facilities. (OP NMS 21) Shared spaces complement and supplement service users’ individual rooms. Service users have access to safe and comfortable indoor and outdoor communal facilities. (OP NMS 20) Service users have the specialist equipment they require to maximise their independence. Service users have the specialist equipment they require to maximise their independence. (OP NMS 22) The home is clean and hygienic. The home is clean, pleasant and hygienic. (OP NMS 26) The Commission considers Standards 24 and 30 (Adults 18-65) and Standards 19 and 26 (Older People) 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 and 30 (Young Adults) and 19 and 26 (Older People) The standard of the environment was satisfactory, providing residents with a comfortable environment. EVIDENCE: Tynefield Court was clean, tidy and free from odours at the time of this inspection. There was evidence of ongoing redecoration throughout the home. Residents had been encouraged to personalise their bedrooms, with their own Tynefield Court DS0000002169.V283145.R01.S.doc Version 5.1 Page 17 furniture and belongings. Residents had access to a number of communal areas, including a separate smoking lounge. Heating within the home has improved, as additional heaters have been sited throughout the building. Equipment was available to assist staff to move and transfer residents. Residents had access to a range of bathing facilities. Separate laundry facilities were provided. No issues about the laundry service were raised during this inspection. The Fire Officer visited the home on 10 January 2006. The report indicated that the majority of the recommendations made in the schedule dated 14th June 2006 had been completed, although some work remained outstanding. Tynefield Court DS0000002169.V283145.R01.S.doc Version 5.1 Page 18 Staffing The intended outcomes for Standards 31 – 36 (Adults 18-65) and Standards 27 – 30 & 36 (Older People) are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported and protected by the home’s recruitment policy and practices. (OP NMS 29) Service users are supported by competent and qualified staff. Service users are in safe hands at all times. (OP NMS 28) Service users are supported by an effective staff team. Service users needs are met by the numbers and skill mix of staff. (OP NMS 27) Service users are supported and protected by the home’s recruitment policy and practices. Service users are supported and protected by the home’s recruitment policy and practices. (OP NMS 29) Service users’ individual and joint needs are met by appropriately trained staff. Staff are trained and competent to do their jobs. (OP NMS 30) Service users benefit from well supported and supervised staff. Staff are appropriately supervised. (OP NMS 36) The Commission considers Standards 32, 34 and 35 (Adults 18-65) and Standards 27, 28, 29 and 30 (Older People) 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, 33, 34 and 36 (Adults 18-65) and 27, 28 and 29 (Older People) Staffing levels were in keeping with the needs of the residents living at the care home. The staff team was not fully trained to ensure that they were competent to fulfil their roles. EVIDENCE: Discussion with residents, staff and the person in charge supported that staffing levels were adequate to meet the needs of the current resident group. The staff group was relatively stable, although there was some turnover of staff, due to staff recruited from overseas returning home. Tynefield Court DS0000002169.V283145.R01.S.doc Version 5.1 Page 19 Discussion with the person in charge indicated that no further progress has been made towards meeting the requirement for 50 of care staff trained to NVQ Level 2 or equivalent. Only three members of staff have achieved this qualification. Discussion with care staff and the person in charge indicated that little progress had been made towards meeting the requirement for staff supervision. Care staff confirmed that qualified staff do work alongside them, but that formal supervision sessions do not take place. Staff files were not checked during this inspection. There was a requirement (not time expired) for all required information to be available in staff files. This will be checked at the time of the next inspection. Tynefield Court DS0000002169.V283145.R01.S.doc Version 5.1 Page 20 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 (Adults 18-65) and Standards 31-34, 37 & 38 (Older People) are: 37. Service users benefit from a well run home. 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. (OP NMS 31) Service users benefit from the ethos, leadership and management approach of the home. Service users benefit from the ethos, leadership and management approach of the home. (OP NMS 32) Service users are confident their views underpin all self-monitoring, review and development by the home. The home is run in the best interests of service users. (OP NMS 33) 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 homes record keeping, policies and procedures. (OP NMS 37) Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. Service users rights and best interests are safeguarded by the homes record keeping policies and procedures. (OP NMS 37) The health, safety and welfare of service users are promoted and protected. The health, safety and welfare of service users and staff are promoted and protected. (OP NMS 38) Service users benefit from competent and accountable management of the service. Service users are safeguarded by the accounting and financial procedures of the home. (OP NMS 34) 38. 39. 40. 41. 42. 43. The Commission considers Standards 37, 39 and 42 (Adults 18-65) and Standards 31, 33, 35 and 38 (Older People) 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 and 42 (Adults 18-65) and 31, 33 and 38 (Older People) Whilst the home is generally run in the best interests of the residents, there is a lack of quality assurance, quality monitoring and formal staff supervision to provide the basis for improving the service for the residents and ensuring that care is always of a high standard. EVIDENCE: Tynefield Court DS0000002169.V283145.R01.S.doc Version 5.1 Page 21 The manager has been in post for a number of years, and is an experienced qualified nurse. However, she had not yet enrolled on NVQ Level 4 in management. The person in charge reported that the Responsible Individual visits the home regularly, and prepares a written report on the findings. One resident spoken with commented that residents meetings had not been held recently, and that residents were not aware of how the amenity fund was spent. There was a requirement (not time expired) to establish a quality assurance system for reviewing the quality of care and nursing. This will be checked at the time of the next inspection. It was reported that the fire alarm was being tested on a weekly basis. Staff spoken with confirmed that mandatory training was being provided. There was a requirement (not time expired) for all staff to receive mandatory training in moving and handling, first aid, food hygiene, fire safety and infection control. This will be checked at the time of the next inspection. There was also a requirement (not time expired) to all radiators to be risk assessed and guards fitted where necessary. This will be checked at the time of the next inspection. Tynefield Court DS0000002169.V283145.R01.S.doc Version 5.1 Page 22 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. Where there is no score against a standard it has not been looked at during this inspection. 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 X 3 X 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 3 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 2 33 3 34 2 35 X 36 2 CONDUCT AND MANAGEMENT Standard No Score 37 2 38 X 39 2 40 X 41 X 42 2 43 X X X X X X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 3 15 3 16 2 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Tynefield Court Score X 2 X 2 DS0000002169.V283145.R01.S.doc Version 5.1 Page 23 Yes Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 2 Standard YA16 YA19 Regulation 12(4)(a) 14(1)(a) Requirement Staff practice must respect the privacy and dignity of residents. Continence assessments must be completed for all residents with an identified need. (Previous timescale of 31/12/05 not met) Residents must receive the medication that they are prescribed. Reasons for nonadministration must be recorded on the medication chart. (Previous timescale of 31/12/05 not met) A record must be kept of all medication received into the home. (Previous timescale of 31/12/05 not met) Medication must only be administered to the resident for whom it is prescribed and labelled (Previous timescale of 31/05/04 and 30/11/05 not met) Where a variable dose is prescribed the actual dose administered must be recorded (Previous timescale of 30/11/05 not met) DS0000002169.V283145.R01.S.doc Timescale for action 31/03/06 30/04/06 3 YA20 13(2) 17(1)(a) Sch 3 31/03/06 4 YA20 13(2) 17(1)(a) Sch 3 13(2) 17(1)(a) Sch 3 13(2) 17(1)(a) Sch 3 31/03/06 5 YA20 31/03/06 6 YA20 31/03/06 Tynefield Court Version 5.1 Page 24 7 YA20 13(2) 8 YA20 13(2) 9 YA20 13(2) 10 YA21 12(3) 11 YA32 18(1)(a) 12 YA34 17(2)Sch 4 19(1)(4) 13 YA36 18(2) 14 15 YA37 YA39 18(1)(a) & (c) 24 16 YA42 13(6) 18(1)(2) Robust systems must be in place to ensure that supplies of medication prescribed for a resident are available in the home. Any change in dosage of medication must be clearly stated on the medication record, with details of who authorised the change and the date of commencement. Staff must observe residents taking their medication and then sign the medication record, and not leave medication with a resident. Residents wishes at the time of severe illness or post death must be recorded in the files (Previous timescale of 30/04/04 and 31/12/05 not met) 50 of care staff must be trained to NVQ Level 2 or equivalent. (Previous timescale of 31/12/05 not met) The information required in Schedule 2 and 4 of the Care Homes Regulations 2001 relating to staff must be maintained for all staff. This includes staff recruited from overseas All staff must receive formal and informal supervision on a regular basis. (Previous timescale of 31/12/05 not met) The manager must enrol on an course leading to an appropriate management qualification. A quality assurance system for reviewing the quality of care and nursing must be established (Previous timescale of 31 March 2004 not met) All staff must receive mandatory training in moving and handling, first aid, food hygiene, fire safety DS0000002169.V283145.R01.S.doc 30/04/06 31/03/06 31/03/06 30/04/06 30/06/06 31/03/06 30/06/06 30/06/06 31/03/06 31/03/06 Tynefield Court Version 5.1 Page 25 16 YA42 13(4) and infection control. A risk assessment of all radiators must be undertaken and guards fitted where necessary (Previous timescale of 31 May 2004 not met) 31/03/06 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 YA14 YA20 YA24 Good Practice Recommendations Ongoing efforts should be made to engage residents in social and community activities. Systems should be put in place for the regular removal of full sharps containers. The outstanding recommendations in the Fire Officer’s schedule should be attended to as a matter of priority. Tynefield Court DS0000002169.V283145.R01.S.doc Version 5.1 Page 26 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. Tynefield Court DS0000002169.V283145.R01.S.doc Version 5.1 Page 27 - 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!