Inspection on 18/10/07 for Tynefield Court

This inspection was carried out on 18th October 2007.

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 9 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 13/02/07

Tynefield Court 10/02/06

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 ADULTS 18-65 Tynefield Court Blakeley Lane Egginton Road Etwall Derby DE65 6NQ Lead Inspector Steve Smith Unannounced Inspection 18th October 2007 10:30 Tynefield Court DS0000002169.V353306.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 Tynefield Court DS0000002169.V353306.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. Tynefield Court DS0000002169.V353306.R01.S.doc Version 5.2 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.V353306.R01.S.doc Version 5.2 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 13th February 2007 Brief Description of the Service: Tynefield Court Care Home is a home with 40 places that provides both nursing and personal care. The home cares for older people, as well as young adults with physical disabilities. It is purpose built and resident’s 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 en-suite facilities, 10 of which also have en-suite 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. Information provided by the service in 2007 stated that the fees ranged from £360.00 - £560.00 per week. Details of previous inspection reports can be found on the Commission for Social Care Inspection’s website: www.csci.org.uk Tynefield Court DS0000002169.V353306.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place in just under 6 hours. Discussion was held with two Residents, and the needs of four Residents were ‘case tracked’. The Manager was spoken with, and two members of staff were also seen. A number of records were examined, and the bedrooms of four Residents were looked at and all public areas of the Home were examined. The Commission’s Annual Quality Assurance Assessment, sent to the Manager, had not been returned at the time of this visit to the Home. The Commission’s questionnaire, sent out to ten Residents, had also not been returned by any of the Residents. What the service does well: What has improved since the last inspection? What they could do better: The Registered Providers need to address a large number of items, as there are many issues not addressed from the last inspection of February 2007. The statement of purpose needed to be updated to include all of the items listed with in Schedule 1. The Residents Guide given to Residents should be Tynefield Court DS0000002169.V353306.R01.S.doc Version 5.2 Page 6 provided in a variety of formats such as large print and audiotape. The Residents Guide should also have include in it the views of Residents on what it is like to live in the Home, to inform prospective or new Residents. Residents care plans needed to be shared with those Residents able to understand and comment upon them. Care plans also needed to be formally reviewed at least at 6 monthly intervals of time. Entries made in the plans of care should be made on at least a weekly basis. The Registered Providers and Manager were encouraged to ensure that all staff employed had sufficient command of the English language to talk meaningfully with Residents, given Residents disabilities. Residents meeting should take place to ensure that they are involved in decision-making in the Home. Residents should be encouraged to take part in social and community activities, and include time for staff to accompany Residents out of the Home in the evenings. Nursing and care staff needed to be encouraged to knock and await a reply from Residents able to do this before entering their bedrooms. Improvements were needed in the recording of the distribution of medication to Residents. The Home’s complaints procedure needed to be improved so that it stated that complaints could be made verbally or in writing. Information was needed in the Home on the Public Interest Disclosure Act 1998 and the Dept of Health guidance called ‘No Secrets’. Staff also needed to be informed, via the Safeguarding Adult policy in the Home, that they could not benefit in any way from Residents wills. Radiators throughout the Home needed to be assessed and upgraded to safeguard Residents. All bedroom should have lockable storage space provided, and the smoking lounge needed re-decoration. When new staff are appointed to the Home a full history of employment must always be obtained. At least 50 of Care staff also needed to be trained to NVQ level 2 in Care. All care staff needed to be provided with individual supervision sessions on at least a two month basis. The Manager should also be encouraged to obtain an NVQ level 4 in Management. The Registered Providers and Manager need to ensure that a complete quality assurance programme is provided and updated on an annual basis. The Manager needed to provide risk assessments, for all staff, on all working practice topics in order to ensure that significant findings were recorded and that all staff are safeguarded. A large number of staff needed training in basic subjects such as First Aid, Food Hygiene and Infection Control. Tynefield Court DS0000002169.V353306.R01.S.doc Version 5.2 Page 7 The Registered Providers needed to formally ‘inspect’ the Home on at least a monthly basis and record their ‘inspections’ in line with the requirements of Regulation 26. 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. The summary of this inspection report can be made available in other formats on request. Tynefield Court DS0000002169.V353306.R01.S.doc Version 5.2 Page 8 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 Tynefield Court DS0000002169.V353306.R01.S.doc Version 5.2 Page 9 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 1 & 2. The quality in this outcome area was Adequate. This judgement was made using available evidence including a visit to this service. The statement of purpose lacked significant information, and so Residents were not appropriately informed of the operation of the Home. However, all new Residents moving to the Home were appropriately assessed prior to their admission, so that they and their families were reassured that their needs would be met. EVIDENCE: The Home’s statement of purpose and Residents Guide were reviewed during this visit. The statement of purpose was well laid out, but possibly did not include all of the issues listed within the Regulations and Schedule 1. For example, the statement of purpose did not include the address of the Registered Providers, nor their qualifications. It also lacked details of the arrangements for Residents to be consulted on the operation of the Home, the arrangements for Residents to take part in any religious services (Christian and non-Christian) chosen by the Resident, and the arrangements made for contact between Residents and their relatives. The statement of purpose also possibly lacked details of the arrangements in place to ensure the privacy and dignity of Residents was respected. The statement of purpose also referred to an Activities Coordinator, but the Manager said that such a person was not currently employed in the Home. Tynefield Court DS0000002169.V353306.R01.S.doc Version 5.2 Page 10 The Residents Guide was well laid out, but did not include the views of Residents on the quality of the Home, and nor was it available in other formats to ensure that all Residents had adequate access to it. However, the Residents Guide did contain information on how to make a complaint, and referred Residents to the location of the Commission’s most recent inspection report. When new Residents were admitted to the Home, the Manager was provided with a summary of the needs of each person, completed by the Social Services Dept Care Manager supporting each Resident, copies of which were seen. The Manager also assessed all Residents sponsored by Social Services Depts. If the Residents were self-funding from the outset, the Manager completed her own summary of needs, which were also seen during this visit to the Home. Tynefield Court DS0000002169.V353306.R01.S.doc Version 5.2 Page 11 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 6, 7, 8 & 9. The quality in this outcome area was Adequate. This judgement was made using available evidence including a visit to this service. Greater efforts were required to ensure that Residents were able to participated fully and make more decisions about life in the home. EVIDENCE: To help assess Standard 6, the Residents Plan of Care, the records of four Residents were examined, for the purpose of case tracking. All of the basic information, concerning the Residents, was found to be in the files examined. Copies of the initial assessment completed by the Social Services Care Managers were available, and the Manager had completed her own initial assessment of needs for the Residents. There were also satisfactory care plans and risk assessments available in the records examined, providing staff with information to met the Residents needs. Tynefield Court DS0000002169.V353306.R01.S.doc Version 5.2 Page 12 The files showed that satisfactory records of events affecting the Residents were kept. Entries were only made when a significant event had occurred for the Resident, which meant that entries were sometimes made up to at least a week apart, but often further apart. The Residents formal reviews of care, to be undertaken on a six monthly basis, had not been completed. However, Social Services Dept reviews of care were provided, but these were only done on an annual basis. The Residents records were easy to read and were detailed. The files were also well organised. Residents spoken with said that they had not been shown their records, and the files of Residents care seen did not have Residents signatures in them. In the daily entries in one of the files examined a member of staff had written ‘Please Observe’, but only one member of staff had commented on the issue, three days after the request was entered in the record. The member of staff requesting the ‘observation’ had also not indicated in the record when the ‘observation’ was no longer needed. In one file it was found that only 6 entries had been made since the beginning of the 2007, and three of those entries had been made in one month. Poor recording was therefore judged to be taking place in this file. Residents spoken with said that staff respected their rights to make decisions about their lives, and would advise them when necessary – ‘Yes, staff do things my way.’ – ‘They allow me to do things the way I want.’ Staff spoken with said that Residents were able to choose their clothing each day, and to chose their meals. Staff and Residents said that staff would shop for Residents if requested to do so. They also both said that some Residents went out to the shops with staff, although the shops were some way from the location of the Home. Residents were encouraged to manage their own money, and at the time of this visit at least 4 Residents were able to do this. The Registered Providers employ a number of staff from overseas. One such member of staff was spoken with, but she could not understand the questions put to her. One Resident, with a speaking limitation, said that some staff, from overseas, could not understand her and she found this extremely frustrating. Residents spoken with said that their files had not been shown to them, and so they had no opportunity to comment on the quality of the record made. Tynefield Court DS0000002169.V353306.R01.S.doc Version 5.2 Page 13 Residents said that no Residents meeting were held by the Manager to allow them to participate in the running of the Home. This was later confirmed by the Manager. Staff were able to indicate how Residents risk-taking was managed. For example, Residents were helped to assess the heat of bath and shower water, which was confirmed by Residents. Staff also enabled those Residents who needed this assistance to determine the heat of food provided. Tynefield Court DS0000002169.V353306.R01.S.doc Version 5.2 Page 14 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 12, 13, 15, 16 & 17. The quality in this outcome area was Good. This judgement was made using available evidence including a visit to this service. Residents preferred lifestyles were respected by the Home, which was confirmed by Residents. Residents were given a wholesome and appealing diet in pleasant surroundings. EVIDENCE: The Manager commented that Residents, in the past, had been enabled to attend a college to pursue academic activities, although currently no Residents did this. Should a Resident have benefit or financial problems this was usually addressed with the help of the Manager, who liaised with the Benefit Agency or with a Resident’s Care Manager from a Social Services Dept. One Resident spoken with said that she went out with staff shopping, which she greatly enjoyed, saying she would like to go more often. Staff spoken with said that Residents regularly went to the shops, public houses, restaurants, places of worship or simply went out from the Home, often on ‘mobility Tynefield Court DS0000002169.V353306.R01.S.doc Version 5.2 Page 15 scooters’, with relatives or staff. One Resident and staff said that Residents were on the voting register that enabled Residents to take part in national and local elections. Staff said that although time could often be provided for staff to go out with Residents during the day, including accompanying them around the grounds of the Home, they were not able to go out with them during the evening. Staff said that relatives were encouraged to visit as often as they wished. Relatives were said to also be encouraged, during visits, to join in any activities provided. They could also spend time with the Resident in their room or in a room set aside for this purpose. Staff said that they always knocked on Residents bedroom doors and waited to be invited in, if the Resident was capable of doing this. One Resident confirmed that this was what care staff did, although it was also said that nursing staff simply knocked and walked into the bedroom. Another Resident said that all staff simply walked into their room. Residents and staff were able to say that all mail Residents received was opened by the Residents, and not be staff. Again, Residents and staff were able to say that Residents were always called by their preferred name. Residents spoken with explained the rules in the Home for smoking. Residents and staff both said that a choice was always offered at all meals provided. Residents and staff also said that breakfast could be taken either within their bedroom or in the dinning room, most apparently preferring their bedroom. Tynefield Court DS0000002169.V353306.R01.S.doc Version 5.2 Page 16 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 18, 19 & 20. The quality in this outcome area was Good. This judgement was made using available evidence including a visit to this service. Residents’ personal needs were well met, ensuring that their privacy, dignity and independence were maintained. The system of administering medication was good, and ensured Residents medication needs were met. EVIDENCE: Residents and staff said that Residents were encouraged to do as much as possible for themselves. Staff also said that personal care was always provided in private, and when possibly, by a member of staff of the same gender as the Resident. Residents said that they decided on the times of their getting up and going to bed, and that they were enabled to have at least two baths each week. This was also supported be comments made by staff. Staff also said that they have sufficient technical aids and other equipment to meet the needs of Residents. Care staff said that they worked with the nursing staff to ensure that the health needs of Residents were met at all times. Care staff and Residents said that when Doctors called to see Residents they always did this within Residents own bedrooms. Tynefield Court DS0000002169.V353306.R01.S.doc Version 5.2 Page 17 During the visit the Home’s Medication Administration Record (MAR) sheets were examined and in general all was found to be very well managed and maintained. However, the following issue needed attention: Two medications, for two Residents, were found to have been left in the dispensing packs, despite the fact that the MAR sheet said that the drugs had been given. Tynefield Court DS0000002169.V353306.R01.S.doc Version 5.2 Page 18 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 22 & 23. The quality in this outcome area was Good. This judgement was made using available evidence including a visit to this service. Complaints made to the Manager were addressed to meet Residents needs. The protection policies and procedures provided meant that Residents were well protected. EVIDENCE: The Residents spoken with were aware of the complaints procedure. Two Residents said that they had made complaints to the Manager, and each said that their concern was well addressed by her. The complaints procedure was provided in the Residents Guide, detailing that each complaint would be responded to within 28 days. However, the procedure stated that a complaint would need to be made in writing by the Resident or their representative. Two complaints had been made since the last visit made to the Home in February 2007. They were reviewed and considered to have been satisfactorily addressed. The Commission had not received any notice of complaint since the last visit made to the Home in February 2007. The Safeguarding Adults procedure was seen. The Manager also had a Whistle Blowing policy and had relevant information from the Derbyshire Social Services Dept to formally pursue a complaint made against staff. However, copies of the Public Interest Disclosure Act 1998 and the Dept of Health guidance called ‘No Secrets’ were not available within the Home. The Manager said that all allegations and incidents of abuse would be followed up and action would, if necessary, be taken. She also said that any incidents of abuse by her staff would be passed on to the Protection of Vulnerable Adults register, but to Tynefield Court DS0000002169.V353306.R01.S.doc Version 5.2 Page 19 date this had not been necessary. The policies and practices of the Home ensured that physical or verbal aggression by Residents was understood by staff and that staff would only intervene as a last resort to protect the Resident, other Residents or staff. The Home had satisfactory policies and procedures to deal with Residents money and financial affairs. However, the Manager said that the Home did not have a policy to inform staff that they could not benefit, in any way, from Residents wills. This was also confirmed by staff spoken with. Tynefield Court DS0000002169.V353306.R01.S.doc Version 5.2 Page 20 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 24, 25, 26, 27, 28, 29 & 30. The quality in this outcome area was Good. This judgement was made using available evidence including a visit to this service. The Home was well maintained throughout, providing all Residents with a safe, comfortable environment in which to live. EVIDENCE: The premises of the Home were judged to be suitable for caring for Residents, as they were found to be safe and satisfactorily maintained. During this visit only the bedrooms of four Residents were examined, and these where found to be satisfactory. Individual decoration had been provided by the Residents, or their families, making the rooms very homely in appearance. The Home was pleasantly decorated throughout, and the lounge and dining room were comfortable to sit in, and were provided with appropriate items for the Residents. Tynefield Court DS0000002169.V353306.R01.S.doc Version 5.2 Page 21 Toilets were easily available to all Residents, and were clearly marked, although staff had to often assist when a toilet was needed. The Home had an appropriate laundry and clothing was washed at appropriate temperatures. However, the following issues needed attention: All bedrooms should have lockable storage space provided. The smoking lounge needed to be re-decorated. Tynefield Court DS0000002169.V353306.R01.S.doc Version 5.2 Page 22 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 32, 33, 34, 35 & 36. The quality in this outcome area was Adequate. This judgement was made using available evidence including a visit to this service. Inadequate members of staff were trained to NVQ level 2 in Care to meet the needs of Residents. Care staff were also inadequately supervised to ensure that care was provided at an appropriate standard. EVIDENCE: At the time of this inspection it was found that only 25 , 4 out of a total of 16 care staff, held at least a qualification of NVQ level 2 in Care. Staffing provided in the Home was compared with the details provided by the Residential Forum. This showed that during the three weeks of the 10th to the 30th of September 2007, the Home was providing more than sufficient staffing, for 40 Residents, when compared with the High Dependency level of the Residential Forum. These figures were calculated without the Manager’s working time included, as recommended by the Residential Forum. Therefore, suitable amounts of staff time were provided within the Home to meet Residents needs. Tynefield Court DS0000002169.V353306.R01.S.doc Version 5.2 Page 23 The records of two members of staff employed since the last visit made to the Home, in February 2007, were examined to see whether the Manager had obtained all relevant information about them. It was found that all information had been obtained, except for a full history of employment of one of the new staff. A member of staff spoken with said that new staff were provided with copies of the General Social Care Council codes of conduct and practice, and were given the statement of the terms and conditions of employment. The Manager said that new staff would be provided with induction and foundation training, which was confirmed by staff. The Manager was asked about the frequency of supervision she provided for all care staff. She said that this was not provided. Tynefield Court DS0000002169.V353306.R01.S.doc Version 5.2 Page 24 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 37, 39, 42 & 43. The quality in this outcome area was Adequate. This judgement was made using available evidence including a visit to this service. Management arrangements at the Home were not sufficiently robust to ensure that residential care was maintained at a positive standard. EVIDENCE: The Manager had been in post for many years but had not obtained an NVQ level 4 in Management, however, she did hold a nursing qualification. The Manager was aware of many of the issues required to address the Quality Assurance information needed in the Home, and had started work on some of them. However, an annual development plan for the Home had not been provided, and although some surveys of Residents, and professionals visiting the Home had been undertaken, none of this data had been published at the time of this visit to the Home. Tynefield Court DS0000002169.V353306.R01.S.doc Version 5.2 Page 25 The training required by the Regulations was examined. This showed that Moving and Handling and Fire Safety training had been provided for all staff. However, First Aid training was required by 18 staff, Food Hygiene training by 17 staff, and Infection Control training by 19 staff. This was also confirmed by staff spoken with during this visit to the Home. In addition to this required training, the Manager was able to say staff working for the Home were also provided with training in Safeguarding Adults procedures, Control of Substances Hazardous to Health, MRSA training, Health and Safety and Information on Strokes. Radiators were found to be still unguarded throughout the Home, as they had been at the time of the last visit to the Home, although the Manager said that the Registered Providers were planning to address this shortfall in the near future. The Manager was able to show that the Home had complied with the majority of legislation applicable to its operation, although she said she did not have information on the Management of Health and Safety at Work Regulations 1999, the Workplace (Health, Safety and Welfare) Regulations of 1992 or the Provision and Use of Work Equipment Regulations of 1992. The Manager was not able to show that she had provided risk assessments on all safe working practices of staff; that is for care staff, catering staff or domestic staff, and nor had the Registered Providers provided a written statement of the policy, organisation and arrangements for maintaining those safe working practices. However, the Manager was able to confirm that all accidents, injuries and incidents of illness or communicable disease were recorded and reported to the relevant government bodies. She also confirmed, that with the assistance of the Fire Service, fire safety notices were posted in relevant places around the Home. The Registered Providers visited the Home often, at least three or four times each week, but did not complete documentation to show that they had carried out the monthly unannounced ‘inspections’ of the Home, or provided the written report on these ‘inspections’ to the Manager, as required by Regulation 26. Tynefield Court DS0000002169.V353306.R01.S.doc Version 5.2 Page 26 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 2 2 3 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 2 23 3 ENVIRONMENT Standard No Score 24 3 25 3 26 3 27 3 28 3 29 3 30 3 STAFFING Standard No Score 31 X 32 3 33 3 34 2 35 3 36 2 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 3 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 X 2 X 2 X X 2 2 Tynefield Court DS0000002169.V353306.R01.S.doc Version 5.2 Page 27 Are there any outstanding requirements from the last inspection? Yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard YA1 Regulation 4(1)(c) Requirement The statement of purpose must be updated to ensure that all details listed within Schedule 1 are included. Residents plans of care must be shown and discussed with Residents who are able to understand them, and include any comments requested by the relevant Resident. Staff responsible for distributing medication must sign the Medication Administration Record sheets (MAR) only when medication has been given, and use the codes provided on the MAR sheet when medication cannot be given. The Home’s complaints procedure must not require complaints to be made in writing. The Home’s procedure must be altered to state that verbal complaints and written complaints will be treated equally. Timescale for action 13/12/07 2. YA6 15(2)(a) to (d) 13/12/07 3. YA20 13(2) 17(1)(a) Sch 3 3(i) 13/12/07 4. YA22 22 13/12/07 Tynefield Court DS0000002169.V353306.R01.S.doc Version 5.2 Page 28 5. YA34 19 & schedule 2 The Manager must ensure, when appointing new staff, that all the requirements listed in Regulation 19 and Schedule 2 of the Care Homes Regulations 2001, as amended during 2004, are obtained. Of two staff’s records examined, it was found that a full history of employment had not been obtained, dating back to when the member of staff had left school. All care staff must receive formal supervision on a regular basis. (Previous timescales of 31/12/05, 30/06/06 and 30/04/07 not met) A quality assurance system for reviewing the quality of care and nursing must be provided. (Previous timescales of 31/03/04, 31/03/06 and 31/03/07 not met) All staff must receive mandatory training in First Aid, Food Hygiene and Infection Control. (Previous timescale 31/03/07 not met) The majority of the radiators provided in Residents bedrooms were unguarded, and needed guards to protect Residents. The Registered Providers must ensure that the Home is inspected on an unannounced basis, at least once each month in line with the requirements listed in Regulation 26. 13/12/07 6. YA36 18(2) 13/12/07 7. YA39 24 31/01/08 8. YA42 13(6) 18(1)(2) 31/03/08 13(4) 9. YA43 26 13/12/07 Tynefield Court DS0000002169.V353306.R01.S.doc Version 5.2 Page 29 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. Refer to Standard YA1 No. 1. Good Practice Recommendations An Activities Coordinator should be employed by they Registered Providers or reference to such a post be removed from the statement of purpose. Information provided to residents should be available in a variety of formats such as large print, different languages, audiotape etc. (This issue is outstanding from the inspection report dated 31 March 2007) The Residents Guide should include the views of Residents on the quality of the Home, taken from an up to date Residents survey. 2. YA6 The Manager should complete formal 6 monthly reviews of care with Residents. Those attending the review should include the Resident, where possible their relatives and representative, and staff from the home. Where Social Services Depts carry out annual reviews of care this could be one of the 6 monthly reviews. When staff use the Residents record of events to ask other staff to carry out tasks, such as ‘Please Observe’ the task should be addressed on each entry following until the staff member requesting the task signs it off as no longer needed. Entries in Residents files should be made at least at weekly intervals of time, unless events require more frequent entries. 3. YA7 The Registered Providers should review the employment scheme used in the Home and ensure that all staff from overseas have sufficient command of the English language to understand and communicate with Residents with speaking and understanding limitations. There should be evidence on files, such as a signature, to demonstrate that care needs have been discussed and residents were involved in making decisions about their Tynefield Court DS0000002169.V353306.R01.S.doc Version 5.2 Page 30 lives. (This issue is outstanding from the inspection report dated 31 March 2007) 4. YA8 There should be regular Residents’ meeting to ensure that Residents are able to participate in decision-making in the Home. (This issue is outstanding from the inspection report dated 31 March 2007) Ongoing efforts should be made to engage residents in social and community activities, including making time for staff to accompany Residents out from the Home in the evenings. (This issue is outstanding from the inspection report dated 31 March 2007) Care and nursing staff should be made aware of which Residents bedrooms they should knock and await an invitation to enter the bedroom, from the Resident, before doing so, and those Residents bedrooms where they need to knock, pause and enter, because of the limitations of the Resident. A copy of the Public Interest Disclosure Act 1998 and the Dept of Health guidance called ‘No Secrets’ should be available within the Home. Staff should be informed, via the Safeguarding Adult policy in the Home, that they cannot benefit in any way from Residents wills. 8. YA26 All bedrooms should have lockable storage space provided. (This issue is outstanding from the inspection report dated 31 March 2007) The smoking lounge should be re-decorated. (This issue is outstanding from the inspection report dated 31 March 2007) 50 of care staff should be trained to NVQ Level 2 or equivalent. (This issue is outstanding from the inspection report dated 31 March 2007) Supervision should be provided for all care staff in the home on at least a two monthly basis. The Manager should enrol on a course leading to an appropriate management qualification. (This issue is outstanding from the inspection report dated 31 March 2007) DS0000002169.V353306.R01.S.doc Version 5.2 Page 31 5. YA13 6. YA16 7. YA23 9. YA28 10. YA32 11. 12. YA36 YA37 Tynefield Court 13. YA42 The Registered Providers should ensure the Home complies with the Management of Health and Safety at Work Regulations 1999, the Workplace (Health, Safety and Welfare) Regulations 1992 and the Provision and Use of Work Equipment Regulations 1992. The Manager should provide risk assessments, for all staff, on all working practice topics in order to ensure that significant findings are recorded and that all staff are safeguarded. A written statement should also be provided on the policy, organisation and arrangements for maintaining safe working practices in the Home. Tynefield Court DS0000002169.V353306.R01.S.doc Version 5.2 Page 32 Commission for Social Care Inspection Derbyshire Area Office Cardinal Square Nottingham Road Derby DE1 3QT National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 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.V353306.R01.S.doc Version 5.2 Page 33 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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