Inspection on 29/09/05 for Tynefield Court

This inspection was carried out on 29th September 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is 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 14 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 10/02/06

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 29th September 2005 09:00 Tynefield Court DS0000002169.V249894.R01.S.doc Version 5.0 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Tynefield Court DS0000002169.V249894.R01.S.doc Version 5.0 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for 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.V249894.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Tynefield Court Address Blakeley Lane Egginton Road Etwall Derby DE65 6NQ 01283 732030 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.V249894.R01.S.doc Version 5.0 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 8th December 2004 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.V249894.R01.S.doc Version 5.0 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 7.5 hours. Discussions were held with six residents, one relative and with staff during the inspection. Records were examined, including care plans (as part of the case tracking process, which is used to help determine how the home meets the needs of individual service users). 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? Considerable improvement has been made towards involving residents in assessing, planning and reviewing the care that they receive. People spoken with were aware of their files and confirmed that they had been involved in planning their care. The files provided detailed information for staff on how to meet individual needs. The home has been successful in recruiting additional staff. The manager reported that this has improved continuity of care for residents. Although the manager has started to provide supervision for staff, this has been infrequent. Ongoing work needs to continue in this area. Tynefield Court DS0000002169.V249894.R01.S.doc Version 5.0 Page 6 What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Tynefield Court DS0000002169.V249894.R01.S.doc Version 5.0 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.V249894.R01.S.doc Version 5.0 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): 2, 3 and 5 (Young Adults) and 2, 3 and 4 (Older People) Pre-admission procedures were in place to ensure that residents were admitted on the basis of a comprehensive assessment of their needs, with written confirmation that individual needs could be met. EVIDENCE: The care plans of three residents were examined in detail as part of the case tracking process, which is used to help determine how the home meets the needs of individuals. Considerable improvements in the standard of the documentation have been made. There was evidence within care plans that assessments had been undertaken prior to the admission of residents, which gives confidence that the staff were making judgements about the suitability of this care home to meet the needs of individuals. Tynefield Court DS0000002169.V249894.R01.S.doc Version 5.0 Page 9 Staff from Tynefield Court assess residents before admission, including where a Care Management assessment and NHS nursing assessment has been compiled. The assessment documents examined at this inspection had been completed (and signed) by staff, and written confirmation of whether the home could meet the assessed needs of the resident provided. Assessments for residents who had lived at Tynefield Court for a period of time had been updated to reflect any changes to their needs. Contracts between the local authority responsible for funding care and the home were in place for those residents whose care was funded in this way. The manager reported that the terms and conditions were included within the Service User Guide. Tynefield Court DS0000002169.V249894.R01.S.doc Version 5.0 Page 10 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): 6, 7, 9 and 10 (Young Adults) and 7 and 14 (Older People) People living the home were involved in all aspects of their care, and made decisions about their daily lives and were supported to take responsible risks. EVIDENCE: The care plans of three residents were examined in detail as part of the case tracking process, which is used to help determine how the home meets the needs of individuals. Again, considerable improvements in the standard of the documentation have been made. Discussion with residents and a relative supported that they had been involved in assessing, planning and reviewing their care and were aware that they could look at their files. Tynefield Court DS0000002169.V249894.R01.S.doc Version 5.0 Page 11 The care plans promoted residents’ individuality and independence, and provided clear instructions for staff on how this may be achieved. The support provided to the people living in the home was reviewed at least every six months. Efforts were also made to review the care every month. Information about the day to day lives of residents was recorded in the files. Observation of residents and the files indicated that they made decisions and were involved in all aspects of their daily lives. Residents spoken with confirmed that staff provided support and assistance as required, whilst promoting independence. People living in the home were enabled to take responsible risks, and these had been identified and planned for. Information relating to residents was securely stored, and policies on confidentiality in place. Tynefield Court DS0000002169.V249894.R01.S.doc Version 5.0 Page 12 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 (Young Adults) 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. Tynefield Court DS0000002169.V249894.R01.S.doc Version 5.0 Page 13 EVIDENCE: Residents spoken with confirmed that the routines at the home were flexible. Staff provided support and assistance as required, and residents were observed making good use of the communal areas as well as their bedrooms. Residents stated that staff respected their privacy and dignity, and staff were observed knocking on bedroom doors prior to entering. One resident spoken with did not wish to socialise with other residents and remained in their room, and confirmed that staff respected this decision. Other residents socialised both in their bedrooms and in communal areas. Residents were encouraged to maintain links with their friends and families, and several residents regularly went out with families. This information was well recorded in the files. The one relative spoken with said that there were no limitations of visits and that the staff always made them welcome. A small number of residents make good use of motorised scooters to access the amenities in the local village. A small number of residents go on holiday with their families. Some residents choose to socialise together both inside and outside the home. Residents commented that there were very few organised activities, although they did enjoy the movement to music sessions. However, residents did not indicate that they would like more activities. Residents commented on the in house entertainment that had been organised recently. None of the people living at the home were currently attending college courses, although these have been arranged in the past. Residents and relatives spoken with considered that the meals provided were good, and provided choice and variety. The majority of residents prefer to have their meals in the dining room, but can remain in their rooms if they wish. A number of residents require staff support at meal times, and this was provided in a discreet and relaxed manner. A tour of the kitchen was not undertaken as part of this inspection. Tynefield Court DS0000002169.V249894.R01.S.doc Version 5.0 Page 14 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): 18, 19, 20 and 21 (Young Adults) and 8, 9, 10 and 11 (Older People) Residents’ personal and health care needs were met with support and assistance from staff and the multidisciplinary team. Inconsistencies in staff practice around administration and recording of medication potentially placed residents at risk. EVIDENCE: The majority of people living at Tynefield Court require support and assistance with personal care. Residents spoken with confirmed that staff do provide support and assistance when required. Residents did not raise any issues about privacy and dignity during this inspection. Residents were treated as individuals and this was reflected in their appearance. Tynefield Court DS0000002169.V249894.R01.S.doc Version 5.0 Page 15 Access to health care professionals has improved, and the multi-disciplinary team provide better support for residents and staff. Continuity of care was provided through the same GP visiting weekly to review residents. One resident stated that in their opinion this GP was very good. Referrals and visits were recorded in the residents files. Staff regularly monitored residents health care needs through the use of risk assessments. These risk assessments were updated regularly, and appropriate action taken. However, residents continence needs were not assessed. Residents weights were monitored on a monthly basis. Although systems were in place for the management of medication, staff used these inconsistently. On a small 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 is not acceptable and must stop. This practice has been noted during previous inspections. Handwritten entries did not always record the full information as recorded on the dispensing label. Efforts were being made to record details the personal wishes of the residents at the time of severe illness or post death, although this information was not in place in all three files examined. Tynefield Court DS0000002169.V249894.R01.S.doc Version 5.0 Page 16 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 12, 13, 15, 16 and 17 (Adults 1865) 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 and 18 (Older People) Residents and relatives felt confident that their concerns were listened to and acted upon. People living in the home were protected through staff training and written policies and procedures. EVIDENCE: Residents and relatives commented that the manager was approachable, and felt confident to raise any concerns with her. They commented that they felt confident that their concerns were listened to and acted upon. The home’s record of complaints was not examined during this inspection. The Commission has not received any complaints concerning Tynefield Court during 2005. Policies relating to the Protection of Vulnerable Adults and Whistle Blowing were in place. Staff receive a copy of the local authority Protection of Vulnerable Adults policy and the Whistle Blowing policy. Staff training was provided through a training video. Staff were booked onto the local authority Protection of Vulnerable Adults training when places were available. The manager had a good knowledge of the adult protection procedure. Tynefield Court DS0000002169.V249894.R01.S.doc Version 5.0 Page 17 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): These standards were not assessed during this inspection. EVIDENCE: Tynefield Court DS0000002169.V249894.R01.S.doc Version 5.0 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, 35 and 36 (Young Adults) and 27, 28, 29, 30 (Older People) Staffing was adequate to meet the needs of the residents. Continued efforts need to be made to ensure that staff receive adequate training in addition to the induction and foundation training. EVIDENCE: Residents and relatives spoken with considered the staff to be hard working and committed, and were able to meet their needs. The staffing levels were in accordance with the registered numbers and the dependency of the residents admitted to the care home. The duty rota demonstrated that new staff were being supported during their induction shifts by more experienced care staff. Tynefield Court DS0000002169.V249894.R01.S.doc Version 5.0 Page 19 The duty rota demonstrated that the use of agency staff has reduced, and that home recruited additional care staff. This has assisted with continuity of care. There is a requirement to provide a minimum of 50 trained members of staff (NVQ Level 2 or equivalent). This has not been achieved yet, as only three members of care staff have achieved this qualification. New staff were supported to develop their skills and knowledge by working through the induction and foundation programme that meets the specifications. These staff were supported by the college tutor, who visits every two weeks, and by experienced staff working at the home. Other training opportunities were also available. There had been limited ongoing development of supervision for staff. The manager acknowledged that one of the experienced care staff works alongside other care staff, and supervising their practice. Discussion took place with regard to further developing this role and formally recording the supervision sessions. Staff files were not examined during this inspection. The requirement in the previous inspection report is therefore carried forward. Tynefield Court DS0000002169.V249894.R01.S.doc Version 5.0 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): 39 and 42 (Young Adults) and 33 and 38 (Older People) Continued efforts need to be made to ensure that staff receive all of the mandatory training. Effective quality assurance systems need to be developed to ensure that residents views are sought and acted upon. EVIDENCE: Tynefield Court DS0000002169.V249894.R01.S.doc Version 5.0 Page 21 The manager acknowledged that no further progress has been made with the development of systems for reviewing the quality of care and services provided at the home. The training matrix clearly identified which staff had attended mandatory training and where training was outstanding. Fire training was being provided the week after the inspection. Infection control training had been arranged. However, only a small number of staff have a first aid certificate. The manager reported that this training has yet to be arranged. No progress had been made to meet the outstanding requirement to carry out risk assessments on all radiators and fit guards where necessary. The fire records did not support that the fire alarm was tested on a weekly basis. Tynefield Court DS0000002169.V249894.R01.S.doc Version 5.0 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 3 3 3 4 X 5 3 INDIVIDUAL NEEDS AND CHOICES CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 X 25 X 26 X 27 X 28 X 29 X 30 X STAFFING Standard No Score 31 X 32 2 33 3 34 2 35 3 36 2 CONDUCT AND MANAGEMENT 37 X 38 X 39 2 40 X 41 X 42 2 43 X Standard No 6 7 8 9 10 LIFESTYLES 11 12 13 14 15 16 17 Score 3 3 X 3 3 X 3 3 3 3 3 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 2 2 2 Tynefield Court DS0000002169.V249894.R01.S.doc Version 5.0 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 YA19 YA20 Regulation 14(1)(a) 13(2) 17(1)(a) Sch 3 13(2) 17(1)(a) Sch 3 13(2) 17(1)(a) Sch 3 13(2) 17(1)(a) Sch 3 13(2) 17(1)(a) Sch 3 12(3) Timescale for action Continence assessments must be 31/12/05 completed for all residents with an identified need. Residents must receive the 30/11/05 medication that they are prescribed. Reasons for nonadministration must be recorded on the medication chart. A record must be kept of all 30/11/05 medication received into the home. Medication must only be 30/11/05 administered to the resident for whom it is prescribed and labelled (Previous timescale of 31 May 2004 not met) Where a variable dose is 30/11/05 prescribed the actual dose administered must be recorded All hand written entries on the 30/11/05 medication records must include the name, dose and administration instructions. Residents wishes at the time of 31/12/05 severe illness or post death must be recorded in the files (Previous timescale of 30 April 2004 not DS0000002169.V249894.R01.S.doc Version 5.0 Page 24 Requirement 3 4 YA20 YA20 5 6 YA20 YA20 7 YA21 Tynefield Court 8 9 YA32 YA34 18(1)(a) 17(2)Sch 4 19(1)(4) 10 11 YA36 YA39 18(2) 24 12 YA42 13(6) 18(1)(2) 13(4) 13 YA42 14 YA42 23(4) met) 50 of care staff must be trained to NVQ Level 2 or equivalent. 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 stasff recruited from overseas (Complaince not checked) All staff must receive formal and informal supervision on a regular basis. 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 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) The fire alarm must be tested on a weekly basis and this information recorded. 31/12/05 31/03/06 31/12/05 31/03/06 31/03/06 31/03/06 30/11/05 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 Refer to Standard YA14 Good Practice Recommendations Ongoing efforts should be made to engage residents in social and community activities. Tynefield Court DS0000002169.V249894.R01.S.doc Version 5.0 Page 25 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.V249894.R01.S.doc Version 5.0 Page 26 - 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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