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Inspection on 26/08/08 for Tynwald Residential Home For The Elderly

Also see our care home review for Tynwald Residential Home For The Elderly for more information

This inspection was carried out on 26th August 2008.

CSCI found this care home to be providing an Excellent service.

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

What follows are excerpts from this inspection report. For more information read the full report on the next tab.

What the care home does well

It is evident through the Inspectors talking to members of staff that the emotional health of the residents at Park View is of a high priority to the home and that staff are pro-active in maintaining and supporting residents with their emotional needs in order to maintain their quality of life. The home and its staff are committed to supporting the residents in accordance with their needs and goals. This was evidenced through feedback received from surveys, AQAA and comments made on the day of inspection by residents. The AQAA (Annual Quality Assurance Assessment) was completed by the manager and was seen to be of an excellent quality. This gave the Inspector a greater insight into what the home considers it does well, what we could do better, what has improved within the last 12 months and plans for improvement. The AQAA stated that residents benefit from an excellent information pack about the home and on their admission to the home. Staff benefit from a comprehensive inductions programme and regular reviews on development. Documentation surrounding regulations/legislation is clear and updated regularly. Residents` concerns, wishes and suggestions are respected and action taken promptly. The home operates full compliance with the equal opportunities and Data Protection Act. Health professionals are given full support from staff when visiting the home to see residents. Staff benefit from training opportunities through South Kent Collage, `Training 4 Care` programmes.

What has improved since the last inspection?

It was evident through the inspection process that the manager is taking appropriate steps to continually review and improves the standards of care within the home. The home is now registed with the Learning Skills Council. The home has improved the nurse call system which gives less mobile residents the freedom to go into the garden and feel safe because of the additional life lines they can carry around their necks.

What the care home could do better:

On standards inspected during this key announced inspection some shortfalls were noted and recommendations made with regard to: Whilst care planning was of a good standard it was felt that improvements could be made with regard to making the plan of care more person centred and include hopes, aspirations and goals. The monthly reports prepared by the Trustees could detail better a cycle of auditing that covers all of the National Minimum Standards.

CARE HOMES FOR OLDER PEOPLE Tynwald Residential Home For The Elderly Hillside Street Hythe Kent CT21 5DH Lead Inspector Robert Pettiford Unannounced Inspection 26th August 2008 08:40 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Tynwald Residential Home For The Elderly DS0000023596.V369363.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Tynwald Residential Home For The Elderly DS0000023596.V369363.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Tynwald Residential Home For The Elderly Address Hillside Street Hythe Kent CT21 5DH 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) 01303 267629 tynwaldhythe@aol.com The Alice Butterworth Charity Mrs Marie Elizabeth Rose Care Home 24 Category(ies) of Dementia - over 65 years of age (3), Old age, registration, with number not falling within any other category (24) of places Tynwald Residential Home For The Elderly DS0000023596.V369363.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. Service users with a diagnosis of DE(E) are restricted to 2 whose DOB are and 17/01/1919 and 30/04/1920 21st September 2006 Date of last inspection Brief Description of the Service: Tynwald was established as a charitable trust to provide residential care to twenty-four older people who have lived in the Hythe area, or have connections with Hythe. The Home is situated a short distance from the town centre where there are shops, health centres, churches, a library and other amenities. The Home provides personal care and support in a non-institutional setting. The Manager places great emphasis on encouraging residents to remain active and independent, and the services include a variety of activities and entertainment. All the homes bedrooms are single, and there is both a shaft and stair lift. There is a choice of sitting areas, and an attractive and accessible garden. Fee levels for this service range from between £320 - £346 per week Tynwald Residential Home For The Elderly DS0000023596.V369363.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 3 star. This means the people who use this service experience excellent quality outcomes. The inspection took place at 8:40AM on 26th August 2008. The Inspectors agreed and explained the inspection process with the Deputy Manager and the Registered Manager who was present for part of the inspection. The focus of the inspection was to assess Tynwald in accordance with the Care Home Regulations 2001 and the National Minimum Standards for Older Persons. In some instances the judgement of compliance was based solely on verbal responses given by those spoken with. The Inspectors used a varied method of gathering evidence to complete this inspection, pre-inspection information such as the previous report and discussion and correspondence with the registered provider/manager was used in the planning process to support the Inspectors to explore any issues of concern and verify practice and service provision. The home has completed an annual quality assurance assessment questionnaire (AQAA), which was received on time. This provided the Inspectors with information relating to what the home considers it does well, what we could do better, what has improved within the last 12 months and plans for improvement. The judgements have been made using the Key Lines of Regulatory Assessment (KLORA), which are guidelines that enable the CSCI to be able to make an informed decision about outcome areas. Further information can be found on the CSCI website with regards to information on KLORA’s and AQAA’s. Documentation and records were read. Time was spent reading a sample of written policies and procedures, reviewing care plans and records kept within the home. Other area’s viewed included risk assessments, pre-admission assessments, rota’s, training records and recruitment records. In addition an environmental tour took place. The Inspectors identified several residents for case tracking. In addition the Inspectors had the opportunity to speak with several of the residents and a number of staff. Additional evidence was gained to inform judgements following the observation of many of the residents and their interactions with staff. Tynwald Residential Home For The Elderly DS0000023596.V369363.R01.S.doc Version 5.2 Page 6 Surveys were sent to Residents, Healthcare Professionals, Care Managers, Doctors and staff. This provided additional information to enable the Inspectors to make sound judgements on the quality of care. What the service does well: What has improved since the last inspection? What they could do better: On standards inspected during this key announced inspection some shortfalls were noted and recommendations made with regard to: Tynwald Residential Home For The Elderly DS0000023596.V369363.R01.S.doc Version 5.2 Page 7 Whilst care planning was of a good standard it was felt that improvements could be made with regard to making the plan of care more person centred and include hopes, aspirations and goals. The monthly reports prepared by the Trustees could detail better a cycle of auditing that covers all of the National Minimum Standards. 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. Tynwald Residential Home For The Elderly DS0000023596.V369363.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Tynwald Residential Home For The Elderly DS0000023596.V369363.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 3 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Residents can be fully confident their needs are assessed prior to admission. Intermediate care is not provided EVIDENCE: People who are considering moving into the home are provided with an informative information pack. This contains a statement of purpose and residents guide. These documents inform people about what it is like to live in the home. People who move into the home can be confident that their needs will be met. Several pre assessments were inspected. Evidence from these demonstrated that a thorough pre admission assessment is carried out to enable the unit manager to make a judgement as to whether the home will be suitable for and can meet the needs of the individual. These assessments Tynwald Residential Home For The Elderly DS0000023596.V369363.R01.S.doc Version 5.2 Page 10 include information gathered from care managers and health professionals. Upon admission, a further assessment is undertaken by the manager. Information from all the assessments informs care planning and risk assessment. Initial assessments do not include all of the information on the wishes and aspirations of residents however. Nor do they state who the information where given is being given by (prospective resident/relative/health professional). Residents would benefit where possible if the home recorded who they gathered information from, and what the prospective resident’s wishes and aspirations were. The assessment process recognises cultural needs and the importance of promoting equality and diversity rather than just meeting needs in a reactive manner. The inspector recommended that the home reviews it equalities and diversity policy and considers carrying out an equalities impact assessment. This is requested to ensure that all of the information and policies relating to residents are inclusive to all members of the community and comply with all current legislation and good practice. Additionally it was recommended that Equality and Diversity training for all staff including management is considered and actioned. Tynwald Residential Home For The Elderly DS0000023596.V369363.R01.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9,10 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Resident’s benefit from detailed care plans overall. There health care needs are generally met however they are not always sufficiently documented and supported with proactive healthcare. Work is also not as yet complete to ensure all plans of care are reviewed embracing the principles of independence, choice, inclusion, equality and empowerment, which have a holistic model as its base. Residents can feel confident that the home’s policy and procedures with regard to the handling and administration of medication are generally sound. However they need to be reviewed to ensure that the recording of such medication meets with current guidance. Residents can feel assured that they will be treated with respect and dignity and their rights to make decisions about their lives is respected and they have the opportunity to be consulted on, participate in, all aspects of life within the home as they wish or their capacity allows. Tynwald Residential Home For The Elderly DS0000023596.V369363.R01.S.doc Version 5.2 Page 12 EVIDENCE: The inspector viewed and discussed with the manager the care records relating to several residents at Tynwald. In the care plans viewed there were guidelines in respect to support needed. The home undertakes regular reviews. Formal reviews involving significant professionals and relatives where possible are also undertaken. Evidence was not seen in all plans of care viewed that residents were involved in drawing up personal care plans, where this is possible. In the documentation no evidence was seen that residents were consulted in reviewing and amending such care plans. The care planning system overall was of a good standard. The manager needs to introduce however a more person centred planning approach to care plans, which will also have a socially lead model as a core element. It was felt that further improvements could be made with regard to social care planning and fully exploring the resident’s needs and wishes where possible and opportunities for social development and enrichment. The care plan is used as a working tool and is understood by all staff. It is written in clear language and can be used in an emergency by people who are not familiar with its content. The inspector viewed a sample of care records and specific health care records relating to several residents. Records viewed confirmed resident’s had access to a range of health care inputs as and when required and as part of regular health checks for some of the residents, but this was not the case for all residents care plans viewed. Whilst it was accepted that many of the relatives of resident’s might ensure that they have access to Dentists and Opticians etc it was not fully evidenced in the care plans. The home needs to ensure that resident’s have health check up’s (if possible), Dentist, Optician in addition to identified specialist health care input. The manager is requested to that there is a provision to ensure that the home complies with standard 8.1 and regulation 12(1)(a) of the Care Home Regulations 2001. No requirement has been made at this time. The documentation seen confirmed that all Residents have a Doctor and visits from other health professionals are arranged and enabled. The health care issues of the residents were seen recorded in the daily record. It was recommended that visits to health professionals be documented separately on its own page to enable the home to more easily document the outcomes for each visit. This was recommended to enable the records to be more easily understood and dispense with the need to read through all the daily notes to extract specific information re a visit to a certain health professionals. Risk assessments sampled were not sufficiently detailed with regard to identifying the risk and the control measures needed to minimise risks. The manager present recognised this and is committed to ensure that all residents Tynwald Residential Home For The Elderly DS0000023596.V369363.R01.S.doc Version 5.2 Page 13 have comprehensive risk assessments to minimise risk. Management of risk needs to take into account the age, specialist needs of people who use the service, balanced with their aspirations for independence and choice. Where limitations are in place, the decisions have been made following consultation with the resident, relative where appropriate and social services care management. The inspector visited the home at 8:40AM. During the inspection the inspector noted that residents were seen making choices about their lives and were seen to be part of the decision process. A relaxed atmosphere was noted with the residents interacting with staff. The inspector also had the opportunity to speak with several residents who expressed a great deal of satisfaction with the care offered and given. They felt that the home offered an inclusive family atmosphere and that the manager was receptive to their comments and suggestions. Daily records were not wholly comprentaneous in that they did not follow current guidance. It was strongly recommended that the home follow the Nursing and Midwifery Council guidance “guidelines for records and record keeping”. The inspector viewed the storage arrangements and some records including Medication Administration Record (MAR) sheets, and the protocols for the administration of “PRN/As Required” Medication. MAR sheets. The manager confirmed that all staff that dispense medication have received appropriate training. No residents currently manage their own medication and the home currently uses the Boot’s MDS system (Medicines are packed into separate compartments allowing the resident to be given the correct medicine, at the correct dose, at the correct time.). MAR sheets were seen to be completed correctly and medication was stored appropriately. The manager confirmed that all staff that dispense medication have received appropriate training. PRN or as required medication protocols were not written up. The PRN strategies need to fully inform staff when and how much and under what circumstances it should be given. The home could not demonstrate that as required medication is given following a comprehensive agreed protocol. It was recommended that an up to date copy of the medication policy and current guidelines from the Royal Pharmaceutical Society of Great Britain be kept in the room where medication is stored. No requirement has been made at this time. It is evident through talking to members of staff at Tynwald that the emotional health of the resident’s is of a high priority to the home and that staff are proactive in maintaining and supporting resident’s with their emotional needs in order to maintain their quality of life from interactions witnessed. Tynwald Residential Home For The Elderly DS0000023596.V369363.R01.S.doc Version 5.2 Page 14 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14,15, Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Residents’ social and recreational interest and needs are provided for with a range of activities organised and are supported to maintain contact with family and friends, which ensures they continue to receive stimulation and emotional support. However opportunities to access the community could be improved. The dietary needs of residents are well catered for and their views and opinions are sought regarding the choice of meals served where possible. Residents feel confident that they are enabled to exercise choice and control over their lives. EVIDENCE: The home offers a programme of activities and employs an activities coordinator who works twelve hours per week. This included art, reminiscence and other activities. One resident said she enjoyed watching the television and talking to staff and visitors. Various other social events are arranged with families being invited. Occasional day trips are also organised. Residents Tynwald Residential Home For The Elderly DS0000023596.V369363.R01.S.doc Version 5.2 Page 15 spoken with generally expressed satisfaction with regard to activities and opportunities for choice and participation. However several residents spoken with were of the opinion that they would like more opportunities to access the community and go down to the town. This was further evidenced from a care plan that confirmed that one of the residents had not had the opportunity to go out since the 7th August 2008. The manager was requested to review the resident’s needs and ensure that they are being met. Family and friends are made to feel welcome within the home are very much seen as priority in maintaining emotional health and know they can visit the home at any time. Staff always make time to talk to visitors and share information with the agreement of the resident. Residents are encouraged to exercise choice and control over their lives where possible; staff were willing to assist if necessary. Evidence seen confirmed residents could bring personal items on admission. The residents spoken with said the food was of good quality and that they had a choice. Three full meals plus snacks were available every day with drinks readily available. Evidence was seen that the residents were offered a choice at every meal and that it was well balanced and nutritious. The inspector viewed the menus, which offered a selection of fruit and vegetables on a daily basis. Specialist diets could be provided when advised by health care professionals or residents, including any cultural food needs Small amounts of money belonging to several of the residents are handled and receipted by the home. Manager confirmed that records were in place. However no audit took place on this occasion. Tynwald Residential Home For The Elderly DS0000023596.V369363.R01.S.doc Version 5.2 Page 16 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16,18, Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. The home has a complaints system in place, families are aware of its contents. Residents are protected by robust adult protection policies and procedures EVIDENCE: The home had a written complaints procedure, which was seen in the foyer. From the completed survey comment forms received by the Commission, this confirmed that relatives with were aware of the contents and felt free to voice their concerns. The home has received no formal complaints since the last inspection. The home had also received compliments from families regarding the level of care offered. The inspector viewed and discussed copies of the Home’s Policy for the Protection of Residents and staff “Whistle blowing” procedure. These include procedures for the reporting of suspicion or evidence of abuse with a format for the recording of any allegations and action to be taken. Full training is provided in abuse. Criminal Record Bureau Checks (CRB) have been obtained for all staff. Evidence was seen at time of inspection. The Registered Manager is aware of her obligations with regard to ensuring the safety of Residents and protecting Tynwald Residential Home For The Elderly DS0000023596.V369363.R01.S.doc Version 5.2 Page 17 them from abuse. It was recommended however that the home refers to the Criminal Records Bureau and renews CRB’s in accordance to its current guidance. Tynwald Residential Home For The Elderly DS0000023596.V369363.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19,20,26, Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Resident’s benefit from living in a home that provides for a homely environment which provides safe access to comfortable indoor and outdoor communal areas. The standards of internal and external decoration were found to be generally of a good quality. EVIDENCE: The home stands on a well proportioned plot with good-sized and generally very well maintained gardens, with ample seating in different areas. Several doors open onto all the gardens. The inspector observed and was invited into several rooms by residents who were pleased to show their plants or photographs. Tynwald Residential Home For The Elderly DS0000023596.V369363.R01.S.doc Version 5.2 Page 19 The management and staff encourage residents to see the home as their own home. It provides a very well maintained, safe, comfortable, attractive home, which has all the specialist equipment and adaptations needed to meet individual resident’s needs. As well as a good selection of general aids such as bath hoists and adapted baths. The home ensures that equipment is individualised for each resident and all staff members are trained in the safe use of aids and equipment. The bathrooms include a selection of different ways to bath, for example assisted and unassisted showers and baths and there are a number of toilets strategically placed around the home. All residents are assessed for their need to have equipment or aids before they move into the home and these are provided to them on admission. The fixtures and fittings are of a good quality, well maintained and adapted to meet the wishes of the present resident. There is a selection of communal areas, according to the numbers of residents, this means that residents have a choice of place to sit quietly, meet with family and friends or be actively engaged with other residents. The management has a proactive infection control policy. Staff wear protective clothing (gloves & aprons) when providing personal care or handling soiled linen. The manager stated that comprehensive infection control guidelines are followed. The laundry room is situated in a appropriate environment. The washing machine has a sluice facility and can provide a hot wash at 95C. Tynwald Residential Home For The Elderly DS0000023596.V369363.R01.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29,30 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Resident’s can feel confident that their care, social and emotional needs are fully promoted by the employment of care staff in sufficient numbers to meet their needs at all times and trained to the required standards. Residents are fully protected by the recruitment procedures within the home. EVIDENCE: The ratios of care staff to residents are determined according to the assessed needs of residents. Following discussions with the manager, a review of the rota and observations made during the inspection. The Inspectors were of the opinion that sufficient care staff were on duty to support residents to meet their personal needs and take all reasonable steps to ensure their health and safety. Evidence at time of the inspection confirmed that their immediate needs were being meet and that the residents spoken with were happy and content. Feedback from surveys confirmed that residents are well supported with their needs. The manager stated that staffing is constantly kept under review. Tynwald Residential Home For The Elderly DS0000023596.V369363.R01.S.doc Version 5.2 Page 21 The home employs a higher than average number of ancillary staff in the view of the Inspectors who work as cleaners, laundry, cooks, maintenance staff. Thus allowing care staff the time to meet the needs of resident’s. The staff training records indicated undertaken training. Individual and group staff training needs had been identified. From documentary evidence seen the standard of staff training was very good, with the majority of staff completing basic and additional courses At present the home has achieved an NVQ (National Vocational Qualification) Level 2 or above care qualification for at least 50 of care staff. The home is to be commended on the level and standard of training within the home. The manager confirmed that the home has a development programme for all new staff, which meets Sector Skill’s council’s workforce training targets and ensures staff fulfill the aims of the home and meet the changing needs of resident’s. The home showed that it undertakes a recruitment practice including submission of an application form detailing all previous work history, requests proof of identity and copies of qualification certificates, seeks two written references, and confirms work status. The home was requested to review its staff files to ensure compliance with the Care Home Regulations 2001. However it is recognised that obtaining all records for longer serving staff members will not be possible. Tynwald Residential Home For The Elderly DS0000023596.V369363.R01.S.doc Version 5.2 Page 22 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31,33,38 Quality in this outcome group is good Residents benefit from living in a good run and managed home. Residents and or their relatives can be generally very confident that their views and opinions effect how the home is run and can be fully assured that residents best interest are wholly safeguarded by appropriate policies and procedures. EVIDENCE: The homes management team and staff are to be complemented on the quality of care within the home. The leadership style of the management was seen to be supportive of staff and steps are taken to ensure that quality of care is not compromised. Evidence to make this judgement was gathered from a wide source of evidence. Namely The completed AQAA, surveys, feedback from Tynwald Residential Home For The Elderly DS0000023596.V369363.R01.S.doc Version 5.2 Page 23 many stakeholders, staff, management, residents and from observations of good practice observed by the inspector. Quality assurance was discussed and the views and opinions of many of the resident are sought where capacity allows. They confirmed a great deal of satisfaction in living within the home and felt confident that the staff and management valued their views and opinions. The manager confirmed that the home does undertake quality assurance by means of asking resident’s to complete questionnaires. The views of other stakeholders are also sought. The registered provider of the home does visit the home regularly along with other trustees. A Monthly audit / report is completed that identifies any issues within the home. The inspector saw this as being the equivalent of what is known as a Regulation 26 visit (Statutory documented visits by the provider to monitor standards within the home). This requires the provider to assess the quality of care within the home and ensure that it is meeting with the required National Minimum Standards. Such visits however need to focus more on outcomes for resident’s with regard to quality of care, staffing, adult protection, audits of policies and procedures and that they are followed, staff training, Activities, Health and Safety etc. along with speaking to staff and resident’s. The manager was requested that issues identified within the inspection are picked up within such visits and actioned. The home has developed a health and safety policy that meets health and safety requirements and legislation. The Inspectors viewed records relating to Health and Safety Procedures, maintenance and servicing, and risk assessments. The Inspectors viewed the Fire Log book. The Inspectors was able to evidence that checks and servicing of fire safety equipment / emergency lighting had been undertaken at the required frequency. Fire risk assessments were in place along with gas safety checks. Standards 35 were not inspected on this occasion. Tynwald Residential Home For The Elderly DS0000023596.V369363.R01.S.doc Version 5.2 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 x x 3 x x x HEALTH AND PERSONAL CARE Standard No Score 7 3 8 2 9 3 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 x 18 3 3 3 x x x x x 3 STAFFING Standard No Score 27 3 28 3 29 3 30 4 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 4 x 3 x x x x 3 Tynwald Residential Home For The Elderly DS0000023596.V369363.R01.S.doc Version 5.2 Page 25 Are there any outstanding requirements from the last inspection? No STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. Standard Regulation Requirement Timescale for action RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Tynwald Residential Home For The Elderly DS0000023596.V369363.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Maidstone Office The Oast Hermitage Court Hermitage Lane Maidstone ME16 9NT 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 Tynwald Residential Home For The Elderly DS0000023596.V369363.R01.S.doc Version 5.2 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. 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