Care Home: Tye Green Lodge

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What the care home does well People living in the home and their relatives are complimentary about the environment and the care that is provided. One relative said they are happy now their relative has moved to Tye Green Lodge and someone living in the home said, "Excellent care".Interactions between staff and people in the home are excellent. Staff are able to provide support for people in a way that meets their needs and wishes and it was noted that people are encouraged by staff to state how they wish to be supported. Thus offering a more person centred way of caring for people. They ensure the personal and healthcare needs of people living in the home are met and relevant healthcare professionals are consulted where appropriate. People are treated individually and the manager is able to demonstrate an excellent awareness of individual needs, wishes and preferences. The good staffing levels in the home help ensure people are able to receive the care and support they need in a relaxed way. The menu in the home provides people with a well-balanced, varied appetising diet. Staff provide good home cooked food that is enjoyed by people living in the home. Tye Green Lodge provides a comfortable, homely environment with pleasant communal areas and bedrooms that reflect individual tastes and personalities. What has improved since the last inspection? Some of the care plans in the home could be developed to contain a little more detail. This information would better inform staff of the needs of the person and therefore they could deliver even better care. The records of the administration of medication must be well maintained to prevent the risk to people living in the home. CARE HOMES FOR OLDER PEOPLE Tye Green Lodge Yorkes Tye Green Village Harlow Essex CM18 6QR Lead Inspector Sharon Thomas Unannounced Inspection 4th September 2008 09:00 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Tye Green Lodge DS0000064980.V371170.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Tye Green Lodge DS0000064980.V371170.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Tye Green Lodge Address Yorkes Tye Green Village Harlow Essex CM18 6QR 01279 770500 01279 770577 tye@quantumcare.co.uk www.quantumcare.co.uk Quantum Care Limited Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Miss Melanie Jayne Kemsley Care Home 61 Category(ies) of Dementia - over 65 years of age (61), Old age, registration, with number not falling within any other category (61), of places Physical disability over 65 years of age (61) Tye Green Lodge DS0000064980.V371170.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 4. Persons of either sex, aged 65 years and over, who require care by reason of old age only (not to exceed 61 persons) Persons of either sex, aged 65 years and over, who require care by reason of dementia (not to exceed 61 persons) Persons of either sex, aged 65 years and over, who require care by reason of a physical disability (not to exceed 61 persons) The total number of service users accommodated in the home must not exceed 61 persons 26th September 2006 Date of last inspection Brief Description of the Service: Tye Green Lodge is a Care Home for Older People located on the edge of Harlow in a residential suburb known as Tye Green Village. As well as the large town centre facilities accessible via public transport, there are local shops and pubs within walking distance of the home. The building was purpose built to provide accommodation for 60 older people in four units. Each unit has a self-contained kitchen, dining and living area, with corridors leading to bedrooms, bathrooms and toilets leading off. The bedrooms are single and have en-suite shower rooms. Additional facilities include a treatment room, hairdresser’s salon, two communal lounges and visitor’s room. There are secured landscaped gardens with pathways and seating located around the building. The service caters for residents requiring support due to physical frailty and residents with a diagnosis of dementia. The ranges of fees charged by the service are between £570 and £685 per week. The service also provides a respite facility and the cost of this ranges from £620 per week. There are additional charges for hairdressing, chiropody and outings and entertainment. This information was provided to the Commission by the provider in October 2008. Tye Green Lodge DS0000064980.V371170.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 2 star. This means the people who use this service experience good quality outcomes. A range of evidence was looked at when compiling this report. Documentary evidence was examined, such as menus, staff rotas, care plans and staff files. Completed surveys were received from members of staff, people living in the home and their relatives. The manager completed an Annual Quality Assurance Assessment with information about the home and evidence of how they meet the needs of the people living there. This document will be referred to as the AQAA throughout the report. A visit to the home took place on 4th September 2008; this visit was unannounced. On the day of the inspector’s visit the atmosphere in the home was relaxed and welcoming and we, the Commission for Social Care Inspection (CSCI), were given every assistance from the manager and the staff team. During the inspection a situation arose and we were able to observe the management and staff team deal with a person who lives in the home who had become distressed. The staff dealt perfectly with the situation as it escalated to a situation that involved staff being physically attacked. The staff remained calm throughout and dealt with the situation with sensitivity, warmth and professionalism. The situation called for the staff to communicate with other agencies and to decrease the risk to both themselves and other people living in the home. Throughout the situation the staff treated the person with respect and care and this element of practice was seen in all interactions between care staff and people living in the home. The visit included a tour of the premises, discussions with people living in the home, the manager, members of staff and visiting relatives. Observations of how members of staff interact and communicate with people living there have also been taken into account. What the service does well: People living in the home and their relatives are complimentary about the environment and the care that is provided. One relative said they are happy now their relative has moved to Tye Green Lodge and someone living in the home said, “Excellent care”. Tye Green Lodge DS0000064980.V371170.R01.S.doc Version 5.2 Page 6 Interactions between staff and people in the home are excellent. Staff are able to provide support for people in a way that meets their needs and wishes and it was noted that people are encouraged by staff to state how they wish to be supported. Thus offering a more person centred way of caring for people. They ensure the personal and healthcare needs of people living in the home are met and relevant healthcare professionals are consulted where appropriate. People are treated individually and the manager is able to demonstrate an excellent awareness of individual needs, wishes and preferences. The good staffing levels in the home help ensure people are able to receive the care and support they need in a relaxed way. The menu in the home provides people with a well-balanced, varied appetising diet. Staff provide good home cooked food that is enjoyed by people living in the home. Tye Green Lodge provides a comfortable, homely environment with pleasant communal areas and bedrooms that reflect individual tastes and personalities. What has improved since the last inspection? 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. The summary of this inspection report can be made available in other formats on request. Tye Green Lodge DS0000064980.V371170.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Tye Green Lodge DS0000064980.V371170.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 3 & 6: Quality in this outcome area is good. People living in the home are well informed and have their needs assessed prior to moving in. Changing and developing needs are assessed to make sure they are appropriately met by the service. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Pre-admission assessments are carried out by the manager or deputy manager. A sample pre-admission assessment document was looked at, and included a basic dementia assessment. The pre-admission documents of the last three people coming to live in Tye Green Lodge were looked at this visit. All three individuals were diagnosed with dementia and due to the affect on their communication were unable to contribute directly to their admission information. However their families were provided with an opportunity that asks them to provide information such as the family history, the individuals normal routine, their likes and dislikes, and any issues that cause them Tye Green Lodge DS0000064980.V371170.R01.S.doc Version 5.2 Page 9 distress, the things that soothe them and the warning signs of their increased anxiety. The admission assessment document was very substantial with questions across a variety of aspects of an individual’s lifestyle that gives a detailed picture of the person and how the service and staff may need to support them. The manager’s AQAA states: “We have very good feedback from the resident and relative questionnaires, Home Forums, and resident meetings. Positive feedback from other professionals. We carry out a full assessment prior to admission involving the relevant professionals, we ensure that we have current assessment information from hospitals, adult care services and GPs, and when needed we arrange a pre-admission meeting. Prior to admission, potential residents are invited to come for lunch/tea so that they can get a ‘feel’ for the home; this hopefully gives them a taste of what the home is like. With undertaking the assessment prior to admission we start to gather information to build a care plan; this continues to be a working document throughout the resident’s time at Tye Green Lodge. A review meeting is held at 6 weeks where the individual’s care needs are discussed. This meeting is also to make the placement permanent if appropriate. Staff are trained to meet the individual residents needs, and all staff receive mandatory core skill training and all are trained in Dementia Care”. Tye Green Lodge does not provide intermediate care. Tye Green Lodge DS0000064980.V371170.R01.S.doc Version 5.2 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9, 10: Quality in this outcome area is good. People can be confident that their personal and healthcare needs will be met in the home and they may be confident that they will be treated with respect. Their changing and developing needs are consistently assessed to make sure that they are appropriately met by the service. This judgement has been made using available evidence including a visit to this service. EVIDENCE: There is a care plan in place for each person living in the home along side a good standard of risk assessments. There is evidence that consultation with the person takes place and that their choices are included when delivering the care that they need. We looked through 5 care plans that indicated that specialist services are catered for, that appropriate equipment is provided and in place for those that need it. All files contained an assessment form completed on admission and used to generate the care plans. The assessments detailed the individuals’ wishes for funeral arrangements and additional individual assessments had been completed in regard to specific needs (e.g. Tye Green Lodge DS0000064980.V371170.R01.S.doc Version 5.2 Page 11 risk of falls, moving and handling, dependency, continence, nutrition, pressure sore risk, dementia etc.) The care plans are detailed with lots of information that will help staff provide people with an excellent level of care. The care plans contain information on the person’s strengths, abilities and wishes, they detail how staff should treat the person in a sensitive and professional manner. However, 2 of the care plans we looked at did not contain as full arrange of information as the other 3, and the manager agreed that these care plans could do with some more work. The home is in the process of transferring the care plans to a new format and during this process the documents will be updated. There is a good process for the monitoring of falls; pressure sores and other health issues. All those who live in Tye Green Lodge have access to a GP, district and community nurse, chiropody, optician, audiologist and dental practice. Good paperwork shows that staff liaise well with other professionals and have strong links and good partnerships with the local healthcare teams team. This was also confirmed from completed surveys received from people living in the home and their relatives. The home has a medication policy and procedure that are available to staff. Medication is provided by the local pharmacy in pre-dispensed packs and individual containers. Appropriate ordering and disposal procedures are followed and were found accurate on the day enhancing the safety of the people living in the home. Medication was stored in suitably secure trollleys and areas within the home. A medication fridge is available in the mediaction room. Medication is administered by designated staff who have received relevant training. A list of authorised staff names with signatures and initials is available. The home’s Medication Administration Records were examined and we found errors in the recording of three of the people living in the home. The errors were where staff had failed to record whether they had administered the mediaction to the person. This lack of recording can potentially place people at risk as the duplication or ommission of medication may occur. Supplies of medications were checked and confirm that the prescribed medication was available. Care plans contained clear information and indicated each person’s preferred name. Staff were observed to be friendly toward people but to also treat them with respect and to uphold their privacy and dignity when providing personal care. People are not routinely provided with keys to their room but the manager confirmed this could be arranged if they wish. During the situation that occurred in the home with the person who became distressed the staff team used their training and maintained the relationship that they have with person. Staff spoke to people in a calm and soothing manner, they walked away when the situation became too heated, diffusing the actions of the person. Tye Green Lodge DS0000064980.V371170.R01.S.doc Version 5.2 Page 12 The manager’s AQAA says: “Care plans are personalised to meet the individuals needs. Care plans are written clearly and the residents are involved in this process. Staff spend time with individual residents involving them in this process. Residents are encouraged to be involved with their care plan, this is an ongoing process and is reviewed monthly and updated regularly. Individual’s medication is stored in Trolleys on the units. Each resident has a MAR sheet, which accurately details medications prescribed. Checks on medication are carried out twice a day and recored on monitoring sheets. All staff receives medication training before administering medication, this involves a theory session as well as three practical assessments. This is reviewed yearly. We have a company Medication Policies and Procedures Manual which is continuously updated and reviewed. We have a good rapport with our local Health Centre and GP’s who visit regularly and will also answer queries and concerns over the telephone if also needed. All staff are made aware of the importance of respecting privacy and dignity within their induction training and this is promoted within the home when assisting with personal care”. Tye Green Lodge DS0000064980.V371170.R01.S.doc Version 5.2 Page 13 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 and 15: Quality in this outcome area is excellent. People living in Tye Green Lodge have opportunities to maintain a lifestyle that meets their needs and wishes. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The sample of care plans we looked at showed us that there is appropriate information regarding peoples’ personal and social histories, personal choices, and daily social routines. Assessments of people’s social needs is evident in care plans and their participation in activities is recorded. The home has no formal structured programme of activity however there is ample evidence that activities take place and these activities meet the needs of the people living in the home. Staff in the home provide activity on a go with the flow basis, they watch people and their moods and match the activity to the needs of that moment, providing a person centred approach. One relative said that “there is always something going on and they offer nice activities to people but they can choose whether to get involved or not they take into account if the person’s history it would be no good encouraging people to do bingo if they always hated bingo ”. The home brings external entertainment into the home and also provides a host of activities including: exercise, board games, memory recall, Tye Green Lodge DS0000064980.V371170.R01.S.doc Version 5.2 Page 14 DVD’s, music, supporting people to undertake domestic tasks that makes them feel productive to name a few. One person spoken with said that “I don’t always take part in the activities on offer but that is my decision and I could if I wanted” and another said, ”the staff do a good job to keep us entertained, the birthdays are well celebrated, staff are lovely”. Relative comments and staff spoken with indicated that the service encouraged relatives to maintain an active role in the people lives following admission. One relative who completed a survey said the home always provides a warm welcome, and they are able to visit family members or friends in private. Generally, people were observed to be able to move around the home and involve themselves in activities and routines they felt happy doing. Peoples’ rooms that were seen were personalised, showing that people could bring their own possessions into the home with them. All rooms had locks and people are able to have keys to their room should they wish. People spoken with said they were supported to choose how to live their daily lives (e.g. time in getting up, going to bed, where and what they ate etc.). On the day of the inspection we saw people making some small choices including whether they wanted to stay in their room or the lounge for lunch. People spoken with who are able to express their opinions are very positive about being able to choose the way they want things done. One person who chooses to spend most of their time in their room watching television is supported to do so, while others socialise in the lounges. People spoken with said that although generally they may choose not be involved in group type activities, they could if they wished to join in occasionally. One person spoken with said, “I like living here it is such a family home”. People spoken with are positive about the menu that they have in the home. The chef on duty has the skills and knowledge around providing nutritional appetising meals. Food stores were examined and there was evidence of a variety of fresh, frozen and dried foods available. The chef stated that the budget for food is generous and the home is never short of stocks. The dining rooms have a domestic type layout, which ensures that meals are served up fresh and hot. We saw that mealtimes for people at Tye Green Lodge are sociable occasions with people enjoying their meal in a relaxed supportive environment. Surveys received said there are “very good cooks with a choice of menu” and “The meals are varied and of a high standard”. Breakfast is served in the dining rooms, but people did have the choice of eating in their bedrooms should they choose to do so. People are offered a choice of cereals or porridge, fruit juice, toast and marmalade and on Sundays they are offered a cooked breakfast in addition to the standard choice. The lunch on the day of inspection was appetising and people were offered a choice Tye Green Lodge DS0000064980.V371170.R01.S.doc Version 5.2 Page 15 plus another alternative. This was confirmed in discussion with people who said they could have soup, omelettes, or salad or nearly anything they wanted if they did not want the main choice. People spoken with said they had “a good choice of puddings, cakes and snacks”, and “the food here is lovely and we get more than enough” one person who enjoys the puddings invited us to try some and it was tasty. The chef stated that special diets such as diabetic, high fibre, low salt, low fat diets could be catered for. The manager’s AQAA says: “Tye Green Lodge has a warm friendly family environment. We actively encourage family members to come and visit at anytime of the day, we also try and involve families in participating in activities within the home and on trips out. We have many party’s at the home so that families can enjoy themselves with their family member. We have an Activities Co-ordinator that has developed a full activities programme that has been devised around the service user’s needs and preferences. We also have frequent trips out. Each resident has a food preference sheet in his or her care plan. This details the likes and dislikes in relation to food and drink. This is completed with the resident and their family members. A copy of this is then given to the Chef Manager, so that she is aware of their dietary requirements. Our Chef Manager will adapt the menu to meet the needs and preferences of the residents. She also gets feedback from the residents so that she can make any changes that may be needed. Religious needs are respected, catered for and detailed on the individual’s care plan”. Tye Green Lodge DS0000064980.V371170.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 and 18: Quality in this outcome area is good. People living in Tye Green Lodge are kept safe by the home’s policies procedures relating to complaints and safeguarding vulnerable adults. People can be confident that their concerns will be taken seriously. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home has a complaint policy and procedure that is up to date and clear. People living in Tye Green Lodge, their relatives and staff are aware of the procedure and know who to contact should they need to raise a complaint. People spoken with were able to point out senior members of staff and the manager who they confirmed that they would speak with should they be concerned about their care or staff practices. The home’s complaint log was looked at and recorded 4 new complaints had been entered since the last inspection, the records stated what the complaint was, the action taken by the home, and the outcome of the complaint and action taken into any practice or procedure not working for the people living in the home. The home has a Safeguarding Adults policy and procedure in place and all staff have received up to date training on this subject. Staff genuinely care about the people they work with and confirmed to us that they would report bad practice, they also said that they would contact external agencies if they were not satisfied with the management response to their concerns. Senior staff and management staff were able to describe the procedure that they would take should an allegation of abuse be made. The steps that they described would Tye Green Lodge DS0000064980.V371170.R01.S.doc Version 5.2 Page 17 protect the people living in the home from abusive situations. The senior staff are aware of the steps that they would need to take and the staff teams genuine care and commitment to the people living in the home would ensure that the necessary would be taken. The home has had one incident that required them to refer the matter to the local Social Services department; the management followed all of the procedures in a professional and sensitive manner. All staff have received safeguarding adult training. The home has referred one situation to the local safeguarding team and the home’s process was followed and all actions were well recorded. The manager’s AQAA said “The company has a complaints procedure which is in the admission pack and this explains to potential residents and their families at the time of their admission what they can do if they have a concern or complaint. Staff talk to residents frequently to ensure they are satisfied with the service we provide”. Tye Green Lodge DS0000064980.V371170.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 and 26: Quality in this outcome area is good. Tye Green Lodge is safe, well maintained, and has a homely environment; peoples’ rooms are individually furnished and equipped for their safety, comfort and privacy. The home is clean and hygienic with established infection control practices that are well adhered to. This judgement has been made using available evidence including a visit to this service. EVIDENCE: A full inspection of the premises was made that included communal areas, a number of peoples’ rooms, the kitchen, the sluices, clinical room, kitchen and the laundry. The home is well maintained and well decorated and is furnished in accordance with the client group needs and wishes. Positive comments were received from relatives spoken with and in completed surveys from both individuals and their representatives: ‘the home is kept clean and fresh and is always welcoming’; ‘the home has an excellent atmosphere and staff do their Tye Green Lodge DS0000064980.V371170.R01.S.doc Version 5.2 Page 19 best to get to know their people’; ‘the home is very well looked after; ‘the home is always comfortable and warm I feel my loved one is very safe’. The home has passenger lifts to enable access throughout the premises and to the gardens. There are grab rails, and aids in bathrooms, toilets and communal rooms to meet the needs of the people living there and making their daily lives safer. Assisted baths and toilets are provided and the home is fully accessible to wheelchair users. Designated storage areas for equipment are provided. Call systems are provided throughout all individual and communal rooms so if people get into difficulty anywhere around the home they have the opportunity to call for help. Pressure relieving mattresses and cushions are available and the district nursing service also provides specialist equipment as needed. All equipment is serviced as per manufacturers recommendations and confirmed from the records inspected. Tye Green Lodge has succeeded in creating an extremely homely atmosphere despite its size. The layout of the home is such that it feels like a warm and cosy domestic setting. The people living in the home are comfortable enough to move around the various parts of the home. People are found in various parts of the home, using the communal areas, lounges and dining rooms and also using their bedrooms to spend their time watching television, reading and snoozing. The home has policies and procedures for infection control in place for staff to use. The home is clean and hygienic throughout. The laundry room is large and very well maintained, the staff working here are proud of the good service that they provide. Positive comments was received from residents spoken with: “the laundry service is excellent’; not a word to fault it’; ‘nothing gets messed up”. Sluice facilities are located on each floor of the home. Systems are in place to minimise risk of infection via the use of red bags for any soiled laundry that is placed directly in the washing machines, which had the capacity to carry out sluice wash cycles. Personal protective clothing (gloves and aprons) and appropriate hand washing facilities are provided for staff safety. Tye Green Lodge DS0000064980.V371170.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 and 39: Quality in this outcome area is excellent. People living in Tye Green Lodge benefit from a competent, well trained and supervisied staff team. The recruitment procedure provides the safeguards that ensure appropriate staff are employed. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The weekly staff rotas were looked at and these showed that there is enough staff on duty with a variety of skills that addresses the needs of the people living in the home. Of 41 staff 27 have gained their NVQ level 2 or above while the remaining 14 members of staff are currently working toward the qualification. The staff training programme indicates that all staff have received training around the Protection of Vulnerable Adults. Staff training certificates are kept in personnel files. Records examined confirm that staff have received training in dementia, medication, pressure sore management and continence. The manager said that dementia training is ongoing and more in-depth courses are planned for staff. Staff spoken with are able to demonstrate a good knowledge of their responsibilities and ensuring they follow good practices. The training and support that staff receive is reflected in the way that they deliver care to people. The staff team genuinely care for the people that they work with, they are kind caring and patient. They are passionate about the quality of the care Tye Green Lodge DS0000064980.V371170.R01.S.doc Version 5.2 Page 21 that they provide and they are proud of the care that they give to people on a daily basis. The care they give is reflected in the people who live in the home who are happy, relaxed and comfortable in their surroundings. Observations on the day of the inspection confirm that staff carry out their roles in a caring and professional manner. People living in Tye Green Lodge benefit from being cared for by a competent staff team. Three members of staff spoken with were positive about working at Tye Green Lodge. One person said, “working here is very satisfying, it is a really friendly home and the staff team really get on it feels like home and family”. The manager’s AQAA states, “I ensure that we maintain adequate staffing levels on each shift, with minimal use of agency staff. Where possible I plan for a good skill mix of staff per shift. Staff turnover is low. I continually seek to recruit to any vacant positions. New staff receive mandatory core skill training. There is a training plan for each staff members and all are required to develop to NVQ Level 2. At present I have 8 NVQ Assessors actively working with staff to attain their NVQ award and have over 50 of staff achieved this award. Staff receives regular review discussions and team meetings”. Tye Green Lodge DS0000064980.V371170.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, 35 and 38: Quality in this outcome area is good. People living in the home benefit from a knowledgeable and competent management team. Staff are protected by the homes health and safety systems. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The manager of the home is a skilled and competent manager she has achieved her Registered Managers Award and the NVQ Level 4 in care. During our visit to the home she was approachable knowledgeable and supportive to her staff team. The manager understands the needs of the people living in the home and is an asset to Quantum Care. Her passion for older people and providing them with the best possible experience is evident and she has passed this on the staff team. Staff who we spoke with praised the manager’s skill and the ability to support them on a daily basis. Tye Green Lodge DS0000064980.V371170.R01.S.doc Version 5.2 Page 23 Completed surveys from people using the service and their relatives are complimentary about the way the home is run. A relative said, “the manager is good and lovely with the clients” and a resident stated, the “Manager is very good”. The home has an established quality assurance system in place that is supported by Quantum Care. The home has produced a written report. A copy of which is to be sent to the CSCI. The people living in the home, representatives and staff are involved in the user surveys and the information gathered from those surveys has been used to enhance and improve peoples’ lifestyles within the home. The home has systems in place that ensures that any amount of money held on behalf of people living there is safeguarded. Records examined show that appropriate maintenance checks are carried out. These include Portable Appliance Testing certificate, emergency lights, electrical installation, gas certificate, lifting equipment, hoists, passenger lifts, and a current local authority environmental services premises inspection. The homes Health & Safety policy contains clear guidelines for staff setting out staff responsibilities. The manager is committed to the welfare and safety of both people living there and staff working in the home. Risk assessments are in place for individuals, the staff, and the environment. The manager’s AQAA says, “The management team are responsible for supporting and developing their own team of staff and identify areas of strengths and developments, that then form the staffs training plan. Regular review discussions and team meetings. Myself and management team are actively visible within the home, frequently working alongside the care staff to have first hand knowledge of issues and methods to resolve them, and to be a coach, mentor, and role model for staff. I have 17 years experience in working in the Social Care profession, and 6 years of this in a management position. I have participated in management development courses and I have undertaken my RMA and my NVQ 4. Tye Green Lodge DS0000064980.V371170.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 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 4 14 4 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 4 30 4 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 4 X 3 X 3 X X 3 Tye Green Lodge DS0000064980.V371170.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. 1. 2 Refer to Standard OP7 OP9 Good Practice Recommendations The registered person should ensure that the quality of care plan information supports all aspects of peoples’ needs, strengths and wishes. The records of the administration of medication must be well maintained to prevent the risk to people living in the home of duplication or omission of medication by staff. Tye Green Lodge DS0000064980.V371170.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Eastern Region Commission for Social Care Inspection Eastern Regional Contact Team CPC1, Capital Park Fulbourn Cambridge, CB21 5XE 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 Tye Green Lodge DS0000064980.V371170.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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