Tandy Court

On this page

• Overview
• Learning culture
• Safe systems, pathways and transitions
• Safeguarding
• Involving people to manage risks
• Safe environments
• Safe and effective staffing
• Infection prevention and control
• Medicines optimisation

Safe – this means we looked for evidence that people were protected from abuse and avoidable harm.

At our last inspection we rated this key question Requires Improvement. At this assessment the rating has changed to Good. This meant people were safe and protected from avoidable harm.
At our last inspection there was a breach of regulation in relation to safe care and treatment. At this inspection we found the provider had made the necessary improvements and were no longer in breach of the regulations.

This service scored 69 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The provider had a proactive and positive culture of safety, based on openness and honesty. Staff listened to concerns about safety and investigated and reported safety events. Lessons were learnt to continually identify and embed good practice.
People told us staff responded effectively to any concerns they had. One person told us, “The night staff always come in to check on you.”
Staff told us they enjoyed working at the service and felt supported to raise any concerns with the registered manager. They felt confident action would be taken. One staff member said, “We are well supported and can raise any concerns with the management.” Staff said they received training suitable to their role, which enabled them to meet people’s needs safely.
The provider regularly reviewed accident and incident records to ensure any events within the service were appropriately identified, managed, and acted upon. The registered manager told us they had daily meetings with staff to discuss any issues related to people’s care, and where they could identify any potential staff learning needs related to providing safe care.

The provider worked with people and healthcare partners to establish and maintain safe systems of care in which safety was managed or monitored. Pre-assessment documentation did not always contain required information.
We identified improvements were required in relation to pre-assessment documentation to ensure all relevant information was captured before people began to receive support from the service. The management team were receptive to our feedback and made the required changes and evidenced new pre-assessment documentation being used within the service.
People told us they were happy with how their admission to the home was managed. Some told us this was discussed with them and others mentioned family members were involved in arranging their transfer to the home.

The provider worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. Staff concentrated on improving people’s lives while protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The provider shared concerns quickly and appropriately.
People told us they felt safe living at the home and in particular with the staff. One person told us, “I feel safe here and it’s clean and tidy.”
Appropriate legal authorisations had been sought in relation to any restrictions imposed on people. People can only be deprived of their liberty to receive care and treatment when this is in their best interests and legally authorised under the Mental Capacity Act (MCA). In care homes, and some hospitals, this is usually through MCA application procedures called the Deprivation of Liberty Safeguards (DoLS).
Staff understood their role in protecting people from poor care, abuse and discrimination. Staff told us they had received safeguarding training and understood their responsibilities to keep people safe. One member of staff said, “There are different types of abuse such as physical, emotional and financial”. Another staff member told us, “If I witnessed abuse, I would first make sure the person was safe. I would report the incident to my manager. If I was unhappy with how the incident was managed, I would contact the safeguarding local authority, the Police and CQC”
Care plans recorded if people had capacity to make day to day decisions for themselves. Best interest meetings were also recorded to confirm any agreements made to support people’s needs.

The provider worked with people to understand and manage risks by thinking holistically. Staff provided care consistently to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.
Risk management plans were in place linked to people’s needs such as mobility, continence care, skin and nutritional needs. Staff spoken with understood the risks associated with the people’s needs and the importance of involving people in risk management. Daily care records demonstrated people were supported to monitor their own health and wellbeing so they could share information with staff and ensure any risks and concerns were not missed and people continued to achieve good outcomes.
People were involved in decisions related to their care so that risks were effectively managed. One person who was non-verbal had a care plan that detailed how they communicated when they needed support by making vocal sounds to alert staff. This is important because it ensured all people could express themselves and makes choices regarding their care.
Care plans informed staff how to involve people in managing risks, for example, 1 care plan stated how staff needed to give a person time to process information so they could independently respond to the question being asked.

The provider detected and controlled potential risks in the care environment. They made sure equipment, facilities and technology was available to support staff in the delivery of safe care.
People did not express any concerns in relation to the environment and were able to access communal areas and equipment they needed to support their needs to keep them safe freely.
Staff demonstrated a clear understanding of the actions they needed to take to keep people and themselves safe. Staff told us they had completed fire safety training and understood the action needed to keep people safe in the event of a fire or other emergency. Guidance was available to staff on how to support visitors in case on any accidents or should the fire alarm sound.
Guidance was in place to instruct staff to check equipment prior to use to ensure it was in good working order. Records viewed detailed when people’s equipment was last checked by the manufacturer, serial numbers and the contact details in case of any faults.

The provider ensured there were enough qualified, skilled and experienced staff, who received effective support. Staff received supervision and development and worked together to provide safe care that met people’s individual needs.
People spoke positively of the staff. On the day of our visit staff were responsive to people’s needs in communal areas, and when people used call bells, these were responded to promptly. One relative told us, “I go on an evening after work and at weekends, I take [name of person] out. From what I have seen there is enough staff.”
Staff told us staffing levels were sufficient to provide safe and effective care.
The registered manager told us they completed a dependency scoring tool for the home on a monthly basis which showed staffing needs for each floor. They advised this would be reviewed with any changes and updated.
Staff said they had received an induction to the service when they started, which included training appropriate to their role. One staff member told us, “My induction included shadowing experienced staff members. After my induction, I felt comfortable to support people; I was also given the option of extending my induction if I needed to.” Staff received ongoing supervision to support them in their role and said they were provided with regular training to update their skills and knowledge to support people’s needs.
The provider followed safe recruitment practices and had ensured appropriate pre-employment checks were completed before staff were employed. During our visits we saw staff were not rushed and had the opportunity to respond to and converse with people in a relaxed manner. We observed staff being attentive and supportive of people’s needs.

The provider assessed and managed the risk of infection. They detected and controlled the risk of it spreading and shared concerns with appropriate agencies promptly.
People told us their rooms were kept clean. One person said, “The home is clean and tidy; they are always cleaning.” People confirmed staff used personal protective equipment (PPE) such as gloves and aprons to help prevent the risk of the spread of infection.
Staff told us they had completed infection prevention and control training and demonstrated an understanding of how to reduce the risks of the spread of infection. We observed staff using personal protective equipment (PPE) in line with good practice.
Care plans included guidance/risk assessments for staff to follow regarding the use of PPE. There was guidance of how to support people in isolation if they had an infection. This included information on the safe disposal of used continence products and steps to take to minimise the spread of Covid.
The provider ensured regular checks of infection prevention and control were completed to confirm staff followed their procedures. Audit records showed any areas needing improvement and actions needed with target dates for completion.
We saw the home appeared clean and tidy and was free from odour.

At the last inspection we found the provider had failed to ensure staff were safely dispensing and managing people's medicines. At this inspection we found improvements had been made.
The service made sure that medicines and treatments were safe and met people’s needs, capacities and preferences.
We reviewed electronic medicines administration records and electronic care records. We observed a medicine administration round, and we inspected the clinic room where medicines were stored.
Systems were in place to safely administer and store medicines. Controlled drugs (medicines requiring more control due to their potential for abuse) were stored and recorded appropriately. Records we checked showed people were having their regular medicines administered safely. We checked the quantities and stocks of medicines and found stock balances to be correct. This meant we could be assured that people had received their medicines as prescribed.
Staff were kind and caring when interacting with people and provided support when medicines were administered. We saw that good infection prevention control practice was used when administering medicines. Staff had completed medicines training and had their competency regularly assessed.
Fridge temperatures and room temperatures were being recorded. Maximum and minimum fridge temperatures were monitored to ensure the medicines were stored safely.
Allergy statuses were accurately recorded and people’s profiles had up-to-date photos of the people in the service. People were given their medicines including time sensitive medicines at the right time to ensure that they were effective.
Medicines audits were completed regularly to check that systems were safe. There was a process in place for managing and reporting any errors or incidents involving medicines.
When medicines were opened and their shelf life was reduced, expiry dates were not always recorded correctly. Staff had been recording the manufacturer’s expiry date rather than the shortened expiry date once opened. The provider’s medicines policy clearly set out the requirement to amend expiry dates in these circumstances; however, this was not being followed. This was raised with the provider on the day of the inspection, and we were assured that the process would be amended going forward to ensure compliance with the policy.