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Archived: Tancred Hall Care Home Requires improvement

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Inspection Summary


Overall summary & rating

Requires improvement

Updated 7 October 2016

This inspection was carried out over two days on 17 and 18 August 2016 and the inspection was unannounced.

Tancred Hall Care Home provides personal and nursing care and accommodation for up to 49 people who have nursing and/or dementia care needs. The home is located in a rural setting on the outskirts of Whixley village between Harrogate and York. There is a large car park to the side of the home. Care is provided in two separate units. There is disabled access and two lifts to the rooms on the first floor. At the time of our inspection there were 33 people receiving a service.

The provider registered the service as Tancred Hall Care Home on 10 August 2012 and this was their first comprehensive inspection. There was a registered manager in post. A registered manager is a person who has registered with the CQC to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.

The registered provider had a medication policy in place however; we found this information required updating. The nurse in charge had received training in the management and administration of medicines in their previous employment but they told us this required updating and we were unable to see how their competencies were assessed by the registered provider. We found management and administration of medications was not always safe.

The registered provider completed pre-employment checks on care workers to help ensure they were of suitable character to work with vulnerable people. However, the induction process for new care workers failed to demonstrate how they were supported, skilled and assessed as competent before independently carrying out their roles.

We found the registered provider had established systems and processes in place to assess monitor and drive improvement in the quality and safety of the service provided. These measures included the review of policies and procedures and audits on documentation that included care plans. Despite the measures in place, we found these were not always up to date or effective in their purpose and information was sometimes out of date. They did not always reflect people’s individual needs and care workers did not always have access to up to date records.

The registered manager discussed how they obtained feedback from people who received support and care at the home. They told us they had a schedule to send out questionnaires quarterly and that the results were evaluated to help improve any areas of concern. However, we did not see any evidence that suggested feedback was collated and evaluated to drive improvement to the quality or safety of the service.

There was a cleaner in the home and systems were in place to ensure the environment was clean which helped people remain free from infections. However, the environment was not always free from odours despite a cleaning process in place.

A record was on people’s file with regard to their interests and preferred activities. Activities were provided but at times, these were limited due to pressures on staff resources. Staffing was monitored by the registered provider. Due to concerns raised by other care workers we asked the registered provider to review their staffing dependency to ensure sufficient staff were available at all times to meet people’s individual needs.

Risk assessments and associated support plans were in place to identify and manage risks to people and the environment, which helped people to live safely and maintain their independence and personal choices.

Staff had completed up to date training in safeguarding adults from abuse and understood how to keep people safe from harm and abuse and how to raise their concerns.

People received an assessment of need as part of their admission process to the home. This meant the provider could ensure they were ab

Inspection areas

Safe

Requires improvement

Updated 7 October 2016

The service was not always safe.

Medicines were not always managed safely and associated policies and procedures for the safe management of medication required updating.

The environment was not always free from odours despite a cleaning process in place.

Staff understood how to keep people safe from harm and abuse and how to raise their concerns.

Systems were in place to identify and manage risks to people and others accessing the home, equipment and the environment.

Effective

Requires improvement

Updated 7 October 2016

The service was not always effective.

The induction process for new care workers did not demonstrate how they were supported, skilled and assessed as competent before independently carrying out their roles.

People were involved in development and review of their care plans. Where people lacked capacity the registered provider followed the Mental Capacity Act 2005.

People were supported to remain healthy and food was prepared freshly to meet people�s individual dietary requirements and preferences.

Caring

Good

Updated 7 October 2016

The service was Caring.

Staff understood the need to treat people with dignity and respect and understood how to maintain people's confidentiality.

Care plans promoted a person�s individual choice and preferences and as appropriate.

People were supported by the use of independent advocacy support services.

People had been consulted and their end of life preferences were recorded.

Responsive

Good

Updated 7 October 2016

The service was responsive.

People had personalised plans of care and support which helped care workers to provide support and care that was responsive to their individual needs. However, some areas of the care plan required updating.

Activities were provided and reflected people's preferences. However, at times there was insufficient staff to provide support for these activities.

People were provided with information on how to complain and raise concerns and processes were in place to respond.

Well-led

Requires improvement

Updated 7 October 2016

The service was not always Well-Led.

Systems and processes that were in place to assess monitor and mitigate risk including policies and procedures and staff induction were not always up to date or effective in their purpose.

Records were not always well maintained, accurate and up to date.

There was some evidence of quality assurance checks in place. However, there was no evidence to suggest appropriate checks had been implemented to drive improvement and shape service delivery.

There was a clear management structure in place and staff had an understanding of their roles and responsibilities.