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Inspection on 18/10/07 for Tutnall Hall Nursing Home

Also see our care home review for Tutnall Hall Nursing Home for more information

This is the latest available inspection report for this service, carried out on 18th October 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

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

What has improved since the last inspection?

A particular area in management practices including those relating to:Care planning and care planning documentation Leisure/social activities for Residents Staff recruitment Staff training Communication with Residents/Relatives, e.g. regular (minuted) Residents` meetings Communication between staff Quality Assurance audits, e.g. `post viewing` survey following Resident`s initial visits to the Home Staff supervision

What the care home could do better:

Whilst acknowledging training provision has improved, sufficient to meet Requirements relating to Staff training, it should be noted the proportion of Care Staff who have attained a minimum of NVQ Level 2 remains well below the level identified in the relevant Standard, i.e. 50%. The organisation needs to work more vigorously towards increasing their percentage with a view to attaining the required minimum 50% within the foreseeable future. The Manager must apply to the Commission for formal Registration as Manager.

CARE HOMES FOR OLDER PEOPLE Tutnall Hall Nursing Home Tutnall Lane Tutnall Bromsgrove Worcestershire B60 1NA Lead Inspector Keith Salmon Unannounced Inspection 09:30 18 October 2007 th 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 Tutnall Hall Nursing Home DS0000004149.V339155.R02.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. Tutnall Hall Nursing Home DS0000004149.V339155.R02.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Tutnall Hall Nursing Home Address Tutnall Lane Tutnall Bromsgrove Worcestershire B60 1NA 01527 875854 01527 875742 info@alphacarehomes.com www.alphacarehomes.com Alpha Health 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) Post Vacant Care Home 40 Category(ies) of Dementia - over 65 years of age (3), Old age, registration, with number not falling within any other category (40), of places Physical disability over 65 years of age (40) Tutnall Hall Nursing Home DS0000004149.V339155.R02.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 6th November 2006 Brief Description of the Service: Tutnall Hall is part of the Alpha Health Care Group of care homes, and is registered to provide nursing care and accommodation for a maximum of 40 residents over the age of 65 years. As part of their registration, the home may also accommodate up to three older people with a dementia-related illness. Situated in a quiet, rural location, between Bromsgrove, and Redditch, the home provides accommodation on three floors, accessed via two passenger lifts, or staircases located on either side of the building. There are a total of 19 single rooms and 10 shared rooms. En-suite facilities are provided in 16 single and 6 shared rooms. Fees range from £443.00 - £610.00 per week, and do not include items such as newspapers, private healthcare (i.e. private chiropody), toiletries and hairdressing. Tutnall Hall Nursing Home DS0000004149.V339155.R02.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This Unannounced ‘Key’ Inspection commenced at 9.30am, concluded at 4.00pm, and was conducted by Mr Keith Salmon. Present on behalf of the Home was the Manager, Mrs. Mercy Johnson. In addition to the inspection of ‘Key’ Standards, this Inspection also sought to review progress in meeting ‘Requirements’ arising from the most recent Unannounced ‘Key’ Inspection, held in November 2006, and previous inspections. This Report is based on observations made during a tour of the Home, a review of care related documentation, staff duty rotas and staff files, plus a range of other documents/records reflecting the general operation of the home. The Inspector also held individual discussions with 6 Residents, 3 Visitors, an attending local General Practitioner, the Manager, and several other members of staff. What the service does well: What has improved since the last inspection? A particular area in management practices including those relating to:Care planning and care planning documentation Leisure/social activities for Residents Staff recruitment Staff training Communication with Residents/Relatives, e.g. regular (minuted) Residents’ meetings Communication between staff Tutnall Hall Nursing Home DS0000004149.V339155.R02.S.doc Version 5.2 Page 6 Quality Assurance audits, e.g. ‘post viewing’ survey following Resident’s initial visits to the Home Staff supervision 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. Tutnall Hall Nursing Home DS0000004149.V339155.R02.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 Tutnall Hall Nursing Home DS0000004149.V339155.R02.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): 1 & 3. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Prospective Residents, and/or their ‘supporters’, are provided with information, which enables them to make a decision as to the home’s suitability to meet care needs. Processes to ensure appropriate and thorough care needs assessment, prior to admission, are effectively applied. The findings are utilised to ensure appropriate placement and care provision. EVIDENCE: Care plans and documentation relating to four Residents (the two most recently admitted and two selected at random) were reviewed in detail. The review covered the period prior to admission through to this Inspection date. This process demonstrated that appropriate, and thorough, care needs assessment is undertaken by suitably experienced staff, prior to admission. Tutnall Hall Nursing Home DS0000004149.V339155.R02.S.doc Version 5.2 Page 9 It was also evident that information gathered is utilised to enable an informed decision regarding the Home’s capability in meeting the individual care needs of each prospective Resident. Tutnall Hall Nursing Home DS0000004149.V339155.R02.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. This judgement has been made using available evidence including a visit to this service. Improvements in the quality of entries indicate Residents’ individual assessed care needs are now being more reliably met. With medication records now being satisfactorily completed the storage, reception, disposal, and record keeping, relating to medicines’ administration are all in accordance with accepted ‘good practice.’ The care provided is delivered considerately and effectively with Residents’ privacy and dignity being respected. EVIDENCE: At the previous ‘Key’ Inspection, held in November 2006, four Requirements were cited relating to Standards under this Outcome Group, as follows:• “Risk assessments must be regularly reviewed when a risk has been identified.” DS0000004149.V339155.R02.S.doc Version 5.2 Page 11 Tutnall Hall Nursing Home • “Care plans must be formally agreed either with the resident, or with their representative when the resident is unable to provide informed agreement.” “Care plans must be developed to include the care required to meet the assessed needs of residents. Care plans must be written to ensure staff understand the care to be provided, and to ensure that care is provided in a consistent manner.” “Care plans must be formally agreed either with the resident, or with their representative when the resident is unable to provide informed agreement.” • • Since the previous Inspection care-planning documentation has been reviewed, and a revised model brought into use. A review of all care related documentation appertaining to four ‘case tracked’ Residents’ demonstrated Care Plans are now well organised, easy to understand and up-to-date. Evidence was also observed indicating involvement/agreement of Residents or Relatives with care planning proposals – a fact directly confirmed through conversation with Residents and their visiting Relatives. Care plans provided further verification that regular care needs review is now undertaken by the Manager on a minimum of a monthly basis. The revised care plan now in use appears to ensure Carers are enabled to fully meet individual care needs, in an informed and safe manner, through improved continuity of information. All four Requirements are met. Inspection of medicine storage provision and administration records demonstrated the Home’s practices meet the guidelines of the Royal Pharmaceutical Society. Tutnall Hall Nursing Home DS0000004149.V339155.R02.S.doc Version 5.2 Page 12 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. The home is making good progress in involving Residents in promoting, wherever possible, choice and control over their lives, including their day-today life pattern. Leisure/social activities have particularly shown improvement. Opportunities for contact with family/friends/community are established and encouraged. The Home provides a daily choice of attractive and nutritious meals based on Residents’ specialist dietary needs and preferences. EVIDENCE: The Home has recently appointed a new Activities Coordinator who provides input 5 days per week from 10.30am to 3.30pm with the hours covered being determined at a Residents’ meeting, as providing the most practical value to them as consumers. Residents, Visitors, and Staff informed the Inspector that the post-holder has brought energy and invention to the role. Tutnall Hall Nursing Home DS0000004149.V339155.R02.S.doc Version 5.2 Page 13 Particularly noteworthy is evidence of leisure/social care activities being tailored to individual preferences and abilities with all Residents having a personal ‘Activities’ care plan. A significant example of this approach has been consultation with Age Concern on how to develop activities for Residents with memory impairment and dementia. Activities now offered to Residents include Craft activities (e.g. Christmas card making, spider making - soft toys for Halloween - and painting); hand massage; make-up sessions; singing, listening to music, including that provided by entertainers from outside the Home; videos; meetings by a group of Residents who, with the Activities Coordinator, review and discuss newspaper articles, current affairs and local events. On the afternoon of the Inspection Residents were entertained by a singer who had brought along various instruments to enable Residents to join in with informal music making. The Inspector observed this was clearly very much enjoyed and provided an invaluable opportunity for co-ordination and mental stimulation. Having a client group with wide ranging needs/dependency levels it can be difficult to satisfactorily address this aspect of care and the home is to be commended for it’s efforts in this area. The home employs two chefs and a kitchen assistant, who provide meals based on a four-week menu cycle. A review of meals offered is a topic discussed at the monthly Residents’ meeting with comments and suggestions incorporated into future menu planning wherever possible. Discussion with Residents and Visitors provided a consensus the meals were of good quality and well presented. One Resident who requires a special diet was especially complimentary informing the Inspector… “The food here is very good particularly as they have to provide a special diet for me.” Tutnall Hall Nursing Home DS0000004149.V339155.R02.S.doc Version 5.2 Page 14 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 satisfactory complaints system with evidence that Service Users and relatives feel their views are listened to and acted upon. Robust procedures and practices are in place to ensure that individuals are protected from abuse. Service users are provided with up-to-date information about adult protection. EVIDENCE: The Home’s Complaints Procedure is displayed within the entrance to the Home and up-to-date information advising on how to proceed in making a complaint is found in the Service Users’ Guide. A review of the complaints log demonstrated there had been three complaints since the previous Inspection, held in November 2006, and all were well documented with evidence of full investigation and appropriate remedial action having been taken as necessary. There were no complaints received by the Commission during this period. Residents and Visitors, consulted during the inspection, stated they would raise any matters of concern with the Manager, and were confident issues raised would be dealt with properly. Training records evidenced an ongoing programme of staff training in relation to complaints and the protection of vulnerable people. Tutnall Hall Nursing Home DS0000004149.V339155.R02.S.doc Version 5.2 Page 15 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): 19,25 & 26. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents live in a comfortable, generally safe, environment. Specialist equipment, consistent with meeting the assessed care needs of Service Users, and the demands of tasks carried out by Care Staff, is available, and appropriately serviced and maintained. EVIDENCE: The tour of the Home demonstrated it offers comfortable and homely accommodation. There are separate lounge and dining provisions, and a random sample of bedrooms visited (i.e. ten) showed them to be comfortable and with evidence of Residents bringing their own personal possessions into the Home. Five bedrooms have recently benefited from replacement suites of bedroom furniture, each comprising wardrobe, bedside table and chest of draws. Tutnall Hall Nursing Home DS0000004149.V339155.R02.S.doc Version 5.2 Page 16 At the previous Inspection two Requirements relating to ‘Environment’ were issued, as follows: • “All floor coverings within the home must be audited, and any areas that are fatigued, ripped, loose fitting or irreparably marked or stained must be replaced. Any area of floor covering that is marked or stained, and can be improved by cleaning must be cleaned.” “Fatigued items of glazing must be replaced.” • Floor coverings have been replaced in many areas including new carpets in some corridors, with wood laminate in the dining room and some corridors. All remaining floor coverings were found to be clean and in good order. The problem area of glazing referred to glass in the conservatory extension, which is in need of refurbishment/upgrading. The Inspector was informed work is in hand to improve this area, which an expected completion by the end of November. Both Requirements are considered met. Records were observed confirming the Home’s maintenance staff test the temperature of hot water at outlets accessible to Residents, on a regular basis, and all were found to be satisfactory. However, during the tour of the home there was concern that the water temperature at the sluice room hand-wash basin was too hot to permit safe hand washing without the addition of cold water. It is ‘Recommended’ the outlet is fitted with a thermostatic control to ensure a water temperature of about 43o Celsius facilitating safe hand washing for staff working in the sluice room. Further to this, the hot water supply to the basin, in the laundry, designated for hand washing, was tested, and in this instance it took several minutes for the water to reach a ‘warm’ temperature – a problem acknowledged by the Manager. It is further ‘Recommended’ this matter be addressed as soon as possible to ensure safe usage and infection control. Tutnall Hall Nursing Home DS0000004149.V339155.R02.S.doc Version 5.2 Page 17 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. Staffing levels have shown improvement and are currently able to ensure the provision of safe care to Residents. Recruitment procedures are sufficiently robust to ensure that Residents are not placed at risk. Staff receive training, which enables them to be competent to carry out their role in providing safe care to Residents. EVIDENCE: Five Requirements with regard to ‘Staffing’ were issued at the previous Inspection – with the first relating to levels of staff on duty • “Staffing levels must be reviewed to ensure that staffing levels are sufficient to meet the needs and expectations of residents within the home.” The Home’s staffing establishment is sufficient to meet the assessed care needs of current numbers/dependency levels of Residents, and, since the previous inspection the Home has been successful in recruiting new staff so as to meet those levels. Tutnall Hall Nursing Home DS0000004149.V339155.R02.S.doc Version 5.2 Page 18 A review of recent duty rosters, and staff numbers/deployment at the time of this Inspection, suggested staff cover should now be sufficient to meet Resident’s assessed care needs. Specifically these are:two Registered Nurses working on all daytime shifts, plus seven care staff (mornings and afternoons) one Registered Nurse covering evenings plus five care staff one Registered Nurse covering the night time period plus three care staff The Manager is additional to these numbers. This Requirement is met. A second Requirement related to employment documentation • “Completed application forms must be submitted to the home prior to any job interview being undertaken. These must be scrutinised prior to interview, and used to influence the structure of the interview to ascertain the suitability of each applicant.” The staff employment files relating to the three most recently employed staff were reviewed, and demonstrated recruitment practices at the home to be satisfactory, with all elements required by Care Homes Regulations being completed, and evidence retained on file. This Requirement is met. A further group of four related to staff training i.e. • “Staff must receive appropriate training such as moving and handling prior to commencement of work with residents.” “Training records must specify the actual course content.” “All staff must receive formal induction prior to undertaking direct care duties.” “All persons employed by the registered person to work at the care home must have training appropriate to the work they perform. This is to include first aid training, dementia care training, infection control training, moving and handling training, abuse training (all subjects were required in the previous inspection report) and nutrition training.” • • • Training records were reviewed and it was found the majority of staff have undertaken appropriate induction training, plus further mandatory training including - moving and handling, medication administration, dementia Tutnall Hall Nursing Home DS0000004149.V339155.R02.S.doc Version 5.2 Page 19 awareness (including management of challenging behaviour), adult protection, care planning, risk assessment, infection control, and fire awareness. Much of the training undertaken is conducted ‘in-house’, with documentation clearly setting out training content. On the day of the Inspection a new member of Care Staff was undertaking first day induction – this involves the use of a printed ‘Induction Pack’, which the Inspector observed being completed. These four Requirements are considered met. Whilst acknowledging training provision has been improved sufficiently to meet the above training related Requirements, it should be noted the proportion of Care Staff who have attained at least NVQ Level 2 remains well below the level identified in the relevant Standard, i.e. 50 . The Home currently employs 28 Care Staff, of whom 3 have attained NVQ Level 2 or higher, with 4 currently working towards Level 2. It is ‘Recommended’ the Home enables all Care Staff who have not, as yet, undertaken NVQ Level 2 training to do so. On a more positive note opportunities for formal training are extended to support staff, e.g. domestic staff are partaking in NVQ Level 2 ‘housekeeping’, and kitchen staff NVQ Level 2 ‘cooking’. Tutnall Hall Nursing Home DS0000004149.V339155.R02.S.doc Version 5.2 Page 20 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, & 38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. A suitably qualified, and experienced person manages the home. However, whilst management of the organisation has improved there is a need for the Manager to seek formal Registration with CSCI. The systems for consultation with Residents have improved, with evidence suggesting their views are acted upon. Health, safety, and welfare of service users, and staff, are promoted fully by safe working systems being in place. Tutnall Hall Nursing Home DS0000004149.V339155.R02.S.doc Version 5.2 Page 21 EVIDENCE: Although this group of outcome Standards were not examined at the previous Inspection it was noted there was no registered manager in post. At that time a new manager had been recruited and was to commence employment on the Monday following the inspection. This led to the Inspector issuing a Requirement • “A competent manager must be appointed to manage the home, and an application for registration must be submitted to CSCI’s Central Registration Team.” During the intervening twelve months the then appointed ‘new manager’ has left the post and the previous Deputy Manager, Mrs. Mercy Johnson, has been promoted to the post of Manager. This was initially in an ‘acting’ capacity, with promotion to full substantive Manager being recently approved. Although Mrs. Johnson has not, as yet, made application for registration the Inspector is satisfied, following conversations with Mrs. Johnson and Ms. Caroline Wood, Area Manager for Alpha Health Care, that an application to CSCI for Registration as Manager is imminent. Nonetheless, due to the importance of this process being satisfactorily completed this Requirement will remain. In the meantime the Inspector is able to report that during her period as ‘Acting Manager’, Mrs. Johnson – supported by Ms. Wood - has led and developed improvements in management processes, including:Care planning and care planning documentation Leisure/social activities for Residents Staff recruitment Staff training Communication with Residents/Relatives e.g. regular (minuted) Residents’ meetings Communication between staff Quality Assurance audits e.g. ‘post viewing’ survey following Resident’s initial visits to the Home Staff supervision Containers of antibacterial hand rub were observed, in various locations around the home, for use by staff and visitors, paper towels and liquid soap were in place within toilets, and the laundry maintained in line with infection control procedures. Through observation, and consultation with Residents, it was evident the cleanliness of the home is maintained to a satisfactory standard. Tutnall Hall Nursing Home DS0000004149.V339155.R02.S.doc Version 5.2 Page 22 The Area Manager undertakes regular visits to the home and prepares written reports as required under Regulation 26. These reports are held at the home with copies provided to the Commission on a monthly basis. The Home manages cash for a number of Residents and a review of arrangements for safeguarding the interests of Residents was undertaken. The inspector concluded that accounting practices (including audit) were appropriate, thorough and in accordance with the Standard. Following her appointment the Manager reviewed practices in relation to Staff supervision, and records demonstrated that formal staff supervision is now conducted in accordance with the related Standard. The Inspector understands that the delay, in the manager seeking Registration with the Commission, has been due to the Manager having to reapply for a work permit following change of post. The Inspector saw a copy of the new permit. It does however remain a Requirement that the manager make application to the Commission as soon as possible. At the time of this inspection no potential hazards were identified and a review of relevant records provided evidence that Health and Safety Policies/ Procedures/Practices are satisfactory, with all COSHH requirements met. Records were observed providing evidence the Home has satisfactorily undertaken appropriate maintenance of equipment, including electrical, lifts, hoists, and gas appliances. In summary, the Manager has made good progress in ensuring the Home has met a number of Requirements, many of which had been outstanding from several earlier Inspections. This positive response to meeting these Requirements enables the Inspector to move the rating for this section from the previous ‘adequate’ rating to ‘good’. It is vitally important this progress is maintained and built upon, and an essential adjunct to this will be the satisfactory completion of the Manager’s application to become Registered Manager of the Home. Tutnall Hall Nursing Home DS0000004149.V339155.R02.S.doc Version 5.2 Page 23 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 N/A 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 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X X 3 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 3 Tutnall Hall Nursing Home DS0000004149.V339155.R02.S.doc Version 5.2 Page 24 Are there any outstanding requirements from the last inspection? YES STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP31 Regulation 8 Requirement The Manager must submit application to CSCI’s Central Registration Team for formal Registration as Manager of the Home. Timescale for action 30/11/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard OP25 Good Practice Recommendations It is ‘Recommended’ that the hot water outlet to the sluice room hand-wash basin is fitted with a thermostatic control to ensure a water temperature of about 43o Celsius to facilitate safe hand-washing by staff working in the sluice room. It is ‘Recommended’ that the supply of hot water to the basin for hand washing in the laundry is improved, to ensure a water temperature of about 43o Celsius to facilitate hand-washing by staff working in the laundry. DS0000004149.V339155.R02.S.doc Version 5.2 Page 25 2. OP25 Tutnall Hall Nursing Home 3. OP28 It is ‘Recommended’ all Care Staff who have not yet undertaken NVQ Level 2 training are enabled to do so. Tutnall Hall Nursing Home DS0000004149.V339155.R02.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Worcester Local Office Commission for Social Care Inspection The Coach House John Comyn Drive Perdiswell Park, Droitwich Road Worcester WR3 7NW 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 Tutnall Hall Nursing Home DS0000004149.V339155.R02.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. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!