Inspection on 16/07/08 for Tadworth Grove

This inspection was carried out on 16th July 2008.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. 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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Tadworth Grove 07/07/09

Tadworth Grove 27/07/07

Tadworth Grove 29/06/06

Tadworth Grove 21/11/05

Tadworth Grove 08/08/05

Tadworth Grove 29/11/04

Tadworth Grove 15/06/04

Similar services:

The Shelley

Springfield House

Sutton Lodge Nursing Home

St Helier`s Residential Hotel

St Joseph`s

Ridgemount

Wingham Court

Old Hastings House

Extracts from inspection reports are licensed from CQC, this page was updated on 28/09/2008.

CARE HOMES FOR OLDER PEOPLE Tadworth Grove The Avenue Tadworth Surrey KT20 5AT Lead Inspector Lisa Johnson Unannounced Inspection 09:00 16thJuly 2008 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 Tadworth Grove DS0000013354.V367744.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. Tadworth Grove DS0000013354.V367744.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Tadworth Grove Address The Avenue Tadworth Surrey KT20 5AT 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) 01737 813695 01737 813285 deanef@bupa.com www.bupa.co.uk BUPA Care Homes (CFC Homes) Ltd Manager post vacant Care Home 71 Category(ies) of Dementia - over 65 years of age (13), Old age, registration, with number not falling within any other category (71) of places Tadworth Grove DS0000013354.V367744.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 27th July 2007 Brief Description of the Service: Tadworth Grove is a large property situated in a quiet residential road on the outskirts of Tadworth in Surrey. Accommodation is provided in two separate buildings that are linked by a ground floor corridor. Nursing care is offered in the three-storey building and residential/dementia care, in the smaller twostorey building. Both buildings are fitted with shaft lifts that give access to all floors. The grounds are spacious and attractively landscaped to provide seating and shade for the service users. Ample car parking spaces are available. The current fees per week range from £ 650.00 for residential care and £790.00 for nursing care per week. Tadworth Grove DS0000013354.V367744.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 1 star. This means that people who use this service experience adequate quality outcomes. This site visit was part of a key inspection. The visit was unannounced and took place over eight hours commencing at 9.00am and finished at 6.00 pm. Mrs. L Johnson Regulation Inspector carried out the visit Information was provided to us by the service prior to this visit in the Annual Quality Assurance Assessment. (AQAA) This is a self-assessment that focuses on how well outcomes are being met for people using the service. Reference is made to this assessment throughout this report. Since the previous visit the registered manager is no longer in post, although the organisation has recently appointed a new manager who was present during this visit. We received four surveys from people living in the service and relatives and we spoke to seven people during this visit. A tour of the home took place, staff recruitment, and training records, care plans and policies and procedures were sampled. The inspector also spoke to four members of staff. The inspector would like to thank people living in the home and staff for their time, assistance and hospitality during this visit. The new manager (although not yet registered for this service with the Commission) recently appointed by the provider has made significant improvements to the service. However these improvements including training of staff and updating them are imbedded into practice and demonstrate sustainability people using the service may not be fully protected from harm. The quality rating is a reflection of this. What the service does well: Comprehensive information is provided to all prospective people and heir representatives considering the home as a place to live. Detailed pre- admission assessments are conducted prior to any person moving into the service. Tadworth Grove DS0000013354.V367744.R01.S.doc Version 5.2 Page 6 People have detailed and comprehensive person centred care plans, which have been carried out in consultation with people using the service and/or their representatives, which are regularly reviewed. A relative commented, “The registered nurses are excellent at meeting the needs of people and everything in the care plan is normally acted upon”. People are provided with nutritious meals that are well presented. Positive comments were received about the meals provided including, including “ Very good choice”; “the food is good”; “always receive good meals, if anything extra is required it is provided” and “my relative appears to enjoy their food and the meals I see are usually attractively presented”. What has improved since the last inspection? What they could do better: Improvements required include ensuring that all staff receive up to date statutory training including safeguarding vulnerable adults from abuse. This is to ensure the health, welfare and safety of people using the service. It was identified that one matter had not been reported following the local safeguarding vulnerable adults procedures. The manager has now attended to this matter and has provided written confirmation to us that this has now been completed. The registered person must ensure that at all times there are sufficient care staff on duty to meet the assessed needs of people living in the residential unit. Monthly quality monitoring visits must be carried out unannounced. During a tour of the premises a fire exit door was observed to be propped open on two occasions. This matter was immediately actioned by the manager. Two good practice recommendations have also been made as a result of this visit. Tadworth Grove DS0000013354.V367744.R01.S.doc Version 5.2 Page 7 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. Tadworth Grove DS0000013354.V367744.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Tadworth Grove DS0000013354.V367744.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 3 & 6 People using the service experience good outcomes this area. This judgement has been made using available evidence including a visit to this service. Prospective people considering the home as a place to live are provided with the information to enable them to make a choice about the homes suitability as a place to live. The home is able to demonstrate that pre-admission assessments are completed prior to admission to the home. The home does not support people for intermediate care. EVIDENCE: The home provides a statement of purpose and service user guide, which is made available to prospective people moving into the home and their representatives. Information supplied in the self-assessment reveals that the homes brochure has been updated since our previous visit. The service also provides a booklet which details other BUPA homes in the area so that people and their representatives can make an informed decision. These documents were also displayed in the reception area with the Commission for Social care Inspection report. Tadworth Grove DS0000013354.V367744.R01.S.doc Version 5.2 Page 10 The service conducts pre- admission assessments prior to any person moving into the home to ensure that the service is able to meet their needs. The assessments sampled were detailed and comprehensive covering health, personal, emotional, communication, social, cultural and religious needs. Trial stays are accommodated. The self-assessment states that that training has commenced for staff to carry out effective pre- admission assessments. Tadworth Grove DS0000013354.V367744.R01.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8, 9 & 10 People using the service experience good outcomes this area. This judgement has been made using available evidence including a visit to this service. The home has a plan of care that the person or their representative has been involved in making. Peoples health, personal, emotional and social needs are met. People are treated with dignity and their right to privacy is respected and they are protected by the home’s medication policy and procedures EVIDENCE: People living in the home have an individualised plan of care based on full needs assessment using a system called QUEST which includes an extensive assessment which forms the care plan. During this visit four care plans were sampled taken from each unit. Care plans recorded comprehensive details of the current needs of people and instructions of the care to be given were recorded. Information provided in the care plans demonstrated that care plans were kept under regular review and that the person or their representatives were consulted and had signed their care plans to confirm their agreement. Daily notes sampled were detailed and reflected the care objectives as recorded in the care plan. Information supplied Tadworth Grove DS0000013354.V367744.R01.S.doc Version 5.2 Page 12 in the self-assessment states that a selection of care plans are selected and audited monthly. Detailed and comprehensive risk assessments were completed including moving and handling and where people are identified as at risk of falls. One persons care plan identified that this person requires support with using a walking frame when mobilising. Staff demonstrated that this support was provided. Staff demonstrated that another person was provided with full support with eating and drinking, which had been recorded in their care plan. Information recorded each care plan demonstrated that nutritional screening and monthly weight checks are completed. Tissue viability assessments were conducted and where specialist equipment is required such as “air flow” mattresses this was documented. Risk assessments had also been completed in respect of people requiring bedrails for their safety and wellbeing. Information provided in care plans demonstrated that a range of health care specialist supports people. Detailed records were maintained of health care professional appointments and consultations including the General Practitioner, district nurse, chiropodist, dentist and optician. We were informed that referrals could be made through the General Practitioner for health care specialists such as physiothepy. A relative commented, “The doctor connected with the home is very good” A relative commented, “The registered nurses are excellent at meeting the needs of people and everything in the care plan is normally acted upon”. The home has a policy in place for respecting people’s privacy and dignity including their right to have their cultural and religious needs respected. During this visit staff were seen to be respectful, caring and attentive to the needs of people living in the home. However one matter was identified needing improvement in respect of mealtimes. (See also standard 15) A number of positive comments were received from people about the care and support from staff including, “ very happy with the care”; “several of the staff are very kind”: “the staff are excellent ” and “ I am very pleased where I have placed my relative”. During this visit peoples privacy was respected by ensuring doors were kept shut when carrying out personal care in bedrooms and bathrooms. Two people spoken with confirmed that staff knock on their bedroom doors before entering. It was observed that people living in the nursing units were waiting for a period of time in the reception area before being supported to go to the sitting room downstairs. The manager was advised to review this practice Tadworth Grove DS0000013354.V367744.R01.S.doc Version 5.2 Page 13 The homes medication policies and practices were examined in one of the nursing units. There is a clear policy in place Medication is dispensed by the local chemist in blister packs. Records were maintained for the receipt and disposal of medication, which was stored appropriately. Each medication administration record contained a photograph of the person and all medication administration records had been signed confirming that people had received their medication. A controlled drug medication cupboard was in place, which was examined as well as the controlled drugs register. The register was appropriate maintained and recorded. The balance for one medication was checked and found to be correct as recorded in the register. Tadworth Grove DS0000013354.V367744.R01.S.doc Version 5.2 Page 14 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 &15 People using the service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. People living in the home are provided with a range of recreational and leisure activities and their cultural and religious beliefs are respected. People are able to maintain relationships with their families, friends and representatives. People are supported to make choices in their daily lives and they have well balanced and attractive meals and snacks, which are available at all times. EVIDENCE: The service has a structured activities programme in place which was displayed throughout the home and there is an activities organiser in post. People’s choices and preferences are considered. During this visit a musical entertainer was visiting the home. This activity was attended by a number of people and their relatives, which everybody appeared to enjoy. One person was unable to attend due to health matters and the entertainer visited them individually in their room. Another person told us she attends a stroke club, which held outside of the home. Tadworth Grove DS0000013354.V367744.R01.S.doc Version 5.2 Page 15 The home also provides gentle exercise classes, reminiscence and bingo Occasional visits are organised and the home was invited to an event at the local school. There is a large hairdressing and beauty salon available. The home holds seasonal events including strawberries and cream, which took place during Wimbledon, and events are organised to celebrate Christmas, Valentines Day and St. George’s day. The self-assessment has identified that more activities have been provided including the weekend and the customer satisfaction survey completed last year was favourable in this area. Positive comments were received from people about the activities, although three people commented that on Saturdays there is not a lot arranged. This matter was bought to the attention of the manager. The manager has identified that they plan to continue providing a wider range of activities and to provide more effective one to one activities with people more regularly. The religious needs of people are considered and the home holds a church service on Sundays. The home employs an open visiting policy. During this visit a number of visitors were attending the home throughout the day and some people were receiving visits in private in their bedrooms. Some people were also observed to have telephones in their rooms to maintain contact The home provides a four weekly rotating menu. Which is also changed seasonally. We were informed that menus are planned to allow for peoples choices and preferences. The service has A BUPA menu master, which ensures that menus meet he nutritional, needs of people ad is customer led. Meals are chosen one day ahead. The lunch consisted of two choices of meals and deserts. We were informed that other alternatives could be provided as well such as salads. The service provides a nite bite menu which means that food is available twenty-four twenty-four hours ensures that people can choose to eat when they feel like it. The lunchtime meal was observed which was attractively presented and tables were with tablecloths and napkins. Refreshments and condiments were provided. We saw the lunchtime meal in Willow and on one floor in the residential unit. It was observed that a number of people require support with eating and drinking. Staff were available throughout and meals were kept in the kitchen for people who require support with feeding to keep them at a satisfactory temperature. Staff were seen interacting with people throughout and there was a general improvement to the support being provided. However on one occasion a member of staff was observed to be standing up feeding one person while they were sitting at the table, which was bought immediately to the attention of staff. Another member of staff was also supporting two people at the same time until another member of staff came to provide support. These matters were bought to the attention of the manager. Tadworth Grove DS0000013354.V367744.R01.S.doc Version 5.2 Page 16 Six people spoken with and from three surveys received expressed with the meals provided. Comments included, “ Very good choice”; “the food is good”; “always receive good meals, if anything extra is required it is provided” and “ “My relative appears to enjoy her food and the meals I see are usually attractively presented”. However one person said they enjoy heir meals sometimes and another person surveyed commented. “More salads would be appreciated”. Tadworth Grove DS0000013354.V367744.R01.S.doc Version 5.2 Page 17 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 People using the service experience adequate outcomes in this area. This judgement has been made using available evidence including a visit to this service. People living in the home and their representatives have access to an effective complaints procedure and their views are listened to. Further improvement is needed to ensure that allegations are referred to the relevant agencies and that staff receive up to date training ensuring that people living in the service are safeguarded from abuse. EVIDENCE: The home has complaints procedure in place, which was seen on display in the home and is also included in the service user guide. The complaints procedure includes agreed timescales for managing concerns and the outcomes are recorded. Since the previous visit the home has received twelve complaints. The Commission has also received two complaints. One matter was referred to the local authority following the safeguarding vulnerable adults from abuse procedures. The second complaint that was received was in respect of loss of clothing, which the informant stated that this had not been dealt with by the provider. This matter was addressed with the provider and has been followed up by the current manager, which led to a satisfactory resolution. The manager has identified in the self-assessment that improvement is needed to ensure that staff manage at the time all concerns and refer on if necessary. The manager has identified that they intend to ensure that all staff are aware of the complaints policy encouraging them to respond positively to issues and treat all complaints seriously. Tadworth Grove DS0000013354.V367744.R01.S.doc Version 5.2 Page 18 Five people spoken with during this visit said that they would know whom they would talk to if they had any concerns. Four surveys received stated that staff listen and act on what they say. A relative commented, “I believe the staff do listen and act” and another relative said, “ I would speak to the registered nurse in charge, they are always very good”. While viewing the complaint records it was observed that a visitor who wished to remain anonymous had raised a concern to another organisation after witnessing inappropriate handling of a person. The manager had attempted to gain further information via the informant to gain more detail and information as to whom this may concern. However this matter had not been reported to the local authority. Therefore it was required that this matter is reported ensuring the well-being and safety of people living in the home. The manager has responded to this matter and has provided written confirmation to us that appropriate action has been taken. The manager has also addressed this matter with staff and reinforced current manual handling techniques. Since our previous visit four matters have been referred by the home following the Surrey local authority multi agency safeguarding vulnerable adults policy. This has resulted in a number investigations being carried out. Two matters could not be substantiated. One matter resulted in a member of staff being disciplined for talking to person inappropriately. Another incident occurred between two people living in the service. One of these people no longer resides in the service. The service has detailed safeguarding adults from abuse and whistle blowing policy. During this visit the manager acquired the updated local authority safeguarding vulnerable adults from abuse procedure. It is recommended that this document is made available on each unit for staff information and access. The self-assessment states that the home could improve in developing a greater awareness of abuse. Staff spoken with during this visit demonstrated that they some awareness of abuse but were not fully aware of the role of other agencies. Three members of staff training records were sampled. Two records indicated that staff had received training, which was also confirmed by two members of s staff, however these records indicated that this training had taken place two years ago and must be updated. There was no record for a third member of staff to verify that this training had been completed. Tadworth Grove DS0000013354.V367744.R01.S.doc Version 5.2 Page 19 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 People using the service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service The home is generally maintained, although improvement is needed in the decoration of some areas in the home ensuring that people living in the service have a comfortable home to live in. People are provided with specialist equipment that promotes their independence and they live in a home that is clean and hygienic EVIDENCE: The home is located in a residential street near to Tadworth village. Accommodation is provided in two units, Willow which supports people with nursing needs and pine lodge, which provides residential accommodation. A corridor connects both units. The ground floor in Willow is used for people who may be staying in the home for respite care but was this area was unoccupied at the time of this visit. People residing in the nursing units in Willow use the dining room and sitting room which are situated on the ground floor which is accessed by a lift. The residential unit have their own dining areas. People who have dementia occupy Tadworth Grove DS0000013354.V367744.R01.S.doc Version 5.2 Page 20 the second floor of Pine lodge. Memory boxes were available outside of people’s bedrooms in this unit, which contained familiar photographs and pictures to assist orientation. The home was generally maintained but looks tired and in need of redecoration and some refurbishment including carpet replacement in areas particularly in the corridors. Two people spoken with also raised that some improvement was needed in the décor. The manager informed us they have now secured a bid of money for this work to be conducted. Information supplied in the selfassessment that there is a refurbishment plan in place for defined areas including bedrooms and corridors. A spacious hairdressing salon is available that was converted from a smoking area. There are accessible, secure well-maintained gardens to the rear of the home, which people can enjoy in the summer months. The home provides a range of specialist equipment including assisted baths and specialist baths. Grab rails were observed throughout to assist people’s mobility. The home has also requested more profiling beds. During a tour of the home a fire door in the ground floor corridor was found propped open which was bought to the attention of the manager. Later on during this visit this door was found open again. The manager promptly dealt with this matter during this visit. (See also standard 38) Bedrooms viewed were generally well maintained. One person living in the service said, “ I am very happy with my bedroom”. Bedrooms were personalised with people’s belongings including furniture, ornaments, pictures and photographs. Some people had televisions and radios During this visit improvement was observed in the cleanliness, tidiness and organisation of this area. We were informed that bed linen is sent to an external laundry and new bed linen, which will be available in different colours for each unit have been ordered to assist identification. At the previous visit some concerns were raised about lost clothing particularly nightwear. This matter was raised again after the Commission received a complaint. Another person spoken with during this visit also informed us that they have had nightwear not returned. This matter was discussed with the manager who is monitoring this. Staff have been provided with marker pens should any clothing require labelling. A new laundry supervisor has been appointed. It was recommended that the organisation consider looking at extending the laundry considering the size of the service. During this visit the home was clean and hygienic. There were no pervading odours. Infection control procedures are in place. We were informed that the environmental health has visited the home, which was satisfactory. Staff were observed to be wearing protective aprons and gloves. The manager is Tadworth Grove DS0000013354.V367744.R01.S.doc Version 5.2 Page 21 planning to ensure that all staff has received updated infection control training through distance learning. Tadworth Grove DS0000013354.V367744.R01.S.doc Version 5.2 Page 22 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 People using the service experience adequate outcomes in this area. This judgement has been made using available evidence including a visit to this service. The numbers of staff on duty were in the main meet the needs of people living in the home. People are protected by the homes recruitment policies and procedures. Further improvement is needed in ensuring that staff all staff receive updated training in statutory training ensuring that people living in the service are in safe hands at all times. EVIDENCE: Information supplied in the self-assessment has identified that forty-five full and part time nursing and carers are employed. At the time of this visit the home was supporting thirty-eight people. Registered nurses who were supported by two carers headed both nursing floors in Willow. The home also employs catering, ancillary, laundry and administration staff. There are no qualified nursing vacancies and recruitment continues for care staff. The home has discontinued the use of agency staff. Four people surveyed said that staff are available when they need them and three people spoken with said that staff respond to call bells. We also visited Pine Lodge (residential unit). At the time of this visit there were eleven people residing there over two floors. There was a senior carer on duty on the ground floor and two carers on duty on the second floor. The senior carer was also overseeing and administering the medication for both Tadworth Grove DS0000013354.V367744.R01.S.doc Version 5.2 Page 23 floors. The senior carer stated that this can cause difficulties at time especially related to the health matters of one person who at times requires additional observation. Therefore it is required that an ongoing review of the dependency of people and the number of staff on each shift in the residential unit must lead to appropriate staffing levels at all times. Staff are supported to complete National Vocational Qualifications. The self assessment states that out of thirty one carers employed twelve have achieved National Vocational Qualifications (Level 2) and above and seven members of staff are completing the programme. The manager stated that they continuing to increase the number of staff with National vocational training. New staff receive induction and follow the Skills for Care common induction standards. The self-assessment states the company has achieved Investors in People accreditation in recognition of staff training and development-training records were sampled for four members of staff. Staff files sampled for two registered nurses revealed that they have attended a range of specialist training including continence, palliative care, catheterisation, wound healing. Two registered nurses spoken with said that they have attended courses for them to be trainers for other staff in moving and handling and continence awareness. Three members of staff files sampled demonstrated that staff had completed mandatory training including moving and handling although, one persons record indicated they had not received updated training for two years and two peoples records did not state if they had completed health and safety training. Shortfalls were also identified in respect of safeguarding vulnerable adults from abuse training. There had been no permanent manager in the home for six months and the current manager is aware that there are some gaps in the training programme and is working towards ensuring that all mandatory training is current and up to date. A new training matrix specific to the home is in place and will identify the training requirements of staff. Four members of staff were sampled, which contained the required information including two written references. Protection of Vulnerable Adult checks (POVA) and Criminal Record Bureau checks are conducted. Files sampled for registered nurses contained a copy of their up to date personal identification number issued by the nursing Midwifery Council ensuring that they are registered to practice. Staff are provided with the General Social Care code of conduct (GSCC). The current manager has reintroduced formal staff supervision, which was confirmed by records seen on personal files and during discussion with staff. The manager is also intending to conduct staff appraisals by the end of the year. Tadworth Grove DS0000013354.V367744.R01.S.doc Version 5.2 Page 24 Tadworth Grove DS0000013354.V367744.R01.S.doc Version 5.2 Page 25 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 People using the service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. The registered manager is able to demonstrate that she has the appropriate qualifications and experience. The home is run in the best interests of people living in the home and their financial interests are protected. The environment health, welfare and safety of people are mainly protected. EVIDENCE: Since our previous visit there had been no permanent registered manager in the home for six months. Another manager has taken the running of the home since April 2008 who is registered with the Commission for her previous management position and is in the process of making an application to us to register for this position. The manager has experience of working with older people and has and has managed a number of other BUPA care homes. The manager is a qualified Registered General Nurse and holds the Registered Tadworth Grove DS0000013354.V367744.R01.S.doc Version 5.2 Page 26 Managers Award. During this visit the manager was observed to have an open approach. The manager stated that she has appointed a new deputy manager and discussion took place where improvements have been made and where further development needs to take place. Staff spoken with during this visit stated that during the six months while there was there was some lack of leadership and that they felt improvements were now being made and we were informed that staff meetings are being conducted. Comments received from staff included, “The manager is approachable”, “the staff are happier and more motivated”;” the manager has an open approach and a good knowledge”;” systems have improved”. The self-assessment has identified that staff retention has now improved. Information supplied in the self-assessment states that BUPA have in place a “Personal best” programme that encourages staff to provide a person centred approach to all tasks. The personal best programmes aim is to ensure that the views of people living in the service are always at the forefront of the care provided. Annual customer satisfaction surveys are carried out annually both internally and externally. The outcomes for the survey carried out last year were favourable. Information supplied in the self-assessment has identified that the manager intends to consult more with people and their representatives ensuring that they involved in decision-making and relative meetings have already commenced. Monthly quality visits are conducted in the home and these reports were available for viewing, although during discussion with the manager there are occasions when managers from other homes carry these out and that they are not always conducted unannounced. Therefore it is required that these visits are carried out unannounced as required by legislation. The company has a policy on handling people’s financial affairs. . We were informed that the service does not handle any monies on behalf of people. People handle their own affairs or by families. Where people are supported by representatives the home provides an invoice system for the payment of items such as hairdressing. Information in the self-assessment identifies that there are dedicated health and safety teams with thin the regions and regular health and safety meetings take place. There are a range of policies and procedures. During this visit Information provided demonstrated that water temperatures are regularly monitored and fire alarm checks and fire drills are conducted. Accident and incident records were maintained including any copies of notifications that are provide to the Commission. Records and certificates identified that systems are in place for routine service and maintenance arrangements for the environment and equipment. Tadworth Grove DS0000013354.V367744.R01.S.doc Version 5.2 Page 27 During a tour of the premises a fire exit was found propped open on two occasions, which was bought to the attention of the manager who took immediate action. Tadworth Grove DS0000013354.V367744.R01.S.doc Version 5.2 Page 28 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 3 X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 2 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 2 17 X 18 2 2 X X X X X 3 3 STAFFING Standard No Score 27 2 28 2 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 2 X 3 3 X 2 Tadworth Grove DS0000013354.V367744.R01.S.doc Version 5.2 Page 29 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. 1 Standard OP18 Regulation 13(6) 18(1) (c) (1) 18(1)(a) Requirement The registered person must ensure that all staff receive updated training in safeguarding vulnerable adults from abuse. The registered person must ensure that at all times there are sufficient care staff on duty to meet the assessed needs of people living in the residential unit. That an ongoing review of the dependency of people and the number of staff on each shift must lead to appropriate staffing levels at all times The registered person must ensure that monthly quality visits must be carried out unannounced. Timescale for action 16/10/08 2 OP27 16/08/08 3 OP33 26 16/08/08 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Tadworth Grove DS0000013354.V367744.R01.S.doc Version 5.2 Page 30 1 OP18 2 OP30 It is recommended that a copy of the updated local authority safeguarding vulnerable adults from abuse procedure and a copy should be maintained on each unit for reference and information. It is recommended that the registered persons consider extending the laundry room considering the size of the home. Tadworth Grove DS0000013354.V367744.R01.S.doc Version 5.2 Page 31 Commission for Social Care Inspection Maidstone Office The Oast Hermitage Court Hermitage Lane Maidstone ME16 9NT National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Tadworth Grove DS0000013354.V367744.R01.S.doc Version 5.2 Page 32 - 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. 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