Inspection on 21/11/05 for Tadworth Grove

This inspection was carried out on 21st November 2005.

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

Other inspections for this house

Tadworth Grove 07/07/09

Tadworth Grove 16/07/08

Tadworth Grove 27/07/07

Tadworth Grove 29/06/06

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 09/07/2008.

CARE HOMES FOR OLDER PEOPLE Tadworth Grove The Avenue Tadworth Surrey KT20 5AT Lead Inspector Denise Debieux Announced Inspection 21st November 2005 10:00 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Tadworth Grove DS0000013354.V257610.R01.S.doc Version 5.0 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.V257610.R01.S.doc Version 5.0 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 BUPA Care Homes Limited To be confirmed Care Home 72 Category(ies) of Dementia - over 65 years of age (4), Old age, registration, with number not falling within any other category (72), of places Terminally ill over 65 years of age (4) Tadworth Grove DS0000013354.V257610.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 4. Up to 46 of the registered places can be used for acute and continuing nursing care. Up to 6 beds may be used for respite care. Up to 4 beds may be used for palliative care. Up to 4 of the personal care beds may be used for service users in the category DE(E), dementia over 65 years of age. 8th August 2005 Date of last inspection 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 for up to 46 people is offered in the threestorey building and residential care for up to 26 people in the smaller twostorey building. Both buildings are fitted with 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. Tadworth Grove DS0000013354.V257610.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This announced inspection took place over 7 hours and was the second inspection to be undertaken in the Commission for Social Care Inspection year April 2005 to March 2006. This inspection was carried out by Denise Débieux, Lead Inspector for the service. Miss Marie Buyers (Registered Manager) and Mrs Teresa Rattenbury (Deputy Manager) were present as the representatives for the establishment. Prior to the inspection, survey forms were sent to the home and distributed to service users, with eight being returned, to their relatives, with six being returned and to GPs and health and social care professionals, with five being returned. The results of these surveys and comments made are used in this report. A tour of the buildings took place with seven service users and six onduty staff being spoken with during the tour. The menus, care plans, staff rota, recruitment information, maintenance records, activity schedules, medication storage and records, safety check records and staff training records were all sampled. The inspector would like to thank the service users, manager and staff for their time, assistance and hospitality during this inspection and the service users, their relatives and health and social care professionals who participated in the surveys. What the service does well: What has improved since the last inspection? What they could do better: Tadworth Grove DS0000013354.V257610.R01.S.doc Version 5.0 Page 6 Requirements have been made regarding the maintenance of service user care plans and risk assessments, staffing levels, staff recruitment and the protection of vulnerable adults. 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. Tadworth Grove DS0000013354.V257610.R01.S.doc Version 5.0 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 Tadworth Grove DS0000013354.V257610.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): NONE EVIDENCE: Standard 3 was fully assessed and met at the last inspection and was not covered on this occasion. Standard 6 does not apply to this home. Tadworth Grove DS0000013354.V257610.R01.S.doc Version 5.0 Page 9 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7 and 9 The home needs to ensure that all service users have an individual care plan that details the care required to fully meet their health, personal and social care needs. Policies, procedures and practices are in place to ensure the safe administration of medication. EVIDENCE: All relatives and health care professionals surveyed stated they were satisfied with the overall care provided at the home, with seven of the eight service users saying that they felt well cared for and one answering ‘sometimes’. Four care plans were sampled during this inspection. The care plans were based on needs assessments but the home needs to review their documentation. The care plans sampled did not include all areas of identified needs. No care plans had been signed by service users or their representatives to signify their agreement with the contents and not all care plans had risk assessments for falls or the use of bed rails (where applicable). The daily notes also need to relate to the care plans to evidence that actions are being taken to meet the identified needs and each page of the care plan Tadworth Grove DS0000013354.V257610.R01.S.doc Version 5.0 Page 10 documentation needs to include the name of the service user and be signed and dated by the member of staff filling in the details. This was discussed at the inspection and requirements and a recommendation have been made. Medication administration record (MAR) sheets, medication storage and the lunchtime medication round was observed during this inspection. The medication administration and storage observed was in line with the home’s policies and procedures. All interactions observed between the staff and service users were seen to be caring and respectful. Tadworth Grove DS0000013354.V257610.R01.S.doc Version 5.0 Page 11 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12 and 15 The routines of daily living and activities are flexible and varied to suit individual service users’ wishes. Meals are well-balanced and varied with individual choices and preferences catered for. EVIDENCE: The home has recently employed an assistant to work with the activity coordinator and service users are able to choose which activities they attend or participate in. Activities available include: exercise sessions; bingo; cards and visiting entertainers, with local library facilities and involvement with local churches. A recent survey carried out by the home indicated that improvements could be made with the food provision. The inspector was advised that changes had been made in the light of those findings. Menus for two weeks were inspected and seen to be varied and well-balanced. Service users are able to request alternatives if there is something they do not like on the menu. The lunchtime meal was taking place during the inspection and the food was presented in an appetising manner. Ample staff were present and offered help or assistance where needed in a discreet and sensitive way. The atmosphere in the dining room was convivial and unhurried. Tadworth Grove DS0000013354.V257610.R01.S.doc Version 5.0 Page 12 Four of the service users surveyed stated that they liked the food, with three answering ‘sometimes’. One service user commented that there had been a ‘Big improvement lately.’ Tadworth Grove DS0000013354.V257610.R01.S.doc Version 5.0 Page 13 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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18 The policies and procedures in place to protect service users from harm or abuse need to be reviewed in line with the Surrey Multi-agency Procedure and the Department of Health ‘No Secrets’ guidelines. EVIDENCE: The home has a copy of the latest Surrey Multi-agency Procedure for the Protection of Vulnerable Adults and the manager advised the inspector that she would follow this procedure should an occasion arise. However, the corporate policy does not, at present, refer to local procedures and a requirement and recommendation has been made that also include staff training in the Surrey procedures. All service users surveyed stated that they felt safe at the home. One service user commented that they would like better lighting outside the home, this comment was passed to the manager, who assured the inspector that this will be looked into. Tadworth Grove DS0000013354.V257610.R01.S.doc Version 5.0 Page 14 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 26 The location and layout of the home is suitable for it’s stated purpose. It is accessible, safe and well-maintained with a pleasant and homely atmosphere. EVIDENCE: During the tour of the home the premises were seen to be well maintained with service users able to access all areas of the home and grounds. Service users spoken with expressed their satisfaction with the accommodation provided at the home. On the day of inspection the home was found to be warm, clean and bright with a homely atmosphere. Tadworth Grove DS0000013354.V257610.R01.S.doc Version 5.0 Page 15 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30 The staffing levels need to be reviewed to ensure that the needs of all service users are met at all times. Action must be taken to improve the staff recruitment and training procedures to ensure that the service users’ safety is protected. EVIDENCE: Of the six relatives that returned comment cards, five stated that they did not feel there were always sufficient numbers of staff on duty with one commenting that they felt there were not enough night staff and additional comments that are being dealt with directly by the BUPA area management team. Staffing levels were looked at in some depth during this inspection. The Residential Forum system was used to check the staffing numbers for the amount of service users currently on the nursing side of the home and the rota reflected the required level apart from the hours between 7 and 8am and 8 and 10pm, which need to be increased. On the residential unit, the Residential Forum system indicated that there should be two staff members of staff on duty between 10pm and 7am and three members of staff between 7am and 10pm, (which is higher than the staffing levels currently at the home.) A requirement and recommendation has been made. The manager expressed a strong commitment to National Vocational Qualification (NVQ) training for the staff. The home have been working towards having 50 of their care workers qualified to NVQ level 2 in care or higher by 31st December 2005. Eleven of the thirty-seven care workers have Tadworth Grove DS0000013354.V257610.R01.S.doc Version 5.0 Page 16 already achieved NVQ level 2 qualifications and a further seven are enrolled to start the NVQ level 2 training in December. The home have now received Criminal Record Bureau (CRB) certificates for all people brought into the home to provide a service (e.g. hairdressers, chiropodists). Four staff files were reviewed at this inspection and were found to contain much of the information required of the regulations. However, the files inspected did not include full employment histories, reasons for leaving previous jobs and gaps in employment were not fully explained. This was highlighted at the last inspection and, while improvements have been made, the previous requirements have not been fully met and are carried forward to this report to be dealt with as a priority. The inspector was shown letters from the two agencies used to provide additional staff when needed. These letters stated that the agencies carry out CRB checks on all their staff. However, the Care Homes Regulations 2001 require that the registered person obtains written confirmation that the agency have obtained and verified all information set out in Schedule 2 of the Regulations and a requirement has been made. Staff training is provided by the BUPA training department with much of the training being provided ‘in house’. All new staff are provided with induction training that meets the Skills For Care (previously TOPSS) specifications. The manager is new in post and is in the process of organising the training records and determining that all required training and is up to date. The inspector was advised that, once this is done, the manager will carry out an individual training and development assessment and profile with all staff. A recommendation has been made to that effect. All service users spoken with confirmed that the staff treat them well and, during this inspection, the staff were seen to respond to the service user’s needs and requests promptly and with respect. Tadworth Grove DS0000013354.V257610.R01.S.doc Version 5.0 Page 17 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 and 38 Service users benefit from the clear management approach at the home. The home has a quality assurance and monitoring system in place that is based on seeking the views of the service users. Service users’ financial interests are safeguarded by the policies and practices of the home. All other policies, procedures and practices are in place to ensure, so far as is reasonably practicable, the health, safety and welfare of service users and staff. EVIDENCE: The new registered manager is a registered nurse and has been qualified since 1983. She has previous experience as a registered manager and has completed her Registered Managers Award training. Service users views are sought on a regular basis, monthly visits by a representative of the responsible individual take place and the home have a six monthly survey carried out by an external company. As mentioned earlier in Tadworth Grove DS0000013354.V257610.R01.S.doc Version 5.0 Page 18 this report, the manager demonstrates that action is taken in response to any issues arising from the surveys. There are three monthly residents’ meetings and also a three monthly newsletter is produced. A recommendation has been made that the home include stakeholders in the community (e.g. GPs etc) in their quality assurance surveys. The home do not handle financial affairs for service users. However, on occasions when service users want valuables stored securely for a short period of time, the home has a safe which can be used. Any items stored in this way are recorded in the service users’ files. All required safety monitoring checks, fire drills and safe working practice training and updates have been carried out. Staff were observed to be following appropriate health and safety practices as they went about their work. Tadworth Grove DS0000013354.V257610.R01.S.doc Version 5.0 Page 19 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 X X X X HEALTH AND PERSONAL CARE Standard No Score 7 2 8 X 9 3 10 X 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 X 14 X 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 X 17 X 18 2 X X X X X X X 3 STAFFING Standard No Score 27 2 28 3 29 1 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 2 X 3 X X 3 Tadworth Grove DS0000013354.V257610.R01.S.doc Version 5.0 Page 20 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 OP7.1-6 Regulation 14(2 15(1) 15(2) Requirement The registered person must ensure that each service user has an individual plan of care that includes the following: • A comprehensive assessment of needs covering all areas of health, personal and social care needs • Risk assessments, to include prevention of falls, use of bed rails and risk of pressure sore development • Details of all individual needs identified • Goal/objective for each need • Actions to be taken to ensure the goals are met • Daily report writing to evidence that identified needs and goals are being met • Monthly reviews with newly identified needs or problems promptly added to the care plan • Signature of service user/representative to signify their agreement with the plan • Each page to include the service user’s name and be signed by the staff member completing the details. DS0000013354.V257610.R01.S.doc Timescale for action 21/02/06 Tadworth Grove Version 5.0 Page 21 2 OP7.3 3 OP18 4 OP27 5 OP29.1-6 The registered person must ensure that each service user has an up to date falls risk assessment and, where applicable, a completed risk assessment for the use of bed rails. 13(6) The registered person must ensure that all staff are aware of the Surrey Multi-agency Procedure for the Protection of Vulnerable Adults and review the corporate policy in line with the local procedure and the Department of Health ‘No Secrets’ guidance. 18(1)(a) The registered person must review the staffing levels at the home and ensure that suitably qualified, competent and experienced persons are working at the home in such numbers to meet the needs of the service users accommodated at any one time. 19(1)(a-c) The registered person shall not Schedule employ a person to work at the 2 care home unless the person is fit to work at the care home and he/she has obtained, in respect of that person, the information and documents specified in paragraphs 1 to 9 of Schedule 2 of the Care Homes Regulations 2001, as amended by The Care Standards Act 2000 (Establishments and Agencies)(Miscellaneous Amendments) Regulations 2004. (Timescale of 08.08.05 not met) 13(4)(c) 28/11/05 21/01/06 21/12/05 21/11/05 Tadworth Grove DS0000013354.V257610.R01.S.doc Version 5.0 Page 22 6 OP29.1-6 7 OP29.1-6 8 OP29.4 19(1)(a-c) The registered person must Schedule obtain the following information: 2 • full employment history • explanation of any gaps in employment • verification of reason for leaving employment • two satisfactory, written references, including, where applicable, a reference relating to the last period of employment which involved working with vulnerable adults retrospectively for each member of staff employed by the company after The Care Standards Act 2000 (Establishments and Agencies)(Miscellaneous Amendments) Regulations 2004 came into force on 26th July 2004. (Timescale of 08.10.05 not met) 19(4)(a-c) The registered person shall not Schedule allow an agency worker to work 2 at the care home unless he/she has received written confirmation that the agency have obtained the information and documents specified in paragraphs 1-9 of Schedule 2 of The Care Homes Regulations 2001, as amended by The Care Standards Act 2000 (Establishments and Agencies)(Miscellaneous Amendments) Regulations 2004. 18(4) The registered person to provide all care staff with copies of the code of conduct and practice set by the GSCC. 21/12/05 21/11/05 21/02/06 Tadworth Grove DS0000013354.V257610.R01.S.doc Version 5.0 Page 23 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 2 Refer to Standard OP7 OP18 Good Practice Recommendations It is recommended that the home review, with all registered nurses, the guidelines of the Nursing and Midwifery Council for records and record keeping. It is recommended that the manager and deputy manager are enrolled on the soonest available training in The Surrey Multi-agency Procedure for the Protection of Vulnerable Adults. It is recommended that the manager carry out a specific survey with service users and their representatives around the issue of staffing numbers. It is recommended that the manager carries out an individual training and development assessment and profile with each staff member. It is recommended that the views of stakeholders in the community (e.g. GPs, chiropodists etc.) are included in the home’s quality assurance and monitoring system. 3 4 5 OP27OP33 OP30.4 OP33.7 Tadworth Grove DS0000013354.V257610.R01.S.doc Version 5.0 Page 24 Commission for Social Care Inspection Surrey Area Office The Wharf Abbey Mill Business Park Eashing Surrey GU7 2QN National Enquiry Line: 0845 015 0120 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.V257610.R01.S.doc Version 5.0 Page 25 - 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!