Inspection on 27/07/07 for Tadworth Grove

This inspection was carried out on 27th July 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 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 16/07/08

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 09/07/2008.

CARE HOMES FOR OLDER PEOPLE Tadworth Grove The Avenue Tadworth Surrey KT20 5AT Lead Inspector Suzanne Magnier Unannounced Inspection 27th July 2007 10:30 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.V345581.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.V345581.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 buysm@bupa.com www.bupa.co.uk BUPA Care Homes (CFC Homes) Limited Marie Buys 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.V345581.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 29th June 2006 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 £ 670.00 for residential care and £795.00 for nursing care per week. Tadworth Grove DS0000013354.V345581.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The Commission has, since the 1st April 2006, developed the way it undertakes its inspection of care services. This inspection of the care home was an unannounced ‘Key Inspection’. Some additional standards were assessed and have been included within the report. Ms S Magnier Regulation Inspector carried out the inspection and the registered manager represented the service. For the purpose of the report the individuals using the service are referred to as people living in the home. The inspector arrived at the service at 10.30 and was in the home for six hours. It was a thorough look at how well the home is doing. It took into account detailed information provided by the home and any information that CSCI has received about the service since the last inspection. The inspector spent time talking with people living at the home in order to seek their views about the home and the care they receive. Responses to questionnaires that the Commission had sent out and written comments have been included within the report. The inspector looked at how well the service was meeting the standards set by the government and has in this report made judgements about the standard of the service. Documents sampled during the inspection included the homes Statement of Purpose and Service User Guide, the terms and conditions of residency in the home, care/person centred plans, daily records and risk assessments, medication procedures, staff files, a variety of training records, and several of the services policies and procedures. Following the previous key inspection in June 2006 the service has met all the requirements made. The home had submitted the Annual Quality Assurance Assessment (AQAA) prior to the inspection, some details of which have been added to the report. From the evidence seen by the inspector and comments received, the inspector considers that the home would be able to provide a service to meet the needs of individuals who have diverse religious, racial or cultural needs. The inspector would like to thank the people living in the home, the staff and the manager for their time, assistance and hospitality during this inspection. What the service does well: Tadworth Grove DS0000013354.V345581.R01.S.doc Version 5.2 Page 6 People who use the service are able to maintain bonds with family and friends. The physical layout of the home enables people who use the service to live in a safe and generally well-maintained environment. The management of the home is robust. What has improved since the last inspection? What they could do better: All medication must be administered at the frequency as prescribed by the doctor and accurate records must be kept of all medication administered to individuals in order to promote the safety and well being of all individuals in the home. It has been required that home must improve the provision of care, support and supervision for people during meal times to ensure that individuals needs and safety are promoted. A variety of repairs must be undertaken in the home to ensure the safety of all people in the home. Infection control procedures need to be further promoted to ensure the health and safety of all people in the home. It is recommended that documented risk assessments be developed with regard to the homes laundry and safe use of the wooden sheds at the rear of the care home. Please contact the provider for advice of actions taken in response to this Tadworth Grove DS0000013354.V345581.R01.S.doc Version 5.2 Page 7 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.V345581.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.V345581.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): 1,2, 3, 5 & 6. Quality in this outcome area is good. This judgement has been made using a range of evidence including a visit to this service. People who use the service have information about the home in order that they can make an informed choice about moving to the home. The homes admission and assessment procedures ensure that individual’s needs are appropriately identified and met. Terms and conditions/contracts of stay at the home are available to all individuals. People are encouraged to visit the home prior to residency. EVIDENCE: The inspector sampled the homes Statement of Purpose and Service User Guide which evidenced that appropriate information regarding the services of the home were clearly documented to inform prospective individuals or their representatives about the services provided by the home. The Annual Quality Assurance Assessment (AQAA), which has been completed by the home acknowledges that the homes brochure needs to be updated to include the facilities in the residential dementia unit. Tadworth Grove DS0000013354.V345581.R01.S.doc Version 5.2 Page 10 All files sampled contained documented terms and conditions of the individuals stay in the home in order that they are fully informed of their rights of residency and cost of services provided by the home. The manager explained that she or the deputy manager undertake the pre admission procedures for individuals considering admission to the home. The inspector sampled a variety of care plans for people living in the home and noted that each contained a documented pre admission assessment about the care and support needs of the individual. Some assessments had been completed with the support from a relative or representative, prior to the individual’s admission to the home. Prospective residents are encouraged to visit the home and meet with other individuals and staff. The home does not provide intermediate care. Tadworth Grove DS0000013354.V345581.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. Quality in this outcome area is adequate. This judgement has been made using a range of evidence including a visit to this service. The health and personal care that people receive is based on their individual needs set out in their care plans. Monitoring of risk assessments is maintained to ensure the safety of people in the home. Medication procedures do not ensure that medication is administered to all individuals in a safe and appropriate way. People’s dignity and respect is promoted. EVIDENCE: Since the previous inspection BUPA have introduced a care planning system called QUEST and all individuals in the home have this system for their individual plans of care. The inspector sampled four individual’s plans of care and found them to contain well-documented care plans and a variety of risk assessments including moving and handling. The individual or their representative had signed each care plan. Tadworth Grove DS0000013354.V345581.R01.S.doc Version 5.2 Page 12 The plans included the preferred name of the individual, their next of kin or significant person, the individuals photograph, documents regarding medication, their GP (general practitioner) and any other health care professionals support. The individuals choices regarding gender specific care, their communication abilities, a twenty four hour plan of their preferred lifestyle and daily living choices, their support needed regarding personal care, sleeping patterns, their emotional, nutritional needs and preferences. It was evident that the care plans were kept under review to reflect the changing needs of the individual and the daily notes were well written to reflect peoples rights to the dignity and respect and reflected the care and support offered and provided by staff. Documented risk assessments had been completed where individuals and staff had identified hazards for example falls within the home and the use of bedrails, documented evidence of pressure ulcers and nutritional screening to ensure individuals safety and well being in peoples daily lives. The manager explained that the home has strong links and support from the homes general practitioner (G.P.) who was in the home during the inspection and visits weekly. The manager explained that in emergencies the out of hour’s doctor service is available to the home. One comment received stated ‘Clinical assessment not always relayed appropriately e.g. very sick patient asked for visit but 999 should have been called. No sense of urgency for visit.’ The inspector addressed the comment with the manager who advised that she would look into the comment and address this with the trained nurses in the home to ensure prompt response to peoples needs. The manager stated that there is good health care support from other practitioners, which include the opticians and chiropodists, Macmillan nurses, tissue viability nurse, dentist, physiotherapist, dietician support and attendance to specialist clinics. The inspector noted that each file contained record’s detailing healthcare professional visits to evidence that individuals received ongoing support to ensure their healthcare needs were met. A comment received stated ‘the home communicate well with outside agencies, friendly welcoming and supportive. They would benefit from deaf awareness training, which can be provided free’. This was brought to the manager attention and may be included in the staff development programme. A variety of comments from people living in the home and from relatives regarding the care provided by the home included the home ‘care for my relative in a very professional and caring way at all times’ ‘some carers are excellent, patient and helpful a few are unkind and shout at them and sometimes very slow to answer buzzers’. ‘Sometimes not told when he falls when no injury’. ‘Very kind and pleasant staff’. ‘Sometimes personal things not done e.g. nail cleaning, hair washing not very good, teeth cleaning some care could be better. ‘Carers to be polite and kind without exception and never Tadworth Grove DS0000013354.V345581.R01.S.doc Version 5.2 Page 13 shout at clients’. These comments were discussed with the manager and she confirmed that some details had already been addressed by the home for example if relatives wish to be informed if their relatives have sustained a fall in the home and the concern regarding hair care and other comments of concern would be addressed. The manager explained that the medication procedures of the home had recently changed and included a monitored dosage (MDS) system, which has been implemented by a local pharmacy. The medication trolleys are stored in locked clinical areas and each trained nurse has responsibility for the medication trolley in their work area. The manager advised the inspector that the homes policy and procedure had been recently updated and the medication policies and procedures were available for the trained nurses. During the inspection the inspector spoke with the manager regarding a comment received from a relative regarding their relatives medication. The manager explained that a staff member had raised concern regarding the timing of a persons medication and in order to reflect the individuals right to have their medication when they chose written guidelines had been developed and were included in the individuals care plan. The inspector did not sample a medication round yet examined the medication administration charts. Overall the documents were well recorded and all records contained a recent photograph and known allergies of the person. There were several gaps on the medication administration charts, which were brought to the manager’s attention. The records indicated that on the day of inspection the medication round for three people on the dementia unit had been undertaken at 10.30 and not at 09.00 and the midday medication had therefore not been administered. The manager and inspector spoke with the nurse in charge who advised that they had been running late due to staff sickness. The manager and deputy manager explained to the inspector that this was not a usual occurrence and generally staff would seek support and assistance either from another trained nurse or the manager would undertake the medication round. Requirements have been made that accurate records must be kept of all medication administered to individuals and medication must be administered at the frequency as prescribed by the doctor in order to promote the safety and well being of all individuals in the home. During the inspection it was noted that there was a calm atmosphere throughout the home. Staff addressed people in a professional and caring manner. Individuals were addressed by their first or full name and where appropriate names of endearment were used to support trusting relationships. Staff were observed to preserve and maintain peoples dignity and privacy by knocking on their room doors and waiting to enter, supporting people discreetly to the bathroom and being observant and attentive to people who were not fully able to maintain their own dignity. Quiet areas in the home were available to people to use. Tadworth Grove DS0000013354.V345581.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. Quality in this outcome area is adequate. This judgement has been made using a range of evidence including a visit to this service. People who use the service are able to exercise choice in the daily lives, maintain bonds with family and friends, and take part in social, cultural, religious and recreational activities. In general the home provides a healthy and balanced diet in a pleasant spacious dining area however further improvements need to be made with regard to staff engagement with individuals at mealtimes. EVIDENCE: The inspector spoke to a variety of people during the day all of which spoke highly of the activities, staff and general running of the home. It was noted that people were moving freely around the home. There was an air of anticipation as the home were organising a beach party in the garden the following day and some people told the inspector they were excited about it. Several people told the inspector that they enjoyed the activities arranged by the home, which included bingo, reminiscence, cards, gentle exercise, a visiting piano player and other visiting entertainers. One comment stated ‘Lovely garden outside my relatives room’. The AQAA advises that the home Tadworth Grove DS0000013354.V345581.R01.S.doc Version 5.2 Page 15 have increased activities on weekends and arranged for an external beauty therapist to do facials & another to do manicures. The inspector met with one of the homes volunteers who chatted freely with the individuals in the home offering support and companionship. The inspector noted that an activity programme is available in the home and the staff explained that people are involved in the planning and choices regarding meaningful activities if they choose to. The AQAA received by the commission detailed that there are no restricted visiting hours for friends & relatives, the inspector observed visitors moving freely around the home. Those visitors spoken with praised the home, staff and mangemenent. The inspector observed that people were able to visit their relatives and friends in privacy. The AQAA states that there are 2 local churches & volunteers from the congregation collect people who choose to attend church every weekend. Other services are held at the home. The inspector observed a christian cleryman in the home during the inspection. The inspector observed the midday meal throughout the home moving to each area over the course of the mealtime. The meal consisted of a choice of lasagne or fish and chips with a variety of deserts. The inspector observed that the dining areas were well decorated, bright and spacious and the dining tables were pleasantly arranged with napkins, tablecloths, appropriate cutlery and condiments of choice. Some individuals were enjoying their meal using their fingers whilst others preferred to use the cutlery available. In general staff were supportive and engaged with individuals with discretion and dignity during the meal time however on one occasion a staff member was observed by the inspector and manager to support a person with their meal and did not speak to the individual to state they were going to help the person to eat their meal, offered no explanation of what the meal was and offered no encouragement to the individual with regard to eating their meal. The manager and inspector also noted on another occasion a carer in the dining area showed little engagement as they were going to read a magazine whilst people were having their meal. It has been required that home must improve the provision of care, support and supervision for people during meal times to ensure that individuals needs and safety are promoted. People spoken with during and after their meal stated that they enjoyed their meal. The commission had received a variety of written comments regarding the quality of the meals served in the home and these included ‘Residents are given choice but do not always receive the meal ordered. Food is very good and well balanced’. ‘The food is much better now.’ Whilst speaking with one Tadworth Grove DS0000013354.V345581.R01.S.doc Version 5.2 Page 16 individual they told the inspector that they had not received the meal that they ordered and the manager was prompt to offer an alternative stating that this shortfall would be addressed. The manager explained that over the last 12 months the home have introduced a BUPA Menu Master which helps to ensure the menu meets the nutritional needs of all individuals at the home. Menus are rotated every season & the menu manager is used ensuring 5 a day principals. The home have also started a Night Bite system to ensure that food is available 24 hours a day. Tadworth Grove DS0000013354.V345581.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. Quality in this outcome area is good. This judgement has been made using a range of evidence including a visit to this service. People who use the service are able to express their concerns and have access to a complaints procedure. They are protected from abuse and have their rights protected. EVIDENCE: The home has a clear complaints procedure. The inspector sampled the complaints file. The AQAA indicates that eleven complaints had been received since the previous inspection. Whilst sampling the complaints log the inspector noted that there was a detailed clear chronology of events for example dates and details of correspondence and outcomes regarding complaints received by the home. All complaints apart from one had been satisfactorily concluded. Written comments received by the commission regarding the homes complaints process included that the homes complaints procedure was available to people in the home and people knew how to make a complaint and actions would be taken to address any concerns they may have. During the inspection the inspector raised with the manager some concerns that people had expressed regarding their relatives lost laundry, support needs at meal times, medication concerns and personal care concerns. The manager demonstrated an awareness of these concerns and advised that all these matters had been brought to her attention prior to the inspection. Procedures for example reimbursement of funds for lost clothing, the change of dispensing Tadworth Grove DS0000013354.V345581.R01.S.doc Version 5.2 Page 18 pharmacy to the home and employment of a new hairdresser following the resignation of the previous hairdresser had all been implemented to address the concerns raised. The manager advised that these matters would continue to be monitored by the home. The inspector sampled that the home has the local authorities multi agency procedures for safeguarding adults and the manager advised that the home follows these procedures with documents available on each of the homes work areas. The AQAA and the manager stated that there had been one safeguarding referral under the safeguarding adults procedures, which was concluded following one multi agency-planning meeting. The inspector noted that the home has a whistle blowing policy and procedure, which is available to staff in order to safeguard people in their care. Staff spoken with during the inspection demonstrated an understanding of the procedures for safeguarding adults. Staff training records detailed that staff receive safeguarding adults awareness training, from an external source and also have access to a training video. Tadworth Grove DS0000013354.V345581.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, 20, 24 & 26. Quality in this outcome area is adequate. This judgement has been made using a range of evidence including a visit to this service. The physical layout and indoor and outdoor communal areas of the home enable people who use the service to live in a safe and generally wellmaintained environment. Individual’s bedrooms suit their needs. Improvements must be made to ensure household repairs and more robust infection control standards are implemented. EVIDENCE: Comments received from visitors to the home regarding the environment and cleanliness included ‘Could do with some updating (décor)’. ‘Rooms cleaner in the last 2 weeks but have been filthy in the past particularly at weekends’. ‘Always clean rooms to a higher standard’. These comments were discussed with the manager who advised that a maintenance programme was in place and that the link between Willow House and Pine Lodge and the second floor corridor had been decorated. The first Tadworth Grove DS0000013354.V345581.R01.S.doc Version 5.2 Page 20 floor was currently being decorated. The AQAA received by CSCI indicates that the home has a maintenance plan in place and are waiting for new curtains to be fitted in residential lounge and various other areas throughout the home. The second floor bathroom has been redecorated and a new parker bath fitted. Six new commodes have been purchased and a new maxi Arjo hoist with fitted elctronic scale. The smokers room has been converted to a spacious hairdressing salon which is also used by complimentary therapists and chiropodist. The homes indoor and outdoor communal areas were well maintained and appropriate access was available to all persons in the home. The external pathway to the rear of the home had been relaid following the previous requirement made at the last inspection. With regard to the comment of the cleanliness of the home the manager explained that there had been a shortfall due to staff sickness and this had been rectified by utilising the services of a bank housekepper at weekends. The inspector undertook a tour of the premises and observed that generally the home was well maintained however some concerns were raised which are as follows. Several fire doors were noted to not be shutting correctly and the handy person immediately took action to rectify the hazard on the day of inspection. Confirmation to CSCI by email was also made that two other fire doors in the premises had been repaired the day after the inspection. The inspector observed that two sluice doors on the first and second floors were not closing properly. It has been required that these repairs are undertaken in order to ensure the safety and health of all people in the home. Several bedroom carpets were ‘lifting’ in areas, which could constitute a trip hazard. It has been required that this hazard is rectified in order to ensure the safety and well being of people when in the bedroom. Whilst touring the premises the inspector noted that the bathroom on the second floor ‘west’ was used for storage for commodes and portable hoists. The bathroom door did not have a door handle and the inspector was advised that the staff had to move all the items from the bathroom if people living in the home wanted to have a bath. The manager advised the inspector that there were sufficient bathrooms for people living in the home yet it was problematic having to move the items, some of which were stored in corridors when the bath was in use. It has been required the alternative storage, for example the small unused Tadworth Grove DS0000013354.V345581.R01.S.doc Version 5.2 Page 21 bathroom adjacent to the bathroom is used as storage in order that people wishing to use the bathroom have easy access and staff are not put at risk with regard to moving and handling furniture. The bathroom door handle must be replaced in order to promote people’s safety and dignity. There have been some concerns raised by relatives regarding lost property including nightclothes, blouses and spectacles. As previously documented in the complaints section of the report the inspector was advised that procedures had been put in place to safeguard peoples belongings. The manager explained that all bed linen is sent to an external laundry and the home only launder people’s personal clothing and as a result of these measures the loss of peoples clothing and other articles has reduced. The manager also explained that staff have been advised to be more attentive and vigilant regarding peoples belongings. It was noted that the homes laundry area was small and yet orderly. The laundry room lacked ventilation apart from the back door being open and the area was cluttered. It has been recommended that the home undertake a documented risk assessment of the laundry area to clarify the procedures already in place to address identified hazards and identify remaining hazards to minimise risks to people using the laundry area. People spoken with in their bedrooms told the inspector that they liked their bedrooms, which were comfortable. It was noted that people’s bedrooms were individualised and some contained their own items of furniture, personal possessions, leisure items including televisions, radios, books, and equipment to promote individuals lifestyles. Concerns were noted regarding the lack of the homes infection control procedures. Shortfalls identified included the following. A staff member undertaking the laundry duty and a housekeeper were not wearing protective aprons whilst transferring people’s soiled clothing from a basket into the washing machines and undertaking cleaning tasks. On both occasions this shortfall was brought to the staff member’s attention who then immediately put on protective aprons to promote control of infection. Soiled laundry was strewn across the laundry floor by the washing machines and it was noted that no hand washing facilities were available in the laundry area. The member of staff advised that they went to the nearest bathroom or staff room to wash their hands. The lids of the clinical waste bins to the rear of the building were noted to be open due to the lock on the bins being left in the locked position. The manager made immediate arrangements for the bins to be replaced the day after the inspection. Tadworth Grove DS0000013354.V345581.R01.S.doc Version 5.2 Page 22 It has been required that these shortfalls are rectified and that the home must make suitable arrangements to prevent infection, toxic conditions and the spread of infection in the home by reviewing the current infection control policies and procedures to promote the health, safety and well being of all individuals in the home. Tadworth Grove DS0000013354.V345581.R01.S.doc Version 5.2 Page 23 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 a range of evidence including a visit to this service. Staff in the home are trained, skilled and in sufficient numbers to support the people who use the service. The home has a robust system for the induction, training development and recruitment of staff to ensure peoples needs are met appropriately and safely. EVIDENCE: The inspector was advised that the home is currently supporting 54 individuals and have a total of 48 staff. The manager explained that some agency staff are currently being employed by the home. Written comments and comments received on the day of the inspection regarding the staff at the home included ‘Staff always listen and are very well meaning but then change of staff, handover not always good.’ The staff do a very good job’. Staff are always helpful and kind’, ‘very good receptionist-just retired new one very helpful’. ‘More staff carers to answer bleep within 5 minutes’. The staffing numbers on the day of the inspection were observed to meet the current needs of the people living in the home. Staff views regarding the staffing numbers were positive. The manager explained that the call bell system relies on the registered nurses carrying bleeps however two of the Tadworth Grove DS0000013354.V345581.R01.S.doc Version 5.2 Page 24 bleeps were broken awaiting repair. It was brought to the inspector’s attention that the current call bell system was sometimes not swift due to the nurse having to locate a staff member to offer assistance. It has been recommended that the call bell system is reviewed in order to ensure that people summoning assistance are responded to in a timely fashion. The manager explained that the home employs a multi-cultural workforce and equality and diversity issues are addressed both by people living in the home and staff. The inspector sampled three staff recruitment files. All files evidenced that the home undertakes safe vetting practices concerning the recruitment of staff in order to ensure the safety and protection of people living in the home. The staff induction and mandatory training records were sampled and evidenced that the home is committed to the ongoing training and development of staff in order to ensure that the homes staff are suitably trained and competent in their duties. The AQAA advises that staff training has improved over the last 12 months and a rolling training programme was evidenced by the inspector. The records indicated that all staff had undertaken the necessary mandatory training and where refresher courses were needed these had been identified through the accuracy of the record keeping. The AQQA indicated that sixteen staff had achieved their National Vocational Qualification (NVQ) in care with 26 of staff working towards achievement of the award. Tadworth Grove DS0000013354.V345581.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. Quality in this outcome area is good. This judgement has been made using a range of evidence including a visit to this service. The management and administration of the home is robust and the home is run in the best interests of people who use the service. Peoples’ safety, financial protection and welfare is promoted. EVIDENCE: The atmosphere in the home was calm and orderly. The pace of the home was designed to meet the needs of the individuals living at the home and there was no sense of hurry. It was evident through observation and talking with people who use the service and staff that the manager had good knowledge about managing the care home and had the skills and experience to ensure the safety and well being of all persons in the home. Tadworth Grove DS0000013354.V345581.R01.S.doc Version 5.2 Page 26 The manager explained that people’s views about the service were actively sought and quality assurance procedures were in place to seek the views of people who use the service and any visitors to the home. The AQAA advises that BUPA Care Homes has appointed a Director of Quality and Compliance and has developed a national Quality and Compliance team of experts. The inspector evidenced that regular meetings were held with people living in the home with the inclusion of relatives and friends. The inspector sampled the system and accounting process regarding the safekeeping of individuals money and all documentation was accurate and clearly recorded. Health, safety and maintenance records were sampled to evidence that the home undertakes safety checks in order to promote the health, safety and welfare of people in the home. During the tour of the premises the inspector noted that two wooden sheds at the rear of the home were used as an area for ironing, including the use of a rotary iron and storage for chemicals and wipes etc. One shed contained a free standing heater and it was observed that both sheds did not contain a fire extinguisher. A member of staff informed the inspector that staff work on their own in the buildings. It has been recommended that a risk assessement of the buildings and contents be documented and measures put in place to safeguard people working in the buildings to ensure their safety and wellbeing. Tadworth Grove DS0000013354.V345581.R01.S.doc Version 5.2 Page 27 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 3 3 X 3 3 HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 3 X X X 3 X 2 STAFFING Standard No Score 27 2 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 2 Tadworth Grove DS0000013354.V345581.R01.S.doc Version 5.2 Page 28 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 OP9 Regulation 17.(1)(a) Requirement Timescale for action 01/08/07 2 3 OP9 OP15 4 OP19 5 OP19 6 OP19 Accurate records must be kept of all medication administered to individuals in order to promote the safety and well being of all individuals in the home. 12.(1)(b) All medication must be administered at the frequency as prescribed by the doctor 12.1(a)(b) The home must improve the provision of care, support and supervision for people during meal times to ensure that individuals needs and safety are promoted. 23.(2) (b) The two sluice doors on the first and second floors, which were not closing properly, must be repaired in order to ensure the safety and health of all people in the home. 23.(2) (b) Several bedroom carpets were ‘lifting’ in areas, which could constitute a trip hazard and must be rectified in order to ensure the safety and well being of people when in the room. 23.(2) (l) Alternative suitable provision must be made for the storage of items in a bathroom for DS0000013354.V345581.R01.S.doc 01/08/07 27/08/07 10/08/07 10/08/07 27/08/07 Tadworth Grove Version 5.2 Page 29 7 8 OP19 OP26 23.(2) (b) 13.(3) example, commodes and portable hoists in order that people may have safe access to the bathroom facilities at all times. The bathroom door handle must be replaced in order to promote people’s safety and dignity. The home must review the current infection control policies and procedures in the home in order to promote the health, safety and well being of all individuals in the home. 03/08/07 03/08/07 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 OP19 Good Practice Recommendations It is recommended that the home undertake a documented risk assessment of the laundry area to clarify the procedures already in place to address identified hazards and identify remaining hazards to minimise risks to people using the laundry area. It has been recommended that the call bell system be reviewed in order to ensure that people summoning assistance are responded to in a timely fashion. The home must complete a documented risk assessement of the external wooden sheds in order to ensure the safety and wellbeing of the people working in the buildings. 2 3 OP27 OP38 Tadworth Grove DS0000013354.V345581.R01.S.doc Version 5.2 Page 30 Commission for Social Care Inspection Oxford Area Office Burgner House 4630 Kingsgate, Cascade Way Oxford Business Park South Cowley Oxford OX4 2SU 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.V345581.R01.S.doc Version 5.2 Page 31 - 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!