Inspection on 29/06/06 for Tadworth Grove

This inspection was carried out on 29th June 2006.

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 16/07/08

Tadworth Grove 27/07/07

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 Kenneth Dunn Unannounced Inspection 29th June 2006 09:30 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.V301813.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.V301813.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 www.bupa.co.uk BUPA Care Homes (CFCHomes) Limited Marie Buys 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.V301813.R01.S.doc Version 5.2 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 4 beds may be used for palliative care. Up to 6 beds may be used for respite 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. 21st November 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 is offered in the three-storey building and residential care in the smaller two-storey 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. Tadworth Grove DS0000013354.V301813.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was unannounced and undertaken by Kenneth Dunn. The Registered Manager Marie Buys was present throughout the inspection. There was opportunity to meet and talk with several service users during the visit. Some service users were able to comment about their experience living in the home in more detail then others. The service users being nursed in bed were well cared for and appeared comfortable. It was also possible to meet and talk with staff on duty. They were knowledgeable about the service users in their care and able to confirm various aspects of training they had undertaken. A tour of the premises was undertaken and records relating to the care of the service users and the management of the home were examined. The inspector would like to thank the manager service users and staff for their help and hospitality during this visit. What the service does well: What has improved since the last inspection? What they could do better: The manager must ensure that the all service users have their rights upheld, all documentation regarding the service users must be based by supporting facts. The manager must also ensure that the internal redecoration and remedial work in the garden is completed as a matter of some urgency. Tadworth Grove DS0000013354.V301813.R01.S.doc Version 5.2 Page 6 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.V301813.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Tadworth Grove DS0000013354.V301813.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 3 & 6 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The services statement of purpose and service user guide are well presented providing service users and/or their representatives with clear user-friendly information, enabling an informed choice to be made about admission to the home. Contract are signed and retained on file. The arrangements for assessing needs are adequate ensuring service users needs are gauged and identified before admission to the home. Tadworth Grove does not provide for intermediate care. EVIDENCE: The home has a statement of purpose and service user guide they well presented and clearly written in plain English to make the information accessible to staff, service users and relatives. The manager informed the inspector that the documents were under review and at the time of the inspection they were awaiting feed back and impute form external professional GP, Care Managers and the local Primary Care Trust. The manager stated that the documents would be further updated once the feedback has been received and collated. The inspector randomly selected a percentage of service users files they all contained a signed contract detailing the terms and conditions of the home. Tadworth Grove DS0000013354.V301813.R01.S.doc Version 5.2 Page 9 The home has a policy on assessment of needs and the manager stated service users are admitted to the home only after a full assessment, which covers health, personal and social care needs. The inspector sampled care plans and noted service users had completed needs assessments and a written care plan, which included personal safety and risks. Tadworth Grove DS0000013354.V301813.R01.S.doc Version 5.2 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. 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 available evidence including a visit to this service. The arrangements for care planning needs strengthening. The management of medications at the home is high quality promoting good health. The arrangements for privacy and dignity are adequate. EVIDENCE: The care plans are drawn up with the involvement of the service users and or their representatives the plan sets out in details the action needed to ensure service users needs are met. Care plans sampled indicated that there is clear information for the staff to follow to ensure that the needs of the individuals are met. However during the random review of the care plans there was evidence of unsubstantiated records indicating behavioural issues with individual service users. In discussion with the manager and the service user the inspector was unable to find any supporting evidence to infer that any behavioural issues existed and that staff were at risk from the individual. The manager must ensure that only relevant and factual information is recorded on service users plans. The manager must instruct her staff that if there is no factual evidence to uphold an entry then they should not make reference to this as it could be regarded as discriminatory. The manager should conducts a random monthly review of care plans to ensure that the process has been Tadworth Grove DS0000013354.V301813.R01.S.doc Version 5.2 Page 11 completed and that all care plans are signed and dated by the relevant individuals. Service users are registered with a GP and have access to hearing and sight tests, chiropody and dental services are sourced within the local area. During the inspection the manager was assisting one service user to arrange an appointment with her dentist. The home has a policy on medications in line with the National Minimum Standards. Medications were appropriately stored and medication record sheets were dated and signed by staff. Staff have training in the administration of medications and attendance dates were in staff training files. The home has a policy guaranteeing the service users privacy and dignity. The staffs knocked on doors before entering service users bedrooms and were on the whole respectful of the individual they were engaging with. However two service users stated that they were not always respected and in some cases staff members could be very brisk with them. They both felt that this might in part be due to the fact that they have raised issues in the past. In addition a service user with Alzheimer’s was being incorrectly addressed by staff, this could cause even greater confusion for this individual as this persons condition deteriorates. The manager must ensure that staff are aware of the correct method of addressing any service users and ensure that all of the documents adhere to the same format. Tadworth Grove DS0000013354.V301813.R01.S.doc Version 5.2 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12 & 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home arranges a wide range of activities, which enhance the lives of its residents. Meals are nutritiously balanced and offer a healthy and varied diet for the service users living at Tadworth Grove. EVIDENCE: Service users preferred social and leisure interests are recorded in their care plans and records kept show what activities are undertaken at the service. A notice board displays up to date information about activities and social events. Activities available include: exercise sessions; bingo; cards and visiting entertainers, with local library facilities and involvement with local churches. The service users have access to an in house hairdresser, which one service user commented on being a “treat that she looks forward to”. Individual service users have the opportunity to participate in religious ceremonies as their faith so determines. Menus are varied, balanced and appeared to provide a good choice. The service users were divided in respects of the meals offered at the home 5 mentioned that the food was excellent and that they were very happy with what they were being provided. However 3 service users felt that the food was sometimes very bland and on occasions unappetising one felt that could do Tadworth Grove DS0000013354.V301813.R01.S.doc Version 5.2 Page 13 with a “being sorted out” and maybe more impute from the residents was required. It was recommended that the manager open the meal planning and designing to the service users in an effort to bring their tastes and experiences into consideration when providing food. Tadworth Grove DS0000013354.V301813.R01.S.doc Version 5.2 Page 14 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 & 18 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. An appropriate complaints procedure is in place to ensure that the views of the residents, their families. The home has an up to date copy of the local authority (Surrey County Council) Multi Agency Safeguarding Adults Policy. EVIDENCE: The service has comprehensive policies and procedure in place for dealing with complaints and they are accessible to service users and their representatives. Information is made available in the service users guide about how a complaint, concern or a suggestion should be made and how they should be handled. However as was previously mentioned on page 10 of the report there has been issues brought to the attention of staff that have not been dealt with using the prescribed methods established within the policies and procedures. This has resulted in more than one service user feeling uncomfortable and very isolated. The manager recognised this issue and informed the inspector that measures will be strengthened and if new policies have to be developed that is what must happen. When the manger was made aware of the feelings of the service users she acted promptly and effectively in an attempt to minimise the negative feelings felt by the people concerned. The manager must however ensure that all service users issues are dealt with equal respect and gravity and in addition the staff have a responsibility to the manager to keep her apprised of all issues good or bad that are occurring within the home. Tadworth Grove DS0000013354.V301813.R01.S.doc Version 5.2 Page 15 All service users spoken to on the day of the inspection stated that they felt safe at the home, and although one or two had some issues with the service 85 of the residents had no complaints and felt that the fully met their needs. Tadworth Grove DS0000013354.V301813.R01.S.doc Version 5.2 Page 16 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): 19, 22, 24, 25 & 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The environment was safely and adequately maintained to a good standard of repair in order to ensure the welfare of service users and staff. The standard of hygiene in the service was good. EVIDENCE: The furniture and furnishings are homely and adaptations have been made where a service user has a specific need. The range of communal space means that there can be different activities happening throughout the home at the same time. The home is built in a large landscaped garden, which was described by one resident as “one of the main reasons for her coming to stay at Tadworth Grove”. The overall décor of the home is not as good as it should be in areas the wall were scuffed and paint has been chipped away by constantly being hit by wheelchairs and trolleys. The back garden area is a great amenity for the service users whose bedrooms have direct access onto it however the general poor state of the paths could be regarded as a trip hazard. It is then a Tadworth Grove DS0000013354.V301813.R01.S.doc Version 5.2 Page 17 requirement that the manager develops a programme of redecoration and repair for these areas to return them to there previously high standard. Tadworth Grove DS0000013354.V301813.R01.S.doc Version 5.2 Page 18 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 & 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The staff rota reviewed demonstrated that the staffing numbers and skill mix were appropriate to meet the assessed care needs of the service users in the home on the day of inspection. The Registered Manager ensures that care workers receive appropriate induction and training, including National Vocational Qualifications (‘NVQ’) training. EVIDENCE: Review of the month’s rota demonstrated that adequate numbers of care workers with appropriate skill mix were roistered on duty, with special attention to increased staffing at peak periods. Service users spoken to inform the inspector they were not rushed, and could get up or go to bed at a time they preferred. The recruitment process is robust and is designed to minimise any potential risk to the service user. The Manager is committed NVQ training for all staff, on the day of the inspection 5 members of staff were being assessed for their level 2 NVQ in care award. The independent NVQ assessor informed the inspector that there was a strong commitment in the home to assist staff to gain qualifications and the manger was willing to assist her staff in any way possible. The manager has developed a detailed training matrix for all staff, these documents list all training requirements and can highlight any gaps within a persons development Tadworth Grove DS0000013354.V301813.R01.S.doc Version 5.2 Page 19 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 & 38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users benefit from the clear management approach at the home. The home has systems in place to monitor the quality of care and service s provided. 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 registered manager is a registered nurse and has completed her Registered Managers Award training. All service users spoken to on the day of the inspection spoke very highly of the professionalism and accessibility the manager has brought to the home. 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 Tadworth Grove DS0000013354.V301813.R01.S.doc Version 5.2 Page 20 monthly survey carried out by an external company. There are three monthly residents’ meetings and also a three monthly newsletter is produced. The home does not handle financial affairs for service users. 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. Samples of health and safety certificates were inspected and found to be in order. Tadworth Grove DS0000013354.V301813.R01.S.doc Version 5.2 Page 21 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 X 3 HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 1 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 2 17 X 18 2 2 X X 3 3 3 3 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 3 Tadworth Grove DS0000013354.V301813.R01.S.doc Version 5.2 Page 22 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 OP10 Regulation 12(4 a) Requirement The manager must ensure that only relevant and factual information is recorded on service users plans. The manager must instruct her staff that if there is no factual evidence to uphold an entry then they should not make reference to this as it could be regarded as discriminatory The manager must ensure that staff are aware of the correct method of addressing service users and ensure that all of the documents adhere to the same format. The manager must ensure that the service users can have confidence in a robust complaints policy. The manager must ensure that the interior redecorations and the exterior remedial works to the garden are completed as a matter of urgency. Timescale for action 29/06/06 2 OP10 12(4 a) 29/06/06 3 OP16 22(1,3&4) Schedule 4.11 16(1) 23(1 & 2) 30/09/06 4 OP19 30/09/06 Tadworth Grove DS0000013354.V301813.R01.S.doc Version 5.2 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 Refer to Standard OP10 Good Practice Recommendations The manager should conducts a random monthly review of care plans to ensure that the process has been completed and that all care plans are signed and dated by the relevant individuals. It was recommended that the manager open the meal planning and designing to the service users in an effort to bring their tastes and experiences into consideration when providing food. 2. OP15 Tadworth Grove DS0000013354.V301813.R01.S.doc Version 5.2 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.V301813.R01.S.doc Version 5.2 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. 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