Inspection on 07/07/09 for Tadworth Grove

This inspection was carried out on 7th July 2009.

CQC 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 CQC 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 16/07/08

Tadworth Grove 27/07/07

Tadworth Grove 29/06/06

Tadworth Grove 21/11/05

Tadworth Grove 08/08/05

Tadworth Grove 29/11/04

Tadworth Grove 15/06/04

Similar services:

The Shelley

Springfield House

Sutton Lodge Nursing Home

St Helier`s Residential Hotel

St Joseph`s

Ridgemount

Wingham Court

Old Hastings House

Extracts from inspection reports are licensed from CQC, this page was updated on 17/02/2010.

Key inspection report CARE HOMES FOR OLDER PEOPLE Tadworth Grove The Avenue Tadworth Surrey KT20 5AT Lead Inspector Lisa Johnson Key Unannounced Inspection 09:10 7th July 2009 DS0000013354.V375869.R01.S.do c Version 5.2 Page 1 This report is a review of the quality of outcomes that people experience in this care home. We believe high quality care should: • • • • • Be safe Have the right outcomes, including clinical outcomes Be a good experience for the people that use it Help prevent illness, and promote healthy, independent living Be available to those who need it when they need it. We review the quality of the service against outcomes from the National Minimum Standards (NMS). Those standards are written by the Department of Health for each type of care service. Copies of the National Minimum Standards – Care homes for older people can be found at www.dh.gov.uk or bought from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop. The mission of the Care Quality Commission is to make care better for people by: • Regulating health and adult social care services to ensure quality and safety standards, drive improvement and stamp out bad practice • Protecting the rights of people who use services, particularly the most vulnerable and those detained under the Mental Health Act 1983 • Providing accessible, trustworthy information on the quality of care and services so people can make better decisions about their care and so that commissioners and providers of services can improve services. • Providing independent public accountability on how commissioners and providers of services are improving the quality of care and providing value for money. Tadworth Grove DS0000013354.V375869.R01.S.doc Version 5.2 Page 2 Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report Care Quality Commission General Public 0870 240 7535 (telephone order line) Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CQC copyright, with the title and date of publication of the document specified. www.cqc.org.uk Internet address Tadworth Grove DS0000013354.V375869.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Tadworth Grove Address The Avenue Tadworth Surrey KT20 5AT Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 01737 813695 01737 813285 deanef@bupa.com www.bupa.co.uk BUPA Care Homes (CFC Homes) Ltd Vacant Care Home 71 Category(ies) of Dementia (0), Old age, not falling within any registration, with number other category (0) of places Tadworth Grove DS0000013354.V375869.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category/ies of service only: Care home with nursing - (N) to service users of the following gender: Either Whose primary care needs on admission to the home are within the following categories: Old age, not falling within any other category (OP) 2. Dementia (DE). The maximum number of service users to be accommodated is 71. Date of last inspection 16th July 2008 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 £ 500 for residential care and £700 for nursing care per week. Tadworth Grove DS0000013354.V375869.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this care home is 1 star- adequate service This site visit was part of a key inspection. The visit was unannounced. We arrived at 9.15 am and left at 6.40 pm Information was provided to us by the service prior to this visit in the Annual Quality Assurance Assessment. (AQAA). This is a self-assessment that focuses on how well outcomes are being met for people using the service. We received the AQAA by the expected date, which provided us with all the information we asked for. Reference is made to this assessment throughout this report. As part of this key inspection we were accompanied by an expert by experience. An expert by experience is a person who because of their shared experiences of using services and/or ways of communicating helped us to get a picture of what it is like to live in the home and their observations are included in this report. During this visit the expert by experience spent three and half hours in the service and explored people’s routines, staff interaction, how people are supported to make choices, raise their views, activities, looked at the suitability of the environment and observed the lunchtime arrangements. The expert by experience provided feedback to the inspector and the manager. The expert by experience provided a written report to us of their findings, which are incorporated in this report. Throughout this report they will be referred to as the Expert. Other methods used to inform our judgments made in this report include discussions with people, their representatives and members of staff, which also included two surveys. Since our previous visit the registered manager has transferred from this service and the home is currently being run by another manager from within the organisation (BUPA), with whom we had the opportunity to speak with. We looked at staff recruitment, and training records, care plans, risk assessments, menus, quality assurance systems, medication administration policies, health and safety records and policies and procedures were sampled. We also reviewed other information that we have received since our previous including notifications that the service is required to inform us about. . Tadworth Grove DS0000013354.V375869.R01.S.doc Version 5.2 Page 6 What the service does well: The service carries out detailed pre admission assessments prior to any person moving in to ensure that they will be able to meet their needs. Detailed care plans and risk assessments are in places, which contain information how people’s needs are met. The service has a structured activity programme, which includes events such as musical entertainers, movement and music, film shows, reminiscence, social events and the home recently held a strawberries and cream afternoon to celebrate the Wimbledon tennis finals. People receive well balanced and presented meals which meet with their preferences and they are provided with choices and alternatives. People told us they enjoyed their meals. Comments included, “Very good food” “and lots of choices”. What has improved since the last inspection? What they could do better: Further improvement is needed to ensure that people using the service and/or their representatives are consulted about their care plans to ensure they are fully involved and agree to their care plans Tadworth Grove DS0000013354.V375869.R01.S.doc Version 5.2 Page 7 Some matters were identified, which impact on people’s privacy and dignity, which must be addressed. People need to be more enabled to make choices and decisions about their lives within the home, which would result in person centred outcomes The service must ensure that notifications about information that the service is required to inform us and other agencies about is reported promptly. It is recommended that information that people using the service need to know is made more accessible. If you want to know what action the person responsible for this care home is taking following this report, you can contact them using the details on page 4. The report of this inspection is available from our website www.cqc.org.uk. You can get printed copies from enquiries@cqc.org.uk or by telephoning our order line – 0870 240 7535. Tadworth Grove DS0000013354.V375869.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.V375869.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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 1, 3, & 6 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The service does not provide intermediate care Information available that people need to know about the home but this would benefit from being made more accessible to them. People’s needs are assessed prior to admission to the home ensuring that the service can meet their needs. The service does not support people for intermediate care. EVIDENCE: During this visit we looked at the information provided to people who use the service to see whether it is able to supply detailed information about everything that people or their representatives need to know about the service. There is a statement of purpose and service guide. The AQAA states that this information is provided to all prospective people considering the home as a place to live. This information was also provided in each person’s room, Tadworth Grove DS0000013354.V375869.R01.S.doc Version 5.2 Page 10 although one person that we spoke with was not aware of this. Information about the service including the home’s aims and objectives. was also available in the reception area, but this was observed to be available in small print and placed at standing height which was more accessible to visitors rather then people using the service. The service has a clear admissions procedure, which includes an assessment process, which involves gathering information from the person, their representatives, care management assessments and any relevant health professionals. During this visit we looked at four people’s pre admission assessments, which were detailed and covered people’s health, personal, emotional, communication, social, cultural and religious needs. The service does not support people with intermediate care. Tadworth Grove DS0000013354.V375869.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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 ,10 &11 People using the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People’s health, personal, and social needs are set out in an individual care plan, although further improvement is needed to ensure people and /or their representative have been involved and consulted about their care plan. People’s health and personal care needs are in the main met. Some matters were identified that impact on people’s privacy and dignity. The home supports people with medication in a safe way. EVIDENCE: Each person has an individualised care plan in place, which were based on full up to date needs care assessment tool called Quest. During this visit we sampled four people’s care plans, which were detailed and covered health, emotional personal, social, lifeskils, relationships, culture and religion. Tadworth Grove DS0000013354.V375869.R01.S.doc Version 5.2 Page 12 Information seen demonstrated that these were regularly reviewed and up-todate. People’s care plans identified how support for each person is to be provided. People’s preferred names of address and routines were recorded as part of their care plan. However a person spoken with said, “Some things are not as good as they were”. This person told us that they sometimes get assisted to go to bed early when this is not always their preference and staff do not always assist them regularly enough with their toileting needs. Information supplied in the AQAA stated that people and their representatives are encouraged to attend care reviews and that they are involved in personal care planning. A member of staff told us that they review care plans with people and their representative. However four care plans we looked at contained a sheet to record resident and relative involvement but these were blank. Four people spoken with told us that were not aware of seeing a care plan and this was also confirmed by a relative spoken with. Therefore it is required that people and/or their representative are consulted, involved and confirm their agreement. The current manager told us that they are currently addressing some people’s care plans with them and their representative and they have identified that further improvement is needed in ensuring that consultation with people needs to take place Staff spoken with and two staff surveys received indicate that they receive up to date information about the needs of people they support Information seen demonstrated that nutritional, regular weight monitoring tissue viability and moving and handling assessments had been completed, which were up to date. Where equipment was required such as the use of hoists and the staff required to carry out these tasks were recorded. Where people may require bed rails risk assessments were in place. One person’s care plan identified that they require two members of staff when manoeuvring. This person told us that this is provided. Where people were identified at risk of falls risk assessments were completed and where people were identified a risk of developing pressure areas appropriate equipment such as pressure relieving mattresses had been provided. We were informed that a number of staff are completing a distance learning course in dementia awareness, which meets the needs of a number of people living in the service Four members of staff spoken with confirmed that they are completing this. During this visit the Expert observed a member of staff to have good skills in diffusing a hostile situation which had occurred in the Tadworth Grove DS0000013354.V375869.R01.S.doc Version 5.2 Page 13 dementia unit, which was causing distress to other people living there. This was short lived due to the care worker making boundaries clear and using good distraction techniques. The AQAA states that the service has links to regional and national specialists that are available for consultation. Records were maintained of all health consultations that people receive such as visits from the General Practitioner, chiropody and attendance at hospital clinics. A member of staff told us that they have links with community mental health specialists. Two people we spoken with thought that the home provided physiotherapy, although the service user guide states this can be arranged through private arrangement and they were not aware of general practitioner referral. This matter was brought to attention the manager. Information supplied in the AQAA stated that people can choose their own General practitioner, which was confirmed by the manager at the time of this visit. However some people spoken with by the Expert were not aware that if they lived locally and their General practitioner was happy to visit them in the service they could continue with their services. During this visit staff were observed to speak to people respectfully and were observed to respect people’s privacy. People spoken to by the expert mainly appeared satisfied with the home’s facilities and services and supportive of staff. One person said, “The staff do their best when they are so busy”. Other comments included, “Staff are respectful and I am happy”, “I am looked after well “’ “They try to do everything they can for you” and another person was particularly complimentary about one of the registered nurses on their unit. The Expert spoke to a visiting relative who stated, “They could not fault staff in any way their relative was cared for and felt everything necessary was being done for them” However two people said some staff have a better approach then others. A person said that that some staff do not communicate with you as well and sometimes they do not knock before entering. Another person told us that they were handed a telephone while using the bathroom despite being told this, although this has not occurred again. During this visit we looked at the medication administration practices in the service. Each unit has their own medication trolley and clinic room. During this visit we viewed the medication on one of the nursing units in Willow. Medication was stored appropriately in the clinic room. Medication is obtained from a local chemist using the monitored dose system (MDS). Records were kept of all quantities of medication received by the home. Fridge temperature records were maintained to ensure that medication that requires refrigeration is stored correctly. Tadworth Grove DS0000013354.V375869.R01.S.doc Version 5.2 Page 14 Systems were in place for the safe storage of controlled medication and we viewed the register, which was recorded correctly. We were informed that the pharmacy visit to carry out audits. A list was maintained of staff with their signatures that are trained and authorised to administer medication. Medication administration records contained photographs of the person for identification and four medication administration records sampled had been signed with no gaps present. End of life of life plans have been addressed, which were recorded in care plans sampled, which was also confirmed by people spoken to by the Expert. Tadworth Grove DS0000013354.V375869.R01.S.doc Version 5.2 Page 15 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 & 15 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People are provided with activities that meet with their interests social, cultural and religious needs. People in the home need to be more enabled to make decisions and choices and have control over their lives People are provided with varied and well balanced meals, but some practices are not person centred. EVIDENCE: The home has a weekly activities time table in place, which was seen on display, although this would benefit from made accessible to people in the living areas. Three activity coordinators are employed by the home, although one was away at the time of this visit. The expert observed that there were no collective or individual activities taking place, although later on we saw activities taking place with people in the dementia unit in Pine lodge who were participating in memory games and another coordinator was visiting people in the afternoon. People living in this unit also have the opportunity to take part Tadworth Grove DS0000013354.V375869.R01.S.doc Version 5.2 Page 16 in activities in the main lounge. The home provides a large hairdressing salon and we were informed that there are volunteers who visit. Some of the activities provided included, film afternoons, theme events, and movement with music, quizzes, bingo and visiting entertainers. A person spoken with told us that they are unable to visit the main lounge due their needs but was very appreciative that a musical entertainer visited them in their room. Occasional visits outings take place to garden centres, tea rooms and a tea dance was advertised. The home held a Wimbledon finals event with strawberries and cream. A person told the Expert that were very appreciative of a new member of staff who had enabled them to have lunch in their room so that she could watch the Wimbledon Men’s final on the television. Once they had made the request other people also requested to have lunch in their room and the member happily complied with all requests. Each person has Map of Life incorporated in their care plan, which provides information about people’s interests and hobbies and life histories. Some people told the Expert that were taken out from time to time and that the service could order accessible transport. One person said that they used to be able to walk to the library but due to a change needs was now unable to do this now and had asked staff several times for this information as phoning the library had produced no response . People’s religious needs are respected and three local churches visit the home every third Sunday where people can enjoy a short service. The service employs an open visiting policy taking in to account people’s wishes. Relatives and friends are invited to attend social events. During this visit some people were receiving visitors and some people told us they go out with their relatives and friends. Some people have their own telephone for maintaining contact and we informed that a portable telephone is also available for people to receive calls if they do not have their own telephone. A person was observed to have a computer in their room and the manager told us that it is intended that intranet access in all bedrooms will be made available. People are able to bring in their own furniture and personalise their room to their choice and are encouraged to handle their financial affairs. The Care plan considers information including whether people have a lasting power of attorney and we were informed that one person recently admitted to the service has an appointed Independent Mental Capacity Advocate (IMCA) On looking around the home the Expert observed that in both the residential and nursing home accommodation, there was no information available on display, which told people about their rights, opportunities and choices. Further improvement could be made to assist people to become more empowered to Tadworth Grove DS0000013354.V375869.R01.S.doc Version 5.2 Page 17 make more choices and decisions. The expert spoke with one person who was not happy about their admission to the home but was not aware that they could request an independent advocacy for reassessment. Prior to lunch being served, the Expert observed one person requesting a cup of tea and this request resulted in a small group of people all being served tea. When one person was asked if they would like a second cup, the resounding response was “Yes please”, to which the member of staff said, “Its only twenty minutes to lunchtime, don’t you think it will spoil your lunch”. The person quickly agreed that they would do without. The home provides a four weekly rotating menu, which is changed seasonally. The menu was varied and well balanced and consisted of choices and alternatives. There is a choice of cooked breakfast each day, which one person told us that they enjoyed. The service provides a night bite menu, which ensures that food is available for twenty four hours. Meals are provided to meet different dietary and cultural needs The menu was seen on display on the dining room wall, although it was advised that the menu be made more accessible to people for them to be able to see this more clearly. The manager showed us the menu holders that they intending to use to provide the menus on the tables. During this visit refreshments were provided through the day with home made biscuits and cakes. The supper served in the evening was well presented. People can receive their meals in their bedrooms if this meets with their preference. The Expert observed the lunch time arrangements and saw that that the majority of people, mainly wheelchair users had their lunch in the main dining room. Tables were of a good height and placed far enough apart to enable both comfort for both people and staff who were required to assist people with their meals. People were supplied with napkins and where assistance was required people were helped to place these. The main dish was served on an individual plate and placed before each person and the vegetables were offered from serving dishes with each person asked for their preferred portion size. There was unanimous agreement that the food was “nice” but it was not very hot. The Expert observed that where people could communicate conversation was taking place. Where staff were assisting people to eat, one member of staff never spoke with the person and another member of staff asked the person so many questions and with fork full’s of food regularly being offered, there was no time for the person to respond. Tadworth Grove DS0000013354.V375869.R01.S.doc Version 5.2 Page 18 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 16 &18 People using the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People using the service and their representatives concerns and complaints were listened to. Improvement is needed to ensure that staff report any safeguarding matters promptly to relevant agencies EVIDENCE: We looked at information provided to people, which tells people about how they can make complaints. During this visit we saw a copy of the homes complaints procedure, which was seen on display in the reception area. The Expert observed that this information is mainly provided in small print and is positioned at standing height and would not be accessible to people using wheelchairs. This information is also provided in the service guide, but would benefit from being displayed in other prominent areas throughout the home where people live. The home also has a suggestions box, which would also benefit from being placed in areas where people using the service mainly access. Tadworth Grove DS0000013354.V375869.R01.S.doc Version 5.2 Page 19 Four people spoken with said that would be confident of approaching the manager or a registered nurse in charge if they had any concerns or complaints. Two members of staff surveyed said that they are aware of the procedure about what to do if somebody raised a complaint. Since our previous visit the service has received seventeen complaints. During this visit we sampled some of the complaints that had been raised. These were varied ranging from lost items to care matters. One matter has resulted in the local authority safeguarding procedures being invoked. Clear and detailed records were maintained of all the complaints and the concerns received and the action that has been taken to resolve them. .. The service has safeguarding vulnerable adults from abuse and whistle blowing procedures in place. The most recent local authority procedure has been obtained, which has been made available in all of the units throughout the home for reference. Three members of staff spoken with during this visit told us that were aware of the procedures, that they had attended training and were clear about their responsibilities should they witness or be made aware of any incident where the safety of a person is compromised. We sampled three members of staff training records and looked at the staff training matrix, which confirmed that action has been taken in ensuring that staff have received updated safeguarding vulnerable adults from abuse training. Since our previous visit four safeguarding referrals have been made following the local authority safeguarding vulnerable adults from abuse procedures, which have resulted in two matters being accepted by the local authority which the service brought to the attention of the Commission. These two matters have now been concluded. However while viewing the accident and incident records information was seen that one matter pertaining to an incident between two people living in the service had not been brought to our attention or to the local authority, this was brought to the attention of the manager. This incident had taken place in between the previous manager leaving and the new manager commencing, which had not been reported. The current manager has now taken prompt action and has supplied this information to us and to the local authority safeguarding team. Tadworth Grove DS0000013354.V375869.R01.S.doc Version 5.2 Page 20 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 19, 22 &26 People using the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People using the service live in an environment that is in the main safe, maintained, comfortable and clean but will be enhanced with the refurbishment of the residential unit EVIDENCE: Accommodation is provided in two units, Willow, which supports people who require nursing care and Pine lodge, which provides residential accommodation. Since our previous visit the reception area has been upgraded. The link corridor between Willow and Pine lodge and the lounge Tadworth Grove DS0000013354.V375869.R01.S.doc Version 5.2 Page 21 areas in Willow have been redecorated. The service is supported in maintaining the environment by a central team. A large lounge is available and dining room dining room which was well maintained. The Expert observed that little touches like flowers and fruit were not present. There was a non working grand father clock in a small sitting room and a large clock in the large sitting area was high up on the wall with the time obscured by the light. During this visit the home was observed to be accessible for people using wheelchairs and a lift is provided. Grab rails were provided throughout and assisted bathrooms are available. At the time of this visit the ground floor, which is vacant was having a walk-in shower installed to provide more choice to people. However the Expert observed that hand gel- based sanitizers were sited in a number of communal areas and are extremely difficult if not impossible for disabled people to operate and use because of their position. There are well maintained gardens and some people told the Expert that their rooms faced on to the lawn and flower beds and were appreciative of this aspect. We were invited by some people to visit their rooms, which were personalised with their belongings. One person told us when they were first admitted to the home, they expressed dissatisfaction at their allocated room, which was not appropriately decorated and clean. After raising this matter with the manager they were then allocated an alternative room, although this person would have benefited from being supplied with a mirror. The Expert visited Pine lodge, where one floor accommodates people with dementia. It was observed that bedrooms were situated of corridors and all the carpeting was similar in design and colour and doors and walls were a cream tone and each door had a small name plate with the persons name on card in small type face, which does not assist people with orientation. The manager informed us that there are plans in process for this unit to be redecorated. The AQAA states that people and their representatives are to be consulted about the impending refurbishment, which also includes further improvements to Willow. At the time of this visit the service was observed to be clean. Specialist cleaning systems are in place and the AQAA states that the housekeeping rota has been reviewed to ensure that that there are enough of them during the day. Infection control procedures are in place and the home has received a visit from environmental health, which was satisfactory. Tadworth Grove DS0000013354.V375869.R01.S.doc Version 5.2 Page 22 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 & 30 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The staffing levels currently meet the needs of people living in the service. Staff are in the main supported to attend training and development to ensure that they are able to meet the needs of people and they are protected by robust recruitment procedures. EVIDENCE: Currently there are forty five registered nurses and care staff employed by the service, Information supplied by the AQAA states that there has been minimal staff turnover and since our previous visit the skill mix of staff has improved. Although the home is registered for seventy one people, there are a number of vacancies and the home is currently supporting thirty eight people. The current manager informed us that the current staffing levels are based on these numbers and on the dependency levels of people, which is continuously reviewed to ensure that appropriate staffing levels are supplied. The Expert spoke with two people who said there was not enough staff. Two people told us that sometimes there can be delay when responding to call bells. Tadworth Grove DS0000013354.V375869.R01.S.doc Version 5.2 Page 23 A registered nurse heads each nursing unit that are supported by two to three carers. We were informed that Pine lodge, which provides residential care, is headed by a senior carer that holds National Vocational Qualification (Level 3). At the time of this visit there were three members of staff available in this unit, which is also overseen by the Home’s deputy manager. The duty rota was sampled, which confirmed that the names of staff on duty and the agreed numbers of staff were provided. Four members of staff spoken with thought the staffing levels were sufficient. Staff is also supported by catering, activity coordinators, laundry, domestic, maintenance and administrative staff. New staff receive induction, which follows the Skills for Care core induction standards. Three members of staff confirmed that had received induction. Out of thirty five care staff employed eleven hold National Vocational qualifications (Level 2) or above. The deputy manager told us that there are some staff completing the qualification and they are intending to enrol some more staff on the course shortly. Information supplied in the AQAA stated that the organisation (BUPA) has obtained Investors in People accreditation for staff training and development. The current manager has attended training on the mental capacity act and Deprivation of Liberty Safeguards and is aware that staff require training in these matters to enhance their understanding. We were informed that equality and diversity training has also been requested. The service has implemented a staff training matrix which records training which they have attended including statutory training. Improvement was identified in this area and four members of staff spoken with told us about the statutory training that they have completed in the last year, although the matrix record would benefit from being made clearer. The manager also told us that they are intending to appoint a training coordinator for the home. Four members of staff spoken with and a survey received stated that staff are supported to attend training and development, although one survey indicated that not all staff are trained Staff recruitment is based on equal opportunities and the current staff are of mixed gender and ethnicity. Four members of staff personnel files were sampled during this visit, which included all the documentation, which is required including fully completed application forms, two written references and enhanced criminal record bureau checks (CRB). Staff are provided with the General Social Care Code of conduct (GSCC). A file sampled for a registered nurse contained their personal identification number nurse registration number, although it was observed that this needed updating as it was now of out of date. Tadworth Grove DS0000013354.V375869.R01.S.doc Version 5.2 Page 24 Tadworth Grove DS0000013354.V375869.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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 31,33, 35 & 38 People using the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The organisation needs to appoint a permanent manager. Further improvement is needed to ensure that the home is run in the best interests of people living there. People’s safety and welfare is in the main protected. EVIDENCE: Prior to this key inspection the registered manager has transferred from this service. The home is temporarily being run by another experienced registered manager from another service within the organisation (BUPA). We were informed that the permanent manager vacancy is already being advertised. The current manager was available for this visit, who had only been working in Tadworth Grove DS0000013354.V375869.R01.S.doc Version 5.2 Page 26 the service for three weeks, who told us that they are intending to be at the service for at least the next three to four months to ensure that effective handover takes place to the new appointed manager. During our visit some concerns were raised from people and staff about the changes in manager, however we received some positive comments including, “The new manager is accessible and approachable”. During discussion with the current manager they had already identified areas that need to improve and was positive in their approach about the changes that they wish to address. Four members of staff spoken with told us that regular team meetings take place, that they enjoy working in the service and feel supported by the managers. The Expert also spoke to some staff who also said that they enjoyed their job. During this visit we looked at the home’s certificate of registration, which has been changed to reflect that there is registered manager’s vacancy. The numbers and categories of people being supported were correct. Monthly unannounced quality monitoring visits are conducted by the registered provider, which was available for viewing. In addition a range of other quality audits are conducted such as care plans, and medication. The organisation has demonstrated that feedback is obtained from people living in the service to gain their views. Annual quality assurance surveys have been carried out to gain the views of people and their representatives. The outcomes have been analysed and action plans have been implemented. The service holds resident and relative meetings, although some of the minutes sampled did not state which people had attended. The manager is intending to implement coffee mornings with people to provide a further opportunity for listening to people’s views about the service. The home also provide a news letter to keep people and their relatives informed of developments and changes. Policies and procedures are in place for the safe handling of people’s monies. We were informed that the service does not handle monies on behalf of people. People handle their own affairs or by their representatives. The service provides an invoicing system for the payment of items such as hairdressing. We were shown some records, which demonstrated that all expenditure is recorded and receipts are maintained. Staff receive regular formal one to one supervision, which was demonstrated by records maintained in their personal files and this was also confirmed by staff spoken with. The service has a range of health and safety procedures in place. Monthly health and safety audits care carried out and water temperature monitoring is conducted. Staff training records sampled demonstrated that they receive Tadworth Grove DS0000013354.V375869.R01.S.doc Version 5.2 Page 27 statutory training including first aid, moving and handling and health and safety. Information supplied in the AQAA and from records sampled during this visit confirms that regular servicing and maintenance of equipment takes place. Accident and incident records were maintained, although one matter was identified that had not been reported to us, which is required by the regulations (see standard 18). Tadworth Grove DS0000013354.V375869.R01.S.doc Version 5.2 Page 28 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 2 X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 3 10 2 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 2 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 2 2 X X 2 X 3 X 3 STAFFING Standard No Score 27 3 28 2 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 3 X 3 3 X 2 Tadworth Grove DS0000013354.V375869.R01.S.doc Version 5.2 Page 29 Are there any outstanding requirements from the last inspection? No STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP7 Regulation 12 (2) 15(1)(2) (a)(C) 12 (4) (a) 12 (2) 37 Requirement The registered person must ensure that people and/or their representative are consulted about their care plan. The registered persons must ensure that people’s dignity and privacy is respected at all times. The registered persons must ensure that people are enabled to make decisions and choices The registered persons must ensure that notice is given to the Commission without delay of the occurrence of any event in the home which adversely effects the well being or safety of any service user. Timescale for action 09/09/09 2 2 3 OP10 OP14 OP38 09/08/09 09/09/09 14/07/09 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 OP14 Good Practice Recommendations It is recommended that information provided in the home DS0000013354.V375869.R01.S.doc Version 5.2 Page 30 Tadworth Grove is made more accessible to people. Tadworth Grove DS0000013354.V375869.R01.S.doc Version 5.2 Page 31 Care Quality Commission South East Region Citygate Gallowgate Newcastle upon Tyne NE1 4WH National Enquiry Line: Telephone: 03000 616161 Email: enquiries@cqc.org.uk Web: www.cqc.org.uk We want people to be able to access this information. If you would like a summary in a different format or language please contact our helpline or go to our website. Copyright © (2009) Care Quality Commission (CQC). 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