Inspection on 08/08/05 for Tadworth Grove

This inspection was carried out on 8th August 2005.

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 27/07/07

Tadworth Grove 29/06/06

Tadworth Grove 21/11/05

Tadworth Grove 29/11/04

Tadworth Grove 15/06/04

Similar services:

The Shelley

Springfield House

Sutton Lodge Nursing Home

St Helier`s Residential Hotel

St Joseph`s

Ridgemount

Wingham Court

Old Hastings House

Extracts from inspection reports are licensed from CQC, this page was updated on 09/07/2008.

CARE HOMES FOR OLDER PEOPLE Tadworth Grove The Avenue Tadworth Surrey KT20 5AT Lead Inspector Denise Débieux Unannounced 8 August 2005 @ 10.00am th 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 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 H58 H09 S13354 Tadworth Grove V231491 080805 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Tadworth Grove Address The Avenue Tadworth Surrey KT20 5AT 01737 813695 01737 813285 Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) BUPA Care Homes Limited Mrs Loraine Stompé CRH - Care Home 72 Category(ies) of DE(E) - Dementia over 65 - (4) registration, with number OP - Old Age - (72) of places TI(E) - Terminally ill - (4) Tadworth Grove H58 H09 S13354 Tadworth Grove V231491 080805 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: 1 - Up to 46 of the registered places can be used for acute and continuing nursing care. 2 - Up to 6 beds may be used for respite care. 3 - Up to 4 beds may be used for palliative care. 4 - Up to 4 of the personal care beds may be used for service users in the category DE(E) demential over 65 years of age. Date of last inspection 29 November 2004 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 H58 H09 S13354 Tadworth Grove V231491 080805 Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place over 5.75 hours and was the first inspection to be undertaken in the Commission for Social Care Inspection year April 2005 to March 2006. This inspection was carried out by Denise Débieux, Lead Inspector for the service. Mrs Loraine Stompé, Registered Manager, was present as the representative for the establishment. A tour of the premises took place. Three care plans were inspected in depth and the statement of purpose, service users’ guide, the complaint’s log, three staff files and policies and procedures were all sampled. Three of the service users were spoken to at length; with a further six service users and seven on-duty staff being spoken with during the tour. The inspector would like to thank the manager, staff and service users for their time, assistance and hospitality during this inspection. What the service does well: What has improved since the last inspection? Improvements to the home made with the ongoing redecoration and refurbishment programme were apparent at this inspection. Tadworth Grove H58 H09 S13354 Tadworth Grove V231491 080805 Stage 4.doc Version 1.30 Page 6 What they could do better: 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 H58 H09 S13354 Tadworth Grove V231491 080805 Stage 4.doc Version 1.30 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 Standards Statutory Requirements Identified During the Inspection Tadworth Grove H58 H09 S13354 Tadworth Grove V231491 080805 Stage 4.doc Version 1.30 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 standard(s) 3 (Standard 6 does not apply as the home does not offer intermediate care) Each service user is only admitted to the home following a needs assessment to ensure that the home can meet the service user’s identified needs. EVIDENCE: The three care plans sampled during this inspection were seen to be based on comprehensive assessments of needs and clearly set out staff actions required to be taken in order to meet those needs. In conversation with a relative of one service user it was clear that he was confident that his relative is well cared for. Three service users were spoken with at length and all indicated that they felt that their needs were being met. Tadworth Grove H58 H09 S13354 Tadworth Grove V231491 080805 Stage 4.doc Version 1.30 Page 9 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 7, 8 and 10 Personal care and healthcare support and assistance is planned and was seen to be provided, where needed, in a respectful and sensitive manner. EVIDENCE: Service users spoken with were complimentary regarding the care they receive at the home. One service user, when asked if the staff looked after her well, replied ‘Oh yes, of course they do.’ Care plans inspected were comprehensive and set out actions which need to be taken by care staff to ensure that all aspects of the health and personal care needs of the service users are met. It was discussed and has been recommended that staff relate their daily report writing to the required actions identified in the care plans. On the tour of the home staff were observed to knock before entering the service users’ bedrooms and all interactions were seen to be respectful and caring. Tadworth Grove H58 H09 S13354 Tadworth Grove V231491 080805 Stage 4.doc Version 1.30 Page 10 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 standard(s) 13 and 14 Service users are supported and encouraged to maintain contact with family and friends and to exercise choice and control over their lives. EVIDENCE: There are no restrictions to visiting at the home and contact with family and friends are encouraged. Service users can visit with relatives in the communal areas or in the privacy of their own room as they prefer. Local entertainers that come to the home include a local fiddler, piano player and singers. Local clergy people also visit the home on a regular basis. The service users’ rooms seen all contained many personal possessions and were arranged, where possible, to the service users’ individual wishes. Care plans sampled included personal choices, where identified, one service user described how she likes to plan her day and that staff always respect her wishes. Service users handle their own financial affairs where appropriate. The inspector was advised that the home do not handle the financial affairs of any service users. Tadworth Grove H58 H09 S13354 Tadworth Grove V231491 080805 Stage 4.doc Version 1.30 Page 11 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 standard(s) 16 The home has a simple, clear and accessible complaints procedure which includes timescales for the process. EVIDENCE: There have been six complaints to the home in the past twelve months. These complaints had been well documented and the home’s policy followed in each case. Acknowledgement letters had been written promptly, followed by letters to the complainant with the outcome. Complaints were seen to be dealt with in an efficient and prompt manner. All service users spoken with stated that they knew who to go to if they had a concern. Tadworth Grove H58 H09 S13354 Tadworth Grove V231491 080805 Stage 4.doc Version 1.30 Page 12 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 standard(s) 19 and 24 The location and layout of the home and gardens are suitable for their stated purpose. An ongoing maintenance and redecoration programme provides the service users with clean, pleasant and homely surroundings in which to live. EVIDENCE: The home was toured during this inspection. The maintenance and redecoration programme for the home was seen to be ongoing with new carpets having been fitted in the upstairs of Pine Lodge (the residential unit). The gardens are well maintained and set out to the front, side and back of the home with seating provided in both shaded and sunny areas and providing pleasant surroundings for the service users and their visitors in the warmer weather. The gardens are fully accessible to all service users and the home is currently building a new patio seating area which will be accessed via the communal dining room. Tadworth Grove H58 H09 S13354 Tadworth Grove V231491 080805 Stage 4.doc Version 1.30 Page 13 On the day of inspection the home was found to be warm and bright with a comfortable and homely atmosphere. One service user commented that ‘I don’t think you can find a better home.’ Tadworth Grove H58 H09 S13354 Tadworth Grove V231491 080805 Stage 4.doc Version 1.30 Page 14 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 28 and 29 The home has a staff training programme which is designed to ensure, as far as reasonably possible, that service users are in safe hands at all times. Action must be taken to improve the staff recruitment procedures to ensure that service users’ safety is protected. EVIDENCE: The home is currently working towards having 50 of their care workers qualified to National Vocational Qualification (NVQ) level 2 in care or higher by 31st December 2005. Seven of the thirty-four care workers have already achieved the qualification, four are currently on the course and the home has six places reserved on the course due to commence in September of this year. Three staff files were reviewed at this inspection and were found to contain much of the information required. However, the manager was not aware of changes in legislation and amendments to The Care Homes Regulations 2001 that came into force on 26th July 2004. These changes relate to the information and documentation that care homes are required to obtain prior to offering new staff employment. The files inspected were for staff that had been employed after that date and did not include full employment histories, reasons for leaving previous jobs, gaps in employment were not explained and one file only had one reference. The home was also not aware that references to people being employed at the home, within the Regulations, applies to people who are brought into the home to provide a service e.g. hairdressers, chiropodists, clergy people etc. Requirements have been made regarding these areas of recruitment. Tadworth Grove H58 H09 S13354 Tadworth Grove V231491 080805 Stage 4.doc Version 1.30 Page 15 The manager is in overall charge of the day to day running of the home and the arranging of staff training and staff recruitment. The home employs an administrative assistant who assists in this but is also responsible for all other administrative tasks within the home, such as billing etc. A recommendation has been made that the home review the administration hours that are available to the manager in fulfilling her role. All service users spoken with stated that they felt safe with the staff with one service user stating that ‘The staff are always kind’. Tadworth Grove H58 H09 S13354 Tadworth Grove V231491 080805 Stage 4.doc Version 1.30 Page 16 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31 Service users benefit from the clear management approach at the home. EVIDENCE: The Manager is a registered nurse and has been at Tadworth Grove for the past twelve years. She is in day to day control of the home and all interactions observed between the manager and staff during this inspection clearly demonstrated an open, positive and inclusive atmosphere. The inspector was advised that Mrs Stompé will be retiring at the end of August 2005. A new manager has been appointed and will shortly be taking up her position. Tadworth Grove H58 H09 S13354 Tadworth Grove V231491 080805 Stage 4.doc Version 1.30 Page 17 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score x x 3 x x N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 x 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 x 13 3 14 3 15 x COMPLAINTS AND PROTECTION 3 x x x x 3 x x STAFFING Standard No Score 27 x 28 3 29 1 30 x MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x x 3 x x x x x x x Tadworth Grove H58 H09 S13354 Tadworth Grove V231491 080805 Stage 4.doc Version 1.30 Page 18 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 29.1-6 Regulation 2(3) 19(1)(a-c) Schedule 2 Requirement Timescale for action 08.08.05 2. 29.1 29.2 The registered person shall not employ a person to work at the care home unless the person is fit to work at the care home and he/she has obtained, in respect of that person, the information and documents specified in paragraphs 1 to 9 of Schedule 2 of the Care Homes Regulations 2001, as amended by The Care Standards Act 2000 (Establishments and Agencies)(Miscellaneous Amendments) Regulations 2004. This includes people brought into the home to provide a service e.g. hairdressers, chiropodists, clergy people. 19(1)(a-c) The registered person must Schedule obtain the following information: 2 - full employment history - explanation of any gaps in employment - verification of reason for leaving employment - two written references, including, where applicable, a reference relating to the last period of employment which involved working with vulnerable adults H58 H09 S13354 Tadworth Grove V231491 080805 Stage 4.doc 08.10.05 Tadworth Grove Version 1.30 Page 19 3. 29.1-3 29.6 retrospectively for each member of staff employed by the company after The The Care Standards Act 2000 (Establishments and Agencies)(Miscellaneous Amendments) Regulations 2004 came into force on 26th July 2004. 2(3) The registered person must 19(1)(a-c) obtain a criminal record bureau Schedule certificate for all persons 2(7) employed at the home, including any persons brought into the home to provide a service, e.g. hairdressers, chiropodists, clergy people etc. 08.11.05 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. Refer to Standard 7 29 Good Practice Recommendations It is recommended that staff relate their daily report writing to the required actions identified in the care plans to evidence how service users needs are being met. It is recommended that the registered persons explore ways to ensure that the policies and procedures of the home are updated promptly in line with any new and/or amended legislation. It is also recommended that the hours provided in administrative assistance to the manager be reviewed in order to facilitate this process. Tadworth Grove H58 H09 S13354 Tadworth Grove V231491 080805 Stage 4.doc Version 1.30 Page 20 Commission for Social Care Inspection 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. 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