Inspection on 18/12/07 for The Tudors

This inspection was carried out on 18th December 2007.

CSCI found this care home to be providing an Adequate service.

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

The Tudors 04/01/07

The Tudors 15/02/06

The Tudors 06/09/05

The Tudors 17/03/05

The Tudors 07/09/04

The Tudors 30/03/04

Similar services:

Fairfields Country Rest Home

Poldhu

Queensmount

Trevaylor Manor

Didsbury Court Rest Home

Belma

Hunters Care Centre

Manor Lodge

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

CARE HOMES FOR OLDER PEOPLE The Tudors Street Road Glastonbury Somerset BA6 9EQ Lead Inspector Justine Button Unannounced Inspection 18th December 2007 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 The Tudors DS0000015996.V355515.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. The Tudors DS0000015996.V355515.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service The Tudors Address Street Road Glastonbury Somerset BA6 9EQ 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) 01458 831524 01458 831608 MRS NOREEN MARIA KHAN Mrs Wendy Lavinia Weddell Care Home 21 Category(ies) of Old age, not falling within any other category registration, with number (21) of places The Tudors DS0000015996.V355515.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection Brief Description of the Service: The Tudors provides residential accommodation for adults under the Older Persons category of registration. The home is owned by Mrs N. M. Khan-Mullane. The registered manager is Mrs Wendy Weddell. The home is sited in Street Road, not far from the centre of Glastonbury, sited at the base of a hill and facing an access road to the town. There is a large supermarket just opposite and local facilities nearby. There are patio areas and steps leading to an attractive hill garden at the back of the property. Access to the garden is limited to mobile residents who can manage the stairs but there is easier access to the patio areas. There is car parking space at the front of the property. Residents’ accommodation is on two floors. The first floor is accessed by stair lifts. Some bedrooms of the first floor have nice views of the hill beside it, others of the garden or the front of the house. The home has one double room. All other rooms are single, some with en-suite and all have washing facilities. Communal areas, staff office and the kitchen are sited on the ground floor. The Tudors DS0000015996.V355515.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 service is 1 star. This means the people who use this service experience adequate quality outcomes. This was the third key inspection using the Commission for Social Care Inspection’s new Inspecting for Better Lives methodology. The site visit was unannounced and carried out over one day. Additional information not available on the day of the inspection was forwarded to us following the inspection. At the time of this inspection visit there were 20 service users in the care home. During the day the inspector was able to speak at length to a number of people living in the home, observe the care practices and lunch, talk to relatives, tour the home and review records. As part of the pre-planning inspection comment cards were sent to visiting professionals, relatives and people living at the home. The replies received were all very positive. The inspector was able to have detailed discussions about the service delivery with the registered provider and registered manager. The inspection included the case tracking. Records reviewed included staff files, care plans and medicine administration records. The care home’s complaint and vulnerable adult policies were reviewed. The quality rating for this service is 2 star. This means the people who use this service experience Good quality outcomes. The Tudors DS0000015996.V355515.R01.S.doc Version 5.2 Page 6 What the service does well: What has improved since the last inspection? Visits to prospective residents are now completed by the manager. A pre admission assessment is completed and the information is used, in conjunction with that received from other agencies, to ensure that the home can meet the needs of the individual prior to admission. The home’s environment continues to be upgraded and fixtures and fittings replaced. This includes some bedroom the laundry and access to one of the bedrooms. An additional bedroom which was considered unsuitable as you had to go through one bedroom to access another is no longer in use thus ensuring the privacy of the individuals at the home. The home has recently purchased it’s own transport which has improved access to the community and the opportunity to undertake activated outside of the home. The care planning system continues to be developed. The Tudors DS0000015996.V355515.R01.S.doc Version 5.2 Page 7 What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The Tudors DS0000015996.V355515.R01.S.doc Version 5.2 Page 8 The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. The Tudors DS0000015996.V355515.R01.S.doc Version 5.2 Page 9 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 The Tudors DS0000015996.V355515.R01.S.doc Version 5.2 Page 10 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 3, 4, 5 standard six is not applicable to this service. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Information about the home is available although this needs to be reviewed. Admissions to the home only take place if the service is confident that they are able to meet the assessed needs of the prospective resident. Not all people living at the home is provided with a statement of terms and conditions before making a decision on residency. EVIDENCE: The home produces a Statement of Purpose and a service users guide that gives information about the way the home is run to prospective residents and their family. These documents were viewed during the inspection. The The Tudors DS0000015996.V355515.R01.S.doc Version 5.2 Page 11 documents were last reviewed by the management team in April 2006. It is recommended that these be reviewed to ensure that the information that they contain is still relevant and applicable to the services provided. The contract to occupy the care home accommodation is not given to all prospective residents and their relatives/representatives. This needs to be completed in line with the recommendations made by the office of fair trading. The manager or a senior member of staff meets with prospective residents and their relatives/representatives and a pre admission assessment is undertaken to ensure that the home can meet their needs before they move into the home. The home also takes into account information provided by prospective residents GPs, district nurse and social services if funded via care management arrangements. Prospective residents are encouraged to visit the home and spend time there before making a decision on residency. This was confirmed by viewing the file of a person who had recently moved into the home. There are extra charges for newspapers, hairdressing, chiropody, clothing and some trips and activities. These are charged at cost. The Tudors DS0000015996.V355515.R01.S.doc Version 5.2 Page 12 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9,10. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The standard of care delivered is good and the registered person has improved the quality of the care plans so that they have become a working tool and contain all necessary assessment tools. The home has good relations with the local healthcare services. Medications management in the home is adequate EVIDENCE: The inspector sampled three care plans and met with the individual residents as part of the case tracking process. Individual residents preferences and cultural needs were reflected in two of the care plans sampled. One of the care plans sampled contained social profiles. The Tudors DS0000015996.V355515.R01.S.doc Version 5.2 Page 13 The care plans seen contained a nutritional needs assessment. Pressure and moving and handling risk had also been assessed. A range of risk assessments had been completed for all individuals. It was evident in one of the plans that one individual had reduced vision. This had not been taken into account when completing the risk assessments. The management need to ensure that all plans are completed consistently, contain the necessary information and consider the individuals needs. There was evidence in all of the plans viewed that individuals living at the home or their representative were involved in the development and review of their plan of care. The home has good communication with the local hospital and community health care services. The home has recently purchased it’s own transport. This is used to enable people to access the local GP surgery’s and hospital appointments if they are able. This is positive and gives the feeling of normality to the people living at the home. Surveys from Health Care Professionals and GP’s indicated that they were satisfied overall with the level of care provision at the home. Visitors spoken to were satisfied with the provision of care. People living at the home consulted with told inspectors that the staff were kind and caring and the majority indicated that the home meets their needs. People seen looked well cared for and those seen nursed in bed were clean and comfortable. Those residents requiring specialist pressure relieving equipment had been provided with it and it being used effectively. Diet and fluid charts are in place for some people living at the home. These are completed correctly however it could not be confirmed how these influence the care given. The medication area was inspected. Medicines were appropriately stored, including CDs. Records of all medicines were well maintained and appropriately signed. The temperature of the medicines fridge was recorded daily. Residents have been provided with lockable medicines cupboards in their bedrooms and could hold some or all their medication depending on own wishes and ability Staff demonstrated a good understanding of how to promote privacy and dignity and examples of how they do this were seen. Health and social care professionals confirm that they see their residents in private through surveys received. Staff were seen interacting kindly to residents and were seen knocking on doors before entering. Residents spoken to confirmed that staff treated them with respect and helped to maintain their privacy when delivering personal care. The Tudors DS0000015996.V355515.R01.S.doc Version 5.2 Page 14 The Tudors DS0000015996.V355515.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. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13 14, 15. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home provides a range of activities. People are able to maintain links with family and friends and the local community. People living at the home are able to exercise control of their lives. The food is of a good standard and takes into account personal preferences. EVIDENCE: The Tudors DS0000015996.V355515.R01.S.doc Version 5.2 Page 16 November activities sheet was copied and taken during the inspection. Activities for November included scrabble, bingo, visit to garden centre, watching the carnival with buffet supper, entertainment, reminiscence, suduko. December activities included pub lunch, christmas party, families and visitors party. The home has purchased it’s own transport which enables activities outside the home and access to local community to be completed on a regular basis. People living at the home confirmed that there are things to do and that they enjoyed the activities that are on offer. People stated that the use of the transport had improved their lives. People confirmed that staff are always polite and respectful. People spoken to confirmed that staff always knock on the door before entering. Lunch was observed and consisted of roast chicken. Staff confirmed that there is no choice on “roast” days as very one chooses this. There is a choice available on all other days. People confirmed that the evening meal consisted of lighter meals including eggs, cheese on toast, beans on toast, sandwiches. Copies of the 4 week rolling menu were taken. This confirmed the finding on the day of the inspection. The meals are on the whole traditional “British” food although the staff member spoken to confirmed that they would cater for any specialist diets. The tables were nicely laid with condiments and fluids available. Staff were observed to offer assistance in a discreet manner. The majority of the care plans now contain the service users preferences including diet and daily routines although these were not completed in all cases. Staff need to therefore ensure that these are consistently completed. People spoken to stated that they have a choice of when they would like to get up and go to bed. All stated that the food was of a good standard. The Tudors DS0000015996.V355515.R01.S.doc Version 5.2 Page 17 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16.18 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents and visitors to the home have the information to enable them to make a complaint or raise concerns. Arrangements for protecting residents from harm or abuse were adequate. EVIDENCE: Staff (x3) spoken to during the inspection were aware of whistleblowing and action to be taken if they were concerned about any abuse issues. The abuse policy was on display on the office wall to ensure that all staff are aware of this. It could not be confirmed if all staff have received training in this area as the training matrix was not available on the day of the inspection. This information was received from the manager following the inspection and confirmed that staff have not received training in this area. This is recommended. People spoken to during the inspection were aware that they could raise concerns and all stated that they would be happy raising any concerns with the manager. No complaints have been received. The complaint procedure was The Tudors DS0000015996.V355515.R01.S.doc Version 5.2 Page 18 viewed and was satisfactory although this should state that the CSCI can be contacted at any time if people have concerns or complaints about the service. The Tudors DS0000015996.V355515.R01.S.doc Version 5.2 Page 19 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 21, 22, 23, 24, 25, 26. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home continues to be upgraded and fixtures and fittings replaced. This upgrading needs to continue to ensure that the home provides a well maintained environment. The cleanliness of the home was spasmodic on the day of the inspection. The home provides any specialist equipment required. This is supported by the community nursing service. There are sufficient and suitable washing and bathing facilities. People living at the home are able to personalise their bedrooms. The Tudors DS0000015996.V355515.R01.S.doc Version 5.2 Page 20 EVIDENCE: A tour of the building was conducted on the day of the inspection. Since the last inspection a number of improvements to the environment have been under taken including redecoration and replacement of some fixtures and fittings in a number of bedrooms and some of the communal areas. One bedroom previously could only be accessed via the laundry. A conservatory was in the process of being built on the day of the inspection. This will link one of the communal areas to this bedroom removing the need to go through the laundry. This conservatory will also provide a small seating area with views of the garden. This development is welcomed. An additional bedroom can only be accessed by walking through another bedroom. This bedroom is no longer occupied and the manager stated that this will remain the case to ensure the privacy of the occupant of the bedroom. This is welcomed by the CSCI. A number of areas have been subject to redecoration and updating of fixtures and fittings. This included some communal areas and some bedrooms. These have been completed to an adequate standard. In addition the laundry and the kitchen area are in the process of being refitted and modernised. The modernisation of the remaining areas was discussed with the manager on the day of the inspection who stated that works will continue until all areas had been completed. As part of the works completed at the home two walk in wet rooms have been created and the flooring in the remaining bathrooms replaced. Unfortunately this flooring has become very stained and dirty in a relatively short period of time. This was discussed with the manager who stated that she was in talks with the manufactures and hopes that the flooring will be replaced by them in the near future. The home has a steep garden to the rear. Although part of this has been made accessible the remaining areas would not be usable to any person with reduced mobility. The manager stated that there are plans to complete works in the summer to increase the usable space in the garden. The cleanliness of the home was spasmodic on the day of the inspection with the majority of the bedrooms and communal space being clean tidy and well presented. Some areas however were in need of a deep clean this was particularly evident in a number of the bathrooms and toilets. The specific areas raising concern were raised with the manager at the end of the inspection. The Tudors DS0000015996.V355515.R01.S.doc Version 5.2 Page 21 It should be noted that The Tudors is positioned on a busy main road and as such some of the bedrooms at the front of the house are subject to traffic noise. These rooms would benefit from double-glazing to reduce this. The Tudors DS0000015996.V355515.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. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29, 30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home provides are very stable staff group the majority have worked at the home for a significant period of time. Any recruitment that has been completed is in line with good practise guidelines and ensures the safety of the people living at the home. The majority of staff have received training in order to fulfil their role although some staff would benefit from abuse training in order to safeguard the people living at the home. Induction for new staff is not in line with current expected standards. EVIDENCE: The staff duty rota for two weeks was reviewed as part of the inspection process. This demonstrated that there are adequate numbers of staff on duty at all times. The Tudors DS0000015996.V355515.R01.S.doc Version 5.2 Page 23 The majority of staff have worked at the home for a number of years. This ensures that there is a good continuity of care available. Staff spoken to during the inspection stated that they felt that the home was an excellent place to work and that they appreciated the teamwork within the home. People living at the home all gave extremely positive comments about the care and support they received from staff. All stated that the staff would go out of their way to help in way they could. All stated that the staff treated them with respect and gave all consideration to their dignity. Staff recruitment files were not viewed in detail on this inspection as no new staff have been employed. Three staff files were viewed for existing staff however and all contained necessary checks including Criminal Record Bureau checks and two written references. The manager and staff all confirmed that they had received all mandatory training including moving and handling and fire awareness. A staff training matrix was received by us following the inspection. It could not be confirmed if all staff have received training in abuse awareness. This is recommended to ensure that people living at the home are safeguarded. Nine (out of 20 staff employed) members of staff have an undertaken an NVQ award. Additional training such as dementia care, healthier foods and diet’s care of medicine, have also been completed by some staff. All senior staff have done or are studying the package on safe handling of medicines. Although no new staff have been employed the home does not currently have an up to date induction package. It is required that the home develops an induction package based on the Skills for Care Induction Standards. This needs to be in place for any new care staff that are employed. The Tudors DS0000015996.V355515.R01.S.doc Version 5.2 Page 24 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 32, 33, 36, 38 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. People living at the home benefit from a stable staff team and manager. Staff do not receive formal supervision. The quality assurance systems at the home require additional development. Health and safety is not maintained in all areas. The Tudors DS0000015996.V355515.R01.S.doc Version 5.2 Page 25 EVIDENCE: Service users spoken to knew the management structure of the home, and felt the manager was very good and kind. They felt the home was run well and was a homely place to be in. The registered manager is committed to promoting equality and diversity in the service and meeting service users individual needs. Staff indicated that they felt very well supported in their roles by Mrs Weddell who often works with them. They also meet frequently and have discussions about what the home aims to achieve. Despite this staff do not currently have formal staff supervision. The registered manager is committed to introducing staff appraisal and supervision in the near future. The relationship shared between staff and the registered person is such that service users can feel safe. During the inspection it was confirmed that quality assurance questionnaires had been completed by people living at the home and relatives in April 2006. The management need to ensure that they have a robust quality assurance system in place which is regularly conducted. Servicing of equipment is completed on a regular basis. During the inspection however it could not be confirmed that a gas safety certificate had been obtained. Following the inspection Mrs Weddell confirmed that she had been in contact with British Gas who had explained that there was a delay in their workload and that this would be completed in the near future. The home has a fire risk assessment in place. This however had not been dated so it could not be confirmed when and if this had been reviewed. The home currently tests the fire alarm on a monthly basis. The manager needs to ensure that the current testing arrangements are in line with good practise and in line with the risk assessment that is in place. The last staff fire drill had been conducted in July 2007. The Tudors DS0000015996.V355515.R01.S.doc Version 5.2 Page 26 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 1 3 3 3 X HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 3 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 2 2 3 3 3 3 3 3 2 STAFFING Standard No Score 27 3 28 3 29 3 30 1 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 3 X X 2 X 1 The Tudors DS0000015996.V355515.R01.S.doc Version 5.2 Page 27 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 OP2 Regulation 14 (1) (d) Requirement It is required all people living at the home or their representative have a copy of the terms and conditions of their stay including the fee levels, arrangements has to how these are to be paid and the room to be occupied. It is required that the current staff induction programme is reviewed to ensure that it meets the skills for care guidelines It is required that the gas system is serviced and a gas safety certificate is obtained. It is required that the fire risk assessment is reviewed. Fire safety checks including practise fire drill and fire alarm checks should be conducted in line with the fire risk assessment Timescale for action 30/03/08 2. OP30 18 (1) (a) 30/08/08 3 4. OP37 OP37 23 (1) (b) 23 (4) 28/02/08 28/02/08 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. The Tudors DS0000015996.V355515.R01.S.doc Version 5.2 Page 28 No. 1 2. Refer to Standard OP1 OP7 Good Practice Recommendations It is recommended that the homes statement of purpose and service user guide be reviewed to ensure that they remain up to date and accurate. It is recommended that the service user plans continue to be developed to ensure that all assessments and information is consistently recorded for all people living at the home. It is recommended that charts including fluid, diet and positional change, influence the care and support received. It is recommended that personal risk assessments are reviewed to ensure that they consider all the needs of the individual including such things as vision. It is recommended that the on going refurbishment of the property continue. The complaints policy should make clear the complainants are able to contact Commission for Social Care Inspection at any stage of a complaint. This should also be amended in the statement of purpose and the service user guide. The whistle blowing policy should include the details and contact number of Public Concern at Work and the CSCI. All staff should undertake training in the protection of vulnerable adults from abuse. It is recommended that the home develop a more complete quality assurance system. It is recommended that a system of staff supervision is commenced. 3. 4. 5. OP8 OP8 OP19 6 OP16 8. OP18 9. OP18 10. 11 OP33 OP36 The Tudors DS0000015996.V355515.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection South West Regional Office Colston 33 33 Colston Avenue Bristol BS1 4UA National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI The Tudors DS0000015996.V355515.R01.S.doc Version 5.2 Page 30 - 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. 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