CARE HOMES FOR OLDER PEOPLE
The Tudors Street Road Glastonbury Somerset BA6 9EQ Lead Inspector
Ms Sue Hale Unannounced Inspection 4th January 2007 10:45:a 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.V325964.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.V325964.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.V325964.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION
Conditions of registration: Date of last inspection 15th February 2006 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.V325964.R01.S.doc Version 5.2 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This is the first key inspection of The Tudors Residential Home using the Inspecting for Better Lives methodology introduced by the Commission for Social Care Inspection in April 2006. The inspection methodology used by the Commission for Social Care Inspection enables the inspector to make a judgement on the quality of the service delivery based on the outcomes for residents The inspection was carried out on one day in January 2007. The Inspector looked at some resident and staff files records, and other documentation related to the running of the home. The inspector spoke to several residents and some staff that were on duty and looked around the home. Surveys were sent to some residents, some relatives/visitors to the home, some staff and health and medical professionals. At the time of writing this report 12 surveys had been returned from residents, 9 from relatives/visitors to the home, three from staff and 4 from medical and health care professionals. The responses from the surveys are incorporated into this report. On the day the inspection there were 17 people living at the home and 2 in hospital. The current fee ranges from £295 to £361. What the service does well:
The home produces a statement of purpose, service user guide and brochure that gives prospective residents and their relatives/representatives information about the services available at the Tudors. All staff appeared familiar with individual residents care, health and social needs. Relationships between staff were friendly but professional; the atmosphere in the home was relaxed and comfortable. Medication practices at the home were well organised and safeguarded residents. The organisational and staff culture of the home is all geared towards treating residents with respect and to make sure that their right to privacy is respected. Residents are very happy with the way they receive care and attention in the home. They liked the staff and felt safe and well looked after by them. They were satisfied with the standard of the laundry service in the home.
The Tudors DS0000015996.V325964.R01.S.doc Version 5.2 Page 6 The needs of the home are generally planned round the residents’ needs and wishes in, residents were confident that staff were familiar with their likes, dislikes and preferences and that these would be respected. A range of activities is available and residents are supported and encouraged to participate according to their preferences and abilities. Residents spoken to were satisfied with the level of activities provided. Visitors are welcomed and residents are assisted with maintaining contact with relatives and friends. One relative/visitor to the home said that they were ‘happy with the excellent services provided by Tudor Lodge’. Residents were very satisfied with the range and quality of food available to them. The dining room provides a pleasant area to make mealtimes a social occasion for residents. All residents spoken to during the inspection were clear about the manager and staffs role and were confident that they could raise any concerns or complaints and that they would be dealt with. All residents said that they felt safe and well looked after. The home has a copy of the local procedures should an allegation of abuse be received. The Tudors offers a homely, clean and pleasant environment that residents are satisfied with. Residents are able to see their visitors in the privacy of their own rooms or in the shared areas. The home offers a choice of toilet and bathing faculties. All residents spoken to were very positive about the care they received at the home and about the staff who look after them. Staff were described as ‘very good’ and some people commented that they received very good care ‘particularly if they were ill’. One resident said that ‘the home couldnt get a better manager’. Residents’ benefit from the ethos and leadership of the manager that places their wellbeing at the centre of the home’s activities. Residents also benefit from the honest and open style of management of Mrs Weddell and from the informal arrangements to support staff in the performance of their roles. The home follows good recruitment procedures to ensure the safety and protection of residents. The views of residents and health and social care professionals is sought and used to improve the services offered at the home. Records are safely stored and accessible for staff. The home continues to provide a safe environment for residents and staff. The Tudors DS0000015996.V325964.R01.S.doc Version 5.2 Page 7 What has improved since the last inspection? What they could do better:
The statement of purpose must include all the information required by the regulations and should be reviewed and updated. It should reflect what actually happens in the home for those living there. The service user guide should include a description of the individual accommodation and communal space proved, the relevant qualifications of the registered provider, manager and staff, the type of care the home provides, i.e. personal care only, service users views of the home and reference to where interested parties can see a copy of the latest inspection report. New residents must not be admitted to the home unless a pre admission assessment has been completed and used to inform an initial care plan to give staff clear information to enable them to provide appropriate care. The pre admission assessment document should include all the topics recommended in the national minimum standards to make sure that all aspects of prospective residents health, social and care needs have been considered and can be met. Copies of the funding authorities assessment and care plan must be obtained prior to admission and should be used to inform the care plan. Serious consideration should be given to keeping these documents with residents care files so that staff have a full picture of residents needs. The home is registered to provide care for residents who require personal care and this must be taken into account when considering the needs of prospective residents. Consultation should take place with residents as to their preferred time of an early-morning drink and if they wish to be woken. It should be recorded on their care plans and all staff made aware of individuals preferences. Care records need to be significantly improved so that working records include more comprehensive care plans and risk assessments that provide a full picture of the person’s abilities, needs and areas of risk, giving clear instructions to staff. Risk assessment in relation to moving and handling, pressure sores and falls must be undertaken for all residents on admission and thereafter as necessary. Risk assessment in relation to nutrition should also be undertaken on admission and thereafter as necessary. Pre admission
The Tudors DS0000015996.V325964.R01.S.doc Version 5.2 Page 8 assessments and care plans should cover all the topics recommended in the national minimum standards. The complaints policy should make clear the complainants are able to contact Commission for Social Care Inspection and any stage of a complaint. The whistleblowing policy should include details of Public Concern at Work and their contact number and also make clear to staff that they are able to contact the CSCI and give details of how to do this. All staff should undertake training in how to protect vulnerable adults from abuse and should be aware of the correct procedure to follow should an allegation be received. An adult protection policy must be developed and readily accessible to staff. The programme of refurbishment should be continued until all areas of the home are of a good standard. The use of room 11 to accommodate a resident that is only accessible via the laundry must be reviewed to ensure the safety of the residents. The laundry room floor is broken and in a bad state and must be replaced as a matter of priority for safety and hygiene reasons. This was identified in the last inspection report. All chemicals should be stored in locked cupboards to reduce the risk of ingestion or spillage and possible risk to residents. The staff application form should make it clear that posts at the home are exempt from the Rehabilitation of Offenders Act. The home should continue its efforts to increase the number of staff qualified to NVQ level 2 to make sure that the majority of staff are qualified and skilled to meet residents needs. All staff must undertake moving and handling training. Residents personal finance records should be audited monthly to ensure correct procedures are followed. 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. The summary of this inspection report can be made available in other formats on request. The Tudors DS0000015996.V325964.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.V325964.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): 1,3.Standard 6 is not applicable to this service. Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. The home produces information about the services they provide for prospective residents and their relative/representatives. Applications for admission to the home are agreed without any reference to a needs assessment. Funding authorities assessment and care plans do not inform the homes own care planning system. EVIDENCE: The home produces a statement of purpose that is dated 2004 which gives information about the services the home provides. This document does not
The Tudors DS0000015996.V325964.R01.S.doc Version 5.2 Page 11 include all the information required and needs reviewing and updating. The home also produces a colour brochure. The home also produces a service user guide dated April 2006 but this did not contain the majority of information deemed by the national minimum standards necessary to give prospective residents enough information to make an informed choice when choosing a home. There was no evidence on residents care files checked that the home undertakes a written preadmission assessment that covers all the topics recommended in the national minimum standards. Staff spoken to confirmed that prospective residents are seen in hospital or wherever they are staying before they move into the home and that all admissions are for a trial period of time. There was no evidence on residents files checked that copies of the funding authorities assessment and care plans were obtained and used as part of the care planning process. The manager was reminded to be mindful of the homes registration when undertaking pre admission assessments to make sure that the physical environment and the staff team could meet prospective residents needs and that new residents had needs which were within the home’s registration. The Tudors DS0000015996.V325964.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. Each resident has a care plan but these lack detail and do not give clear instructions to staff on how to meet the residents needs. Risk assessments were not undertaken routinely or when needs were apparent. Residents have access to appropriate medical and healthcare professionals. The home works to an efficient medication policy supported by procedures and practice guidance. Residents are happy in the way that staff deliver their care and respect their dignity and right to privacy. The Tudors DS0000015996.V325964.R01.S.doc Version 5.2 Page 13 EVIDENCE: A selection of care records was inspected. They all had a plan of care and evidence of monthly reviews to which the resident had participated. However, some plans were incomplete, some were unsigned and risks assessed were very few. Where risks had been assessed, they lacked the necessary instructions for staff to show how to minimise the identified risks or in one case was out of date. Risk assessments in relation to moving and handling, nutrition, pressure sore risk and falls were not undertaken routinely or when a particular risk was clearly shown on the care file. Instructions to staff were also lacking in the care plans, i.e. no reasons given for use of special equipment or for a prescribed care procedure. Care plans did not cover all the recommended topics in the national minimum standards and did not cover all of the residents identified needs. The daily record lacked detail and in the majority of entries staff had recorded ‘fine’ giving no other information. Positional change charts were not used for a resident who was bedfast. It was evident from records checked that residents are supported and encouraged to access appropriate medical and healthcare professionals as necessary. Residents have access to chiropody services, opticians and dentists. One professional working with the home commented that they liaise regularly with appropriate professionals including social workers, community psychiatric nurses and GPs. 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 are aware of the need to treat residents with respect and to consider dignity when delivering personal care. Residents spoken to confirmed that staff knocks on their doors before entering and are always polite and respectful. The Tudors DS0000015996.V325964.R01.S.doc Version 5.2 Page 14 Daily Life and Social Activities
The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The needs of the home are generally planned round the residents’ needs and wishes. Early morning routines appear to be planned to suit the staff. A range of activities is available and residents are supported and encouraged to participate according to their preferences and abilities. Visitors are welcomed and residents are assisted with maintaining contact with relatives and friends. Residents are supplied with the quality and variety of food served at the home. EVIDENCE: Residents spoken to said that the routines of the home were generally flexible to suit individuals needs. However, some residents said they were woken very early at approximately 6 a.m. to 6:30 a.m. A notice in the kitchen told staff not to ‘give out cups of tea before 6.15am at the earliest’. A member of staff
The Tudors DS0000015996.V325964.R01.S.doc Version 5.2 Page 15 told the inspector that all residents had to get up from 7am so that staff ‘can get through everything’. All of the relatives/visitors to the home that returned survey forms commented that they were made welcome and could visit and see their relatives/friend in private at any time. The majority of respondents said that they were kept informed of important factors affecting a resident. Information provided by the home said that the activities included scrabble, cards, bingo, quiz afternoons, the drives and trips out. All the residents spoken to were satisfied with the range and level of activities available. The views of the residents is sought informally, and people spoken to were confident that staff were aware of their preferences, likes and dislikes The home has a rotating four-week menu that is changed regularly to reflect seasonal availability and to offer a good range and variety of food. The majority of residents spoken to do a very satisfied with the variety and quality of food served at the home. One resident said ‘we have plenty to eat and the food’s good’. One resident and one relative/visitor to the home commented that the quality of meat was unsatisfactory and could be improved. The inspector spoke to the manager who stated that all food including meat was bought from a local supermarket and was of good quality. This was confirmed by the Inspector who checked the food stock available in the kitchen. Fresh fruit and vegetables were available. The dining-room tables had cloths on and condiments were readily available. The cook was familiar with a dietary requirements and preferences of residents and provides a diet that meets individual needs. Residents enjoy the flexibility of meal arrangements and enjoyed being able to eat in their own room if they wished. The Tudors DS0000015996.V325964.R01.S.doc Version 5.2 Page 16 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 were confident of their right to raise concerns or complaints and that they would be listened to. Complaints and whistleblowing policies are in place. An adult protection policy was not readily accessible for staff and staff lack training in how to protect vulnerable adults from abuse. EVIDENCE: The home nor the CSCI has not received any complaints since the last inspection. All the residents spoken to during the inspection were very clear about their rights to raise concerns or complaints and are confident that the manager or any member of staff would deal with it effectively. The home has a complaints procedure that these minor revision to make sure the complainants know they can contact the Commission for Social Care Inspection at any stage of a complaint. The whistleblowing policy does not include the public concern at work telephone details and telephone number or advice staff that they are able to
The Tudors DS0000015996.V325964.R01.S.doc Version 5.2 Page 17 contact the CSCI. Staff are given clear advice that they must not accept gifts from residents and must not benefit from residents’ wills. The home has a copy of Safeguarding Vulnerable Adults for Adult Protection in Somerset Multi Agency policy and practice guidance. However, there was no adult protection policy specific to the home available on the day the inspection or accessible for staff. Some of the staff spoken to were unaware of the correct procedure to follow should an allegation be received. Information supplied by the home indicated that training in how to prevent abuse was planned. Residents are protected from the risk of abuse as the home undertakes POVA first checks before new staff start work. The Tudors DS0000015996.V325964.R01.S.doc Version 5.2 Page 18 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, 26 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents’ benefit from a home that provides a generally comfortable and clean environment, which is gradually being refurbished to a good standard. The shared areas provide a choice of communal space for residents and their visitors. Residents are able to access the rear garden, which has a patio area. There is a choice of recently improved bathing and toilet facilities throughout the home. The floor in the laundry continues to pose a potential risk to health and safety due to poor condition. The Tudors DS0000015996.V325964.R01.S.doc Version 5.2 Page 19 EVIDENCE: All residents spoken to were satisfied with their rooms and the communal areas. Residents told the inspector their rooms were always clean and tidy and they were able to bring their own possessions in and personalise their rooms to their individual taste. Since the last inspection, improvements have continued. Most bedrooms are now refurbished to a good standard. A door connects two rooms. This is considered a double room and is the only double room used as such in the home. The recently set up dining room was popular with residents. Information provided by the home advised the inspector that one bathroom has been changed to a shower room, and another bathroom has a new bath and has been redecorated. Some new furniture and carpets have been provided and some rooms have been decorated since the last inspection. The hall, stairs and landing have also been redecorated. A new cooker and freezer are in place in the kitchen. However, some areas of the home would benefit from further updating and refurbishment. One resident’s room was only accessible via the laundry room. This meant that the laundry was always unlocked. There was no evidence that this had been risk assessed either from the individual’s perspective or the risk of other residents being able to go into the laundry where chemicals were stored. This has been raised with the manager who told the inspector that consideration was being given to accessing the private room via another means and whilst the current arrangement is still in place all chemicals will be locked away. The home was generally clean, there were no odours and materials and equipment for the control of infection were available in all key areas. Infection control training for staff took place in July 2006.The cupboard in which cleaning materials were stored was not locked and residents could access these, this could present a health and safety risk. The inspector noted that infection control measures were not documented in individual care plans when a risk had been identified. The laundry room floor was broken and in a very poor condition and must be replaced for safety and hygienic reasons. This was identified in the last inspection report. Residents spoken to said that their clothes were well laundered and returned to them promptly. The Tudors DS0000015996.V325964.R01.S.doc Version 5.2 Page 20 Staffing
The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29,30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents benefit from good staffing levels in the home and from a stable and experienced staff team. The recruitment and selection procedures are efficient and protect residents from potential harm. A training programme is in place to ensure that staff have the skills and knowledge to meets residents needs. EVIDENCE: The home employees 16 care staff six of whom are qualified to NVQ level 2. All staff are supported and encouraged to stuffy for NVQ level 2 and 3 qualifications. Staffing levels in the home were good and discussions with staff and residents confirmed that the pace was unhurried and that the home’s existing staff covers absences. The files of 3 new members of staff were checked. All files contained 2 references, application forms and POVA First and CRB checks. Staff are asked to sign a document to declare that they do not have any convictions or
The Tudors DS0000015996.V325964.R01.S.doc Version 5.2 Page 21 cautions that neither this nor the staff application form makes clear that jobs at the home are exempt from the Rehabilitation of Offenders Act. New staff are appointed on a probationary basis for a trial period of 13 weeks. Following successful completion they are given a statement of terms and conditions of employment. All staff is given a copy of the employee handbook that includes some information about their employment rights, confidentiality, whistleblowing and brief information about adult abuse. There are now 2 waking night staff on duty to make sure residents needs can be met. All new staff undertakes an induction programme that is overseen by the manager. One member of staff is undertaking a course in supervisory management. The Tudors DS0000015996.V325964.R01.S.doc Version 5.2 Page 22 Management and Administration
The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31,33,35,38 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents’ benefit from the ethos and leadership of the manager that places their wellbeing at the centre of the home’s activities. Residents also benefit from the open style of management of Mrs Weddell and from the informal arrangements to support staff in the performance of their roles. However, whilst recognising the improvement made in the home since Mrs Weddell has been in post as referred to earlier in this report admission, risk assessment and care planning systems need to improve significantly to make sure residents needs are assessed and met. The views of residents and health and social care professionals is sought and used to improve the services offered at the home. The Tudors DS0000015996.V325964.R01.S.doc Version 5.2 Page 23 Records are safely stored and work continues to ensure a safe environment and procedures throughout the home. EVIDENCE: The manager was on leave on the day of the inspection and the inspector spoke with her a later date. Mrs Weddell has nearly completed the registered managers award. Mrs Weddle’s aim is to work together with staff to continually improve the service provided to residents. All staff spoken to were very positive about the way the home is managed and said that Mrs Weddell is always available for advice and support. Improvements continue to be made in the training programme arranged by the manager to further the staff teams knowledge and skills. A resident told the inspector that ‘we couldn’t have a better manager’. One health/medical professional commented that The Tudors was a ‘happy, efficient, well-run residential home with helpful caring staff’. A visitor to the home commented that they were very happy with the care and personal service provided by the manager and staff. Mrs Weddell meets regularly with health and medical professionals and through these meetings obtains feedback on what people think about the services the home provide. The home has a survey form to give out to resident sot find out their views of the meals served at the home and the responses are discussed with the cook and used to inform the menu. Records were checked of two residents personal finances, both of which were inaccurate. A record of incoming and outgoing finances with receipts is kept. Records were not audited monthly to check the accuracy of the accounting. The home has a diversity and equality policy but this applies only to people working at the home not those living there. The statement of purpose tells readers that meetings with residents are held four times a year to consult with them about the running of the home. However, there was no evidence that these meetings actually take place. Records relating to the servicing of the fire system and equipment were up-todate. Records were kept of water temperature checks. The lift was serviced regularly as were the hoists. Control measures were in place to reduce the risk of legionella. Records seen confirmed the clinical waste contract was in place, gas equipment had been serviced and the home had a current hard wiring certificate. The Tudors DS0000015996.V325964.R01.S.doc Version 5.2 Page 24 Information supplied by the home showed that staff had undertaken training in fire safety, use of fire extinguishers and basic food hygiene. One member of staff had been trained to train other staff in moving and handling but there was no evidence on the day of the inspection or in information supplied by the home that all staff had completed up to date training. The Tudors DS0000015996.V325964.R01.S.doc Version 5.2 Page 25 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 1 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 1 8 1 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 2 X X X X X X 2 STAFFING Standard No Score 27 3 28 2 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 2 X X 2 The Tudors DS0000015996.V325964.R01.S.doc Version 5.2 Page 26 Are there any outstanding requirements from the last inspection? Yes 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 OP1 Regulation 4 (1)(1) Schedule 1 Requirement The registered person must ensure that the Statement of Purpose contains all the information required in the care homes 2001 regulations. (This relates to the size of individual residents rooms, the category of registration, that nursing is not provided at the home and specific detail on the arrangements for dealing with complaints). The registered person must obtain copies of the funding authorities care plan and assessments for those residents funded by care management arrangements. The registered person must ensure that risk assessments in relation to pressure sores are undertaken on admission and as necessary thereafter. The registered person must ensure that residents’ health and welfare is promoted and provided for. (This refers to the use of positional change charts for residents who are
DS0000015996.V325964.R01.S.doc Timescale for action 30/04/07 2 OP3 14(1)(b) 30/04/07 3 OP8 12(1) 30/03/07 4 OP8 12(1) 31/03/07 The Tudors Version 5.2 Page 27 5 OP8 6 OP7 7 OP18 8 OP19 9 OP26 10 11 OP26 OP38 permanently bedfast). The registered person must ensure that moving and handling and falls assessments are undertaken for all residents on admission and as necessary thereafter. 15(1) All plans of care must be completed in full, with each service user, dated and signed by both parties. Care plans must fully describe how needs will be met, include areas of risk and action to be taken to minimise identified risks. Requirement outstanding since 2004. 13 (6) An adult protection policy specific to the home and readily accessible for staff at all times must be developed. 13(4)(a) The registered person must review the suitability of room 11 for use by the resident,and safety of all residents, as it is only accessible via the laundry. 2 (b) The laundry room floor must be replaced for health and safety reasons. (Previous timescale of 31/03/06 not met). 13(4)(a)(c All cupboards in which chemicals ) are stored must be kept locked at all times. 18 (1) All staff must complete moving and handling training. (Previous timescale of 31/5/06 not met). 13(5) 31/03/07 31/03/07 31/03/07 31/03/07 30/04/07 31/03/07 31/03/07 The Tudors DS0000015996.V325964.R01.S.doc Version 5.2 Page 28 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 OP1 OP2 Good Practice Recommendations The statement of purpose should be an accurate reflection of the services offered and what actually happens in the home. The service user guide should include a description of the individual accommodation and communal space proved, the relevant qualifications of the registered provider, manager and staff, the type of care the home provides, i.e. personal care only, service users views of the home and reference to where interested parties can see a copy of the latest inspection report. Funding authorities care plans and assessments should be used to inform the homes own care planning. Serious consideration should be given to keeping such documents with residents care files. Care plans and the pre admission assessment should cover all the topics recommended to in the national minimum standards (3.3). Serious consideration should be given to obtaining a nutritional risk assessment tool and this should be undertaken for all residents on admission and as necessary thereafter. The manager should consult with residents about the time they wish to be taken drinks in the morning. Details of their choices should be recorded on the care plan. 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 whistleblowing 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 on going refurbishment of the property continue. Efforts must be made to increase the number of staff qualified to NVQ level 2. The staff application form should make clear that posts at the home are exempt from the Rehabilitation of Offenders Act.
DS0000015996.V325964.R01.S.doc Version 5.2 Page 29 3 OP3 4 5 OP7 OP8 6 7 OP12 OP16 8 9 10 11 12 OP18 OP18 OP19 OP28 OP29 The Tudors 13 OP35 Serious consideration should be given to the manager auditing residents financial accounts monthly. The Tudors DS0000015996.V325964.R01.S.doc Version 5.2 Page 30 Commission for Social Care Inspection Somerset Records Management Unit Ground Floor Riverside Chambers Castle Street Taunton TA1 4AL 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
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