Inspection on 10/04/06 for The Tudors Residential Home For The Elderly

This inspection was carried out on 10th April 2006.

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

The Tudors Residential Home For... 29/01/08

The Tudors Residential Home For... 02/04/07

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Claremont House

Oak Ridge

Sun Court Nursing Home

Ashville House

Bilney Hall

Hill Barn

Mabbs Hall Nursing Home

Henrietta House

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

CARE HOMES FOR OLDER PEOPLE The Tudors Residential Home for the Elderly Rayners Way North Street Stanground, Peterborough PE2 8HR Lead Inspector Andy Green Key Unannounced Inspection 10th April 2006 10:00 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 Residential Home for the Elderly DS0000065754.V288410.R01.S.doc Version 5.1 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 Residential Home for the Elderly DS0000065754.V288410.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service The Tudors Residential Home for the Elderly Address Rayners Way North Street Stanground, Peterborough PE2 8HR 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) 01733 892844 01733 554306 Gold Care Homes Limited Care Home 43 Category(ies) of Dementia - over 65 years of age (18), Old age, registration, with number not falling within any other category (25) of places The Tudors Residential Home for the Elderly DS0000065754.V288410.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection Brief Description of the Service: The Tudors is a large detached property, which has been converted and extended from two large modern houses and provides 43 bedrooms. Within the premises there is a 17-bedded area for the specific needs of service users who have been assessed as having dementia care needs. There are a four communal lounges and two dining rooms. There is a passenger lift to the first floor. The home is situated in a quiet cul-de-sac in a residential area near to the city of Peterborough. There are gardens to the front and rear of the property The Tudors Residential Home for the Elderly DS0000065754.V288410.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. Andy Green and Janie Buchanan conducted this unannounced inspection on 10th April 2006. This inspection was the first inspection of the home following an additional visit made in December 2005. The inspectors met with the manager, the activities co-ordinator, senior carers, service users, relatives and care staff to assess a number of standards and monitor compliance requirements that were made at the previous visit. A number of documents and records were seen and a tour of the building was undertaken. What the service does well: What has improved since the last inspection? What they could do better: The care plans need to be kept under review and the participation of relatives should be sought when drawing up the care plan. Care plans need to be stored securely. Medication administration records need to be recorded accurately The office area in the dementia care unit needs to be relocated as it compromises confidentiality and dignity of service users. An application must be submitted to CSCI to register a manager for the home The Tudors Residential Home for the Elderly DS0000065754.V288410.R01.S.doc Version 5.1 Page 6 Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The Tudors Residential Home for the Elderly DS0000065754.V288410.R01.S.doc Version 5.1 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection The Tudors Residential Home for the Elderly DS0000065754.V288410.R01.S.doc Version 5.1 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1,3,4,5, 6 The home produces a variety of information so that prospective service users can decide if they wish to live in the home. EVIDENCE: There have not been any further additions to the Statement of Purpose or Service Users Guide since the last inspection. The manager stated that these documents will be updated throughout the year to ensure that information remains up to date. The home receives assessment information regarding service users from the local authority and a copy of the care plan. Service user files contained assessments as part of the care management process outlining the individuals care and support requirements. Relatives or representatives of service users have an opportunity to visit the home as part of choosing whether the home meets the prospective service users needs. The home does not provide intermediate care The Tudors Residential Home for the Elderly DS0000065754.V288410.R01.S.doc Version 5.1 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 the following standard(s): 7, 8, 9, 10, Service users receive appropriate health and personal care to meet their assessed needs. Improvements in the recording of the administration of medication are needed to ensure all service users receive their prescribed medication. EVIDENCE: There have been improvements made to the care planning system since the last inspection. Goldcare has now implemented a new system and all of the previous care plans have been discontinued. There is clearer documentation in place including assessment documents, healthcare, personal profiles and risk assessments. There was evidence of reviews of care being undertaken. Eight care plans were inspected including four from the dementia care unit. The inspectors were satisfied that care plans are now improving with a more professional and consistent approach being taken. The manager stated that she will be developing care plans further to include more personal profiles regarding service users past life and personal history so that staff can engage with service users. It was also recommended that families of service users or their representatives should involved in drawing up the care plan where the service user is unable to participate or have any involvement in the process. The Tudors Residential Home for the Elderly DS0000065754.V288410.R01.S.doc Version 5.1 Page 10 There has also been in-house training given to the senior care staff by a manager from Goldcare outlining the expected requirements and documentation to be contained in care plans. It was noted that care plans were not being kept in a secure location so this must be arranged. The office area in the dementia care lounge needs to be re-sited, as this comprises confidentiality and the dignity and respect of service users. Medication records were inspected and they were generally satisfactory but it was noted that there were a number of signature gaps and handwritten additions to the records, which were not signed and dated. These administration discrepancies were pointed out to the manager and she stated that all staff involved in the administration of medication would be reminded to complete all records accurately. She also stated that she had contacted a local pharmacy who will provide medication awareness and administration training. The Tudors Residential Home for the Elderly DS0000065754.V288410.R01.S.doc Version 5.1 Page 11 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, 15 Staff provide appropriate support to ensure that service users have access to activities appropriate to their needs. EVIDENCE: There is now an Activities Co-ordinator in post who is developing a programme of activities throughout the home. She is particularly keen to offer specific programmes in the dementia care unit and she will be contacting local dementia care specialists to gain further guidance and information. She will also be attending the one-day dementia awareness course to aid her knowledge. One of the inspectors observed her with a small group of service users in the dementia care unit engaged in an appropriate activity in a very sensitive and social manner. The atmosphere in the home was lively and busy and service users were socialising with each other and staff in the lounge. There is a varied range of meals offered throughout the day and service users have choice of alternatives to the suggested menu choices. Snacks and drinks are also available at all times during the day. The Tudors Residential Home for the Elderly DS0000065754.V288410.R01.S.doc Version 5.1 Page 12 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16, 17, 18 The home has a complaints process to make sure that service users have their complaints or concerns listened to and acted upon properly. EVIDENCE: The home has a clear complaints procedure, which includes agreed timescales to make sure that all complaints are fully investigated and actioned appropriately. The home has received a recent complaint from a relative and this has been responded to in an appropriate manner using the organisation’s complaints format. The home has a satisfactory policy regarding Adult Protection, which is in line with the Local Authority policies. Staff receive training in the protection of vulnerable adults to make sure that service users are protected from abuse. The manager is undertaking a ‘Key Practitioners’ course in POVA issues so that she will be able to provide ongoing training to all staff on a regular basis. The Tudors Residential Home for the Elderly DS0000065754.V288410.R01.S.doc Version 5.1 Page 13 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 23, 25, 26 The interior of the home generally meets the needs of service users. The environment of the home provides service users with a safe and comfortable place in which to live. EVIDENCE: There are a number of improvements being made to the environment. Redecoration is planned in the communal areas of the home and in service user bedrooms. The manager stated that a maintenance audit has been carried out identifying areas for refurbishment and an ongoing maintenance programme will be rolled out during the year. Carpets in the dementia unit have been cleaned but they are still showing signs of wear and need to be replaced. The manager stated that all carpets in the two main lounges and the corridors in the dementia care unit are being replaced in the next few weeks. An area of flooring in a sitting area is also being replaced with more robust wood flooring. The Tudors Residential Home for the Elderly DS0000065754.V288410.R01.S.doc Version 5.1 Page 14 The manager stated that the colour and pattern of the carpeting in the dementia care unit would be chosen to aid service users who may have problems navigating their way around the environment. It was also recommended that pictorial signs should also be added to service users’ bedrooms and bathrooms/WCs to aid service users with dementia care needs in recognising these facilities. The flooring in the laundry area in the dementia care unit has been replaced with an impermeable surface to meet health and safety needs. Both inspectors felt that it was inappropriate to have the ‘office area’ in the lounge area of the dementia care unit, as it comprises service users privacy and dignity. The outside areas have been improved and are generally tidier. The gardens are being regenerated to provide more attractive planted areas for service users to enjoy. The ornaments left by the previous provider have also been removed from the grounds. The manager also stated that a full time maintenance person has now been employed to carry out ongoing repairs and renewals in the home. He will also have responsibility for the maintenance of the garden areas. The Tudors Residential Home for the Elderly DS0000065754.V288410.R01.S.doc Version 5.1 Page 15 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29, 30 An induction and training programme is provided to ensure that care staff are competent to deliver care to the service users they support. EVIDENCE: The manager has completed an audit of training needs in the home and individual staff files have been updated. She is in the process of booking updates for mandatory courses for all staff and she is compiling a training matrix to clearly display dates for when training has been completed and when updates are due. The manager is also attending a ‘Key Practitioners’ course in moving and handling, which she will then deliver to care staff in the home throughout the year. Training records regarding dementia care were inspected and all members of care staff working in the dementia care unit have all received a three-day training session organised through the local authority. Care staff who do not normally work in the dementia care unit are also receiving a one day dementia awareness course delivered by a local CPN who provides ongoing support to the home. The manager stated that training regarding dementia care would be a continuous process to ensure that staff will be kept up to date regarding good practice issues. One of the inspectors spoke with staff in the dementia care unit and they displayed a good level of dementia care knowledge and they all stated that The Tudors Residential Home for the Elderly DS0000065754.V288410.R01.S.doc Version 5.1 Page 16 they had found the three-day course extremely beneficial regarding assisting service users with dementia care needs. The manager has also implemented a six-week induction programme, which is in line with ‘Skills for Care’ and NVQ guidelines. She is implementing a supervision process so that all staff will receive at last six recorded sessions. The manager stated that she will undertake all sessions initially and then senior staff, after receiving supervision guidance/training, will be delegated groups of carers to formally supervise. There were seven members of care staff on duty in the morning and six members of care staff in the afternoon/evening. In addition there was also the manager, administrator, cleaning and laundry staff, cook and kitchen assistants on duty during the day. The manager also stated that she carries out unannounced visits during nighttimes and at weekends to monitor care in the home. The Tudors Residential Home for the Elderly DS0000065754.V288410.R01.S.doc Version 5.1 Page 17 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 32, 33, 35, 36, 38 The home is well managed and the manager provides supportive leadership and guidance to staff to ensure that service users receive high quality care. EVIDENCE: The manager has been in post since February 2006 and she has the relevant skills and experience to manage the home. She was previously a registered manager in a care home prior to taking up this appointment. She has completed the Registered Managers award and she is also a qualified NVQ assessor. An application to register a manager must be submitted to CSCI. In the short time that she has been managing the home she has been able to review a number of procedures and processes including training, supervision and care planning. She has a positive attitude and she is keen to create a professional approach and improve the services provided in the home. She stated that she has received ongoing support from the Operations Manager The Tudors Residential Home for the Elderly DS0000065754.V288410.R01.S.doc Version 5.1 Page 18 and they are meeting regularly to discuss developments and monitor progress that is being made in the home. The Tudors Residential Home for the Elderly DS0000065754.V288410.R01.S.doc Version 5.1 Page 19 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 X 3 3 3 3 HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 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 3 18 3 2 3 X X 3 X 3 3 STAFFING Standard No Score 27 3 28 3 29 X 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 3 3 X 3 3 X 3 The Tudors Residential Home for the Elderly DS0000065754.V288410.R01.S.doc Version 5.1 Page 20 Are there any outstanding requirements from the last inspection? no STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP7 Regulation 15 (2)(c) (d) Requirement The service user plan needs to be reviewed regularly and the input of relatives or representatives must be incorporated. Service user plans must be kept securely Medication administration records must be accurately maintained The office area in the lounge of the dementia care unit must be sited in a more appropriate area to meet the needs of the service users and staff. An application must be submitted to CSCI to register a manager for the home. Timescale for action 30/06/06 2 3 4 OP7 OP9 OP19 17 (1)(b) 13(2) 23(b) 10/04/06 10/04/06 10/04/06 5 OP31 8 30/06/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations The Tudors Residential Home for the Elderly DS0000065754.V288410.R01.S.doc Version 5.1 Page 21 The Tudors Residential Home for the Elderly DS0000065754.V288410.R01.S.doc Version 5.1 Page 22 Commission for Social Care Inspection Cambridgeshire & Peterborough Area Office CPC1 Capital Park Fulbourn Cambridge CB1 5XE National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI The Tudors Residential Home for the Elderly DS0000065754.V288410.R01.S.doc Version 5.1 Page 23 - 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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