Inspection on 02/04/07 for The Tudors Residential Home For The Elderly

This inspection was carried out on 2nd April 2007.

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... 10/04/06

Similar services:

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 2nd April 2007 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.V335283.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 Residential Home for the Elderly DS0000065754.V335283.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service The Tudors Residential Home for the Elderly Address Rayners Way North Street Stanground Peterborough PE2 8HR 01733 892844 01733 554306 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) www.goldcarehomes.com GCH (Heath Lodge) Limited ***Post Vacant*** Care Home 43 Category(ies) of Dementia - over 65 years of age (20), Old age, registration, with number not falling within any other category (23) of places The Tudors Residential Home for the Elderly DS0000065754.V335283.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 10th April 2006 Brief Description of the Service: The Tudors is a large detached property situated in a quiet cul-de-sac in a residential area near to the city of Peterborough. There are 43 bedrooms provided. Within the premises there is a 20-bedded area for the specific needs of service users who have dementia care needs. Four communal lounges and two dining rooms are provided for service users. A passenger lift to the first floor is provided. There are well-maintained gardens to the front and rear of the property. The fees range from £372 to £575 per week. Copies of CSCI reports are made available to service users and their relatives upon request. The Tudors Residential Home for the Elderly DS0000065754.V335283.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. Regulation Inspectors, Andy Green and Alison Hilton conducted this key unannounced inspection on 2nd April 2007. The inspectors met with the acting manager, senior carers, service users, relatives and care staff to assess key standards and monitor compliance regarding requirements that were made at the last inspection. A number of documents and records were inspected and a tour of the premises was undertaken. What the service does well: What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The Tudors Residential Home for the Elderly DS0000065754.V335283.R01.S.doc Version 5.2 Page 6 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 Residential Home for the Elderly DS0000065754.V335283.R01.S.doc Version 5.2 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.V335283.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 1,2,4 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home provides comprehensive information to service users and their relatives before they move in ensuring that they are aware of all the services provide. EVIDENCE: The Statement of Purpose has been completely reviewed since the last inspection and the acting manager stated that these documents would 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 detailed assessments as part of the care management process outlining the individuals care and support requirements. Usually two members of senior staff carry out an assessment visit to the The Tudors Residential Home for the Elderly DS0000065754.V335283.R01.S.doc Version 5.2 Page 9 prospective service user and the homes own pre assessment form is completed to ensure that all relevant information is in place. Pre-admission visits to the home can be arranged where possible. Relatives or representatives of service users have an opportunity to visit the home as part of choosing whether the home will be able to meet the prospective service users needs. The home does not provide intermediate care The Tudors Residential Home for the Elderly DS0000065754.V335283.R01.S.doc Version 5.2 Page 10 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 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Service users are treated with dignity and respect and receive personal care to meet their assessed needs. EVIDENCE: There have been improvements made to the care planning system since the last inspection. A more person centred approach is in place and all of the previous care plans, apart from current information, have been discontinued. There is clearer documentation in place including assessment documents, healthcare, weight and nutritional screening charts, personal profiles and risk assessments. There was evidence of regular reviews of care in place. Six care plans were inspected including three from the dementia care unit. The inspectors were satisfied that care plans are now improving with a consistent approach being taken. The families of service users are asked to complete a personal profile regarding their relatives past life and personal history so that staff can gain a wider understanding of individual service users. Evidence of this document was seen The Tudors Residential Home for the Elderly DS0000065754.V335283.R01.S.doc Version 5.2 Page 11 in care plans. The acting manager stated that he will be developing care plans further to include personal activities in liaison with the home’s Activities Coordinator and key workers. Further training is planned for staff to ensure that the expected requirements and documentation contained in care plans remain professional and consistent. It was noted that although care plans had improved more detail is needed to give specific guidelines to staff regarding the assistance that service users require, as some guidelines that are currently recorded were vague. The acting-manager accepted this and he will action this point. Consequently a requirement will be made regarding this issue. It was noted that the mattress cover, on the bed of a service user with MRSA, was split. The acting-manager immediately actioned this to ensure that a new mattress and cover was in place to minimise any further infection control issues. Medication records were accurately recorded and they have improved since the last inspection. A local pharmacist continues to provide medication awareness and administration training. The Tudors Residential Home for the Elderly DS0000065754.V335283.R01.S.doc Version 5.2 Page 12 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 staff provide appropriate support to ensure that service users can engage in activities appropriate to their needs. Service users have a choice of meals, which are prepared and served in a homely manner. EVIDENCE: The atmosphere in the home was lively and busy and service users were socialising with each other and their relatives in the lounge. There is an Activities Co-ordinator in post who has developed a programme of activities throughout the home. There was evidence of regular activities, which are recorded, in an activities record book for both the dementia area and residential side of the home. Activities include: cookery sessions, music, bingo, paid entertainers, dancing to music, horse racing games, quizzes, listening to book tapes, hairdressing and nail care, pat-dog, skittles and walks in the garden and in the local community. The Tudors Residential Home for the Elderly DS0000065754.V335283.R01.S.doc Version 5.2 Page 13 The atmosphere in the dementia care unit was calm and organised and staff were seen to be attentive to service user’s needs on a social level and when giving personal care. One of the inspectors observed a small group of service users in the dementia care unit who were engaged in an appropriate activity in a very sensitive and social manner. Staff were also observed to knock on the door of service user’s bedrooms before entering. Service users are able to get up in the morning at a time they prefer and are assisted in choosing the clothes they wish to wear during the day. The home has a good rapport with local CPN’s who provide regular input in the dementia care unit. Lunch was unhurried, in both areas of the home, and a varied range of meals were available with service users having a choice of alternatives to the suggested menu choices. A number of service users confirmed that there was a choice of food and that meals were of good quality and that drinks and snacks were available throughout the day. The Tudors Residential Home for the Elderly DS0000065754.V335283.R01.S.doc Version 5.2 Page 14 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 good. This judgement has been made using available evidence including a visit to this service. The home has a satisfactory complaints process to make sure that service users and their representatives are able to raise concerns and have them dealt with appropriately. EVIDENCE: The home has a complaints procedure, which includes agreed timescales to ensure that all complaints are fully investigated and responded to appropriately. The home has received a complaint from a relative and this has been responded to by the acting-manager in a detailed manner using the organisation’s complaints format. A response from the complainant is awaited. 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 Tudors Residential Home for the Elderly DS0000065754.V335283.R01.S.doc Version 5.2 Page 15 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): 19,20,24,25,26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The environment of the home provides service users with a safe, comfortable, clean place 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 acting-manager stated that there is an ongoing maintenance programme rolled out throughout the year. Carpets in the dementia unit are regularly cleaned but there are areas, which showed some staining. The acting-manager stated that these areas of carpeting would be cleaned. Carpets in the two main lounges and the corridors The Tudors Residential Home for the Elderly DS0000065754.V335283.R01.S.doc Version 5.2 Page 16 in the dementia care unit have been replaced. An area of flooring in a sitting area in the dementia unit has also been newly carpeted. Nine bedrooms have been redecorated and re-carpeted since the last inspection. The staircase near to the front entrance has been altered with a door with a keypad security system to the first floor area. The fire system is being upgraded so that all doors on the keypad system will release automatically when the fire alarms are activated. Some pictorial signs have been added to service users’ bedrooms and bathrooms/WCs to aid service users with dementia care needs in recognising these facilities. The ‘office area’ in the lounge area of the dementia care unit has been changed and a small area for writing notes etc. has been installed to preserve service users privacy and dignity. The acting-manager stated that the gardens are being regenerated to provide more attractive planted and sensory areas for service users to enjoy. A full time maintenance person is employed to carry out ongoing repairs and renewals in the home. He also has responsibility for the maintenance of the lawns and garden areas. The acting-manager stated that there had been some problems with the lift in the home but he is hoping to resolve this with a new service engineer. Any faults with the lift have not caused inconvenience to service users. The Tudors Residential Home for the Elderly DS0000065754.V335283.R01.S.doc Version 5.2 Page 17 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. The agency’s recruitment policy and processes ensure that service users are protected from harm. Training is provided to make sure that care staff are competent to deliver personal care to the service users they support EVIDENCE: Mandatory courses for all staff are in place, which was evidenced in the training matrix displaying dates for when training has been completed, and when updates are due. Staff confirmed that they had received a variety of training including dementia and challenging behaviour, POVA, first aid, moving & handling, infection control and NVQ training at levels 2 and 3. Training records regarding dementia care were inspected and all members of care staff working in the dementia care unit have all received a detailed training session organised via the local authority training centre. The actingmanager stated that training regarding dementia remains 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 stated that they had found recent training beneficial to ensure that dementia care needs could be met. The Tudors Residential Home for the Elderly DS0000065754.V335283.R01.S.doc Version 5.2 Page 18 Care staff that do not normally work in the dementia care unit are also receiving a dementia awareness course delivered by a local CPN who provides ongoing support to the home. The acting acting manager stated that home was fully staffed. Seven members of care staff were on duty in the morning and six members of care staff in the afternoon/evening. The manager, administrator, cleaning and laundry staff, cook and kitchen assistants are also on duty during the day. Staff receive regular recorded supervision. The Tudors Residential Home for the Elderly DS0000065754.V335283.R01.S.doc Version 5.2 Page 19 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): 31,33,35,36,38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is well managed and the acting manager provides supportive leadership to ensure quality care is delivered and monitored through staff supervision and quality assurance processes. EVIDENCE: One of the organisation’s Project Managers is currently providing management in the home. Recruitment for the manager’s post is underway and the actingmanager stated that he will remain in the home until the recruitment and induction has been successfully completed. The Tudors Residential Home for the Elderly DS0000065754.V335283.R01.S.doc Version 5.2 Page 20 In the short time that he has been in charge of the home the acting-manager has created a supportive approach and communicates a clear sense of direction to ensure that the home is well managed. He has reviewed a number of policies and procedures and he is keen to develop the service in consultation with staff members and service users. Staff spoken to during the inspection confirmed that they received supportive and inclusive style of management and were positive about the acting-manager. Records of weekly fire alarm were seen and found to be accurate. It was noted that emergency lighting tests have not been carried out. The acting-manger stated that this would be immediately actioned and would be incorporated in the weekly alarm testing. A requirement will be made regarding this issue. Service contracts are also in place to ensure that equipment and services in the home are maintained regularly. The Tudors Residential Home for the Elderly DS0000065754.V335283.R01.S.doc Version 5.2 Page 21 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 3 X 3 X X HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 X 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 X 3 3 X X X 3 3 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 3 X 2 The Tudors Residential Home for the Elderly DS0000065754.V335283.R01.S.doc Version 5.2 Page 22 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(1) Requirement All people using the service must have a care plan in sufficient detail to ensure that staff are clear about the care that is to be provided. Arrangements must be in place for the testing of the emergency lighting system. Timescale for action 02/06/07 2 OP38 17(2) Schedule 4 (14) 02/04/07 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.V335283.R01.S.doc Version 5.2 Page 23 Commission for Social Care Inspection Cambridgeshire & Peterborough Area Office CPC1 Capital Park Fulbourn Cambridge CB21 5XE 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 Residential Home for the Elderly DS0000065754.V335283.R01.S.doc Version 5.2 Page 24 - 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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