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Inspection on 15/08/06 for Tordarrach Nursing Home

Also see our care home review for Tordarrach Nursing Home for more information

This inspection was carried out on 15th August 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. 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 found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

What follows are excerpts from this inspection report. For more information read the full report on the next tab.

What the care home does well

This home provides care for up to twenty elderly people many of who have advanced stages of dementia. The atmosphere in the home is friendly and welcoming and all of the residents spoken with were complimentary about the staff and especially about the homes manager. Several residents and their relatives commented on her kindness. It was however, considered that she should now be given more time in a supernumerary capacity in order to discharge her responsibilities fully and supervise other staff members. One resident told the inspector "you could never find anything better, it`s the best home in London ". Others said how lovely the staff were and " everyone is always helpful " During the inspection they were observed to have sufficient time to spend talking with residents as they cared for them. A pre admission assessment is undertaken, to ensure that the home can meet the needs of potential residents, and care plans are compiled from this detailing the help and support required. The relatives of one resident, who had recently been admitted, confirmed that they were given all of the help and information that they needed when first choosing the home.The care plans assessed showed that residents changing needs are identified and that they have access to other members of the primary healthcare team as necessary. A key worker system is in operation in the home, which contributes to continuity of care and gives staff an insight into resident`s particular problems. Staff training is given a high priority and all staff have undertaken training relevant to the work that they do. There was evidence that recruitment policies are in place, which will help to ensure the protection of residents. The majority of the residents were complimentary about the food served in the home, this includes a hot snack supper if they would like it, and activities are provided which suit their remaining abilities. All of them are encouraged to make choices within their daily lives as much as they are able to and their families and friends are welcome to visit them. In order to make them feel more at home, residents have been encouraged to bring some of their possessions with them to personalise their bedrooms which are all very pleasantly decorated. Records kept by the home and relating to ensuring the health and safety of residents and staff were generally in good order.

What has improved since the last inspection?

Since the last inspection the majority of concerns that were raised have been addressed. Residents have been offered a lockable facility in which to keep personal items and some have had these put into their rooms. Concerns had previously been raised about resident`s safety in the event of a fire and automatic door closers linked to the fire alarm have now been fitted where residents wish to keep their bedroom doors open. Other issues rising from the Fire Safety Officers visit have also been complied with although one is still outstanding. Staff training has improved considerably with all staff receiving training appropriate to the work that they undertake in order to improve the care that they deliver to residents. A quality assurance questionnaire has been distributed to residents and their relatives to monitor their satisfaction with the care and services provided by the home although it was suggested that the results of theses are now collated and made available.

CARE HOMES FOR OLDER PEOPLE Tordarrach Nursing Home 11 Hall Road Wallington Surrey SM6 0RT Lead Inspector Alison Ford Key Unannounced Inspection 15th August 2006 10:30 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Tordarrach Nursing Home DS0000019129.V308210.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. Tordarrach Nursing Home DS0000019129.V308210.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Tordarrach Nursing Home Address 11 Hall Road Wallington Surrey SM6 0RT 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) 020 8669 1494 020 8669 3533 tordarrach@yahoo.co.uk Dr R Obaro Mrs Ayodele Obaro Mrs Victoria Olufunto Akindele Care Home 20 Category(ies) of Dementia - over 65 years of age (0), Old age, registration, with number not falling within any other category (0) of places Tordarrach Nursing Home DS0000019129.V308210.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 16th November 2005 Brief Description of the Service: Tordarrach is a home providing nursing care to older people, the majority of whom have dementia. The home is a domestic style property enlarged and converted to provide accommodation for up to 20 residents over the age of 65. It is situated in a pleasant tree-lined road in Wallington, close to local amenities. Communal space and bedrooms are arranged over the ground, first and second floors and there is passenger lift serving all floors. There are eight single and six double bedrooms. The home has a large dining room with adjacent lounge. There are toilet and bathing facilities on each floor a large, accessible garden to the back and parking facilities at the front. At the time of this inspection fees ranged from £550-£600 per week with any additional charges payable being agreed prior to admission. A copy of the inspection report can be obtained from the home, from The Commission for Social Care Inspection or via the internet. Tordarrach Nursing Home DS0000019129.V308210.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was an unannounced visit, lasting 5 hours, although a further visit was made two days later, to check that an engineer had been called to adjust the temperature of the hot water. A tour of the premises was undertaken and several staff members, residents and their relatives were spoken with in order to gain their views of their life in the home. To assess the care that was being provided, a sample of care plans were looked at along with various records, kept by the home, which provide evidence that equipment and services are properly maintained. Staff on duty were spoken with about recent training that they had received and also about the residents that they were caring for in order to demonstrate their understanding of the needs of this client group. Prior to the inspection comment cards are sent, by The Commission, to people who live in the home or visit regularly. Replies were received from three residents, four relatives and a care manager What the service does well: This home provides care for up to twenty elderly people many of who have advanced stages of dementia. The atmosphere in the home is friendly and welcoming and all of the residents spoken with were complimentary about the staff and especially about the homes manager. Several residents and their relatives commented on her kindness. It was however, considered that she should now be given more time in a supernumerary capacity in order to discharge her responsibilities fully and supervise other staff members. One resident told the inspector “you could never find anything better, it’s the best home in London “. Others said how lovely the staff were and “ everyone is always helpful “ During the inspection they were observed to have sufficient time to spend talking with residents as they cared for them. A pre admission assessment is undertaken, to ensure that the home can meet the needs of potential residents, and care plans are compiled from this detailing the help and support required. The relatives of one resident, who had recently been admitted, confirmed that they were given all of the help and information that they needed when first choosing the home. Tordarrach Nursing Home DS0000019129.V308210.R01.S.doc Version 5.2 Page 6 The care plans assessed showed that residents changing needs are identified and that they have access to other members of the primary healthcare team as necessary. A key worker system is in operation in the home, which contributes to continuity of care and gives staff an insight into resident’s particular problems. Staff training is given a high priority and all staff have undertaken training relevant to the work that they do. There was evidence that recruitment policies are in place, which will help to ensure the protection of residents. The majority of the residents were complimentary about the food served in the home, this includes a hot snack supper if they would like it, and activities are provided which suit their remaining abilities. All of them are encouraged to make choices within their daily lives as much as they are able to and their families and friends are welcome to visit them. In order to make them feel more at home, residents have been encouraged to bring some of their possessions with them to personalise their bedrooms which are all very pleasantly decorated. Records kept by the home and relating to ensuring the health and safety of residents and staff were generally in good order. What has improved since the last inspection? Since the last inspection the majority of concerns that were raised have been addressed. Residents have been offered a lockable facility in which to keep personal items and some have had these put into their rooms. Concerns had previously been raised about resident’s safety in the event of a fire and automatic door closers linked to the fire alarm have now been fitted where residents wish to keep their bedroom doors open. Other issues rising from the Fire Safety Officers visit have also been complied with although one is still outstanding. Staff training has improved considerably with all staff receiving training appropriate to the work that they undertake in order to improve the care that they deliver to residents. A quality assurance questionnaire has been distributed to residents and their relatives to monitor their satisfaction with the care and services provided by the home although it was suggested that the results of theses are now collated and made available. Tordarrach Nursing Home DS0000019129.V308210.R01.S.doc Version 5.2 Page 7 What they could do better: It became apparent during the visit that one resident had been admitted who did not fit within the registration category for the home and a variation will need to be applied for if they wish to remain in the home. Care plans are regularly reviewed to ensure that resident’s needs are being met however sometimes, if there is no change, there is no evidence that this is being done. It was suggested that this should be amended so that everyone was aware that the assessment process was ongoing and they all knew what support was currently needed. Although most residents said how much they enjoyed the food in the home, a new chef has started work there and it was suggested that he should hold regular meetings with them to see which dishes they would like to see on the menu. In response to a fire safety visit the internal locks have been removed from the fire doors. In order to prevent any resident leaving the home unnoticed or falling on the fire escape these doors should be alarmed and this still remains to be done. It was noted at this inspection that the bath water was very hot and could pose a danger to both residents and staff. A second visit 48 hours later revealed that although it had been attended to the temperature still had a tendency to fluctuate. The Registered Provider has agreed to fit a different sort of regulator valve to prevent this from happening. A quality assurance programme has started, to monitor the views of residents and their families, and the results will now need to be collated and made available. The Registered Provider is frequently in the home and she will develop a more formal approach to recording her visits. This will provide information both for her, and to contribute to the inspection process, about how the residents enjoy living in the home and how much it meets their needs. Please contact the provider for advice of actions taken in response to this Tordarrach Nursing Home DS0000019129.V308210.R01.S.doc Version 5.2 Page 8 inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Tordarrach Nursing Home DS0000019129.V308210.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 Tordarrach Nursing Home DS0000019129.V308210.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 3,6 Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to the service. An assessment, undertaken prior to residents moving into the home, ensures that they can be confident that their healthcare needs will be met and that the home is suitable for them. This home does not offer intermediate care. EVIDENCE: Five care plans were looked at during the inspection and there was evidence that pre-admission assessments had been undertaken in order to ensure that the home would be able to meet the needs of the resident. This assessment then forms the basis for subsequent care planning. Regular reviews of the changing needs of residents take place throughout the year. The relatives of one resident, who had been admitted recently, commented on how helpful the staff had been to them during this process. Tordarrach Nursing Home DS0000019129.V308210.R01.S.doc Version 5.2 Page 11 During the inspection it became evident that one resident under the age of 65 had been admitted. This does not comply with the registration category of the home and a variation must be applied for if this resident wishes to remain there. Tordarrach Nursing Home DS0000019129.V308210.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9,10 Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to the service. Residents all have an individual care plan, documenting the help and support that they require, so that all members of staff are aware of how they prefer to be cared for. These ensure that residents assessed health care needs remain met even though they may change. Residents can be confident that they will be treated with respect and dignity and medication policies and procedures are in place to ensure their safety. EVIDENCE: All residents have a comprehensive care plan and five of these were examined at this inspection. They all contained assessments of physical and mental health, risk assessments, continence and tissue viability assessments. Entries in them show that other healthcare professionals are consulted as required. Assessment of those at risk of developing pressure sores is monitored regularly and appropriate interventions and equipment are used. Tordarrach Nursing Home DS0000019129.V308210.R01.S.doc Version 5.2 Page 13 Care plans are reviewed regularly although there must be evidence of this, even when there is no change required in the level of support that is needed. A key worker system is in use in the home and a member of the care staff was able to demonstrate an in depth knowledge of their particular residents. Personal care is given in service users own rooms and visitors could be received there if they wished although, those spoken with at the time of the inspection were happy to sit in the lounge. Staff were observed treating residents respectfully and both they and their relatives commented on how kind the staff were. All of the residents appeared clean and well cared for and relatives agreed that this was always so. Medication rerecords and storage were seen to be in order and procedures for disposal of unwanted drugs are in line with current legislation. Trained nurses administer all of the medication in the home ; no resident currently in the home is able to manage this for themselves. Tordarrach Nursing Home DS0000019129.V308210.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 at least once during a 12 month period. 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 from evidence gathered both during and before the visit to the service. Activities offered to residents suit their preferences and expectations and provide interest in their daily lives and they are encouraged to exercise their choice over their daily lives as much as they are able. Their relatives and friends are encouraged to visit and maintain their relationships with them. Residents enjoy the food served in the home although some would welcome the opportunity to influence the menus. EVIDENCE: The advanced stages of dementia of many of the residents, limits the amount of choices that they are able to make and the activities that they can participate in. Those able to express their preferences, agreed that they enjoyed the quizzes and musical entertainment. Three members of staff have undertaken a course to enable them to run chair based exercise sessions and residents enjoy these. Some residents are able to go out if accompanied and enjoy a stroll down the road or a visit to church. Tordarrach Nursing Home DS0000019129.V308210.R01.S.doc Version 5.2 Page 15 Relatives and friend are encouraged to visit the home and join in social occasions that are held. Menus that were received prior to the inspection were disappointing with regard to the choice of meals being served. Since that time a new chef has been appointed. Although the majority of residents spoken with were happy with the meals served, it appeared that options provided were limited. It was recommended that the chef should have regular meetings with the residents to find out which dishes they would like to see on offer before drawing up new menus. It was pleasing to hear that a hot snack supper is provided for those residents who would like it. Tordarrach Nursing Home DS0000019129.V308210.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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16,18 Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to the service. Residents can be confident that any complaints that they might have would be dealt with promptly and appropriately and that measures are in place to ensure that they are protected from abuse. EVIDENCE: An appropriate complaints procedure is in place in the home and there is a copy on the wall in the entrance hall. Residents and relatives that were spoken with all agreed that they could raise any concerns with Matron and she would deal with them. The complaints book was seen and contained only concerns that had been raised by residents themselves. These had all been addressed. The Comission has received no complaints about the home since the last inspection. All staff have received training in recognising and reporting adult abuse and all have appropriate clearance from The Criminal Records Bureau. The home has a policy regarding the protection of vulnerable adults and any concerns would be referred to the appropriate agency. Tordarrach Nursing Home DS0000019129.V308210.R01.S.doc Version 5.2 Page 17 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): 19,26 Quality in this outcome area is poor. This judgement has been made from evidence gathered both during and before the visit to the service. This home provides a comfortable, clean and generally safe environment for residents to live in, which suits their needs, and they have been encouraged to bring in their own possessions to enable them to personalise their rooms and feel at home. Some concerns were raised which could affect the health and safety of both residents and staff in the home. EVIDENCE: The home, a converted private house, is situated in a pleasant tree-lined road and is clean, homely and generally well maintained. Ramps facilitate access in through the front door and out to the attractive large garden A tour of the home was undertaken and it was found to be clean and odour free. Resident’s bedrooms are pleasant and they have all been personalised by their occupants. Residents have all been offered lockable facilities in their Tordarrach Nursing Home DS0000019129.V308210.R01.S.doc Version 5.2 Page 18 rooms and some of them have accepted these. Automatic door closers operating in the event of a fire have also been fitted where resident wish to leave their bedroom doors open. One upstairs bedroom had no window restrictor and to ensure the safety of the resident this must be rectified. In response to the Fire Safety Officers visit fire doors are left unlocked however, in order to ensure the safety of residents and prevent them leaving the home unnoticed an alarm must be fitted to these. It was also recommended that consideration should be given to fitting a smoke detector inside the linen cupboard. Some bedroom doors were quite creaky and it was recommended that these should be looked at to ensure resident were not disturbed when they were asleep. Soap dispensers in some bedrooms needed cleaning out, although there are apparently plans to replace these, and paper towels must be available by hand basins to enable staff to wash and dry their hands. To prevent any accidents it is recommended that the fire extinguisher should be attached to the wall. It was noted that bath water was extremely hot on the day of the inspection and could pose a danger to both residents and staff. An immediate requirement was issued to rectify this situation and a return visit was made 48 hours later. At this time there was evidence that an engineer had attended to the problem however, water temperatures although lowered, were still variable. The Registered Provider has agreed to replace the one regulator valve on the hot water tank with individual ones on water outlets. Until such time as this work is completed there must be evidence that water temperatures are tested prior to any resident having a bath. Tordarrach Nursing Home DS0000019129.V308210.R01.S.doc Version 5.2 Page 19 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 Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to the service. Residents an be sure that sufficient numbers of appropriately trained staff will be on duty in the home in the home to meet their needs and that recruitment policies and procedures are in place to protect them. EVIDENCE: The home is staffed 24 hours a day by a trained nurse supported by care staff. In addition there are catering and domestic staff in sufficient numbers to provide a quality service to residents. Since the last inspection there has been a higher priority given to staff training with sessions including health and safety, safe handling of medicines, infection control, fire safety, first aid and health and safety. The matron and two other staff members have undertaken a dementia awareness certificate and the expectation is that they will now teach the other staff. Given the numbers of residents with dementia it is recommended that consideration should be given to some care staff undertaking an NVQ qualification in dementia care. Appropriate checks are made prior to new staff commencing employment and the file of the only nurse employed since the last inspection was seen. Tordarrach Nursing Home DS0000019129.V308210.R01.S.doc Version 5.2 Page 20 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): 31,33,35,38 Quality in this outcome area is adequate. This judgement has been made from evidence gathered both during and before the visit to the service. Residents can be sure that the home is managed by a person who is fit to be in charge and that it is run in their best interests. EVIDENCE: The Registered Manager of the home is a trained nurse and demonstrated an awareness of the issues experienced by the residents of the home. Everyone that was spoken with commented on her kindness and she was receptive to the inspection process. Off duty rots showed that when she is on duty she is also the designated trained nurse in the home. In order to discharge her responsibilities fully and provide supervision and training to staff, a requirement is issued that she must now be given some supernumery time. This should be agreed between herself and the Registered Provider. Tordarrach Nursing Home DS0000019129.V308210.R01.S.doc Version 5.2 Page 21 A quality assurance monitoring system has started and questionnaires were distributed to residents and their relatives. It was recommended that the results from this should now be collated and made available. Although the Registered Provider is often in the home, there was no evidence of any visit undertaken within the framework of regulation 26 to ensure that residents are satisfied with the level of care provided in the home. This must now be formalised and a record of such visits available for future inspections. The home does not take responsibility for the money of any of the residents. Certificates of worthiness were seen for equipment and services in the home and were satisfactory. The accident book was seen and there had not been any serious injuries since the last inspection. Kitchen records were all in order however a requirement is made to install a fly screen or insect destroyer in the kitchen to help to prevent infection. A fire risk assessment has now been compiled and staff have undertaken fire training. Tordarrach Nursing Home DS0000019129.V308210.R01.S.doc Version 5.2 Page 22 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 X X 2 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 2 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 3 2 X X X X X X 1 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 2 X 2 X 3 X X 2 Tordarrach Nursing Home DS0000019129.V308210.R01.S.doc Version 5.2 Page 23 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 OP3 Regulation 23(1)(a) Requirement The Registered Provider must ensure that all residents are within the category of registration for the home. The Registered Manager must ensure that there is always evidence in care plans that they have been reviewed. The Registered Provider must ensure that alarms are fitted to fire exit doors. (Previous timescale 13/01/06 not met ) The Registered Provider must ensure that soap dispensers are cleaned or replaced The Registered Provider must ensure that paper towels are available by hand basins. The Registered Provider must ensure that the temperature of water required for total body immersion remains around 43C (Immediate requirement issued) 7 OP26 13(4)(c) The Registered Manager must DS0000019129.V308210.R01.S.doc Timescale for action 15/08/06 2 OP8 15(2)(b) 15/11/06 3 OP19 13(4) 15/11/06 4 5 6 OP19 OP19 OP26 13(3) 13(3) 13(4)( c) 15/11/06 15/11/06 15/08/06 15/08/06 Page 24 Tordarrach Nursing Home Version 5.2 8 OP31 18(2) 9 OP33 26 10 11 OP38 13(3) 23(4)(a) (b)(c)(d) OP38 ensure that there is evidence that water temperatures `are tested prior to any resident having a bath The Registered Provider must ensure that the homes manager is allocated some supernumerary time. The Registered Provider must ensure that there is evidence available of visits undertaken within the framework of regulation 26. The Registered Provider must provide a fly screen or destroyer in the kitchen. The Registered Manager must ensure that all of the requirements issued at the Fire Safety Officers visit are complied with. (Previous timescale 13/01/06 not met) 15/11/06 15/11/06 15/11/06 15/11/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 2 3 Refer to Standard OP15 OP19 OP33 Good Practice Recommendations It is recommended that the chef should meet regularly with residents to discuss meals that they would like to see included on the menu. It is recommended that the fire extinguisher should be fixed to the wall with a bracket. It is recommended that results from quality assurance surveys should be collated and distributed to residents and their relatives. Tordarrach Nursing Home DS0000019129.V308210.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection Croydon, Sutton & Kingston Office 8th Floor Grosvenor House 125 High Street Croydon CR0 9XP 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 Tordarrach Nursing Home DS0000019129.V308210.R01.S.doc Version 5.2 Page 26 - 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. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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