Inspection on 24/08/05 for Tudor Bank Ltd

This inspection was carried out on 24th August 2005.

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

Tudor Bank Ltd 03/04/07

Tudor Bank Ltd 26/01/06

Tudor Bank Ltd 26/01/05

Tudor Bank Ltd 03/08/04

Similar services:

Sunny Bank (P.R.S.) Ltd

Ashwood Court Unit 1

Thornton Lodge

Alfred House Residential Care Home

Barkerhouse Road (123)

Fernhaven

Thames House

Creative Support

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

CARE HOME MIXED CATEGORY MAJORITY OLDER PEOPLE Tudor Bank Ltd 2 Beach Road Southport Merseyside PR8 2BP Lead Inspector Mike Perry Unannounced 24 August 2005 th 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 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 and Care Homes for Adults 18 – 65*. 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. Tudor Bank Ltd F53 F03 S57945 Tudor Bank V240419 25.08.05 Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Tudor Bank Ltd Address 2 Beach Road Southport Meseyside PR8 2BP 0208 863 4637 0208 861 4457 Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Tudor Bank Ltd Mrs Mary Elizabeth Pagett N - Care Home with Nursing 46 Category(ies) of DE(E) - Dementia - over 65 - 28 Places registration, with number MD - Mental Disorder - 18 Places of places Tudor Bank Ltd F53 F03 S57945 Tudor Bank V240419 25.08.05 Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: 1. The service should, at all times, employ a suitably qualified and experienced Manager who is registered with the CSCI. 2. Service users to include up to 28 Dementia (over 65 years of age) and up to 18 Mental Disorder, excluding learning disability or dementia. Date of last inspection 26th January 2005 Brief Description of the Service: Tudor Bank is a large detached nursing home set in its own grounds and occupying a position close to both Southport sea front and town centre. It provides nursing care for two resident groups of both younger adult and older persond with mental health needs. The home is owned by Tudor Bank Ltd and the responsible individual is Mr Himat Gami. Externally the home has a black and white tudor style appearance and the original building has been added to over recent years with 2 purpose built extentions in order to meet the requirments of the Care Standards Act 2000. There is an enclosewd rear garden which is accessed from two of the day areas. The front of the buiding is given over to parking. The home has its own mini bus which is well used for trips out. The Registered Manager of Tudor Bank is Mary Pagett who is a qualified nurse. she has been in post for 5 years. Tudor Bank Ltd F53 F03 S57945 Tudor Bank V240419 25.08.05 Stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection was unannounced and was conducted over a period of 5 hours on one day. All day and recreation areas were seen and some of residents bedrooms. Care records and other records kept in the home such as health and safety records were also viewed. In total 10 residents in the home were spoken to along with 2 relatives, 6 members of staff including the 2 trained nurses on duty. A series of comment cards were also left in the home for elatives, professionals and visitors to complete. 11 of the 20 Core standards were covered on the inspection. There were many positive aspects to the inspection and the management were responsive and open to comments made. The feedback from both resident and relative interviews painted a picture of a well organised home with a strong ethos of caring. What the service does well: Prospective residents are assessed prior to being admitted to the home so that any care needs are more assured a being met. Following admission there are further assessments made which cover all areas of daily living such as personal care and health needs as well as domestic and self help skills. The care plans agreed with residents include their input and are regularly reviewed. Copies of the care plans are kept with the residents in each of their bedrooms. One residents care file reviewed on the inspection included needs centred on the process of dying. The care here had been carried out evidencing good liaison with health care support from the palliative care team. Good practice guidelines using the ‘vigil’ care programme helped ensure that all needs were met comprehensively including those of the family. Residents spoken to were clear that staff respected the right to privacy and that dignity was preserved. An example of this is the attention paid by staff to the cleanliness and the appropriateness of dress for the elderly residents who are confused. Relatives commented that ‘residents are always clean and tidy’. As the staff interacted with residents they were warm and supportative. Good staffing levels are maintained so that elderly residents can always be observed and supported if they require personal care. Residents spoken to where enthusiastic about the activities in the home, which centre on a planned weekly programme. There is input into this from residents Tudor Bank Ltd F53 F03 S57945 Tudor Bank V240419 25.08.05 Stage 4.doc Version 1.40 Page 6 at the weekly communal meeting. Three of the younger adults in the home are attending training / education course outside the home and this has help increase confidence and social skills. Residents commented positively on the food in the home. There is good choice [3 main choices most of the time] and one resident commented that the chef would always cook something individual if requested. The home has good overall management systems in place including a complaints procedure and Health and Safety policies and procedures. All the routine maintenance checks and certificates were up to date providing for a safe and well-maintained environment in the home. The staffing levels are good and there is good support from ancillary staff in the home. The manager is able to work supernummery for much of the time so that good overall supervision of the standards ion the home is possible. Both residents and relatives spoken to felt that staff were very kind and supportative with one commenting ‘staff really care’. What has improved since the last inspection? What they could do better: There are only two recommendations from this inspection. One is that all care plans should be signed by the nurse completing them. The other related to the removal of a fire exit sign above an exit in one of the bedrooms as this is confusing and is nor required following changes to the fire procedures some time ago following upgrading work. The requirement on the last inspection report for elderly residents to have terms and conditions of residency supplied has not been assessed on this inspection and remains until the next inspection. Tudor Bank Ltd F53 F03 S57945 Tudor Bank V240419 25.08.05 Stage 4.doc Version 1.40 Page 7 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. Tudor Bank Ltd F53 F03 S57945 Tudor Bank V240419 25.08.05 Stage 4.doc Version 1.40 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home Health and Personal Care Daily Life and Social Activities Complaints and Protection Environment Staffing Management and Administration Scoring of Standards Statutory Requirements Identified During the Inspection Older People (Standards 1–6) (Standards 7-11) (Standards 12-15) (Standards 16-18) (Standards 19-26) (Standards 27-30) (Standards 31-38) Adults 18 – 65 (Standards 1–5) (Standards 6, 9, 16 and 18–21) (Standards 7, 15 and 17) (Standards 22–23) (Standards 24–30) (Standards 31–35) (Standards 8, 10 and 37–43) Tudor Bank Ltd F53 F03 S57945 Tudor Bank V240419 25.08.05 Stage 4.doc Version 1.40 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 (Older People) and Standards 1 – 5 (Adults 18 – 65) are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. (YA NMS 1) Each service user has a written contract/ statement of terms and conditions with the home. Each Service User has an individual contract or statement of terms and conditions with the home. (YA NMS 5) No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Prospective Service Users’ individual aspirations and needs are assessed. (YA NMS 2) Service users and their representatives know that the home they enter will meet their needs. Prospective Service Users know that the home they choose will meet their needs and aspirations. (YA NMS 3) Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Prospective service users have an opportunity to “test drive” the home. (YA NMS 4) Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. 6. The Commission considers Standards 3 and 6 (Older People) and Standard 2 (Adults 18-65) the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 3 The assessments carried out by the home are good and help ensure that the home can meet the needs of residents admitted. EVIDENCE: Three residents files were seen. All residents had been assessed prior to admission and there was reference to community assessments from professionals [social workers and hospital and community nurses]. The homes assessment is very detailed and covers all aspects of the care standards including history of falls and self-medication assessments. Assessments also include mental state, risk and nutrition. The assessments provide information so that the home can make a decision as to whether they can meet the care needs adequately. They also form the base from which a care plan can be drawn up. Tudor Bank Ltd F53 F03 S57945 Tudor Bank V240419 25.08.05 Stage 4.doc Version 1.40 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 (Older People) and Standards 6, 9, 16, 18 –21 (Adults 18-65) are: 7. The service user’s health, personal and social care needs are set out in an individual plan of care. Service Users know their assessed and changing needs and personal goals are reflected in their individual plan. (YA NMS 6) Also Service Users are supported to take risks as part of an independent lifestyle. (YA NMS 9) Service users’ health care needs are fully met. Service Users physical and emotional health needs are met. (YA NMS 19) 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, retain, administer and control their own medication where appropriate and are protected by the home’s policies and procedures for dealing with medicine. (YA NMS 20) Service users feel they are treated with respect and their right to privacy is upheld. Service Users rights are respected and responsibilities recognised in their daily lives. (YA NMS 16) Also Service Users receive personal support in the way they prefer and require. (YA NMS 18) Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The ageing, illness and death of a Service User are handled with respect and as the individual would wish. (YA NMS 21) 8. 9. 10. 11. The Commission considers standards 7, 8, 9 and 10 (Older People) and Standards 6, 9, 16, 18, 19 and 20 (Adults 18-65) are the key standards to be inspected at least once during a 12 month period JUDGEMENT – we looked at outcomes for standard(s) 7,8,10,11 Individual care plans are drawn up with the resident’s involvement and reflect changing needs and personal goals. Residents are assisted to make personal decisions and generally feel included in the running of the home, which helps ensure participation and develops quality of life. Residents and relatives spoken to felt that staff were supportative and appropriate in their care so that respect and dignity is maintained. The care reviewed for one resident who had died in the home evidenced good liaison with health care professionals and followed principals of good care so that the resident and family were treated with sensitivity and respect. Tudor Bank Ltd F53 F03 S57945 Tudor Bank V240419 25.08.05 Stage 4.doc Version 1.40 Page 11 EVIDENCE: The residents in the home all have care plans. These are drawn up with the resident’s involvement and copies are given and kept in individual bedrooms in a folder along with information about the home. 3 care records were seen and these listed the care needs very clearly and were reviewed on a regular [weekly] basis. Notes are made in the care record. The nurse involved in drawing them up did not sign some of the care plans seen. One resident was able to discuss the care plan and the needs listed were relevant and included realistic interventions by staff as well as detailing the self help goals that the resident should try and attain. The care notes of a resident who had recently died in the home was reviewed with the nursing staff. It was clear from the notes that there had been appropriate liaison with health care professionals as the residents physical state declined. The palliative care team had been involved and the ‘vigil’ care pathway had been implemented which clearly documented how the resident had been cared for up to death and included close input from family members and ensuring that the resident was not alone for any period. Residents interviewed felt comfortable in the home and stated that staff were respectful of their privacy and were supportative. Residents were observed to be appropriately dressed and attention to maintaining personal hygiene was good. This was particularly relevant with the older persons with dementia were some residents are resistive to personal care. Relatives interviewed stated that residents are ‘always clean and tidy’ and that the standard was consistent. Staff interviewed displayed an understanding of the need to maintain dignity for residents and gave examples of how people with dementia, for example, had to be closely monitored if they displayed behaviour that compromised their dignity. The younger adult residents spoke positively about the staff and the interactions between staff and residents were observed to be warm and supportative. Tudor Bank Ltd F53 F03 S57945 Tudor Bank V240419 25.08.05 Stage 4.doc Version 1.40 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 (Older People) and Standards 7, 11– 15 and 17 (Adults 18-65) are: 12. 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 have opportunities for personal development. (YA NMS 11) Also Service Users are able to take part in age, peer and culturally appropriate activities. (YA NMS 12). Also Service users engage in appropriate leisure activities. (YA NMS 14) Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service Users are part of the local community. (YA NMS 13) Also Service Users have appropriate personal, family and sexual relationships. (YA NMS 15) Service users are helped to exercise choice and control over their lives. Service Users make decisions about their lives with asssistance as needed. (YA NMS 7) Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. Service Users are offered a healthy diet and enjoy their meals and mealtimes. (YA NMS 17) 13. 14. 15. The Commission considers standards 12, 13, 14 and 15 (Older People) and Standards 12, 13, 15 and 17 (Adults 18-65) the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12, 13,15 Activities are provided and continue to be developed in the home and assist in providing some quality of life for all residents. Arrangements to involve relatives in the home and in the care of residents are good so that relatives feel supported and in contact with events. Daily choices of meals are always available and nutritious meals and special diets are provided, to ensure residents received a wholesome balanced diet. EVIDENCE: There is a residents meeting every Friday were views can be aired and residents can have some input into the activities programme which is advertised on a weekly basis with regular trips in the mini bus being a main Tudor Bank Ltd F53 F03 S57945 Tudor Bank V240419 25.08.05 Stage 4.doc Version 1.40 Page 13 feature. Residents spoken to where able to relate trips to the cinema, swimming, walks locally as well as longer day trips to the Lake District. Some of the elderly residents benefit from music afternoons as well as more 1:1 activities such as foot massage and nail care and just time to sit and socialise with staff. The latter was observed during the afternoon of the inspection. There was good rapport between staff and relatives and relaxed feel to the main lounge. Three of the younger adult group attend regular training courses in social skills, exercise classes and computer training. One resident had been out to the library on the day of the inspection and felt hat the college course he was attending was very beneficial. The relatives interviewed felt that staff included them at all levels in the care and activities in the home. One resident comes from abroad and had been supported to go on a recent holiday to his own country to visit family. Another resident had moved into the home to be with his wife [who was already a resident] and had been cared for through the process of dying in the home with the inclusion of the rest of the family who had also been supported. The residents spoken to were pleased with the food and meal times. There are usually 3 choices available at the midday and teatime meal. The mealtime seen was relaxed and afforded the opportunity to socialise. One resident said that ‘they will always cook me something individual if I ask’. Tudor Bank Ltd F53 F03 S57945 Tudor Bank V240419 25.08.05 Stage 4.doc Version 1.40 Page 14 Complaints and Protection The intended outcomes for Standards 16 – 18 (Older People) and Standards 22 – 23 (Adults 18-65) 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 feel their views are listened to and acted on. (YA NMS 22) Service users’ legal rights are protected. Service Users are protected from abuse, neglect and self-harm. (YA NMS 23) Service users are protected from abuse. Service Users are protected from abuse, neglect and self-harm. (YA NMS 23) The Commission considers standards 16 and 18 (Older People) and Standards 22 and 23 (Adults 18-65) the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 16 The home have a complaints procedure and complaints are listened to and investigated so that residents and relatives feel that their concerns are dealt with. EVIDENCE: The home has a complaints procedure and this is included in the information guide for the home. Residents interviewed felt that staff were available to listen to concerns and these would be acted on. There is a weekly forum attended by the younger adults in the home were any issues can be raised. Any formal complaints are recorded [there have been no complaints over recent inspections]. There is also a complaints and comments book left out for people to fill in if they wish. Residents and relatives spoken to felt that the homes staff were approachable and would listen to any concerns. Staff interviewed could explain the complaints process. Tudor Bank Ltd F53 F03 S57945 Tudor Bank V240419 25.08.05 Stage 4.doc Version 1.40 Page 15 Environment The intended outcomes for Standards 19 – 26 (Older People) and Standards 24 – 30 (Adults 18-65) are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service Users live in a homely, comfortable and safe environment. (YA NMS 24) Service users have access to safe and comfortable indoor and outdoor communal facilities. Shared spaces complement and supplement service users’ individual rooms. (YA NMS 28) Service users have sufficient and suitable lavatories and washing facilities. Service Users toilets and bathrooms provide sufficient privacy and meet their individual needs. (YA NMS 27) Service users have the specialist equipment they require to maximise their independence. (YA NMS 29) Service users’ own rooms suit their needs. Service Users’ own rooms suit their needs and lifestyles. (YA NMS 25) Service users live in safe, comfortable bedrooms with their own possessions around them. Service users’ bedrooms promote their independence. (YA NMS 26) Service users live in safe, comfortable surroundings. Service Users live in a homely, comfortable and safe environment. (YA NMS 24) The home is clean, pleasant and hygienic. The home is clean and hygienic. (YA NMS 30) The Commission considers standards 19 and 26 (Older People) and Standards 24 and 30 (Adults 18-65) the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 19 Tudor Bank is well maintained and is clean so that residents live in a safe environment that meets their needs. EVIDENCE: The younger residents are not physically segregated from the older client group in the home although there are designated day areas allocated. This includes a smocking area. Choice of space is therefore available. The younger residents bedrooms are situated on the lower ground floor (female) and top floor (male). There has been work completed in the last few years to comply with minimum Tudor Bank Ltd F53 F03 S57945 Tudor Bank V240419 25.08.05 Stage 4.doc Version 1.40 Page 16 standards and the home is comfortable, bright and clean There has been ongoing refurbishment and since the last visit the patio area adjacent to the elderly care lounge has been enclosed creating more day space. There has also been work completed on the garden area and the residents that were sat enjoying the weather on the day of the inspection were appreciative of this. The home is well maintained with a full time maintenance person employed and a routine maintenance rota was seen. Tudor bank is situated near to both Southport sea front and town centre and residents interviewed appreciated the convenience of this. Tudor Bank Ltd F53 F03 S57945 Tudor Bank V240419 25.08.05 Stage 4.doc Version 1.40 Page 17 Staffing The intended outcomes for Standards 27 – 30 (Older People) and Standards 31 – 35 (Adults 18-65) are: 27. 28. 29. Service users needs are met by the numbers and skill mix of staff. Service users are supported by an effective staff team. (YA NMS 33) Service users are in safe hands at all times. Service Users are supported by an effective staff team. (YA NMS 32) Service users are supported and protected by the home’s recruitment policy and practices. Service Users benefit from clarity of staff roles and responsibilities. (YA NMS 31) Also Service Users are supported and protected by the home’s recruitment policy and practices. (YA NMS 34) Staff are trained and competent to do their jobs. Service Users individual and joint needs are met by appropriately trained staff. (YA NMS 35) 30. The Commission considers standards 27, 29 and 30 (Older People) and Standards 34 and 35 (Adults 18-65) the key standards to be inspected at leat once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27 There are appropriately trained and experienced nurses and care staff employed so that residents feel supported and that their needs are understood and met. EVIDENCE: On the day of the inspection there were 44 residents in the home and the staffing consisted of 2 trained nurses and 8 care staff. The duty rota confirmed that the usual staffing is 9 care staff but a staff member had reported sick that day. In addition to this there are 3 domestic staff [including laundry], a cook and kitchen assistant and some administration support. The manager also works 30 hrs per week. Residents felt that there was always enough staff around to attend to their needs and offer support where necessary. Relatives interviewed echoed this view. During the inspection it was observed that all of the day areas were regularly monitored [elderly areas continually staffed]. Tudor Bank Ltd F53 F03 S57945 Tudor Bank V240419 25.08.05 Stage 4.doc Version 1.40 Page 18 Relatives felt that staff were competent and supportative and always kept them in formed of any changes in the care. It was also felt that ‘staff really care’ and another comment was that ‘staff always make me feel welcome’. Tudor Bank Ltd F53 F03 S57945 Tudor Bank V240419 25.08.05 Stage 4.doc Version 1.40 Page 19 Management and Administration The intended outcomes for Standards 31 – 38 (Older People) and Standards 8, 10, 23, 37 – 43 (Adults 18-65) are: 31. 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 a well run home. (YA NMS 37) Service users benefit from the ethos, leadership and management approach of the home. (YA NMS 38) The home is run in the best interests of service users. Service Users are consulted on and participate in, all aspects of life in the home. (YA NMS 8) Also Service Users are confident their views underpin all selfmonitoring, review and development by the home. (YA NMS 39) Service users are safeguarded by the accounting and financial procedures of the home. Service Users benefit from competent and accountable management of the service. (YA NMS 43) Service users’ financial interests are safeguarded. Service Users are protected from abuse, neglect and self-harm. (YA NMS 23) Staff are appropriately supervised. Service Users benefit from well supported and supervised staff. (YA NMS 36) Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. Service Users know that information about them is handled appropriately, and that their confidences are kept. (YA NMS 10) Also Service Users rights and best interests are safeguarded by the home’s polies and procedures. (YA NMS 40) and (YA NMS 41) The health, safety and welfare of service users and staff are promoted and protected. The health, safety and welfare of service users and staff are promoted and protected. (YA NMS 42) 32. 33. 34. 35. 36. 37. 38. The Commission considers standards 33, 35 and 38 (Older People) and Standards 23, 39 and 42 (Adults 18-65) the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 38 Health and Safety issues in the home are well managed and monitored and ensure that the safety and well fare of the residents are promoted and protected. Tudor Bank Ltd F53 F03 S57945 Tudor Bank V240419 25.08.05 Stage 4.doc Version 1.40 Page 20 EVIDENCE: There is a full time maintenance person who works in conjunction with key care staff in maintaining health and safety in the home. One of the trained nurses has completed a Health and Safety training course. For example there are key staff who are involved in the manual handling assessments of residents and the training of staff. Staff training in fire safety is also organised by key staff and the maintenance person completes routine fire checks and maintenance, which are recorded. Routine risk assessments of the environment are carried on a regular walk around basis and then also a full 3 monthly audit. All maintenance certificates [fire, electric, gas] were available and up to date. General policies are available and he overall Health and Safety policy is given to staff as part of their induction. Some bedrooms were seen. The fire exit sign above the exit door in room 39 needs to be removed as this is no longer a fire exit following review by the fire brigade following some upgrading work in the home. Tudor Bank Ltd F53 F03 S57945 Tudor Bank V240419 25.08.05 Stage 4.doc Version 1.40 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 x 2 x 3 3 4 x 5 x 6 x HEALTH AND PERSONAL CARE ENVIRONMENT Standard No 19 20 21 22 23 24 25 26 STAFFING Score 3 x x x x x x x Score Standard No 7 8 9 10 11 Score 3 3 x 3 4 Standard No 27 28 29 30 3 x x x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 x 15 3 COMPLAINTS AND PROTECTION Standard No 16 17 18 Score 3 x x MANAGEMENT AND ADMINISTRATION Standard No Score 31 x 32 x 33 x 34 x 35 x 36 x 37 x 38 3 Tudor Bank Ltd F53 F03 S57945 Tudor Bank V240419 25.08.05 Stage 4.doc Version 1.40 Page 22 no Are there any outstanding requirements from the last inspection? 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 2 Regulation 5 Requirement Older Persons who are not privately funded must have standard terms and conditions of residency supplied to them or their representatives at the point of moving into the home. Timescale for action 1.1.06 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. Refer to Standard 7 38 Good Practice Recommendations All care plans should be signed by the nurse who has written them. The fire exit sign above the door in rm 39 shoukld be removed as this is no longer a fire exit following the upgrading work to this area. Tudor Bank Ltd F53 F03 S57945 Tudor Bank V240419 25.08.05 Stage 4.doc Version 1.40 Page 23 Commission for Social Care Inspection Burlington House, 2nd Floor, South Wing Crosby Road North Liverpool L22 0LG 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. Tudor Bank Ltd F53 F03 S57945 Tudor Bank V240419 25.08.05 Stage 4.doc Version 1.40 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. 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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