CARE HOME MIXED CATEGORY MAJORITY OLDER PEOPLE
Tudor Bank Ltd Tudor Bank 2 Beach Road Southport Merseyside PR8 2BP Lead Inspector
Mr Mike Perry Unannounced Inspection 26th January 2006 09:00 X10029.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 Tudor Bank Ltd DS0000057949.V280657.R01.S.doc Version 5.1 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People 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 DS0000057949.V280657.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION
Name of service Tudor Bank Ltd Address Tudor Bank 2 Beach Road Southport Merseyside PR8 2BP 01704 569260 01704 567938 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) Tudor Bank Ltd Mrs Mary Elizabeth Pagett Care Home 46 Category(ies) of Dementia - over 65 years of age (28), Mental registration, with number disorder, excluding learning disability or of places dementia (18) Tudor Bank Ltd DS0000057949.V280657.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION
Conditions of registration: 1. 2. The service should, at all times, employ a suitably qualified and experienced Manager who is registered with the CSCI. Service users to include up to 28 Dementia (over 65 years of age) and up to 18 Mental Disorder, excluding learning disability or dementia 24.8.2005 Date of last inspection 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 elderly people with mental health needs. Tudor Bank Ltd owns the home 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 two purpose built extensions. There is an enclosed rear garden, which is accessed through two day areas. The front of the building is given over to parking. The home ha its own minibus, which is well used for, trips out. The Registered Manager of Tudor Bank is Mary Pagett who is a qualified nurse. Tudor Bank Ltd DS0000057949.V280657.R01.S.doc Version 5.1 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 5.5 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 policies and procedures where also viewed. In total 7 residents in the home were spoken to along with 4 relatives, 5 members of staff including the 2 trained nurses on duty. 9 of the 20 Core standards that were not reviewed on the previous inspection were covered on the inspection. There were also some outstanding requirements from that inspection, which were also reviewed. For a fuller picture of the home this report should be read in conjunction with the previous report from august 2005. 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 was again very positive on the day. All relatives and residents spoke of the caring nature of the staff in the home. There were some requirements made on this inspection around the administration of medication records and some recommendations for good practise such as the updating of the staff with respect to their awareness of the role of the statutory bodies [police, social services, Care Standards Commission] in the investigation of any allegations of mistreatment or abuse. What the service does well:
There is a good approach to the planning of care in the home. This is best exemplified by the care taken to share the written care plans for each resident. Care plans are kept in resident bedrooms and are therefore easily available and residents and relatives can feel that they have some ownership of the care. The plans are well written and clear and give appropriate social background including reference to family input. One relative commented that they ‘make my dad a human being’. How the home manages to ensure residents have some choice and control over their lives was mainly reviewed with reference to the elderly residents. The home cares for people with dementia and the balance between ensuring safety / monitoring of this group with encouraging some choice and selfTudor Bank Ltd DS0000057949.V280657.R01.S.doc Version 5.1 Page 6 direction is very difficult to achieve. The staff interviewed understood the importance of trying to achieve this and gave practical examples of how they tried to individualise the care. For example getting residents to choose clothing to wear if possible. Also ensuing some preferences for choice of food is known. Bedrooms were personalised with resident possessions and ornaments. Staff interviewed displayed a good understanding of how they would recognise abusive practice and were also able to understand the principals of good care such as the need to maintain a person’s dignity and privacy. [There was also an understanding of how these are sometimes compromised by the communal living experience of a care home]. One relative commented on the staffs ability to deal calmly with difficult behaviours such as aggression from some residents. The ongoing maintenance of the home is good so that residents are able to live in comfortable surroundings. The recruitment policy and procedures are good so that staff receive thorough checking prior to being employed in the home with all of the necessary references on file. The manager has drawn up training plans for all staff. The home is registered with an external body that assists with training needs of staff particularly around the induction process. Staff spoken to described some of the training undertaken and felt that it both prepared them for and complimented the work that they did. NVQ training is ongoing in the home. Out of 24 care staff employed 10 have an NVQ qualification and 7 others are currently working towards one. Mary Paget has managed Tudor bank for the past 6 years. She has been a consistent figure over the transfer of ownership 2 years ago and has maintained good standards in the home over a period of change and development in the home. The feedback from the staff, residents and relatives interviewed on this inspection was very positive. Relatives in particular were appreciative of her communication skills and found her approach to be caring and supportative. Tudor Bank has continued to develop as a care home over recent years and has been assisted in this process by the introduction of some external and internal quality audits that aim to try and seek the views of the residents and the users of the service. For example there are regular meetings with the younger residents as well as meetings with relatives of the elderly residents [started more recently] so that views can be aired. Tudor Bank Ltd DS0000057949.V280657.R01.S.doc Version 5.1 Page 7 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 report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Tudor Bank Ltd DS0000057949.V280657.R01.S.doc Version 5.1 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 Outcomes 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 DS0000057949.V280657.R01.S.doc Version 5.1 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 the following standard(s): Not assessed. EVIDENCE: Not assessed. Tudor Bank Ltd DS0000057949.V280657.R01.S.doc Version 5.1 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 the following standard(s): 7, 9 [OP] Individual care plans are drawn up with the resident’s involvement and reflect changing needs and personal goals. The administration of medication records needs to be of a consistent standard so that residents are protected accordingly. EVIDENCE: The care plans seen on the inspection are kept in resident’s rooms so that residents feel they can ‘own’ and contribute towards the care. One relative of an elderly resident in the home was able to show and discuss the care plan and
Tudor Bank Ltd DS0000057949.V280657.R01.S.doc Version 5.1 Page 11 felt that it was clear and easy to understand. It was written in a personalised way that ‘makes my dad a human being’. The care plan gave some useful background social history and mentioned the role of the relative in supporting the care. Relatives interviewed at the time of the inspection felt that staff kept them updated and informed about any changes. The mediation procedure was reviewed and discussed with staff. There are policies and procedures available so that staff can refer to them. The receiving and returning of medicines in the home was reviewed and is satisfactory. The home maintains a record of medicines returned. The medicine storage room is very small for the size of the home and it is important that stock is kept under scrutiny and unused medicines are disposed of. The supplying pharmacist completes audits on a regular basis. There was no thermometer in the storage room on the day of the inspection. It is important that medicines are stored in a temperature not higher than 25 centigrade. The medication administration records were seen and there were a lot of omissions in the records where it was not possible for staff to be sure whether medicines had been given or not. These were pointed out to the staff and there was some discussion as to the importance of accurate records being maintained and if medicines are omitted then a record should be maintained with the reason for the omission. Tudor Bank Ltd DS0000057949.V280657.R01.S.doc Version 5.1 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 assistance 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 the following standard(s): 14 [OP] The home is able to demonstrate an understanding of need for residents with dementia as well as those younger adults with mental health needs to exercise some control over their lives so that their rights are respected EVIDENCE: The personal exercise of choice and control over resident’s daily life in the home is a difficult balance to achieve given the lack of mental capacity of the elderly resident group. There were examples however of how the home were trying to achieve a good balance. For example staff interviewed were aware of individual residents likes and dislikes in terms of dress and food preference.
Tudor Bank Ltd DS0000057949.V280657.R01.S.doc Version 5.1 Page 13 Individual bedrooms displayed photographs and ornaments, which reflected individual’s history and personality. One care staff described how she assisted residents to get ready for the day each morning and understood the need for time to chose preferred clothing and also, later on in the day, to join in an appropriate activity which is linked to a personal interest if possible. Staff are aware of the importance of advocacy and understand its use. One care assistant explained - ‘if a resident has nobody to look after their affairs we can get an advocate in to speak for them’. Tudor Bank Ltd DS0000057949.V280657.R01.S.doc Version 5.1 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 the following standard(s): 18 The home provides a protective and caring environment but there needs to be more awareness amongst the management and staff regarding the local adult protection procedures so that residents are fully protected from abuse. EVIDENCE: Each of the resident lounges has folders with policies, procedures and information for staff and relatives to look at and these include information on, for example, elder abuse and concepts such as confidentiality. Staff spoken to had received some training in the awareness and understanding of abuse and were able to give examples of how they would recognise abuse and what the principal’s of good care where in terms of the need for dignity and privacy for example. One member of staff described an external course she had been on with social services and how this had linked in with her NVQ training. Staff were able to give an account of how an allegation of abuse might be dealt with but did not have an understanding of the role of the statutory bodies such as the police, social services or the Commission for Social Care Inspection
Tudor Bank Ltd DS0000057949.V280657.R01.S.doc Version 5.1 Page 15 [CSCI]. The homes policies and procedures were out of date and more recent Adult Protection Procedures should be accessed so that the home is in a position to report allegations appropriately. Relatives interviewed on the day felt that the staff approach to the care of vulnerable residents was supportative and respectful. One relative gave an account of how staff deal with some difficult behaviours such as aggression from some residents and manage this very appropriately with due regard for the dignity of the residents concerned. Tudor Bank Ltd DS0000057949.V280657.R01.S.doc Version 5.1 Page 16 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 the following standard(s): 19,26 The home shows evidence of ongoing maintenance and upgrading and was found to be clean and hygienic so that residents can live in a pleasant environment. EVIDENCE: There was a limited tour of the home conduced. It was clear that there continues to be ongoing work in terms of décor and since the last inspection there have been a number of bedrooms decorated and the younger adults spoken to were please with this. One of the lounges is used as an area where
Tudor Bank Ltd DS0000057949.V280657.R01.S.doc Version 5.1 Page 17 residents can smoke. It was observed that the carpet in this area is badly stained and needs replacing. All other areas inspected were clean and maintained. Relatives and residents spoken to commented on the standard of cleanliness and some remarked that there is never any offensive odour apparent. Tudor Bank Ltd DS0000057949.V280657.R01.S.doc Version 5.1 Page 18 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, 28, 29 and 30 (Older People) and Standards 32, 34 and 35 (Adults 18-65) the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 28,29,30 There is a staff-training programme ongoing which has nearly met the standard for 50 of care staff to be trained to NVQ level so that care is delivered safely and references good practice. Residents are protected by the homes recruitment processes, which include appropriate checks for all staff. EVIDENCE: Three staff files were inspected. These were staff that had more latterly commenced work in the home. The records were comprehensive and contained evidence of all of the recruitment checks required such as Criminal Records [CRB] and Protection of Vulnerable Adults [POVA] checks. There were also appropriate references on file. The manager has drawn up training plans for all staff and these were reviewed with the inspector. One of the trained nurses has been delegated responsibility
Tudor Bank Ltd DS0000057949.V280657.R01.S.doc Version 5.1 Page 19 for the monitoring of training in the home. The home is registered with an external body that assists with training needs of staff particularly around the induction process. Staff spoken to described some of the training undertaken and felt that it both prepared them for and complimented the work that they did. One staff described completing manual handling, fire awareness updates as well as commencing an NVQ in care over the past 6 months. NVQ training is ongoing in the home. Out of 24 care staff employed 10 have an NVQ qualification and 7 others are currently working towards one. Tudor Bank Ltd DS0000057949.V280657.R01.S.doc Version 5.1 Page 20 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 policies 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 31, 33, 35 and 38 (Older People) and Standards 37, 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 the following standard(s): 31,33,35 The manager of the home has the experience and qualifications to ensure that Tudor Bank is run satisfactorily and that residents best interests are maintained. The quality systems in place ensure good monitoring and ongoing improvements take place so that resident care can be progressed and procedures are appropriately managed to ensure smooth running of the home.
Tudor Bank Ltd DS0000057949.V280657.R01.S.doc Version 5.1 Page 21 EVIDENCE: Mary Paget has managed Tudor bank for the past 6 years. She has been a consistent figure over the transfer of ownership 2 years ago and has maintained good standards in the home over a period of change and development in the home. She is a qualified nurse and has previous management experience running a charity organisation. She has a good record of continual update of skills and the feedback from the staff, residents and relatives interviewed on this inspection was very positive. Relatives in particular were appreciative of her communication skills and found her approach to be caring and supportative. The home undergoes an external audit on a yearly basis in order to monitor and improve quality. Resident and relative feedback is canvassed as part of this audit but the management also carry out their own internal satisfaction survey and the results of this are displayed in the home. There are meetings organised on a regular basis with the younger adult group and any issues raised are followed upon. An example of this was a recent request for tea making facilities o be made more available and some residents have been supplied with this facility in their bedrooms. The older residents have a family forum which relatives can attend and air any views. The various policies and procedures for the home are reviewed on a regular basis and staff reported that the manager communicates any change in policy on a regular basis. The manager carries out a series of audits, which look at deferent areas of the care standards in the home. Some of these lack information as to how conclusions are reached [i.e. what was audited and how many sampled etc]. The management of resident’s finances was discussed and records were seen of petty cash and valuables kept in the safe. The home manages only 3 resident’s personal allowances. The management of residents’ personal allowance was reviewed. The owner is appointee for 8 of the residents who are younger adult. Moneys are paid into a residents account and then residents request any money on a weekly basis, which is then withdrawn and paid to residents concerned. There is a petty cash sheet, which records these transactions. Other younger adults manage their own money more directly. There is a policy and procedure for reference purposes. Tudor Bank Ltd DS0000057949.V280657.R01.S.doc Version 5.1 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 X 2 X 3 X 4 X 5 X 6 X HEALTH AND PERSONAL CARE Standard No Score 7 4 8 X 9 2 10 X 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 X 14 3 15 x COMPLAINTS AND PROTECTION Standard No Score 16 X 17 X 18 3 ENVIRONMENT Standard No Score 19 3 20 X 21 X 22 X 23 X 24 X 25 X 26 3 STAFFING Standard No Score 27 X 28 2 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No Score 31 4 32 X 33 3 34 X 35 3 36 X 37 X 38 x Tudor Bank Ltd DS0000057949.V280657.R01.S.doc Version 5.1 Page 23 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 OP9 Regulation 17 Requirement Medication records [MAR] must include a record of all medication administered. If omitted the reason must be recorded. Timescale for action 01/05/06 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 OP9 OP18 Good Practice Recommendations The temperature of the medication storage room should be monitored and should not exceed 25 centigrade. The manager should ensure that the homes policies and procedures are updated regarding the management and reporting of Adult Protection / abuse issues and that all staff are aware of these. The carpet in the ‘smocking’ lounge should be replaced [stained and worn]. The NVQ training programme should continue and meet the standard of 50 care staff trained to this level. The quality audits should contain information on the process of the audit which can supply the evidence for the conclusions reached. 3 4 5 OP19 OP28 OP33 Tudor Bank Ltd DS0000057949.V280657.R01.S.doc Version 5.1 Page 24 Commission for Social Care Inspection Knowsley Local Office 2nd Floor, South Wing Burlington House 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 DS0000057949.V280657.R01.S.doc Version 5.1 Page 25 - 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. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!
