Inspection on 16/11/05 for Tudor Beech Place

This inspection was carried out on 16th November 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 found no outstanding requirements from the previous inspection report, but made 1 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Tudor Beech Place 19/04/07

Tudor Beech Place 24/05/05

Tudor Beech Place 15/11/04

Tudor Beech Place 07/07/04

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

CARE HOME ADULTS 18-65 Tudor Beech Place Tudor Beech Place Horley Lodge Lane Salfords Surrey RH1 5EA Lead Inspector Peter Benthom Unannounced Inspection 16th November 2005 10:00 Tudor Beech Place DS0000013815.V252293.R01.S.doc Version 5.0 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 Beech Place DS0000013815.V252293.R01.S.doc Version 5.0 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 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 Beech Place DS0000013815.V252293.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Tudor Beech Place Address Tudor Beech Place Horley Lodge Lane Salfords Surrey RH1 5EA 01293 824339 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) Surrey Oaklands NHS Trust Mrs Tracey Sakhmani Care Home 6 Category(ies) of Learning disability (6) registration, with number of places Tudor Beech Place DS0000013815.V252293.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. The age/age range of the persons to be accommodated will be: 30 45 YEARS Of the six (6) beds registered for learning disability (LD), one (1) may have an additional physical disability. Of the six (6) beds registered for learning disability (LD), one (1) may have a sensory impairment. 24th May 2005 Date of last inspection Brief Description of the Service: The home is comprised of a detached bungalow set in extensive grounds in a private road. All accommodation is at ground floor level, with equipment present to assist some service users with a physical disability. Residents’ bedrooms are attractive and have many personal items present. The home is owned by Metropolitan Housing Association, but run and managed by Surrey Oaklands NHS Trust and has 6 beds. Residents have severe learning disabilities and some also have physical problems. Tudor Beech Place DS0000013815.V252293.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection was second of the year 2005/6 and was conducted by an inspector from CSCI. The manager is has been registered for some considerable time and was not present for the inspection. Three members of staff were on duty and two of the five Service Users in the home were spoken with. A tour of the premises took place and care, training and Health and Safety records were inspected. What the service does well: What has improved since the last inspection? What they could do better: It was observed that the home is operating extremely well and that all policies, procedures and practice issues are of a good standard. However the statement of purpose and service users guide need to be updated to provide more up to date information particularly the details of the CSCI. Tudor Beech Place DS0000013815.V252293.R01.S.doc Version 5.0 Page 6 Please see requirements on page 20 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 Beech Place DS0000013815.V252293.R01.S.doc Version 5.0 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Tudor Beech Place DS0000013815.V252293.R01.S.doc Version 5.0 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 3, 4 and 5 Service users are admitted only following a full assessment undertaken by the manager who was able to demonstrate the homes capacity to meet the assessed needs. EVIDENCE: The home had a comprehensive statement of purpose, which accurately depicted the services provided by the home. However this along with the service users guide is now in need of some updating in order for it to contain more accurate information. All potential service users are assessed prior to admission. It was reported that the service only admits new service users based on an assessment of needs, and appropriateness of placement The initial assessment was used to form the basis of the care plan and the support plan, which identified the actions that carers should follow to assist an individual living at the home. The home manager carries out assessments of prospective service users. Overall care plans were very well documented The organisation’s policy on transitional arrangements and admission process is detailed in the Statement of Purpose and Service Users Guide, both of which require some minor updating. Tudor Beech Place DS0000013815.V252293.R01.S.doc Version 5.0 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7, 8, 9 and 10 The systems for Service User consultation are good with evidence that their views are sought and acted upon. EVIDENCE: Extensive care plans have been drawn up, with the help of the service user wherever possible and relatives/representatives. Care plans were well documented and highlighted all areas of care needs for each service user. All care plans showed evidence of regular reviews. Risk assessments were in place where appropriate. During the inspection it was evident that staff respect the Service Users’ right to make decisions. Evidence was provided with examples of the Service Users’ opportunities to participate in the day-to-day running of the home. Staff enabled Service Users to take responsible risks - wherever possible – and this was clearly documented in each individual care plan. Risk assessments were being carried out as/when necessary and existing ones regularly updated. Tudor Beech Place DS0000013815.V252293.R01.S.doc Version 5.0 Page 10 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 11, 12, 13, 14, 15, 16 and 17 Links with relatives, friends and the local community are good. These links support and enrich Service Users social and educational opportunities EVIDENCE: Examination of the home’s records confirmed a high degree of personal empowerment and choices in services users daily lives. They were encouraged and supported in the use of community amenities and in maintaining relationships with friends and families. The activities programme was individualised in accordance with Service Users wishes and made appropriate use of college courses, community amenities and facilities. All Service Users go out into the local community on a regular basis supported by members of care staff. Tudor Beech Place DS0000013815.V252293.R01.S.doc Version 5.0 Page 11 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 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, 19 and 20 The healthcare needs of Service Users are well met with evidence of good multi – disciplinary working taking place on a regular basis. EVIDENCE: The home has a key work system in place. Key workers are responsible for ensuring that Service Users receive personal support in a way they prefer and/or require and this is documented in the care plans. Bathrooms and toilets were fitted with locks for privacy. The organisation has a policy governing all administration of medication and the medication is stored securely in a locked cabinet in the office. The records showed assessed medical needs were followed up properly and notes taken of the care given. The Homes’ policies and procedures placed particular emphasis on the core values of caring, such as independence, privacy and dignity. Tudor Beech Place DS0000013815.V252293.R01.S.doc Version 5.0 Page 12 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23 The home has a satisfactory complaints system that is made available to all Service Users and staff. Arrangements were in place in respect of adult protection matters. EVIDENCE: The home had a complaints policy and procedure in place. There have been no complaints made in relation to the service since the last inspection. The complaint procedure was compliant with statutory requirements. Complaint forms were available for recording complaints. Service Users are well protected by the organisation’s training policies and procedures with regard to the protection of vulnerable adults. Up to date training in the Protection of Vulnerable Adults is in place and is part of the organisation’ s ongoing commitment to staff training. Tudor Beech Place DS0000013815.V252293.R01.S.doc Version 5.0 Page 13 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 25, 26, 27, 28, 29 and 30 The standard of décor and equipment in this home is very good with evidence of improvement through continual maintenance and refurbishment. EVIDENCE: The location of the home is suitable for its stated purpose; it is accessible, safe and well maintained, meeting service users’ individual and collective needs in a comfortable and homely way. All areas were found to be clean, tidy and well organised. The garden was observed to be well maintained and easily accessible. Overall the home was in good condition; appropriately decorated, well maintained and furnished to a high standard. The secluded garden is particularly attractive and of a large size, stocked with garden furniture. Some bedrooms were seen during the inspection. These were each highly personalised and individual in style. Most of the bedrooms had photographs and other items linked to the Service Users family life outside the home. There were sufficient bathrooms and toilets to meet the national minimum standard. Tudor Beech Place DS0000013815.V252293.R01.S.doc Version 5.0 Page 14 The communal areas in the home were considered safe and accessible for the Service Users. It is recommended that the greenhouse is re-located to an area that is more easily accessible for service users. Please recommendations on Page 20 Tudor Beech Place DS0000013815.V252293.R01.S.doc Version 5.0 Page 15 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 32, 33, 34, 35 and 36 The manager is supported well by the senior staff in providing clear leadership throughout the home with all staff demonstrating an awareness of their roles and responsibilities. EVIDENCE: Staff spoken to at the day of the inspection had a good understanding of their job descriptions and their responsibilities and they were able to identify the roles of other members of staff in the hierarchy. Communication between staff was good. Training and development of staff has been given a high priority with staff doing the NVQ and a range of other training to help them care for and support the residents. This was well evidenced in individual training profiles and a wellpresented training programme prominently displayed. The manager is involved in all aspects of staff recruitment and policies and procedures were in place for recruitment and employment. Records of good practice were seen in the Home. The recruitment procedure was observed to be robust. There are arrangements to carry out CRB checks and two written references are required for all staff. Tudor Beech Place DS0000013815.V252293.R01.S.doc Version 5.0 Page 16 It is recommended that the current sleeping in facility is re-located to the vacant bedroom until a new service users is admitted to the home folowo9ng full assessment. The current facility is not good in terms of it providing a comfortable area for sleeping in staff. Please see recommendations on Page20. Tudor Beech Place DS0000013815.V252293.R01.S.doc Version 5.0 Page 17 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. 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 are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 38, 39, 40, 41, 42 and 43 The manager is well supported by the senior staff team and by the organisation in providing clear leadership throughout the home with all staff demonstrating an awareness of their roles and responsibilities. EVIDENCE: The manager is NVQ Level 4 qualified and has had extensive relevant experience. She is employed full time working supernumerary to staffing levels. Records examined included; care plans, medication procedures, staff meeting minutes, risk assessment policies and service user activity programmes. Detailed policies and procedures were in place in relation to safe working practices. Staff were trained in First Aid, Food Hygiene and other aspects of Health and Safety. Tudor Beech Place DS0000013815.V252293.R01.S.doc Version 5.0 Page 18 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score 2 3 3 3 3 Standard No 22 23 Score 3 3 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 3 3 3 3 3 Standard No 24 25 26 27 28 29 30 STAFFING Score 3 3 3 3 3 3 3 LIFESTYLES Standard No Score 11 3 12 3 13 3 14 3 15 3 16 3 17 Standard No 31 32 33 34 35 36 Score 3 3 3 3 3 3 CONDUCT AND MANAGEMENT OF THE HOME 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Tudor Beech Place Score 3 3 3 3 Standard No 37 38 39 40 41 42 43 Score 3 3 3 3 3 3 3 DS0000013815.V252293.R01.S.doc Version 5.0 Page 19 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 YA1 Regulation 4 and 5 Requirement It is required that the home’s Statement of Purpose and Service Users guide are updated to contain all relevant information. Timescale for action 31/01/06 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 N/A N/a Good Practice Recommendations It is recommended that the home’s greenhouse is relocated to a more accessible area for service users to enjoy. It is recommended that the sleeping in facility be relocated to the current vacant bedroom in order for staff to enjoy a more congenial environment. This can be a temporary arrangement until the new service user is admitted following a full pre admission assessment. Tudor Beech Place DS0000013815.V252293.R01.S.doc Version 5.0 Page 20 Commission for Social Care Inspection Surrey Area Office The Wharf Abbey Mill Business Park Eashing Surrey GU7 2QN 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 Beech Place DS0000013815.V252293.R01.S.doc Version 5.0 Page 21 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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