Inspection on 19/04/07 for Tudor Beech Place

This inspection was carried out on 19th April 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found no outstanding requirements from the previous inspection report, but made 4 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Tudor Beech Place 16/11/05

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 Kenneth Dunn Unannounced Inspection 19th April 2007 10:00 Tudor Beech Place DS0000013815.V333114.R01.S.doc Version 5.2 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.V333114.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 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.V333114.R01.S.doc Version 5.2 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 and Borders Partnership NHS Trust Mrs Tracey Sakhmani Care Home 6 Category(ies) of Learning disability (6), Physical disability (1), registration, with number Sensory impairment (1) of places Tudor Beech Place DS0000013815.V333114.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 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. 16th November 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 and Boarders Partnership NHS Trust. The service is registered to offer care for up to six people in the category of Younger Adults. At the time of this site visit the service had only four people using the service all of whom had severe learning disabilities, and some also have physical problems. Weekly charges from all four people using the service was set at £1,696.84 Tudor Beech Place DS0000013815.V333114.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced site visit formed part of a key inspection and took place over four hours commencing at 09:30 and finishing at 12:30 on the 19th of April 2007. Mr K Dunn regulation inspector completed the visit and Mrs.T Salhmani Registered Manager represented the establishment. The inspector was informed and observations confirmed that all of the people who use this service have communication difficulties and judgements were made about them based of their mood, behaviour and information given by staff. A tour of the premises took place and the inspector observed the staff interacting with the people who use the service. Records were sampled as part of the inspection process including care plans, policies and procedures and employment records. The inspector would like to thank the people who use the service, the staff and the manager for their time, assistance and hospitality during this site visit. What the service does well: What has improved since the last inspection? What they could do better: The responsible individual must ensure that all staff are fully aware of their duties in respect to safeguarding the people who use the service. A review must take place of the home COSH procedures ensuring that a staff are fully aware of the consequences of their omissions in not complying with the policies and procedures set to safeguard the people that use the service. A Tudor Beech Place DS0000013815.V333114.R01.S.doc Version 5.2 Page 6 maintaince and refurbishment plan must be developed to ensure that the service can continue to offer a homely and comfortable place to live in. 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. The summary of this inspection report can be made available in other formats on request. Tudor Beech Place DS0000013815.V333114.R01.S.doc Version 5.2 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.V333114.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 1 and 2 were assessed. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The homes statement of purpose and service user guide are designed to ensure prospective people who will use this service and or their representatives have up to date information on which to make decisions about admission to the home. The arrangements for assessing needs are good ensuring the aspirations and needs of prospective residents are assessed before admission to the home. EVIDENCE: The home had a statement of purpose and service user guide, which was written in plain English, nicely presented and available in a user-friendly format. The manager had fully reviewed and updated both documents and the most recent version was introduced to the service January 2007. The inspector noted the manager was aware of the disability of the people who use the service and to make the information understandable to them. The manager stated that prospective people who will use the service would be admitted to the home following a full assessment of their needs. The procedure in operation for assessing individuals ensures that the service is suitable and that they will be best placed if they chose to move into the home. Tudor Beech Place DS0000013815.V333114.R01.S.doc Version 5.2 Page 9 A review of records confirmed needs assessment covered personal care, health needs and social support, which was dated and signed by the manager. The inspector noted there had been no admissions to the home since the last inspection by the CSCI and at the time of this site the service has two vacancies. Tudor Beech Place DS0000013815.V333114.R01.S.doc Version 5.2 Page 10 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 6, 7, and 9 were assessed. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People who use the service are provided with an individual Person Centred Plans (PCP), which records their individual needs and goals. The individuals currently residents at the service are supported to make decisions about their lives with assistance where appropriate. Risks assessments are in place to ensure the people who use the service are assured as independent lifestyle as possible. EVIDENCE: The inspector sampled all 4 of the people who use the services PCP’s. Each PCP was based on full needs assessment including personal care, health and emotional needs, communication, safety and social skills. Individual PCP’s were of a good standard they were detailed and structured. The PCP’s offered the reader a clear representation of the priorities, objectives and goals of the individual concerned. The sample demonstrated the knowledge of the staff with regards to the individuals support plans. The PCP’s outlined the persons Tudor Beech Place DS0000013815.V333114.R01.S.doc Version 5.2 Page 11 routines, strengths and need clearly defining preferences for example favourite community and leisure activities and individuals preferred diet. It was evident that plans were regularly reviewed with annual, six monthly and monthly reviews recorded. All PCP’s Plans agreed and signed by professionals and where possible by the representatives of the peoples who use the service. The sampled care plans were clear and offered the reader a clear picture of the person however in areas the manager should ensure that terms and phrases used could be clearly understood by anyone reading the document. This was clearly demonstrated in one PCP where the individual’s communication pattern was described in a way that was clearly understood by the staff group but to an outside person it was misleading. This was discussed with the manager and there was an understanding that the information needed to assist the individual people who use the service on a daily basis should be open and transparent to anyone who needs to read the documents. Therefore a recommendation has been made please refer to page 25 of the report. A wide range of comprehensive risk assessments have been developed in order to assist the individual residents in their daily lives these included personal care such a bathing and health. Tudor Beech Place DS0000013815.V333114.R01.S.doc Version 5.2 Page 12 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 12, 13, 15 and 17 were assessed. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The people who use the can engage in a range of appropriate activities within the service or in the community. The individual’s residents are supported by staff to become part in the local community. The rights and responsibilities of the individual are respected by the policies and procedures in operation. The home is able to demonstrate that service users are provided with a wellbalanced and nutritious diet. EVIDENCE: The service provides a range of recreational and leisure activities for people who use the service. There was evidence that activities were tailored to suit individual needs and preferences. All individuals resident at the service have a detailed activity plan designed to reflect their needs and aspirations. The inspector sampled three plans, which included horse riding, arts and crafts, music sessions, shopping trips, there was clear documentation on two individual being regularly supported by staff to attend church on Sundays. Tudor Beech Place DS0000013815.V333114.R01.S.doc Version 5.2 Page 13 The people who use the service are fully supported by staff to maintain links with their family and friends. A review of the visitor’s book demonstrated the frequent visits made by family members to the service. The manger stated that the policy of the service is to actively assist appropriate contact wherever possible between the people who use the service and their families. The service had a 100 return on a recent quality audit of family members of the people who use the service, there was a clear indication that they felt welcomed when they visited the home and that their relative at Tudor Beech was supported appropriately. The manager provided copies of the homes menus, which were varied and well balanced. Two people using the service were on special diets, which had been designed specifically for them by a dietician. Tudor Beech Place DS0000013815.V333114.R01.S.doc Version 5.2 Page 14 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 18, 19, and 20 were assessed. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The arrangements for personal support are good ensuring the people who use the service receive personal support in the way they prefer and require. The systems in place for the health care of the individuals is good and ensures that their physical and emotional needs of are met. Service users are protected by the homes medication administration procedures. EVIDENCE: The home provided flexible personal support and the PCP’s reflected the preferred routines and likes and dislikes of people who use the service. A review of records indicated guidance regarding personal care with risk assessments to support individuals and promote privacy and dignity. During the visit staff were observed to knock on individuals bedroom doors prior to entering in order to offer the occupant maximum privacy. The manager stated that the people who use the service choose their own clothing with assistance from staff as is necessary and observations confirmed Tudor Beech Place DS0000013815.V333114.R01.S.doc Version 5.2 Page 15 that the individuals had good personal hygiene and were appropriately dressed. The home had arrangements for meeting the health needs of the people who use the service, they are all registered with a local GP (General Practitioner) and the home had input from a district nurse and community learning disability nurse. The homes Medication administration practices were examined. Protocols were in place for service users receiving “As required” medication. Four medication administration cards were examined. Photographs of the persons receiving the medication were available with their records and a list was available for all staff that are trained and authorized to administer medication. All medication administered was signed for. The home appropriately maintains records for all medication received and disposed of. Tudor Beech Place DS0000013815.V333114.R01.S.doc Version 5.2 Page 16 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 22 and 23 were assessed. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The complaint process is well developed and robust with complaint information available to the people who use the service, staff and relatives. The service is committed to ensuring that the individuals using the service are protected from abuse. EVIDENCE: There have been no complaints received by the home since the previous site visit. Comments received from relatives indicated that they were happy with the arrangements in place at the home and that they had never felt the need to make a complaint. A sample of staff training records indicates that staff have received training in safeguarding adults from abuse. The Trust has as safeguarding adult and whistle blowing policy. The local authority safeguarding adults procedures were also available. However on the day of the site visit one of the people who use the service answered the front door to the inspector, contrary to local protocols, which stated that this individual must be supported by staff when opening the front door to visitors. Two locum members of staff remained seated at the dining table and did not respond to the door alarm as they had been instructed to do in order to safeguard the individual. A requirement has been made in respect to this situation please refer to page 25 of this report. Tudor Beech Place DS0000013815.V333114.R01.S.doc Version 5.2 Page 17 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 24, 26 & 30 were assessed. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The people who use the service live in a relatively well-maintained, comfortable, homely and safe environment. The home is able to demonstrate that individual’s bedrooms promote their independence. The home is clean and hygienic ensuring that service users have a pleasant home to live in. EVIDENCE: The home’s premises are suitable for its stated purpose and in keeping with the local community. The home has a relatively good standard of décor and is clean, nicely presented and comfortable. However during a tour of the home some minor maintenance and refurbishment issues were identified that need some attention including repainting the front door and its surround as the paint was flaking off and has been damaged by wheelchairs, again there was wheelchair scuffs on the paintwork throughout the home, silver tape sticking down edges of a rug and the poor standard of seating in the main room of the service. Requirements have been made in that respect of these items; please refer to page 25 of the report. Tudor Beech Place DS0000013815.V333114.R01.S.doc Version 5.2 Page 18 The inspector was unable to gain permission from 3 of the people who use the service to access their private bedrooms but the one room that was viewed was comfortable and had a varied range of possessions, which meets their interests and preferences of the person occupying it. The home has a policy on infection control. Evidence observed indicated the home had adequate laundry facilities with washing machines and a dryer and staff have training in infection control. Observations confirmed hand washing facilities were prominently sited and staff practiced infection control measures by washing their hands regularly to prevent the spread of infection in the home. Tudor Beech Place DS0000013815.V333114.R01.S.doc Version 5.2 Page 19 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 32, 34 & 35 were assessed. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The service employs competent and appropriately trained and qualified staff. The people who use the service are protected by the homes robust recruitment policy. EVIDENCE: There was sufficient numbers of staff on duty for the number and assessed needs of the people who use the service who were at home on the day of the visit. The directly employed staff team on duty demonstrated an overall good skill mix in supporting adults with learning disabilities. Surrey and Boarders Partnership NHS Trust has developed a very robust recruitment policy designed specifically to ensure the safety of the people who use the service. Five staff personal files were sampled they were maintained in good order and contained the required information; completed application forms, two references, statement of terms and conditions, job descriptions, CRB (Criminal Record Bureau) disclosure information and a recent photograph of the employee. The staff are recruited to the home in line with the GSCC (General Social Care Council) code of conduct with copies given to staff for information. Tudor Beech Place DS0000013815.V333114.R01.S.doc Version 5.2 Page 20 The home has a structured induction programme, which is extended to all staff working in the service. Further evidence confirmed training is linked to service users’ needs and staff have development plans including regular appraisal. A review of records confirmed the home had an induction checklist dated and signed by staff on completion of the training course. Following discussions with the manager regarding the actions of two locum care workers (page 17) a requirement has been made to ensure that all staff are fully aware of local protocols for supporting individuals to answer the front door. Tudor Beech Place DS0000013815.V333114.R01.S.doc Version 5.2 Page 21 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 37, 39 & 42 were assessed. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The service is able to demonstrate that the people who use the service benefit from a home, which is well run, and in their best interests. The health safety and welfare of individuals within the service are protected. EVIDENCE: The home has a registered manager with the RMA (Registered Manager Award) qualification. The inspector noted the home had a management structure with clear lines of accountability and communication. During discussions a member of staff stated ‘‘the manager works as part of the team’’ and a family member commented that “good communication and openness’’. The home had a policy on quality assurance and used questionnaires to obtain feedback about the home. The inspector sampled the most recent family survey (January 2007), which demonstrated a high level of satisfaction with Tudor Beech Place DS0000013815.V333114.R01.S.doc Version 5.2 Page 22 the service and the care their relatives were receiving at Tudor Beech. Further evidence confirmed the home had regular Regulation 26 (monitoring visits) with appropriate management action taken to safeguard the welfare of the people who use the service and its staff. A review of records confirmed the home had regular meetings with staff and the people who use the service in order to allow them to participate in decision making and running of the home as appropriate. The home had a policy on health and safety and staff have training in fire safety, food hygiene, first aid and other appropriate and relevant training. Further evidence indicated the home had a current gas safety certificate, electrical wiring certificate and a legionella bacteria test. Observations confirmed the kitchen appeared clean and hygienic, and fridge and freezer temperatures were within normal limits to promote food safety. However during the tour of the home the inspector observed two areas where staff had not complied with the services COSH procedures; a COSH cupboard was left unlocked in the laundry room and a quantity of paints were left unattended on a chair in the garden. In both cases the people who use the service were not at risk as they were engaged in activities with staff in the main sitting room of the home. In discussion with the manager it was agreed that this was in direct contravention to the policies and procedures established within the home for the safeguarding of the residents ensuring that they cannot be harmed by toxic substances. As a result a requirement was made to ensure that all staff are made fully aware of the service COSH policy to ensure that they comply to it in future. Tudor Beech Place DS0000013815.V333114.R01.S.doc Version 5.2 Page 23 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 Standard No Score 1 3 2 3 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 2 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 2 33 X 34 3 35 X 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 3 X 3 X X 2 X Tudor Beech Place DS0000013815.V333114.R01.S.doc Version 5.2 Page 24 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. 2. Standard YA23 YA32 YA42 Regulation 10, 12, 13, 18 & 37 13 & 23 Schedule 3.3 j Requirement All staff must be made aware of their roles in safeguarding the people who use the service. All COSH policies and procedures must be reviewed. The staff must be aware of their role in safeguarding the people who use the service in regards to items contained within the COSH regulations. The responsible individual must develop a time scale and action plan for the redecoration and refurbishment of the communal areas. Timescale for action 23/06/07 23/06/07 3. YA24 16 & 23 23/06/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 Refer to Standard YA6 Good Practice Recommendations The responsible individual should review all PCP’s to ensure that they are clear and accessible to all relevant parties and not limited to the staff working within the home. DS0000013815.V333114.R01.S.doc Version 5.2 Page 25 Tudor Beech Place Commission for Social Care Inspection Burgner House 4630 Kingsgate Oxford Business Park South Cowley Oxford OX4 2SU National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. 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