CARE HOMES FOR OLDER PEOPLE
Tudor Court, Seymour Street, Heywood, Rochdale, OL10 3AJ. Lead Inspector
Tracey Devine Unannounced 13 September 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. 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 Court, F06 F56 S32850 Tudor Court V230497 13.09.05 Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION
Name of service Tudor Court Address Seymour Street, Heywood, Rochdale, OL10 3AJ. 01706 364427 01706628700 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) Rochdale MBC Beryl Chapman Care Home 27 Category(ies) of Physical Disability Elderly 3, Old Age 27 & registration, with number Physical Disability 1 of places Tudor Court, F06 F56 S32850 Tudor Court V230497 13.09.05 Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION
Conditions of registration: 1. The home is registered for a maximum of 27 service users to include up to:27 service users in the category of OP (Older people), 1 service user in the category of PD (Physical disability), 3 service users in the category of PD(E)) (Physical disability over 65 years of age). 2. The service should at all times employ a suitably qualified and experienced manager who is registered with the Commission for Social Care Inspection. 3. Within the maximum of 27 OP(Older people) there can be up to:12 Intermediate Care Places, and 6 Short Stay/Emergency Placements. Date of last inspection 19TH October 2004 Brief Description of the Service: Tudor Court is a purpose built residential home owned by Rochdale Council offering accommodation for 27 service users. It currently offers care for 6 permanent service users and can accommodate up to 12 intermediate care clients. In addition, there are two assessment/recovery beds and 4 short stay beds. Day care clients may also be accommodated. The Intermediate Care Unit offers a short-term programme of rehabilitation for between two and six weeks for older people leaving hospital or for those in the community who may otherwise need admission to a hospital bed. The unit does not cater for people with intensive nursing needs. Over a period of time, the permanent care beds are to be phased out and ultimately the unit will cater solely for those people requiring an intensive rehabilitation programme. No new permanent admissions are to be accommodated and the day care serivce is also being phased out. All rooms are single and suitable for wheelchair users. There are no en-suite facilities. The home is situated approximately half a mile from the centre of Heywood where there is a wide variety of shops, pubs, cafes etc. Ramped access for wheelchair users is provided to the front and rear of the home. There are safe garden areas, which residents enjoy during the summer months. Adequate parking is available to the front of the building. Tudor Court, F06 F56 S32850 Tudor Court V230497 13.09.05 Stage 4.doc Version 1.40 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This unannounced inspection took place on 13th September 2005 by 1 Inspector. The inspection started at 10.00am and finished at 2.00pm – a period of 4 hours. Time was spent time talking with residents to see what they thought of the home and the staff, talking with the Manager and staff about the home and seeing what they do for residents, and looking at how some records are kept. The particular areas looked at on this inspection were: how the intermediate care units operate, if the furnishings and decoration in the bedrooms, lounge areas, bathrooms, toilets and dining rooms is satisfactory, if the home is a safe environment, how complaints are handled, and if sufficient staff are on duty. What the service does well: What has improved since the last inspection?
Since the last inspection, the manager has made sure that some of the matters the Commission For Social Care Inspection asked her to do she has done, such as ensuring that sufficient ancillary staff are on duty, for the emergency call system to be serviced, for staff files to contain all the required information, for the bedrooms which were smelly to be better cleaned, and for all service users to receive either a contract or a copy of the terms and conditions of their stay. These matters have all been addressed. Tudor Court, F06 F56 S32850 Tudor Court V230497 13.09.05 Stage 4.doc Version 1.40 Page 6 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 Court, F06 F56 S32850 Tudor Court V230497 13.09.05 Stage 4.doc Version 1.40 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS
Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Standards Statutory Requirements Identified During the Inspection Tudor Court, F06 F56 S32850 Tudor Court V230497 13.09.05 Stage 4.doc Version 1.40 Page 8 Choice of Home
The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 6 Service users are enabled to regain their skills in a supported environment, to allow them to return home. EVIDENCE: Service users are subject to a full assessment prior to moving onto the Intermediate Care Unit. This assessment usually is undertaken by one of the intermediate care professional staff – Occupational Therapist, Physiotherapist etc. The assessment details the service user’s needs and a care plan details how the needs are to be met and by whom. Service users spoken with said they were fully aware that the unit had a focus to enable them to become independent and return home, and all felt that this aim was being achieved for them. One service user commented on how “quickly they had got him on his feet again”, another was revisiting her cooking skills and had made lunch for herself and a fellow service user on the day of this inspection. Such activities are part of the plan of care in rehabilitation. The Intermediate Care Unit within the home is self contained in respect of services and facilities. Dedicated care staff are not provided with the home’s
Tudor Court, F06 F56 S32850 Tudor Court V230497 13.09.05 Stage 4.doc Version 1.40 Page 9 manager preferring to have staff rotating around the differing units ensuring that a suitable skill mix is available at all times to all service users, and permanent residents. Tudor Court, F06 F56 S32850 Tudor Court V230497 13.09.05 Stage 4.doc Version 1.40 Page 10 Health and Personal Care
The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) EVIDENCE: None of these standards were assessed on this inspection. assessed at the next inspection. All will be Tudor Court, F06 F56 S32850 Tudor Court V230497 13.09.05 Stage 4.doc Version 1.40 Page 11 Daily Life and Social Activities
The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) EVIDENCE: None of these standards were assessed on this inspection. at on the next inspection. All will be looked Tudor Court, F06 F56 S32850 Tudor Court V230497 13.09.05 Stage 4.doc Version 1.40 Page 12 Complaints and Protection
The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 16, 17, 18 The home has a satisfactory complaints procedure in place, ensuring that service users views are listened to and acted upon. Arrangements in place for the Protection of Vulnerable Adults are sufficient and ensure that residents live in a safe and protected environment. EVIDENCE: A formal complaints procedure is in place and included in information provided to service users. Service users spoken to said they had no complaints about the home and felt that the service provided by the staff was “pretty good”. Service users confirmed they received information on how to complain, and all felt if they had anything to say they would speak to a member of staff first. The manager has a copy of the Inter Agency Guidelines on the Protection of Vulnerable Adults, and was clear as to their use. Copies of this procedure are left available in the staff room and staff sign to acknowledge they have read and understood it. Adult protection training is also offered to staff. The home has a range of policies and procedures in place for staff to follow in respect of service users monies/gifts/wills etc. Tudor Court, F06 F56 S32850 Tudor Court V230497 13.09.05 Stage 4.doc Version 1.40 Page 13 Environment
The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 19, 20, 21, 22, 23, 24, 25, 26 Service users live in reasonably comfortable and homely environment which suits their needs. Health and safety issues relating to fire protection and environmental health need to be improved in order that service users live in a safe environment. EVIDENCE: The home is currently split into distinct areas of residential care for permanent residents, and two units for Intermediate Care. Facilities and services, such as bedrooms, bathrooms, toilets, lounge and dining areas are contained on each unit. The home is generally well maintained if a little dated in decoration. A number of the requirements (from the last inspection report) relating to the environment have not been complied with, owing mainly the manager said to the refurbishment of the home which is due to commence in January 2006. Tudor Court, F06 F56 S32850 Tudor Court V230497 13.09.05 Stage 4.doc Version 1.40 Page 14 The Fire Officer’s report of 3 November 2004, has not been fully complied with. Matters still outstanding relate to fire doors being fitted with smoke seals, self closers to be fitted to some doors, the fire alarm system to be upgraded, a carbon dioxide extinguisher to be fitted on the kitchenette areas, and regular fire drills. The Environmental Health Officer’s report of 9th November 2004, has also not been fully complied with. Outstanding issues relate to the provision of hand wash on the sinks on the kitchenettes, supply of blue plasters for the first aid boxes on the kitchenette areas, and daily recording of the fridge temperatures. Bedrooms, toilets, bathrooms, lounge and dining areas were all seen to be clean and odour free. Service users spoken with said they found the home to be “comfortable and clean”. Tudor Court, F06 F56 S32850 Tudor Court V230497 13.09.05 Stage 4.doc Version 1.40 Page 15 Staffing
The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27, 30 The staff had a good understanding of the service users’ support needs, and are employed and trained in sufficient numbers to ensure that such needs are met. EVIDENCE: The rotas in place demonstrated that the home had sufficient staff on duty to meet the needs of service users. Service users spoken with said the staff “were lovely”, “were very patient”, “very welcoming”, “knew what they were doing”. Interactions between staff and service users were observed to be friendly and good natured. Staff receive mandatory training of fire safety, food hygiene, infection control, first aid, and moving and handling and a number of personnel files selected had certificates in place confirming such training. Other training does take place although it was less easy to confirm the nature of this or which of the staff group had attended. To identify all the training undertaken, or to identify any gaps in training a full assessment of the personnel files would need to take place by the manager. Staff induction does take place, but of new staff whose files were looked at, it still is not taking place within the timescales decreed of 6 weeks initially and 6 months for foundation training. One new starter did not commence induction until she was 5 months in post. Tudor Court, F06 F56 S32850 Tudor Court V230497 13.09.05 Stage 4.doc Version 1.40 Page 16 Tudor Court, F06 F56 S32850 Tudor Court V230497 13.09.05 Stage 4.doc Version 1.40 Page 17 Management and Administration
The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) EVIDENCE: None of these standards were assessed on this inspection. assessed at the next inspection. They will be Tudor Court, F06 F56 S32850 Tudor Court V230497 13.09.05 Stage 4.doc Version 1.40 Page 18 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score x x x x x 3 HEALTH AND PERSONAL CARE Standard No Score 7 x 8 x 9 x 10 x 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 x 13 x 14 x 15 x
COMPLAINTS AND PROTECTION 3 x x x x x x x STAFFING Standard No Score 27 3 28 x 29 x 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 3 3 x x x x x x x x Tudor Court, F06 F56 S32850 Tudor Court V230497 13.09.05 Stage 4.doc Version 1.40 Page 19 Yes 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 24 Regulation 16 Requirement An additional electrical socket must be supplied in each bedroom. (The timescale of 30.11.04 has expired) An annual development plan must be put into place. (The timescale of 30.11.04 has expired) A business and financial plan must be written. (The timescale of 30.11.04 has expired) Monthly visits on behalf of the provider must be made to the home. (The timescale of 30.11.04 has expired) The corridor carpets on Howard Unit must be replaced. (The timescale of 31.12.04 has expired) All new staff must receive TOPSS induction training within the first 6 weeks and foundation training within the first 6 months. All matters still outstanding from the fire officers report must be addressed. The service must contact the Fire Officer, to explain the matters which they have not addressed are to be included in the refurbishment of the home and ensure the Fire
F06 F56 S32850 Tudor Court V230497 13.09.05 Stage 4.doc Timescale for action 28/2/06 2. 33 25 30/10/05 3. 4. 34 37 25 26 30/10/05 30/10/05 5. 19 16 28/2/06 6. 30 18 30/10/05 7. 25 23 28/2/05 Tudor Court, Version 1.40 Page 20 8. 26 23 Officer is satisfied with the timescale. All matters outstanding from the Environmental Health Officers report must be addressed. 30/10/05 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 30 Good Practice Recommendations The manager should have a system in place whereby she can easily see the training staff have undertaken and when, and who still needs to receive such training. Tudor Court, F06 F56 S32850 Tudor Court V230497 13.09.05 Stage 4.doc Version 1.40 Page 21 Commission for Social Care Inspection Turton Suite, Paragon Business Park, Chorley New Road, Horwich, Bolton, BL6 6HG. 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 Court, F06 F56 S32850 Tudor Court V230497 13.09.05 Stage 4.doc Version 1.40 Page 22 - 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!
