Inspection on 08/02/06 for Tudor Court LA

This inspection was carried out on 8th February 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. 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 there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Tudor Court LA 11/01/08

Tudor Court LA 28/11/06

Tudor Court LA 13/09/05

Tudor Court LA 19/10/04

Tudor Court LA 27/04/04

Similar services:

Chirnside House

Keer Sands Residential Home

Ruskin Lodge

Bushell House

Langrigg House

Parkside

Dystlegh Grange

Thornton Lodge

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

CARE HOMES FOR OLDER PEOPLE Tudor Court LA Tudor Court Seymour Street Heywood Rochdale Lancs OL10 3AJ Lead Inspector Mike Murphy Unannounced Inspection 8th February 2006 09:30 X10015.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 Court LA DS0000032850.V263694.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 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 LA DS0000032850.V263694.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Tudor Court LA Address Tudor Court Seymour Street Heywood Rochdale Lancs OL10 3AJ 01706 364427 01706628700 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) Rochdale M.B.C. Mrs Beryl Lamelia Chapman Care Home 27 Category(ies) of Old age, not falling within any other category registration, with number (27), Physical disability (1), Physical disability of places over 65 years of age (3) Tudor Court LA DS0000032850.V263694.R01.S.doc Version 5.0 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) The service should at all times employ a suitably qualified and experienced manager who is registered with the Commission for Social Care Inspection. Within the maximum of 27 OP(Older people) there can be up to:12 Intermediate Care Places, and 6 Short Stay/Emergency Placements. 13th September 2005 2. 3. Date of last inspection 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 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 were being accommodated and day care was also being phased out. All rooms were single and suitable for wheelchair users as they all measured in excess of 12 square metres. There were 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 LA DS0000032850.V263694.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place on the 8th of February 2006. The inspection took place over 5 hours. The inspector spent time seeking the views of residents, their relatives, staff at the home and the operational team manager responsible for the home. Residents care records and various other documents relating to the running of the home were inspected as was the general environment. What the service does well: What has improved since the last inspection? There has been a general review of formal care planning review within the home, particularly in respect to intermediate care residents. This ensures that resident’s care is reviewed regularly and that such reviews are recorded. Tudor Court LA DS0000032850.V263694.R01.S.doc Version 5.0 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 LA DS0000032850.V263694.R01.S.doc Version 5.0 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 Outcomes Statutory Requirements Identified During the Inspection Tudor Court LA DS0000032850.V263694.R01.S.doc Version 5.0 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 the following standard(s): 3,6. Residents are appropriately assessed prior to them being admitted to the home to ensure that the special services the home provides are appropriate to meet their needs. EVIDENCE: All residents who are admitted to the home have undergone a detailed assessment that is conducted by one of the intermediate care team’s health care professionals. This assessment identifies the individual resident’s needs and goes on to be developed into a series of care plans that clearly describe how those needs will be met and by which group of staff. Discussion with those resident’s receiving intermediate care indicated that they had been consulted and actively involved in all stages of the process. Comments that were made by resident’s included ‘ they have helped me to get my confidence back, especially with walking’, ‘I know now I will be going home thanks to all the help the staff here have given me, I can’t thank them enough’. Tudor Court LA DS0000032850.V263694.R01.S.doc Version 5.0 Page 9 The intermediate care service is delivered in a unit dedicated to that provision and residents have their own services and facilities. The inspector was informed that a major refurbishment of the home is at the advanced stages of planning. Tudor Court LA DS0000032850.V263694.R01.S.doc Version 5.0 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 the following standard(s): 7,8,9,10. The health and personal care needs of all groups of resident’s within the home were being addressed appropriately. Resident’s and their relatives felt confidant that health care services were accessible and that service users were enabled to be supported by them. EVIDENCE: Four residents care records, were inspected, two from the intermediate care unit and one from the permanent residents unit. The care plans in place for residents on the intermediate care unit were detailed and covered all relevant areas. They included Physiotherapist and Occupational Therapist input as well as personal/social care needs. They were reviewed on a very regular basis, in some instances daily and clearly showed agreed goals, which were being worked towards. It was clear, from talking to residents on the intermediate care unit that they were fully involved in the care planning and review processes. The 2 care plans inspected for the permanent stay service users, were detailed, addressed all aspects of care but were in need of review on a more regular basis. The inspector was informed that all care records were currently Tudor Court LA DS0000032850.V263694.R01.S.doc Version 5.0 Page 11 the subject of a review within the home. Residents spoken to stated they felt they were fully involved in the care planning process. Signatures to care plans/risk assessments are obtained from service users or their representatives but in some instances, this had not been possible due to the absence of a relative/representative. Risk assessments were also updated regularly and addressed all identified risk areas. Residents health and personal care needs were being appropriately met on both the intermediate care and permanent units. Residents spoken to stated they were enabled to access health care services, this was supported by the record of professional visits/interventions maintained in each resident’s care file. The home clearly benefits from having the multi-disciplinary team of health care specialists on site to consult and seek advice from as necessary. Other health care services were accessed as required. Appropriate documentation was in place with regard to the care of service users with pressure areas. A monitored dosage system for the medicines of permanent residents is in current use. Residents on the intermediate care unit, bring their own prescribed medication with them, which was routinely reviewed by the visiting G.P. and Pharmacist. Staff are adhering to the procedures in place for the receipt, storage and disposal of medication. A controlled drugs book was in place and had been completed appropriately. A ‘drug returns’ book was completed appropriately and had been signed by the pharmacist. All staff responsible for administering medication had received training. Residents on the intermediate care unit are encouraged to self medicate as part of their rehabilitation process. Lockable spaces are provided and individual risk assessments are in place. Discussion with residents throughout the home indicated that staff treated residents with respect and sought to maintain their dignity and privacy especially when ‘personal care was being given’. Comments from resident’s included, ‘ all the staff speak to me nicely and help me to do things I can’t do for myself anymore’, ‘ they [the staff] always knock on my door before coming into my room’, ‘I am able to go to my own room when I want to be on my own sometimes’. A relative, spoken to, commented on how respectfully the staff treat the residents when they have been visiting (on numerous occasions). Certainly on the day of inspection staff were observed to assist residents appropriately, and sensitively and to interact well with them. Tudor Court LA DS0000032850.V263694.R01.S.doc Version 5.0 Page 12 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 the following standard(s): 12,13,14,15. The general view was that residents are encouraged to live a lifestyle in which they retain as much personal freedom, to make their own choices and keep control over their own lives as much as possible. EVIDENCE: Tudor Court LA DS0000032850.V263694.R01.S.doc Version 5.0 Page 13 Residents spoken to expressed their satisfaction with the range of activities that are available to them. Care records for the permanent residents include a social history from which staff can identify individual interests/hobbies. On the day of inspection, service users were playing bingo. An activities programme was prominently displayed in the home. Residents and their relatives who were spoken to reported no unreasonable restrictions in respect of the visiting arrangements at the home. Relatives were also of the view that they were made to feel welcome when they visited. Residents throughout the home stated that they were able to make as many personal choices in respect of their daily lives as possible within a communal living setting. For example the following comments were made to the inspector, ‘I don’t have to go to bed or get up at a set time, and I often have a lie in’, ‘I pick for myself what activities or outings I want to join in, and you don’t have to do things if you don’t want to’, ‘I have lots and bits and pieces from home in my room and am able to have it the way I want’. Menus are varied, provide choice, and are balanced nutritionally. Meals are prepared on site. Residents spoke positively about the quality and the quantity of the meals served to them. They felt they could make reasonable choices of what they eat and drink and felt comfortable to request something else if a particular choice that was available was not suitable. Lunch was observed at the time of this inspection. This was a hot, substantial and well presented meal served in clean comfortable dining areas in the home. Meal times were thought to be reasonable and as flexible as possible by residents and all stated they could get something to eat and drink outside set meal times if they desired. Each unit of the home has facilities for making hot drinks and snacks. Tudor Court LA DS0000032850.V263694.R01.S.doc Version 5.0 Page 14 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 the following standard(s): Not inspected at this time. EVIDENCE: These standards were inspected in the September 2005 inspection. They will be inspected again at the next inspection. Tudor Court LA DS0000032850.V263694.R01.S.doc Version 5.0 Page 15 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 the following standard(s): 19,20,21,22,23,24,25,26. Residents live in reasonably comfortable and homely environment that generally meets their needs. However the home is schedule for a major refurbishment programme that the inspector was informed is due to commence in 2006. 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 as they are to be addressed in the major refurbishment programme referred to above. This was due to commence in January 2006 but had not commenced at the time of this inspection (8th Tudor Court LA DS0000032850.V263694.R01.S.doc Version 5.0 Page 16 February 2006) The operational team manager who is responsible for the home informed the inspector that the refurbishment is at the advanced planning stage and that he will be shortly be liaising with the CSCI to provide more detailed proposals and discuss any registration implications. The requirements of the Fire Officer’s report of 3 November 2004 have still not been fully complied with as the operational team manager states some of the issues contained within that report are to be addressed as part of the refurbishment programme. Bedrooms, toilets, bathrooms, lounge and dining areas were all clean and free of malodours. The arrangements in respect of resident’s laundry were satisfactory. Appropriate environmental aids and adaptations were in place throughout the home. Individual resident’s needs for specialist equipment/aids are addressed following assessment by the appropriate health care professional. Tudor Court LA DS0000032850.V263694.R01.S.doc Version 5.0 Page 17 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 consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29,30. The staff had a good understanding of residents needs, and are employed and trained by the home in sufficient numbers to ensure that such needs are met. EVIDENCE: Staffing arrangements indicated that the home had sufficient staff on duty to meet the needs of residents. Staff members have been provided with recent training in 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. The home operates a suitable recruitment procedure that seeks to ensure as far as possible that persons employed are suitable to work with vulnerable people. No one is employed until the outcome of a criminal records bureau check has been received and 2 satisfactory written references have been obtained. No new staff had been recruited since the last inspection. Tudor Court LA DS0000032850.V263694.R01.S.doc Version 5.0 Page 18 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 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31,32,33,34,35,37,38. The home is currently without a registered manager following the recent retirement of the previous manager. However the current interim arrangements to manage the home are satisfactory whilst a new registered manager is appointed. However some issues in respect of electrical safety documentation and the completion of the fire-log book were identified. EVIDENCE: At the time of inspection the day-to-day management of the home is being shared by four senior members of staff who are in turn supervised and supported by an Operational Team Manager who is a representative of the registered provider. The latter informed the inspector he is currently seeking to recruit a registered manager for the home as soon as possible. Tudor Court LA DS0000032850.V263694.R01.S.doc Version 5.0 Page 19 However the current arrangements were well organised and residents, their relatives and staff spoken to felt confidant from their perspectives that the home was being suitably managed. The personal allowance of one resident was being managed (in terms of safe keeping) by the home at the time of this inspection. These arrangements were secure and appropriately documented. An annual development plan must be put into place. And a business and financial plan must be written to demonstrate that there is efficient and effective management of the buisiness. Regulation 26 visits were said to be taking place but no written reports, since June 2004, were available for inspection. Documentation was inspected in respect of gas safety certification, the maintenance of hoists and the passenger lift, the maintenance of the fire alarm and fire fighting equipment, fire risk assessment, the ‘nurse call’ bell system, disinfection of cold water storage and shower heads. These were all found to be satisfactory. However no documentation was available for inspection in respect of the 5 yearly NIEIC electrical safety inspection. It was also noted that the fire safetylog book has not been completed in respect of fire drills held at the home. Tudor Court LA DS0000032850.V263694.R01.S.doc Version 5.0 Page 20 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 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 3 X X 3 HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 X 17 X 18 x 2 3 3 3 X 3 3 3 STAFFING Standard No Score 27 3 28 X 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 3 3 2 3 X 2 2 Tudor Court LA DS0000032850.V263694.R01.S.doc Version 5.0 Page 21 Are there any outstanding requirements from the last inspection? Yes 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 OP31 Regulation 8 Requirement That the CSCI is informed in writing how the process to appoint a registered manager has progressed That all resident’s care plans are reviewed and evaluated regularly That fire drills are conducted at regular intervals and that these drills are recorded in the fire-log book. That a copy of the certification in respect of electrical safety in the home is provided to the CSCI That all matters still outstanding from the fire officers report of the 3/11/04 must be addressed within the action plan that is submitted to the CSCI in respect of the proposed refurbishment. (This is a previously outstanding requirement) An annual development plan must be put into place. And a business and financial plan must be written. (both are previously outstanding requirements) That a written action plan is submitted to the CSCI that details proposed timescales for the proposed major DS0000032850.V263694.R01.S.doc Timescale for action 30/04/06 2 3 OP7 OP38 15 23 30/04/06 30/04/06 4 5 OP38 OP38 13 13 30/04/06 30/04/06 6 OP37OP34 25, 26. 30/04/06 7 OP19OP24 16. 30/04/06 Tudor Court LA Version 5.0 Page 22 refurbishment of the home and includes (1) confirmation that an additional electric socket will be supplied in each bedroom, (2) confirmation that the corridor carpets on Howard unit are to be replaced. (Both are previously outstanding requirements) RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Tudor Court LA DS0000032850.V263694.R01.S.doc Version 5.0 Page 23 Commission for Social Care Inspection Bolton, Bury, Rochdale and Wigan Office 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 LA DS0000032850.V263694.R01.S.doc Version 5.0 Page 24 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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