Inspection on 11/05/06 for Tudor House

This inspection was carried out on 11th May 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 House 04/07/07

Tudor House 23/11/05

Tudor House 16/06/05

Tudor House 15/04/04

Similar services:

Henry Nihill House

Birchwood

The Infirmary

Orchard House Nursing Home

St Josephs Rest Home

Red Court Nursing Home

Spinney (The)

Queen Elizabeth House

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

CARE HOMES FOR OLDER PEOPLE Tudor House Tudor House Nursing Home 4 Birdhurst Road South Croydon Surrey CR2 7EA Lead Inspector Ms Rin Saimbi Key Unannounced Inspection 11th May 2006 9:30am 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 House DS0000019044.V293735.R01.S.doc Version 5.1 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. 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 House DS0000019044.V293735.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Tudor House Address Tudor House Nursing Home 4 Birdhurst Road South Croydon Surrey CR2 7EA 020 8410 3399 0208 410 6506 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) Assured Services Limited Mrs Grace Samathanam Perera Care Home 37 Category(ies) of Old age, not falling within any other category registration, with number (37) of places Tudor House DS0000019044.V293735.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 12 nursing 25 which can be either nursing or residential A variation has been granted to allow one specified service user in the Dementia - over 65 [DE(E)] service user category to be accommodated. 23rd November 2005 Date of last inspection Brief Description of the Service: Tudor House is a purpose built property in South Croydon, which can accommodate up to 37 elderly service users. The accommodation compromises of a lower ground floor with a large lounge and dining room, conservatory, office space, kitchen and medical room. The ground, first and second floor all have bedrooms, additionally the ground floor benefits from a further lounge. The third floor is used by the proprietors for office space and also has various training rooms. To the rear of the property there is a mature and well-kept garden; to the front there is parking for a number of vehicles. The home has 31 single bedrooms and three double rooms. All the rooms have their own en- suite facilities, wardrobe, chest of drawers, comfortable chairs, natural light and ventilation. The home is situated close to local facilities and transport links. The home’s current charges are in the range of £524.58 to £650 per week. Tudor House DS0000019044.V293735.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was the home’s first inspection for the year 2006/07. It was an unannounced inspection. The inspection started at 10.00 am and took approximately seven hours to complete. Prior to the commencement of the inspection, all documentation and contact relating to the home received by the Commission for Social Care inspection was reviewed. The inspection involved, looking through documentation, which related to the service users and staff; talking to service user, observing activities and the care given and taking lunch with the service users. There were interviews and discussions with staff, manager and proprietors, and a tour of the building. Questionnaires were also given out during the inspection to service users and their family and friends. To date, eight completed questionnaires have been received, seven of which could be deemed as very positive or positive; one respondent was negative, however, the inspector could find no evidence to verify the issues raised, nor could they make contact directly as the respondent was anonymous. On the day of the inspection service users were generally very positive about the care they received, comments made included ‘they are lovely here and really look after you’. Two of the service users commented on how relatives had looked at a number of homes, and then returned saying ‘this is the one for you’ or ‘I’ve found a lovely home’. One of the service users did say that although she was ‘very happy in the home, it was disappointing that there weren’t more people that she could talk to’, by this she meant that some of the other service users were confused and that she could not have an engaging conversation with them. There had been a period of uncertainty with the previous manager being ready to retire for some months; her retirement had been delayed, as a replacement could not be found. This inevitably impacted to the home. A new manager was appointed to the home before Christmas and has made some changes to the way that the home functions. Tudor House DS0000019044.V293735.R01.S.doc Version 5.1 Page 6 What the service does well: What has improved since the last inspection? The appointment of a new manager, who has only been in post for five months, has created a sense of openness and leadership. The manager has instigated a number of changes, which have already impacted in a major way to the running of the home and to the welfare of the service users. These have included areas, which have been ongoing requirements for a number of inspections. The areas that the inspector would wish to highlight are, firstly that the paperwork within the home has generally improved both in terms of the quality and that it is up to date. Secondly, that supervision has been instigated for all staff. Previously, there had been examples of staff receiving only one or two supervision sessions per year. There is now evidence that supervision takes place on a regular basis, in Tudor House DS0000019044.V293735.R01.S.doc Version 5.1 Page 7 a systematic way, and that these supervisions are appropriately recorded and signed by both parties. Thirdly, that the level of training available to staff has increased. Previously a requirement had been made that staff were not receiving the minimum of three paid days training per year 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 House DS0000019044.V293735.R01.S.doc Version 5.1 Page 8 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 House DS0000019044.V293735.R01.S.doc Version 5.1 Page 9 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): 1,2,3,4,5 and 5 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. In general, the home produces sufficient information regarding the services that it provides in order that prospective new service users are equipped with the information they require to make an informed choice about the suitability of the home. EVIDENCE: The home does have a detailed statement of purpose, which outlines their aims and objectives and the facilities that will be provided. This was viewed at the last inspection and was deemed to be satisfactory New service users are only admitted on the basis of an assessment completed by the manager. In addition, the manager gathers as much information as Tudor House DS0000019044.V293735.R01.S.doc Version 5.1 Page 10 possible from the service users themselves, family and friends, and other involved professionals. Service users are then invited to the home for a trail period, which normally lasts six weeks. After this period there is a meeting with all relevant professionals including the service users which determines whether the placement should go ahead or not Information was viewed regarding four service users, two of whom who had recently been admitted to the home. The assessments included details of medication, hearing and vision, next of kin and mobility. Whilst not a comprehensive assessment it was adequate for the purposes required. The manager stated that he would be reviewing the assessment form so that it was comprehensive and tailored to the information required by the home. With regard to service users documentation, only one of the service users files had terms and conditions included which the appropriate parties signed. With regard to two of the new service users, one document was with a relative, one required a signature. However, one service user did not have any copy of terms and conditions. A requirement has therefore been made in this regard that all service users must have a copy of the terms and conditions signed by all appropriate parties. The majority of service users who live at Tudor House are from a white/British background. There is however, one service users who is Iranian and speaks only Persian. The home’s manager stated that they do try to meet her needs however, they are very specific. The home tries to cook dishes that would be specific to her region; however, in terms of language the home relies to relatives to communicate with her effectively. Some members of staff are able to understand through gestures some of her needs; the manager has stated that he is in the process of getting an interpreter. Tudor House does not provide intermediate care and therefore this standard has not been assessed. Tudor House DS0000019044.V293735.R01.S.doc Version 5.1 Page 11 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 and 10 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The assessment process and the subsequent care plan does define the care that is given to the service users and indicate the changing needs so that service users get the care that they require. Service users in general are treated with respect and their right to privacy is upheld. EVIDENCE: The initial assessment completed by the manager is translated by a senior member of staff into the care plan. This care plan identifies the actual care that is to be given to each individual service users. The care plans viewed are generally much improved in this home. Those viewed by the inspector were up to date and generally reflected the actual care given. The entries could be expanded so that they contain more detail; the Tudor House DS0000019044.V293735.R01.S.doc Version 5.1 Page 12 home’s manager is aware of this difficulty and the home has initiated English classes for some of its staff, whose written English needs to be improved. There was evidence available via documentation that the care plans are reviewed regularly on a monthly basis by the home and the service user. There has been an improvement with regards to risk assessments, the previous inspection had identified that they were sometimes not reviewed, in one case for over a year. Risk assessments were available for all service users in relation to pressure sores and manual handling. The manager stated that he would again be revising this form so that it is more appropriate to the needs of the service users. Body charts have been introduced in the home so that pressure sores can be recorded accurately; the home is also using photographic evidence for this purpose. The home has records of health appointments for individual service users. The GP visits the home on a weekly basis, and any service user who needs a health appointment can be seen immediately. A chiropodist and opticians also come into the home on a six monthly basis. Audiologist and a dietician are accessed via the GP if required. There are currently four service users who have a diagnosis of diabetics, one of which is insulin dependent. Records were checked of sugar levels, to verify that the levels were taken on a regular basis. Service users weight is monitored monthly as a matter of course, and would be completed on a weekly basis if required. The records for this were checked and found to have been completed. Medication is stored in room, which is kept locked at all times. The medication is only administered by Registered General Nurses; records were viewed and found to be accurate. There were however, omissions on the ‘week beginning’ section of the Medication Administration Records (MAR). Although not dangerous, it is still of concern that this was left blank, therefore a requirement has been made in this regard that all sections of the MAR sheets must be completed in full. The administration of medication is audited internally by the manager on a monthly basis. There is also an external audit, which was last completed in September 2005. With regard to service users privacy and dignity, staff were asked questions about how they ensure that dignity is maintained whilst providing personal care. All staff were able to give an appropriate response. Tudor House DS0000019044.V293735.R01.S.doc Version 5.1 Page 13 From observations it was generally apparent that staff were aware of the issues and were able to respond. Some of the service users have their own telephone in their bedrooms and receive mail unopened. Of the bedrooms viewed, service users all had plenty of their own clean clothes available. Whilst touring the premises, it was observed by the inspector that a member of staff on two separate occasions could have been more aware of service users privacy. One such incident was knocking on a service users bedroom door and then showing the inspector into the room, however the service user was unwell and in bed and was startled to see a visitor. On another occasion, a conversation was initiated about two service users whilst they were within hearing distance. These two issues were raised with the member of staff and with the manager. A requirement has therefore been made that all staff must respect service users privacy and dignity at all times. Tudor House DS0000019044.V293735.R01.S.doc Version 5.1 Page 14 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): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home does manage to achieve a balance of providing a range of activities and facilities for service users via the activities coordinator. Whilst ensuring that independence and choice is maintained wherever possible. The home has a friendly, relaxed atmosphere where visitors are welcome, thus creating a homely environment. EVIDENCE: The home employs an activities co-ordinator who works five days a week between 10 – 4 pm. The co-ordinator arranges a number of activities including bingo, quizzes, and craftwork and for an outside instructor to take a weekly exercise class and radio show. As well as the routine activities that take place on a weekly basis, the activities co-ordinator also arranges for visits from community groups and outings. There are also trips to the theatre and shows, the local park and using the Tudor House DS0000019044.V293735.R01.S.doc Version 5.1 Page 15 tram for an outing. Over the summer there is also at least two outings to the seaside. The activities co-ordinator stated funds were always available for activities; these came from a variety of sources, through fundraising, donations and the proprietors Many of the activities take part in the lounge; however, there are other rooms available for the use of service users. Some visitors took tea in the conservatory; there is also a small lounge adjacent to the large room known as the library. There is also a lounge on the ground floor, which is sometimes used for social events. The home had a relaxed atmosphere whilst being quite busy with the coming and goings of friends and relatives. Service users are able to choose whether to see friends and family in a communal area or in their bedrooms Mealtimes are clearly an important time for service users. Service users are provided with a menu from which they have a choice of two meals, meals are on a seven-week rota. On the day of inspection, service users had a choice of roast chicken or a fish dish. With homemade rice pudding, yoghurt or bananas for pudding. The food was presented well, nutritious and balanced. Service users in general spoke positively about the range and quality of the food available, with the only compliant being ‘that there is too much’. Service users have a choice for breakfast, which includes a cooked breakfast; one of the service users was delighted that the home had managed to provide her with the brand of yoghurt that she liked within two days of being there. The lunchtime meal is the main meal, and for tea there is usually something lighter such as cheese on toast or chicken nuggets. One of the service users stated that ‘the evening meals were sometimes dubious’. There is always one cook on duty for twelve hours of the day, and an assistant for eight hours. Food that is prepared in the kitchen and needs to be transferred to service users bedrooms in done so via a ‘dumb waiter’ thus ensuring that it always arrives hot. The cook is able to cater for special dietary requirements in particular diabetics; the cook stated that she is constantly trying to extend the range of food such as bacon roll which was a dish cooked during the war; and new foods such as pasta. The home has an Iranian service user for whom the cook tries to make rice dishes; these have a mixed response from the service user. Tudor House DS0000019044.V293735.R01.S.doc Version 5.1 Page 16 Tudor House DS0000019044.V293735.R01.S.doc Version 5.1 Page 17 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): 16 and 18 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. The home has a clear complaints policy; and complaints are always taken seriously and acted upon. Service users therefore felt that their views are listened to. The home must take seriously its responsibility with regard to vulnerable adults. Whilst acknowledging that the home has improved in some areas, it remains a concern that there are still areas that need to be addressed. These have been ongoing requirements identified in previous inspection and could potentially put service users at risk EVIDENCE: The home has a complaints policy and a log of the complaints that are made. Since the last inspection, no complaints have been. The Commission have not received any complaints. Service users stated that they felt that their views were listened to either by the manager or by other staff, and acted upon accordingly. All service users spoken to were very positive about the new manager. In relation to safeguarding the welfare of service users, the home has yet to acquire Croydon’s policy and procedures regarding vulnerable adults, this is a Tudor House DS0000019044.V293735.R01.S.doc Version 5.1 Page 18 requirement dating back to July 2004. It is of grave concern that the home was told to rectify this at the last inspection and still has not done so Further to this, the homes own policy entitled ‘Managing the Suspected Third Party Abuse of a service users’ is factually incorrect in many areas. Indeed, it would jeopardise any investigation undertaken. A requirement has therefore been made that this policy must be withdrawn for with, and that a new policy is drawn up which uses Croydon’s policy and procedure as a reference. Tudor House DS0000019044.V293735.R01.S.doc Version 5.1 Page 19 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 and 26 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The focus of the home is very much in the main lower ground lounge; other rooms are available however providing quieter areas and privacy. The home is decorated and maintained to a high standard throughout. Service users are able to bring in their own furniture, which gives the home a pleasant, homely feel. There were a number of minor repairs to the premises, some of which were outstanding from the previous inspection. Of greater concern, was that the home had received a visit from the fire department in January 2006, and that there were still outstanding actions from his visit. EVIDENCE: Tudor House DS0000019044.V293735.R01.S.doc Version 5.1 Page 20 The home is purpose built with facilities for the service users arranged over four floors. The lower ground area has a large lounge/dining room, which is the main communal area for the home. Via this room there is access to a conservatory and the garden. There are further smaller lounges, which provide greater privacy for service users. In addition, the manager’s office, medical room and kitchens are located here. The home has thirty-one single bedrooms all with en-suite facilities, arranged over three floors. The home has three double bedrooms. Each floor has its own kitchenette area and a nurse’s station; all the floors are decorated in different colours for ease of identification by the service users. During a tour of the building a sample of bedrooms were viewed on each floor. One of the service users complained that the door handle to his bathroom was loose. This was mentioned to the manager, and a requirement has been made in this regard. The home is decorated and furnished to a high standard with the focus on providing a homely environment. The home has a rolling programme of maintenance to ensure that this high standard is maintained. The home is equipped with suitable aids and adaptations; there is lifts, handrails, call bells, ramps and specifically adapted bathrooms. The home was generally clean throughout, although it was noted that there was an unpleasant smell of urine in one of the bedrooms and corridor. A requirement has therefore been made in this regard that the home must adequately clean rooms and carpets, in order to remove any unpleasant odours. The condition of the carpet in the staff room does need to be reviewed, and either needs to be cleaned or replaced, this has been an outstanding requirement from previous inspections. In addition, it was noted that there was a leak in the laundry from a water pipe, which was substantial. A requirement has therefore been made in this regard. Bedrooms were well furnished with some degree of personalisation in the choice of ornaments and photographs. Each service user had keys to their bedroom and a lockable space. The home was visited by the fire department on the 25.1.06, from that visit action was required at three levels. Firstly that there was no record of fire drills in the last six moths; secondly, fire doors to the kitchen and ground floor do not self close; thirdly, staff have insufficient understanding of action to the taken in the event of a fire. Tudor House DS0000019044.V293735.R01.S.doc Version 5.1 Page 21 During the inspection, the home could still not provide written evidence of a fire drill having taken place, although a number of staff did recall a drill. The fire door between the kitchen and ground floor still does not self-close. Finally, staff were able to give an acceptable response to the action that would need to be taken in case of an emergency. It is not acceptable that four months after a visit from the fire department that action remains outstanding. A requirement has therefore been made in this regard and must be acted upon immediately. Tudor House DS0000019044.V293735.R01.S.doc Version 5.1 Page 22 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 and 30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. In general, the staffing levels and skill mix are adequate to meet the needs of the service users to ensure that they are well cared for. The current recruitment practices within the home are not in general, sufficiently rigorous to protect the welfare of the service users from abuse. EVIDENCE: The home aims to have seven members of care staff on duty in the mornings which covers their busy period; during the afternoon there would be five members of care staff. In addition, the home has two registered nursed on duty during the day. At night, there is one waking member of staff on duty on each floor, and also a waking nurse. Duty staff rota’s for two were checked at random, and indicated that sufficient staff were on duty during the given weeks. The home also employs various other domestic staff, including cleaners, cooks and a handy man. Tudor House DS0000019044.V293735.R01.S.doc Version 5.1 Page 23 Service users continue to speak warmly of the care that they receive; one of the service users who was at the home for respite said ‘ I don’t really want to be here, I’d much rather be at home…….but all things considered I do feel looked after.’ Staffing records including recruitment were checked, three files were chosen at random including one of a new member of staff. Of the files checked, on did not have any references. The new member of staff who was already working at the home, albeit under constant supervision, did not have a Criminal Records Beaux (CRB) check, nor did she have a PoVA first. There was evidence that a CRB had been applied for; the manager was not aware of the existence of PoVA first checks; one of the proprietors was aware, but had not applied for one. A requirement has therefore been made in this regard, that all appropriate checks must be made prior to the commencement of employment of any member of staff. The home has made improvements in the area of training; a previous requirement that some members of staff have not had the required level of training as set out in the National Minimum Standards for Older People, that is to say, at least three paid training days per year has been withdrawn. Nine members of staff are currently undertaking the safe handling and administration of medication course, which is in modular form; a similar number will attend the infection control course planned for the near future. Excluding the Registered General Nurses, there are nineteen members of staff, eight of whom have already completed the NVQ Level 2; it is planned by the manager that the NVQ course will be bought in-house and completed by Nescott. An individual training profile does exist for all staff, however a recommendation is made that the home develops an assessment profile for the home, anticipating the future needs of the service users. Tudor House DS0000019044.V293735.R01.S.doc Version 5.1 Page 24 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): 31,32,33,35,36,37 and 38 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The quality of the care provided by the home is strongly influenced by the calibre of the registered manager and their relationship with the registered provider. The previous situation was the manager had been waiting to retire for some considerable time was both unsettling for service users and for staff. Now that a new manager is in post there is an ethos of openness, leadership and management style, which benefits the service users. EVIDENCE: The current manager has considerable experience and knowledge in the area of older people, he is an RGN and has worked both as a deputy and manager of services for older people; he is qualified to NVQ Level 4 and has his Tudor House DS0000019044.V293735.R01.S.doc Version 5.1 Page 25 registered managers award. The manager has yet to register with the Commission for Social Care Inspection as the manager for this home. During discussions with the staff team and service users, all spoke very warmly and positively about the new manager. This has clearly impacted on the home, so that there is now a sense of openness and leadership, which was not apparent previously. With regard to quality assurance and monitoring systems, Tudor Lodge has a number of measures in place. There is an annual development plan, which was available for inspection. In addition, the home sends out questionnaires annually to service users and their families. The response rate from service users themselves is generally good, however family’s respond infrequently. The home also holds residents meetings approximately three times a year, minutes of which were viewed. There is one specific area however, that the home msut address in regard to quality assurance, that is to say, the Regualtion 26 visits which are required by the Care Standards Act 2000. the Act states that the registered provider must visit the jpremises at least monthly and provide a written report of the conduct of the home. A requirement has therefore been made in this regard. There has been ongoing concern regarding the lack of supervision within the home. The standards state that staff must receive supervision at least six times a year. The evidence from the files previously is that staff have received one or two supervisions per year. The home is much improved in this area, the new manager has instigated regular supervision of all staff, and evidence of this was viewed for three members of staff chosen at random. There was also evidence of the sessions having been appropriately recorded and signed by both parties. The manager has also initiated a system, which records supervision and anticipates when they are due. With regrd to safe working practices, the home has a number of policies and procdues in place to ensure the safe working practices of the home. There are risk assessments in place for the moving and handling, and appropriate equiepment in situ. There was an awareness and understanding of infection control amongst the staff, and the provision of gloves and protective clothing, there is a sluice room on ever floor of the home. There was evidence of some reguarl checks taking place such as the fire alarm and equipment was checked on the 4.1.06. However, a number of checks were overdue – Legionella water check was last completed in October 2004 and therefore nineteen months overdue; PAT and gas checks were also overdue. A requirement has therefore been made in this regard that all measures must be taken to ensure the welfare of service users and staff. Tudor House DS0000019044.V293735.R01.S.doc Version 5.1 Page 26 Tudor House DS0000019044.V293735.R01.S.doc Version 5.1 Page 27 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 3 2 3 3 3 3 HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 10 2 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 3 17 X 18 1 2 3 2 3 3 3 3 2 STAFFING Standard No Score 27 3 28 3 29 1 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 2 X 3 3 3 2 Tudor House DS0000019044.V293735.R01.S.doc Version 5.1 Page 28 Are there any outstanding requirements from the last inspection? Yes Tudor House DS0000019044.V293735.R01.S.doc Version 5.1 Page 29 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 OP2 Regulation 4(1)(b) Requirement The home must ensure that all service users have a copy of terms and conditions signed where applicable by the appropriate parties All sections on the MAR sheets must be completed in full All staff must respect service users privacy and dignity at all times The home must ensure that they obtain locally drawn policies and procedures regarding vulnerable adult; and that in line with these procedures, draw up the homes own guidelines. Outstanding since 31.7.04 The home must be maintained and safe for its intended purpose a) The leak in the laundry must be repaired b) The building complies with the requirements of the local fire service and therefore the door between the kitchen and the rest of the building must be self closing The door handle to the bathroom 11/06/06 for the identified service users must be fixed Timescale for action 11/08/06 2 3 4 OP9 OP10 OP18 17(1)(a) 12(4)(a) 12(1)(a) 11/05/06 11/05/06 11/06/06 5 OP19 23(4) 11/06/06 6 OP21 23(2)(b) Tudor House DS0000019044.V293735.R01.S.doc Version 5.1 Page 30 7 8 OP26 OP29 23(2)(d) 13(6) 9 OP33 26 10 OP38 12(1)(a) The smell of urine from the corridor and one of the bedrooms must be removed All staff must have the appropriate checks prior to the commencement of employment, these include references, and at the very least a PoVA check The registered proprietor must complete visits on a monthly basis to compile with quality assurance All checks relating to the health and safety of service users must be completed within the allotted timescales. This is in relation to the Legionella water testing, PAT and gas appliances 11/05/06 11/05/06 11/07/06 11/06/06 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 OP19 OP30 Good Practice Recommendations The condition of the carpet in the staff room should be made good. With regard to training the home should develop a profile and plan which meets the anticipated needs of its service users for the forthcoming year. Tudor House DS0000019044.V293735.R01.S.doc Version 5.1 Page 31 Commission for Social Care Inspection Croydon, Sutton & Kingston Office 8th Floor Grosvenor House 125 High Street Croydon CR0 9XP 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. 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