Inspection on 12/12/05 for Tudor House

This inspection was carried out on 12th December 2005.

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

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Tudor House 26/07/06

Tudor House 30/09/05

Tudor House 10/12/04

Tudor House 06/08/04

Similar services:

1 Marten Road

Daubeney House

Three Gables

Aldwick House

49 Glendale

The Springs Community

Crossways Community

Belle Vue Country House

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

CARE HOMES FOR OLDER PEOPLE Tudor House 79 Victoria Drive Bognor Regis West Sussex PO21 2TB Lead Inspector Ms J Hartley Unannounced Inspection 12th December 2005 03:00 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 DS0000014807.V265355.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 House DS0000014807.V265355.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Tudor House Address 79 Victoria Drive Bognor Regis West Sussex PO21 2TB 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) 01243 823406 Mr Marimuthu Subramaniam Mrs Brenda Swee Chin Subramaniam Mrs Brenda Swee Chin Subramaniam Care Home 24 Category(ies) of Dementia - over 65 years of age (24), Mental registration, with number Disorder, excluding learning disability or of places dementia - over 65 years of age (24) Tudor House DS0000014807.V265355.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 30th September 2005 Brief Description of the Service: Tudor House is a care home providing personal care and accommodation for twenty-four older people over the age of sixty-five who have dementia. It is privately owned by Mr & Mrs Subramaniam and Mrs Brenda Subramaniam is the registered manager. The home is situated in a residential area of Bognor Regis, West Sussex and is a short distance from the town. The property is an extended detached house with accommodation arranged on two floors both of which are served by a passenger lift. The home has a combination of single and double rooms with seven of the single bedrooms having en-suite facilities. There is an enclosed rear garden and large front garden both of which are accessible to service users and very well kept. Tudor House DS0000014807.V265355.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The unannounced inspection was carried out over a period of four and a half hours. The inspector examined information held on the service file since the last inspection in September 2005, and read the previous two inspection reports, the Service User Guide and the Statement of Purpose During the inspection the inspector spoke to two service users, two relatives, and one member of staff. The inspector undertook a tour of the premises and looked at three care plans and three staff files. Various record books, policies and procedures were also examined. This report should be read in conjunction with the report of the announced inspection held on 30th September 2005. All the key standards, which should be inspected in a twelve-month period, are covered in these two reports What the service does well: What has improved since the last inspection? What they could do better: The registered manager should obtain a full employment history for prospective employees. It is suggested that the weekly menu be displayed for service users in communal areas. Tudor House DS0000014807.V265355.R01.S.doc Version 5.0 Page 6 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 DS0000014807.V265355.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 House DS0000014807.V265355.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): 1 Tudor House has a statement of purpose and service user guide that contain information to enable service users to make an informed choice about where to live. Standard Three was inspected during the last inspection and was found to have been met. Tudor House does not provide intermediate care therefore Standard Six does not apply to this service. EVIDENCE: An up to date statement of purpose and service users’ guide were seen prior to the site visit. They contain the information required to enable service users to make an informed choice about the home. Tudor House DS0000014807.V265355.R01.S.doc Version 5.0 Page 9 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): 9 Tudor House has robust policies and procedures regarding medication. Due to the high level of needs of the service users living at Tudor House, no-one is able to self-medicate. Standards Seven, Eight and Ten were inspected during the last inspection and were found to have been met. EVIDENCE: Medication records seen were up-to-date and correctly recorded. The home has a procedure for the receipt, recording, storage, handling, administration and disposal of medicines. The controlled drugs register was seen and found to be accurately recorded. Each entry is signed and dated by two witnesses. The medication cabinet was seen to be in good order with no over-stocking of medication. The home’s medication procedures are inspected by Boots pharmacy on a regular basis. The certificate for the last inspection in October 2005 was seen. Reviews and changes to medication were seen to be clearly recorded in individual service users’ files. Due to the needs of the service users at Tudor House, no one is currently self-medicating. Tudor House DS0000014807.V265355.R01.S.doc Version 5.0 Page 10 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, 15 Service users are provided with a choice of activities. The menu at Tudor House is varied and nutritious. Standards Thirteen and Fourteen were inspected at the last inspection. Standard Fourteen was met, Standard Thirteen was exceeded. EVIDENCE: Tudor House has a full and varied activities programme in place for service users. The manager employs the services of an organisation that specialises in providing activities for people with dementia. On the Saturday prior to the inspection the home had held a Christmas party for residents and their relatives. Service users interests were seen to be recorded in their individual care plans. Mr. Subramaniam cooks all the main meals at the home. A record of food eaten is kept in the diary. On the day of the inspection the food provided looked nutritious and well presented. Staff were seen assisting service users in an unhurried manner. Service users appeared to be enjoying their meal. It is recommended that a menu is displayed in a communal area of the home to enable service users to know what meals are going to be provided. Tudor House DS0000014807.V265355.R01.S.doc Version 5.0 Page 11 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): None of the above Standards were inspected during this inspection. Standards Sixteen and Eighteen were inspected during the last inspection and were found to have been met. EVIDENCE: Tudor House DS0000014807.V265355.R01.S.doc Version 5.0 Page 12 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): 25 Tudor House provides a safe and comfortable environment for service users. The requirement made at the last inspection for the radiators to be covered has now been met. Standards Nineteen, Twenty, Twenty-Four and Twenty-Six were inspected during the last inspection and were found to have been met. EVIDENCE: Tudor house was found to be clean and free from offensive odours on the day of the inspection. The home has central heating. All radiators and pipe work have now been covered. Windows have restrictors fitted for safety. One window restrictor was found to be broken on the day of the inspection. Mr. Subramaniam said he would repair it. Emergency lighting is provided throughout the home. A Legionella test was done in May 2005. Tudor House DS0000014807.V265355.R01.S.doc Version 5.0 Page 13 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 Tudor House has a skilled, well-trained staff team. There are adequate numbers of staff on duty to meet the needs of the service users. The home has a thorough recruitment procedure, however not all staff have supplied a full employment history. A full employment history should be requested prior to employment, and any gaps in employment should be explored. Two written references are now being requested for new staff. EVIDENCE: The number of staff on duty on the day of the inspection was appropriate for the size of the home and the needs of the service users. The rota for the home was seen and staffing levels for the period inspected were adequate. Tudor House employs extra staff for the morning period when the home is busiest. There are two waking night staff on duty every night. Tudor House currently has a minimum of fifty per cent of staff with an NVQ2 or equivalent qualification. The home’s recruitment policies and procedures were found to be thorough. A requirement was made at the last inspection for two written references to be obtained prior to offering employment to prospective staff. This has been met for staff employed since the last inspection. Criminal Records Bureau and Protection of Vulnerable Adults checks are carried out prior to employment. It was noted that application forms do not request a full employment history. A full employment history of prospective service users should be obtained prior Tudor House DS0000014807.V265355.R01.S.doc Version 5.0 Page 14 to employment. The manager should explore any gaps in employment with the prospective employee. Staff records show that all new staff undertake induction training within six weeks of starting work. The induction programme meets the current guidelines. The home has a training programme in place for staff. Training available includes Health and Safety and courses relevant to the specific needs of the service users, including Communication and Dementia Care. Tudor House DS0000014807.V265355.R01.S.doc Version 5.0 Page 15 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, 33, 35 The registered manager is competent and qualified to manage the home. The home is run in the best interest of service users. Service users financial interests are safeguarded by the policies and procedures of the home. Standard Thirty-Eight was inspected during the last inspection and was found to have been met. EVIDENCE: Mrs. Subramaniam’s qualifications and experience show her to be competent to run the home. She is a registered nurse and has recently completed the Level Four NVQ Registered Manager Award. Tudor House has a quality monitoring system in place. Once a year they send out questionnaires regarding the quality of care and the running of the home. The replies are then audited to enable the home to monitor its performance Tudor House DS0000014807.V265355.R01.S.doc Version 5.0 Page 16 and identify areas for improvement. The inspector has seen the results of the last survey. The manager acts as appointee for one service user. The manager keeps a record of all transactions, and ensures that monies are kept separate from that of the home. Records of transactions were seen to be accurate and up to date. Relatives or solicitors handle the finances of the other service users due to their dementia. Tudor House DS0000014807.V265355.R01.S.doc Version 5.0 Page 17 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 X X X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 X 8 X 9 3 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 X 14 X 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 X 17 X 18 X X X X X X X 3 X STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X X Tudor House DS0000014807.V265355.R01.S.doc Version 5.0 Page 18 Are there any outstanding requirements from the last inspection? No 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 OP29 Regulation 13 Requirement The registered manager should ensure that a full employment history is obtained from prospective employees and that any gaps in employment are explored. Timescale for action 12/01/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard OP15 Good Practice Recommendations It is suggested that the weekly menu be displayed in a communal area of the home. Tudor House DS0000014807.V265355.R01.S.doc Version 5.0 Page 19 Commission for Social Care Inspection Worthing LO 2nd Floor, Ridgeworth House Liverpool Gardens Worthing West Sussex BN11 1RY 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 House DS0000014807.V265355.R01.S.doc Version 5.0 Page 20 - 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. 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