Inspection on 15/04/09 for Tudor House

This inspection was carried out on 15th April 2009.

CQC found this care home to be providing an Adequate service.

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

Similar services:

Claremont House

Oak Ridge

Sun Court Nursing Home

Ashville House

Bilney Hall

Hill Barn

Mabbs Hall Nursing Home

Henrietta House

Extracts from inspection reports are licensed from CQC, this page was updated on 19/06/2009.

Key inspection report CARE HOMES FOR OLDER PEOPLE Tudor House 76 West Street Dunstable Bedfordshire LU6 1NX Lead Inspector Mrs Louise Trainor Unannounced Inspection 15th April 2009 07:30 DS0000072613.V374816.R01.S.do c Version 5.2 Page 1 This report is a review of the quality of outcomes that people experience in this care home. We believe high quality care should: • • • • • Be safe Have the right outcomes, including clinical outcomes Be a good experience for the people that use it Help prevent illness, and promote healthy, independent living Be available to those who need it when they need it. We review the quality of the service against outcomes from the National Minimum Standards (NMS). Those standards are written by the Department of Health for each type of care service. Copies of the National Minimum Standards – Care homes for older people can be found at www.dh.gov.uk or bought from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop. The mission of the Care Quality Commission is to make care better for people by: • Regulating health and adult social care services to ensure quality and safety standards, drive improvement and stamp out bad practice • Protecting the rights of people who use services, particularly the most vulnerable and those detained under the Mental Health Act 1983 • Providing accessible, trustworthy information on the quality of care and services so people can make better decisions about their care and so that commissioners and providers of services can improve services. • Providing independent public accountability on how commissioners and providers of services are improving the quality of care and providing value for money. Tudor House DS0000072613.V374816.R01.S.doc Version 5.2 Page 2 Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report Care Quality Commission General Public 0870 240 7535 (telephone order line) Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CQC copyright, with the title and date of publication of the document specified. www.cqc.org.uk Internet address Tudor House DS0000072613.V374816.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Tudor House Address 76 West Street Dunstable Bedfordshire LU6 1NX 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) 01582 663700 01582 673287 Janes Care Homes Ltd Manager post vacant Care Home 18 Category(ies) of Dementia (18), Old age, not falling within any registration, with number other category (18) of places Tudor House DS0000072613.V374816.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following categories of service only: Care Home only - Code PC to service users of the following gender: Either whose primary care needs on admission to the home are within the following categories: Old age, not falling within any other category - Code OP Dementia - Code DE The maximum number of service users who can be accommodated is 18 Not applicable 2. Date of last inspection Brief Description of the Service: Tudor House is situated on a busy road near the centre of Dunstable within a short walk of the towns many amenities. The home provides personal care for up to eighteen people over the age of 65 years who may also have dementia and/or physical disabilities. The registration for physical disabilities was not required as the home could meet the needs of those with physical frailties and mobility problems associated with old age under the category for older persons. The accommodation is distributed over two floors that are accessed by staircases and a shaft lift. There are fourteen single bedrooms and two double rooms. The dining and lounge facilities are located on the ground floor together with the kitchen, conservatory, laundry, bathrooms, WC’s and some bedrooms. The second floor accommodates the manager’s office, sleeping in room and training room for staff. To the rear of the property is a garden with seating areas. The fees for this home vary from £457.00 per week, to £550.00 per week, depending on the funding source and assessed needs of the person. Additional charges are made for hairdressing, barber services and newspapers. Tudor House DS0000072613.V374816.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 1 star. This means the people who use this service experience adequate quality outcomes. This inspection was carried out in accordance with the Care Quality Commission (CQC) policy and methodologies, which require review of the key standards for the provision of a care home for older people that takes account of service users’ views and information received about the service since the last inspection. Evidence used and judgements made within the main body of the report include information from this visit. This was the first Key Inspection for this service, since New Providers took over the business in October 2008. This visit was carried out on the 15th of April 2009, by Regulatory Inspector Mrs Louise Trainor, between the hours of 07:30 and 13:00 hours. The homes manager arrived on duty at 09:00 hours, and was present until the inspection completed. Feedback was given both during, and on completion of this inspection. During this inspection we tracked the care of two people who live in this home. This involved reading their records and comparing what was documented, to the care that was being provided. We also looked at the pre admission work that had been done for someone who had recently been admitted to the home. Documentation and records relating to: staff recruitment, training and supervision, medication administration, complaints, quality assurance and health and safety in the home were also examined. We also spent some time in the communal areas of the home, talking to staff and residents and observing the care practices that were carried out during this five and a half hour inspection. A full tour of the premises also took place. We would like to thank everyone involved for their support and assistance during this visit to the home. Tudor House DS0000072613.V374816.R01.S.doc Version 5.2 Page 6 What the service does well: The home understands the importance of having enough information when choosing a care home. Pre Admission documentation was in place, and was being completed appropriately. Care plans had been completed in sufficient detail to ensure that staff could provide consistent care. They included personal preferences and had been written in consultation with individuals and their representatives. There was a four-week rolling menu plan in place, offering a variety of healthy nutritious meals. A choice of two main meals was available daily, with lighter options in the evening. This home has a complaints policy, which is on display and easily accessible to residents and visitors to the home. This document details expected timescales for responses, and guidance for any complainant that remains dissatisfied with investigatory outcomes. We looked at the health and safety file, which indicated that fire call points, water temperatures and food temperatures are being checked on a regular basis. What has improved since the last inspection? What they could do better: Discrepancies on Medication Administration Record (MAR) sheets indicate that residents may not always be protected. The home tries to be flexible and attempts to provide a service that is as individual as possible, however, although some residents are given choices, this process could be improved to include those with more severe disabilities. Tudor House DS0000072613.V374816.R01.S.doc Version 5.2 Page 7 This home is clean, comfortable and free from offensive odours, however some areas of the environment require attention to ensure that the health and safety of the residents is promoted at all times. This service recognises the importance of training and tries to deliver a programme that meets the National Minimum Standards. There are, however, some gaps, which the manager is aware of and is planning to deal with. The manager is aware of the need to keep up to date with practice and continuously develop her own skills. Checks show that record keeping is generally up to date; however there are occasional omissions and entries are not always clear. If you want to know what action the person responsible for this care home is taking following this report, you can contact them using the details on page 4. The report of this inspection is available from our website www.cqc.org.uk. You can get printed copies from enquiries@cqc.org.uk or by telephoning our order line – 0870 240 7535. Tudor House DS0000072613.V374816.R01.S.doc Version 5.2 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 DS0000072613.V374816.R01.S.doc Version 5.2 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 3, 4, 5, 6, People using the service experience good quality outcomes in this area. The home understands the importance of having enough information when choosing a care home. Pre Admission documentation was in place, and was being completed appropriately. We have made this judgement using a range of evidence, including a visit to this service. EVIDENCE: There is a combined Service User Guide and a Statement of Purpose in place for this home. This document is held electronically and reviewed at regular intervals, and is on display in the reception area so that it is easily accessible to residents and their relatives at all times. The documents that we saw Tudor House DS0000072613.V374816.R01.S.doc Version 5.2 Page 10 correctly reflected the details of the new owners and present management of the home. We viewed a pre admission assessment that had been for a recent admission. The document was clearly dated and signed. The manager had carried it out on the 30th of October 2008 in preparation for an admission, which took place on the 6th of November 2008. The document contained sufficient details relating to individuals’ needs, and the manager had used the information to assist in generating an initial care plan following admission. Contracts of terms and conditions were in place for the residents’ whose files we examined. Some of the information relating to the Care Quality Commission (CQC) is in need of review. This home does not provide intermediate care. Tudor House DS0000072613.V374816.R01.S.doc Version 5.2 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9, 10, 11 People using the service experience adequate quality outcomes in this area. Care plans had been completed in sufficient detail to ensure that staff could provide consistent care. They included personal preferences and had been written in consultation with individuals and their representatives. Discrepancies on Medication Administration Record (MAR) sheets indicate that residents may not always be protected. We have made this judgement using a range of evidence, including a visit to this service. EVIDENCE: During this inspection we looked at the personal files of two of the residents who live at Tudor House. Tudor House DS0000072613.V374816.R01.S.doc Version 5.2 Page 12 Files were tidy and generally well organised. Care plans were well written, and contained sufficient detail to ensure that staff could deliver care with continuity. The files that we looked at contained numerous care plans to address a variety of needs ranging from, nutrition and dietary requirements, communication, social activities, and religious beliefs, to dental and foot care. They were written in the first person, and there was an accompanying ‘care plan agreement’ indicating that residents had been involved in this planning process, and were aware of their content. Personal wishes and preferences were included in the care plans, as was guidance on how staff should avoid and recognise related conditions. For example one resident’s file identified that they should avoid certain foods due to the medication they were prescribed, and also identified the signs and symptoms, relating to a medical condition, which may require medical intervention. Care plans were also completed to identify individuals’ wishes in relation to death and dying. Families had also been involved in this process. Both of the files that we looked at contained various risk assessments, which identified the level of support each person required to minimise risks to them. These risk assessments were reflected in the individual care plans. And all documents were all being reviewed on a monthly basis to reflect any changes in need. Discussions with residents, and observations of staff interactions with residents indicated that people are generally satisfied with the care provided in this home. Residents were relaxed, happy, well presented, and said they felt generally well looked after. Observations of care, identified people being treated with respect, and addressed in a way that was their preference, with the exception of one lady who was repeatedly addressed as ‘little lady’. This could be interpreted as rather patronising. We examined the Medication Administration Record (MAR) sheets for all of the residents presently living in the home. Although it was only the third day of the present charts, we identified several missed signatures where corresponding medication was not in the blister packs. This indicated that it had been given but not signed for. We also found a stock discrepancy for one resident’s Warfarin. Where 17 tablets had been carried forward from the previous month, two tablets had been signed as administered, however only 14 tablets were remaining in stock, leaving one tablet unaccounted for. Another resident was in hospital, however there was no code or indication on the MAR sheet to identify this. Tudor House DS0000072613.V374816.R01.S.doc Version 5.2 Page 13 There were no Controlled Drugs in use in the home at the time of this inspection, however appropriate storage and recording facilities are available if required. Tudor House DS0000072613.V374816.R01.S.doc Version 5.2 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, 15 People using the service experience adequate quality outcomes in this area. The home tries to be flexible and attempts to provide a service that is as individual as possible, however, although some residents are given choices, this process could be improved to include those with more severe disabilities. We have made this judgement using a range of evidence, including a visit to this service. EVIDENCE: There is an activity programme on display in the entrance of this home. It identifies a range of activities, which includes, music and dancing, movie sessions, nail care, newspaper and reminiscing groups, religious services, baking and quizzes. The home was decorated to reflect the Easter festival, and Tudor House DS0000072613.V374816.R01.S.doc Version 5.2 Page 15 one resident told us how she had helped to make Easter table decorations. These were on display. There is presently no one specifically employed as an activity organiser, however we understand the cooks’ hours include two hours a day activity/ group work. This also includes the co ordination of resident’s meetings, and trips out to the town and local facilities, including the market. On the day of this inspection there was little evidence of planned activities taking place in the morning, however residents were relaxed, and generally doing what they chose. One resident spent time in the garden, another was watching television, whilst another chose to spend the morning in her room. There were however two residents, that appeared to be sitting at the dining table from breakfast time through to lunch, with very limited interactions. When we asked a member of staff what activities were in place for the day, she replied. “We do activities in the afternoon usually, but are trying to keep every everything as clean as possible”. We were unable to ascertain what she meant by this. The manager told us that she is in the process of resourcing other leisure activities, such as swimming for one particular resident. We look forward to seeing how this progresses in the near future. There was a four-week rolling menu plan in place, offering a variety of healthy nutritious meals. A choice of two main meals was available daily, with lighter options in the evening. Drinks, snacks and fresh fruit are readily available throughout the day. Observation of the midday meal indicated that the residents were enjoying their meal, and assistance was being given by staff in an unhurried and dignified manner. Tudor House DS0000072613.V374816.R01.S.doc Version 5.2 Page 16 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 16, 18 People using the service experience good quality outcomes in this area. This home has a complaints policy, which is on display and easily accessible to residents and visitors to the home. This document details expected timescales for responses, and guidance for any complainant that remains dissatisfied with investigatory outcomes. We have made this judgement using a range of evidence, including a visit to this service. EVIDENCE: This home has a complaints policy, which is on display and easily accessible to residents and visitors to the home. This document details expected timescales for responses, and guidance for any complainant that remains dissatisfied with investigatory outcomes. We looked at the complaints file. Since the new providers have taken over this home there has only been one complaint, which was made verbally by a Tudor House DS0000072613.V374816.R01.S.doc Version 5.2 Page 17 visitor. The matter had been fully investigated by the manager and a letter of response had been sent out within the policies specified time frame. The manager demonstrated a clear understanding of Safeguarding protocols and related reporting processes. She has a basic knowledge of the Mental Capacity Act and Deprivation of Liberty legislation and how it affects the residents in this home, and is aware of who she should contact if she requires further information. This knowledge needs to be cascaded to all staff. Safeguarding training has been attended by the majority of the staff in this home, and there are sessions booked for newly appointed staff. Tudor House DS0000072613.V374816.R01.S.doc Version 5.2 Page 18 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 21, 22, 23, 24, 25, 26 People using the service experience adequate quality outcomes in this area. This home is clean, comfortable and free from offensive odours, however some areas of the environment require attention to ensure that the health and safety of the residents is promoted at all times. We have made this judgement using a range of evidence, including a visit to this service. EVIDENCE: The home was clean and free from offensive odours throughout. The reception area is welcoming and displays information about the home. Tudor House DS0000072613.V374816.R01.S.doc Version 5.2 Page 19 The communal areas were generally comfortable, clean and tidy, with pictures and paintings in place on the walls. On the day of the inspection the home was warm and homely, and the dining tables dressed with Easter decorations were set ready for breakfast. The bedrooms that we visited were decorated and furnished with personal photographs and ornaments that reflected the individual’s life history. We understand from staff that there is a plan to replace some of the older more warn carpets in the home, however we were not given a timeframe for this. We visited the kitchen during this visit, and although it was generally clean, a large patch on the ceiling was brought to our attention. Staff advised us that that repairs had done with ‘filler’ to this ceiling sometime ago, however work on this had not been completed, and the ‘filler’ occasionally drops from the ceiling onto the food preparation / work surfaces below. This is unacceptable. We were also told that the extractor fan in the kitchen is twenty years old and does not work. Other issues relating to environmental health and safety have been addressed in more detail in the ‘Management and Administration’ section of this report. Tudor House DS0000072613.V374816.R01.S.doc Version 5.2 Page 20 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29, 30 People using the service experience adequate quality outcomes in this area. This service recognises the importance of training and tries to deliver a programme that meets the National Minimum Standards. There are, however, some gaps, which the manager is aware of and is planning to deal with. We have made this judgement using a range of evidence, including a visit to this service. EVIDENCE: There is a small team of staff in this home. Some have joined the team since the new providers took over last year and others have worked in the home for several years. During this inspection we looked at the files of three staff that had been appointed by the present company. All the relevant recruitment documentation was present in these files including; fully completed application forms, Criminal Record Bureau (CRB) and POVA first checks, various forms of identification including photographs, references from appropriate sources, health questionnaires, interview records and contracts/ terms and conditions of employment. Some documents did however have missing dates and signatures. Tudor House DS0000072613.V374816.R01.S.doc Version 5.2 Page 21 We looked at the training programme, which is in place for staff. This programme runs until 02/06/09 and includes scheduled sessions in a variety of subjects including both mandatory and some more specialist, such as Challenging Behaviour, Dementia, and Dying, Death and Bereavement. We also looked at the training matrix, which identifies when staff have attended courses, and when they are scheduled to next attend. This did indicate that there are presently some gaps, for example only one member of staff is documented as having done Care Planning training, only two have done Health and Safety, and no one has done Nutrition and Diet, or Mental Capacity training. During this inspection, we spoke with some of the staff on duty, and also observed some of the care interactions during the morning. Staff were respectful in their approach to residents, however there were occasions when we saw care staff standing around aimlessly, or involved in duties such as cleaning, when their time would have been better spent engaging in more meaningful activities with residents, particularly those with dementia, who spent much of the morning sitting at the dining table. We were unsure whether this was due to lack of motivation or lack of skills. We were also a little concerned that when we asked one member of staff. “What should be in the fire log?” She told us she had no idea. Tudor House DS0000072613.V374816.R01.S.doc Version 5.2 Page 22 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35, 36, 37, 38 People using the service experience adequate quality outcomes in this area. The manager is aware of the need to keep up to date with practice and continuously develop her own skills. Checks show that record keeping is generally up to date; however there are occasional omissions and entries are not always clear. We have made this judgement using a range of evidence, including a visit to this service. EVIDENCE: Tudor House DS0000072613.V374816.R01.S.doc Version 5.2 Page 23 The new manager came into post in this home at the end of October 2008. She is a qualified nurse, with previous care home experience as a deputy manager within this provider group. This is however her first managers’ role and her registration with the Care Quality Commission is still in progress. She is due to go on maternity leave in the very near future and the Area Manager advised us that contingency plans are in place in preparation for this. We looked at the health and safety file, which indicated that fire call points, water temperatures and food temperatures are being checked on a regular basis. We did however find several issues, which we felt were a health and safety risk and needed to be addressed without delay. This included, a radiator cover in a second floor bedroom, which was in need of repair and had been reported on the 16/02/09. This had not yet been fixed. While we were in this bedroom, we also found that the window restrictor was broken. There was another radiator cover found hanging off the wall, at the rear of the building on the ground floor. The manager asked a male cleaner to remove this, in order to minimise the risk to residents from it falling, however there still remained a risk, as the radiator was hot. A list of the residents was on display by the fire panel for use in the event of evacuation, however this had not been updated to reflect one resident being in hospital? Whilst sitting with a resident in the lounge, a bell sounded, and the ‘fire magnets’ released the door, which consequently closed. We approached staff to enquire if it was fire alarm. Staff told us it was the residents ‘call system’. When asked why the fire doors closed, we were told by staff that it was an old system, which never worked very well and probably needed a new battery. This is unacceptable and may leave residents at risk. We looked at the supervision records file. This indicated that since the new manager has come into this home all staff have received at least one supervision session. This must continue to ensure that standards are met. The manager stated that her own supervision has been very limited since coming into post in this home, with only one session since October 2008. This home only ‘holds’ personal money for three of the residents who live here. We looked at the account records for all of them. Two balanced correctly with funds remaining, however the third was £10 short, despite being audited the day before the inspection. The manager keeps ‘back up’ sheets of all expenditures for the residents, and so was able to identify where this discrepancy had occurred, and provide receipts to support each transaction. However this should have been identified through the audit process. Tudor House DS0000072613.V374816.R01.S.doc Version 5.2 Page 24 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 3 3 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 10 2 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 2 14 2 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 2 2 X X 3 2 2 2 STAFFING Standard No Score 27 2 28 2 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 2 X 2 2 2 1 Tudor House DS0000072613.V374816.R01.S.doc Version 5.2 Page 25 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 OP9 Regulation 13(2) Timescale for action The registered person shall make 30/04/09 arrangements for the recording, handling, safekeeping, safe administration and disposal of medicines received into the care home. Residents must be cared for by staff that understand and adhere to the policies relating to medication in this home. The registered person must ensure that all staff are appropriately trained to care for the residents in this home. The registered person must ensure that all records in the home are fully completed and maintained. This must include all records and documents listed in schedules 3 & 4, of the National Minimum Standards, Care Home Regulations. Requirement 2. OP30 18(1)(a) 31/05/09 3. OP38 17 31/05/09 Tudor House DS0000072613.V374816.R01.S.doc Version 5.2 Page 26 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 OP12 Good Practice Recommendations The home should consider how activities could be more meaningful to residents with cognitive impairment. Tudor House DS0000072613.V374816.R01.S.doc Version 5.2 Page 27 Care Quality Commission Eastern Region Care Quality Commission Eastern Regional Contact Team CPC1, Capital Park Fulbourn Cambridge, CB21 5XE National Enquiry Line: Telephone: 03000 616161 Email: enquiries@cqc.org.uk Web: www.cqc.org.uk We want people to be able to access this information. If you would like a summary in a different format or language please contact our helpline or go to our website. Copyright © (2009) Care Quality Commission (CQC). 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