Inspection on 16/06/05 for Tudor House

This inspection was carried out on 16th June 2005.

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 11/05/06

Tudor House 23/11/05

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 CR2 7EA Lead Inspector Rin Saimbi Announced 16 June 2005 th The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Tudor House G53-G53 S19044 Tudorhouse V211367 160605 stage 0.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Tudor House Address Tudor House Nursing Home, 4 Birdhurst Road, South Croydon, CR2 7EA Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 020 8410 3399 020 8410 3398 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 G53-G53 S19044 Tudorhouse V211367 160605 stage 0.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: The home is registered for a maximum of 37 people who fall into the old age catogery of registration. 1. 12 nursing 2. 25 which can be either nursing or residential 3. A variation has been granted to allow one specified service user Dementiaover 65 [DE(E)] service user category to be accommodated Date of last inspection 6.12.04 Brief Description of the Service: Tudor House is a purpose built property in South Croydon which can accommodate upto 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 propieters for office space and 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 tansport links. Tudor House G53-G53 S19044 Tudorhouse V211367 160605 stage 0.doc Version 1.30 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 2005/06. It was an announced inspection. The inspection was completed in the day taking eight hours, with two inspectors being involved in the morning. The inspection involved, looking through documentation, which related to the service users, talking to service user, staff, manager and proprietors, a tour of the building and ensuring the health and safety of the service users and staff. The Commission had also received a complaint coincidently prior to the inspection taking place, regarding the care provided at the home. There were a total of six elements to the complaint; of which three were upheld; two were unresolved due to lack of evidence and one was found to be unfounded. This report will not specifically highlight the individual elements of the complaint; however, requirements have been made which address the issues identified. What the service does well: The home is decorated and maintained to a high standard, with a rolling programme of refurbishments in place to make sure that this standard is maintained. The home is equipped with good quality domestic style furniture throughout. Within the staff team there are a number of people who have worked at the home for some considerable time. This is reflected in their knowledge and understanding of the needs of the service users. In addition, the support staff including the cook, handy man, activities co-ordinator, and cleaners all have a pleasant manner, which is caring and supportive to the service users. The home has a lively, friendly atmosphere. Service users spoken to during the inspection were all positive about the care that they received and felt that staff were attentive to their needs. Tudor House G53-G53 S19044 Tudorhouse V211367 160605 stage 0.doc Version 1.30 Page 6 What has improved since the last inspection? 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 G53-G53 S19044 Tudorhouse V211367 160605 stage 0.doc Version 1.30 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Standards Statutory Requirements Identified During the Inspection Tudor House G53-G53 S19044 Tudorhouse V211367 160605 stage 0.doc Version 1.30 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 1,3 and 4 In general, the home has provides 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. The home however, must be much clearer in defining that prospective service users are admitted only on the basis that they fall into the homes criteria and that there needs can be met. EVIDENCE: The home does have a detailed statement of purpose, which outlines their aims and objectives and the facilities that will be provided. The statement of purpose still needs to be expanded to include details of qualifications and experience of the manager, staff and registered provider. New service users are only admitted on the basis of a full assessment completed by the manager. In addition, the manager gathers as much information as possible from the service users themselves, family and friends, and other involved professionals. Tudor House G53-G53 S19044 Tudorhouse V211367 160605 stage 0.doc Version 1.30 Page 9 There was evidence regarding one particular service user who may have been admitted to the home inappropriately. As a consequence the needs of this service user was not being met, and was disrupting the placement of others. Tudor House G53-G53 S19044 Tudorhouse V211367 160605 stage 0.doc Version 1.30 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 7,8,9 and 10 The assessment process and the subsequent care plan should define the care that is given to the service users and indicate the changing needs; the records at Tudor House did not do this, thus not ensuring that service users care is appropriate to their needs. Whilst recognising that the observed care given to service users was appropriate during the inspection. The lack of full, comprehensive and up to date care plans is clearly of concern, as potentially it is putting service users well being at risk. EVIDENCE: In general, service users had comprehensive assessments, which appeared to be reviewed regularly. There were dates recorded that indicated a review, however, the information held on the care plan was not always altered to reflect changes. Within the care plans there were a number of omissions, which need to be rectified immediately. The daily record sheets were not up to date in all cases, nor did they actually reflect the care that was given. Tudor House G53-G53 S19044 Tudorhouse V211367 160605 stage 0.doc Version 1.30 Page 11 The care plans also need to be comprehensive covering all aspects of personal and health care. Areas which were identified included a nutritional plan for service users who are diabetic; a continence plan where required and information pertaining to …. One service user who was identified on the care plan as having behaviour difficulties was clearly not in a suitable placement. Service users spoke about the disruptions that she caused, and one service users was clear in her body language demonstrating that she was frightened on this particular service user. After some discussions, the manager and proprietor did agree to review the placement of this particular service user, although this should already have been addressed. The home has a designated nurse whose responsibility it is to administer medication. All documentation relating to medication was up to date and accurate; the member of staff was knowledgeable about their subject. The home held 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. From a discussion with the GP surgery it was clear that service users do receive at least an annual review of their health needs. The home does not however, have an accurate record of when reviews took place, if they have any record at all. Tudor House G53-G53 S19044 Tudorhouse V211367 160605 stage 0.doc Version 1.30 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12,13,14 and 15 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. Staff and service users stated that they were encouraged to take part in activities, which often took place in the lounge. However, there was the opportunity for service users to be private and stay in their bedroom if they wished, and also to take meals in their bedrooms if they were feeling unwell. The home had a relaxed atmosphere whilst being quite busy with the coming and goings of friends and relatives. Service users said that they felt that visitors were always welcomed and that they had a choice of where to see Tudor House G53-G53 S19044 Tudorhouse V211367 160605 stage 0.doc Version 1.30 Page 13 them, either in their bedrooms, one of the smaller quieter lounges or in the main lounge. Service users all had a range of clean clothes, from which they are given a choice of what they want to wear. 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. The cook said that she tries to balance meals so that a heavy main meal is balanced with a lighter dessert. In the main, all meals are freshly prepared and appeared nutritious and wholesome. 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. Service users all spoke positively about the range and quantity of food available. Tudor House G53-G53 S19044 Tudorhouse V211367 160605 stage 0.doc Version 1.30 Page 14 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 16 and 18 The home has a clear and robust 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. It is of concern that this issue has been raised in previous inspections and still remains outstanding, and therefore potentially putting people at risk with no training or appropriate policies in place. EVIDENCE: The home has a complaints policy and a log of the complaints that are made. From viewing the log it appears that complaints are dealt with promptly and effectively. The Commission, as stated in the summary have received a complaint recently from someone who visits the home. This individual wishes to remain anonymous to the home. There were six areas identified by the complainant concerning the welfare of the service users. Three of the six areas were upheld, the elements of which feature within the context of this report and are highlighted within the requirements made. Two elements remain unresolved, as there is insufficient evidence, one element is unfounded. Once bought to the attention of the proprietors and manager, they gave assurances that they will be dealt with accordingly, and therefore the Commission in the grading of the standard has scored it as being met. Tudor House G53-G53 S19044 Tudorhouse V211367 160605 stage 0.doc Version 1.30 Page 15 In relation to safeguarding the welfare of service users, the home has yet to acquire Croydon’s policy and procedures regarding vulnerable adults, nor does the home have its own guidelines. It was noted that only one member of staff has attended any training regarding vulnerable adults, this does not include the manager. This was an issue identified in the previous inspection and no progress has been made. A further requirement has been made that the home must address this issue forthwith. Tudor House G53-G53 S19044 Tudorhouse V211367 160605 stage 0.doc Version 1.30 Page 16 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 19,20,21,22,23,24,25 and 26 The general the physical layout of the building and the high standard of decoration throughout, give Tudor house a homely feel. EVIDENCE: 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. Tudor House G53-G53 S19044 Tudorhouse V211367 160605 stage 0.doc Version 1.30 Page 17 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 has recently had an occupational therapy assessment; this requirement has therefore been withdrawn. The home was generally clean throughout and free from offensive odours. The condition of the carpet in the staff room does need to be reviewed, and either needs to be cleaned or replaced. 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. A requirement was made regarding the availability of hot water in the ensuites facilities. That is to say that hot water must be available for service users throughout the day. Tudor House G53-G53 S19044 Tudorhouse V211367 160605 stage 0.doc Version 1.30 Page 18 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27 and 29 The home has policies and procedures in place to ensure that only appropriate, vetted staff are recruited to the home. In general, the staffing levels and skill mix are adequate to meet the needs of the service users. Although there has been at least one occasion when the staffing levels fell far below the required level putting service users are risk. EVIDENCE: Duty staff rota’s were checked at random, and seemed to indicate that sufficient staff were on duty during the given weeks. It was noted that a number of the staff at the home have been there some considerable time, and that the use of bank staff has been reduced to some extent. However, there was an incident, which caused considerable concern to the Commission. It relates to the activities co-coordinator and handy man been left in charge of the service users in the main lounge for an hour, whilst the care staff attended training. This is not acceptable, and therefore a requirement has been made in this regard. The homes recruitment procedure was checked. Staff files were viewed and contained the appropriate information including two written references, Criminal records bureau checks and proof of identification. All staff receive statements of terms and conditions. A requirement has been made that the Tudor House G53-G53 S19044 Tudorhouse V211367 160605 stage 0.doc Version 1.30 Page 19 home must comply with immigration law and check the working permits of staff where applicable. Tudor House G53-G53 S19044 Tudorhouse V211367 160605 stage 0.doc Version 1.30 Page 20 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31,36,37 and 38 The quality and provision of the care and service provided by the home is strongly influenced by the calibre of the registered manager and their relationship with the registered provider. The current situation of the manager waiting to retire once a replacement is found is both unsettling for the service users and the staff, and needs to be addressed urgently. EVIDENCE: The last two inspection reports have made requirements regarding the current managers qualifications; and that the qualifications must be submitted to TOPSS to ensure that they meet the required level. This was not pursued as a statement was made by the proprietors that the manager would be retiring. This has not occurred because of difficulties with recruitment. Notwithstanding the registered individuals must ensure that a suitably qualified and experienced manager is in post forthwith. Tudor House G53-G53 S19044 Tudorhouse V211367 160605 stage 0.doc Version 1.30 Page 21 In general supervision of staff is now taking place at the required level, members of staff confirmed this during discussions. There was no evidence of supervision taking place for one of the night staff, the manager gave assurances that it had taken place and agreed to forward the relevant documentation. This has not been forthcoming and therefore can only be assumed not to have taken place. A requirement has therefore made in this regard. As highlighted throughout this inspection report, recording of information is not satisfactory. Policies and procedures are not in existence for the protection of vulnerable adults. Care plans in particular, lack basic information, are not up to date or are inaccurate. The concern therefore must be that, this situation could jeopardise the well being of service users. Health and safety of service users and staff was not inspected fully this inspection, however it was noted that cleaning staff should be provide with a cleaning trolley which must have a lockable section so that hazardous substances can be locked away whilst not in use. Tudor House G53-G53 S19044 Tudorhouse V211367 160605 stage 0.doc Version 1.30 Page 22 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score 2 x 2 2 x x HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 3 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION 3 3 3 3 3 3 2 2 STAFFING Standard No Score 27 1 28 x 29 2 30 x MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x 1 2 x x x x 2 2 2 Tudor House G53-G53 S19044 Tudorhouse V211367 160605 stage 0.doc Version 1.30 Page 23 yes Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard 1 Regulation 17.2 Requirement The registered person must ensure that the service users guide contains all elements of Standard 1.2, including qualifications and experience of manager, staff and registered providers. Partially met. The registered person must ensure that all care plans and risk assessments are comprehensive, accurate, up to date and that they are reviewed regularly. (Timescale of 31.3.05 not met) The registered person must ensure that they obtain locally drawn up policies and procedures regarding vulnerable adults; and that in line with these procedures draw up the homes own guidelines (Timescale of 31.7.04 not met) The registered person must ensure that staff receive training regarding vulnerable adults (Timsecale of 31.7.04 not met) The registered person must ensure that service users are left with sufficent care staff on duty The registered person must ensure that staff all receive Timescale for action 30.9.05 2. 7 30.9.05 3. 18 13(6) 30.9.05 4. 18 13(6) 30.9.05 5. 6. 27 36 18(1)(a) 18(2) 16.6.05 and henceforth. 30.9.05 Page 24 Tudor House G53-G53 S19044 Tudorhouse V211367 160605 stage 0.doc Version 1.30 supervision. Partly met 7. 3 14(1) The registered person must ensure that only service users who fit the home criteria and registration are admitted to the home The registered person must ensure that the home keeps accurate records of reviews undertaken by health professionals The registered person must ensure that hot water is available in all the ensuite facilities and the bathrooms during the day The registered person must review the conditon of the carpet in the staff room 16.6.05 and henceforth. 16.6.05 and henceforth 16.6.05 and henceforth 30.10.05 8. 8 17(1)(a) (4) 9. 25 23(2)(j) 10. 26 23(2)(d) 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 Good Practice Recommendations Tudor House G53-G53 S19044 Tudorhouse V211367 160605 stage 0.doc Version 1.30 Page 25 Commission for Social Care Inspection CSCI 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. Extracts may not be used or reproduced without the express permission of CSCI Tudor House G53-G53 S19044 Tudorhouse V211367 160605 stage 0.doc Version 1.30 Page 26 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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