Inspection on 23/11/05 for Tudor House

This inspection was carried out on 23rd November 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 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 Unannounced Inspection 23rd November 2005 09:30 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Tudor House DS0000019044.V268557.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 DS0000019044.V268557.R01.S.doc Version 5.0 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.V268557.R01.S.doc Version 5.0 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. 16th June 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. Tudor House DS0000019044.V268557.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was the home’s second inspection for the year 2005/06. It was an unannounced inspection. The inspection started at 9.30 am and took approximately seven hours to complete. 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 also interviews and discussions with staff, manager and proprietors, and a tour of the building. 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. 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. The home employs a number of support staff, which allows care staff to concentrate on providing care and enhances the lives of service users. These staff include cleaners, handy man, kitchen staff and the activities co-ordinator. The home has a lively, friendly atmosphere. Service users, relatives and others outside people all commented on how approachable, friendly and involved the manager and proprietors were. Tudor House DS0000019044.V268557.R01.S.doc Version 5.0 Page 6 What has improved since the last inspection? What they could do better: The home is in a period of uncertainty with the current manager due to have retired some months ago, but staying on until her replacement is found. This level of uncertainty does not give consistency or security to the service users or to staff. The proprietors gave assurances that the matter of finding a replacement is in hand. It is perhaps not surprising therefore that it is within the area of management and administration that the home needs to focus on within the next few months. Care plans have improved, however risk assessments and daily recordings need to be reviewed on a regard basis, and the information recorded needs to be improved. There was particular issue that related to a fundamental diagnosis of a service user, and whether the service users should have been admitted to the home at all, or indeed, that the care plan was totally incorrect. Fundamental errors such as this should not occur within a home that is managed appropriately. A further long standing requirement relates to the issue of lack of supervision; appropriate and adequate supervision is fundamental to the delivery of care to service users and therefore the scoring of outcomes reflects the Commissions concern that staff are not being supervised on a regular basis, with some staff receiving just one supervision this year. Tudor House DS0000019044.V268557.R01.S.doc Version 5.0 Page 7 As stated previously, the home has provided training regarding vulnerable adults for over half its staff, this is welcomed. However, there have been longstanding requirements regarding the home acquiring local policies and procedures regarding vulnerable adults, and from this document developing their own policies and procedures. This is still outstanding and needs to be addressed for with. 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.V268557.R01.S.doc Version 5.0 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.V268557.R01.S.doc Version 5.0 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): 1,3 and 6 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. 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 has recently been amended to include details of qualifications and experience of the manager, staff and registered provider. Therefore, the previous requirement relating specifically this issue has been withdrawn. 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 possible from the service users themselves, family and friends, and other involved professionals. Information was viewed regarding three service users who had recently been admitted to the home. The assessments included details of medication, Tudor House DS0000019044.V268557.R01.S.doc Version 5.0 Page 10 hearing and vision, next of kin and mobility. Whilst not a comprehensive assessment it was adequate for the purposes required. The home must ensure that service users are only admitted to the home on the basis that they fall into the homes criteria and that therefore their needs can be met. With regard to one particular service users the paperwork was checked, the initial assessment did query dementia. The care plan, which was reviewed in November, highlighted that the service users needed particular assistance because of their dementia. However, the home is not registered to provide a service for people with dementia. In discussions with the manager, it was suggested that either the service user should not have been admitted to the home, or that the care plan was incorrect. Neither situation is acceptable, the matter needs to be looked into immediately and rectified. Intermediate care is available at the home if requested, however, there has been no such referral for at least three years. Tudor House DS0000019044.V268557.R01.S.doc Version 5.0 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 and 8 The assessment process and the subsequent care plan should define the care that is given to the service users and indicate the changing needs. EVIDENCE: In general, the care plans are improved and are reviewed regularly. Daily recording is completed and is up to date, although the information relating to the actual care given was sometimes incomplete. 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 are much improved from the previous inspection, in that they are more comprehensive covering aspects of nutrition for service users who are diabetic, and a continence plan where it is required. Therefore, this requirement has been withdrawn. Tudor House DS0000019044.V268557.R01.S.doc Version 5.0 Page 12 There was evidence available via documentation that the care plans are reviewed regularly on a monthly basis. However, information pertaining to risk assessments was patchy; it was either not available or, had not been reviewed for some considerable time, in one case for over a year. It was positive to note that the daily log for the actual care provided to service users was up to date in the files sampled. However, the information recorded was sometimes unclear and lacking in detail; for example one days entry was just ‘care given’. The proprietor and manager acknowledge that this is an issue that they are trying to address. For some of the care workers, English is not their first language and there is a reluctance and uncertainty to write anything down for fear of getting it wrong. The proprietors have therefore to their credit, enlisted the help of an organisation that teaches English. This is to be commented. 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. Tudor House DS0000019044.V268557.R01.S.doc Version 5.0 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14,15 The 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. On the day of inspection, there was a radio request programme, which was being enjoyed by a number of the service users in the lounge. There was also a visit from the hairdresser, who stated that there was consistency of staff and a friendly atmosphere within the home. The hairdresser provides a valuable service to the service users who spoke positively about him. Tudor House DS0000019044.V268557.R01.S.doc Version 5.0 Page 14 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. The events for Christmas included, a carol service, bell-ringers and dancers, and two different Pantomimes. The home had also recently enjoyed a firework party, a Harvest Festival service and attended an Armistice Ceremony. 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. One of the service users stated that she was very appreciative of this room, where ‘she could have some piece and quiet’. In addition, there is a further lounge on the ground floor. The home had a relaxed atmosphere whilst being quite busy with the coming and goings of friends and relatives. One relative stated that she was always welcomed warmly. 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 for lunch of chicken stew or fish fingers with freshly prepared vegetables. The food was presented well, nutritious and balanced. Service users in general spoke positively about the range and quality of the food available. One service users stated that she did not like the food on offer for lunch that day but nonetheless managed to eat most of it. Service users have a choice for breakfast, which includes a cooked breakfast; the lunchtime meal is the main meal, and for tea there is usually something lighter such as cheese on toast or chicken nuggets. There are two roast dinners per week. 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; this was confirmed by one of the service users spoken during lunch. Tudor House DS0000019044.V268557.R01.S.doc Version 5.0 Page 15 Tudor House DS0000019044.V268557.R01.S.doc Version 5.0 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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 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 generally take seriously its responsibility with regard to vulnerable adults. EVIDENCE: The home has improved in some areas regarding adult protection , there is still areas that need address. These have been ongoing requirements identified in previous inspection. The home has a complaints policy and a log of the complaints that are made. Since the last inspection, three complaints have received by the home and it appears that they have been dealt with in a timely fashion, and in accordance with the homes own policy. 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. One example was given by the relative of a service user who objected to the celebration of Halloween, and so therefore the home instead celebrated Harvest Festival, which was more appropriate to them. 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.V268557.R01.S.doc Version 5.0 Page 17 requirement dating back to July 2004, and therefore must be rectified immediately. 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. It was noted at the previous inspection that only one member of staff has attended any training regarding vulnerable adults, this did not include the manager. It is therefore positive to note, that a trainer has recently provided half a days in-house training regarding vulnerable adults, this was completed on the 11.11.05. Discussions with a member of staff who attended the course confirmed the areas covered by the training and their subsequent knowledge of the issue. Tudor House DS0000019044.V268557.R01.S.doc Version 5.0 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 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 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. 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. During a tour of the building a sample of bedrooms were viewed on each floor. Tudor House DS0000019044.V268557.R01.S.doc Version 5.0 Page 19 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 previous requirement was made regarding the availability of hot water in the en-suites facilities; the hot water was tested on all floors and found to be sufficiently hot throughout the day, therefore this requirement has been withdrawn. Tudor House DS0000019044.V268557.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27 and 30 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. 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 nurses 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 were checked at random, and indicated 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. The home also employs various other domestic staff, including cleaners, cooks and a handy man. Service users spoke warmly of the care that they received; one stated ‘they really look after you’, and another service user who had been in the home only Tudor House DS0000019044.V268557.R01.S.doc Version 5.0 Page 21 a short time said ‘I don’t want to be here, but I had to come……………..I’ve settled in and everyone’s lovely.’ The home does have a training and assessment profile for all its members of staff. It does appear however, 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. A requirement has therefore been made in this regard. Tudor House DS0000019044.V268557.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31,33,35,36. The quality of the care provided by the home staff is compromised by the uncertainty of the future of the home’s management. The lack of staff supervision effects the quality of care provide to service users. EVIDENCE: With regard to quality assurance and monitoring systems, Tudor House 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 twice a year 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. Tudor House DS0000019044.V268557.R01.S.doc Version 5.0 Page 23 The home does not use paper money, instead all transactions that the service users are liable for, namely hairdressing, newspapers, trolley and some outings are recorded by the appropriate individuals. This information is then transferred to a computer system, and then once every quarter, the service users or the appropriate responsible authority is invoiced. The computer records were checked for two of the service users and appeared to be in order. In terms of safe working practices, food items that had been taken out of the freezer were placed in the refrigerator with a use by date, which appeared to be out of date. The home must ensure that items taken out of the freezer must be dated as such. The lack of staff supervision in the home is a concern. This has been an ongoing issue over a period of time, and therefore the scoring of outcomes reflects the concern. Staff must receive supervision at least six times a year. The evidence from the files is that staff have received since the start of the year, two or sometimes one supervision. These supervisions are at least recorded. 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. Tudor House DS0000019044.V268557.R01.S.doc Version 5.0 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 X 2 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 X 10 X 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 2 3 3 3 3 3 3 3 3 STAFFING Standard No Score 27 3 28 X 29 X 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 3 X 3 1 X X Tudor House DS0000019044.V268557.R01.S.doc Version 5.0 Page 25 Are there any outstanding requirements from the last inspection? Yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 2 3 4 Standard 3 7 7 18 Regulation 14(1) 14(2)(a) 17(3)(a) 12(1)(a) Requirement Timescale for action 23/11/05 The home must ensure that only service users who fit the homes criteria are admitted to the home The home must ensure that 23/02/06 service users risk assessments are reviewed regularly The home must ensure that daily 23/02/06 records reflect the actual care given to service users The home must ensure that they 23/12/05 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 Care staff must receive at least three days paid training per year The manager must have the necessary qualifications for managing the home The home must ensure that all staff receive supervision at least six times a year Timescale of 30.9.05 not met The home must ensure that food items taken out of the freezer DS0000019044.V268557.R01.S.doc 5 6 7 30 31 36 18(1)(c) (i) &(ii) 9(2)(b)(i) 18(2) 23/02/06 23/02/06 23/11/05 8 38 12(1)(a) 23/11/05 Tudor House Version 5.0 Page 26 9 26 23(2)(d) must be dated accordingly The home must review the condition of the carpet in the staff room Timescale of 30.10.05 not met 23/01/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Tudor House DS0000019044.V268557.R01.S.doc Version 5.0 Page 27 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. Extracts may not be used or reproduced without the express permission of CSCI Tudor House DS0000019044.V268557.R01.S.doc Version 5.0 Page 28 - 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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