Inspection on 25/08/05 for Tudor House

This inspection was carried out on 25th August 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 28/09/07

Tudor House 21/11/06

Tudor House 28/12/05

Tudor House 18/02/05

Tudor House 07/09/04

Tudor House 02/03/04

Similar services:

Maple Lodge

Heathlands

Aston Court Nursing Home

Breme

Ravenhurst

Bank House

Inspirations

Ashcroft Hollow Nursing Home

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

CARE HOMES FOR OLDER PEOPLE Tudor House 159 Monyhull Road Kings Norton Birmingham B30 3QN Lead Inspector Brenda O Neill Announced 25 August 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 E54_S42487_TudorHse_V238704_250805 - Stage 2.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Tudor House Address 159 Monyhull Road Kings Norton Birmingham B30 7QN 0121 451 2529 0121 447 8540 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) Tudor House Limited Honor Morris Care Home 23 Category(ies) of Care Home registration, with number of places Tudor House E54_S42487_TudorHse_V238704_250805 - Stage 2.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: 1. That within three months of registration or sooner the owner submits a proposal with plans as to how he intends to improve the office accommodation and the dining facilities. 2. That following consultation and agreements with the CSCI the Owner has completed all of the above within twelve months. 3. That one named person, who is diagnosed as having Dementia at the time of admission can be accommodated and cared for in this Home. Date of last inspection February 18th 2005 Brief Description of the Service: Tudor House is located in a popular residential suburb on the South side of Birmingham and enjoys easy access to public bus routes for local areas and the city centre. There are local shops and community facilities within walking distance of the home. The home was originally two properties, which have been converted to offer residential care for 23 older people. Since the last inspection there had been further improvements made to the environment and others were planned. Due to the ongoing improvements service users were not using some areas of the home. At the time of the inspection the home had only one lounge in use and a dining room however there were only 15 service users in residence. Only one double bedroom remained and several bedrooms had been changed to offer an en-suite facility. There were three bathrooms, two of which had been converted to a walk in shower giving easy access for those service users with mobility difficulties and those who required staff assistance. The other bathroom, when complete, will be equipped with a Parker bath. Toilets were located throughout the home. There was also a main kitchen, small laundry and office located on the ground floor. All floors were served by a shaft lift. There was parking available at the front of the home and there was a wellmaintained garden to the rear. Tudor House E54_S42487_TudorHse_V238704_250805 - Stage 2.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The announced inspection took place over one day and was the first of the statutory inspections for the home for 2005/2006. During the visit a tour of the premises was carried out, three resident and three staff files were sampled as well as other care and health and safety records and some policies and procedures. The inspector spoke with the manager, the proprietor, three of the other staff on duty and seven of the fifteen residents. What the service does well: The home had a very relaxed and friendly atmosphere and there were evident friendly relationships between the staff group and the residents. Comments received about the staff group from the residents and from relatives on comment cards included: ‘They’re marvellous, can’t praise them enough.’ ‘Staff are wonderful.’ ‘Good level of service.’ ‘All credit must go to the staff, a brilliant team.’ ‘We have a good relationship with staff who are very keen to oblige and help.’ There was a lot of ongoing building work in the home and the manager and the staff team had worked very hard to ensure that the disruption to the residents had been as little as possible. None of the residents spoken with were at all concerned about the works being undertaken in the building. The assessments, care plans and risk assessments in the home were good and contained a lot of detail about how the residents wanted to be cared for and what they could do for themselves. There were plans in place to minimise any identified risks. It was evident that the staff knew the residents well and were aware of their likes and dislikes. The manager continued to be very pro-active in ensuring that the health care needs of residents were met. She was very insistent with health care professionals to ensure any illnesses were monitored appropriately and that any additional needs were addressed. All the residents spoken with were happy with the meals at the home stating the food was ‘good’ or ‘very good’. Residents were able to eat in their bedrooms or the lounge instead of the dining room if they wished. There were a variety of activities on offer in the home and the residents confirmed they could spend their time as they chose. Tudor House E54_S42487_TudorHse_V238704_250805 - Stage 2.doc Version 1.40 Page 6 The staffing levels at the home were good ensuring there were enough staff on duty to look after the residents. The home was well managed and the manager was careful when employing staff to ensure all the right checks were carried out before employing anyone. Health and safety of staff and residents were very high priority and extremely well managed. What has improved since the last inspection? What they could do better: The manager needed to ensure that residents are issued with contracts/terms and conditions of residence at the point of admission to the home so that they are aware of the terms of their stay. The home needed to have a formal quality assurance system for monitoring the quality of the service they offered and this needed to be based on seeking the views of the residents. Staff needed to ensure they recorded how the residents were spending their days to evidence their social needs were being met. The complaints procedure needed to be amended and be consistent in all the documents throughout the home to ensure the residents were aware they could refer a complaint to the CSCI at any time. The manager needed to ensure that staff received updated fire training to ensure they were clear about the procedures to follow in the event of a fire. Tudor House E54_S42487_TudorHse_V238704_250805 - Stage 2.doc Version 1.40 Page 7 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 E54_S42487_TudorHse_V238704_250805 - Stage 0.doc Version 1.40 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 Standards Statutory Requirements Identified During the Inspection Tudor House E54_S42487_TudorHse_V238704_250805 - Stage 0.doc Version 1.40 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 standard(s) 2, 3, 4 and 5. The assessment procedures in the home were good ensuring the needs of the residents were known and could be met by the staff. Residents were able to visit the home prior to admission to assess the quality, facilities and suitability of the home. Residents needed to have a signed contract/statement of terms and conditions with the home at the point of admission to ensure they were aware of the terms of their stay. EVIDENCE: The residents’ files sampled evidenced that where applicable social workers had undertaken assessments and drawn up the initial care plans for the residents. In addition the home’s manager was carrying out her own assessments both prior to admission and on the pre-admission visits to the home to ensure that prospective residents met the criteria for the home and that the home could meet their needs. Once admitted to the home further assessments were undertaken and these informed the first care plan that was drawn up. The service user guide included a copy of the terms and conditions of residence at the home and although these included all the necessary details they were not being completed and signed at the point of admission. The Tudor House E54_S42487_TudorHse_V238704_250805 - Stage 0.doc Version 1.40 Page 10 manager needed to ensure these were discussed and completed so that the residents were aware of and agreed with the contents. There was evidence on the files of prospective residents visiting the home prior to admission and the residents spoken with also verified this. The practices observed throughout the inspection evidenced that staff were able to meet the needs of the residents, for example, interactions with residents with dementia and appropriate terms of address. There was evidence on daily records of personal care needs being met. There was good documentation that the assessed medical needs of the residents were met including specialist services, for example, referrals to psychiatrists. There were aids and adaptations throughout the home to assist those residents with mobility difficulties. The manager was also able to recognise when the home could no longer meet the needs of residents and called on social workers for reassessments when necessary. The home had a variation to their registration to care for one resident with dementia and this person was observed to be very settled and content in the home and his needs were being met. Tudor House E54_S42487_TudorHse_V238704_250805 - Stage 0.doc Version 1.40 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 standard(s) 7, 8, 9, and 10. The care planning system in the home was good ensuring staff knew the individual needs of the residents and how they were to be met. Some minor additional details were needed to ensure staff knew the types of assistance needed. There were comprehensive risk assessments for residents that included strategies for minimising any risks. Health care needs were being identified and followed up and the systems for administration of medication were good ensuring resident’s medication needs were being met. EVIDENCE: Three residents’ files were sampled and generally the care plans and risk assessments were very detailed. One of those seen was for a very recent admission and although there was not a full care plan as the assessment was on going there was a very good overview of the residents needs and how these were to be met for staff. The other two care plans were well detailed and included a nocturnal needs assessment, plans for personal hygiene, mobility, communication, social activities and religious and cultural needs. Some minor amendments were needed to clarify what prompting and guidance and full assistance meant. There was documented evidence that the residents had been consulted about their care plans and that they were being reviewed monthly. Tudor House E54_S42487_TudorHse_V238704_250805 - Stage 0.doc Version 1.40 Page 12 There were manual handling and personal risk assessments on the files sampled. Some of these were very well detailed, for example, for the use of a kettle and an iron which were being continually reviewed to ensure the resident was safe. The manual handling risk assessments needed a little more detail, for example, where the use of a hoist had been identified the sling size needed to be included and where no equipment was identified to be used when moving from the floor to a chair how this was to be done needed to be detailed. The manager continued to be very pro-active in ensuring that the health care needs of residents were met. She was very insistent with health care professionals to ensure any illnesses were monitored appropriately and that any additional needs were addressed. There was evidence on resident’s records of input from G.P.s, district nurses, opticians, chiropodists and psychiatrists where necessary. All service users had had tissue viability and nutritional screenings undertaken and where a risk had been identified actions to minimise the risk had been documented. Pressure relieving equipment was being was being obtained as necessary. There was also evidence of continence assessments being undertaken by the district nurse and the necessary aids being obtained. All service users were being weighed regularly and any weight loss or gain was being followed up. Good systems had been installed in the home for the management of medication. All medication was being acknowledged when received into the home, administered and disposed of. The manager was undertaking regular staff drug audits to ensure their competence. There were only two minor issues raised in relation to ensuring there was an audit trail for any homely remedies being used and to ensure that any remaining balances were carried forward to the next MAR (medication administration record) chart. No issues were raised with the inspector in relation to the privacy and dignity of the residents. There were evident friendly but professional relationships between staff and residents, appropriate terms of address were used and staff were seen to knock on residents’ doors before entering their rooms. There was one double bedroom and this had appropriate screening. All bedroom doors had been fitted with appropriate locks and residents were able to have keys if they wished. As the bedroom furniture was being replaced a lockable facility was being included. For all rooms that did not have this residents were asked if they wanted a lockable facility and if so one was provided. Tudor House E54_S42487_TudorHse_V238704_250805 - Stage 0.doc Version 1.40 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 standard(s) 12, 14 and 15. There were no rigid rules or routines in the home and activities were available to offer stimulation to residents. Documentation needed to detail the activities residents were taking part in to evidence their social needs were being met. The meals in the home were good with choices available for residents. EVIDENCE: All the residents seen and spoken with were very content and confirmed that they could spend their time as they chose. Residents were seen to wander freely around the home, spend time quietly in their rooms, reading or chatting with each other or staff. Two residents were attending a day centre on the day of the inspection. There were twice daily visits to the local shops for those residents wishing to go. The inspector was informed that activities such as skittles, darts, cards, activity plus and board games took place. Staff had also started to do scrap books with the residents about their lives. Only some of the activities were being documented by staff. All activities offered to the residents and how residents were spending their days needed to be documented to evidence their social needs were being met. There were details on the care plans and assessments sampled of residents’ likes, dislikes and preferences, where they were to be offered choices and to what extent they were able to care for themselves. Residents made ongoing choices about what to wear, what to eat, when to get up and go to bed and how they spent their time. One of the residents continued to manage all his Tudor House E54_S42487_TudorHse_V238704_250805 - Stage 0.doc Version 1.40 Page 14 financial affairs and several others managed some of their own finances. Residents were encouraged to personalise their bedrooms to their choosing and personal possessions were observed in all the bedrooms. One of the most recent residents admitted to the home told the inspector that the manager had been and fetched the personal possessions he wanted from his former home. The menus seen were varied and nutritious and choices were available for the residents at each meal. The inspector joined the residents for lunch and the food was well cooked and presented. Staff were available to assist the residents where necessary. Some of the residents were seen to have adapted cutlery and crockery to assist them maintain their independence at meal times. It was evident staff knew the likes and dislikes of the residents and the preferred portion sizes by observing what was being served. All the residents spoken with were happy with the meals at the home stating the food was ‘good’ or ‘very good’. Residents were able to eat in their bedrooms or the lounge if they wished. Tudor House E54_S42487_TudorHse_V238704_250805 - Stage 0.doc Version 1.40 Page 15 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 residents were issued with a complaints procedure. The manager needed to ensure they were aware they could refer complaint to the CSCI at any point. The policies and procedures on site and the training staff received ensured staff were aware of the importance of protecting the residents from abuse. EVIDENCE: The manager stated the home had not received any complaints and none had been lodged with the CSCI. There was a complaints procedure and all residents received a copy of this in the service user guide and these were seen in residents’ bedrooms. The complaints procedure had been amended as required in the statement of purpose but not elsewhere. The manager needed to ensure that the procedure was consistent and informed complainants that they could refer a complaint to the CSCI at any point. Residents spoken with stated they would have no hesitation in approaching the manager with any concerns and were confident they would be resolved. There was also a ‘grumbles book’ in the entrance hall of the home for residents, visitors, or staff to complete on behalf of residents for any every day grumbles. There were policies and procedures on site for physical intervention and adult protection. The manager needed to ensure that the adult protection procedures were in line with the multi agency guidelines for adult protection to ensure the correct procedures were followed. Several of the staff had received training in adult protection issues and this was also covered during induction training for new staff. Tudor House E54_S42487_TudorHse_V238704_250805 - Stage 0.doc Version 1.40 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, 24 and 25. The home was safe, accessible, comfortable and well maintained. The refurbishment of the home is ongoing and when complete will offer residents a very high standard of accommodation throughout. EVIDENCE: There was extensive refurbishment work being undertaken on the home at the time of the inspection and this had been ongoing for some time. Several improvements had already been made and many more were in process. Several of the bedrooms had been refurbished and had en-suite toilets and wash hand basins incorporated as well as new furniture, bedding, curtains and carpets. The two steep internal ramps had been addressed making them much easier for staff and residents to negotiate and a ramp had been installed in the rear garden so the residents could access all the garden. A new laundry had been built and was nearing completion, the location of the office had changed. The old office and adjoining space was in the process of being made into the kitchen. The previous dining room had been extended and opened up to make a very large lounge and was almost complete with carpets and furnishings on order. Tudor House E54_S42487_TudorHse_V238704_250805 - Stage 0.doc Version 1.40 Page 17 There were two assisted shower rooms and one bathroom at the home. At the time of the inspection the bathroom was not being used as it was waiting to have a parker bath fitted. There were adequate numbers of toilets throughout the home and a further assisted toilet had been installed close to the new lounge area. There were aids and adaptations throughout the home that appeared to meet the needs of the residents including ramps, shaft lift, hand and grab rails and an emergency call system. Bedrooms varied in size and most had been refurbished, four were in the final stages and awaiting carpets and furnishings before they were occupied. When all are completed all but three of the rooms in the home will offer en-suite facilities. Some of the bedrooms did not have all of the required furniture, for example, two chairs. Bedrooms needed to be audited against the requirements of the National Minimum Standards and furniture provided as necessary. If a resident chooses not to have all the required furniture then this must be documented. The garden was well maintained and had furniture for the residents use. Ramps had been installed to give easy access for the residents and raised flowerbeds had been incorporated so that residents could assist in the garden if they wished. The home was found to be clean, hygienic and odour free. There were infection control procedures on site and staff had undertaken infection control training. There was an appropriate system for the disposal of clinical waste and protective clothing was available for staff when needed. The laundry was appropriately located and equipped however it was very small. At the time of the inspection a new laundry room was almost complete. The kitchen was not inspected during this visit however there had been a recent visit by the environmental health officer and the report stated ‘very good practices in place’. The requirements made by the fire officer had been met or negotiated with them until the completion of all the work in the home. Tudor House E54_S42487_TudorHse_V238704_250805 - Stage 0.doc Version 1.40 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, 28, 29 and 30. Adequate staffing levels were being maintained by a trained staff group that could meet the needs of the residents. There were robust recruitment and selection procedures at the home ensuring the protection of service users. EVIDENCE: Staffing levels were being maintained at a minimum of two care assistants plus a senior care throughout the waking day and two waking night staff with the manager’s hours as supernumerary. The home also employed cooks, domestic assistants, a maintenance operative and general helper. These levels were adequate for the needs of the current resident group. The staff team had been much more stable since the last inspection which was good for the continuity of care of the residents. Comments received about the staff group from the residents and from relatives on comment cards included: ‘They’re marvellous, can’t praise them enough.’ ‘ Staff are wonderful.’ ‘Good level of service.’ ‘All credit must go to the staff, a brilliant team.’ ‘We have a good relationship with staff who are very keen to oblige and help.’ The files for the three most recently employed staff were sampled. All the required documentation was included in the files and all the required checks had been carried out evidencing robust recruitment procedures. Tudor House E54_S42487_TudorHse_V238704_250805 - Stage 0.doc Version 1.40 Page 19 There was documented evidence of induction training being carried out with new employees. There was an induction checklist which was worked through during the first few days of employment and then further training was organised. The manager had been involved in compiling an induction programme with an outside agency (BCDA) that covered all the topics required by the learning skills council and was piloting it at the home with the new staff. Other training that had taken place included, protection of vulnerable adults, infection control, medication management, diabetes care and health and safety. Over 50 of care staff had completed their NVQ level 2 or above and others were undertaking this. Tudor House E54_S42487_TudorHse_V238704_250805 - Stage 0.doc Version 1.40 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, 32, 33, 35, 36 and 38. The manager ensured the smooth running of the home in a competent manner. The health and safety of the residents and staff was very well managed. The home needed to formalise their systems for monitoring the quality in the home to ensure the quality of care being provided is in keeping with the aims and objectives of the home. EVIDENCE: The manager is a registered general nurse and had specialised in elderly care, she also had experience as a recruitment manager and a home care coordinator. She had completed her Registered Manager’s Award. She demonstrated throughout the inspection her knowledge of the needs of the residents in her care and the running of a care home. She was very keen to ensure the staff team had all the skills and knowledge necessary to fulfil their roles and to this end was very proactive in accessing training for staff and herself. There were clear lines of accountability in the home and it was evident she was thought very highly of by both staff and service users. Tudor House E54_S42487_TudorHse_V238704_250805 - Stage 0.doc Version 1.40 Page 21 The atmosphere in the home was very friendly and it was clear there were very good relationships between the manager, staff, residents and visitors to the home. Residents expressed the view that they would have no hesitation in approaching the manager with any issues that may arise. There was no formal quality assurance system in the home and the manager was aware of the requirement for this. There were ways of keeping the residents involved in the home and seeking their views and these included a recently developed monthly newsletter which kept residents up to date with the building work in the home, staffing, forthcoming events and activities. This had been developed as the residents had commented they were not keen on meetings. There were also questionnaires for residents and relatives to get their views on the home. The manager was only holding money in safe keeping for one resident at her request and a record of this was being kept. For those residents who were unable to handle their own finances the proprietor would purchase any items the residents required and then invoiced the appropriate person. There was documented evidence of a staff supervision and appraisal system and it appeared this would meet the required level of six sessions per year. Health and safety at the home were very well managed. Staff had received training in safe working practices, with the exception of fire training which was out of date, there were infection control procedures on site and appropriate systems in place for the disposal of clinical waste. There was evidence on site of the regular servicing and maintenance of all equipment and all the in-house checks on the fire system were up to date. There were numerous risk assessments in place for the premises and an outside agency had completed the fire risk assessment. The manager was very proactive with the risk assessments in view of the ongoing building work and was constantly reviewing them. Accident and incident recording and reporting were appropriate. Tudor House E54_S42487_TudorHse_V238704_250805 - Stage 0.doc Version 1.40 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 x 2 3 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 4 9 2 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 x 14 3 15 3 COMPLAINTS AND PROTECTION 3 3 3 3 x 2 3 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 2 x 2 3 3 2 x 3 3 x 2 Tudor House E54_S42487_TudorHse_V238704_250805 - Stage 0.doc Version 1.40 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 2 Regulation 5(1)(b)(c) Requirement All residents must be issued with a contract/statement of terms and conditions of residence at the point of admission to the home. Care plans must include detail of what assistance is needed by the residents. Manual handling risk assessments must include details of how the residents are to be moved from the floor if no equipment is to be used. Where the use of a hoist is identified the sling size must be detailed. There must be an audit trail for any homely remedies kept in the home. Any balances of medication held at the end of the month must be carried forward to the next MAR chart. (Previous time scale of 01/03/05 not met.) Staff must ensure they record how the residents are spending their days to evidence their social needs are being met. (Previous time scale of 01/04/05 not met.) The complaints procedure must be consistent in all documents Timescale for action 14/10/05 2. 3. 7 7 15(1) 13(5) 01/11/05 14/10/05 4. 5. 9 9 13(2) 13(2) 01/10/05 01/10/05 6. 12 12(1)(a) 01/11/05 7. 16 22(7)(b) 01/11/05 Page 24 Tudor House E54_S42487_TudorHse_V238704_250805 - Stage 0.doc Version 1.40 8. 18 13(6) 9. 24 23(2)(e) (f) 10. 33 24(1)(a) (b) 11. 38 23(4)(d) and ensure that complainants are aware they can refer a complaint to the CSCI at any point. (Previous time scale of 01/04/05 not met.) The manager must ensure that the homes policies and procedures on adult protection comply with the multi agency guidelines (Previous time scale of 01/04/05 not met.) The registered person must ensure that all the furnishings detailed in the National Minmum Standards are available in bedrooms. If a resident chooses not to have all of the required furnishings this should be documented in their file.(Previous time scale of 01/04/05 not met.) The home must have effective quality assurance and quality monitoring systems in place, based on seeking the views of the residents. Fire training for staff must be updated. 01/11/05 01/12/05 01/12/05 01/10/05 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 E54_S42487_TudorHse_V238704_250805 - Stage 0.doc Version 1.40 Page 25 Commission for Social Care Inspection Birmingham and Solihull Local Office 1st Floor, Ladywood House 45/46 Stephenson Street Birmingham, B2 4UZ 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 E54_S42487_TudorHse_V238704_250805 - Stage 0.doc Version 1.40 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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