Inspection on 28/12/05 for Tudor House

This inspection was carried out on 28th December 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 25/08/05

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 Hall Road Kings Norton Birmingham West Midlands B30 3QN Lead Inspector Brenda O’Neill Unannounced Inspection 28th December 2005 09:45 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 DS0000042487.V269102.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 DS0000042487.V269102.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Tudor House Address 159 Monyhull Hall Road Kings Norton Birmingham West Midlands B30 3QN 0121 451 2529 0121 447 8540 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) Tudor House Limited Vacant Care Home 23 Category(ies) of Old age, not falling within any other category registration, with number (23) of places Tudor House DS0000042487.V269102.R01.S.doc Version 5.0 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. That following consultation and agreements with the CSCI the Owner has completed all of the above within twelve months. That one named person, who is diagnosed as having Dementia at the time of admission can be accommodated and cared for in this Home. 25th August 2005 2. 3. Date of last inspection 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 the refurbishment of the home was almost complete. 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. On the ground floor of the home there was a main kitchen, which had been relocated, a newly built laundry and office space. 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 DS0000042487.V269102.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was unannounced and carried out over part of a day in December 2005. It was the second of the statutory visits for the home for 2005/2206. To get a full overview of all the standards assessed this report should be read in conjunction with the report written following the inspection on August 25th 2005. During this visit a partial tour of the premises was carried out, three resident files were sampled as well as other care and health and safety records. The inspector spoke with the service manager, two members of staff and six of the twenty residents. What the service does well: The staff team at the home had remained stable which was very good for the continuity of care of the residents. Friendly relationships were evident between staff and residents. All the residents spoken with were content and very positive in their comments about the staff team. Comments included: ‘ They are very kind.’ ‘ They listen to us.’ ‘ They are friendly.’ ‘ It’s good to have people to talk to about my health.’ The former manager and the staff team had worked very hard to ensure that the ongoing building work in the home had caused as little disruption to the residents as possible. None of the residents spoken with were at all concerned about the work being undertaken. There was documented evidence that the personal care needs of the residents were being met and that health care needs were identified and followed up. The residents spoken with confirmed there were no rigid rules or routines in the home and they were free to spend their time as they chose. There were no restrictions on visitors to the home within reasonable hours or on residents going out either independently (if they were able) or with visitors. The staffing levels at the home were good ensuring there were enough staff on duty to look after the residents. The ongoing improvements in the home had provided residents with a safe and comfortable place to live. Tudor House DS0000042487.V269102.R01.S.doc Version 5.0 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 DS0000042487.V269102.R01.S.doc Version 5.0 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Tudor House DS0000042487.V269102.R01.S.doc Version 5.0 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 2 and 3. The assessment procedures in the home were good but needed to be applied consistently so that the needs of all prospective residents were known prior to admission. Residents were being issued with a statement of terms and conditions/contract at the point of admission ensuring they were aware of the terms of their stay. EVIDENCE: Three resident files were sampled for residents who had been admitted to the home recently. Two of these included comprehensive pre admission assessments that had been carried out by staff at the home which covered all the required areas. The assessments included sufficient information for staff to be able to make an informed decision as to whether they could meet the needs of the prospective residents. The third file had no assessment information included and it could not be determined how staff had decided they could meet the needs of the individual. There was evidence on site that residents were being issued with a statement of terms and conditions of residence at the point of admission to the home. Tudor House DS0000042487.V269102.R01.S.doc Version 5.0 Page 9 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8 and 9. Care plans and risk assessments needed to be completed for all residents in a timely manner so that staff knew how to meet the needs of the residents and how any identified risks were to be minimised. Improvements were needed to the medication system to ensure residents received all their medication at the correct times. EVIDENCE: Three care files were sampled. One of the files included a care plan that covered all the required areas and was adequately detailed. The care plan identified all the needs of the individual, where she required assistance, the type of assistance and to what extent she was able to care for herself. Areas covered in the care plan included, personal hygiene, mobility, communication, social activities and religious and cultural needs. All areas of the care plan were being reviewed on a monthly basis. The other two files did not include care plans and the only needs identified were those on the pre admission assessments and these did not include how staff were to meet the needs of the individuals. The two residents in question were admitted to the home in October 2005 and had had their placements reviewed with the social workers present. This had given staff ample time to assess the needs of the individuals and to draw up the care plans. Tudor House DS0000042487.V269102.R01.S.doc Version 5.0 Page 10 None of the files sampled included completed manual handling risk assessments and only one included a personal risk assessment. It was evident when reading some of the daily records that some risks had been identified for one of the residents but as there were no risk assessments it could not be determined how staff were managing these. It was also noted that that on occasions staff were not being adequately explicit when recording in daily in daily notes, for example, ‘not in the best of moods’ and ‘taking it out on’ but there was no explanation as to how staff had come to these conclusions. There was also an incidence of aggression recorded in the daily notes of one of the residents and although there was a risk assessment for aggression on the individual’s file this had not been reviewed in light of the incident. None of the files sampled included completed tissue viability or nutritional screenings. Residents were being weighed on a regular basis. Daily records did evidence that personal needs were being met and health care needs were being identified and followed up, for example, visits from the doctor and chiropodist and general creams being applied. Medication was being administered via a 28 day monitored dosage system. All medication was being acknowledged when received into the home, administered and disposed of, copies of prescriptions were being kept and any balances of medication being held at the end of the month were being carried forward to the next medication administration record (MAR). There were some homely remedies being kept but there were no running balances and therefore these could not be audited. Some of the medication that had been dispensed in boxes and bottles were audited and some discrepancies were found in the amounts of tablets that had been received into the home, what had been signed for as administered and the amounts remaining. The responsible individual needed to ensure that regular staff drug audits were undertaken before and after drug rounds to ensure staff competence. It was also noted that there was a container of eye drops that had not been dated on opening and therefore staff would not know when they had been open for 28 days and should have been discarded. There were also eye drops in the medication fridge that had not been opened but had been signed for as administered on the MAR chart. Tudor House DS0000042487.V269102.R01.S.doc Version 5.0 Page 11 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 and 13. There were no rigid rules or routines in the home and the residents appeared very content. There were no restrictions on visitors to the home in reasonable hours. EVIDENCE: Residents spoken with were very content with their lives at the home and confirmed there were no rigid rules or routines in the home. Residents were observed wandering freely around the home, some were still getting up, others were sat in the lounge chatting or watching television. One of the residents went to the local shop to get his newspaper during the course of the inspection and this was a daily event for him. All the residents spoken with had enjoyed Christmas at the home. The full extent of the activities offered to the residents was not assessed during this visit. There were no restrictions on visitors to the home during reasonable hours and visitors were seen to come and go throughout the course of the inspection. There was also evidence in daily records of relatives visiting the home and of residents going out with them. Tudor House DS0000042487.V269102.R01.S.doc Version 5.0 Page 12 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): EVIDENCE: These standards were not assessed during this visit. Any requirements made following the last inspection have been brought forward to this report. Tudor House DS0000042487.V269102.R01.S.doc Version 5.0 Page 13 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, 22, 24, 25 and 26. 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: Extensive refurbishment work had been ongoing in the home for a considerable amount of time and was nearing completion. Numerous improvements had been made to the home including: 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 of the garden. A new larger laundry had been built and had new equipment installed, the location of the office had changed. The old office and adjoining space had been made into the kitchen which was a great improvement as this location meant the kitchen had natural light and ventilation. The previous dining room had been extended and opened up to make a very large comfortable lounge that had been equipped with new Tudor House DS0000042487.V269102.R01.S.doc Version 5.0 Page 14 furnishings and curtains. The old lounge and previous kitchen had been combined and made into a spacious dining room that was well furnished and decorated. The majority of the work to be completed in the home was cosmetic, for example, decoration to the first floor corridors and carpets to the entrance hall. 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, a further four had been completed since the last inspection. It was the aim of the proprietor to have as many en-suite rooms in the home as possible. 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. Tudor House DS0000042487.V269102.R01.S.doc Version 5.0 Page 15 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. Adequate staffing levels were being maintained to meet the needs of the residents. EVIDENCE: The rotas seen evidenced that there were always three staff on duty during the waking day one of whom was a senior and two waking night staff. The home also employed cooks, domestic assistants and a maintenance operative. There had been little staff turnover since the last inspection which was very good for the continuity of care of the residents. All the residents spoken with were very positive about the staff team and there were friendly relationships evident. Tudor House DS0000042487.V269102.R01.S.doc Version 5.0 Page 16 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 and 38. The service manager and senior staff at the home were ensuring the smooth running of the home in a competent manner in the absence of a manager. The registered individual needed to ensure a manager was appointed for the home and an application for registration was forwarded to the CSCI so that residents were assured someone was accountable on a day-to-day basis. The health and safety of the residents and staff was well managed. EVIDENCE: The registered manager who had been in post since the home was taken over by the present owner had left the week before the inspection to take up another post. At the time of the inspection the service manager and the senior care assistants were overseeing the management of the home. The service manager informed the inspector that interviews had taken place for a new manager and an appointment had been made but references had not yet been received. The service manager who was overseeing the management of the home had a lot of experience of caring for older people and was a registered Tudor House DS0000042487.V269102.R01.S.doc Version 5.0 Page 17 manager of an establishment prior to her present post. She was very positive about the staff team at the home and that they were managing well however she was aware of the importance of having a manager in post as soon as possible. Health and safety at the home was well managed. The inspector was aware that staff had received training in safe working practices and the requirement made following the inspection to update fire training had been met. There was evidence on site of the regular servicing and maintenance of all equipment, with the exception of the gas 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. Tudor House DS0000042487.V269102.R01.S.doc Version 5.0 Page 18 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 X 3 2 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 2 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 X 15 X COMPLAINTS AND PROTECTION Standard No Score 16 X 17 X 18 X 3 3 X 3 X 2 3 3 STAFFING Standard No Score 27 3 28 X 29 X 30 X MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X X X X X X 2 Tudor House DS0000042487.V269102.R01.S.doc Version 5.0 Page 19 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. Standard OP3 Regulation 14(1)(a) Requirement Timescale for action 14/01/06 2. OP7 15(1) 3. OP7 13(5) 4. OP7 12(1)(a) There must be evidence that the needs of the residents have been assessed prior to their admission to the home. All residents must have care 01/02/06 plans that detail how all their needs in relation to health and welfare are to be met by staff. All residents must have manual 14/01/06 handling risk assessments that 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. (Previous time scale of 14/10/05 not met.) All residents must have personal 14/01/06 risk assessments that detail how any identified risks are to be minimised. Personal risk assessments must be regularly updated if any issues arise. Staff must ensure they are explicit when recording daily issues such as mood changes as to how this was displayed. DS0000042487.V269102.R01.S.doc 5. OP8 12(1)(a) 14/01/06 Tudor House Version 5.0 Page 20 6. 7. OP8 OP9 12(1)(a) 13(2) All residents must have tissue viability and nutritional screenings. There must be an audit trail for any homely remedies kept in the home. (Previous time scale of 01/10/05 not met.) All eye drops must be dated on opening and discarded after 28 days. The registered person must ensure that eye drops are administered as prescribed. The registered person must ensure that staff drug audits take place on a regular basis to confirm their competency. Staff must ensure they record how the residents are spending their days to evidence their social needs are being met. (Previous time scale given 01/11/05 not assessed for compliance at this visit.) The complaints procedure must be consistent in all documents and ensure that complainants are aware they can refer a complaint to the CSCI at any point. (Previous time scale of 01/11/05 not assessed for compliance at this visit.) The manager must ensure that the homes policies and procedures on adult protection comply with the multi agency guidelines (Previous time scale of 01/11/05 not assessed for compliance at this visit.) The registered person must ensure that all the furnishings detailed in the National Minimum Standards are available in bedrooms. If a resident chooses not to have all of the required furnishings this should be DS0000042487.V269102.R01.S.doc 01/02/06 14/01/06 8. OP9 13(2) 01/02/06 9. OP12 12(1)(a) 01/02/06 10. OP16 22(7)(b) 01/02/06 11. OP18 13(6) 01/02/06 12. OP24 23(2)(e) (f) 01/02/06 Tudor House Version 5.0 Page 21 13. OP31 8(1)(a)(b) 14. OP33 24(1)(a) (b) 15. OP38 23(2)(c) documented in their file. (Previous time scale of 01/12/05 partially met.) The registered person must ensure that a manager is appointed for the home and an application for registration is forwarded to the CSCI. The home must have effective quality assurance and quality monitoring systems in place, based on seeking the views of the residents. (Previous time scale of 01/12/05 not assessed for compliance at this visit.) The registered person must ensure that there is evidence on site that the gas appliances have been serviced. 31/03/06 01/12/05 14/01/06 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 DS0000042487.V269102.R01.S.doc Version 5.0 Page 22 Commission for Social Care Inspection Birmingham 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 DS0000042487.V269102.R01.S.doc Version 5.0 Page 23 - 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. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!