Inspection on 28/09/07 for Tudor House

This inspection was carried out on 28th September 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. 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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Tudor House 21/11/06

Tudor House 28/12/05

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 Jill Brown Key Unannounced Inspection 28th September 2007 08:20 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.V345499.R01.S.doc Version 5.2 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.V345499.R01.S.doc Version 5.2 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 459 3845 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 Mr Sebastian Vvube Care Home 23 Category(ies) of Old age, not falling within any other category registration, with number (23) of places Tudor House DS0000042487.V345499.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 21st November 2006 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. The home has a shared bedroom all the rest being single. A number of the bedrooms have en suite facilities and work was in progress for two further bedrooms to have an en suite during this inspection. 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 was equipped with a Parker bath. Toilets were located throughout the home. On the ground floor of the home there was a main kitchen, 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. Fees for this home are available on request there are extra charges for hairdressing, chiropody, newspapers and toiletries if these are required. Tudor House DS0000042487.V345499.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. An inspection took place on a day in September without prior notice. This was a key inspection, which looked at majority of the national minimum standards. The inspection took place over 10 hours. During the inspection 3 residents were case tracked from admission. Case tracking involves talking to the residents looking at all the records and information about them, including their medication and personal rooms. The inspector talked to or observed the care of these three residents. Relatives of these residents and a further five residents were spoken to. This information was used to make a judgement about the care given. The inspector also took into account information we had received from all sources about the home since the last inspection. Services are required to complete an Annual Quality Assurance Assessment (AQAA) on a yearly basis; information from this was used in this report. An allegation of poor care was made to a representative of the service provider this was reported to all the appropriately agencies such as social services and ourselves. An investigation took place and measures were put and continue to be put into place to ensure the best care can be given. What the service does well: The home provides good information for residents and their families before they are admitted to the home. Information is available in residents’ rooms and in the reception area. Residents have a contract of terms and conditions of their stay. Information is collected about residents’ preferred daily routines, likes and dislikes as well as their health and personal care needs before admission this information enables staff to ensure residents needs are met. Care plans are in place to meet residents needs and for the most part these are detailed enough to ensure that residents needs are met in a consistent way. The care is enhanced by a well qualified staff group. Risks to residents, such as falling and moving and handling, are assessed and risk management plans are put in place to lessen the risks identified. Residents have access to health professionals when needed, residents health concerns are monitored and their health needs are met. A comment card Tudor House DS0000042487.V345499.R01.S.doc Version 5.2 Page 6 received from a relative stated that the everyday general care of residents was done well. There is a good process and checks for the administration of medication and this means that residents get the medication they need to maintain their health. Residents talked to were happy with the service provided and we observed that residents were treated well and with respect. Residents are encouraged to make friends and spend time together and this is important for residents well being. The environment is clean and fresh. There is a good state of repair and decoration throughout the home. The service provider ensures that staff have an opportunity to gain the recognised National Vocational Qualification level 2 (NVQ2) in care. The numbers of staff that have achieved this and a NVQ3 are above the amount recommended by the standard. The home has the benefit of an experienced and qualified manager. What has improved since the last inspection? What they could do better: Whilst the majority of care plans are detailed more personal information on how the resident likes their personal care given would enhance care. Tudor House DS0000042487.V345499.R01.S.doc Version 5.2 Page 7 Care plans for medicines need to be developed to ensure that staff are aware what medication is for and any special precautions or side effects that they need to be aware of. Whilst residents are weighed routinely, and residents appeared to be of a reasonable weight changes in weight over a period of time were not always monitored. This means that residents ill health may not be spotted quickly. Whilst the previous requirements about the environment have been completed the front garden area, a number of carpets on the stairs and the corridor needed attention and a bedroom showed signs of water damage. A food risk assessment should be completed to meet the Food Safety department’s requirements. The staff training could be improved to ensure there is a greater compliance with the update training for mandatory courses to ensure that staff training remains current. These included Fire Safety, Moving and Handling and adult protection. The home had an inspection of the electrical wiring which showed some deficits, the details of the plan to rectify these was not immediately available at inspection. The home must ensure that a satisfactory certificate is supplied to us. 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. The summary of this inspection report can be made available in other formats on request. Tudor House DS0000042487.V345499.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Tudor House DS0000042487.V345499.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 2,3 &4 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Good information was available to residents and their relatives about the home when needed. Residents were protected by a contract that outlined terms and conditions of their stay and the current level of fees. Residents had their needs assessed before admission and the home ensured that they could meet these needs. EVIDENCE: The home’s statement of purpose and the recent inspection report were in the reception area. These had been signposted and visitors were informed that they were welcome to look at these. Residents had contracts and these contracts were routinely updated. Information was collected about residents needs prior to their admission. The amount of information varies some have charts rating residents’ abilities on Tudor House DS0000042487.V345499.R01.S.doc Version 5.2 Page 10 areas such as mobility, eating, health, communication, chiropody, allergies, sleeping, communication and so on. Others contain additional more detailed information about how the resident difficulties affect them. For example for one resident that has dementia it is recorded hat the resident ‘is able to communicate when they are in pain,’ ‘ can become anxious.’ There was enough information about key areas of residents needs to ensure that appropriate care plans could be put in place. Personal information collected was good such as ‘likes cigarettes, the odd sherry and goes to a day centre.’ The manager informed the resident, or their relatives after the assessment about whether the service could meet the resident’s needs. The residents of the home were currently from a white UK or white Irish background the staff group has staff from these backgrounds and other ethnic and cultural backgrounds. There were 3 male staff and this means for some of the time male residents could opt for a male carer. Residents have their religious beliefs recorded and asked if they wish to continue to practise. A church service is available once a week. Tudor House DS0000042487.V345499.R01.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9 & 10 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Care plans were in place and for the most part detailed enough to ensure that good care was given to residents. Residents’ health and personal hygiene needs were met. There was a robust medication administration process in place that ensured that residents received the medication they needed to maintain their health. Residents were treated kindly and with respect. EVIDENCE: Care plans were well ordered and fully detailed in most cases. Care plans covered set areas of care needed such as mobility, personal hygiene, eating, communication, oral care, continence, social activities, religion and culture, emotional and night care. There were especially good night care and oral care plans that were detailed to show the individual arrangements needed for the residents’ care. Personal hygiene plans were not always as detailed however Tudor House DS0000042487.V345499.R01.S.doc Version 5.2 Page 12 residents clearly had their personal hygiene needs met. A number of residents spoken to said that they had a very good wash down that morning. Relatives spoken to were happy with how their residents personal hygiene needs were met. Specialised plans and monitoring were in place for health conditions such as seizures. There were risk assessments in place for moving and handling, nutrition, skin care and falls where necessary. Residents were routinely weighed, where possible, however a process of reviewing changes in weight needed to devised to ensure that these changes could be responded to. One relative however spoke about how their relative had put on weight since being admitted. Residents’ records showed that residents had access to health services of GPs, District Nurses, chiropody and dental services if needed. The majority of medication came into the home in a monitored dosage system. This system showed the name of the resident’s individual medicine and had the amount needed of that medicine in a separate blister pack for the time and day it needed to be taken. The medications in this system sampled were correct with the record. Prescriptions were checked from the doctors against the Medication Administration Record (MAR) for any errors. Photocopies of prescriptions were taken before being sent to the chemist and medication dispensed was checked. The system for medication not in this system was generally good with very few errors. The medication system could be enhanced by a care plan for medication that shows what the medication is prescribed for and any special arrangements that need to be made. A number of medications prescribed have information such as keep the resident ‘out of sunlight’ and ‘do not take any other indigestion remedies.’ There is only one shared bedroom and the residents occupying this room have known each other for a long time, screening is available if needed. Residents are able to have a key to their bedroom; an assessment is undertaken if it is felt the resident cannot use a key. Good relationships between residents and staff were seen with staff taking time to approach residents, gain their attention before trying to talk to them. Residents were heard to say such things as ‘you are my sunshine.’ Tudor House DS0000042487.V345499.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14, & 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The arrangements for activities were good and this means that residents were involved in the home. Residents could decide where and when they had their care and relatives were made welcome and this enhances residents’ lives. Meals could be improved to offer more choice to residents. EVIDENCE: Records of activities residents were involved with were not well maintained and did not reflect was seen on the day of inspection. Residents had the option of and some were involved in playing floor basketball, connect four, drawing talking, to staff individually, reading the newspaper as well as watching the television or radio. A number of residents went out either with relatives or to day centres. Residents spoken to thought they had enough to keep them happy. Arrangements were being made for the residents to go out for a Christmas event and for entertainers to visit the home. A church service is held Tudor House DS0000042487.V345499.R01.S.doc Version 5.2 Page 14 at the home one day a week, there is a visit from people once a month who provide music and once a month there is a visit from a person that provides an exercise session. Residents were encouraged to maintain relationships and a number of residents chose to spend time together throughout the day. Relatives of the residents’ case tracked were happy with the service provided by the home. They thought that they were informed about any changes in their relative’s health and wellbeing and that they were made welcome in the home. Residents spoken to thought that they could get up when they wanted and go to bed when they wanted. The majority of residents came down for breakfast at a set time however a few residents had their meals, care and entertainment in their bedrooms. The menu supplied to us showed that residents had a choice of meals during the day on most days. On the day of the inspection residents were given cereals and toast for breakfast ad arrangements were made to cover the cook who was not available at short notice. A resident said ‘They offer a meal if we don’t like it there is always something else.’ A resident said that they wished for more alternatives at teatime other than sandwiches. There was a record kept of the choices that residents made of food. Tudor House DS0000042487.V345499.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 16 &18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Systems are in place to respond to complaints and concerns when they arise. The management are aware of their responsibilities and work with other agencies to ensure that concerns are resolved and this protects residents. EVIDENCE: There was an appropriate complaint procedure and this was seen at previous inspections. The Annual Quality Assurance Assessment (AQAA) stated that the home has the other policies and procedures such whistle blowing to ensure that the home responds well to concerns raised. We have received no complaints about this service since the last inspection. There was a record in the home of one complaint from a resident following the introduction of the smoking legislation and this was dealt with appropriately by the home. A comment book was maintained in the reception area but this had no comments documented. The manager was aware that residents find it difficult or may not have the ability to raise concerns and was keen to look at other ways to gain views from residents. The last residents’ meeting was in February. Relatives were surveyed about their views of the home in April. The home has copies of the Multi Agency guidelines available. There was an adult protection concern raised at the home. The management acted appropriately by contacting us and the social services about this. The concern was investigated and shortfalls were identified. The process of moving and handling of residents were looked at for improvement. At the time of the Tudor House DS0000042487.V345499.R01.S.doc Version 5.2 Page 16 inspection planned adult protection training had not taken place as the management had planned and an immediate requirement was sent about this. This has been rearranged. A number of staff had moving and handling training session, further sessions had been arranged for the remaining staff. Residents have an inventory of their belongings on admission to the home. Tudor House DS0000042487.V345499.R01.S.doc Version 5.2 Page 17 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. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home environment was generally good; improvements to the environment were continuing to benefit the residents. EVIDENCE: A tour of a number of areas in the building was undertaken and the home was found to be generally in a good order and decorative repair. There was a good response to previous requirements made. the service provider has a maintenance operative that attends to the maintenance needs of the building. The access to the building had been improved with the creation of permanent wheelchair access at the front of the building. The back garden had been improved and made a good space for residents to enjoy. Some carpets on the stairs and in reception needed to be renewed however we were informed that this was planned in the Annual Quality Assurance Assessment. Tudor House DS0000042487.V345499.R01.S.doc Version 5.2 Page 18 The home had appropriate number of assisted bathing facilities for the number residents. All of the bedrooms seen were decorated well and were light and airy. Residents appeared to have adequate levels of furniture. In a few rooms decisions had been made to limit furniture for the safety of particular residents and this is acceptable. Mattresses and bedding were looked at in a number of bedrooms and these were of good quality and met the residents’ needs. One bedroom appeared to have some evidence of damp and this should be investigated and put right. The temperatures of hot water outlets tried were restricted to a safe temperature and radiators seen were covered; this means that residents should not get scalded. A visit was untaken by the Food safety department few requirements were made and the majority of these were acted upon however a detailed food risk assessment was still required. The home was fresh and clean. There were adequate laundry facilities to meet the needs of the residents. Tudor House DS0000042487.V345499.R01.S.doc Version 5.2 Page 19 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. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29 &30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The staffing levels were sufficient to ensure that resident’s care needs were attended to. Staff were trained to a high level however update training showed some gaps that may mean that staff are not aware of new practices. The recruitment of staff was robust and this protects residents. EVIDENCE: Staffing levels provided are a senior and 2 care staff on duty from 7am until 9pm and 2 night carers on duty between 9pm and 7am. They are supported by domestic cooking and management hours. The residents seem to be receiving good care, relatives feel supported and this suggests the staffing levels are enough to meet the needs of the residents. The home has a high level of staff that have completed a National Vocational Qualification Level 2 (NVQ2) in care with 71 of staff achieving this qualification and a further 23 enrolled on this course. A further 50 of staff that have achieved an NVQ 2 have further achieved an NVQ3. This means that staff have the knowledge to care for older people well. Tudor House DS0000042487.V345499.R01.S.doc Version 5.2 Page 20 Recruitment practices were good with staff having to complete a process of application form, interview, references and Criminal Record Bureau and Protection of Vulnerable Adult checks before being employed. The manager has started using the Common Induction Standards recommended by the Skills for Care Organisation and this is an improvement since the last inspection and ensures that new staff have good consistent information and training about the work that they are to perform. References were received but not all were validated, a validation process ensures that references are genuine. The chart of staff’s mandatory training and the poor attendance at recent courses suggest that staff may not be update in all practices. A number have to complete moving and handling, adult protection and fire safety courses and management is needed to ensure that staff attend these courses. Tudor House DS0000042487.V345499.R01.S.doc Version 5.2 Page 21 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. JUDGEMENT – we looked at outcomes for the following standard(s): 31,33,35 &38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is managed appropriately and residents’ interests were safeguarded by the homes arrangements for health and safety and managing residents’ money. EVIDENCE: The manager is Sebastian Vvube he has the managed the home for over a year, he has the experience and the qualifications to manage the home. Progress has been made on previous requirements made by us. There have been attempts to improve the communication with residents and relatives with a production of a newsletter. There was a survey of relatives undertaken in April and the completed questionnaires were available for Tudor House DS0000042487.V345499.R01.S.doc Version 5.2 Page 22 inspection. There was a high level of satisfaction demonstrated in these returns. The AQAA showed that the manager was aware of the improvements needed in the service over the next 12 months. There has not been a residents meeting since February, different ways of gaining residents views should be explored to help the quality assurance process. The home has started to gain views of relatives and residents and need to produce an annual development plan that can be shared with them. The home encourages residents to manage their own money where possible. Residents that are unable usually have relatives that assist. The home invoices the relative for services such as hairdressing where this is required. The inspector sampled some money held for residents and this matched the records. The names on the hairdressing record were seen to match residents that had their hair done on the day of the inspection. Checks were undertaken on the health and safety aspects of the building such as checks on fire, gas and electrical safety. For the most part these checks were in place. An inspection of the electrical installation found that there was work to do we were not told of the plans in regard to this work and an urgent letter was sent. The service provider has responded and this work is now being undertaken. Tudor House DS0000042487.V345499.R01.S.doc Version 5.2 Page 23 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 X 3 3 X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 4 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 2 Tudor House DS0000042487.V345499.R01.S.doc Version 5.2 Page 24 No 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 OP7 Regulation 15(1) 13(2) Requirement There must be a care plan in place for residents’ medication that advises what medication is for and of any special precautions that may need to be taken. This is to ensure that changes in residents’ health that may be require a change in medication can be identified and their health maintained. A system for identifying residents weight gains and loss and response to them must be put in place. Timescale for action 31/12/07 2 OP8 12(1)(a) 31/12/07 3 4 OP19 OP30 23(2)(b) 23(4)(d) 5 OP30 13(4)(c) This is to ensure that signs of a resident’s ill health can be acted upon quickly. An identified bedroom must have 31/12/07 an area of damp investigated and décor put right. All staff must have fire safety 31/12/07 training. To ensure they are aware of how to act in case of fire in the building All staff must have moving and 30/11/07 DS0000042487.V345499.R01.S.doc Version 5.2 Page 25 Tudor House 6 OP30 13(6) 7 OP38 23(2)(b) handling training. To ensure the safety of residents during transfers from place to place. All staff must have adult protection training. To ensue that staff are aware of their individual responsibilities in recognising and reporting abuse. Copies of a satisfactory NICEIC periodic inspection of electrical installation certificates must be sent to us by. 15/12/07 31/12/07 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 2 Refer to Standard OP7 OP12 Good Practice Recommendations Details of how personal hygiene needs are to be met are in Must be in enough detail to inform new members of staff how to provide care. Good records must be kept of the activities individual residents have been involved in to ensure that all residents have the benefit of activities appropriate to them. The front garden must be kept in good state of repair. Carpets on the stairs and reception area should be scheduled for replacement. The food safety risk assessment must be completed to ensure that good food practices are maintained at all time. References obtained during the recruitment of staff should be validated to ensure that they are genuine and evidence retained. 3 4 5 6 OP19 OP19 OP26 OP29 Tudor House DS0000042487.V345499.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Birmingham Office 1st Floor Ladywood House 45-56 Stephenson Street Birmingham B2 4UZ National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 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.V345499.R01.S.doc Version 5.2 Page 27 - 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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