Inspection on 30/09/05 for Tudor House

This inspection was carried out on 30th September 2005.

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 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 26/07/06

Tudor House 12/12/05

Tudor House 10/12/04

Tudor House 06/08/04

Similar services:

1 Marten Road

Daubeney House

Three Gables

Aldwick House

49 Glendale

The Springs Community

Crossways Community

Belle Vue Country House

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

CARE HOMES FOR OLDER PEOPLE Tudor House 79 Victoria Drive Bognor Regis West Sussex PO21 2TB Lead Inspector Jo Hartley Announced 30 September 2005, 09:00 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 H60-H11 S14807 Tudor House V266686 300905 Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Tudor House Address 79 Victoria Drive, Bognor Regis, West Sussex, PO21 2TB 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) 01243 823406 Mr Marimuthu Subramaniam Mrs Brenda Swee Chin Subramaniam Mrs Brenda Swee Chin Subramaniam Care Home (CRH) only )PC) 24 Category(ies) of Dementia - over 65 years of age (DE(E)), (24) registration, with number Mental Disorder, excluding learning disability or of places dementia - over 65 yers of age (MD(E)), (24) Tudor House H60-H11 S14807 Tudor House V266686 300905 Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 10 December 2004 Brief Description of the Service: Tudor House is a care home providing personal care and accommodation for twenty-four older people over the age of sixty-five who have dementia. It is privately owned by Mr & Mrs Subramaniam and Mrs Brenda Subramaniam is the registered manager. The home is situated in a residential area of Bognor Regis, West Sussex and is a short distance from the town. The property is an extended detached house with accommodation arranged on two floors both of which are served by a passenger lift. The home has a combination of single and double rooms with seven of the single bedrooms having en-suite facilities. There is an enclosed rear garden and large front garden both of which are accessible to service users and very well kept. Tudor House H60-H11 S14807 Tudor House V266686 300905 Stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The site visit of this announced inspection was carried out over a period of four and a half hours. Prior to the site visit the inspector received, and noted the content of the Pre-Inspection Questionnaire, and twenty-seven comment cards: eighteen from relatives/visitors and nine from service users. The inspector also read information held on the service file since the last inspection in December 2004, and read the previous two inspection reports, the Service User Guide and the Statement of Purpose. During the inspection the inspector spoke to four service users and two members of staff. The inspector undertook a tour of the premises and looked at three care plans and three staff files. Various record books, policies and procedures were also examined. What the service does well: What has improved since the last inspection? What they could do better: The manager needs to ensure that two written references are obtained for prospective employees before employment commences. Since the last inspection some radiators have been covered. This work needs to continue to include all radiators. Tudor House H60-H11 S14807 Tudor House V266686 300905 Stage 4.doc Version 1.40 Page 6 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 H60-H11 S14807 Tudor House V266686 300905 Stage 4.doc Version 1.40 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Standards Statutory Requirements Identified During the Inspection Tudor House H60-H11 S14807 Tudor House V266686 300905 Stage 4.doc Version 1.40 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 1, 3 Prospective service users are provided with information they need to make an informed choice about the home. The manager undertakes an assessment of the service users’ needs prior to the moving into the home. Tudor House does not provide intermediate care therefore Standard Six does not apply to this service. EVIDENCE: An up to date statement of purpose and service users’ guide were seen prior to the site visit. They contain the information required to enable service users to make an informed choice about the home. Service users’ files were seen to contain assessments made prior to their admission into the home. These assessments are used to ascertain that the home is able to meet the needs of individual service users, and form the basis of individual care plans. Tudor House H60-H11 S14807 Tudor House V266686 300905 Stage 4.doc Version 1.40 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 standard(s) 7, 8, 10 Service users have individual care plans that set out their personal and social care needs. Service users’ health care needs are met by the home and from community health services. Service users are treated with respect and their privacy is upheld by the staff at the home. EVIDENCE: Service user files inspected held care plans setting out in detail the health, personal and social care needs of individuals. It was noted that care plans are reviewed and updated regularly. Service users’ records showed that health care needs are met through the staff at the home and by the use of community health services. Service users are registered with a local GP, and records seen showed that service users have access to chiropodists, opticians, dentists and other health professionals as required. Personal care, including oral hygiene, is undertaken on a regular basis. Tudor House H60-H11 S14807 Tudor House V266686 300905 Stage 4.doc Version 1.40 Page 10 Aids and equipment were seen to be provided for the promotion of continence. The manager is a lead nurse for continence promotion, and records seen showed that staff have received training on the subject. Risk assessments were seen for those service users who may be at risk of developing pressure sores. The manager informed the inspector that there were no incidents of pressure sores at present. Staff were seen treating service users with respect. Personal care takes place behind closed doors, ensuring that service users’ privacy is upheld. Screening is provided in shared rooms to ensure that personal care is provided in private. Tudor House H60-H11 S14807 Tudor House V266686 300905 Stage 4.doc Version 1.40 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 standard(s) 13, 14 Service users are very well supported in maintaining contact with friends and relatives. Service users are assisted to make choices in their lives, although the level of dementia experienced by individuals in the home limits this. EVIDENCE: Eighteen comment cards were received from relatives/visitors to the home prior to the inspection. They all stated that the staff/owners welcomed them into the home at any time. Sixteen said that they were able to visit their friend/relative in private, but two said that they were unable to. This was raised with the manager, who said that anyone wishing to visit a service user in private is able to if the service user agrees. She said she would ensure that visitors are aware of this. The manager holds regular relatives support meetings and keeps relatives informed about news and changes in the home. Minutes of support meetings were seen during the inspection. The support given to relatives of service users is very high and is reflected in the positive feedback received from relatives and visitors. Due to the level of dementia experienced by service users, they are unable to look after their personal finances. Records seen indicated that relatives and Tudor House H60-H11 S14807 Tudor House V266686 300905 Stage 4.doc Version 1.40 Page 12 solicitors manage their finances for them. Clear records were seen regarding the management of personal allowances. Tudor House H60-H11 S14807 Tudor House V266686 300905 Stage 4.doc Version 1.40 Page 13 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, 18 The home has a written complaints procedure which most relatives are aware of. The home’s policies, procedures and staff training help to protect service users from abuse. EVIDENCE: The home’s complaints procedure and records were seen during the inspection and found to meet the relevant standard, including how to contact the Commission for Social Care Inspection. No complaints have been received since the last inspection. The complaints procedure is included in the Statement of Purpose and the Service User’s Guide. Feedback received from relatives/visitors confirmed that most of them were aware of the home’s complaints procedure. Two comment cards said they were not. The manager said she would inform relatives again of the procedure. Policies and procedures regarding Adult Protection and Whistle Blowing were inspected and found to be robust. Staff training records showed that staff receive training on recognising and responding to suspicions of abuse. Staff spoken to confirmed that they have undertaken these training courses. Policies and procedures on dealing with verbal and physical aggression were also inspected and found to be adequate. Tudor House H60-H11 S14807 Tudor House V266686 300905 Stage 4.doc Version 1.40 Page 14 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, 24, 25, 26 The environment at Tudor House is clean and comfortable and generally well maintained throughout. Some radiators still need to be covered, and a commode and a toilet frame are in need of maintenance. Service users are able to have their own possessions in their rooms. EVIDENCE: On the day of the inspection the home was found to comfortable, homely, clean throughout and free from offensive odours. Mr. Subramaniam is responsible for the day to day maintenance of the home. Since the last inspection the dining room and hall have been redecorated. The grounds were found to be well maintained and accessible to service users. Service users’ rooms were seen to be adequately furnished, although they do not all have a table and two chairs. During the last inspection some of the bed linen was found t be worn. No worn linen was seen during this inspection. Some appeared quite old but still in usable condition. Rust was seen on a Tudor House H60-H11 S14807 Tudor House V266686 300905 Stage 4.doc Version 1.40 Page 15 commode and a toilet frame; this needs to be addressed, as it could be an infection control risk. All rooms are fitted with suitable locks. Rooms are kept locked during the day, to prevent disruption that may be caused by service users wandering into the wrong room. Those who are assessed as capable are given their own key. Emergency lighting is provided throughout the home. Most radiators were seen to be covered. Some radiators have not yet been covered; in the meantime furniture such as chests of drawers have been placed in front of them in an attempt to make them less dangerous. The remainder of the radiators need to be covered. Since the last inspection hot water pipes have been covered with foam lagging to prevent burns in the event of falls. Tudor House H60-H11 S14807 Tudor House V266686 300905 Stage 4.doc Version 1.40 Page 16 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) 29 The home’s recruitment policy and practice supports and protects service users, but the manager needs to ensure that she obtains two written references prior to employing new staff. EVIDENCE: Three staff files were examined and found to include most of the required documents, including Criminal Records Bureau and Protection of Vulnerable Adult checks. Two files only had one written references instead of the two required. The manager explained that this was due to difficulties in obtaining references from abroad. Tudor House H60-H11 S14807 Tudor House V266686 300905 Stage 4.doc Version 1.40 Page 17 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) 38 The health, safety and welfare of service users and staff are promoted and protected through the home’s policies, procedures and staff training programme. EVIDENCE: Records of staff training were inspected and showed that staff receive training in Manual Handling, Fire Safety, First Aid, Food Hygiene, Infection Control, Dealing with Aggression and Dementia. Hazardous substances are safely stored. Records were seen to show that electrical and gas appliances are regularly serviced including the lift and central heating. A clear Legionella test certificate was seen. A written health and safety policy, which includes the control of infection, was seen and found to be comprehensive. Tudor House H60-H11 S14807 Tudor House V266686 300905 Stage 4.doc Version 1.40 Page 18 All accidents are recorded and safety notices are posted up where necessary. Tudor House H60-H11 S14807 Tudor House V266686 300905 Stage 4.doc Version 1.40 Page 19 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 3 x 3 x x N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 x 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 x 13 4 14 3 15 x COMPLAINTS AND PROTECTION 3 3 x x x 3 2 3 STAFFING Standard No Score 27 x 28 x 29 2 30 x MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x 3 x x x x x x x 3 Tudor House H60-H11 S14807 Tudor House V266686 300905 Stage 4.doc Version 1.40 Page 20 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 25 Regulation 13 Requirement All radiators need to be covered to minimise the risk of burns. This is an outstanding requirement from the last inspection. Timescale for action was March 2005. The manager needs to ensure that two written references are obtained before appointing a member of staff. Timescale for action 30th December 2005 2. 29 19 30th October 2005 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 Good Practice Recommendations Tudor House H60-H11 S14807 Tudor House V266686 300905 Stage 4.doc Version 1.40 Page 21 Commission for Social Care Inspection 2nd Floor, Ridgeworth House, Liverpool Gardens Worthing West Sussex BN11 1RY 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 H60-H11 S14807 Tudor House V266686 300905 Stage 4.doc Version 1.40 Page 22 - 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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