Inspection on 04/07/07 for Tudor House

This inspection was carried out on 4th July 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 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 11/05/06

Tudor House 23/11/05

Tudor House 16/06/05

Tudor House 15/04/04

Similar services:

Henry Nihill House

Birchwood

The Infirmary

Orchard House Nursing Home

St Josephs Rest Home

Red Court Nursing Home

Spinney (The)

Queen Elizabeth House

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

CARE HOMES FOR OLDER PEOPLE Tudor House Tudor House Nursing Home 4 Birdhurst Road South Croydon Surrey CR2 7EA Lead Inspector Ms Rin Saimbi Key Unannounced Inspection 4th July 2007 09:30 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Tudor House DS0000019044.V344703.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 DS0000019044.V344703.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Tudor House Address Tudor House Nursing Home 4 Birdhurst Road South Croydon Surrey CR2 7EA 020 8410 3399 020 8 410 6506 tudorhouse@gmail.com Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Assured Services Limited Post Vacant Care Home 37 Category(ies) of Old age, not falling within any other category registration, with number (37) of places Tudor House DS0000019044.V344703.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 12 nursing 25 which can be either nursing or residential A variation has been granted to allow one specified service user in the Dementia - over 65 [DE(E)] service user category to be accommodated. 11th May 2006 Date of last inspection Brief Description of the Service: Tudor House is a purpose built property in South Croydon, which can accommodate up to 37 elderly people. The accommodation compromises of a lower ground floor with a large lounge/ dining room, a library, further small lounge, conservatory, office space, kitchen and medical room. The ground, first and second floor all have bedrooms, additionally the ground floor benefits from a further lounge. The third floor is used by the proprietors for office space and also has various training rooms. To the rear of the property there is a mature and well-kept garden; to the front there is parking for a number of vehicles. The home has 31 single bedrooms and three double rooms. All the rooms have their own en- suite facilities, wardrobe, chest of drawers, comfortable chairs, natural light and ventilation. The home is situated close to local facilities and transport links. The home’s current charges are in the range of £524.58 to £700 per week. Tudor House DS0000019044.V344703.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was the home’s first inspection for the year 2007/08. It was an unannounced inspection. The inspection started at 9.30 am and took approximately six hours to complete. Prior to the commencement of the inspection, all documentation and contact relating to the home received by the Commission for Social Care inspection was reviewed. The inspection involved, looking through documentation, which related to the people who use the service and staff; talking to service user, observing activities and the care given and taking lunch with the service users. There were interviews and discussions with staff, manager and proprietors, and a tour of the building. On the day of the inspection people who use the service were positive about the care that they received. When asked ‘do they look after you/’, the replies were ‘yes’; one person said, ‘the girls are so kind’. The inspector would like to thank the people who use the service and staff members for their time and co-operation during the inspection process. What the service does well: The home is decorated and maintained to a high standard, with a rolling programme of refurbishments in place to make sure that this standard is maintained. The home is equipped with good quality domestic style furniture throughout. The home employs a number of support staff, which allows care staff to concentrate on providing care and enhances the lives of people who use the service. These staff include cleaners, handy man, kitchen staff and two part time activities co-ordinator. These co-ordinators are responsible in part, for the home having a lively and friendly atmosphere, where visitors are welcomed. Tudor House DS0000019044.V344703.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: The home has made many improvements in the recent past regarding staff files. However, it is of concern that they still do not have the appropriate procedures in place prior to the commencement of employment. That is to say, that all staff must have at least a PoVA first check prior to coming to the home. In addition, the home must apply for a CRB check as soon as is reasonable, and that portability of CRB’s is no only acceptable. Supervision within the home has improved over time. It has come to the notice of the inspector however, that RGN’s were not being supervised as the manager was under the misapprehension that it was not necessary. This is not the case, as all staff must receive supervision and therefore a requirement has been made in this regard. Tudor House DS0000019044.V344703.R01.S.doc Version 5.2 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. The summary of this inspection report can be made available in other formats on request. Tudor House DS0000019044.V344703.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 DS0000019044.V344703.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): 2,3,5 and 6 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. In general, the home produces sufficient information regarding the services that it provides in order that prospective people coming into the service are equipped with the information they require to make an informed choice about the suitability of the home. EVIDENCE: The home does have a detailed statement of purpose, which outlines their aims and objectives and the facilities that will be provided. This was viewed at previous inspections and was deemed to be satisfactory Prospective new people coming into the service are only admitted on the basis of an assessment completed by the manager. In addition, the manager Tudor House DS0000019044.V344703.R01.S.doc Version 5.2 Page 10 gathers as much information as possible from the people themselves, family and friends, and other involved professionals. Prospective new people are then invited to the home for a trail period, which normally lasts six weeks. After this period there is a meeting with all relevant professionals including the people themselves, which determines whether the placement should go ahead or not Information was viewed regarding four people who use the service, one of whom had recently been admitted to the home, another was receiving respite care. The assessments included details of medication, hearing and vision, next of kin and mobility. Whilst not a comprehensive assessment it was adequate for the purposes required. There was also documentation which gave the terms and conditions of the placement, these were signed by the person, their representative and by the placing authority. The majority of people who use the service at Tudor House are from a white/European background. There are however, a small percentage of people who use the service who are from differing backgrounds, there is one AfroCaribbean and an Asian women who have recently been admitted to the home. There is also an Iranian woman who only speaks Persian. The home has tired to meet her language needs, by the recruitment of a volunteer from the Iranian community. Unfortunately, this has only been short-lived, as the demand for Iranian speakers is extensive. The home continues to struggle to find a suitable interpreter, however, in the meantime, a relative is visiting weekly and the carers are communicating through signs and gestures. Although this in not an ideal situation, it is difficult to know what else the home can do at this stage. Tudor House does not provide intermediate care and therefore this standard has not been assessed. Tudor House DS0000019044.V344703.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 and 10 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The assessment process and the subsequent care plan does define the care that is given to people who use the service. Care plans are reviewed regularly to reflect the changing needs of the individual. People who use the service in general are treated with respect and their right to privacy is upheld. EVIDENCE: The initial assessment completed by the manager is translated by a senior member of staff into the care plan. This care plan identifies the actual care that is to be given to each individual person using the service. Tudor House DS0000019044.V344703.R01.S.doc Version 5.2 Page 12 Care plans for four people who use the service were viewed and in general they appeared to reflect the care given. There was evidence available via documentation that the care plans are reviewed regularly on a monthly basis by the home. Risk assessments were available for all people who use the service in relation to pressure sores and manual handling. Again, there was evidence via documents that risk assessments are reviewed on an ongoing basis. Body charts have been introduced in the home so that pressure sores can be recorded accurately; the home is also using photographic evidence for this purpose. At the time of the inspection, there was no incidence of bedsores; one person within the home had had a sore recently when they arrived from hospital, this had now in fact healed and was no longer being treated. The home has records of health appointments for individual people who use the service. The GP visits the home on a weekly basis, and anyone who needs a health appointment can be seen immediately. A chiropodist and opticians also come into the home on a six monthly basis. Audiologist and a dietician are accessed via the GP if required. A district nurse visits regularly; the home can also provide palliative care if required. Service users weight is monitored monthly as a matter of course, and would be completed on a weekly basis if required. The records for this were checked and found to have been completed. Medication is stored in room, which is kept locked at all times. The medication is only administered by Registered General Nurses; records were viewed and found to be accurate. No one in the home currently self medicates. The administration of medication is audited internally by the manager on a monthly basis. With regard to people who use the service and how their privacy and dignity is maintained, a selection of staff were asked questions. All were able to give an appropriate response. From observations it was generally apparent that staff were aware of the issues and were able to respond; they knocked on bedroom doors, and whilst personal care was being provided they ensured that the door was closed, discussions about people who use the service were discreet in order to maintain their confidentially. This is an area that the home has made noticeable improvements in. Some of the people who use the service have their own telephone in their bedrooms; there is a pay telephone available in quiet area of the home for others. . Tudor House DS0000019044.V344703.R01.S.doc Version 5.2 Page 13 Tudor House DS0000019044.V344703.R01.S.doc Version 5.2 Page 14 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 and 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home does offer a range of activities via the coordinators. Whilst ensuring that independence and choice is maintained wherever possible. The home has a friendly, relaxed atmosphere where visitors are welcome, thus creating a homely environment. EVIDENCE: The home employs two activities co-ordinators who between them work five days a week, 10 – 4 pm. The co-ordinators arrange a number of activities including bingo, quizzes, and craftwork and for an outside instructor to take a weekly exercise class and radio show. As well as the routine activities that take place on a weekly basis, the coordinators also arrange for visits from community groups and outings. There are also trips to the theatre and shows, the local park and using the tram for outings. Over the summer there is also at least two outings to the seaside. Tudor House DS0000019044.V344703.R01.S.doc Version 5.2 Page 15 There are also a number of 100th birthday celebrations that need to be arranged in the coming year. On the day of the inspection the home was preparing for its summer fair at which people who use the service have their own stall, were they sell things that they have made. There were also a number of entertainers coming into the home. Many of the activities take part in the lounge; however, there are other rooms available for people who use the service. There is a conservatory; a small lounge adjacent to the large room known as the library. On the ground floor there is a further lounge, which is used for social occasions. The home had a relaxed atmosphere whilst being quite busy with the coming and goings of friends and relatives. People who use the service are able to choose whether to see friends and family in a communal area or in their bedrooms Mealtimes are clearly an important time for within the home. People who use the service are provided with a menu from which they have a choice of two meals, meals are on a seven-week rota. On the day of inspection, people had the choice of roast chicken or an omelette, with apricot crumble and custard or strawberries and grapes for desert. Lunch was taken with people who use the service who spoke positively about the quality of the food provided. There was one person who was diabetic who stated that; ‘the cook always makes sure that there is something for me’. People who use the service have a choice for breakfast, which includes a cooked breakfast. The lunchtime meal is the main meal, and for tea there is usually something macaroni cheese, eggs on toast or sandwiches. In general, there is either a cook or an assistant cook on duty for twelve hours of the day. Food that is prepared in the kitchen and needs to be transferred to bedrooms in done so via a ‘dumb waiter’ thus ensuring that it always arrives hot. The cook stated that she is constantly trying to extend the range of food provided; recently she has tried kedgeree, tuna bake and other rice dishes with varying degrees of success. Tudor House DS0000019044.V344703.R01.S.doc Version 5.2 Page 16 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home has a clear complaints policy; and complaints are always taken seriously and acted upon. People who use the service can therefore feel that their views are listened to. In general, the home takes its responsibility towards vulnerable adults seriously. There are areas that need to be addressed to ensure that people who use the service are not being put at potential risk. EVIDENCE: The home has a complaints policy and a log of the complaints that are made. Since the last key inspection in May 2006, the log indicated that four complaints have been made and all have been resolved within the timescales required. Several people who use the service were asked what they would do if they have a problem, all stated that they would talk to the manager. This indicates that the manager makes himself available and the people who use the service feel that their views are listened to. Tudor House DS0000019044.V344703.R01.S.doc Version 5.2 Page 17 In relation to protecting vulnerable adults, the home has now acquired Croydon’s policy and procedures. This has been an outstanding requirement dating back to July 2004. It is now deemed to have been meet and is therefore withdrawn. However, the home’s rewritten internal policy regarding the procedures of protecting vulnerable adults is incorrect and contradictory and could therefore jeopardise any investigation undertaken. The section that is incorrect refers to ‘service users giving their consent before a referral is made to Social Services unless the service user is in physical danger’; later in the document it makes reference to a referral to Social Services regardless. A requirement has been made that this section must be amended for with. In discussions with some members of staff, a vulnerable adults scenario was given to them to test their understanding and knowledge of what was required. It was positive to note that staff were able to give an appropriate response. Tudor House DS0000019044.V344703.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19,21,22 and 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The focus of the home is very much in the main lower ground lounge; other rooms are available however providing quieter areas and privacy. The home is decorated and maintained to a high standard throughout. Service users are able to bring in their own furniture, which gives the home a pleasant, homely feel. EVIDENCE: The home is purpose built with facilities arranged over four floors. The lower ground area has a large lounge/dining room, which is the main communal area for the home. Via this room there is access to a conservatory and the garden. Tudor House DS0000019044.V344703.R01.S.doc Version 5.2 Page 19 There are further smaller lounges, which provide greater privacy people. In addition, the manager’s office, medical room and kitchens are located here. The home has thirty-one single bedrooms all with en-suite facilities, arranged over three floors. The home has three double bedrooms. Each floor has its own kitchenette area and a nurse’s station; all the floors are decorated in different colours for ease of identification by the service users. The inspector conducted a tour of the home accompanied by a member of staff. The home is decorated and furnished to a high standard with the focus on providing a homely environment. The home has a rolling programme of maintenance to ensure that this high standard is maintained. The home is equipped with suitable aids and adaptations; there is lift, handrails, call bells, ramps and specifically adapted bathrooms. It was noted however, that the lift in the premises had been out of action intermittently for some nine days. The manager produced a number of invoices as evidence that engineers had been called out a number of times. Staffing levels had not been increased over this period to compensate for the loss of the lift. During discussions, the proprietor stated that two additional volunteers had been available, and that some activities had taken place in the ground floor lounge. A requirement is not being made on this occasion as the proprietor could verify that people who use the service were not unduly affected. However, should the lift breakdown again, there is an expectation that staffing levels are increased in line with the needs of the people who use the service. The home was generally clean throughout, although it was noted that there was an unpleasant odour in two of the bedrooms viewed. A requirement has therefore been made in this regard that the home must adequately clean rooms and carpets, in order to remove any unpleasant odours. The previous inspections had identified that the condition of the carpet in the staff room needed to be reviewed. In fact, the carpet has now been removed and replaced with lino. This requirement is therefore withdrawn. Bedrooms were well furnished with some degree of personalisation in the choice of ornaments and photographs. Each service user had keys to their bedroom and a lockable space. Tudor House DS0000019044.V344703.R01.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29 and 30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. In general, the staffing levels and skill mix are adequate to meet the needs of the people who use the service to ensure that they are well cared for. The recruitment practices within the home are not in general, sufficiently rigorous to protect the welfare of the service users from abuse. EVIDENCE: The home aims to have seven members of care staff on duty in the mornings which covers their busy period; during the afternoon there would be five members of care staff. In addition, the home has two registered nursed on duty during the day. At night, there is one waking member of staff on duty on each floor, and also a waking nurse. Duty staff rota’s for two weeks were checked at random, and indicated that sufficient staff were on duty. Tudor House DS0000019044.V344703.R01.S.doc Version 5.2 Page 21 The home also employs various other domestic staff, including cleaners, cooks and a handy man. People who use the service speak warmly of the care that they receive, when asked if they were looked after, all stated ‘yes’. Staffing records including recruitment were checked, three files were chosen at random including one of a new member of staff and an agency member of staff. The files were generally in good order containing the application form, interview questions references terms and conditions and Criminal Record Beaux checks (CRB). However, it was noted that one member of staff had only a CRB check from another organisation and no Protection of Vulnerable Adults check (PoVA). This member of staff was being supervised. The proprietors and managers are reminded that portability of CRB’s are not acceptable and that no one must start employment within the home unless they have at the very least a PoVA check. This requirement has been outstanding since May 2006. The home is currently employing a trainer, he currently offers at least one session of training per month to all staff. The home has also initiated a training portfolio which, identifies when training was completed by each member of staff and when refreshers are required. Staff were able to confirm the level of training that they have received, courses have included manual handling, fire safety and the Mental Capacity Act. All staff are now receiving the minimum of three days paid training per year, as identified in the National Minimum Standards for Older People. The home currently has a staffing establishment of nineteen carers; of these carers nine have completed National Vocational Qualification (NVQ) Level 2 and a further four are in the process of completion. The area of staff training is one in which the home have improved upon in recent times. Tudor House DS0000019044.V344703.R01.S.doc Version 5.2 Page 22 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31,33, 36 and 38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The quality of the care provided by the home is strongly influenced by the calibre of the registered manager. A competent manager is adept at fostering an atmosphere of openness so that people who use the service and staff feel that they are valued and that the service that is being provided is high quality. EVIDENCE: The current manager has considerable experience and knowledge in the area of older people, he is an RGN and has worked both as a deputy and manager of services for older people; he is qualified to NVQ Level 4 and has his registered managers award. The manager has yet to register with the Tudor House DS0000019044.V344703.R01.S.doc Version 5.2 Page 23 Commission for Social Care Inspection as the manager for this home, although the inspector was assured that this was underway. With regard to quality assurance and monitoring systems, Tudor House has a number of measures in place, which have been reviewed at previous inspections; these include an annual development plan and questionnaires to people who use the service and their families. There is also a residents meetings approximately three times a year, which is facilitated by the activities co-ordinator. At previous inspections a requirement has been made regarding the Regulation 26 visits, that is to say that the registered provider must visit the premises at least monthly and provide a written report of the conduct of the home. The proprietors have now delegated this task to a nominated individual, whose reports were available for inspection purposes. This requirement has therefore been withdrawn, although a recommendation has been made that the nominated individual seeks guidance regarding the function and purpose of these visits. Supervision records for staff were chosen randomly, they indicated that supervision was taking place at the required level, that is to say, a minimum of six per year. There was evidence of these sessions having been recorded appropriate and signed by both parties. Supervision had not been taking place for the Registered General Nurses (RGN’s), as the manager was under the misapprehension that they did not need to be supervised. The National Minimum Standards for Older People clearly state that all staff are supervised as part of the normal management process. Therefore a requirement has been made that the manager must supervise RGN’s at least six times a year. With regard to safe working practices, the home has a number of policies and procedures in place to ensure the safe working practices of the home. There are risk assessments in place for the moving and handling, and appropriate equipment in situ. There was an awareness and understanding of infection control amongst the staff, and the provision of gloves and protective clothing; there is a sluice room on every floor of the home. There was evidence of some regular checks taking place, fire alarms were tested weekly and the equipment was last checked on the 15.5.07. Legionella testing was completed on the 20.09.06; Landlords gas certificate was dated 8.12.06. In the kitchen, fridge and freezer checks are completed daily, and the temperature of food at the time of serving was recorded; Food packets were labelled on the day of opening. It was noted that on the containers of herbs and spices the use-by date could no longer been seen, presumably as it had Tudor House DS0000019044.V344703.R01.S.doc Version 5.2 Page 24 rubbed off over time. It is therefore recommended that staff are mindful of this, to ensure that out of date foodstuffs are not used. Tudor House DS0000019044.V344703.R01.S.doc Version 5.2 Page 25 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 3 X 3 3 HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 3 X 3 3 X X X 2 STAFFING Standard No Score 27 3 28 3 29 1 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 2 X X 2 X 3 Tudor House DS0000019044.V344703.R01.S.doc Version 5.2 Page 26 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 OP18 Regulation 12(1)(a) Timescale for action The home must rewrite their own 04/09/07 internal policies and procedures regarding vulnerable adults to ensure that they are in line with the Croydon’s policies. Outstanding since 31/07/04 2. 3. OP26 OP29 23(1)(d) 13(6) The home must be free from unpleasant odours throughout All staff must have the appropriate checks prior to the commencement of employment, at the very least a PoVA check. Outstanding since 11/05/06 4. OP36 18(2) All staff including the RGN’s must 04/08/07 be supervised on a regular basis 04/07/07 04/07/07 Requirement Tudor House DS0000019044.V344703.R01.S.doc Version 5.2 Page 27 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 OP33 OP38 Good Practice Recommendations The home should seek guidance regarding the information required for regulation 26 visits The home should be aware of the use-by-dates of containers of herbs and spices Tudor House DS0000019044.V344703.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Croydon, Sutton & Kingston Office 8th Floor Grosvenor House 125 High Street Croydon CR0 9XP 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 DS0000019044.V344703.R01.S.doc Version 5.2 Page 29 - 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!