Inspection on 11/09/06 for Tudor House Nursing Home

This inspection was carried out on 11th September 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is (sorry - unknown). 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 Nursing Home 28/07/09

Tudor House Nursing Home 31/07/08

Tudor House Nursing Home 22/08/07

Tudor House Nursing Home 11/01/06

Tudor House Nursing Home 08/07/05

Tudor House Nursing Home 25/11/04

Tudor House Nursing Home 01/06/04

Similar services:

Abbey The

Snydale Care Home

Hawkhills

Larchfield Manor

Beeches The - North Yorkshire County Council

The Grove Waltham

Staveley Birk Leas Nursing Home

Carentan House

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

CARE HOMES FOR OLDER PEOPLE Tudor House Nursing Home 12 Leeds Road Selby North Yorkshire YO8 4HX Lead Inspector Denise Rouse Key Unannounced Inspection 11th September 2006 09:45 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Tudor House Nursing Home DS0000027990.V311305.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 Nursing Home DS0000027990.V311305.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Tudor House Nursing Home Address 12 Leeds Road Selby North Yorkshire YO8 4HX 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) 01757 701922 F/P01757 701922 Roche Healthcare Limited Mrs Karen Newsome Care Home 34 Category(ies) of Old age, not falling within any other category registration, with number (34), Physical disability over 65 years of age (1) of places Tudor House Nursing Home DS0000027990.V311305.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 60 years plus Category PD(E) for one named service user and this condition will be removed at such point that the service user no longer resides in the home. 11th January 2006 Date of last inspection Brief Description of the Service: Tudor House, which is owned by Roche Healthcare Limited, is a care home providing personal and nursing care for up to 34 older people. The home is situated on a main road, and within walking distance from the centre of the market town of Selby, which benefits from a variety of local amenities. The premises consist of a two-storey building. The first floor is accessed by passenger lift. Twenty-six of the bedrooms are single, and four are shared. Tudor House Nursing Home DS0000027990.V311305.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The accumulated evidence used in this report has included: • A review of the information held on the homes file since its last inspection. • Information submitted by the registered provider in the pre inspection questionnaire • Surveys received from two service users, three relatives, three general practitioners and a care manager. • An unannounced visit to the home, which lasted five hours and fifteen minutes, and occurred over one day. This included a full tour of the premises. Evidence gained by talking with service users, management and staff. Inspection of records, including care profiles, service user guide, staff files and the policy and procedure manual. What the service does well: What has improved since the last inspection? Nurse call systems have been provided within all the lounge areas. The medication systems have been improved and the drugs fridge temperatures were being monitored and recorded. Medications were being disposed of in line with current law and legislation. Clinical waste was being handled correctly; this protects service users and staff. Staff training had been commenced in certain areas, but more was needed, to ensure the staffs and service users health and safety was being protected. Tudor House Nursing Home DS0000027990.V311305.R01.S.doc Version 5.2 Page 6 What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Tudor House Nursing Home DS0000027990.V311305.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Tudor House Nursing Home DS0000027990.V311305.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Standard 1 3 Quality in this area was adequate. Service users had their needs assessed prior to moving into the care home, however there were some shortfalls relating to the information provided to help service users make an informed choice about the home. The judgment has been made using available evidence including a visit to this service. EVIDENCE: Intermediate care is not undertaken. The service user guide was available within the bedroom of one of three service users being case tracked. This document was being updated by the administrator, throughout the home upon the day of the site visit. This document was inspected, there were several shortfalls .The relevant qualifications of the provider manager and staff, and service users views about the home were not evident, the information relating to the range of fees charged was not current. This information must be included to ensure that Tudor House Nursing Home DS0000027990.V311305.R01.S.doc Version 5.2 Page 9 prospective service users can make an informed choice about the service based on up to date information. However two service user surveys received indicated that they felt they had enough information about the home to make an informed choice. Three service users were case tracked, there was evidence that two service users had received a pre admission assessment prior to entering the home. This ensured that the service users needs could be met. One service users pre admission assessment could not be located the service user had been admitted to the home some years ago. The registered manager stated that the information from the pre admission assessment would have been used as a base line for the service users care plans, however this could not be evidenced. The registered manager must ensure that the initial pre admission assessments are available for Inspection, to ensure that the service users needs were adequately assessed and their needs continue to be met. Tudor House Nursing Home DS0000027990.V311305.R01.S.doc Version 5.2 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Standard 7 8 9 10 Quality in this outcome area was adequate. Service users health care needs were met, however inadequate recording and infrequent reassessment of service users needs, placed some service users at risk of harm. The judgment has been made using evidence including a visit to the service. EVIDENCE: Two service user surveys received indicated that service users felt that they “ Always” received the care and support they needed. One indicated the staff “Mostly” listen and act on what the service user said; another stated this “always” happened. Surveys indicated that staff were available when service users needed them “ always” and “ usually”. Service users were seen to be treated with dignity and respect by the staff, and were seen to be addressed by their preferred names. Service users see their general practitioners within their own rooms. Mail was delivered to service users unopened. A pay phone was available to service users who did not have their own phone line. Tudor House Nursing Home DS0000027990.V311305.R01.S.doc Version 5.2 Page 11 Three service users were case tracked. Two had relevant risk assessments and care plans in place. One care plan for one service user was not signed or dated by the staff, this document must be dated to ensure that the care plan is current and relates to the needs of the service user. Two of the service users had not had a social assessment completed within their care profile, however this information had been captured within the pre admission questionnaire and had not been transferred across to the care profile. This does not ensure that service users preferred social needs were being met. There was no evidence to confirm that service users were involved in care plan reviews, and it was evident that the care plans were not always reviewed monthly, or as the service users needs changed, this must be addressed to ensure service users receive the care they require. However the daily entries for all case tracked service users related to each care plan and what care had been given relating to the service users needs within the care plans. The care plans were effectively being reviewed daily due to this. Management must ensure that the systems to record care being delivered are consistent and that care plans are reviewed at least monthly or as the service users needs change. One of the case tracked service users needs had changed recently, There was a care plan relating to this, and the general practitioner had become involved, however there was no evidence that the service users nutritional needs were being adequately met, and weight loss had occurred. A nutritional risk assessment was undertaken in August 2004 and had not been updated, this was pointed out to the registered manager who immediately asked the staff to update this document and ask the service user if they would consent to be weighed. The care plans and nutritional assessment were reviewed and the documentation was altered to reflect this service users current needs. The registered manager stated that she would commence auditing service user profiles to ensure that they were all current and up to date. This would be advisable, and would ensure that the service users needs were being met. It was evident that service users needs were well known, but service users care profiles did not always reflect all the care and needs of service users, which was being delivered by the staff, this must be addressed. Medication systems were inspected, three service users medications were case tracked, balances of medications received were recorded on the medication administration record. Controlled medication balances checked were found to be correct, however only one member of staff was signing the register to state that these medications had been administered. It was recommended that to ensure staff and service users were protected there should be two members of staff, who take the medication to service users and observe the medication being taken. This was discussed with the registered manager and this system will be implemented following in house staff training. Tudor House Nursing Home DS0000027990.V311305.R01.S.doc Version 5.2 Page 12 There was evidence of two hand written entries upon a medication administration record; this practice should be avoided to ensure transcription errors do not occur, which may place the service user at risk. Medications were being disposed of correctly. Service users looked well cared for; they spoke highly of the staff who were seen to treat them with dignity and respect. Two service users surveys indicated they received the care and support they required. The manager confirmed that staff were not involved in legal or financial issues for service users. Tudor House Nursing Home DS0000027990.V311305.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 12 13 14 15 Quality in this outcome area was adequate. Service users receive a wholesome nutritious diet, however there were shortfalls relating to activities being provided at present, which must be addressed. The judgment has been made using evidence including a visit to this service. EVIDENCE: Three service users were case tracked. Surveys indicated that service users felt that activities were available to them, which were suitable to them “ always” and “ sometimes”. Two service users had their social needs recorded within the pre admission assessment, however this information was not transferred onto their social activities assessment record within their care profile. This does not ensure that service users preferred social needs were being met. Service users surveys indicated they received the care and support they required Activities available within the home were listed in the statement of purpose, and a brief description was contained in the service user guide, however Tudor House Nursing Home DS0000027990.V311305.R01.S.doc Version 5.2 Page 14 service users were not receiving a weekly programme of activities in a format relevant to their individual needs. This must be provided to ensure service users are fully aware of activities available to them, so they can plan to attend if they so wish. The activities co-ordinator had resigned and ceased work the weekend prior to the site visit. However the registered manager was about to interview for the position. Two service user surveys received indicated that activities were provided by the home that they could “sometimes” take part in. Service users were seen watching television in the lounges, reading newspapers or listening to music. They had access to board games, or library books, with normal or large print. Local outings for residents were provided, once a month using the Roche Health care mini bus, the residents had been on a trip to Scarborough the week before the site visit. Local clergy also visited the home. The home must provide activities for service users in the absence of the activities co-ordinator to ensure continued social stimulation for the service users. Two surveys from relatives or visitors confirmed service users could receive visitors in the communal lounges or privately in their own bedrooms at any time. The kitchen was inspected, food prepared looked appetizing and well presented. The chef was aware of service users who required a special diet. A four-week menu was available. Food was correctly stored and labelled. Temperature records and cleaning schedules were inspected and found to be correct, this ensured food hygiene and health and safety was being maintained. The chef and kitchen staff took pride in the food and services they were providing to the service users. The dining room was being utilized by service users who were able to socializing with each other. The menu was displayed within the reception area. The kitchen staff asked the service users the day before and again on the day what they would like to eat. Service users stated that “ the food is good, I’ve put on some weight, I’m going to have to diet” and “the home baking was always excellent”. Two service user surveys completed stated “Always” to the question “Do you like the meals at the home”. The service user surveys asked “ Do you like the meals at the home?” two responses indicated “ always”. Service users surveys indicated they received the care and support they required Staff were observed at lunch mealtimes service users who required assistance with their meal were given assistance from the care staff. This ensured that service users needs were being met. Tudor House Nursing Home DS0000027990.V311305.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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 16 18 Quality in this outcome area was adequate. Service users can be assured that their concerns would be listened to, and acted upon. Service users were protected from abuse; however further training for staff was required in this area. This judgment has been made using available evidence including a visit to this service. EVIDENCE: There have been no complaints received since the last Inspection. The home had a complaints procedure, which was displayed at reception and available within the service users guide. Complaints were resolved within a 28day time scale. The details to on how to contact the Commission of Social Care Inspection were available within this document. The home had a policy and procedure for the Protection of Vulnerable Adults. Training for fifteen staff relating to abuse had taken place within the home, and another training session was being scheduled for the rest of the staff before the end of the month. The home provides a member of staff who undertakes this training in house. The home operates a whistle blowing policy, which helps to protect service users from abuse. Tudor House Nursing Home DS0000027990.V311305.R01.S.doc Version 5.2 Page 16 Three staff files were inspected two out of the three had evidence that a Criminal Records Bureau check had been undertaken, the third member of staff had one being processed and evidence of this was shown to the Inspector. This member of staff was being supervised whilst the result of this check was being awaited. This ensured the safety of service users was being protected. The home operates a whistle blowing procedure, one staff file did not contain evidence that a Criminal Records Bureau check had been undertaken, this must be undertaken for all staff to ensure they are suitable to work with vulnerable adults. Tudor House Nursing Home DS0000027990.V311305.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 19 26 Quality in this outcome area was adequate. Service users live in a safe environment, however there were some shortfalls, relating to the garden and carpeting which placed service users and staff at risk. This judgment has been made using available evidence including a visit to this service. EVIDENCE: A tour of the building was undertaken, the lounges were well decorated and the reception area and dining room had lots of period charm. The home was clean and tidy; there were no malodours within the home. The nurse call system was available within all the lounges. All bedrooms seen had been personalized by the service users. Tudor House Nursing Home DS0000027990.V311305.R01.S.doc Version 5.2 Page 18 The corridor carpets on both floors were stained and looked dirty; the registered manager informed the inspector that these carpets had been measured in view to having these replaced. These carpets must be cleaned or replaced to ensure that the home environment is maintained to a high standard, which ensures infection control and a pleasant environment for service users visitors and staff. One downstairs lounge carpet was stained in several areas. The registered manager stated this was due to a recent spillage and the cleaning staff were having difficulty removing the stains. This must be addressed. The laundry was inspected and was spacious and airy, and very clean and tidy. The garden was looking well kept. The gardener had arrived to cut the lawns. There was no risk assessment in place for this, which must be created by the registered manager. Also a risk assessment must be created for the possible risk of drowning in the garden pond, for service users visitors and staff. Two service users surveys indicated that they felt the home was fresh and clean. There were gloves, aprons and hand wash facilities available throughout the building, which helped to ensure adequate infection control. Tudor House Nursing Home DS0000027990.V311305.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 27 28 29 30 The judgement in this outcome area was adequate. Service users were looked after by adequate numbers of staff, however there were shortfalls relating to staff records and training, this may place service users at risk. This judgement has been made using available evidence including a visit to the service. EVIDENCE: Staff recruitment was continuing and this helps provide stability of the workforce and helps to achieve continuity of care for service users. Three staff files were case tracked. All folders contained an application form. One file did not have evidence that a Criminal Records Bureau check had been completed, this was being undertaken. Only one file contained any evidence of staff supervision the other files indicated there had been no supervision. The home must ensure all staff receive training and supervision at least six times per year, to ensure that staff receive formal input in areas where they need to develop their skills to ensure service users are not placed at risk, from poorly trained staff. Two members of staff who had worked within the home for a long period, had only just had their Criminal Records Bureau check completed, one result was still outstanding. This was due to their disclosures being misplaced at the Tudor House Nursing Home DS0000027990.V311305.R01.S.doc Version 5.2 Page 20 Bureau. The registered manager should have ensured that these checks had been carried out to a satisfactory conclusion previously. All other staff had completed the relevant checks. The home manager provided names of staff that had just undertaken Protection of Vulnerable Adults training. First aid training had been undertaken but the home did not have enough staff who currently held the qualification to provide adequate cover to the home over a seven-day period, this must be addressed. A training matrix had been be commenced to help identify outstanding staff training needs. This helps to ensure that care would be delivered by staff that had received training, which would promote service users health and well being. Statutory training in moving and handling and control of substances hazardous to health must be provided for all relevant staff, to ensure that service users and staff were not placed at risk. This must be undertaken and evidence sent to the Commission for Social Care Inspection that this training has been completed. Tudor House Nursing Home DS0000027990.V311305.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 31 33 35 38 The judgement in this outcome area was adequate. Service users were looked after by adequate numbers of staff, however there were shortfalls relating to staff records and training, this may place service users at risk. This judgement has been made using available evidence including a visit to the service. EVIDENCE: The registered manager was in charge of the home on the day of the site visit, she was seen to be approachable and was running the home effectively. There was also a deputy manager and two night sisters to help and support the manager. Tudor House Nursing Home DS0000027990.V311305.R01.S.doc Version 5.2 Page 22 Surveys received from three local GPs indicated that they had no concerns, relating to services provided within the home. Separate domestic staff were employed by the home so that care staff did not have to undertake cleaning. This ensures care staff have quality time to care for service users. The home has achieved a 50 ratio of care staff that hold a National Vocational Qualification in Care, at level two or three. This ensures care staff have the relevant underpinning knowledge and expertise to administer care to service users. Regulation 26 reports have now been sent to Commission for Social Care Inspection in relation to the home, to evidence that the registered provider continues to check how the home was running. This must be continued. Roche Healthcare have a Quality Assurance Manager who will review quality issues at the home. A yearly questionnaire was sent out to service users. A resident and relatives meetings was advertised within the home, but the registered manager stated these were not usually attended by many people, they should continue to be held so that feedback can be received by the manager relating to the services the home provides. There was no annual development plan in place for the home; this must be created to ensure that the home has clear direction. Personal allowance account balances were checked for the case tracked service users and found to be correct. Receipts were kept for each individual transaction made. The monies were held separately and not pooled. Service users financial interests were safeguarded within the home. The health safety and welfare of service users was not always appropriately promoted and protected, by lack of risk assessments relating to the garden, and its maintenance, this must be addressed. The home had general risk assessments in place. General maintenance was undertaken and there was evidence that lifts and hoists were serviced and maintained. Safety certificates were available for gas and electrical appliances and fire systems had been tested and maintained. This ensured that service users and staff were protected on the whole. Tudor House Nursing Home DS0000027990.V311305.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 2 X 2 X X X HEALTH AND PERSONAL CARE Standard No Score 7 1 8 3 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 1 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 2 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 2 30 1 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 2 X 3 X X 2 Tudor House Nursing Home DS0000027990.V311305.R01.S.doc Version 5.2 Page 24 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 OP1 Regulation 456 Requirement The service user guide must contain all relevant up to date information including; Service users views of the home The qualifications of the manager and staff Up to date information relating to fees. To ensure service users; relatives and visitors can make an informed choice about the service. 2 OP3 15 The pre admission assessment for all service users must be made available for inspection. The registered person must ensure that service users Care profiles are completed in enough detail to ensure adequate care can be provided. All entry’s must be signed and dated. Actual care plans and risk assessments must be reviewed and updated at least monthly or when the service users need Tudor House Nursing Home DS0000027990.V311305.R01.S.doc Version 5.2 Page 25 Timescale for action 31/10/06 31/10/06 3 OP7 15 (1) (2) 31/10/06 change. Service users and/ or their representative must be invited to be involved with this process. Controlled medication must be witnessed when being administered to service users. The controlled medication register must be signed by two members of staff. Service users interests and social needs must be recorded within an individual care plan to ensure that their individual needs are being met. Service users must receive information relating to the provision of activities in a suitable format. The registered manager must ensure that sufficient staff have an up to date first aid qualification in order that there is a first aider available at all times. OUTSTANDING REQUIREMENT FROM THE LAST INSPECTION All staff must receive the following mandatory training: Moving and Handling Fire safety Infection control Protection of vulnerable adults And COSHH All records of training must be kept up to date. A copy of the training record must be sent to Commission for Social Care Inspection upon completion. Carpets within the corridors and downstairs lounge must be cleaned or replaced. Risk assessments relating to mowing the lawn and the garden pond must be created and implemented. Tudor House Nursing Home DS0000027990.V311305.R01.S.doc Version 5.2 Page 26 3 OP9 13 (2) 30/09/06 4 OP12 16 (2) (m) 30/09/06 5 OP38 13 (4) 31/12/06 6 OP18 OP30 13 (5) 31/12/06 7 OP38 OP19 23 (d) (o) 31/10/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 2 Refer to Standard OP29 OP33 Good Practice Recommendations Criminal records bureau checks should be undertaken in a timely manner for all staff. A robust quality assurance system should be implemented The registered manager should commence auditing care profiles. Tudor House Nursing Home DS0000027990.V311305.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection York Area Office Unit 4 Triune Court Monks Cross York YO32 9GZ 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 Nursing Home DS0000027990.V311305.R01.S.doc Version 5.2 Page 28 - 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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