Inspection on 22/08/07 for Tudor House Nursing Home

This inspection was carried out on 22nd August 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 Nursing Home 28/07/09

Tudor House Nursing Home 31/07/08

Tudor House Nursing Home 11/09/06

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

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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 Unannounced Inspection 22nd August 2007 10:15 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.V345606.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.V345606.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 tudor@rochehealthcare.com Roche Healthcare Limited Mrs Karen Newsome Care home with nursing (N) 34 Category(ies) of Old age, not falling within any other category registration, with number (OP)(34)(Both), Physical disability (PD)(34) of places (Male), Dementia (DE) (34) (Both) Tudor House Nursing Home DS0000027990.V345606.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. The registered person may provide the following category of service only: Care home with nursing - Code N, to service users of the following gender: Either, whose primary care needs on admission to the home are within the following categories: Old age, not falling within any other category - Code OP, Dementia - Code DE, Physical disability - Code PD. The maximum number of service users who can be accommodated is: 34. 11/09/06 3. 4. 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. Fees charged on the day of the site visit ranged from £329.50 per week for residential care to £620.00 for private nursing on the dementia unit. Chiropody and hairdressing was charged for separately and not included in the fees. Tudor House Nursing Home DS0000027990.V345606.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 home’s file since the last inspection. • Information submitted by the registered provider in the Annual Quality Assurance Assessment documentation. • Surveys received from two people who live in the home and three Relatives. • An unannounced visit to the home, which lasted four hours fifteen minutes and included a full tour of the premises. Evidence gained by direct observation, talking with people who use the service and staff. Inspection of records, including care profiles, medication administration records, staff files and some of the homes policies and procedures. What the service does well: What has improved since the last inspection? More detail has been added to some care profiles, which helps to ensure people’s needs are known and can be met. The recording of controlled medications has been improved so that these medications are witnessed by two people, to ensure safety. Tudor House Nursing Home DS0000027990.V345606.R01.S.doc Version 5.2 Page 6 Training has been provided, to more staff in different subjects to enhance care, and ensure that people’s health and safety is better protected. The environment has been improved in certain areas, a new dementia unit has been created and this unit was well thought out, ensuring the home is a pleasant place to live. 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. The summary of this inspection report can be made available in other formats on request. Tudor House Nursing Home DS0000027990.V345606.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.V345606.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. JUDGEMENT – we looked at outcomes for the following standard(s): Standard 3. (6 not applicable) People who use this service experience good quality outcomes in this area. People were assessed prior to moving into the home to ensure their needs could be met. We have made this judgement using a range of evidence, including a visit to this service. EVIDENCE: Two people were case tracked, there was evidence that a full assessment of their physical, social and mental health needs had been undertaken prior to the home offering them a trial placement to ensure their needs were known and could be met. During the trial period, further assessment was undertaken by staff as people settled in to their new environment, allowing staff time to get to know any new needs that people may have. This was particularly beneficial for people being admitted into the Dementia Unit. Tudor House Nursing Home DS0000027990.V345606.R01.S.doc Version 5.2 Page 9 People could visit the home with their relatives to look round, and speak to staff, to allow them to gain insight about how they may feel when residing at the home. One person stated “I came to have a look round with my family, just a general look to make my mind up”. Information about the services the home provided was available to people to ensure that they could make an informed choice about if the home was the right place for them. One person stated “I was given written information, and the manager came to see me before I moved in.” Intermediate care was not undertaken at the home. Tudor House Nursing Home DS0000027990.V345606.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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 7, 8, 9, 10. People who use this service experience adequate quality outcomes in this area. People had their needs met, however there was a shortfall in the recording of some of this information. We have made this judgement using a range of evidence, including a visit to this service. EVIDENCE: People stated that they received the care and support, which they needed; a comment received was “Whatever I ask they follow through, and staff go with my whims and fancies”. It was evident peoples needs were well known, but their care profiles did not always reflect all the care and social activities, which were being delivered by staff, this must be addressed. Care plans for two new admissions were inspected. Care plans were being created, and social needs were recorded for this individual. However a moving Tudor House Nursing Home DS0000027990.V345606.R01.S.doc Version 5.2 Page 11 and handling assessment had not been undertaken. This was completed at the time of the site visit. There was a risk assessment in place for bed rails, however there was no evidence, signed by the person or their representative that risks associated with this intervention had been thoroughly discussed. This must be addressed and evidence recorded. The second person had been in the home for nearly two months, however their social assessment was not completed, this was even more important because of their poor memory. Care plans were evident and were detailed and had been reviewed monthly, however these were created three weeks after the person had been admitted. Whilst it is valuable to wait to create care plans until the persons needs are understood in more detail, basic plans should have been in place in a more timely manner, to ensure that this persons needs were understood, recorded and being met. This was discussed with the manager who agreed that these should have been in place quicker. Again the bed rail risk assessment for bed rails required discussing with the person’s family. This was to be undertaken. Care plans were not signed by the individual or their chosen representative, this was discussed with the manager who was to write to people asking them if they wished to be involved in this review process. Special equipment was provided for people and general practitioners and health care professional visited the home as necessary. Consultations were carried out in people’s own bedrooms to ensure privacy and dignity was maintained. Medication systems were inspected. Nurses were writing medications upon medication administration charts. This practice may lead to potential errors being made and is not good practice. The manager must consider how this could be changed to help protect people. Recently one controlled medication tablet had been lost; this had been reported to the Commission for Social Care Inspection. The manager must follow the company procedure and should clarify if the police should be informed of this loss. People spoken with stated that they were given care in a way that respected their privacy and dignity. One comment received was “The level of care given is always first class making sure that the individual is always well cared for”. Tudor House Nursing Home DS0000027990.V345606.R01.S.doc Version 5.2 Page 12 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): Standards 12, 13, 14, 15. People who use this service experience adequate quality outcomes in this area. People have their social needs met, however there were slight shortfalls relating to recording social preferences, and activities available, which must be addressed. We have made this judgement using a range of evidence, including a visit to this service. EVIDENCE: Activities were being provided within the Dementia unit. On the day of the site visit, people were seen decorating buns, which they had made the day before. There was a sensory room, which had visual and sensory stimulation in the form of projected images onto a wall of fish in an aquarium, coloured fibre optic lights and a revolving ballroom light. A beanbag chair was available as well as a conventional easy chair; feather boas and textured small cushions were available to take hold of. Reminiscent music was playing from a gramophone style player. The room was decorated with light reflective stars on the ceiling and the door could be closed and lighting adjusted to help people relax in this special environment. All activities on the dementia unit Tudor House Nursing Home DS0000027990.V345606.R01.S.doc Version 5.2 Page 13 were recorded on a daily basis in the activities book. Staff were seen to be patient, kind and very attentive to the people who lived upon the unit. A Christmas fayre was being planned and people on the dementia unit had commenced making beautiful hand made cards for this event. Two people were case tracked, one had their social needs recorded the other had not had this information recorded, and even though there were lots of input and add hock activities being provided, the preferred social activities of this person must be documented, to ensure their needs were being considered and could be met. In the main house there was an activities co-ordinator providing a programme of activities three days per week. The programme of activities was not displayed, this information should be provided so that people can choose what activities they may wish to attend. Two people spoken with, in the main house, confirmed that there were activities provided that they could take part in if they wished. Activities included trips to the railway museum and local garden centres. Visits by singers to the home were appreciated by one person who stated, “I’ve always been interested in music, sometimes a woman comes to play the organ, and I try to sing with her”. And “I have been on trips to the railway museum and out for lunch two or three times”. Communion was provided at the home once per month and local clergy attended as requested to ensure that peoples religious needs were being met. People were seen following their chosen routines and could sit in the television lounge or quiet lounge, entrance or small conservatory. Visiting was open and people stated they felt welcome and could attend the home at any time. People were assisted to visit family if they wished; this ensured that quality time could be enjoyed within the home or elsewhere. The kitchen was inspected. Food provided looked nutritious and well presented. A comments received included” The food is very nice, there is always a choice, if I don’t like either choice they always deliver something I fancy”. However the four-week menu required reviewing in regard to the teatime choice for people who required a puree diet. The manager and chef were to revise this so that the puree option was clearly stated. Other foods offered, such as homemade soup should also be recorded, to allow people to choose from the full menu. People who required assistance and prompting with their meal were assisted with dignity and respect. Tudor House Nursing Home DS0000027990.V345606.R01.S.doc Version 5.2 Page 14 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): Standards 16, 18. People who use this service experience good quality outcomes in this area. People could be assured that their concerns would be listened to and acted upon. We have made this judgement using a range of evidence, including a visit to this service. EVIDENCE: The complaints procedure was available and contained all the relevant information. People spoken with stated that any concerns they had would be listened to and acted upon. Comments received included “If I was not happy I would speak to the manager” and “I would speak to the nurse in charge if I was unhappy with anything”. There had been no complaints received since the last inspection. Issues raised by one person had been promptly looked into by management and relevant action was being undertaken to solve the problem. Staff received training in relation to safeguarding people; a whistle blowing policy was in place. Staff knew what action to take if they suspected abuse; this helps to protect vulnerable people. All necessary pre employment checks were carried out for new staff, commencing at the home. Where necessary supervision was carried out. This ensured that people were protected by the recruitment process, from staff that may not be suitable to work in the care industry. Tudor House Nursing Home DS0000027990.V345606.R01.S.doc Version 5.2 Page 15 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): Standards 19, 26. People who use this service experience good quality outcomes in this area. People live in a well maintained home. We have made this judgement using a range of evidence, including a visit to this service. EVIDENCE: The home had secured entry, to the main door and to the Dementia unit, which ensured people were kept safe. Disabled access was permitted by a ramp, to the front door, however this was made of wood leading up to a concrete step; this was due to be improved. All areas of the home were clean and tidy. There were period features in some areas, which give the environment character. Corridor carpets had been replaced and risk assessments for the garden pond and mowing the lawn, had been created, to assure peoples health and safety was maintained. The Tudor House Nursing Home DS0000027990.V345606.R01.S.doc Version 5.2 Page 16 grounds looked well kept. People could choose where to go throughout the house and garden. Restricted access was provided to the dementia unit, which was newly decorated in brighter colours. Personalized collections of photographs were placed on peoples doors to help prompt peoples memories as to which bedroom was theirs. A sensory room and a smaller corner of the lounge, was provided for quieter reflection. There was a good-sized shower room and access through the lounge dining area to an enclosed garden with furniture. The ramp leading to the garden required a handrail to be fitted, this must be addressed. The laundry was inspected; infection control practices were in place. Hand washing facilities were provided throughout the home, which helped to prevent cross infection and maintain hygiene. Comments received included “the home is always fresh and clean”. And “My room gets cleaned and hoovered every day”. General maintenance was undertaken and safety checks were undertaken, to ensure peoples safety was maintained. However the upstairs bathroom had a manual bath hoist for staff to use, this should be reviewed, the provision of a non-manual bath hoist should be considered for the health and safety of staff. Tudor House Nursing Home DS0000027990.V345606.R01.S.doc Version 5.2 Page 17 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): Standards 27, 28, 29, 30. People who use this service experience adequate quality outcomes in this area People were looked after by staff that received training; however further training in certain areas for some staff was still required. We have made this judgement using a range of evidence, including a visit to this service. EVIDENCE: A senior carer staffed the dementia unit on the day of the site visit. However there was no separate staffing available for this unit on the nighttime. This must be reviewed, as although the unit is only six beds peoples needs are more complex and they would require quick supervision if getting up during the night. The manager stated that new staff were about to commence and the staffing levels were to be increased to accommodate this. Staffing levels must be reviewed to ensure that people’s needs are being met. Staff received statutory training, more training has been provided in First Aid and Manual Handling. However the home still was not able to have twenty four hour cover for First Aid and this must be rectified. Domestic staff also received training in Moving and Handling, to ensure that their safety was maintained. Tudor House Nursing Home DS0000027990.V345606.R01.S.doc Version 5.2 Page 18 All senior staff had completed a safe administration of medication course. Staff were encouraged to undertake the National Vocational Qualification in Care qualification at level two or three. The home had achieved a fifty percent ration of staff who had achieved this, which helped to ensure that care was being delivered by staff who had the correct underpinning knowledge. Staff stated they were encouraged and supported to undertake training. Safeguarding training had been undertaken, however some staff still had not completed this, this must be undertaken to ensure that staff are fully informed, and would act appropriately if an allegation of abuse were to be made. Staff files were examined for new staff and for two existing staff members, records were held of training undertaken. The recruitment process was thorough. New staff were undertaking induction training, and their manual handling training was to be undertaken. A training matrix for all the staff was created but was not quite up to date; this should be updated to ensure that it could prompt the manager about training, which needed to be kept up to date. Staff spoken with confirmed that they felt supported and worked well as a team together. Staff meetings were held, and minutes recorded. Comments received included “No one is rude or rough, staff always do a good job, they are undervalued by the state generally”. And “Occasionally staff can spend quality time, quite often they will, if I want a chat I will ask to see the manager, and she does come when she can”. Supervision was being undertaken, but was not up to date for all staff, this should be addressed. Appraisals also had been commenced and required to be undertaken and completed for all staff. Comments received included “I think that staff do a good job and are very caring. Nothing is too much bother”. And “staff are very friendly, nothing seems to be too much trouble for them”. Tudor House Nursing Home DS0000027990.V345606.R01.S.doc Version 5.2 Page 19 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): Standards 31, 33, 35, 38. People who use this service experience adequate quality outcomes in this area People live in the home, which is adequatly managed. However further development of audits and quality assurance systems was required. We have made this judgement using a range of evidence, including a visit to this service. EVIDENCE: The manager was approachable and was efficient and experienced, she was supported by a deputy and night sisters, who made up the management team in the home. Visits also occurred from the Estates Manager, Operations Manager and Quality Assurance Manager to ensure that full support was given to the home. Surveys received indicated people felt the manager was approachable and would listen to their views and act upon them. Regular Tudor House Nursing Home DS0000027990.V345606.R01.S.doc Version 5.2 Page 20 reports were sent to Commission for Social Care Inspection, to provide evidence that the registered provider, continued to check how the home was running. Some quality assurance systems were in place, a yearly questionnaire had just been was sent out to people who resided at the home, to gain their views about the service they were receiving, these results were to be shared with people once they were known. Residents and relatives meetings were advertised, but the registered manager stated these were still not popular; the manager sought feedback informally during general day-to-day conversations with people using the service, their friends and relatives. An annual development plan was being created, to ensure that the home had clear direction, following the introduction of the dementia unit. However audits required creating and quality assurance systems had to be developed further should continue to be addressed. A quality Improvement action plan had been created which was to be actioned, and this was evident. The manager needs to improve and develop systems that monitor practice and compliance to complete documentation relating to care, peoples preferred activities, and moving and handling assessments, to ensure peoples needs are being met. Personal allowance account balances were inspected and found to be correct, ensuring peoples financial interests were safeguarded. The health, safety and welfare of people was generally protected. However issues specified relating to medications, and the provision of a railing on the garden ramp in the dementia unit must be addressed. General and specific risk assessments were in place. The manual hoist provided in the upstairs bathroom should be reassessed to ensure that this does not place staff’s health and safety at risk. During the tour of the building one wooden wedge was found to be used at the entrance of the downstairs toilets. This method of ensuring access to the toilet must not be utilized, as it does not protect people’s safety. The manager ordered a sound activated door guard at the time of the site visit. A programme of maintenance was undertaken including weekly fire tests, to promote people’s health and safety. Issues raised in relation to poor television reception in one bedroom, and poor lighting due to tall trees, was being addressed by the management team. This ensured that people’s needs relating to the home were being listened to and acted upon. Tudor House Nursing Home DS0000027990.V345606.R01.S.doc Version 5.2 Page 21 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 X X X X X X 3 STAFFING Standard No Score 27 2 28 3 29 3 30 2 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.V345606.R01.S.doc Version 5.2 Page 22 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 OP7 Regulation 15 (2) (a) (b) 13 (4) (c) Requirement The manager must ensure that care plans are completed timely, to ensure full care can be provided. Risks assessments for bed rails must be discussed with people. And must be signed by the person or their representative. Moving and handling assessments must be undertaken and recorded promptly. Service users and/or their representative must be invited to be involved in care plan reviews. 2 OP9 OP38 13 (2) (4) (c) Medication policies must be re evaluated in relation to nurse’s hand writing medications onto the medication administration record. The policy for regarding missing medication must be reviewed. 3 OP12 16 (2) (m) People’s social preferences must be recorded timely. DS0000027990.V345606.R01.S.doc Timescale for action 30/09/07 30/09/07 30/09/07 Page 23 Tudor House Nursing Home Version 5.2 An activities programme must be provided in a format, which is suitable for people who use the service. 4 OP15 16 (2) (i) The manager must ensure that the menu reflects the full choices on offer, as well as the puree meals available on a daily basis. Hand railings must be fitted to ramp wall leading down to the garden, in the dementia unit. Staffing levels must be reviewed to ensure that people residing in the dementia unit receive staffs input quickly during the night. Remaining staff who have not received abuse training, must undertake this. The registered manager must ensure that sufficient staff have an up to date first aid qualification, to ensure cover is maintained on each shift. OUTSTANDING REQUIREMENT FROM THE LAST INSPECTION 8 OP33 24 (1) Quality assurance system must be developed further. The manager must commence auditing care profiles to ensure they are up to date and completed timely. 9 OP38 13 (4) (c) The sound activated door closure must be fitted to the downstairs toilet door. The manual bath hoist must be assessed to ensure that staff’s health and safety is being protected. Tudor House Nursing Home DS0000027990.V345606.R01.S.doc Version 5.2 Page 24 30/09/07 5 OP19 OP38 13 (4) (a) 30/09/07 6 OP27 18 (1) (a) 14/09/07 7 OP30 OP38 13 (6) 18 (1) (c) (i) 30/09/07 10/10/07 30/09/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 Refer to Standard OP26 Good Practice Recommendations The staff-training matrix should be kept up to date. Supervision and appraisals for all staff should be undertaken and recorded. Issues raised relating to poor television reception and poor sunlight in relation to tall trees, in one bedroom, should be addressed. 2 OP38 Tudor House Nursing Home DS0000027990.V345606.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection York Area Office Unit 4 Triune Court Monks Cross York YO32 9GZ 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 Nursing Home DS0000027990.V345606.R01.S.doc Version 5.2 Page 26 - 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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