Inspection on 12/12/05 for Tudor House Residential Home

This inspection was carried out on 12th December 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. 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 Residential Home 16/04/07

Tudor House Residential Home 03/08/06

Tudor House Residential Home 01/12/04

Tudor House Residential Home 07/09/04

Similar services:

Maple Lodge

Heathlands

Aston Court Nursing Home

Breme

Ravenhurst

Bank House

Inspirations

Westmead

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

CARE HOMES FOR OLDER PEOPLE Tudor House Residential Home Tudor House 6 Park Crescent West Park Wolverhampton West Midlands WV1 4PY Lead Inspector Ian Harris Unannounced Inspection 12th December 2005 08:00 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 Residential Home DS0000029962.V261528.R01.S.doc Version 5.0 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 Residential Home DS0000029962.V261528.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Tudor House Residential Home Address Tudor House 6 Park Crescent West Park Wolverhampton West Midlands WV1 4PY 01902 429008 01902 832709 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) Mrs Aurora McGarrigle Mrs Pamela Wylde Care Home 9 Category(ies) of Old age, not falling within any other category registration, with number (9) of places Tudor House Residential Home DS0000029962.V261528.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. Maximum number of residents - 9 persons category I females over 60 years and males over 65 years of age. 1st December 2004 Date of last inspection Brief Description of the Service: Tudor House is a nine-bedded care home currently registered for older people. The home is a three storey Victorian building with parking facilities to the front of the building and a small paved patio to the rear. It is located near the centre of Wolverhampton, close to shops, West park and bus routes. The three-storey building currently has a lounge, dining room, kitchen, two toilets, two bedrooms and a bathroom on the ground floor, with the remaining bedrooms on the first floor along with a toilet and bathroom. The second floor has a small flat that is now being used as office space. Tudor House Residential Home DS0000029962.V261528.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was unannounced and took place over 4 hours. The main purpose of the inspection was to check the progress made by the home regarding the recommendations and requirements made in the last inspection report. The fullest co-operation was given to the inspection officer by the Acting Care Manager staff and residents. During the inspection a tour of the premises took place and staff and care records were inspected. Also staff rotas and general records regarding the maintenance of the home were checked. 3 of the 10 care staff were on duty, and 7 of the 9 residents were spoken to. On the day of inspection the atmosphere within the home was found to be warm, friendly and comfortable and safe with contented residents. The preparations for Christmas festivities are well underway and all the residents confirmed that they were happy and well looked after and looking forward to Christmas. What the service does well: What has improved since the last inspection? Tudor House Residential Home DS0000029962.V261528.R01.S.doc Version 5.0 Page 6 There is a rolling programme of redecoration within the home and there has been an updating of some of the fire prevention and electrical equipment. A new kitchen range has been provided. Also there has be a review of a number of policies and procedures and the Statement of Purpose and Service Users Guide. Also the Care Staff have completed Safe Handling of Medication Training. 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 Residential Home DS0000029962.V261528.R01.S.doc Version 5.0 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 Residential Home DS0000029962.V261528.R01.S.doc Version 5.0 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): 2 and 4 The home provides clear and accurate information to prospective residents on the services provided, enabling them to make a properly informed choice about the home. All residents are given a written contract on admission to the home. EVIDENCE: Each resident is provided with a detailed service users guide and statement of terms and conditions when they move into the home. Both theses documents have recently been updated. This statement contains all the required information. The statement is clear on what the fees do and do not cover. Residents are encouraged to visit the home prior to admission. An introductory visit is always offered to prospective residents, on some occasions the visits are declined and relatives visit on behalf of the prospective resident prior to admission. A trial period is included in the statement of terms and conditions of residence and the homes contracts. Tudor House Residential Home DS0000029962.V261528.R01.S.doc Version 5.0 Page 9 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 9 and 11 The systems for the administration of medication are good with clear and comprehensive recording arrangements in place to ensure resident’s medication needs are met. Staff are sensitive to the individual needs of each resident in the terminal stages of life and meet these in a professional manner EVIDENCE: All the residents spoken to were happy and contented and stated they were very happy with the care they received and thought they are well looked after. Medication is administered by means of a monitored dosage system. The system appears to be working very well. The home receives good support from the local pharmacist. All Care Staff have been trained to use the system before they are allowed to administer medication and have recently completed Safe Administration of Medication training. The home has very good policies and procedures regard Medication, which are an integral part of the staff induction programme. Residents’ wishes with regard to terminal care and arrangements after death are obtained at the assessment stage, if possible. Family members are involved in these discussions if appropriate. Unless there are medical reasons Tudor House Residential Home DS0000029962.V261528.R01.S.doc Version 5.0 Page 10 for not doing so, service users are able to spend their final days in their own rooms. Where the needs of service users change, re-assessments are requested. The home has clear policies with regard to dying and death. The Care Manager and Care Staff are conscious of the need to provide extra support to the residents in their final days at the home. All the Staff are very aware of the need to be particularly sensitive, caring and attentive to the residents needs prior to their death. The Acting care manager is also aware of the support the staff should provide to relatives and colleagues. Resident’s relatives are encouraged to be fully involved in the residents care at this particular time. Tudor House Residential Home DS0000029962.V261528.R01.S.doc Version 5.0 Page 11 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 13, 14, and 15 The Staff work in close liaison with residents and their relatives to understand their individual lifestyles and preferences in order that these can be continued when they move the home. Individuals are enabled to exercise choice and control over their lives wherever possible balancing the rights and risks with each individual The meals in the home are good homely type offering both choice and variety and also catering for special dietary needs. EVIDENCE: The home has a basic programme of activities for service users to take part in. The acting care manager stated that a varied programme of activities, which actually reflects the choices, preferences and capacities of the service users will be formulated and implemented with a system of maintaining records of the activities enjoyed by the service users. The staff at the home, encourage regular contact between residents and their relatives by inviting them to parties, fetes and celebrations. It was noted that approximately 4 resident’s regularly are taken out by their relatives. The residents and staff stated that the residents are consulted regarding the day-to-day running of the home through residents informal meetings and by Tudor House Residential Home DS0000029962.V261528.R01.S.doc Version 5.0 Page 12 feedback from their key-workers. The key-workers also identify interests that the residents wish to pursue The observations made, examination of menus and the comments received from the residents confirmed that particular attention is given to the residents’ individual preferences. Comments made by residents regarding the quality, quantity and variety of food provided were highly complimentary. Tudor House Residential Home DS0000029962.V261528.R01.S.doc Version 5.0 Page 13 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 17 The home has a satisfactory complaints system and there is evidence that residents’ and their families feel that their views are listened to and acted upon All residents are assisted to exercise their legal rights, either by family, staff or where appropriate by an advocate provided by Care Aware. EVIDENCE: The home has a complaints procedure, which has recently been updated. The residents and relatives are made aware of the procedure through the statement of their terms and conditions of residence the service users guide and copies are also placed on the notice board in the hall. The home has a complaints file in which all complaints are recorded. It was noted that no formal complaints have been received since the last inspection and all minor complaints are dealt with appropriately and quickly. Residents are assisted to exercise their legal rights, either by family, or staff. All permanent residents are registered on the electoral register to vote. They may vote if they wish either by post, or they are assisted to go to the polling station if this is requested and most residents voted in the last general election. Tudor House Residential Home DS0000029962.V261528.R01.S.doc Version 5.0 Page 14 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19 and 26 The general standard of the environment is good providing service users with a homely and comfortable place to live. The good standard of cleanliness reflects the ongoing cleaning schedule, which maintains this standard throughout the home. EVIDENCE: The home has been established for a number of years and has undergone alterations in order to provide appropriate accommodation for 9 older people. The home is accessible, safe and well maintained. The limited outdoor and indoor space for the residents is accessible to wheelchair users. However, the limited space is compensated by, the homely atmosphere that is created. It was noted that the dining room ceiling has flood damage and needs repairing and that there are some outstanding recommendation of the Fire Safety Officer dated 28th November 2005 that needs addressing. It was noted that the home as yet has not undertaken risk assessment of the premises and facilities by a suitably qualified occupational therapist. The premises were found to be clean, hygienic and free from offensive odours. Tudor House Residential Home DS0000029962.V261528.R01.S.doc Version 5.0 Page 15 The home has good hygiene and infection control policies and all the care and catering staff have undergone Food Hygiene training. Tudor House Residential Home DS0000029962.V261528.R01.S.doc Version 5.0 Page 16 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission 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): 27, and 29 The home is not adequately staffed at all times, which could impact on the quality of care provided and the ability of the home to meet the needs of the service users. The home continues to support staff to complete training. The home has a satisfactory staff recruitment policy and procedure. EVIDENCE: On the basis of information provided the acting care manager and available staff rotas indicated that the home does not meet the National Minimum Standard OP27 and Regulation 18 of the Care Homes Regulations 2001. It was also noted that the Registered Provider does not employ a cleaner or a cook and in addition the two carers on duty on the morning shift are also expected to cover domestic and cooking duties. The staffing rotas do not show clearly who is on duty and in what capacity. Thus these staffing levels deficiencies were discussed with the acting care manager and requested in consultation with the Registered Provider - Mrs. Aurora McGarrigle to address the staffing deficiencies urgently and appropriately. The home operates an efficient recruitment procedure and there is evidence within the home that all the appropriate checks are being carried out. Tudor House Residential Home DS0000029962.V261528.R01.S.doc Version 5.0 Page 17 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 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): 31, 32, 36 and 38 The home is managed satisfactorily but urgent attention to be given to formalising the position of the acting care manager. The staff are clear about their roles and responsibilities. Systems of communication are now in place to seek the views of the service users and their families/families. Health, fire safety and welfare of the service users and staff are promoted by the safe working systems put in place by the management and the staff. EVIDENCE: The Inspector was informed at the previous inspection conducted on 1 of December of 2004, that the Registered Manager Mrs. Pamela Wilde is no longer managing the home but she is working as a night carer. The Inspector was also informed that the new acting care manager would be Mrs Joy Douglas, but to date an application has not been received from the Registered Provider. Therefore, the Registered Provider is required to make an application to register a new manager for Tudor House. However it was noted that the Tudor House Residential Home DS0000029962.V261528.R01.S.doc Version 5.0 Page 18 Acting Care Manager She has very good links with other agencies whom she consults with in order to improve the service provided by the home. There are clear lines of accountability within the home and the manager is very supportive of staff and residents. Observations made and discussions with residents and staff indcated that the Care Manager is very approachable and operates an open door policy. The staff and residents who could express themselves stated that they are happy to approach the Care Manager with any problems they might have. The acting care manager stated that the home has not implemented any formal Quality Assurance systems in the home and that she will establish and implement a system in order to comply with this Standard shortly. The Registered Provider need to visit the care home at least once a month, and prepare a written report on the conduct of the home and a copy made available for inspection by the CSCI. The fire alarm system, emergency lighting system, staff call system and electrical equipment have recently been tested and all records are maintained and appropriate certificates available in the home and for inspection. The registered Provider must ensure that any outstanding recommendations contained in the recent inspection report of the Fire Safety Officer are appropriately implemented as a matter of priority. Tudor House Residential Home DS0000029962.V261528.R01.S.doc Version 5.0 Page 19 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X 3 X 3 X X HEALTH AND PERSONAL CARE Standard No Score 7 X 8 X 9 3 10 X 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 3 18 X 2 X X X X X X 3 STAFFING Standard No Score 27 2 28 X 29 3 30 X MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 1 3 X X X 2 X 2 Tudor House Residential Home DS0000029962.V261528.R01.S.doc Version 5.0 Page 20 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 OP22 Regulation 23 Requirement The Registered Provider must ensure that an assessment is undertaken of the premises and facilities by a suitably qualified persons, including an occpational therapist. The Registered Provider must ensure there is adequate staffing levels maintained at the home at all times, including adequate domestic and catering staff on duty; and the staff duty rotas must indicate clearly who is on duty and in what capacity and wheter the rota actually worked. The registered provider must ensure that the dining room ceiling is repaired The Registered Provider must take appropriate action to formalising the position of the Acting Care Manager, and an application for registration of the Acting Care Manager is brought forward as a matter of priority. The registered provider must ensure that monthly regulation 26 visits to the home takes place and copies of the reports are DS0000029962.V261528.R01.S.doc Timescale for action 01/02/06 2 OP27 18 01/02/06 3 4 OP19 OP31 23 8 01/02/06 01/01/06 5 OP36 26 01/01/06 Tudor House Residential Home Version 5.0 Page 21 sent to the commission. RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Tudor House Residential Home DS0000029962.V261528.R01.S.doc Version 5.0 Page 22 Commission for Social Care Inspection Shrewsbury Local Office 1st Floor, Chapter House South Abbey Lawn Abbey Foregate SHREWSBURY SY2 5DE 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 Residential Home DS0000029962.V261528.R01.S.doc Version 5.0 Page 23 - 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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