Inspection on 11/11/05 for Tudor Lodge Nursing Home

This inspection was carried out on 11th November 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Tudor Lodge Nursing Home 12/09/07

Tudor Lodge Nursing Home 24/01/07

Tudor Lodge Nursing Home 10/06/05

Similar services:

St Vincents

The Cotswold Home

Newbeech House

Winton House

Rush Court

Hillyfield Rest Home

The Maypole Nursing Centre

The Briars

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

CARE HOMES FOR OLDER PEOPLE Tudor Lodge Nursing Home Newgate Lane Fareham Hampshire PO14 1AU Lead Inspector Tim Inkson Unannounced Inspection 11th November 2005 09:30 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Tudor Lodge Nursing Home DS0000063543.V263614.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 Lodge Nursing Home DS0000063543.V263614.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Tudor Lodge Nursing Home Address Newgate Lane Fareham Hampshire PO14 1AU 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) 01329 220322 01329 822075 Mr Mark Colin Palmer Mrs Jane Marie Palmer Mrs Janet Catherine Broad Care Home 24 Category(ies) of Old age, not falling within any other category registration, with number (24), Terminally ill (4), Terminally ill over 65 of places years of age (24) Tudor Lodge Nursing Home DS0000063543.V263614.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. Service users in the category TI, must be at least 55 years of age. Date of last inspection 10th June 2005 Brief Description of the Service: Tudor Lodge is located in a residential area near Fareham, close to local amenities and on a bus route that enables ready access to Fareham town centre. Originally a large family house, the building was extended and converted for use as a care home. There is bedroom accommodation for residents on the ground and first floors of the building and a passenger lift provides access to the first floor. The home has fourteen single and five shared rooms. Four bedrooms have en-suite facilities. The communal/shared facilities include two assisted bathrooms, a lounge and a dining room, and a small annexe room that can provide more privacy for visitors. The home is set in extensive gardens that are easily accessible and other facilities include a laundry service and full board. Tudor Lodge Nursing Home DS0000063543.V263614.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was the second of two inspections of the home that must be undertaken in the 12-month period beginning on 1st April 2005 and the second since new owners took over the home in the late spring of 2005. It started at 09:40 hours and finished at 16:30 hours. The inspection procedure included viewing a sample of some bedrooms (7), an examination of some documents and records, observation of staff practices where this was possible without being intrusive and discussion with residents (9), staff (4) and visitors/relatives (2). At the time of the inspection the home was accommodating 24 residents and of these 3 were male and 21 were female and their ages ranged from 74 to 98 years. No resident was from a minority ethnic group. The home’s registered manager and the owners were present during the day and available to provide assistance and information when required. What the service does well: What has improved since the last inspection? The skill mix of the home’s staff had altered considerably since the last inspection of the home that took place on 10th June 2005. The ratio of health care assistants that had an appropriate formal qualification had increased from 10 to 47 , ensuring that there were sufficient staff with the skills and competence to meet the needs of the residents accommodated in the home. The home had implemented systems for: Tudor Lodge Nursing Home DS0000063543.V263614.R01.S.doc Version 5.0 Page 6 Monitoring the quality of the service provided. This involved seeking the views of all interested parties to enable the need for improvements to be identified. • Providing staff with regular individual formal structured supervision sessions to ensure that their personal and professional development was encouraged and that they felt valued. Improvements to the environment/premises that promoted the comfort and safety of residents included a new ramp at the entrance to the building, new WCs and a hoist in a bathroom. A new conservatory was under construction that will provide more space and choice of communal areas to use for residents. New furniture had been provided in the home’s lounge and some bedrooms had been redecorated. New health and safety practice and procedures had been implemented to ensure the welfare of both staff and residents and these included the display of warning signs where required and the implementation of risk assessments of safe working practices and ensuring that staff received regular fire safety 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 Lodge Nursing Home DS0000063543.V263614.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 Lodge Nursing Home DS0000063543.V263614.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): 3 The home’s admission procedures included good assessments of the needs of potential residents before they moved into the home to ensure that the home could provide the care and support that individuals required. EVIDENCE: The records of 4 residents were examined and these included copies of detailed assessments that the home had arranged of the needs of the individuals concerned. On this occasion as at the last inspection of the home on 10th June 2005 it was apparent from discussion with residents and visitors/relatives as well as from the documents examined that the needs of potential residents were identified before the persons moved into the home. Comments about the home’s pre-admission assessments procedures included the following: • “I came from X I was in the chucker out ward when they came to see me in the hospital to see what I could do and if I could come to this place.” • “The assistant manager went to X to assess her before she came here”. It was also evident from the records examined that the home wrote to potential residents before they moved into the home informing them that the home could meet their assessed needs. Tudor Lodge Nursing Home DS0000063543.V263614.R01.S.doc Version 5.0 Page 9 The pre-admission assessments were complemented by more thorough and comprehensive assessments of a resident’s needs when they actually moved into the home. There was documentary evidence that assessments of residents needs were reviewed regularly and revised as necessary when an individual’s circumstances had changed. Tudor Lodge Nursing Home DS0000063543.V263614.R01.S.doc Version 5.0 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): 7, 9 and 11 There were good plans of care in place that ensured that residents received the help and support that they needed. Good procedures and systems were also in place to ensure that medication was administered safely and death and dying was managed sensitively. EVIDENCE: On this occasion as at the last inspection of the home on 10th June 2005, a sample of the care plans of residents were examined (4). The documents were detailed and the plans were based on the assessments the home carried out in order to identify what help individuals needed (see pages 9 and 10). The plans set out clearly the actions staff had to take and what specialist equipment was needed to provide the support and assistance each person required. Observation and discussion with residents, relatives/representatives confirmed that individuals received the help they needed and that the equipment was in place as set out in their plans of care. There was evidence from both the documentation and discussion with residents that wherever it was possible individuals or their representatives had been involved in developing the plans and agreed with the contents. Residents and visitors/relatives commented about the way the home planned and provided the help that individuals required. • “They help me with bathing and dressing and they also dress my legs and put cream on them”. Tudor Lodge Nursing Home DS0000063543.V263614.R01.S.doc Version 5.0 Page 11 • • • • • “We are delighted my mother is so much brighter. The care that she receives is exactly what the plan says - the staff are very caring, they are lovely”. “If the staff can help they will, they will do what they can for you”. “I have seen my care plan and I am happy with all they do for me”. “The staff are excellent, they are all very good at what they do”. “The staff are very helpful and kind”. All nursing and care staff spoken to were fully aware of the contents of the care plans that were sampled and the assistance that the individuals concerned required. The care plans documents included assessments of the potential risks to residents of among other things, pressure sores, malnutrition, and falls. There was evidence that care plans were evaluated and reviewed regularly. The home had written policies and procedures concerned with the management and administration of medication. Some reference material about medication was readily available including a copy of the British National Formulary (BNF). Medication was kept in a locked and secured trolley, a locked cupboard and where required in a medical refrigerator. If they were required, controlled drugs could also be secured in an appropriate metal locked cabinet. The home operated a monitored dosage system for those medicines that could be dispensed using cassettes that were provided by a local pharmacist each week. Other medicines e.g. liquids, or those that could be spoiled by moisture or exposure to the atmosphere were dispensed from their original containers. The only staff responsible for the management and administration of medication were registered nurses. Records were kept of the ordering, receipt, administration and the disposal of medicines and these were accurate and up to date. At the time of the inspection no resident was managing their own medication but the home’s manager said that this could be arranged, subject to a risk assessment, if a resident desired it. The home had developed links with a local hospice and had “up to date” written guidance and policies available concerned with managing the death of residents. The home’s manager said that staff from the hospice visited Tudor Lodge and provided training for the home’s staff in caring for the dying. The records of two residents that had recently died were examined and it was apparent from notes that had been kept that the comfort of the individuals and the support of their relatives had been paramount. Tudor Lodge Nursing Home DS0000063543.V263614.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 14 The home had good procedures in place for ensuring residents could exercise self-determination. EVIDENCE: The home’s Statement of Purpose referred to core values that were regarded as fundamental to its philosophy and they included the promotion of residents’ rights and independence. At the time of the inspection some residents said that they managed their own financial affairs and a number also indicated that were pleased to have given that responsibility to a relative or friend. Comments from residents about this matter included the following: • “My daughter looks after my money for me and I have money put aside for me”. • “My son-in-law has power of attorney and he deals with all my financial affairs”. • “I look after my own affairs”. • “ I have a solicitor who deals with things for me, arranges payment of the fees and so on”. • “My old neighbour and her husband manage my money for me”. Tudor Lodge Nursing Home DS0000063543.V263614.R01.S.doc Version 5.0 Page 13 The terms and conditions/licence agreements issued to residents when they moved into the home included the following paragraph about individual’s personal effects: “At the discretion of Tudor Lodge Nursing Home items of furniture may be brought in by the resident subject to inspection as to the condition and defects liable to render the article unsafe or unfit …….”. A number of residents said that they had brought small items of furniture into the home with them and all residents had brought some personal effects such as pictures and ornaments. Comments from residents about their ability to furnish or decorate their bedroom accommodation included the following: • “I knew that I could bring things with me and I have some personal items but I did not have any furniture to bring even if I wanted to”. • “ I have some of my own belongings and a couple of bits of furniture, but I did not need much because the home provides everything”. • “I brought my chair and I have loads of pictures and other things that are all mine”. • “I am bringing my own bits and pieces in, my own T.V and wireless” The home’s registered manager was reminded of the requirement to keep records of furniture brought by service users into rooms that they occupied. A number of residents spoken to were aware that they could see records that the home kept about them. The home had a written policy and procedure about access to personal files and data protection requirements. Sensitive information about residents was kept in the home’s office. Comments from residents about records and information that the home kept included: • “I know that they keep records about me but I have never bothered to view them”. • “I can see my records whenever I want”. • “I have seen the things that are written about me”. One resident’s commented about her ability to exercise choice and control over her life and illustrated this by saying: • “I have my individuality and I can go to my room upstairs whenever I want” It is suggested that the home could display and provide information about independent advocacy and information services that residents and their relatives/friends could contact and access if they wanted help. Tudor Lodge Nursing Home DS0000063543.V263614.R01.S.doc Version 5.0 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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 17 The home had satisfactory systems and procedures in place for managing the concerns of residents and their relatives or friends also for ensuring that residents could exercise their legal rights. EVIDENCE: All residents spoken to expressed confidence in their ability to raise any matters of concern or complaints with the home’s staff or manager and most were aware of the home’s complaints procedure. The procedure was set out in the home’s Statement of Purpose/Service Users Guide and also in the terms and conditions/licence agreement issued to all residents when they moved into the home. A copy of the complaints procedure was also prominently displayed. The home kept a record of complaints, and details of how they were investigated and the outcome. There had been no complaints made either to the home or to the Commission for Social Care Inspection during the last 18 months. Comments from residents about making complaints included the following: • “I would certainly complain if I was unhappy about something”. • “I would speak to one of the carers if I had a complaint”. • “If I was unhappy I would speak to the person in charge”. • “I would speak to the manager if I had a complaint as she is very approachable and lovely”. Most residents spoken to confirmed that they could vote in elections, although two said that she did not know or were unsure if they could. • “I had a postal vote and have used it since I have been here”. • “I have not voted – I don’t know if I can”. Tudor Lodge Nursing Home DS0000063543.V263614.R01.S.doc Version 5.0 Page 15 • • “They arranged a postal vote for me”. “I can either go to the polling station or have a postal vote, the choice is mine”. It is suggested that information made available to residents when they move into the home includes reference to their right to participate in the civic process and also if the local council makes them available, an application form to be included on the electoral roll. Tudor Lodge Nursing Home DS0000063543.V263614.R01.S.doc Version 5.0 Page 16 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, 24 and 25 The home’s environment including residents’ bedrooms was generally well maintained, furnished and equipped for service users safety and specific needs. EVIDENCE: There was evidence that since that last inspection of the home on 10th June 2005, improvements to the environment had been implemented and embarked on. These included a new ramp at the entrance to the building that enhanced access for wheelchair users and the foundations of a conservatory at the rear of the premises that would increase the amount of shared/communal space available to residents. Communal toilets and a bathroom on the ground floor of the home had all been reconfigured and re-equipped with grab rails and WCs of a suitable design and height and to meet the needs of residents. More space had been made available in one bathroom by the installation of ceiling track with a hoist. Some furniture in the communal lounge had been replaced and a small area adjacent to the lounge had been made more welcoming by the use of soft furnishings and was being used by visitors at the time of the inspection visit. Tudor Lodge Nursing Home DS0000063543.V263614.R01.S.doc Version 5.0 Page 17 There was evidence from records and discussion with staff and residents that the fire safety in the home was addressed by the home. This included the staff receiving regular and on-going training in fire safety and fire safety systems and equipment being tested, checked and serviced at appropriate intervals. The building and décor and furnishings were generally in good repair and records were seen indicating that all plant, equipment and utilities systems in the home were regularly checked and serviced. A number of bedrooms had been redecorated since the last inspection of the home on 10th June 2005, and a programme of replacement of beds with height adjustable and profiling beds implemented by the new owners and evident at the last inspection was continuing. All residents spoken to expressed contentment with the condition of the accommodation including their bedrooms and indicated that it was looked after. Comments from residents about these matters included: • “I like the garden and trees, the equipment for transferring people is good. The home is comfortable and so is my bed. My room is a bit small when they get the hoist in there”. • “The building is very nice and comfortable to live in. The new owners have changed some of the things downstairs and redecorated. The decoration is first class. I love my room and the view”. • “I like the way its decorated and the furniture is nice and modern”. • “I love my bedroom it like a cottage. I could do with a bigger bed”. • “Its very comfortable here – my bed is lovely it’s kept warm, too warm at times. The furniture and decorations are lovely” Bedrooms viewed varied in size and configuration but were furnished and equipped as expected by Standard 24 of the National Minimum Standards for care Homes for Older People. They were fitted with carpets and doors were fitted with suitable locks, they were naturally ventilated and heated by radiators that were covered with guards to prevent residents from the risk of burns. All shared bedrooms viewed were provided with screening to provide privacy. The nurse call system was tested in one room. It was working and staff responded very quickly when it was activated. There were warnings above wash hand basins where the hot water was delivered above 43°C. Tudor Lodge Nursing Home DS0000063543.V263614.R01.S.doc Version 5.0 Page 18 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): 28 and 30 The home had good systems in place to promote staff training and development and consequently there were sufficient staff with appropriate qualifications and skills to meet the needs of residents. EVIDENCE: There were 15 health care assistants employed to work in the home at the time of the inspection and of these 7 (47 ) had obtained a National Vocational Qualification (NVQ) to at least level 2 in care or its equivalent. Another 3 health care assistants were “waiting to embark” on these qualifications. At the last inspection of the home on 10th June 2005, there were 10 health care assistants working in the home and of those 1 (i.e.10 ) was qualified to at least NVQ level 2 in care or it’s equivalent. The ratio of staff with that had been formally assessed as competent to provide care and support for vulnerable people and had been awarded a qualification as evidence of their abilities had therefore increased considerably since the last inspection of the home. One of the home’s owners said that since the last inspection of the home on 10th June 2005 the manager was supernumerary for several shifts each week and consequently a formal staff appraisal and supervision system had been implemented (see also at page 23 and Standard 36). These staff appraisals were used to identify individuals’ training and professional development needs and comments from staff about this aspect included the following: • “I have been her since July and I have had 2 meetings at which I have talked about how I could contribute to improvements in the home. I have completed my induction and probationary period. A lot of staff have NVQs and things here have got easier since we have got more staff”. Tudor Lodge Nursing Home DS0000063543.V263614.R01.S.doc Version 5.0 Page 19 • • “I have been here 8 months and I have completed my induction. I missed a recent training session in moving and handling, but I did fire training in July and August. I also did a lot of training in my previous place of work”. “I am going to do NVQ next year”. Tudor Lodge Nursing Home DS0000063543.V263614.R01.S.doc Version 5.0 Page 20 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, 33 36, 37 and 38. The home’s manager had the experience and skills necessary to run the home effectively. There were good systems in place to ensure that; the quality of the service provided could be improved; staff were appropriately supervised and supported; and proper record keeping safeguarded residents’ interests. EVIDENCE: Tudor Lodge Nursing Home DS0000063543.V263614.R01.S.doc Version 5.0 Page 21 The registered manager was a registered first level nurse and had been responsible for the home for some 3 years. Prior to that she had managed another nursing home for 10 years. She had attended recent training courses in health and safety topics e.g. moving and handling. At an inspection of the home on 25th January 2005, the manager indicated that she did not intend to obtain a formal management qualification (this is an expectation of Standard 31 of the National Minimum Standards for Care Homes for Older People) because of her age and that she intended to retire within 2 to 3 years. She reiterated that intention again on this occasion. Staff and residents spoken to indicated their confidence in the abilities of the manager and in particular her clinical skills. At the last 2 inspections of the home on 25th January and 10th June 2005, there were no systems in place for monitoring the quality of the service it provided. The new owners had implemented a number of methods for ascertaining from interested parties what the home was doing well and identifying where things could be made better. These included arranging regular meetings with residents, relatives and staff as well as using questionnaires to obtain their views. Comments from residents, relatives and staff about the way the home had been run since the new owners had taken over were generally very positive and included the following: • “I enjoy living in the home – the staff are very nice and do a good job”(resident). • “It is pleasant living here, the people and the staff are easy and pleasant to live with – the carers are all very good at their jobs and the standards are excellent ” (resident). • “I don’t think anything can be improved in the place – it’s generally a good place to live” (resident). • “The new owners are making lots of changes which is good and it’s better than the previous one” (resident). • “We looked at 12 homes for my mother and short-listed this one – it was the consensus that this was the nicest – it’s the people and the atmosphere” (relative). • “We have regular staff meetings now, it’s a lot better since the new owners took over” (staff member). • “The new owners view is that the residents really matter – they really care” (staff member). There were a range of written policies and procedures available that staff could access and which provided information and guidance about every day working practice. The new owners had introduced and also implemented some new policies e.g. risk assessments of safe working practices, that had been unavailable at the last inspection of the home on 10th June 2005. Staff spoken to appreciated the availability of the policies and procedures and their importance. Comments about them included: - Tudor Lodge Nursing Home DS0000063543.V263614.R01.S.doc Version 5.0 Page 22 “I have taken some of the policies and procedures home to read - you need proper guidelines”. • “They are helpful and you need something to refer to sometimes”. There had been 6 requirements arising from the last inspection of the home and all had been actioned and remedied or implemented e.g. a quality monitoring system had been set up (see above); formal staff supervision had been established (see below). At the last 2 inspections of the home there was no evidence of a structured system of formal individual staff supervision. On this occasion one of the owners said “the manager is not on the floor all the time and therefore now has time to provide supervision for and appraisal of the staff team”. There was documentary evidence of formal individual staff supervision sessions being provided and staff spoken to confirmed that they met on a regular basis with the home’s manager (see also pages 19/20 and Standard 30). During the inspection visit a number of statutorily required records were examined and at the time they were all complete, accurate and up to date. The records examined included the following: • • • • • • • • • Assessments and care plans for residents and related records. Statement of Purpose Service Users Guide Medication Fire safety including tests of equipment and drills and staff training Staff Visitors to the home Accidents Complaints • Tudor Lodge Nursing Home DS0000063543.V263614.R01.S.doc Version 5.0 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 X X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 X 9 3 10 X 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 X 14 3 15 X COMPLAINTS AND PROTECTION Standard No Score 16 3 17 3 18 X 3 X X X X 3 3 X STAFFING Standard No Score 27 X 28 3 29 X 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X X 3 3 X Tudor Lodge Nursing Home DS0000063543.V263614.R01.S.doc Version 5.0 Page 24 Are there any outstanding requirements from the last inspection? No 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. Standard Regulation Requirement Timescale for action 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 Lodge Nursing Home DS0000063543.V263614.R01.S.doc Version 5.0 Page 25 Commission for Social Care Inspection Hampshire Office 4th Floor Overline House Blechynden Terrace Southampton SO15 1GW 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 Lodge Nursing Home DS0000063543.V263614.R01.S.doc Version 5.0 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. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!