Inspection on 12/09/07 for Tudor Lodge Nursing Home

This inspection was carried out on 12th September 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 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 24/01/07

Tudor Lodge Nursing Home 11/11/05

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 Anita Tengnah Key Unannounced Inspection 10:00 12 September 2007 th 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.V344385.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 Lodge Nursing Home DS0000063543.V344385.R01.S.doc Version 5.2 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 Patricia Mary Whittingham Care Home 24 Category(ies) of Dementia - over 65 years of age (24), Old age, registration, with number not falling within any other category (24) of places Tudor Lodge Nursing Home DS0000063543.V344385.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 24th January 2007 Brief Description of the Service: Tudor Lodge is a registered to provide nursing and personal care to 56 service users in the older person category. The service is located in a residential area near Fareham, close to local amenities. The building has recently been extended and 25 bedrooms have been added to the new wing. Accommodation is provided on two floors and there two shaft lifts that provide access to all parts of the building. The home has fourteen single and five shared rooms in the old part of the service and there are 25 single rooms with en suite facilities. There are ample communal rooms including lounges, dining rooms, conservatory and quiet sitting room that can be enjoyed by people using the service. The home is set in extensive gardens that are easily accessible. The current fee charged is £570-£750 per week. Tudor Lodge Nursing Home DS0000063543.V344385.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. An unannounced visit to the service was undertaken as part of the inspection on the 12th of September 2007. The process included a tour of the service where a number of the bedrooms, communal areas, kitchen, and bathrooms were viewed. As part of case tracking 6 staff and 8 service users views were sought and care records were looked at. Information gained from the Annual Quality assurance assessment (AQAA) was also used and included in this report, as was information gathered by the commission since the last inspection to contribute in assessing judgements in this report. Positive comments were received from the service users regarding the care that they were receiving at the home. The commission received 12 comment cards from the service users and some contained input from their relatives. The inspector also spoke to some visitors at the service. Care practices observed at the time of the visit showed that the staff and the service users had developed good relationships and care was provided in a respectful manner. What the service does well: What has improved since the last inspection? The décor and carpets in the old part of the building has been renewed and ongoing. Tudor Lodge Nursing Home DS0000063543.V344385.R01.S.doc Version 5.2 Page 6 The care plans were more detailed and contained risk assessments. The record of medication administered was up to date. 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 Lodge Nursing Home DS0000063543.V344385.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 Lodge Nursing Home DS0000063543.V344385.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): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. 3,6 The home has a very good and detailed pre admission process to ensure that the people’s needs are identified and the home can meet them. EVIDENCE: The care records of three recently admitted service users were looked at as part of case tracking. The manager or her deputy assessed all the service users. Detailed pre admission assessments of needs were carried out and staff reported that this information is used to formulate their initial plan of care on admission. Assessments of needs included dietary needs, likes and dislikes, manual handling assessments, skin integrity. As part of the assessment details such as Tudor Lodge Nursing Home DS0000063543.V344385.R01.S.doc Version 5.2 Page 9 social contacts, medical history and sleep patterns were recorded. There was evidence that the service users/ relatives were involved in the assessments, as appropriate in order to ensure that all care needs were identified. It was evident that the pre admission assessment records were updated in particular in the first few days as new information became available about the people’s needs. The manager reported that the service users are offered the choice of visiting the home prior to admission. Two of the service users spoken with confirmed that the staff visited them prior to admission. Comment received from a relative, “I visited the home prior to my sister moving in.” The manager confirmed that the home does not provide intermediate care. Tudor Lodge Nursing Home DS0000063543.V344385.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): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. 7,8,9,10 The care plans provided detailed information. Care plans for new people must be developed and put in place. The health care needs and access to external agencies are well managed. The medication management needed further development to include recording of medication received and management of prescribed wound dressing product. The service users are treated with respect and say that their dignity and their right to privacy is maintained at all times. EVIDENCE: Tudor Lodge Nursing Home DS0000063543.V344385.R01.S.doc Version 5.2 Page 11 The care plans of four service users were looked at as part of case tracking. A requirement was made following the last visit regarding risk assessments for all the service users. Records seen indicated that risk assessments are undertaken and care plans put in place to demonstrate how these risks would be managed. These included manual handling, falls assessments and risk of choking for another person. Staff discussed that new system of care planning had been developed following the last visit. The care plans were detailed and included personal care, mobility, catheter care, diet such as pureed meal. For people identified as risk of falls and requiring bed rails. These were in place following consultation/ consent from either the resident or their next of kin. Risk assessments relating to skin integrity were in place and appropriate pressure relieving mattresses were put in place. A relative commented “ mum was provided with air mattress as soon as the staff realised she needed one.” The care plan seen for one of the people using the service regarding the treatment needed for his leg ulcer was in place. This was detailed and contained a record of dressing changed. As discussed the record should contain details of the wound/ evaluation in order to inform practice. The record of a newly admitted service user showed that no care plan had been formulated. This was discussed with staff and the manager as the detailed assessment available contained enough information for care plan to be commenced. The staff spoken with confirmed that this would be rectified. It was noted that care plans were not reviewed at least on a monthly basis to ensure that the changing needs of the people using the service are identified and appropriate action taken. Staff discussed that there were a number of people who were receiving a lot of nursing care and bed bound at the time of the visit and whose needs were constantly changing. The manager confirmed that this would be addressed with immediate effect. The manager reported that access to the community healthcare team was available. Although the GP did not visit weekly as in the majority of homes, he was available on request. The chiropodist visited on a monthly basis and dental care was available via Fareham dental clinic. The Optician undertook six monthly visits to the service. Recent advice had been sought from the dietician for one person. A sample of the Medication Administration Record was looked at. This indicated that they were maintained appropriately to include medication administered and variable dosages. This requirement from the last inspection has been met. The home was using the NOMAD system and medication was ordered for the twenty-eight day cycle. All medication was stored safely and a record of ointment administered was also maintained. The pharmacy delivered the medication weekly. Tudor Lodge Nursing Home DS0000063543.V344385.R01.S.doc Version 5.2 Page 12 It was noted that staff were only recording the medication received on the first week only and there were no records of medication for the subsequent three weeks. This was brought to the attention of the manager. The home has two different systems of recording medication received and the manager said she would be reviewing this to ensure that there is an easier audit trail. The medicine trolley contained loose medication for one person, and medication received on admission for several people were not recorded. The recording of medication from the pharmacy on the MAR sheet for medication that have not been requested or dispensed for that month must be reviewed as the record is inaccurate and indicated that this had been dispensed. The manager must ensure that all medication received at the home is recorded accurately and medication that are hand written on the MAR sheets by staff contain the dosage, frequency and times that these should be administered. It was noted that there were a number of dressings that were not managed appropriately. Some of the dressings seen had the name of the person that this had been prescribed for deleted on the box and others belonged to people who were no longer at the service. The manager must ensure that dressings are only used for the named person and those no longer required are returned according to the home’s policy. Comment cards received and 6 of the service users spoken with confirmed that the home provided a good service and they had autonomy and choice regarding the activities of daily living. It was evident that the staff had developed good relationship with the service users and good friendly interaction was observed. Comments included ““Staff are friendly and concerned of my mother’s well being.” Other comment was that the home “provides a homely caring environment and are always willing to listen.” Other people spoken with said that staff knocked prior to entering their rooms. One person who had recently moved in said “I have made the right choice” and another comment was “the staff are very good”. Staff practices observed indicated that personal care was provided with respect. Screens were available in the shared rooms seen during the visit. Tudor Lodge Nursing Home DS0000063543.V344385.R01.S.doc Version 5.2 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. 12,13,14,15 The social and recreational facilities for the service users are good and meet with their satisfaction. The service users are supported to maintain links with the community and their family and friends. The service users autonomy and choices are respected in their activities of daily living. The meals are satisfactory and offer the people with a balanced and varied diet. EVIDENCE: The home has a variety of activities and information about what is on offer was displayed on the activity board. The staff reported that external entertainers provide most of the activities. Information from the comment cards received three said “usually” and six said” sometimes when asked if there was adequate activity offered. One said, “there is not enough one-to-one contact”. Activities Tudor Lodge Nursing Home DS0000063543.V344385.R01.S.doc Version 5.2 Page 14 provided included musical sessions, pat a dog, music for health with instrument offered and people supported to encourage participating. Staff said that manicure was available on alternate Tuesdays and the hairdresser visited weekly. A hairdressing salon had been put in place in the new build that was well equipped for the use of people using the service. The local vicar attended the home and Sunday service was available weekly from different denomination. One of the people spoken with said that he went to church with his brother. The home has an open visiting policy and it was evident from the record of visitors as kept by the home that there was no restriction on visiting. Comment received and three people confirmed that they have autonomy to receive their visitors in private. A newly admitted person spoken with said, “people can come at any time within reason and it is not a problem”. Other comments included “we are always made welcome and get my mum ready when being taken out.” The home has a planned menu that is rotated on a regular basis. Comment cards received and the service users spoken with said that the meals were “very good” and hot and cold drinks were available at all times. Comments included “excellent food” and “good choice “. The lunchtime meal was observed and meals appeared appetising, well balanced and nicely presented. Staff were available to offer support with meals as required. The people spoken with confirmed that staff help them with the menu and they are offered a choice of meals. Three of them reported that a cooked breakfast was not available and one went on to say that he had asked for three egg on toast for the three of them and they did not get it. This was discussed with the chef who stated that a cooked breakfast was planned and there has been some difficulty due to the extension of the service. The chef discussed that cooked breakfast would be included on the menu and staff would be reminded to offer this when they do the menu. Other comment was “special requests are not always followed up”. Tudor Lodge Nursing Home DS0000063543.V344385.R01.S.doc Version 5.2 Page 15 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. 16,18 The complaint management is satisfactory and the service users are confident that their complaints would be listened to. Staff demonstrated clear understanding of adult protection and ongoing training ensures that information is available to them. EVIDENCE: The home has a complaint policy and the procedure was prominently displayed in the entrance hall. The home maintained a complaint log and there has been no complaint reported to the commission or the service since the last visit. Comment cards received and people spoken with said that they would approach the manager or the provider if they had any concerns. Comments from people spoken with included ” there is nothing to complain about”. Another comment was “I would speak to the manager if things go wrong”. ” Two people spoken with had on the day approached the provider and the manager with some issues and were satisfied with the proposed action. The staff spoken with were aware of what constituted abuse and said that they would be confident in approaching the manager. The manager stated that training in adult protection was available to staff. Tudor Lodge Nursing Home DS0000063543.V344385.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. 19,26 Accommodation and facility for the people using the service in the new build is excellent. The old part of the service is in the process of being refurbished to achieve the same high standard. The infection control procedures at the home are good. The management of the service users personal laundry is poor. EVIDENCE: The home has been recently extended and the new build consists of twenty new rooms with en suite facilities. A number of the bedrooms were looked at and including the communal lounges, dining rooms, bathrooms, kitchen and Tudor Lodge Nursing Home DS0000063543.V344385.R01.S.doc Version 5.2 Page 17 the new laundry room. The service users are provided with ample communal spaces and well-maintained garden that are accessible for wheelchair users. The people bedrooms seen were personalised and appropriate furnishing. It was evident that people are encouraged to bring in items of personal belongings on admission to the home. One lady said that she has extra space to store her books and was waiting for her pictures to be put up. One of the shared bedrooms had a very strong smell of urine. This was discussed with the person in charge. Staff said that they were aware of this problem and the bedroom’s carpet would be changed as part of the refurbishment. The manager reported that the carpet is cleaned regularly and they were looking into the problem. The provider discussed the major building development programme that was ongoing. Work was in progress to link the two parts of the building and a complete refurbishment of the old part of the service. It was evident that the provider is committed to provide a high standard of accommodation and the people spoken with were highly complimentary about the home and the facilities. Comments included ”I have everything I need in here”. ”The home provides a homely caring environment and are always willing to listen.” “Home always clean and fresh.” The home has a new laundry in place as part of the extension. Staff reported that all the people using the service laundry are undertaken internally. The washing machines were fitted with sluicing programme and the dryers were inn place. The laundry has a separate area where the ironing would take place and also helps to provide a clean area as part of infection control procedures. Staff were observed to follow infection control guidance and used protective clothing and gloves. It was noted that there were two large boxes and some other items of clothing in a wardrobe that staff reported could not be returned to their rightful owners. These clothing were not marked with the people’s names and staff were unable to return them. The manager must ensure that a system is put in place to deal with the people’s personal clothing and these are marked so that they can be returned. A senior staff member said that she was not aware of the extent of the problem and urgent action is needed. Tudor Lodge Nursing Home DS0000063543.V344385.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. 27,28,29,30. The staffing numbers are adequate to meet the present needs of the service users. The home has system in place to ensure that staff have the skills to deliver care safely. The recruitment process is very good. All checks are undertaken prior to employment to ensure the safety of the service users. The home could not evidence training available for staff due to lack of record. EVIDENCE: The home has a duty roster for the carers and nurses and a separate roster for the ancillary workers. Staff spoken with and comments received indicated that there was adequate staff to meet the present care needs of people living there. Comments received included ““Staff are friendly and concerned of my mother’s well being.” The manager and staff reported that two laundry persons have been recruited and this has been good as the carers are no longer responsible for the laundry. Comments from staff included ”this is a very good place to work” and others commented, “we all get on well and work as a team”. Tudor Lodge Nursing Home DS0000063543.V344385.R01.S.doc Version 5.2 Page 19 Information received from the AQAA indicated that there is a training programme for carers to undertake the National Vocational Qualification (NVQ) training in care. The AQAA identified that home has 14 carers who have achieved NVQ level 2 or above and two were working towards this qualification. The manager reported that new staff have the in house induction, however there were no records of these available. Evidence of staff induction training must be maintained at the service. The manager reported that she was planning to introduce the induction programme as Skills for Care. A sample of three recently recruited staff record was seen. All staff completed an application form and references were sought. There was a good recruitment system in place that ensured that all necessary checks were completed prior to employment. These included Criminal Record Bureau checks and POVA first. The home has a training programme for staff. Three of the carers spoken with said that they could request particular training and this would be available. It was not possible to ascertain what training staff had undertaken recently due to lack of records. Discussed that a training matrix should be put in place to help monitor staff training and identify any shortfall particularly in mandatory training in health and safety and moving and handling. Tudor Lodge Nursing Home DS0000063543.V344385.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home has a manager who is highly regarded and has clear lines of accountability for the service. The financial interests of the service users are safeguarded through good accounting. The process of seeking the service users’ views is well managed and ensures that the home is run in their best interests. The supervision programme for staff was inadequate and must be put in place. There is a satisfactory procedure in place to ensure the health and safety of the service users is promoted. Tudor Lodge Nursing Home DS0000063543.V344385.R01.S.doc Version 5.2 Page 21 EVIDENCE: The manager is a registered nurse and has the day-to-day management responsibility of the service. Comments received and those spoken with at the tome of the visit spoke highly of the manager. Comments were that she was always available and “would listen to what we have to say”. The staff said that the manager was supportive and they would approach her with any concerns. The manager undertook regular updates in order to maintain her nursing registration. She demonstrated clear lines of accountability for the service. The provider is fully involved in the service and discussed that her role was to oversee the smooth running of the service. As part of their quality assurance, the provider discussed that she was planning to use an external company to audit the views of the people using the service, relatives and GP, health care professionals in October this year. Regular staff meetings were held as part of keeping staff informed during the recent extension of the building. A sample of the personal allowance as managed by the home was looked at. There was a good system in place and all the service users’ money were kept separately. Receipts and invoices were maintained of transactions. Random checks of three of the service users’ personal account were found to be accurate. All transactions undertaken with the service users were recorded accurately. Discussed receipts to relatives for money received on behalf of the people using the service. The manager reported that a structured supervision programme was available for staff. However this had not taken place since the beginning of the year due to the building work. The manager is aware that staff must have supervision as part of their practice at least six times a year and records of this must be maintained. Information received indicated that there are regular reviews of policies and procedures to ensure that they meet current legislation/ guidelines. Records of regular fire training and drills were maintained. The environmental health officer visited recently, as part of registering the kitchen as part of the new build. There is an ongoing programme for the servicing of fire equipment, hoists, wheelchairs, lift and emergency lighting. All substances that are hazardous to health (COSHH) were kept locked away safely. Staff reported that soaps dispensers and disposable towels were being fitted in the communal areas in the new build. This would ensure good infection control practices are maintained. Tudor Lodge Nursing Home DS0000063543.V344385.R01.S.doc Version 5.2 Page 22 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 3 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 2 X 3 Tudor Lodge Nursing Home DS0000063543.V344385.R01.S.doc Version 5.2 Page 23 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. 1. Standard OP9 Regulation 13(2) Requirement The registered person must ensure that records are maintained for the all medication received at the home for the people using the service. The registered person must ensure that record of medication to be administered includes the dosage, time and route of administration as Royal Pharmaceutical guidelines. The registered person must ensure that wound dressings are only used for the named person. The registered person must ensure that evidence of staff mandatory training is available for all staff to ensure the safety of people using the service. Timescale for action 30/10/07 2 OP9 17(1) schedule 3 30/10/07 3 4. OP9 OP30 13(2) 18 (1) 30/10/07 30/10/07 Tudor Lodge Nursing Home DS0000063543.V344385.R01.S.doc Version 5.2 Page 24 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 OP30 Good Practice Recommendations The development of a training matrix would be useful in identifying any gaps in staff training. Tudor Lodge Nursing Home DS0000063543.V344385.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection Hampshire Office 4th Floor Overline House Blechynden Terrace Southampton SO15 1GW 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. 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