Inspection on 24/01/07 for Tudor Lodge Nursing Home

This inspection was carried out on 24th January 2007.

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 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 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 Val Sevier Key Unannounced Inspection 24th January 2007 10:00 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 Lodge Nursing Home DS0000063543.V322413.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.V322413.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 Mrs Janet Catherine Broad 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 Terminally ill (4), Terminally ill over 65 years of age (24) Tudor Lodge Nursing Home DS0000063543.V322413.R01.S.doc Version 5.2 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 11th November 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. All fees are based on assessed needs and facilities at the home and the range is £513 - £620. Tudor Lodge Nursing Home DS0000063543.V322413.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The purpose of the inspection was to assess how well the home is doing in meeting the key National Minimum Standards and Regulations. The findings of this report are based on several different sources of evidence. These included: an unannounced visit to the home, which was carried out on the 24th January 2007, during which the inspector was able to have discussions with staff and have interaction with the service users at the home. In addition 6 relatives had completed questionnaires prior to the visit. During the visit to the home a tour of the premises was carried out which included bedrooms. Staff and care records were sampled and in addition to speaking with staff and service users, their day-to-day interaction was observed. All regulatory activity since the last inspection was reviewed and taken into account including notifications sent to the Commission for Social Care Inspection What the service does well: What has improved since the last inspection? What they could do better: Tudor Lodge Nursing Home DS0000063543.V322413.R01.S.doc Version 5.2 Page 6 The manager is currently reviewing all the systems and documents / records used at the home. She stated at the inspection that two things have become apparent that need to be changed soon, those are the pre admission assessments and the care plans. The inspector, who sampled four plans, confirmed this as it was noted that there was a lack of consistency in the information available for staff to support identified needs of individuals. There needs to be risk assessments in place for all residents at the home with attention paid to those that have a lack of self safety through dementia. The staff need to be consistent in their recording of medication administration. 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.V322413.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.V322413.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standard 3 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home’s admission procedures included 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. These assessments could be evaluated to ensure that they meet the needs of the home and the standards. EVIDENCE: The home had written policies and procedures concerned with the admission of new residents to the home and these referred to the importance of ascertaining the help required by potential residents before they moved into the home. The inspector sampled four records of residents who had been admitted to the home since the last inspection. It was apparent that new documents were being used by the home to record information about potential residents before they moved into the home. Tudor Lodge Nursing Home DS0000063543.V322413.R01.S.doc Version 5.2 Page 9 Residents spoken to confirmed that senior members of staff from the home saw them before they moved into the home to see what help they needed. • “The nurse visited me at the hospital and made some notes”. • “The matron came to see me at home – I was very lucky she came and chose me”. The pre-admission assessments were complemented by other monitoring tools used to assess 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.V322413.R01.S.doc Version 5.2 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 7, 8, 9, 10 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. There were plans of care in place that ensured that residents received the basic help and support that they needed. The plans would however benefit from including needs other than those purely concerned with physical care and health. The home’s procedures and systems for ensuring that medicines were administered were not consistently managed. EVIDENCE: The new manager explained that she was auditing documents and systems at the home and wanted to alter the admission assessments and the care plans. She feels that there are several changes needed and these two will be the first and she is keen to alter them before the new building is opened later this year. The inspector viewed four care plans and was noted that there was a variable amount of information about the support that the staff needed to give. Two Tudor Lodge Nursing Home DS0000063543.V322413.R01.S.doc Version 5.2 Page 11 care plans offered very little information to staff to assist and were focused on physical support such as dressing and washing. In one case it was noted on the page listing the individual’s medication, that staff should ensure that medication for depression was taken. There was no care plan for the support for the mental well being of the individual. The other two however, gave more detail and included information on those individuals specific needs such as communication and mental well being. There were several examples of monitoring tools, which were completed on admission and then monthly; this included weight, blood pressure and pulse. This information was being recoded in two or three places and is one of the things that the new manager wants to revise. All four care plans had assessment of mobility support such as two staff plus a stand aid. However there were no other risk assessments in place. One individual wanders and becomes confused through their dementia. To assist with the monitoring of their safety an auditory monitoring device is in their room with the other in the office, staff said that they are then aware of when the individual leaves the room. Whilst the assessment of need has been looked at there is no record of this risk assessment and what other methods or support was available. The care plans mentioned that other health support such as chiropody and mouth care was to be offered however; there was no evidence of how this was to be done, how it was to be offered or if it was accepted/took place. In two of the care plans it was noted that the individuals had developed sore areas that the named nurse had assessed and which were having dressings. However there was no plan in place with how the decision was made and what action was to be taken and how often. There was evidence in the daily notes that dressings were changed, although it was not clear whether this was ad hoc or planned and if the sore areas were healing. These issues were discussed with the manager who plans to incorporate them into her new care plans. The manager also wishes to pursue the named nurse system and to have care staff working the named nurse in a key worker team. The homes local pharmacist reviewed the medication storage and administration on 17th October 2006. Several recommendations were made for action by either the home or the pharmacist. All those that the home were recommended to do such as: have an information file on all the medicines that are prescribed for individual at the home, have been fulfilled. The storage has been altered since that visit and meets the home’s polices and guidelines. The medication administration sheets (MAR sheets), were sampled and it was found that there were 15 gaps, where there was no signature or information to indicate whether medication had been given. For one individual it was noted that their medication was out of stock for 8 days, the manager stated that the family purchase this homely remedy and the family had taken a while to bring more to the home. Tudor Lodge Nursing Home DS0000063543.V322413.R01.S.doc Version 5.2 Page 12 There were several instances where staff had not indicated the amount of medication they had given, where there was a choice of 1 or 2 tablets; and where these were ‘as needed’ medication, what the outcome was. Nurses and care assistants spoken to were aware of the contents of the care plans that were sampled and the assistance that the individuals concerned required, although a lot of the information was known due to amount of time the person had been cared for, not written. Comments from residents about the help that they received included the following: “They help me with everything, from taking my pills to taking me to the toilet”. “I sometimes think that I am lucky to be here as my health has improved. I have to watch my diet. I am very independent really but they help me with bathing”. “The people look after me very well”. “I have been here about a month. I was apprehensive coming from hospital but it is great, they look after me well”. “I have been here a while, I was a complete wreck when I came here but look at me now”. “They help me get washed and dressed”. The inspector was able to observe staff interaction with residents and that staff promoted privacy and dignity. The inspector was able to speak with a relative who had visited from a distance and was assisting their parent with their lunch. They spoke highly of the home and said: “When I visit the staff seem to be able to speak to Mum and know what she wants, she is always clean and tidy and seems to have everything she needs”. Tudor Lodge Nursing Home DS0000063543.V322413.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): Standards 12, 13, 14 & 15 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. There are daily activities at the home, which offer stimulation and or fun, which have been chosen by residents and are suitable and appropriate. The home had good procedures in place for ensuring residents could exercise self-determination. The meals in the home were good and provided variety, choice and catered for special dietary needs EVIDENCE: There are daily activities at the home supported by staff or from external visitors examples included: cards, scrabble, bingo, draughts and ball games, which are appropriate for fading eyesight. Armchair exercises, the local library visits and changes books, talking books, music, puzzles, singers, arts and crafts, flower arranging, memory exercises and spiritual services weekly. One resident said that the local churches take it turn to give a service at the home so resident can choose which they prefer. Tudor Lodge Nursing Home DS0000063543.V322413.R01.S.doc Version 5.2 Page 14 The home had several written policies that were concerned with the rights of residents. These included: • Residents’ charter • Confidentiality • Access to personal files and case notes • Voting and the electoral register • Advocacy • Handling money and valuables • Self medication These referred to the right of residents to make their own choices, act independently and enjoy the same rights and freedoms as any person living in the community. The home’s manager said that the home did not take responsibility for the financial affairs of any residents. All the residents spoken with indicated that they were pleased to give the responsibility for such matters to relatives/representatives. The home enables and encourages residents to furnish their own bedroom accommodation if they wanted to do so. Several residents spoken with said they had items of their own in their rooms and appreciated being able to personalise their bedroom accommodation so that it was “like home”. Items seen included tables, dressers, lights and television and audio equipment. The home had written policies and procedures about “Confidentiality” and “Access to Records” (see above). The latter stated among other things that residents had the right to access their own records. Sensitive information about residents was kept in the home’s office in locked filing cabinets. Comments from residents about their ability to exercise control over their daily lives included the following: • “The only restrictions here are self imposed, you can get up and go to bed when you like”. • “There are no rules here, its pretty free and easy” • “All the furniture and things you see in my room belong to me”. All residents spoken with said that the food provided by the home was good. Residents spoken to and who were relatively active said they knew what the main meal of the day was because they could see the menu that was prominently displayed or they could go and ask the cook. All said that if they did not like the meal that was on the menu there were other options. • “They will always change it if you are not keen”. They also confirmed that there three meals a day and could have snacks and drinks at other times. • “We always have a drink in the evenings and I have a biscuit with mine” • “I have a sandwich in the evening, cheese or ham”. • “There is always plenty of coffee all day”. Tudor Lodge Nursing Home DS0000063543.V322413.R01.S.doc Version 5.2 Page 15 “We have our tea at about 5 to 5:30 and you can have something later if you want”. Information about the needs of service users with specific dietary requirements was readily available in the kitchen e.g. diabetic, soft, chopped up, etc. Pureed meals were provided with all their constituents prepared separately ensuring that their appearance was attractive. One resident likes Thai curry and the home has a supply in case they feel like one instead of what is being cooked that day. Another resident mentioned that for their birthday they had had a cake which the homes cook had made and their favourite meal was cooked for all. • Tudor Lodge Nursing Home DS0000063543.V322413.R01.S.doc Version 5.2 Page 16 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 16 & 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home had satisfactory systems and procedures in place for managing the concerns of residents and their relatives or friends There is information and training at the home to help with the protection of residents. 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”. Tudor Lodge Nursing Home DS0000063543.V322413.R01.S.doc Version 5.2 Page 17 • “I would speak to the manager if I had a complaint as she is very approachable and lovely”. Staff spoken with were aware of the Adult Protection procedure and had attended training either as part of the home’s training or on their NVQ course. Tudor Lodge Nursing Home DS0000063543.V322413.R01.S.doc Version 5.2 Page 18 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): 19 & 26. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home’s accommodation was furnished and equipped satisfactorily for residents needs. There were adequate systems and procedures in place to ensure the bedroom accommodation was both safe and comfortable. EVIDENCE: 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 conservatory has been added to the home since the last inspection which offers and additional communal area for residents. All residents spoken to expressed satisfaction with the accommodation both communal and their bedrooms. One individual however commented that she Tudor Lodge Nursing Home DS0000063543.V322413.R01.S.doc Version 5.2 Page 19 had been unhappy that she had had to move rooms a couple of times but that her current room was “alright”. Comments from other residents included: • “I like the garden and I have been watching the new building going up. My room is a bit small when they get the hoist in there”. • “I think it is a nice room”. • “Its OK – warm enough – I can open my window if I want and the light is good enough”. • “My room is pretty good, sometimes it is too warm, the bed is quite comfortable”. • “My room is very comfortable”. • “The lighting is OK and I also have a lamp of my own”. • “My room is alright”. The inspector sampled some of the rooms that varied in size. They were naturally ventilated and heated by radiators that were covered with guards to safeguard residents from the risk of burns. All shared bedrooms viewed were provided with screening to provide privacy. The nurse call system was seen to be available in the rooms sampled. There were warnings above wash hand basins where the hot water was delivered above 43°C. However where there was concern that an individual may not have an understanding of this sign, risk assessments should be in place. The home employs staff to maintain the cleanliness of the home and who the residents spoke of with fondness. The care staff do the laundry and residents commented that their clothes are always back “looking lovely and very quickly”. Tudor Lodge Nursing Home DS0000063543.V322413.R01.S.doc Version 5.2 Page 20 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): 27, 28, 29 &30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users needs are met by staff who are well trained, supportive and in sufficient numbers. The home operates robust recruitment, induction, training and development procedures to ensure that ensure service user’s are not put at risk. EVIDENCE: The inspector was able to sample three weeks of the staffing rota. The rota indicated that there is a nurse on between 8:00am and 8:00pm and one at night, during the day there are 6 – 8 care staff on to support the needs of residents especially at meal times. At night there is one care staff working with the nurse. The staffing levels will be reviewed when the new building is finished. The inspector was able to sample four staff records and found that they were detailed with the necessary checks taken to ensure staff are fit to work at the home. The owner confirmed that 16 staff have completed their NVQ in care with a further 3 currently studying at the local college. Other training staff have Tudor Lodge Nursing Home DS0000063543.V322413.R01.S.doc Version 5.2 Page 21 undertaken includes food hygiene, taking blood samples, and dementia awareness. The manager is waiting for an induction pack so that she can review and alter the induction for staff at the home in line with current standards. One staff member said “ I feel I have adequate training in order for me to carry out my job, I can just ask if I want training, I don’t have to wait until a meeting or my supervision.” It was noted that further training to be arranged or training that has been planned includes, Fire training, first aid infection control and further food hygiene courses. Tudor Lodge Nursing Home DS0000063543.V322413.R01.S.doc Version 5.2 Page 22 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): 31, 33, 35 & 38 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The manager has a clear plan for the home, which appears to have been discussed with the staff, residents and owners. There are systems for consultation and evidence suggest that these views are acted upon. The home is well maintained and health and safety is promoted however there is a lack of risk assessment and concerns over medication, which may place residents at risk. EVIDENCE: The manager has been at the home since September 2006 and has recently 23rd January 2007 attended the CSCI office for her registration interview for Tudor Lodge Nursing Home DS0000063543.V322413.R01.S.doc Version 5.2 Page 23 the home. The manager has worked as a nurse for over 20 years and has spent many years working in the community locally. It seems she is supported by staff who have been at the home for a while or have only been recruited since the new owners took over. She stated that she is spending the first six months ‘getting the feel’ of the home and assessing the changes that are needed such as care plans, assessments and what support staff will need when the new building opens. • “She is very nice, understanding and very supportive………..she seems to know what she is talking about” (staff member). • “She brings me my paper most mornings, she is very nice” (resident). • “ Matron is wonderful” (resident). • “She is very nice” (resident) • “She is very nice, very friendly. You can call her any time if you need help, even if she is at home at weekends. She explains things so we can understand” (staff member). • “She is very good, a very good nurse. She is understanding of staff and if you have any problems you can talk to her in confidence” (staff member). • “She will help me if I need it. She is friendly.” (staff member) • “She is very caring. She goes out of her way if residents have a problem and see that they are looked after” (staff member). The owners have put in place a system of quality assurance for the home and it was noted that they have acted and given feedback regarding the comments they have received. The home does not look after any resident’s personal monies. The home had a range of written policies and procedures that were readily available in the home’s staff room that helped to inform staff working practice. They were reviewed and updated as necessary. Comments from staff about the policies and procedures included the following: “They are handy and they can be referred to if necessary”. Fire training records and tests were seen to have taken place regularly with the next training for staff planned for 6th February 2006. The local fire service visited the home 7th November 2006 with no issues raised. The Environment Health Officer had visited the home on 17th January 2007 and it was noted that the recommendations for action had been completed. The cook explained that a new kitchen was included as part of the new building which it is hoped will be finished in May 2007. Staff receive adequate training on health and safety issues, as evident from the staff training plan, the inspector saw certificates for staff attending moving Tudor Lodge Nursing Home DS0000063543.V322413.R01.S.doc Version 5.2 Page 24 and handling training, food hygiene and Control Of Substances Harmful to Health. The home has risk assessments in place for the building and safe working practices for staff. Certificates showed the maintenance of services within the home were up to date Tudor Lodge Nursing Home DS0000063543.V322413.R01.S.doc Version 5.2 Page 25 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 2 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 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 2 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 2 Tudor Lodge Nursing Home DS0000063543.V322413.R01.S.doc Version 5.2 Page 26 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 OP7 Regulation 15 Sch 3 Requirement The registered person must ensure that there is a consistency in the details care plans contain for staff support for residents identified needs The registered person must ensure that records are maintained for the administration of medication. The registered person must ensure that risk assessments are in place for all residents. Timescale for action 30/04/07 2 OP9 13(2) 25/02/07 3 OP38 13(4) 25/03/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Tudor Lodge Nursing Home DS0000063543.V322413.R01.S.doc Version 5.2 Page 27 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. Extracts may not be used or reproduced without the express permission of CSCI Tudor Lodge Nursing Home DS0000063543.V322413.R01.S.doc Version 5.2 Page 28 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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