Inspection on 07/11/06 for Tudor Rose

This inspection was carried out on 7th November 2006.

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

The inspector found no outstanding requirements from the previous inspection report, but made 1 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Tudor Rose 20/09/05

Tudor Rose 12/06/05

Similar services:

Hillview Farm

Dalewood Respite Care

Orchard,The

REACH Upton Court Road

Fairways

Treloar College

Kestrel House, St Anne`s Opportunity Centre,

Pinta

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

CARE HOME ADULTS 18-65 Tudor Rose Tudor Rose 23 Borovere Lane Alton Hampshire GU34 1PB Lead Inspector Keith Hopkins Unannounced Inspection 7th November 2006 13:00 Tudor Rose DS0000062129.V315433.R02.S.doc Version 5.2 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 Rose DS0000062129.V315433.R02.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 Adults 18-65. 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 Rose DS0000062129.V315433.R02.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Tudor Rose Address Tudor Rose 23 Borovere Lane Alton Hampshire GU34 1PB 01420 544118 01420 544140 annievolt@yahoo.com, or emartin@iliace.com 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) ILIACE Limited Ann-Marie Glass Care Home 4 Category(ies) of Learning disability (4) registration, with number of places Tudor Rose DS0000062129.V315433.R02.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 20th September 2005 Brief Description of the Service: Tudor Rose is registered to provide care and accommodation for four adults with learning disabilities between the ages of 18 and 65. The accommodation is provided in a large detached house, approximately half a mile from Alton town centre. The home has a large lounge, a dining room and kitchen and each service user has a single bedroom. There is an enclosed garden to the rear of the home which service users are able to access. Service users are supported to take part in the running of the home and to take part in employment and educational opportunities. The home is managed by ILIACE Ltd, who have a number of similar services in Hampshire. Fees are £1469.40 per week. Tudor Rose DS0000062129.V315433.R02.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. Four hours were spent visiting the home, during which time the opportunity was taken to look around the home, view records and policies and to talk to the manager and a support worker. Three of the four service users returned to the home later in the day having been supported in undertaking an external activity. The inspector was only able to communicate in a limited way with service users himself but did observe staff responding to expressed needs and interacting with service users in a professional yet friendly manner. What the service does well: What has improved since the last inspection? 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 Rose DS0000062129.V315433.R02.S.doc Version 5.2 Page 6 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Tudor Rose DS0000062129.V315433.R02.S.doc Version 5.2 Page 7 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 2. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. The home has assessed the needs of its current service users well. These needs are clearly recorded and known to staff. EVIDENCE: Two service users’ files were inspected and needs assessments seen within these. Needs assessments for all the current service users had been completed at their previous home prior to their moving as a group to Tudor Rose two years ago. Files contained a good level of detail to enable staff to meet assessed needs. There was, for example, information regarding the degree of assistance needed with personal hygiene. There was also information regarding medical needs together with a handling care plan. Risk assessments about meeting care needs were also in evidence. The inspector also saw evidence that assessments were reviewed on a regular basis by way of a Monthly Evaluation Record. Service users and their families were involved in this process, the inspector noting that a review was planned for the day following the inspection. The inspector also noted that the home had obtained a copy of the Social Services Care Management agreed plan where the Local Authority had been involved with service users. Tudor Rose DS0000062129.V315433.R02.S.doc Version 5.2 Page 8 The manager and member of staff spoken with were clearly well aware of the contents of the assessments. Tudor Rose DS0000062129.V315433.R02.S.doc Version 5.2 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 and 9. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. The home has a good care planning regime, which involves service users, and which addresses identified personal, social and health care needs. EVIDENCE: Two of the individual plans which had been developed from the initial assessments were examined. These contained details of continuing personal and health care needs together with details of the support needed to meet such needs. Service users are involved in planning personal goals such as, for example, the development of skills to complete household tasks and to deal with personal hygiene. The inspector noted that records are kept on a daily basis detailing progress made towards meeting these goals, which are reviewed on a regular basis. On the day of the inspection it had been planned that one service user spend time with the manager on a one-to-one basis developing personal skills. Tudor Rose DS0000062129.V315433.R02.S.doc Version 5.2 Page 10 Service users were observed during the inspection to be making decisions about day-to day activities, assisted by staff when this was necessary. Risk assessments are in place covering all areas of identified risk for service users. The assessments include actions that staff should take to minimise the risk and have been signed by staff to say they are aware of any action they should take. Risk assessments are subject to regular review. Tudor Rose DS0000062129.V315433.R02.S.doc Version 5.2 Page 11 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15, 16 and 17. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. Service users enjoy varied lifestyles and undertake activities of their choice. Contact with families is maintained and encouraged. Service users enjoy a varied and healthy diet. Tudor Rose DS0000062129.V315433.R02.S.doc Version 5.2 Page 12 EVIDENCE: Records examined by the inspector indicated that a full programme of activities and social opportunities was available for all service users, each of whom had an individually devised weekly activity plan. Activities included swimming, art, gardening, canoeing and climbing. Three service users work in local charity shops on a voluntary basis and all service users regularly use the local library, cinema, pubs and shops. When the inspection started three service users were being supported in undertaking an external activity. Forthcoming activities included in-house board games on 9th November and a bookfair on 25th November. The home has an attractive garden to the rear which accessible to service users. It is understood that all service users are registered on the electoral roll; further that some service users attend a local church. There were no visiting relatives during the inspection although the manager reported a good level of continuing involvement with families. Service users are supported in this through use of e-mail and the telephone. The home’s menus were seen and were varied, the inspector being informed that individual and collective likes and dislikes were taken into account. Information regarding the coming week’s meals was available on the home’s noticeboard. It is understood that support is provided for service users to be involved in the preparation of meals and that snacks and drinks are available at all times. Tudor Rose DS0000062129.V315433.R02.S.doc Version 5.2 Page 13 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 and 20. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. The home provides a good level of personal support to service users ensuring that personal, health care and medication needs are met. EVIDENCE: Staff were observed to be supporting service users in undertaking day-to-day activities in a friendly and professional manner. All service users were appropriately dressed and tidily groomed and when staff needed to provide support in undertaking activities of a more personal nature this was done in private. Each service user has a Health Action Plan and the inspector was informed that there was good access to local GPs. Service users access local health care facilities such as the dentist and optician, with one service user currently seeing a podiatrist. There was evidence of access to other health professionals such as a psychologist and psychiatrist when this was necessary. The home has a policy and procedure for staff to follow regarding the dispensing of medication. There is a monitored dosage system in place and the Tudor Rose DS0000062129.V315433.R02.S.doc Version 5.2 Page 14 inspector checked medication for two service users against medication administration records, which were accurate and up-to-date. Medication was securely stored in a locked cupboard in the office. Staff have been trained in dealing with medication. Tudor Rose DS0000062129.V315433.R02.S.doc Version 5.2 Page 15 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. Service users are well protected through procedures for dealing with complaints and suspected abuse, which are known to staff. EVIDENCE: There had been two complaints for the home to deal with since the most recent inspection. The inspector saw that these had been fully recorded and investigated, and dealt with in a timely manner. Service users themselves have information on what to do if they are unhappy, which has been provided in an easy to understand pictorial form. There was evidence of the home involving next of kin and of positively seeking comment on the service offered. The home has policy for dealing with suspected abuse and a copy of Hampshire Social Services Department’s Adult Protection policy was available. Staff were aware of this policy and the manager explained that the Adult Protection Procedure had been appropriately invoked on one previous occasion. The inspector noted that refresher training in Adult Protection was due to take place on the day following the inspection. An issue identified at the previous inspection, which may have left service users at risk of financial abuse, has now been addressed. The inspector examined monies held by the home on behalf of two service users, which tallied accurately with records held. Tudor Rose DS0000062129.V315433.R02.S.doc Version 5.2 Page 16 Tudor Rose DS0000062129.V315433.R02.S.doc Version 5.2 Page 17 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24 and 30. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. The home provides a safe and comfortable environment, which is suitably furnished, adequately maintained and meets service users’ needs. EVIDENCE: The tour of the building showed this to be clean and tidy throughout and there were no undue odours. Communal areas were acceptably furnished and decorated and gave the building a very ‘homely’ and domestic feel. There are adequate bathroom and toilet facilities. Three bedrooms, which were all adequate in size, were inspected and had clearly been personalised, to considerable degrees. One service user was particularly proud to show the inspector her room. Service users were observed to be freely making use of communal areas, such as the lounge and kitchen. Tudor Rose DS0000062129.V315433.R02.S.doc Version 5.2 Page 18 The home’s laundry arrangements are domestic in nature, which suits the size of the home. There is a procedure for dealing with soiled linen, which staff were aware of and protective clothing was available. Various maintenance certificates were seen and were in order and up-to-date, the manager confirming that minor building items requiring attention were recorded in the maintenance log, which was seen by the inspector, and were dealt with speedily. The home has a Health and Safety policy and staff spoken with were clearly aware of Health and Safety issues. Tudor Rose DS0000062129.V315433.R02.S.doc Version 5.2 Page 19 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34 and 35. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to the service. Service users are well supported by a well-trained staff team who are deployed in sufficient numbers to meet their needs. The inspector was unable to access full staff records so the home was unable to fully demonstrate the soundness of its recruitment process. EVIDENCE: The inspector examined two staff files which contained evidence of Criminal Records Bureau checks having been carried out, together with evidence of a sound and comprehensive induction training programme and of staff supervision. However, the files did not contain application forms or references so the home was not able to demonstrate the soundness of its recruitment process. The manager explained that she understood that the forms and references were held at the company’s head office. The inspector was able to examine the home’s training record. This confirmed details of courses undertaken. Courses included Person Centred Planning, Manual Handling, Communication Focus, Protection of Vulnerable Adults, Autism Focus and Health and Safety. Certificates confirming training undertaken were contained in the staff files examined. The organisation’s Tudor Rose DS0000062129.V315433.R02.S.doc Version 5.2 Page 20 corporate training programme continues to provide the opportunity for identified training needs to be met, and staff spoken with confirmed this. During the inspection the inspector observed staff interacting with and supporting service users in a friendly yet professional manner. The staff rota indicated there to be a minimum of two staff members on duty at any one time. There is one sleeping-in member of staff on duty at night. Tudor Rose DS0000062129.V315433.R02.S.doc Version 5.2 Page 21 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. 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 are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 and 42. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. The home is well run by a competent manager. Service users influence the home’s development and their interests are safeguarded by comprehensive policies and procedures. EVIDENCE: The registered manager has had several years experience and is expecting to complete the Registered Managers Award in December 2006. Service users are consulted through a regular monthly meeting and also have the ability to comment on the services on an on-going basis. The manager informed the inspector that service users are also involved in the staff recruitment process. Tudor Rose DS0000062129.V315433.R02.S.doc Version 5.2 Page 22 A quality audit of parents was undertaken in August 2006 and the inspector saw evidence of the action taken to positively address the issues raised through this process. The home has a policy for the control of substances hazardous to health known to staff. Chemicals and other items were securely stored in locked cupboards and staff were aware of health and safety issues. The home has a health and safety policy known to staff. The inspector did not observe any immediate hazards to the health and safety of service users during the tour of the building. A sample of policies, procedures and records required by regulation were inspected and were in order and up to date. This included the home’s fire and accident books. Tudor Rose DS0000062129.V315433.R02.S.doc Version 5.2 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 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 X 2 3 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 2 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 3 X 3 X X 3 X Tudor Rose DS0000062129.V315433.R02.S.doc Version 5.2 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. 1. Standard YA34 Regulation Requirement Timescale for action 31/12/06 19(4)(b)(i) The registered person must ensure that all records required by regulation are available for inspection in the home. 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 Rose DS0000062129.V315433.R02.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: 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 Rose DS0000062129.V315433.R02.S.doc Version 5.2 Page 26 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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. 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