Inspection on 19/12/07 for Tudor Rose Rest Home

This inspection was carried out on 19th December 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 found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Tudor Rose Rest Home 30/11/09

Tudor Rose Rest Home 01/12/08

Tudor Rose Rest Home 23/05/07

Tudor Rose Rest Home 26/10/06

Tudor Rose Rest Home 20/06/06

Tudor Rose Rest Home 03/11/05

Tudor Rose Rest Home 09/08/05

Tudor Rose Rest Home 07/12/04

Tudor Rose Rest Home 13/07/04

Tudor Rose Rest Home 24/02/04

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Maple Lodge

Heathlands

Aston Court Nursing Home

Breme

Ravenhurst

Bank House

Inspirations

Ashcroft Hollow Nursing Home

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

CARE HOMES FOR OLDER PEOPLE Tudor Rose Rest Home 671 Chester Road Erdington Birmingham West Midlands B23 5TH Lead Inspector Mrs Amanda Hennessy Key Unannounced Inspection 19th December 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 Rose Rest Home DS0000059825.V357432.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 Rose Rest Home DS0000059825.V357432.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Tudor Rose Rest Home Address 671 Chester Road Erdington Birmingham West Midlands B23 5TH 0121 384 8922 0121 241 3507 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) Careplex Jackie Barrett Care Home 27 Category(ies) of Mental Disorder, excluding learning disability or registration, with number dementia - over 65 years of age (5), Old age, of places not falling within any other category (27) Tudor Rose Rest Home DS0000059825.V357432.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. Employ a recognised care management consultancy service for the first 12 months following change of registration That the home can care for up to five service users in need of care for reasons of mental health problems (5 MD(E)). 23rd May 2007 Date of last inspection Brief Description of the Service: Tudor Rose is registered to provide residential care for up to 27 persons for reason of old age with a maximum of five who may suffer from mental health illness. The property is a converted and extended domestic residence and the frontage blends well with the adjacent residential properties in the area. The premises are situated on a busy main road close to local shops and amenities. It is very conveniently situated for bus and rail services to Sutton Coldfield and Birmingham city centre. There is sufficient off road parking at the front of the building to accommodate three vehicles and further parking is available in nearby side roads. The majority of the accommodation is located on the ground and first floors; a shared room is situated on the second floor that has its own adjacent bathroom. There is a shaft lift that gives access to all floors and permits a maximum of two persons. This restriction in conjunction with the narrow corridors prohibits the home from caring for presidents who are wheelchair users. Communal toilets and bathrooms are strategically located throughout the home. There are five double bedrooms and seventeen single bedrooms; all have wash hand basins and a call bell system. Communal rooms are situated on the ground floor and consist of two lounges and two dining rooms. There is an extensive rear garden with out houses and a paved area with seating that residents and visitors can frequent during clement weather. Meals and a laundry service are supplied on site. Tudor Rose Rest Home DS0000059825.V357432.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection undertaken by two Inspectors between 10.00 and 16.00hrs over one day in December 07. The inspection included a review of information supplied by the Home Manager called “`An annual Assurance Assessment” which provided information about the establishment, policies and procedures at the home, information about the homes residents and its staff. Before the inspection seven residents completed a survey form known as “have your say about…” telling us about their experiences of life at the home. Seven staff also returned a “Have your say” survey telling about their experience of working at the home. During the inspection the inspectors followed the experiences of living at the home for three residents, including looking at their care records, conversations with them, viewing their rooms and if possible talking to their relatives whenever possible. This process is known as case tracking. The inspectors were able to meet with and talk with other residents and staff. Who told us in their opinion of what it is like to live in the home. A tour of the residents’ rooms and communal and service areas was completed and records about safety of equipment and the building were checked. Fourteen of the previous fifteen requirements have been addressed; three new requirements and twenty-three good practice recommendations were made as a result of this inspection. What the service does well: The home is small and friendly and provides “home from home” as one resident told us. The staff know residents and their needs making it feel more like a “family”. There has been a considerable improvement in care records highlighting residents needs and ensuring that instructions are available to highlight how their needs should be met. Residents weight is recorded on admission and thereafter at least month and appropriate actions are taken if they lose weight. Residents at the home have their healthcare needs met. And they are regularly seen by other Health professional such as dentists and opticians. Food at the home is generally all home cooked and residents generally say that they like it although there remains an issue about the lack of choice. Tudor Rose Rest Home DS0000059825.V357432.R01.S.doc Version 5.2 Page 6 There is a record of all concerns made and actions that have been undertaken even “moans and groans” which if not addressed become major concerns. The Manager and her staff always welcome and follow any advice that they are given from other professionals. The homes response to advice given has enabled them to address all but one of the thirty- seven requirements that were outstanding a year ago. What has improved since the last inspection? What they could do better: There is a need to review the information that the home supplies about living at the home and the terns and conditions of living at the home. The admission of new people to the home needs to be “more person centred” and ensure that their assessment of needs is comprehensively completed. Staff must ensure that they obtain a copy of the persons assessment of needs from the persons Social Worker when appropriate before they admit them to live at the home. Medication procedures need to be reviewed to ensure that medicines are safely administered to residents giving greater assurance that residents will be protected from the risk of error which may result in their harm. The menu has been reviewed but further review is needed to ensure that residents are always given a choice at mealtimes. Staff must review their thinking of Adult Protection procedures and go away from the view that ”abuse will not occur here”. To give assurance that residents will be safeguarded and appropriate actions are taken if there are possible signs of abuse or that abuse has been alleged. Staff must have greater awareness of their responsibilities under the Mental Capacity Act to give greater assurances that residents capacity to consent has been assessed Tudor Rose Rest Home DS0000059825.V357432.R01.S.doc Version 5.2 Page 7 and that when decisions have been made on their behalf are in their best interests. The recruitment and selection of staff needs to be more robust. References and employment history must be authenticated to provide confidence that all possible measures are in place to ensure that people who are unsuitable to work with vulnerable adults do not. Whilst residents like the home being small sometimes it can be a problem that staff do not the opportunity to discuss new developments with others which occurs within larger establishments and organisations. There is a need to look at what additional management arrangements could be put it place to advise the Manager and her staff. 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 Rose Rest Home DS0000059825.V357432.R01.S.doc Version 5.2 Page 8 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 Rose Rest Home DS0000059825.V357432.R01.S.doc Version 5.2 Page 9 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): 1, 2, 3 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents do not always have required information about the home and have their needs sufficiently or appropriately assessed giving no assurance that their needs will be addressed at the home. EVIDENCE: The home does have a statement of purpose and service user guide which are given to people who live at the home/ are thinking about living at the home. Both documents contain useful information about the home although room sizes are not currently supplied as required. The statement of purpose contains the statement “we are trained on how to deal and cope with demented residents” which is an inappropriate statement and should be removed. There is also a note that service users can have access to email should they require it, staff should be clear on how they can accommodate this. Tudor Rose Rest Home DS0000059825.V357432.R01.S.doc Version 5.2 Page 10 Residents do have an assessment of need although they were not always as detailed as required with comments such as “not seen” when assessing physical illness and skin condition. Other information was just one word answers, for example sleeping “good” with no other explanation of what “good” referred to. We observed one person admitted on the day of inspection. This person did not have a comprehensive assessment with many aspects of the assessment report left blank, there was no community care assessment available from the social worker despite her visiting first thing in the morning before he arrived at the home. Staff clearly did not know the gentleman’s needs, although were very friendly to him offering him cups of tea and a meal. Tudor Rose Rest Home DS0000059825.V357432.R01.S.doc Version 5.2 Page 11 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): 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. People’s healthcare and personal needs are generally met but the poor record keeping systems in the home may mean that some peoples needs may not be timely recognised or addressed. There is a need for improvement in the records for the administration and storage of medicine to ensure that people are safeguarded from possible medication error and unsafe practice. EVIDENCE: People who live at the home have a plan of their care that tells staff what their needs are and how they should be addressed. Care records also now include risk assessments for moving and handling which also incorporates a falls risk assessment and nutrition assessment. It is positive that the home ensures that residents weight is recorded on admission and thereafter at least month and further information was seen that evidenced that action is taken when people lose weight. Tudor Rose Rest Home DS0000059825.V357432.R01.S.doc Version 5.2 Page 12 People who live at the home are regularly seen by other Health professionals such as GPs, District Nurses, Opticians. Accidents records seen, showed that these residents had been checked by a Doctor after their fall. A visit to the home by the Commission for Social Care Inspection undertaken at the end of November did however highlight that a person who had fallen 10 days previously and sustained a swollen hand had not been seen by a Doctor which should have been undertaken. The administration and safekeeping of medicines at the home is mostly satisfactory although there are some shortfalls that need to be addressed to ensure the risk of medication error is minimised. One person was found to have run out their pain killers which is unacceptable. It was also noted that staff had used correction fluid on the medication record which is also unacceptable. Other improvements are included within the good practice recommendations section of this report. Staff were seen to knock doors before they entered toilets and bathrooms. One resident was heard to say “ where am I?” and the staff member answered her abruptly “Tudor Lodge” and then proceeded to go about her duties. We did have a complaint that residents were wearing incontinence pads but were continent and were using the toilet and the appropriateness of this should be explored and if appropriate addressed. The home has no “privacy and dignity” policy which would be helpful to provide additional advice and training to staff and could also be included within staff supervision sessions. Tudor Rose Rest Home DS0000059825.V357432.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): 12, 13, 14, 15 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Further developments are needed to ensure that the home provides a daily life that is consistently appropriate or suitable for residents and their needs and choices. EVIDENCE: The home has a member of staff whose main responsibilities are to arrange activities for residents. Several of the residents were tired on the day of the inspection and the Manager told us that last night they had all been to their Christmas party for a meal at a local pub and they all had a great time and it was nice that one resident who never goes out had gone too. When we asked residents if they enjoyed it they said; “Oh we had a lovely time and we all had something to drink-I had whisky”. The time that residents like to get up and go to bed is recorded but when we spoke to staff they said that they do not always stick to this. There is record of activities that people take part in recorded in their care records which includes drawing, reading and pictures and they were having a Tudor Rose Rest Home DS0000059825.V357432.R01.S.doc Version 5.2 Page 14 game of bingo on the day of the visit, although mostly residents “watch TV” or “chatting with friends”. The home have starting to consider their responsibilities under the Mental Capacity Act 2005, which relates to the assessment of peoples decision making abilities. We found that staff spoken to have poor understanding of the Act and their roles in supporting people with reduced capacity to consent. We saw a number of important documents such a terms and conditions of residency, consent to a flu vaccination and general care records that people had either signed themselves or had been signed by their next of kin but their mental capacity had not been established with is contrary to the Mental Capacity Act. On the day of the inspection lunch was either fish or pork draft with stuffing, roast potatoes and vegetables. Staff did ask people what they would like but when the meals were brought to them staff had put gravy on all dinners without asking the residents and had given them both cabbage and peas again without asking them. One resident wanted his pork as a sandwich and staff willingly accommodated this. All residents were given apple pie and custard, which we tried and was nice but no alternative choice was available. There is always a hot meal at lunch time although the records seen highlight that there is not always a choice available and on average just weekly a choice of pudding. One resident said when she was asked if she had enjoyed her dinner “I’ve had a lovely dinner and a lovely pudding” We were told that breakfast is cereals toast with sometimes cooked such as egg on toast , scrambled egg and tomatoes or a bacon sandwich. At tea time there is usually sandwiches, with a hot snack choice such as bubble and squeak, soup, hot dogs or something on toast. Tudor Rose Rest Home DS0000059825.V357432.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): 16, 18 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. There are appropriate arrangements for people to highlight concerns although there is an inconsistent approach to the understanding of safeguarding resulting in the lack of required actions to ensure that residents are consistently protected. EVIDENCE: A copy of the complaints procedure is displayed on the wall in the main hall on entering the home for information. There is a record of all complaints made including “moans and grumbles” with a record of what actions have been undertaken to address the concerns. One complaint highlighted that a resident was using a fluffy toy to keep her door open as she felt closed in when the door was shut. However the actions taken did not highlight a need to for the home to provide a piece of equipment that can keep the door open and closes the door when the fire alarm is activated. The home has a copy of the Multi-agency Vulnerable Adult Guidelines produced by the Local Authority, so that staff have information available to guide them in the event of an allegation of abuse being made. On discussion with staff they were clear of the action to take in the event of an allegation of abuse or concerns in relate to poor practice. Tudor Rose Rest Home DS0000059825.V357432.R01.S.doc Version 5.2 Page 16 All staff have recently had Safeguarding training to highlight actions required if abuse is alleged. Recent concerns highlighted that staff had not been proactive and had taken appropriate safeguarding actions when a resident had unexplained injury. Tudor Rose Rest Home DS0000059825.V357432.R01.S.doc Version 5.2 Page 17 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, 21, 26 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home is clean and warm and suitable for people who do not have mobility difficulties. EVIDENCE: The home is a converted and extended domestic residence over three floors. The corridor space and capacity of the shaft lift prevents the home from accommodating residents who are wheelchair users. Visits by CSCI have found the home to be warm, there are thermometers in all residents bedrooms to monitor the temperature and ensure that they are kept warm. Cleanliness of the home has also been improved since the previous inspection. Tudor Rose Rest Home DS0000059825.V357432.R01.S.doc Version 5.2 Page 18 There is a large garden to the rear of the property, which residents use when weather permits. There are two lounges and two adjoining dining rooms on the ground floor. The carpet in the small dining room is worn across the width and will need replacing as it poses a trip hazard to residents using the area- this was also highlighted at the previous inspection. There are seventeen single bedrooms and five double bedrooms, which have a wash hand basin and call bell facility. There is an ongoing a re-decoration programme for the home, which is well advanced with the addition of new beds, carpets, blinds and bed linen. Bedroom doors have locks to them enabling residents to lock their doors if they wish and there is also lockable facilities available for the storage of medication or valuables within residents rooms. It was nice to see that residents had had the opportunity to personalise their room with treasured belongings. Radiators are covered with guards and water from hot water taps is controlled to prevent the risk of scalding. There are a number of toilets strategically placed around the home, but some are rather small and would be difficult for residents to access with walking aids. There are three assisted bathing facilities one of which has been upgraded to a walk in shower. Tiling has been replaced in some areas although in places appears to be basic. The upgrading to the laundry has now been undertaken as required at a previous inspection. Tudor Rose Rest Home DS0000059825.V357432.R01.S.doc Version 5.2 Page 19 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 adequate. This judgement has been made using available evidence including a visit to this service. There are generally sufficient and qualified staff to meet the needs of people who live at the home. EVIDENCE: Staff and residents indicated that staffing levels are satisfactory for the dependency of residents that the home currently accommodates. Residents were left sitting in the lounge without any staff present for long periods. A complaint made to the Commission to Social Care Inspection also highlighted this and that residents were reluctant to call staff for assistance. Staff files seen showed that there had been improvements made in the safe recruitment and selection of staff since the previous inspection, although further improvements are still required. Most staff had completed an application form although one staff member had submitted a curriculum vitae. Generally there is a need for more information about their previous employment history to enable the manager to assess the suitability of referees. One new member of staff application form had no employment history before 2002 and another no employment history before 2005, although neither were recent school leaver and there was no record of any gap in employment history. Two references were available for all new staff, although one member of staff had references from the homes current deputy and Tudor Rose Rest Home DS0000059825.V357432.R01.S.doc Version 5.2 Page 20 manager which is not good practice. All staff have criminal records checks but sometimes they are employed before they are returned and have a Protection of Vulnerable Adults check (POVA first) as an interim measure. The use of a “ POVA first” is generally acceptable but should only be used when robust recruitment and selection procedures are employed, which would include the authentication of employment history and references and a requirement that the member of staff is supervised at all times, to further safeguard residents which is not the current situation. Records of newly appointed staff did not always demonstrate that they had received induction training to meet the standards of the Social Skills Council. Information provided by the Manager indicated that 50 of care staff are qualified to National Vocational Qualification (NVQ) level 2. Staff spoken to were very positive about the support they receive from the Manager to undertake their care qualification. Tudor Rose Rest Home DS0000059825.V357432.R01.S.doc Version 5.2 Page 21 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. Management arrangements need to be strengthened to give confidence that there is effective leadership and management to give additional confidence that residents are safeguarded and receive the care and attention that they need. EVIDENCE: The home has a Registered Manager who has completed the Registered Managers award. The Manager is supported by a deputy manager both of whom have worked at the home for several years. Staff said that they felt supported by the Manager and Deputy Manager. The home does sometimes appear to struggle as a single home without the support of other senior staff to discuss new developments and regulations with. It is positive that the Tudor Rose Rest Home DS0000059825.V357432.R01.S.doc Version 5.2 Page 22 Manager takes advice that she is given by CSCI Inspectors and acts upon it accordingly and Inspectors are always made welcome at the home. The home does have a quality assurance programme. Surveys were sent out to residents and other stakeholders in October 07, although the manager said that response was poor and despite her asking people do not return surveys. Residents’ questionnaires that were returned to the Commission for Social Care Inspection had been completed with the assistance of staff. We would advise that external support is available to give greater confidence that residents are able to express their feelings freely. Comments in those surveys which we saw were positive about the home. “we are made welcome when we visit” and comments we received included: “its alright here”. There are regular quality meeting but the manager said that attendance from external agencies tends to be poor also. The Manager also undertakes regular audits to ensure that the home is clean, food is acceptable, medication procedures are appropriate etc. The home does keep small amounts of money for residents within the homes safe. There are records of all transactions which is good practice. Money that we checked did not balance for three residents. Money was being kept in brown envelopes that had spilt and we advised the deputy to check all balances and use alternative ways are used to more securely keep peoples money within the safe. We did see that residents had all spent £10-12 on sweets and chocolates and also additional deductions for alcoholic drinks such as whisky and sherry. The manager said that she had the “Christmas chocolates and drinks” upstairs to show us but we had to explain that they should have been for the residents own use and should be kept in their room, she said that “ if we don’t buy them on behalf of the residents they wouldn’t have anything for Christmas”. We also highlighted that previously the home had bought communal toiletries for residents with residents own money which isn’t appropriate practice either. We did look at the health and safety policy which was very brief and appeared to be more of a policy statement and would not meet health and safety regulations. “Our policy is to promote the highest standards of health and safety to prevent our clients , employees and visitors suffering form an accident” although there is no comment how this will be done. The health and safety policy also says: “The Directors have appointed Jackie Barratt as having particular responsibility for the implementation of the policy” the Manager did say that she was happy with these arrangements as she is “hot on health and safety”, however may require additional training to effectively fulfil this role. Staff do have fire drills but they need to evidence which staff attend as currently the names of people attending is not recorded. Tudor Rose Rest Home DS0000059825.V357432.R01.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 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 2 2 2 x x N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 1 10 2 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 2 14 2 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 x 18 2 2 x 2 x x x x 3 STAFFING Standard No Score 27 3 28 3 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 x 2 x 2 x x 2 Tudor Rose Rest Home DS0000059825.V357432.R01.S.doc Version 5.2 Page 24 Are there any outstanding requirements from the last inspection? Yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP3 Regulation 14 Requirement The registered person must ensure: All assessments are comprehensive and fully completed to determine if the home can meet resident’s needs. All assessment documents must be signed and dated by the member of staff undertaking the assessment. Written confirmation that the home is able to meet needs must be sent to the resident or their representative. Timescale of the 15/08/06 was not met, timescale has been extended. Care plans must be developed for short term concerns such as infections to give confidence that staff are made aware of actions they need to take to care for the resident. Medicines must be safely administered to ensure that residents are protected from the risk of error that may harm them. DS0000059825.V357432.R01.S.doc Timescale for action 31/01/08 2. OP7 15(1)(2) 29/02/08 3 OP9 13(2) 29/02/08 Tudor Rose Rest Home Version 5.2 Page 25 4 OP29 19 Recruitment and selection procedures must be robust to ensure that residents are protected from people who are unsuitable to work with vulnerable people. 29/02/08 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 2 3 4 Refer to Standard OP1 OP3 OP8 OP8 Good Practice Recommendations The statement of purpose and service user guide should be reviewed and updated. It is recommended that the home liaise with the social worker for a copy of their assessment of needs. The Registered Person should ensure all staff undertake training in respect of the management of continence. It is recommended that formal auditing of accidents be undertaken. This good practice recommendation was made at the previous inspection but has not been undertaken. Not met Staff should undertake training in respect of tissue viability. Staff should countersign all hand written medication details to confirm its accuracy and reduce the risk of error. Residents photographs should be available on medicine treatment sheets to confirm the identity of the person requiring the medication. A appropriate container should be available and used for counting and checking medication tablets. Opening date should be recorded on short life medicines such as eye drops. The appropriate code should be used when medicines are not administered. The home should have a privacy and dignity policy. Staff should have training to highlight their and the homes responsibilities under the Mental Capacity Act. The use of advocacy services within the home should be explored. DS0000059825.V357432.R01.S.doc Version 5.2 Page 26 5 6 7 8 9 10 11 12 13 OP8 OP9 OP9 OP9 OP9 OP9 OP10 OP14 OP14 Tudor Rose Rest Home 14 15 16 17 18 19 20 21 22 23 OP15 OP26 OP29 OP29 OP30 OP31 OP33 OP35 OP38 OP38 The menu should be revised to ensure that there is a choice available at every mealtime. It is recommended that the Health Protection Unit be contacted regarding the arrangements for cleaning of commode pots etc. The home must ensure that there is a record of a full employment history. When staff are employed on a “ POVA first” a risk assessment should be available and to assess the risk and the staff member should work supervised at all times. All new staff should have an induction training programme that meets Social Skills Council requirements. Arrangements are made to give the homes manager additional professional advice and support. Arrangements should be reviewed to ensure an improved response to surveys, thus may include the use of Advocacy services. Arrangements for the safekeeping of residents money is reviewed. The homes health and safety policy is revised. There is a record of all staff who attend the fire drills. Tudor Rose Rest Home DS0000059825.V357432.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Birmingham Office 1st Floor, Ladywood House 45-46 Stephenson Street Birmingham West Midlands B2 4UZ 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 Rose Rest Home DS0000059825.V357432.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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