Inspection on 20/06/06 for Tudor Rose Rest Home

This inspection was carried out on 20th June 2006.

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 Rose Rest Home 30/11/09

Tudor Rose Rest Home 01/12/08

Tudor Rose Rest Home 19/12/07

Tudor Rose Rest Home 23/05/07

Tudor Rose Rest Home 26/10/06

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

Similar services:

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 Ann Farrell Key Unannounced Inspection 20th June 2006 08:30 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Tudor Rose Rest Home DS0000059825.V300485.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.V300485.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.V300485.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 4. Employ a recognised care management consultancy service for the first 12 months following change of registration That one named person who is under 65 years at the time of admission can be accommodated and cared for in this home That the home can care for one named service user in need of care for reasons of dementia. (1 DE(E)) That the home can care for up to five service users in need of care for reasons of mental health problems (5 MD(E)). 3rd November 2005 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.V300485.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was the first key inspection for 2006-2007 and was undertaken on an unannounced basis over two full days commencing at 8.30am on 16th June 2006. The manager and deputy manger were present for the duration of the inspection. Three members of staff and approximately six residents were spoken to during the course of the inspection, but a number of residents were not able to converse effectively. The inspection process included a tour of the home, inspection of records and documents relating the management of the home and staff. Case tracking of resident’s records was undertaken to determine the care of the resident from the time of admission. A number of areas were identified as requiring attention at the time of inspection, which the manager and deputy manager were keen to address. What the service does well: On entering the home staff were welcoming. The home adopts a proactive approach to requirements generated as a result of inspections and maintains a positive professional relationship with CSCI. The registered manager is well supported by the deputy manager and the responsible individual. The deputy manager has specific management responsibilities and there is a fairly stable staff group who have been working in the home for a number of years. Visiting was flexible. The registered manager is supernumery, she provides personal care if required and assists with tasks such as deep cleaning within the home. Comments received from residents were generally positive regarding accommodation, meals and the services provided by staff. The involvement of external professionals is actively sought and advice is acted upon. Tudor Rose Rest Home DS0000059825.V300485.R01.S.doc Version 5.2 Page 6 The home has a maintenance programme for repairs. is currently undertaking some re-furbishment. Satisfactory staffing levels are maintained. and re-decoration and 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 Rest Home DS0000059825.V300485.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 Rose Rest Home DS0000059825.V300485.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1,2,3,6 Quality in this outcome area is adequate. The judgement has been made using available evidence including a visit to this service. The home has information about the services and facilities available for prospective residents, but it will require updating and further development to reflect the services available. Pre admission assessments are undertaken by senior staff and needs to be developed further to provide staff with the information required to meet resident’s needs effectively and in a consistent manner. EVIDENCE: The home accommodates residents on a long term or respite basis. They have a statement of purpose and it was stated that this is the information that is provided to prospective residents and their families. The statement of service was rather brief and referred to an appendix, which was not available. The home should have a separate statement of purpose and service user guide and have been referred to the National Minimum Standards, Regulations and some guidance has been forwarded to the manager to assist with developing the statement of purpose. Tudor Rose Rest Home DS0000059825.V300485.R01.S.doc Version 5.2 Page 9 Copies of the contract/terms and conditions of residence was available, but this needs reviewing and developing to ensure it provides accurate up to date information. On inspection of a sample of resident’s records it was noted that a senior member of staff undertakes a pre-admission assessment to determine if the home is able to meet prospective residents needs. The assessment form has a part where the person undertaking the assessment can record if the home is able to meet the resident’s needs. However, the Regulations requires that the registered person confirm in writing to the resident or thier representative if the home is able to meet their needs following assessment. The assessment document was comprehensive, but all areas were not completed or were lacking in detail and some had not been signed or dated. Although another assessment document is completed on admission to the home the preadmission document forms the basis for the care plan and does need to be more detailed in order for a comprehensive care plan to be drawn up. The manager could also request a copy of any social workers assessment to assist them in the process of obtaining relevant information. Following admission there was evidence of some risk assessments in respect of smoking, but there was no evidence of risk assessments in respect of moving and handling, nutrition, the use of stairs or lift for residents accommodated on the first and second floors etc. Staff have recently undertaken some basic training in respect of caring for people with dementia and it was stated that they are to undertake a more comprehensive training package in the near future. Tudor Rose Rest Home DS0000059825.V300485.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9,10 Quality in this outcome area is adequate. The judgement has been made using available evidence including a visit to this service. Care plans need to be developed further to ensure that all staff are aware of residents needs and they are met in a consistent manner. Some improvements in respect of the medication system is required to ensure it is fully auditable and demonstrates that residents are receiving the medication prescribed by the G.P. EVIDENCE: The senior staff develop a care plan for all residents entering the home, which outlines how the resident’s needs are to be met by staff. On inspection of a sample of records it was noted there were generalised statements, they were not individualised, there was a lack of clear instructions. They were evaluated monthly, but there was little information in the evaluations to determine how residents were progressing and when there were any changes the care plans had not been updated to reflect the changes. In one case the district nurse was visiting a resident who was in hospital and had removed their notes. The care for this resident could not be tracked as the homes records did not have the relevant information. Daily records did not consistently demonstrate follow Tudor Rose Rest Home DS0000059825.V300485.R01.S.doc Version 5.2 Page 11 up to areas of concerns and in some cases entries were based on staff’s opinions rather than facts. Also there was no evidence that the resident or their representative were involved with the process. The care planning process was discussed at length with the manager and deputy manager in order to provide them with guidance so that the documents can be developed. Resident’s records indicated that residents were weighed regularly, but in one instance the record indicated that the residents had lost half a stone in a relatively short period of time and there was no evidence that any action had been taken. The manager and deputy stated they were not aware of this. Communication systems in the home will need to be reviewed to ensure that all relevant information is passed on to them to enable appropriate action to be taken. Further sampling of resident’s records confirmed residents had access to community healthcare services such as GP and district nurse when required plus the chiropodist and optician visited fairly regularly, but there was no evidence of visits by a dentist. On discussion it was stated that sometimes residents refused services, but there was no evidence that it had been offered and refused. During the inspection it was noted that one resident was sat in their bedroom and did not have access to a call bell. Systems must be in place for all residents to have access to a call bell when they are in their bedrooms. There were also two walking frames in her room one of which did not belong to her and the rubbers were worn on one of them. An audit of all walking frames must be undertaken and rubbers replaced if worn. On touring the home an odour was noted and the cause could not be determined. The manager was advised of the need to review cleaning and the management of continence providing staff with training in respect of continence management where required. The deputy manager stated that arrangements have been made for staff to have training in respect of tissue viability in the near future. Staff record accidents appropriately and it was noted that one resident had experienced a number of falls. On discussion with the manager and deputy they outlined the action taken. It is recommended that a more formal approach be taken to auditing accidents. During the course of the inspection it was noted that a visiting health professional saw a resident in the dining room to provide treatment. This is not appropriate and arrangements should be made for residents to be seen in their own rooms. The home uses a monitored dose medication system and on inspection it was found to be generally satisfactory. However, there were some discrepancies in Tudor Rose Rest Home DS0000059825.V300485.R01.S.doc Version 5.2 Page 12 respect of the boxed medication and in one instance in could not be audited as the record regarding medication carried forward from the previous month was incorrect. Other areas that need to be addressed: • • • • • • • The medicine trolley was not secured to the wall. Handwritten medication details had not been countersigned by two staff. There was no risk assessment for residents who self-administer medication. Creams had not been dated when opened. They should be dated when opened and discarded after one month due to the risk of bacterial infection. The drug fridge was not locked plus the minimum and maximum temperature were not being recorded. It was not clear that all staff who administer medication had undertaken the accredited training as required under the National Minimum Standards. One member of staff was observed to be handling medication with their hands. It should be dispensed into a medicine pot or directly to the resident. On touring the home some residents were not wearing stockings/socks or slippers/shoes and there was a notice about one residents incontinence needs on their bedroom wall. This is not appropriate as it infringes on residents privacy. The deputy manger removed it at the time of inspection. It was stated that one resident refuse to wear footwear and another would keep removing them. These aspects should be recorded in residents care plans. However, if it is because the resident’s feet and legs were swollen it is recommended that the district nurse be contacted regarding an alternative such as Benefoot universal post-operative shoes or similar, which can be obtained through NHS logistics. Tudor Rose Rest Home DS0000059825.V300485.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14,15 Quality in this outcome area is adequate. The judgement has been made using available evidence including a visit to this service. The meals offered are of a satisfactory standard and enjoyed by residents although menus could be further developed. There is an open visiting policy and visitors are made welcome. The arrangements in respect of activities and stimulation of residents need to be reviewed and developed to meet individual needs. EVIDENCE: There were no unnecessary restrictions to resident’s daily routines. On discussion with some residents they stated they were able to get up and go to bed when they wanted and had a cup of tea first thing in the morning. Visiting is flexible and it was noted that residents are able to bring personal items of furnishings etc. into the home. However, the record of belongings was not consistently dated. Residents were observed to be watching the television and some were in the dining room smoking during the day. At one stage a member of staff was observed talking to residents in one of the lounges, but there was little evidence of any other activities, as many of the residents were falling asleep in Tudor Rose Rest Home DS0000059825.V300485.R01.S.doc Version 5.2 Page 14 chairs when the lounges were entered on occasions. On discussion with one of the residents they stated they would like to have done some knitting, but it never happened. There was a visit to Weston Super Mare and Walsall Lights last year and occasionally entertainment is brought in to the home, but there appears to be little stimulation on a day-to-day basis. Records did not demonstrate assessment of residents past interests or hobbies to enable a meaningful plan of activities to be developed. The hairdresser visits on a regular basis. The priest visits regularly in respect of religious needs. On discussion with residents they stated they were happy in the home. However, during the course of the inspection it was noted that some staff did not offer residents a choice of where they wanted to go, what they wanted to do or in respect of meals. On one occasion a resident was helped out of a chair and left to mobilise unaided and another member of staff had to provide assistance and on another occasion a member of staff left a resident to answer the telephone. It appeared that some staff were more task orientated than providing individualised care. The home employs a cook who covers breakfast and lunch leaving sandwiches prepared for the evening meal. There are three main meals and a four-week rotating menu, which provides a choice of meals, but there was some repetition, there were no cultural options, the evening meal was usually sandwiches and fresh vegetables were not used. Consideration must be given to using fresh ingredients and extending the evening menu to include a hot snack to ensure that the food served is wholesome, balanced and nutritious to meet resident’s needs and preferences. All residents will not like frozen or tinned vegetables and will prefer fresh as this has a different taste, texture and appearance. Most residents take their meals in the dining rooms, but may have them in their own rooms if they wish. The dining rooms are situated on the ground floor adjacent to the kitchen. The inspector had lunch with the residents and found the meal to be hot and tasty. Staff were available and provided assistance as required. On discussion with residents they stated they enjoyed the meals. One resident stated, “the cook is an angel, she does the most wonderful meals.” Tudor Rose Rest Home DS0000059825.V300485.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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16,18 Quality in this outcome area is adequate. The judgement has been made using available evidence including a visit to this service. There needs to be an open, positive approach to complaints and further training in respect of the prevention of adult abuse to ensure residents are fully safe guarded. EVIDENCE: A copy of the complaints procedure was available on the wall in the main hall on entering the home. The manger stated they had not received any complaints since the last inspection and the Commission have not received any complaints. On discussion with residents it became apparent that there were some issues in respect of missing items of clothing and some residents were concerned about raising a complaint. When discussing informal complaints it appears that they would be discussed with the manager, but there was no record of these and how they had been addressed. The manager must ensure that all complaints or concerns are recorded indicating the nature of the concern, the investigation, outcome, action taken and resolution. Also all staff must be made aware that there should be an open and positive approach to complaints as part of the quality assurance process. The home does not have an updated copy of the Vulnerable Adult Guidelines produced by the Local Authority. On inspection of the whistle blowing policy it was noted that it requires developing further. On discussion with staff about Tudor Rose Rest Home DS0000059825.V300485.R01.S.doc Version 5.2 Page 16 procedures their knowledge was variable and it could not be guaranteed that all staff would take the appropriate action if there were an allegation of abuse. Staff training will be required in this area. Tudor Rose Rest Home DS0000059825.V300485.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19,20,21,22,23,24,25,26 Quality in this outcome area is adequate. The judgement has been made using available evidence including a visit to this service. The home is currently in the process of re-decoration and re-furbishment to enhance the environment for residents. Further attention needs to be paid to cleanliness, odour control and infection control. 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. The home was found to be warm, comfortable and generally well lit by domestic style lighting, with the exception of some areas that appeared rather dim. The manger will need to review this aspect with residents to determine if the lighting is suitable to meet their needs. There is a large garden to the rear of the property which residents use when weather permits. However, it was noted that the side of the property can be accessed and the ground is uneven and would pose a risk to residents if they wandered into this area. A more secure gate should be Tudor Rose Rest Home DS0000059825.V300485.R01.S.doc Version 5.2 Page 18 fitted to ensure safety of residents. There are also a number of outside storage areas; one of which was not locked and equipment was stored in it. On arrival it was noted that there was a slight odour on entering the home and during the course of the inspection it was noted that the standard of cleaning was not adequate. The manager stated they had been experiencing some problems with domestic staff had had just recruited a new member of staff. There are two lounges and two adjoining dining rooms on the ground floor, one of which is used for smoking when meals are not being served. There are seventeen single bedrooms and five double bedrooms, which have a wash hand basin and call bell facility. However, the call bell and light were not accessible to the bed in one room. Currently a re-decoration programme of the bedrooms is in progress, carpets are being replaced and over bed lighting fitted. The majority of the bedroom doors have locks to them enabling residents to lock their doors if they wish. However, there were no lockable facilities available for the storage of medication or valuables and rooms only had one double electrical socket. During the course of inspection it was noticed that some of the furniture in one room was unstable, commodes were rusting, the supporting straps of a chair were damaged, a mattress had “bottomed out”, plus some of the pillows and quilts were rather thin and lumpy. A full audit of all furnishings must be undertaken to ensure it is stable and in good condition, rusting commodes must be replaced plus a full audit of mattresses, pillows and quilts must be undertaken and any damaged or worn items replaced. Screening was not sufficient in some bedrooms to promote privacy and dignity. It was also noted that some of the intumescent strips on doors were coming away from the door and some doors did not close properly into the rebate, which may be a hazard in respect of fire. All areas are individually and naturally ventilated and the window in the dining room to the front of the property was damaged and will need replacing. 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. The small toilet on the ground floor was found to have a rather loose toilet roll holder attached to the wall and in another the raised toilet seat was cracked and will need replacement. On discussion with staff it was stated that some residents used the toilet roll holder as a grab rail. Although there is a grab rail on the wall this area should be reviewed to ensure residents safety. There are three assisted bathing facilities one of which is currently being upgraded to a flat floor shower. The side of the assisted bath on the ground Tudor Rose Rest Home DS0000059825.V300485.R01.S.doc Version 5.2 Page 19 floor was damaged and will need replacing. There is a further shower on the first floor, which was not working at the time of inspection, and the showerhead was not secured to the wall. In addition, there is a domestic style bath on the second floor. Some aspects in respect of infection control are poorly managed e.g. it was noted that some staff were walking around the home with vinyl gloves on. These gloves should be removed and hands washed after dealing with infected material or body fluids, bar soap was in use and paper towels were not available in some areas for staff hand washing. In bedrooms where staff undertook residents personal care there were no staff hand washing facilities and commode pots were cleaned in the bath. This issue has been discussed with the home and they stated they are waiting to have sluice facilities fitted. They have been advised to contact the health protection unit for advice on the appropriate cleaning of commode pots in the meantime. Waste bins were not operational and the top had to be lifted by hand to deposit any items for disposal. On the second day of inspection a new supply of waste bins were delivered. The laundry has recently had a new washing machine and tumble dryer fitted. On discussion with the staff they were not aware if a sluice wash was available and stated they sluiced items by hand in the sink. This is not appropriate practice. Soiled items must be washed on a sluice cycle in the washing machine. Where items are heavily soiled or infected they should be placed in alginate bags or similar and put directly in to the washing machine. It was noted that the flooring to the laundry was damaged and will need replacing and the door was not locked when the laundry was unattended. A number of toiletries were stored in the laundry and a member of staff stated they were used for residents, but could not be left in their bedrooms due to their condition. All toiletries must be labelled with the residents name to ensure that they are not used communally to reduce the risk of cross infection. The kitchen is situated on the ground floor and was found to be clean and orderly with a designated cook. At the time of inspection it was noted there was no mesh to the windows, some of the crockery was chipped and staff were washing crockery by hand. The Chartered Institute of Environmental Health – food safety first principles state that there should be two sinks and the items should be washed in the first sink at 55 degrees centigrade. Items should then be rinsed in hot water 82 degrees centigrade in the second sink leaving them to soak for 30 seconds using a designated basket for the purpose if possible. Items should be left to air dry in a clean dry area. This practice was not observed at the time of inspection and the home will need to review this or provide a suitable dishwasher. Fridge and freezer temperatures were recorded and were satisfactory, but potatoes were stored on the floor. Tudor Rose Rest Home DS0000059825.V300485.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29,30 Quality in this outcome area is adequate. The judgement has been made using available evidence including a visit to this service. Staffing levels were maintained at a satisfactory level. The recruitment procedure needs to be enhanced to ensure residents are fully protected. EVIDENCE: Current the home has twenty-four residents and staffing rotas indicate there are three care staff and the manager on duty during the day and two care staff on duty overnight. Catering, domestic and maintenance staff support care staff. The staffing levels appeared satisfactory for the dependency of residents. A small number of staff files were inspected for staff who had been employed recently. It was noted that an application form and references had been obtained. However, there was no evidence of other checks such as CRB or POVA and in one case the home had used one from a previous employer. These checks are not portable and the manager must ensure a CRB check is obtained for any new member of staff and they must not commence employment in the home until a POVA check has been obtained. Also there was no evidence of work permit or visa for a member of staff from overseas. The deputy manager stated that newly employed care staff undertake induction training, but there was no evidence of such training on files. The Tudor Rose Rest Home DS0000059825.V300485.R01.S.doc Version 5.2 Page 21 information provided indicates that over 50 of care staff are qualified to NVQ level 2. Tudor Rose Rest Home DS0000059825.V300485.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31,32,33,35,38 Quality in this outcome area is adequate. The judgement has been made using available evidence including a visit to this service. The senior staff are keen to develop areas and address requirements. Currently the quality assurance system is being developed and staff supervision is undertaken. Some areas in respect of servicing, staff training and financial records need to be developed to ensure resident’s health safety and well-being. EVIDENCE: A Registered Manager is in post who has completed the Registered Managers award and was observed to work on the floor with staff and residents. She demonstrated a commitment to addressing issues identified at the time of inspection. Tudor Rose Rest Home DS0000059825.V300485.R01.S.doc Version 5.2 Page 23 Records indicated that there had been one staff meeting in August 2005, but no residents or relatives meetings had taken place. She is in the process of developing a quality assurance process and some staff, residents and relatives have completed questionnaires. It was stated there are plans to obtain feedback from the G.P. and district nurses. It was noted that the same questionnaire had been used for relatives and residents and it was suggested that this be reviewed. Some issues had been raised on the questionnaire and action will need to be taken to follow up these areas and draw up a development plan indicating outcomes for residents. One of the providers was available at the time of feedback and it was stated that he visits the home on a monthly basis and produces a report. However, there were no copies in the home and copies have not been forwarded to the Commission as required under the Regulations. A sample of records were inspected in respect of the money and valuables held on behalf of residents in the home. There is a suitable safe facility and records are kept of money. However, there was no record of valuables held in the home and it was noted that some jewellery for a resident had not been stored in the safe facility. There was no evidence of receipts for deposits and some of the receipts for money spent on behalf of residents were not available, as it was stated they had been given to relatives. The manager must ensure a robust system is in place with receipts for all transactions and a record of all valuables, which must be stored in a safe facility. Samples of records were inspected in relation to maintenance/servicing of equipment and were found to be up to date with the exception of the following, which will need to be addressed; • There was no evidence of servicing of the passenger lift and other documentation indicated there were some issues to be addressed. • There was no evidence to indicate flushing of water outlets that are rarely used. • There was no evidence that the emergency lighting and hot water temperatures were tested on a regular basis in house. • Risk assessments in respect of cleaning materials had not been undertaken and the general risk assessment needed reviewing and developing. The call bell system is two years old and the home has a contract in the event of any problems. Tudor Rose Rest Home DS0000059825.V300485.R01.S.doc Version 5.2 Page 24 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 2 10 2 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 1 13 2 14 2 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 2 2 3 2 2 X 2 2 1 STAFFING Standard No Score 27 3 28 2 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 2 2 X 2 X X 2 Tudor Rose Rest Home DS0000059825.V300485.R01.S.doc Version 5.2 Page 25 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 OP1 Regulation 4 Requirement The registered person must review and enhance the statement of purpose and forward a copy to the Commission. The registered person must review the service users guide ensuring it is in line with the regulations providing adequate information for residents and their representatives. When completed copies must be made available to residents and a copy forwarded to the Commission. The registered person review the contract of residence to ensure it accurately reflects the services and facilities in the home and a copy should be provided in the service user guide. 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 DS0000059825.V300485.R01.S.doc Timescale for action 30/11/06 2 OP1 5 30/11/06 3 OP2 5(1)(b) 30/07/06 4 OP3 14 15/08/06 Tudor Rose Rest Home Version 5.2 Page 26 5. OP7 15(1)(2) 6 OP7 14 7 OP7 17(2) 8 OP8 13(1) 12(4) 9 OP8 12(1) 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. The Registered Person must: • Ensure a comprehensive care plan is drawn up for all residents outlining in detail the action to be taken by staff to meet resident’s needs. • The residents or their representative should be involved in the process. • Care plans should be reviewed every month and care plans updated to demonstrate any changes in care. The Registered Person must ensure care plans include risk assessments in respect of risk areas such as nutrition, manual handling, the use of passenger lift or stairs etc. The registered person must ensure daily records indicate follow up to any areas of concern and are based on fact. The registered person must ensure: • There are systems in place for residents to see a dentist on a regular basis and records are retained in the home. • Arrangements are in place for residents to be seen in private by visiting health professionals The registered person must undertake a review of communication systems within the home and ensure any DS0000059825.V300485.R01.S.doc 30/08/06 15/07/06 30/06/06 30/07/06 30/07/06 Tudor Rose Rest Home Version 5.2 Page 27 10 OP8 12(1) 23(2(n) 18(1) 12(1) 13(4) 11 OP8 12 OP8 13 OP9 13(2) changes in resident’s conditions are followed up appropriately. The registered person must ensure a call bell is accessible to all residents when they are in their room. The Registered Person must ensure all staff undertake training in respect of the management of continence. The Registered Person must ensure an audit of all walking frames is undertaken and any worn rubbers are replaced. The registered person must ensure there is a fully auditable and robust medication system to include: • The correct administration and recording of all medication. • The medicine trolley must be secured to the wall. • Two staff must countersign all hand written medication details. • All creams must be dated when opened and discarded after one month. • The drug fridge must be kept locked when not in use and the minimum and maximum temperature must be recorded on a daily basis. • Medication must be dispensed into a medication pot or directly to the resident. • A risk assessment must be undertaken for any medication that is selfadministered by residents. • Ensure the amounts of any medication carried forward from the previous month are recorded on the MAR chart to enable auditing. DS0000059825.V300485.R01.S.doc 30/06/06 30/07/06 10/07/06 30/06/06 Tudor Rose Rest Home Version 5.2 Page 28 14 OP9 13(2) 18(1) 15. OP10 12(1) 12(4) 16 OP12 16(2)(m) (n) 17 OP13 12(1) 12(3) 18 OP16 22 19 OP18 13(6) The Registered Person must ensure all staff who administer medication undertake accredited training and a record is retained in the home. The registered person must ensure systems are in place to maintain residents privacy and dignity e.g. the use of socks, stockings, and slippers/shoes, use of notices etc. The Registered Person must ensure all residents have access to a range of recreational activities to meet their needs, preferences; past lifestyles and cultural backgrounds and records are retained in the home to demonstrate this. The Registered Person must ensure arrangements are in place to provide an person centred approach to care and residents are offered choices in various aspects of day to day living The registered person must: • Ensure a record of all complaints/concerns are kept to include the date, nature of the complaint, the investigation, outcome and resolution. • Ensure there is an open and positive approach to complaints in order that lessons can be learnt. The Registered Person must ensure: • All staff have training in relation to adult protection procedures and clearly understand their role. • The whistle blowing policy is updated. • A copy of the updated DS0000059825.V300485.R01.S.doc 30/08/06 30/06/06 30/08/06 30/07/06 20/07/06 30/07/06 Tudor Rose Rest Home Version 5.2 Page 29 20 OP19 16(2)(j) 21 OP19 23(2)(b) 22 OP19 23(4) 13(4) 23 OP19 13(4) 24 OP21 23(2)(b) (j)(n) 25 OP24 16(2)(c) 12(1) 23(2)(c) guidance is obtained. The registered person must ensure: • Chipped crockery is replaced. • Food items are not stored on the floor • Mesh if fitted to windows. • Suitable arrangements are made for dishwashing that meet environmental health standards The Registered Person must forward a plan of re-decoration and refurbishment to the Commission. The registered person must ensure: • All doors close properly into the rebates. • Intumescent strips fit properly. The Registered Person must ensure: • The area to the side of the building is made safe or access is restricted. • All out door store area are secured. The registered person must ensure: • The shower on the first floor is in working order. • The toilet roll holder on the ground floor is made safe or replaced by a suitable grab rail. • The damaged raised toilet seat and bath panel are replaced. The registered person must ensure: • Locks are provided to all bedroom doors. • Lockable facilities are provided for all residents in their bedrooms. • Damaged commodes are DS0000059825.V300485.R01.S.doc 15/08/06 30/07/06 15/07/06 15/07/06 30/07/06 30/07/06 Tudor Rose Rest Home Version 5.2 Page 30 26 OP24 16(2)(c) 12(4) 27 OP25 23(2)(p) 28 OP26 13(3) 29 OP26 13(3)(4) replaced. An audit of all furnishing is undertaken and any damaged or unsafe items are replaced or repaired. • Two double sockets are provided in bedrooms. Forward an action plan to the Commission. The Registered Person must ensure: • An audit of all mattresses, pillows and quilts is undertaken and any worn items are replaced. • All privacy screening surrounds beds and washbasin adequately to provide privacy. The registered person must ensure: • All lighting is satisfactory to meet resident’s needs and a light can be accessed from the bed. • The damaged window in the front dining room is replaced. The registered person must; • Review arrangements to ensure staff use the sluice cycle on the washing machine and items of clothing are not sluiced out by hand. • Ensure staff hand washing facilities are available in all areas where staff handle clinical waste. • Bar soap should not be used in communal areas. • Toiletries must be labelled, when stored in communal areas. • Staff must remove gloves and wash hands after dealing with clinical waste The registered person must: • DS0000059825.V300485.R01.S.doc 30/07/06 30/07/06 20/07/06 30/07/06 Page 31 Tudor Rose Rest Home Version 5.2 30 OP26 16(2)(k) 23(2)(d) 31 OP26 13(4) 32 OP29 19 33. OP30 18(1) 34 OP33 25 35 OP33 26 36 OP35 17(2) Sch 4 37. OP38 13 (4)(a) Ensure the door to the laundry is kept locked when not in use. • Replace the flooring in the laundry area. The registered person must ensure; • All areas of the home are kept clean at all times. • The home is odour free. The registered person must ensure the cupboard used for the storage of cleaning materials is kept locked when not in use. The registered person must ensure there is a robust recruitment procedure in place to include POVA and CRB checks plus work permit and visa where necessary and evidence is retained in the home. The registered person must ensure all newly employed staff complete induction training that meets the standards of the Social Skills Council and records are retained in the home The registered person must ensure an annual development plan drawn up following feedback from stake holders indicating outcomes for residents and addressing any issues raised. The responsible individual must ensure a copy of the monthly report is forwarded to the Commission. The registered person must ensure: • All valuables are held in the secure facility and a record is retained in the home. • Receipts are available in the home for all transactions. The registered person must DS0000059825.V300485.R01.S.doc • 30/06/06 30/06/06 20/07/06 30/08/06 30/11/06 30/07/06 15/07/06 30/08/06 Page 32 Tudor Rose Rest Home Version 5.2 38 OP38 13(3) ensure: • All emergency lighting is tested monthly and a record is retained in the home. • The temperature from hot water outlets is recorded on a regular basis and records are retained in the home. • A record is retained to demonstrate that little used outlets are flushed on a regular basis. • Risk assessments are undertaken in respect of cleaning materials etc. • General risk assessments are reviewed and developed. The registered person must ensure: • The passenger lift is serviced on a regular basis and a record is retained in the home. • Issues in respect of the passenger lift are addressed. The Registered Person must ensure all staff undertake mandatory training in respect of manual handling, basic food hygiene and first aid 30/07/06 39 OP38 18(1) 30/11/06 Tudor Rose Rest Home DS0000059825.V300485.R01.S.doc Version 5.2 Page 33 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 5 6 7 Refer to Standard OP3 OP8 OP8 OP14 OP15 OP26 OP32 It is recommended that formal auditing of accidents be undertaken. Where residents do not wear shoes due to swollen feet/ankles it is recommended that this be discussed with the district nurse as outlined in the body of the report. Inventories of resident’s belongings should be dated and signed by the resident or their representative. It is recommended that a review of the menus is undertaken and meals incorporate some fresh vegetables. It is recommended that the Health Protection Unit be contacted regarding the arrangements for cleaning of commode pots etc. It is recommended that staff meeting are conducted more frequently and consideration given to meetings with residents/relatives Good Practice Recommendations It is recommended that the home liaise with the social worker for a copy of their assessment. Tudor Rose Rest Home DS0000059825.V300485.R01.S.doc Version 5.2 Page 34 Commission for Social Care Inspection Birmingham Office 1st Floor Ladywood House 45-46 Stephenson Street Birmingham B2 4UZ 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. 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