Inspection on 23/05/07 for Tudor Rose Rest Home

This inspection was carried out on 23rd May 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 19/12/07

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

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 Mrs Amanda Hennessy Unannounced Inspection 23rd May 2007 09:30 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.V334494.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.V334494.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.V334494.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)). 26th October 2006 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 very limited off road parking at the front of the building to accommodate a maximum of three vehicles, 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. Fees range between £336 to £354 and are dependent on peoples needs and the room that they occupy/. Toiletries, newspapers and non NHS Chiropody is not included in the fee and must be provided at residents own expense. Tudor Rose Rest Home DS0000059825.V334494.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 09.30 and 18.30. The Inspection included a tour of the home, talking to residents and staff, looking at the care record of three residents and four staff files and a review of comment cards sent to the Commission for Social Care Inspection by relatives and residents as well as information supplied by the home before the inspection. The home has addressed twenty-eight of the previous forty-two requirements. There are fourteen requirements that are outstanding; no new requirements were made as a result of this inspection. What the service does well: What has improved since the last inspection? The Manager have worked hard to address the majority of outstanding requirements. The environment of the home is now much cleaner and more pleasant as a result of the refurbishment plan it is essential that this continues. Medication practices are much improved. Staff are receiving additional training giving residents increased confidence that their medicines will be safely managed and staff will recognise any problems quickly and will ensure that they see a Doctor. The home now provides a daily activity for residents with bulbs that they have planted proudly displayed on windows and fireplaces around the home. The manager has developed a quality assurance plan, which includes a monthly audit plan following which she identifies an action plan to ensure that outstanding issues are addressed. Tudor Rose Rest Home DS0000059825.V334494.R01.S.doc Version 5.2 Page 6 What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Tudor Rose Rest Home DS0000059825.V334494.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.V334494.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 2, 3, 4 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. All required information about the home is available for both prospective and current residents, detailing the care and facilities provided. Greater assurance will be given that the home can meet peoples needs if they are fully involved in the assessment of their needs. EVIDENCE: The contracts were available for people whose care records were reviewed. Contracts are not always signed by the resident with a comment “unable to sign” which may not be appropriate under the Mental Capacity Act. Fees are included in the contract and it was good to see they just need further explanation of who is responsible for paying their fees such as the local Social Services Department. People who come to live at the home have an assessment of their needs before they come to live at the home. There was some evidence that residents Tudor Rose Rest Home DS0000059825.V334494.R01.S.doc Version 5.2 Page 9 preferences have been included in the assessment of needs but there is lack of record of their involvement. Staff have had recent training in dementia care and person centred care, however their understanding of dementia and person centred care was minimal. The manager has recently completed a “trainers” course with Mulberry enabling her to deliver the person centred care training but she did not appear to have a sound understanding of what it is or how to begin implementing it. The home also cares for people with mental disorder again the manager showed little understanding of how to care for people with a mental disorder and when we reviewed the training records for staff we noted that only one member of the current staff group has received any training in this area. This is unchanged from the last inspection. Tudor Rose Rest Home DS0000059825.V334494.R01.S.doc Version 5.2 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9, 10 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. The lack of detailed care instructions does not give assurance that residents care needs are consistently met. Medication systems have been improved giving greater assurances that practices safeguard residents’ health and well being. EVIDENCE: Residents have a plan of their care, which is updated monthly. Care plans generally require more information to provide staff with comprehensive details about residents care needs. For example one service user has diabetes but the care plan did not include any contingency plan for staff to follow if the service user experienced either a high or low blood sugar, the care plan simply stated, “keep ……. with a good healthy diet”. Other care plans seen included one for “Confused and forgetful” but no instructions were available to show how staff should meet this need. A plan for continence care stated “reassuring ….. that Jesus doesn’t want her to wet as this is why she says she does it”. There was no practical guidance for staff to follow in managing the continence Tudor Rose Rest Home DS0000059825.V334494.R01.S.doc Version 5.2 Page 11 for this service user. There are improvements that could be made to the care planning process, this would include nutritional screening of all service users so that any potential problems are readily identified and actioned reducing risk to service users. The moving and handling assessments for residents also continue to need further development as identified at previous inspection, they are non-specific to the service user and refer to the use of a hoist. Staff spoken to say that they do not use the hoist for any residents so if was unclear what residents true moving and lifting requirements are. In addition when risk assessments identified a risk to the resident there is no care plan or detailed control measures to show how the risk to the service user will be minimised. Care records did show that residents do see the chiropodist, optician and the dentist. Service users are also visited by social workers and community nurses as their needs dictate. The home did not show that appropriate actions are always undertaken when residents lose weight. One resident has consistently lost weight since their admission to the home, but there is no nutritional screening tool to guide staff on required actions and the care plan lacks sufficient detail to meet their needs. There was also no information in the care records for this service user that the GP or dietician have been consulted about their weight loss. This was discussed with the manager at the time of the inspection, who insisted that the service user had been seen by the GP. This information must be recorded so that all interested parties are clear about the course of action that will be needed to improve the situation for the service user and prevent further weight loss from occurring. The staff have received training in the safe handling and keeping of medicines. It was positive to hear that they are having additional training in medication administration to give them more information about medicines and their safety. The home has met most of the requirements made at the previous inspection in relation to medicines. The home is now keeping a record of the fridge temperature (even though the fridge is outside in the garden). To give additional assurance that medicines are stored safely and appropriately within required temperatures there is a need to check and record the temperature of the room where medicines are stored. Other areas that could be improved upon is the use of photographs to identify residents on their medication record to reduce any risk of confusion and a record of exactly how much medicine is given when the Doctor prescribes one or two tablets. The home currently return all medicines at the end of the month which may include medicines that are given when required, have not been given but are requested again the following month. This practice is a wasteful use of valuable National Health Service money and was also discussed during the inspection. Staff must also ensure that a self administration assessment and consent to administer medicines are undertaken for all residents when they are admitted to the home. Tudor Rose Rest Home DS0000059825.V334494.R01.S.doc Version 5.2 Page 12 Residents were seen to be without stockings or tights on their legs, although the manager did say this was some residents’ choice. Other residents were wearing clothing, which was dirty. Staff were seen to knock doors before they entered toilets and bathrooms. It was nice to see that the home has now provided suitable screening for all residents in shared rooms so that their privacy will not be compromised when personal care is being carried out. Tudor Rose Rest Home DS0000059825.V334494.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 poor. This judgement has been made using available evidence including a visit to this service. There is insufficient information to ascertain whether the home meets residents’ social needs, interests or capabilities. Food is tasty but lacks variety and is unsuitable for some residents’ needs and likes. EVIDENCE: The manager has recently updated the activity programme with activities such as bulb planting, bingo, baking and playing ball available for residents. Whilst the activity programme identifies a daily activity, residents daily notes do not record activities that residents have taken part in. Most daily records simply record “ate and drank well, watched TV”. This was discussed with the manager at the time of the inspection, she assured Inspectors that activities do take place but there is a need for staff to record this. The provider confirmed that he has arranged care planning and record keeping training for his staff. Tudor Rose Rest Home DS0000059825.V334494.R01.S.doc Version 5.2 Page 14 There was little recorded information about residents’ choices such as they time they get up or go to bed. It was positive to see that during the inspection the priest came to give communion to residents, there was no evidence that other residents who are not catholic have a visit from their church or go to their place of worship. We observed the priest speak to one resident and offer communion, but the resident responded that they were a Mormon, upon checking that persons care file this information had not been recorded. Residents are able to receive their visitors in the privacy of their own rooms should they wish to do so. The manager also said that she allowed some visitors to smoke when they visit the home (in the dining room) but this has been done without the prior consent of the people users who live in the home. None of the service users handle their own money but they all have a lockable storage facility in their bedrooms should they choose to do so. No information about the use of an advocacy service was available which could assist people to use a service, which is independent and acts in their best interests. Records identified that the manager has obtained consent for treatment such as flu jabs off residents relatives. No judgment was recorded stating that the person lacked capacity to make decisions about their health care. It is positive that the manager includes relatives in the care and treatment of the resident but this has to be at the service users request or in their best interests. The manager was advised to seek further guidance about the Mental Capacity Act and the implications for practice. Meals are served three times a day and supper is available upon request. The home provides a menu for service users, there are generally two choices available to service users. The menu is limited and requires reviewing, as it is reliant upon a few food items to make up its entire menu, such as burgers, corned beef and pies. On the day of this inspection it was one service users birthday, the home had made a birthday cake for them, to celebrate. We sampled the meals that were on offer, cauliflower cheese and beans, and corned beef hash with baked beans and burger. Both meals were tasty and the portion sizes were adequate. Most service users eat their meals in the dining room. It was concerning that the designated smoking area for this home is the dining room and although residents didn’t smoke during meal times the smell of cigarettes was obvious when you enter the room. This was also discussed with the manager and she was informed that a change of location was needed. She was also advised to contact the environmental health department regarding the smoking cessation guidance for care homes in preparation for 2008. Tudor Rose Rest Home DS0000059825.V334494.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 good. This judgement has been made using available evidence including a visit to this service. The home has appropriate procedures in place to ensure that residents are listened to and safeguarded. EVIDENCE: A copy of the complaints procedure was available on the wall in the main hall on entering the home for information. The manger stated they had received one informal complaint since the last inspection, which had been addressed. 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.V334494.R01.S.doc Version 5.2 Page 16 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 24, 25, 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 generally clean and newly decorated. Infection control concerns have been addressed and now reduce the risk of cross infection to residents. 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 and lit satisfactorily in some areas, but other areas appeared rather dim. The manager will need to review this aspect with residents and ensure all areas are lit satisfactorily to meet resident’s needs and reduce the risk of accidents. There is a large garden to the rear of the property, which residents use when weather permits. At the last inspection 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 Tudor Rose Rest Home DS0000059825.V334494.R01.S.doc Version 5.2 Page 17 wandered into this area and this remains outstanding. A more secure gate should be fitted to ensure the safety of residents. On touring the home there was noted to be some improvement in the standard of cleaning, but further improvement is required in respect of deep cleaning to provide a clean environment. 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. 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. There are seventeen single bedrooms and five double bedrooms, which have a wash hand basin and call bell facility. The call bell and light were not accessible to the bed in some rooms so residents would not be able to summon assistance. Currently a re-decoration programme of the bedrooms is in progress, carpets are being replaced and over bed lighting fitted to enhance the environment for residents. 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 for electrical items. During the course of inspection it was noticed that some of the furniture was unstable and of poor quality and will need to be replaced. Some of the bedrooms did not have a comfortable chair for residents to sit. A full audit of all furnishings must be undertaken and action taken to ensure all furnishings are in a good state of repair, rusting commodes must be removed, and residents must be provided with the furnishings outlined in the National Minimum Standards. Since the last inspection some new beds, privacy curtains and bedding have been provided. All areas are individually and naturally ventilated, but some of the restrainers on windows were broken and resident’s safety is compromised. A full audit of windows must be undertaken and any damaged restrainers repaired. 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. Some of the toilets did not have toilet roll holders accessible for residents use and the lock on the ground floor toilet was not working. There are three assisted bathing facilities one of which has been upgraded to a walk in shower. Some of the floor tiles in the assisted bathing facility on the ground floor were damaged and the bath seat was not working adequately. The shower on the first floor had been repaired, but the water was cold and the water from the shower unit in the walk in shower was too hot and will need to have a thermostatic valve fitted to restrict the temperature of water to Tudor Rose Rest Home DS0000059825.V334494.R01.S.doc Version 5.2 Page 18 reduce the risk of scalding to residents. There is a domestic style bath on the second floor. The bathing facilities do not meet the needs of residents. Since the last inspection liquid soap and paper towels had been fitted in some bedrooms for the purpose of staff hand washing where personal care is provided. However, some aspects in respect of infection control are poorly managed e.g. some staff were walking around the home with vinyl/latex gloves on. These gloves should be removed and hands washed after dealing with infected material or body fluids and staff were not aware of the use of various types of gloves, bar soap was in use, paper towels were not available in some areas for staff hand washing, commode pots were cleaned in the bath and waste bins did not have lids. Also some staff were not aware of the full range of infection control procedures for incidents of infection in the home. The manager stated they were waiting to have sluice facilities fitted at the time of the last inspection. The laundry floor has been patched since the last inspection. The manager stated they are to have a new laundry area with a planned extension. The manager will need to inform the Commission of the date for the new laundry facility. The laundry was found to be dusty and in need of cleaning; a supply of toiletries were found in a cupboard suggesting communal use. All toiletries must be labelled with the residents name to ensure that they are not used communally to reduce the risk of cross infection. Also the lock the laundry door needs to be replaced, as it is not adequate. On discussion with staff about the laundry system and use of the equipment it was found there was not a consistent procedure for using the washing machine, laundry was not separated at source, there were no alginate bags or similar for soiled items, there was only one suitable receptacle for collecting washing from residents bedrooms and staff were taking it to the laundry by hand. It was also noted that there was only three washing bowls in the home and residents who required washing in their bedrooms did not have an individual bowl. These procedures are not appropriate and will need to be reviewed. 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. The kitchen is situated on the ground floor and was found to be clean and orderly with a designated cook. Since the last inspection a second sink has been fitted and they are waiting to have a mesh fitted to the windows. Fridge and freezer temperatures were recorded and were satisfactory, but some sauces had been opened and had not been dated with a use by date. Tudor Rose Rest Home DS0000059825.V334494.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 poor. This judgement has been made using available evidence including a visit to this service. Staffing levels do meet residents’ needs but there is a need to ensure that new staff have robust checks and have an appropriate induction to demonstrate residents are adequately protected. EVIDENCE: Discussion with staff and residents indicated that staffing levels are satisfactory for the dependency of residents that the home currently accommodates. Files of staff employed since the last inspection were reviewed, some improvement in the safe recruitment and selection of staff was noted but further improvements are required. All staff have an application but there is a need for more information about their previous employment history to enable the manager to assess the suitability of referees identified. Two references were not always available and it was difficult to assess whether references were from a past employer. All staff have criminal records checks but sometimes they are employed before they are returned and have a Protection of vulnerable Adults check as an interim measure. The use of a “ POVA first” whilst generally acceptable must only be used when robust recruitment and selection procedures are employed which would include Tudor Rose Rest Home DS0000059825.V334494.R01.S.doc Version 5.2 Page 20 the authentication of employment history and references and a requirement that the member of staff is supervised at all times, 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.V334494.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. There has been an improvement in the management systems of the home but further development is required to ensure resident’s benefit from living in a well managed and safe home. EVIDENCE: The home has a Registered Manager who has completed the Registered Managers award and a deputy manager both of whom have worked at the home for several years. Tudor Rose Rest Home DS0000059825.V334494.R01.S.doc Version 5.2 Page 22 The manager has developed a quality assurance programme and now undertakes regular audits. Planned audits for May included: dignity of residents, disabled access, activities and receipt of medicines. Resident and relative questionnaires were sent out along questionnaires for the Commission for Social Care Inspection but non were returned, so she needs to look at alternative ways of ensuring that residents comments are included within development plans for the home. The providers visit the home regularly; write a report and a copy is forwarded to the Commission in line with the regulations providing feedback about the conduct of the home. A sample of records of residents’ money and valuables held on behalf of residents in the home. Records show that staff obtain receipts for the majority of purchases made although £5 is withdrawn for residents toiletries on a monthly basis, but there is no evidence what toiletries are purchased. Staff also purchase chocolate, fruit and clothing for residents, it would be nice if residents were encouraged to go out and purchase items of their own choice. Records supplied prior to the inspection by the manager confirmed that maintenance and servicing records were up to date. Hot water remains inconsistent with the “hot” water from some taps being merely tepid and not giving adequate hot water for washing residents and providing effective hand washing for staff. The manager has arranged for staff to undertake required mandatory training and this is ongoing. Tudor Rose Rest Home DS0000059825.V334494.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 x 2 2 1 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 1 15 1 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 x 18 3 2 x x x x 2 2 2 STAFFING Standard No Score 27 3 28 3 29 2 30 1 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 x 2 x 2 x x 2 Tudor Rose Rest Home DS0000059825.V334494.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 OP1 Regulation 4 Requirement Timescale for action 30/06/07 2. OP3 14 The registered person must review and enhance the statement of purpose and forward a copy to the Commission. Timescale of the 30/11/06 Not met. Provider agreed to forward the statement of purpose but was not received- Timescale extended The registered person must 31/07/07 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 Not met, timescale extended – The home has assessments but they lack detail are not always signed and dated and Tudor Rose Rest Home DS0000059825.V334494.R01.S.doc Version 5.2 Page 25 3 OP3 OP7 14 4 OP4 12(1) 5. OP7 15(1)(2) 6. OP7 17(2) do not show any service user involvement The registered person must ensure full risk assessments are undertaken on admission to the home to include a nutritional risk assessment and manual handling risk assessment. Timescale of 15/7/06 and 30/11/06 not met. The registered person must ensure all staff undertaken training in respect of dementia care commensurate with their position in the home. Timescale of the 30/03/07 part met- further training required. 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. Timescale of the 30/08/06 not met. Care plans are there they lack sufficient information to guide staff to meet service users needs. The registered person must ensure daily records indicate follow up to any areas of concern and are based on fact. Timescale of the 30/06/06 not met there was little evidence to show that the home records all actions it takes, such as treatment for weight loss for service users. The Registered Person must DS0000059825.V334494.R01.S.doc 30/06/07 30/09/07 31/07/07 31/07/07 7. OP8 18(1)12(1 30/09/07 Page 26 Tudor Rose Rest Home Version 5.2 ) 8 OP8 12(1) 9. OP12 16(2)(m)( n) 10. OP19 23(4)13(4 ) ensure all staff undertake training in respect of the management of continence. Timescale of the 30/0706 not met, timescale extended. The registered person must 30/09/07 ensure all staff undertaken training in respect of tissue viability. Time scale of the 30/12/06 not met. The Registered Person must 31/07/07 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. Timescale of the 30/08/06 partially met- more activities are available but the home needs to demonstrate that activities are the choice of residents accommodated. The registered person must 15/07/07 ensure: All doors close properly into the rebates. In tumescent strips fit properly. Timescale of the 15/07/06 partially met. 11. OP24 16(2)(c)1 2(1)23(2) (c) The registered person must ensure: Locks are provided to all bedroom doors. 30/07/07 12. OP25 23(2)(p) Two double sockets are provided in bedrooms. Timescale of the 30/07/07 not reached. The registered person must 30/07/07 ensure: All lighting is satisfactory to meet resident’s needs and a light can be accessed from the bed. DS0000059825.V334494.R01.S.doc Version 5.2 Page 27 Tudor Rose Rest Home 13. OP26 16(2)(k)2 3(2)(d) 14. OP38 18(1) The damaged window in the front dining room is replaced. Timescale of the 30/07/06 not met lighting in some corridors remains dim Hot water temperature is variable. Some window openers/ restrictors still remain broken. The registered person must ensure; All areas of the home are kept clean at all times. The home is odour free. Timescale of 30/6/06 not met. The Registered Person must ensure all staff undertake mandatory training in respect of manual handling, basic food hygiene and first aid. Timescale of the 30/11/06 all mandatory training is ongoing. 30/06/07 31/07/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 2 3 4 Refer to Standard OP13 OP14 OP14 OP22 Good Practice Recommendations Person centred care should developed. The manager should seek guidance about the Mental Capacity Act and the implications for practice. Alternative arrangements should be made for smoking out of the dining room. A call bell must be accessible; an extension to the staff call should be available to all residents. Tudor Rose Rest Home DS0000059825.V334494.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection West Midlands Regional Office 1st Floor Ladywood House 45-56 Stephenson Street Birmingham 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. 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