Inspection on 30/11/09 for Tudor Rose Rest Home

This inspection was carried out on 30th November 2009.

CQC found this care home to be providing an Adequate service.

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 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 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 17/02/2010.

Key inspection report CARE HOMES FOR OLDER PEOPLE Tudor Rose Rest Home 671 Chester Road Erdington Birmingham West Midlands B23 5TH Lead Inspector Lisa Evitts Key Unannounced Inspection 30th November 2009 08:55 DS0000059825.V378572.R01.S.do c Version 5.3 Page 1 This report is a review of the quality of outcomes that people experience in this care home. We believe high quality care should: • • • • • Be safe Have the right outcomes, including clinical outcomes Be a good experience for the people that use it Help prevent illness, and promote healthy, independent living Be available to those who need it when they need it. We review the quality of the service against outcomes from the National Minimum Standards (NMS). Those standards are written by the Department of Health for each type of care service. Copies of the National Minimum Standards – Care homes for older people can be found at www.dh.gov.uk or bought from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop. The mission of the Care Quality Commission is to make care better for people by: • Regulating health and adult social care services to ensure quality and safety standards, drive improvement and stamp out bad practice • Protecting the rights of people who use services, particularly the most vulnerable and those detained under the Mental Health Act 1983 • Providing accessible, trustworthy information on the quality of care and services so people can make better decisions about their care and so that commissioners and providers of services can improve services. • Providing independent public accountability on how commissioners and providers of services are improving the quality of care and providing value for money. Tudor Rose Rest Home DS0000059825.V378572.R01.S.doc Version 5.2 Page 2 Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report Care Quality Commission General Public 0870 240 7535 (telephone order line) Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CQC copyright, with the title and date of publication of the document specified. www.cqc.org.uk Internet address Tudor Rose Rest Home DS0000059825.V378572.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 350 4040 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 Ms 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.V378572.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category of service only: Care Home Only (Code PC) To service users of the following gender: Either Whose primary care needs on admission to the home are within the following categories: Old age, not falling within any other category (OP) 27 Mental Disorder, excluding learning disability or dementia - over 65 years of age (MD(E)) 5 The maximum number of service users who can be accommodated is: 27 1st December 2008 2. 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 several 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 are five double bedrooms and seventeen single bedrooms; all have wash hand basins and a call bell system. There is a shaft lift that gives access to all floors and permits a maximum of two people. This restriction in conjunction with the narrow corridors prohibits the home from caring for people who are wheelchair users. Tudor Rose Rest Home DS0000059825.V378572.R01.S.doc Version 5.2 Page 5 Communal toilets and bathrooms are strategically located throughout the home. 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 people can frequent during clement weather. Meals and a laundry service are supplied on site. On the day of this visit fee rates for living at the home ranged from £336 £354 per week depending if single or double room. There are no top up fees. These rates are reviewed annually and the home should be contacted for current rates. There is some information on display inside the home and the last inspection report is available for people to read if they choose to. Tudor Rose Rest Home DS0000059825.V378572.R01.S.doc Version 5.2 Page 6 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 1 star. This means the people who use this service experience adequate quality outcomes. The focus of our inspections is upon outcomes for people who live in the home and their views of the service provided. This process considers the care homes capacity to meet regulatory requirements, minimum standards of practice and focuses on aspects of service provisions that need further development. Two inspectors undertook the visit, over one day when the home did not know that we, the commission were coming. At the time of our visit 25 people were living at the home and one person was receiving care in hospital. Information was gathered from speaking to five people who live at the home, one visiting healthcare professional and three staff. Three people were case tracked. Case tracking involves discovering individual experiences of living at the home by meeting or observing people, discussing their care with staff, looking at medication and care files and reviewing areas of the home relevant to these people, in order to focus on outcomes. Case tracking helps us to understand the experiences of people who use the service. Staff files and health and safety records were reviewed. Before we visited the home, the manager completed an Annual Quality Assurance Assessment. (AQAA) In this the home can tell us how they think they are performing against the standards we look at. We sent out surveys to ten people who live at the home and their relatives and to ten staff to find out their views. We received eight surveys from people who live at the home, two from relatives and six from staff. Their comments are included in this report. We looked at the money held by the home on behalf of people that live there. The balances were not correct and we left an Immediate Requirement that this be investigated and corrected. We returned to the home two days later, and were pleased with the actions taken by the home to correct the errors and to ensure the likelihood of it happening again had been reduced. What the service does well: We found that all the people we spoke to were happy with the care and support they receive at Tudor Rose. People said, Tudor Rose Rest Home DS0000059825.V378572.R01.S.doc Version 5.2 Page 7 Cant find fault here, I have nothing to complain about Staff are human, real, they dont bully you I am happy with the food, my room, and the staff I live the life of a lady, everything is done for me Im very happy to be here. The staff are OK…They are there if I need them, they are OK with me. I wouldnt change anything The point is if I ask for anything, it would be done. My room is alright and I have everything I need. If I need to see a Doctor, I tell the staff and they arrange it for me, it is never a problem We found that the staff know the people living at the home well. A lot of the staff have worked in the home for a long time, and have close relationships with the people who live there. One staff member said, It is like a family here, the residents and staff get close to each other. Another said, I really enjoy my job, I have been here 11 years. Staff and residents get on well; it is a happy, friendly place. We found that staff recognise quickly when someones needs change, and they ensure they get medical help promptly. The home meets and assesses people prior to offering them a place in the home. Whenever possible the person is invited to visit Tudor Rose before deciding whether or not to move in. If people need medication the staff are trained and competent to administer this. We found it was stored securely and people had received medication when required. The home has a cook, and all the meals are prepared onsite. We sampled the meal which was well presented, hot and appetising. The food we saw was fresh, and tasty. People had the chance to have a second helping, and were asked how they would like the meal. The manager and deputy manager know the people who live there well. They are approachable, and we saw that people felt able to approach them, and ask them for support or help through out the time of the inspection. All the staff know what is expected of them, the home is generally well run and organised. What has improved since the last inspection? The manager has ensured that things we identified at the last inspection have been sorted out. This included putting an alarm on one external door, resealing some tiles in the bathrooms and toilets and under taking fire drills more often. There are activities to join in with, and when possible people are supported to go to the local shops, bank or post office. Several people we spoke to were looking forward to going out with the staff and fellow residents for a Christmas Tudor Rose Rest Home DS0000059825.V378572.R01.S.doc Version 5.2 Page 8 party. People appreciated being able to opt in or out of these activities as they wished. The AQAA and people living at the home also told us that re-decoration has been on-going to improve the quality of the environment for the people living there. What they could do better: If you want to know what action the person responsible for this care home is taking following this report, you can contact them using the details on page 4. The report of this inspection is available from our website www.cqc.org.uk. You can get printed copies from enquiries@cqc.org.uk or by telephoning our order line – 0870 240 7535. Tudor Rose Rest Home DS0000059825.V378572.R01.S.doc Version 5.2 Page 9 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.V378572.R01.S.doc Version 5.3 Page 10 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 1,2,3,4 & 5 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Arrangements are in place to ensure that people have the information they need and can be confident that their needs will be met if they decide to move in. EVIDENCE: We case tracked three people who live at Tudor Rose. All of their files showed that a pre-admission assessment had been undertaken before they moved in. One person who had most recently moved into the home, had a very detailed assessment, and the manager had confirmed in writing that they could meet his needs before a decision to move in was made. Two people we spoke with could remember what had happened when they moved in to the home, and told us they had been able to visit the home, and Tudor Rose Rest Home DS0000059825.V378572.R01.S.doc Version 5.3 Page 11 received a letter from the manager, before deciding about moving in. This means that people can see what it would be like to live at the home and know their needs can be met before they decide to move in. The Home produces a Statement of Purpose and Service User Guide. These were up to date, and contained the information people need to help them make a decision as to whether they want to live at the home. A copy was freely available in the reception of the home. Each of the people we case tracked had a contract on their file. It listed the fees of the home as being £354 for a single room, and £336 for a double room. There is an extra charge made for hairdressing, chiropody, magazines, dry cleaning, trips, theatre and accompanied hospital visits. Tudor Rose Rest Home DS0000059825.V378572.R01.S.doc Version 5.3 Page 12 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9 & 10 People using the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The personal and health care needs of the people living there are generally met so ensuring their well-being. EVIDENCE: Each person had a written care plan. This is an individualised plan about what support is required from staff in order for the person to meet their needs. We looked at three peoples care files. The people we case tracked at this inspection had a variety of needs, and generally we found that they were being well met. Each person has a care file, and the staff had recorded peoples needs, and had captured the essence of the person. This meant you got a feel for the persons likes and dislikes, and their previous life experiences. Tudor Rose Rest Home DS0000059825.V378572.R01.S.doc Version 5.3 Page 13 We could see that when peoples needs changed, staff are quick to refer them to external professionals for further support. We found that some significant care needs had changed. While staff did know about these, and had ensured that people received the support they needed, the care documents had not always been updated to show this. Some care needs that we identified from the day/night reports were discussed with the staff, and the manager needs to ensure these are planned for, so staff have clear guidance on how to support the person, and to ensure that everyone supports the person in the same way. We spoke to a District Nurse who visits the home. She said, This is a home which has really improved, staff are very perceptive to needs. We have asked staff to do things and they listen, and do things. If anyone has an injury they cover it over straight away and call us. We asked people who live at the home, and saw records that showed that health professionals including the chiropodist, dentist and optician visit. People are supported to either attend the GP surgery, or to see the GP at home as required. People are supported to attend specialist appointments at local hospitals. The people we met were all dressed and presented in a way that they preferred. We spoke to some people who for example had uncut nails, or who appeared to need a haircut, they told us this had been offered, but they did not wish to be supported. Some of the ladies had been supported to apply nail varnish and make up, and a hairdresser visits the home, so that people can have their hair styled in a way that they prefer. Staff weigh people regularly, and undertake nutritional assessments. This ensures people get the diet they need. Staff at the home have received training in the safe administration of medication. We looked at the medication and records for three people. This had all been fully recorded, and people had received medication as required. Systems were in place to ensure medication was ordered, checked on delivery, and disposed of safely. Two people have as required medication, and we have asked the home to ensure the circumstances in which this should be used are made clear in the persons plan. Tudor Rose Rest Home DS0000059825.V378572.R01.S.doc Version 5.3 Page 14 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14 & 15 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People who live in the home experience a lifestyle that is reflective of their individual needs and wishes. EVIDENCE: We spoke to people about the activities on offer to them at the home; we also spoke with staff and the manager about this. Some information was also available in the activity record book, and the AQAA. We found that most people spend a lot of the day watching TV, relaxing and chatting with each other and the staff. Other activities are available sometimes, and these include sing alongs, music concerts, reminiscence, ball games, visiting local shops, and games. We saw posters up in the home advertising activities such as baking, letter writing, drawing, make up for the ladies, and the Christmas outing. Everyone we spoke to found the level of activity to be acceptable. People said: There is plenty to do here, you can opt in or opt out as you wish Tudor Rose Rest Home DS0000059825.V378572.R01.S.doc Version 5.3 Page 15 There are things to do, but often I like to just rest. On each of the dining tables we saw a menu. This showed what was available each day, and generally there was a choice of meals. On the day we visited Roast chicken was on the menu, and this was served as the menu said. The meal looked, smelt and tasted great. People appeared to enjoy the meal and there were lots of empty plates. The meal was calm, and unhurried. People were offered salt, pepper and gravy if they wished. Second helpings were available if people wished for them. Protective aprons were offered to people if they needed them. We spoke to staff and they confirmed that there are quality suppliers of food to the home, and they are able to produce a good, home cooked meal each day, using a variety of fresh and frozen ingredients. When we spoke to people about the food, they all said it was good. Comments included: The food is good, if you want something they will generally get it for you I am very happy with the food, it is lovely How is the food? No problems here The home has an open visiting policy. We saw in peoples notes, and were told that friends and family come to visit. We were pleased to see people making phone calls to people who are important to them, and one person told us they were supported to write letters. This means that people can continue to maintain relationships that are important to them. One of the people we case tracked was Polish, and this had been clearly documented in their care notes, along with ways in which the person wished to express their culture. We spoke with this person, and they were happy with the way the home supported them. Tudor Rose Rest Home DS0000059825.V378572.R01.S.doc Version 5.3 Page 16 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 16 & 18 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. There are systems in place to listen to peoples concerns and complaints and to safeguard people from the risk of harm. EVIDENCE: The complaints procedure was displayed in the home so that people would know what to do if they needed to make a complaint. The home had not received any complaints since our last visit. The manager and owner of the home had a very positive attitude to complaints, and said they are pleased to hear from people, to be able to put things right if there are problems. To support this they have introduced a Moans and groans book for people to record any minor issues to ensure they can be sorted out. We received one complaint about the home earlier in 2009, which we referred to the manager to investigate. She sent us a timely and detailed response. The complaint had not been recorded and the manager should ensure that all complaints received are recorded in the homes complaint log. We asked people how they would raise any concerns they have about the home or their care. All five of the people we spoke with said they felt able to Tudor Rose Rest Home DS0000059825.V378572.R01.S.doc Version 5.3 Page 17 approach the manager, deputy, or any member of staff direct and told us they were confident it would be sorted out. Where the home has concerns for peoples safety or welfare they raise this with the persons social worker. The home has made one safeguarding referral to ensure that people are safe. The case is still ongoing and the outcome is not yet known. The policy which details the action to be taken in event of someone being harmed needs to be reviewed and updated. It needs to ensure that the reader is directed to follow local multi agency guidelines. Tudor Rose Rest Home DS0000059825.V378572.R01.S.doc Version 5.3 Page 18 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 19,21,24,25 & 26 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The environment provides the people who live there with a comfortable and homely place to live. EVIDENCE: We looked at the shared areas of the home, and in the three peoples bedroom that we case tracked. The home was clean and comfortable. In the two lounges there were adequate chairs, tables, a TV, and in one a pet bird. One of the comment cards received from someone living at the home, and one of the people we spoke to at the inspection, asked that a larger TV be provided in one of the lounges. We shared this comment with the manager so that it could be discussed with the owner. Tudor Rose Rest Home DS0000059825.V378572.R01.S.doc Version 5.3 Page 19 All the bathrooms and toilets had adapted facilities including raised toilet seats grab rails, and a bath hoist. There is a passenger lift to the first floor. The bedrooms we saw varied in the amount they had been personalised. Some were basic but they were generally clean and comfortable. We looked at two shared rooms. We saw that one shared room had been made particularly comfortable and homely for a married couple to use. In the other shared room, we saw that a better curtain to screen the room in half was required, as the one in place would not provide adequate privacy. There is a large pleasant garden to the rear of the home. This would be accessible to people who use a wheelchair. There is space provided for people to smoke, and an area has been planted with fragranced plants to provide a sensory garden. The home undertakes its own laundry, and the necessary equipment is available to do this. On three surveys some concerns were raised with the standard of laundry. We looked at this, and found that peoples clothes had been well laundered, and the people we spoke to were happy with the service provided. Environmental Health Inspectors had visited the home to undertake a kitchen inspection in October 2009. The requirements from that visit had been actioned to ensure that people live in a safe environment. We observed staff using good hygiene practices. When we spoke with staff they were aware of good infection control practices, and confirmed they had adequate supplies of gloves, aprons, soap, and towels for example. Tudor Rose Rest Home DS0000059825.V378572.R01.S.doc Version 5.3 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29 & 30 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Staff are suitably trained and sufficient in numbers to meet the needs of the people who use the service. EVIDENCE: The home has a very stable staff team, and only one person has left the home in the past year. The staff we spoke to had worked in the home for 6, 10 and 11 years. They had built up good relationships with the people who live at the home and amongst themselves, which contributes to the good atmosphere in the home. The manager does not use agency staff, and has been able to cover shifts from within the staff team. This means that people know who will be supporting them with their needs. It was positive to see that both male and female staff are available so that people can have their needs met in a way that they prefer. People told us: Staff are human, real, they dont bully you The staff are OK…They are there if I need them, they are OK with me. I wouldnt change anything Tudor Rose Rest Home DS0000059825.V378572.R01.S.doc Version 5.3 Page 21 A lot of effort has been put into training staff. 65 of the team has a National Vocational Qualification (NVQ) level 2, which ensures that people are mainly supported by staff who have the knowledge and skills to meet their needs. The home provides a lot of internal training, and staff files showed courses such as fire, food hygiene, manual handling, medication, emergency first aid, and safeguarding have been provided. When we spoke to staff they were pleased with the amount of training provided, and said they felt they had the skills needed to do their jobs. The home has started to plan training for the next year, and it was positive to see subjects such as dementia, infection control, person centred care and incontinence, being included as well as the statutory subjects. We looked at the recruitment records for two staff, and found that all the necessary checks had been undertaken to ensure they were suitable to work in a care home. Staff and people living at the home said the number of staff available was enough to meet their needs. We have asked the home to ensure that the rota, and shifts people should and actually work is clear, and where possible not to use correction fluid on the rota. Tudor Rose Rest Home DS0000059825.V378572.R01.S.doc Version 5.3 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 31,33,35 & 38 People using the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The management team strive to ensure the home is run in the best interest of the people who live there. EVIDENCE: The manager has worked in the home for over 18 years, and has progressed to manager as she has gained further experience and qualifications. These include NVQ qualifications in care, and the Registered Managers Award. We found that the manager and deputy manager know people very well, and they have a good understanding of how to run a care home. Tudor Rose Rest Home DS0000059825.V378572.R01.S.doc Version 5.3 Page 23 The records and administration of the home were generally in good order; they were quickly located and up to date. We looked at the money and accounts for people who have money managed by the home. We were very concerned to find that all three of the accounts were wrong, and in two cases no transaction had occurred since the last audit. This suggested that the audit might not have picked up the errors. We left an immediate requirement that this be investigated, and the money balanced. We returned two days later, and were pleased to find that the money had been balanced, and that action had been taken to ensure this shouldnt happen again. The AQAA document told us that the health and safety checks were up to date in the home. We sampled records for fire, water, gas and lifting equipment and found these all to be complete and up to date. The manager has a Quality Assurance system in place. She audits different parts of the home in turn. We have asked that each year her findings be drawn together into a report, and used to inform the development plans for the following year. The home does not have meetings for staff or people living at the home, but chooses to speak with people individually. We found this seems to be effective, and both staff and people we spoke to were happy with the arrangement. The owner of the home visits at least once each week and was familiar to the people who live there. We asked that copies of the regulation 26 visits he undertakes be held in the home. One report was made available to us, and this identified that a more thorough report needs to be undertaken and recorded. This would ensure he has checked the running of the home, and can be confident it is meeting peoples needs well. Tudor Rose Rest Home DS0000059825.V378572.R01.S.doc Version 5.3 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 3 3 3 3 3 X HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 3 X 3 X X 2 3 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 2 X 2 X 2 3 Tudor Rose Rest Home DS0000059825.V378572.R01.S.doc Version 5.3 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 OP7 Regulation 12 Requirement Timescale for action 31/01/10 2. OP35 17(2) A full care plan for each person must be available in the home, and updated when needs change. This is to ensure all care needs are known, and can be met. A comprehensive record of 02/12/09 receipts and money held must be undertaken and overseen by the proprietor, so that peoples money is held safely. This was an immediate requirement. 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. Refer to Standard OP9 OP12 Good Practice Recommendations It is recommended that As Required medications are underpinned with a protocol detailing the circumstances in which they should be used. It is recommended that further consultation be undertaken DS0000059825.V378572.R01.S.doc Version 5.3 Page 26 Tudor Rose Rest Home 3. 4. 5. 6. 7. OP16 OP18 OP24 OP33 OP37 and a larger TV obtained if wished. All complaints should be recorded so that people know they are listened to and complaints are acted upon. The safeguarding policy should be updated so that staff have guidelines to follow to safeguard people from harm. It is recommended that a curtain, which fully protects the dignity of the people in shared rooms, be provided. It is recommended that more detail be included in the Regulation 26 visit report, to show the owner is aware of all areas of the homes operation. It is recommended that correction fluid not be used on documents within the home. Tudor Rose Rest Home DS0000059825.V378572.R01.S.doc Version 5.3 Page 27 Care Quality Commission Care Quality Commission West Midlands Region Citygate Gallowgate Newcastle Upon Tyne NE1 4PA National Enquiry Line: Telephone: 03000 616161 Email: enquiries@cqc.org.uk Web: www.cqc.org.uk We want people to be able to access this information. If you would like a summary in a different format or language please contact our helpline or go to our website. Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CQC copyright, with the title and date of publication of the document specified. Tudor Rose Rest Home DS0000059825.V378572.R01.S.doc Version 5.3 Page 28 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!