Inspection on 09/08/05 for Tudor Rose Rest Home

This inspection was carried out on 9th August 2005.

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

The inspector 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 20/06/06

Tudor Rose Rest Home 03/11/05

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

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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 B23 5TH Lead Inspector Kath Strong Unannounced 9 August 2005 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 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 E54 S59825 Tudor Rose V243963 090805 Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Tudor Rose Rest Home Address 671 Chester Road Erdington Birmingham B23 5TH 0121 384 8922 0121 241 3507 careplex@aol.com Careplex Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Jackie Barrett Care Home 27 Category(ies) of Older People, Mental Disorder - over 65 (5) registration, with number of places Tudor Rose Rest Home E54 S59825 Tudor Rose V243963 090805 Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: 1. That the home can care for up to five service users in need of care for reasons of mental health problems (5 MD(E)). Date of last inspection 7 December 2004 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. The premises are situated on a busy main road close to local shops and amenities. It is very convenient for bus and rail services to Sutton Coldfield and Birmingham city centre. The homes frontage blends in well with other properties within the vacinity. There is sufficient off road parking at the front of the building to accommodate three vehicles, further parking is available in nearby side roads. The majority of the accommodation is located on the ground and first floor and a shared room is situated on the second floor, which has its own adjacent bathroom. There is a shaft lift to all floors that permits a maximum of two persons. Communal toilets and bathing facilities are strategically located throughout the home. Bedrooms are a mixture of single and shared rooms and all include wash hand basins and a call sysytem. All communal rooms are based on the ground floor and consist of two lounges and two dining rooms. There is also an extensive rear garden with extra buildings and a paved area with seating that residents and visitors can frequent. Meals and laundry services are supplied on site. Tudor Rose Rest Home E54 S59825 Tudor Rose V243963 090805 Stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The purpose of the visit was to conduct an unannounced inspection and to review the progress made on the few requirements generated from the last inspection. The outcome was determined by various methods. In depth discussions were held with the registered manager and individual discussions with the deputy manager and five residents. Relevant document reading also included three care plans, health care tracking and notice boards. A partial tour of the premises was also carried out. Verbal feedback was supplied to the registered manager at the conclusion of the inspection. What the service does well: What has improved since the last inspection? New dining room tables and chairs have been purchased. Tudor Rose Rest Home E54 S59825 Tudor Rose V243963 090805 Stage 4.doc Version 1.40 Page 6 A hall table and a lounge television cabinet have been provided. A new microwave has been supplied for the kitchen. The hall and stairs have been redecorated; carpets and blinds have been fitted. The tumble dryer in the laundry room has been replaced. The four requirements generated from the last inspection have been fully actioned. 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 E54 S59825 Tudor Rose V243963 090805 Stage 4.doc Version 1.40 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 Standards Statutory Requirements Identified During the Inspection Tudor Rose Rest Home E54 S59825 Tudor Rose V243963 090805 Stage 4.doc Version 1.40 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 standard(s) 1, 2, 3, 4, 5 and 6 Prospective residents are supplied with adequate information to assist them in making an informed decision about the home. Comprehensive pre-admission assessments are carried out in order for the home to demonstrate its ability to meet the individuals’ needs. EVIDENCE: There has been no changes to the service provision, therefore the statement of purpose and service user guide remain satisfactory. A copy of the service user guide, which includes a contract of terms of residency, is issued to each resident. The pre-admission tool utilised by the home is comprehensive and is later used as the framework for the development of the detailed assessment and care plan. The registered manager or the deputy manager undertake the preadmission assessments at a venue convenient to the prospective resident. The inspector was advised that the home is currently considering the admission of a person who has very specific dietary requirements but that the placement Tudor Rose Rest Home E54 S59825 Tudor Rose V243963 090805 Stage 4.doc Version 1.40 Page 9 would not be offered until staff were confident that provision of an acceptable diet could be ensured. Where it is determined with the assistance of external professionals that the home can no longer provide all assessed needs then alternative accommodation is recommended. Prospective residents and their relatives are encouraged to make as many visits to the home as they wish and are invited to remain for a full day to sample a meal and to circulate with other residents. The home does not provide intermediate care. Tudor Rose Rest Home E54 S59825 Tudor Rose V243963 090805 Stage 4.doc Version 1.40 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 standard(s) 7, 8, 9, 10 and 11 The resident’s health and personal care needs are clearly defined and the assistance of health care professionals is readily sought. The procedures for dealing with medications is satisfactory in ensuring that risks to residents are minimised. The privacy and dignity of residents is respected. EVIDENCE: The files examined revealed that the process of care planning appears to cover all aspects of each resident’s needs and how they will be met. Files clearly indicated specific ailments and allergies and the expert advice of external health care professionals for dealing with them. All residents’ weights are monitored and recorded monthly. Regular reviews are being carried out. Files also included personal preferences in respect of activities of daily living and activities. Comments received from residents included, “the home is very nice”, “staff are not too bad at all”. The minor amendments suggested at the previous inspection in respect of the practices utilised for the administration medications have been actioned. The system in place was determined to be satisfactory. The deputy manager Tudor Rose Rest Home E54 S59825 Tudor Rose V243963 090805 Stage 4.doc Version 1.40 Page 11 ensures that safe practices are complied with by conducting regular audits. Care staff are not permitted to administer medications until they have received appropriate training. Information was provided that all care staff have been enrolled on a further detailed and accredited course in medication administration. Observations revealed that staff interactions with residents were appropriate with the preferred term of address being used. All personal care is provided in the resident’s own room or a bathroom. Good levels of communications and negotiations are carried out with all relevant personnel involving the care of very ill residents. All aspects of care needs are addressed including any spiritual requests. Eight members of staff attended the funeral of two residents who chose to die at the home rather than move on to a hospital or nursing home. Tudor Rose Rest Home E54 S59825 Tudor Rose V243963 090805 Stage 4.doc Version 1.40 Page 12 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 standard(s) 14 and 15 The home provides a varied activities programme and residents are supported in maintaining links with the community. Residents exercise control and make decisions about their lives. Meals provided constitute a wholesome, varied and balanced diet. EVIDENCE: The home has a weekly rolling programme of in-house activities, which includes weekends. The activities programme has been tailored to meet the needs of residents who have particular wishes. The situation needs to be regularly reviewed. The home had on display a resident’s newsletter the content was found to be interesting. This is viewed as being good practice. Clerical dignitaries visit the home regularly; one resident informed the inspector that she goes out for the day to relatives every Sunday. Other outings include walks, visits to the park and shopping. The registered manager reported that the residents meetings had ceased due to lack of interest. The home must monitor the situation and re-commence meetings as appropriate. Talking to residents and reviewing of care plans indicated that residents exercise choice in respect of daily routines, for example one resident chooses not to rise until lunch time. Lunch was served during the course of the visit. The meal constitutes the main meal of the day and was observed to be well presented with staff offering Tudor Rose Rest Home E54 S59825 Tudor Rose V243963 090805 Stage 4.doc Version 1.40 Page 13 assistance as required. The menu of the day is displayed on a board in a dining room. The rolling menu did not include alternatives but choices were evidenced during lunch and staff confirmed this. The breakfast menu included a light cooked course and the evening meal provided a variety of choices. Feedback received from residents included, “the food is excellent” and “lunch was very nice”. Tudor Rose Rest Home E54 S59825 Tudor Rose V243963 090805 Stage 4.doc Version 1.40 Page 14 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 standard(s) 16 and 18 The home has a satisfactory complaints process with some evidence that resident’s views are listened to and acted upon. Documentation and staff training in respect of vulnerable adults indicates that staff would take appropriate action to any suspicion or allegation of abuse. EVIDENCE: The written complaints procedure is adequate and a copy is on display in the reception area. Since the last inspection CSCI have received one complaint regarding the misplacement of a personal item. This was upheld and the home took appropriate action in resolving the problem. No other complaints have recently been received by the home. The written policy regarding adult protection required one amendment, which the registered manager confirmed, would be actioned within 48 hours. Staff training is provided regularly in-house by an employee who has had in depth training. The elements and length of training in this aspect is fully documented. Tudor Rose Rest Home E54 S59825 Tudor Rose V243963 090805 Stage 4.doc Version 1.40 Page 15 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 standard(s) 19, 20, 24 and 26 Residents live in a comfortable, safe and well maintained environment, which offers adequate communal facilities. Bedrooms are personalised and ensure that privacy is maintained. EVIDENCE: The home has a maintenance programme, which is regularly reviewed and updated. The corridor space within the home is restrictive for wheelchair users. There is a homely atmosphere and residents advised of their satisfaction with the accommodation. The two separate lounges and dining rooms permit residents to make choices. Furniture, fixtures and fittings are of a good standard and well maintained. All areas of the home were found to be tidy and clean with good evidence of odour control. Bedrooms vary in size and layout. They are personalised to the extent preferred by the occupant. The registered manager advised that where residents request a lockable facility within the room this is supplied. All bedrooms have been fitted with suited door locks and a call system. Tudor Rose Rest Home E54 S59825 Tudor Rose V243963 090805 Stage 4.doc Version 1.40 Page 16 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27, 28, 29 and 30 Staff morale is high resulting in a low staff turnover and consistency of care for residents. The recruitment practices and induction programme are robust offering support and protection to residents. Staff have received sufficient training to provide them the knowledge and skills to meet residents needs. EVIDENCE: Although the home is not fully occupied the staffing levels have remained consistent, which provided added value to the standard of care. The home was actively seeking to recruit a housekeeper to bring the level of staff back up to two per day. Dedicated staff work in the kitchen for the preparation of meals. The home operates safe staff recruitment practices with all relevant checks being carried out prior to commencement of the employee. The home has an induction programme in place that reflects the content of the TOPSS programme. Staff are encouraged and supported in completing training to NVQ level 2 or above. Tudor Rose Rest Home E54 S59825 Tudor Rose V243963 090805 Stage 4.doc Version 1.40 Page 17 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31, 32, 33, 36 and 38 The manager has a clear development plan for the home, which is communicated effectively to residents and staff with the home being run in the best interests of the residents. Formal staff supervision requires further development. One aspect of the homes risk assessment needs reviewing to ensure that the health and safety of residents is protected. EVIDENCE: The home has a clear management structure and clear lines of accountability. The registered manager has extensive experience and adopts an open door approach to staff, residents and relatives. The home has introduced a quality assurance programme that includes departmental audits and actively seeks the opinions of residents, relatives and staff. Tudor Rose Rest Home E54 S59825 Tudor Rose V243963 090805 Stage 4.doc Version 1.40 Page 18 Mandatory training for staff is supplied including refresher courses as required. Written policies and procedures are regularly reviewed. Formal staff supervisory meetings are taking place but further work is required. The documentation needs to be more specific and the signatures of both parties are required. Some of the elements of health and safety were examined and it was determined that the risk assessment regarding fire safety was in need of review. Tudor Rose Rest Home E54 S59825 Tudor Rose V243963 090805 Stage 4.doc Version 1.40 Page 19 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score 3 3 3 3 3 x HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION 3 3 x x x 3 x 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 Standard No 16 17 18 Score 3 x 3 3 3 3 x x 2 x 2 Tudor Rose Rest Home E54 S59825 Tudor Rose V243963 090805 Stage 4.doc Version 1.40 Page 20 No Are there any outstanding requirements from the last inspection? 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 OP36 Regulation 18(2) Timescale for action The documentation in respect of 15th formal staff supervisions must be October comprehensive and include the 2005 signatures of both parties. The registered person must 15th ctober update the risk assessment in 2005 respect of fire safety. Requirement 2. OP38 13(4)c 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. Refer to Standard OP19 Good Practice Recommendations The registered person must review the appropriateness of the current storage system for the mobile employed with the home. Tudor Rose Rest Home E54 S59825 Tudor Rose V243963 090805 Stage 4.doc Version 1.40 Page 21 Commission for Social Care Inspection Birmingham & Solihull Local 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. Extracts may not be used or reproduced without the express permission of CSCI Tudor Rose Rest Home E54 S59825 Tudor Rose V243963 090805 Stage 4.doc Version 1.40 Page 22 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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