Inspection on 21/06/05 for Tupwood Gate Nursing Home

This inspection was carried out on 21st June 2005.

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

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Tupwood Gate Nursing Home 28/03/07

Tupwood Gate Nursing Home 05/01/06

Tupwood Gate Nursing Home 22/09/04

Tupwood Gate Nursing Home 19/04/04

Similar services:

The Shelley

Springfield House

Sutton Lodge Nursing Home

St Helier`s Residential Hotel

St Joseph`s

Ridgemount

Wingham Court

Old Hastings House

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

CARE HOMES FOR OLDER PEOPLE Tupwood Gate Nursing Home 74 Tupwood Lane Caterham Surrey CR3 6YE Lead Inspector Garrett Lesley Unannounced 21 June 2005 10:00 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. Tupwood Gate Nursing Home H58-H09 S13363 Tupwood Gate V231754 210605 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Tupwood Gate Nursing Home Address 74 Tupwood Lane, Caterham, Surrey, CR3 6YE 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) 01883 342275 01883 341951 Cygnet Health Care Limited 179 Kings Road, Kingston, Surrey, KT2 5JH Mrs Jennifer Carol Roach Care Home (CRH) 35 Category(ies) of Old age, not falling within any other category registration, with number (OP), 35 of places Dementia - over 65 years of age (DE(E)), 15 Tupwood Gate Nursing Home H58-H09 S13363 Tupwood Gate V231754 210605 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: 1 Of the total number of Service Users up to 15 beds may be used for the care of older people in category DE(E) 2 The age range of services users will be: over 65 years Date of last inspection 22 September 2004 Brief Description of the Service: Tupwood Gate Nursing Home is a large detached property, converted to provide accomodation for 35 older people who require nursing care. It is situated in a quiet residential area on the outskirts of Caterham. The home is well presented providing a good standard of accomodation. The home has a garden and there is parking to the front and side of the premises. Tupwood Gate Nursing Home H58-H09 S13363 Tupwood Gate V231754 210605 Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place over five hours and was the first inspection to be undertaken in the Commission for Social Care Inspection year April 2005 to March 2006. Lesley Garrett, Lead Inspector for the service, carried out the inspection. Jenny Roach, Registered Manager, represented the establishment. A full tour of the premises took place. The inspector saw most of the residents and spoke with some of them in their rooms but most residents were getting up for the morning and therefore it was not appropriate to disturb them. This was a positive inspection. The inspector would like to thank the residents, staff and manager at Tupwood Gate for their time, assistance and hospitality during this inspection. What the service does well: What has improved since the last inspection? The requirement from the last inspection has now been met and the induction programme is now in line with the TOPPS foundation course. The garden was being refurbished with a new patio being laid and the manager stated that the residents were looking forward to getting outside this summer. Tupwood Gate Nursing Home H58-H09 S13363 Tupwood Gate V231754 210605 Stage 4.doc Version 1.30 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. Tupwood Gate Nursing Home H58-H09 S13363 Tupwood Gate V231754 210605 Stage 4.doc Version 1.30 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 Tupwood Gate Nursing Home H58-H09 S13363 Tupwood Gate V231754 210605 Stage 4.doc Version 1.30 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) 3 All residents moving into the home have their needs assessed by a suitably qualified person. EVIDENCE: The manager stated that she does all pre admission assessments and if she is unavailable a senior sister will do it. The manager uses the Surrey health needs assessment form, which is a detailed document and enables the assessor to understand the needs of the resident prior to admission. The inspector saw a recent new admission documentation and it was all in place and satisfactory. The home does not have intermediate care beds. Tupwood Gate Nursing Home H58-H09 S13363 Tupwood Gate V231754 210605 Stage 4.doc Version 1.30 Page 9 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 & 11 Each resident has plans of care and death and dying is discussed and documented in these plans. EVIDENCE: Each resident has individual plans of care and the inspector saw about ten examples of these. The care plans are kept in the bedrooms of each resident and are updated monthly and more frequently if needs change. The manager also showed the inspector the records that are kept in her office. In the front of each folder there is a transfer sheets that is partially completed and contains a photograph of the resident. This is kept ready in case any resident is transferred to hospital or another establishment. The manager in consultation with another of her trained nurses who works part time at a local accident and emergency department developed it. This is evidence of good practice and has been used by other homes after they had seen what they use at Tupwood. There were risk assessments in place and the home has also developed a resuscitation form, which is completed by all residents and or their relatives or representatives. Tupwood Gate Nursing Home H58-H09 S13363 Tupwood Gate V231754 210605 Stage 4.doc Version 1.30 Page 10 The home has a policy for death and dying and this is discussed with the residents or their representatives and wishes at time of death is discussed and documented. The home can have palliative care residents and the staff has been trained in the use of syringe drivers and they have good support from the local hospice. Tupwood Gate Nursing Home H58-H09 S13363 Tupwood Gate V231754 210605 Stage 4.doc Version 1.30 Page 11 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) 12,13 & 15 The home has a programme of activities with which involves the local community. The menus were seen and the chef spoken with. Family, friends and representatives are able to visit the home. EVIDENCE: The home has a programme of activities and an organiser who is new in post. The inspector met the organiser who was in the conservatory doing a small group activity with six residents. The manager stated that the programme could be altered to suit the needs of the residents on the day. There is also an occupational therapist that visits on a Tuesday afternoon. The home has recently purchased a mini bus to enable them to do visits in small groups to local places of interest and garden centres. There is one resident who enjoys going to the local pub and this is now possible. A local school visits the home on a Wednesday afternoon to talk to the residents, which the manager stated they enjoyed. Some are doing their Duke of Edinburgh award. Some residents went recently to a musical evening held by the school, which they were invited to. Relatives visit regularly and are welcomed into the home and are encouraged to participate in any activity. There had recently been a birthday party for a resident who was 100. The resident was pleased to show the inspector her card from the Queen, which she still has on display. This particular resident Tupwood Gate Nursing Home H58-H09 S13363 Tupwood Gate V231754 210605 Stage 4.doc Version 1.30 Page 12 told the inspector that she did not come out of her room very often as her eyesight is failing but enjoyed her own company and listening to the radio. There is monthly communion services held by the local vicar and the Catholic priest visits weekly. There are also monthly church services. The inspector also met the chef who was busy preparing lunch for that day. The inspector did not sample the food on this inspection but the cake the chef sent to have with coffee was very good. There are four-week rotas and the chef stated that special diets can be catered for and that some of the residents required pureed food due to swallowing difficulties. The chef showed the inspector his daily fridge temperatures, which were up to date. The inspector also met the kitchen assistant who was helping that day, as there is a vacancy he usually works in the laundry. Tupwood Gate Nursing Home H58-H09 S13363 Tupwood Gate V231754 210605 Stage 4.doc Version 1.30 Page 13 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 & 18 The home is protected by a robust complaints procedure and abuse policy and training. EVIDENCE: The manager stated that there had been two complaints this year and that they had both been resolved. The manager showed the inspector the letters and correspondence. One complaint was about the mess in the garden since the conservatory was built but there is work now going on in the garden and will be available for the residents this summer in time for the summer fete. The home has the Surrey multi agency adult protection policy and all staff receives training. There are no issues in the home but the policy is not February 2005 therefore there is a requirement to obtain this. The manager also showed the inspector the UKCC training pack on prevention of abuse and the manager also uses this for all staff, as it is still useful and relevant as extra training. Tupwood Gate Nursing Home H58-H09 S13363 Tupwood Gate V231754 210605 Stage 4.doc Version 1.30 Page 14 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 & 26 The standard of the environment within the home is good providing service users with an attractive and homely place to live. EVIDENCE: The inspector walked around the home with the manager and saw many bedrooms and communal facilities. There is a planned programme of maintenance and as a room becomes vacant then it is decorated and often refurbished. The en-suite bathrooms for some rooms have now been made into shower rooms. These have been well done and the manager said that it now meant the residents did not have to use the communal bathrooms. The home was clean and tidy with no offensive odours and all communal rooms were in use. There is a quiet lounge, which has no television if the residents wish to relax. Tupwood Gate Nursing Home H58-H09 S13363 Tupwood Gate V231754 210605 Stage 4.doc Version 1.30 Page 15 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) 27,29 & 30 There is adequate staff on duty each day and the home has good recruitment practices. There was evidence of staff training. EVIDENCE: The manager told the inspector that they were still using the old staffing notice as set by East Surrey Health Authority, Inspection and Registration Department prior to the National Care Standards Commission in 2002. Although they had empty beds the numbers had not been dropped. The manager stated that the needs of the residents had become more dependent therefore all staff was needed to complete the work. The home has good recruitment practices and a recent new recruits folder was seen. It contained application form two references and photocopies for identification. The CRB, although recent, was for another place of work and the manager and administrator was advised that this would need to be re-done. They both thought that there might be another couple that needed to be checked on and this would be done very soon. The files did not contain photographs and the inspector advised that this also was a requirement. The manager told the inspector that she was an NVQ verifier and one of her level 3 carers was an assessor therefore some NVQ training could take place in the home. Another registered nurse was also doing the assessors course. Most cares were NVQ trained and three had level 3. All staff has training records which the manager showed the inspector and statutory training had taken place and also a variety of other training including customer care, healthy eating and the registered nurses had had CPR updates. Tupwood Gate Nursing Home H58-H09 S13363 Tupwood Gate V231754 210605 Stage 4.doc Version 1.30 Page 16 Tupwood Gate Nursing Home H58-H09 S13363 Tupwood Gate V231754 210605 Stage 4.doc Version 1.30 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) 33, 36 & 38 Residents and representatives views are sought and the manager ensures adequate supervision of staff. The health and safety of residents are protected. EVIDENCE: The manager showed the inspector the recent resident /relative survey and these are done yearly there had been at least an 80 return. It was one of these surveys that suggested something should be done about the garden, which the manager acted upon. Staff is well supervised as the manager insists that the registered nurses help the carers with all care. There are regular staff meetings and all staff have a report in the morning before starting work. Appraisals are done yearly and supervision sessions held regularly. The home has a maintenance man two days a week but will come in more frequently if required. Taps have thermostatic valves and the water temperatures are checked monthly. Fire alarms are checked weekly and there Tupwood Gate Nursing Home H58-H09 S13363 Tupwood Gate V231754 210605 Stage 4.doc Version 1.30 Page 18 is a maintenance contract for the fire appliances Pat testing is done yearly and whenever electrical appliances are bought into the home. Tupwood Gate Nursing Home H58-H09 S13363 Tupwood Gate V231754 210605 Stage 4.doc Version 1.30 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 x x 3 x x x HEALTH AND PERSONAL CARE Standard No Score 7 3 8 x 9 x 10 x 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 x 15 3 COMPLAINTS AND PROTECTION 3 x x x x x x 3 STAFFING Standard No Score 27 3 28 x 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 2 x 2 x x 3 x x 3 x 3 Tupwood Gate Nursing Home H58-H09 S13363 Tupwood Gate V231754 210605 Stage 4.doc Version 1.30 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 18 Regulation 12 Requirement The home shall obtain the 2005 Surrey multi agency protection of vunerable adults. (The home does have the 2001 copy) The home should have a recent phototgraph of all employees. CRBs are not transferable from home to home and therefore the home should apply for new checks. Timescale for action 5/7/05 2. 3. 29 29 19 & schedule 2 19 & schedule 2 19/7/05 5/7/05 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 Good Practice Recommendations Tupwood Gate Nursing Home H58-H09 S13363 Tupwood Gate V231754 210605 Stage 4.doc Version 1.30 Page 21 Commission for Social Care Inspection The Wharf Abbey Mill Business Park Eashing Surrey GU7 2QN 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 Tupwood Gate Nursing Home H58-H09 S13363 Tupwood Gate V231754 210605 Stage 4.doc Version 1.30 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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