Inspection on 28/03/07 for Tupwood Gate Nursing Home

This inspection was carried out on 28th March 2007.

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

Tupwood Gate Nursing Home 05/01/06

Tupwood Gate Nursing Home 21/06/05

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 Damian Griffiths Unannounced Inspection 10:00 28 March 2007 th 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 Tupwood Gate Nursing Home DS0000013363.V329911.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. Tupwood Gate Nursing Home DS0000013363.V329911.R01.S.doc Version 5.2 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 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) 01883 342275 01883 341951 Cygnet Health Care Limited Mrs Jennifer Carol Roach Care Home 35 Category(ies) of Dementia (1), Dementia - over 65 years of age registration, with number (15), Old age, not falling within any other of places category (35) Tupwood Gate Nursing Home DS0000013363.V329911.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 5th January 2006 Brief Description of the Service: Tupwood Gate Nursing Home is a large detached character property, converted to provide accommodation for 35 older people who require nursing care and there is some day-care and respite provision. The home is situated in a quiet residential area on the outskirts of Caterham and is well presented providing a good standard of accommodation. A conservatory at the back of the home provides residents a good view and access to the well-maintained garden and there is parking to the front and side of the premises. Costs per week start from £750.00. Tupwood Gate Nursing Home DS0000013363.V329911.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced site visit formed part of the key inspection process and took 7 hours commencing at 10:30am and ending at 5:30pm. Mr Damian Griffith’s regulation inspector completed the visit. The Registered Manager, Mrs Jennifer Carol Roach, was present and represented the establishment. The inspector ensured that time was spent meeting the residents, staff and relatives visiting the home and observing interaction between residents and staff. Some residents relied wholly on relatives and staff to meet their care needs and to speak on their behalf. A tour of the premises was conducted and the inspector stayed for lunch. Samples of care need assessments and care plans of the resident’s met by the inspector during the visit formed the basis of the inspection. Staff files were inspected for evidence of good practice in the following areas; recruitment, training and the distribution of staff skills as reflected in the staff rota for the day. The inspector would like to extend thanks to the residents, their relatives, management and staff at Tupwood Gate Nursing Home for their time and hospitality. What the service does well: The home was clean light and airy and recently decorated sitting rooms enhanced the unique features of the home. All 21 residents completing CSCI surveys agreed that the home was fresh and clean. Other comments included: “It is the only nursing home that I have visited and know that it smells fresh and is always clean”, “I am always impressed” and “When visiting Tupwood for the first time I was very impressed and had no hesitation to place my Mum in their care”. Titled ‘Resident of the Day’ all staff ; housekeepers, maintenance men and nursing staff focused of the individual resident and reviewed their own skill area to make sure that the resident’s needs were being met. One resident discussing the care support she received stated that, “staff would always tell me what they were going to do”. 21 relatives completing CSCI Surveys stated that they were satisfied with the overall care provided. Tupwood Gate Nursing Home DS0000013363.V329911.R01.S.doc Version 5.2 Page 6 All Health care practitioners completing CSCI Surveys stated that; the home communicated clearly; There was always a senior member of staff available; Staff understood service user needs; Specialist advice was incorporated in care plans; They were satisfied with the overall care provided and practitioners dealing with medication confirmed that it was appropriately managed at the home and when visiting the residents privacy was respected. Residents enjoyed a lifestyle that encouraged and respected their social care, religious and cultural needs. Families, friends and advocates were welcomed at the home and assisted relatives in need of help to make choices in a creative and enjoyable way. “As a relative I enjoy visiting …and taking part in the activities that are organised”. The food available at the home was wholesome and nutritious. ; The CSCI survey included the following comments and findings; “the food looked and smelt wholesome and was given with the utmost patience by staff”. 18 residents stated they always or usually liked the food provided. The matron runs the home efficiently with the support of staff, residents, and relatives. Efficient networking and the promotion of health and safety ensured that the home was working in the best interests of the residents. Comments received about the home included; “a very well run home with a matron at the helm”. “The home makes life better for both residents, staff and relatives alike”. 19 relatives or ‘significant others’ had assisted residents to complete their CSCI survey. What has improved since the last inspection? What they could do better: The home must ensure that suitably trained staff are available to support residents at times. The home must make sure that proof of CRB checks are available for inspection and provide these to the CSCI. Five best practice recommendations were made relating to the following areas. That the home review it’s medication storage arrangements and to ensure that the correct temperature is maintained. Tupwood Gate Nursing Home DS0000013363.V329911.R01.S.doc Version 5.2 Page 7 That staff should record in more detail, information regarding whether medication should be administered before or after meals. That the home reviews its medication disposal regime with the pharmaceutical company it uses. Resident’s did not have assess to a remote control for the television therefore it is recommended that staff and residents select what programmes are to be viewed on a daily basis. It was recommended that a full employment history is obtained from staff and that all gaps in employment are filled. 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. Tupwood Gate Nursing Home DS0000013363.V329911.R01.S.doc Version 5.2 Page 8 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 Tupwood Gate Nursing Home DS0000013363.V329911.R01.S.doc Version 5.2 Page 9 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): Standards 1, 3 and 6 were inspected. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents were confident that their care needs would be met due to the availability of useful information available about the home and the comprehensive assessment of need that they received. The home does not provide intermediate. EVIDENCE: The homes ‘Statement of Purpose’ and previous inspection report was available for scrutiny and next to the visitor’s signing-in book within the entrance lobby. A copy of the ‘service user’s guide’ was available to all residents and located in a convenient Perspex holder attached to the bedroom wall. Tupwood Gate Nursing Home DS0000013363.V329911.R01.S.doc Version 5.2 Page 10 22 residents and their relatives completing the CSCI survey stated that they had received enough prior information to make a choice about moving into Tupwood Nursing home. A sample of five care need assessments were inspected including details of new and day-care residents. The home offers up to four day-care places, the number of day care places provided at the home was dependent on the manager’s assessment and consultation with existing residents to minimise any potential for disruption. The residents assessments sampled were in place and the ‘Surrey health needs assessment form’ was found to be the most useful assessment tool as it detailed the nursing needs of the resident and enabled the assessor to understand the needs of the resident prior to admission. Relatives completing the CSCI survey stated; “When visiting Tupwood for the first time I was very impressed and had no hesitation to place my Mum in their care” Tupwood Gate Nursing Home DS0000013363.V329911.R01.S.doc Version 5.2 Page 11 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): Standards 7,8,9 and 10 were inspected. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. All residents care needs were recorded in care plans detailing their assessed care and healthcare needs. The home observed safe medication administration practices but were in need to review best practice in this area. Residents received daily care support that respected privacy and individual need. EVIDENCE: Care plans were kept in each service users bedrooms and contained the daily requirements essential to assure that the care needs of the resident was met; personal care needs, charts and daily staff record of care. The care plans were regularly monitored and reviewed. The home was trialling a new system of care plan review that encompassed every aspect of the service users daily life. Titled ‘Resident of the Day’ all staff ranging from the housekeepers, maintenance to nursing staff focused of the Tupwood Gate Nursing Home DS0000013363.V329911.R01.S.doc Version 5.2 Page 12 individual resident and reviewed the individual skill area to make sure that the residents needs were being met. All 21 relatives completing CSCI Surveys stated that they were satisfied with the overall care provided. Health care needs were carefully monitored and the appropriate healthcare practitioners were regularly involved including: Marie Currie, General Practitioner, Physiotherapy and Chiropody. Health care Practitioners completing CSCI Surveys stated that the home: communicated clearly, senior staff members were always available, staff understanding of residents needs was good, specialist advice was incorporated in care plans and they were satisfied with the overall care provided. Health care practitioners dealing with residents medication needs confirmed that medication was appropriately managed and private consultation with the resident was respected. Medication administration records were checked for safe and best practice. The morning medication routines were the busiest and to ensure the safety of the resident’s two staff members were involved with the distribution of prescribed medication. Medical administration records were correct and reflected the prescribed dosages. The appropriate security measures and been taken to ensure that controlled medication was recorded and disposed of safely, however, there were some concerns relating to security. The container being used by the pharmaceutical company providing a drugsdisposal service provided a container that could not be secured and medication disposed of in this manner was not accurately recorded. It was recommended that the home review its medication disposal regime with the pharmaceutical company. The homes own thermostat indicated that the correct storage temperatures for the medication were not being maintained by the systems in place. It was recommended that the home review its cold storage facilities. The home manager/matron agreed that more information was required for staff administering medication that is required to be given before or after meals. The inspector met several residents throughout the day were happy to discuss their stay at the home. Staff were observed talking to residents in a polite and respectful manner addressing them by first names as residents preferred. Residents could receive visitors and healthcare practitioners in the privacy of their own rooms. Tupwood Gate Nursing Home DS0000013363.V329911.R01.S.doc Version 5.2 Page 13 The home has ensured that there is now a privacy and dignity policy in place for residents’ relatives and staff guidance. Previous requirements made in the last inspection report have been met in this section. One resident discussing the care support she received stated that, “staff would always tell me what they were going to do”. Completed CSCI surveys showed that 22 service users/relatives felt that they received the care and support they needed and 21 felt that staff listened and acted on what they said. Please see the recommendation section of this report. Tupwood Gate Nursing Home DS0000013363.V329911.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 12,13,14 and 15 were inspected. Quality in this outcome area is good . This judgement has been made using available evidence including a visit to this service. Residents enjoyed a lifestyle that encouraged and respected their social care, religious and cultural needs. Families, friends and advocates were welcomed at the home and assisted relatives in need of help to make choices in a creative and enjoyable way. The food available at the home was wholesome and nutritious. EVIDENCE: Residents were able to partake in various religious preferences and at the time of the inspection the preference was the Church of England and Roman Catholic worship. Religious practitioners regularly attended the home and service was held every month. Special arrangements were made for religious days such as Easter and Christmas. Easter crafts were on show at the home and during the last Christmas celebrations carol singers and entertainers visited residents. An annual newsletter was available for the residents and relatives convenience with listings including the next evening’s entertainment that boasted ‘join in all your favourites oldies’. Tupwood Gate Nursing Home DS0000013363.V329911.R01.S.doc Version 5.2 Page 15 There is a fulltime activities therapist who is also a member of the ‘National Association of Activities for Older People’. Residents had been supported to make good use of the grounds surrounding the home and had ‘planted out’ a sensory area consisting of herbs and fragrant smelling flowers and plants. Another residents was being supported to grow his own vegetable garden. Relatives commenting on the activities arranged for residents said; “Mum is encouraged to join in all activities but not forced”. 20 residents/relatives completing the section of the CSCI section, ‘Activities arranged by the home’ agreed that; residents were always or usually able to take part. Other comments received were; “ the activities that are available are varied and interesting” “ The activities organiser is very good, puts in a lot of time and effort and is particularly good with my Mum”. Regular monthly residents/relative meetings were arranged as social events that fostered good feeling and a relaxed atmosphere. Relatives were encouraged to drop-in after work and refreshments were made available. The inspector was able to discuss the home with a family that was collecting their relative following a period of respite. They confirmed that the home supported and welcomed relative’s visits. 19 relatives or ‘significant others’ had assisted residents to complete their CSCI survey. Comments included: “the home makes life better for both residents, staff and relatives alike” and “As a relative I enjoy visiting and taking part in the activities that are organised”. Six service users were observed sitting in a lounge area with the television on some were reading and other were asleep. There did not seem to be anybody watching the programme selected. When the inspector asked the residents about this she said it was “rubbish” and agreed that she would like it turned off. Resident’s did not have assess to a remote control for the television therefore it is recommended that staff and residents select what programmes are to be viewed on a daily basis. Residents consulted on the day of the inspection confirmed that the food was good. One resident recommended that a glass of red wine a day and a scotch at night had helped him to reach a mature age. The chef made sure that the he was aware of what meals to avoid for each resident by listing these in the kitchen area. Menus were available however residents were consulted daily about their preferences. Special dietary needs such, as pureed food was available and the local dietician was available to assist when needed. The inspector enjoyed a salad and fruit juice and observed residents being offered fresh fruit after a nutritious and balanced meal. Tupwood Gate Nursing Home DS0000013363.V329911.R01.S.doc Version 5.2 Page 16 10 Residents completing the CSCI survey confirmed that they always liked the food provided. A relative commenting on watching staff help a relative to eat their puréed food at mealtimes stated; “the food looked and smelt wholesome and was given with the utmost patience by staff”. Please see the ‘Good Practice’ recommendations section of this report. Tupwood Gate Nursing Home DS0000013363.V329911.R01.S.doc Version 5.2 Page 17 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): Standards 16 and 18 were inspected. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents and their representatives were able to make complaints and were confident their views were noted. Staff were confident that they would protect residents from abusive situations. EVIDENCE: The ‘Complaints Log’ was inspected and evidence was in place to show that complaints had been received and addressed by the home. The complaints ranged from, the threat of trees falling, leaves in neighbours gardens, residents ‘sundry’ payments and a complaint about cold soup. The complaints had been addressed well and to the best ability of the manager. Residents and relatives completing the CSCI survey when asked ‘Do you know how to make a complaint’, 19 said yes. Relatives all knew who to complain to and a relative stated, “the complaint was informal and resolved quickly and satisfactorily” The homes pre-inspection questionnaire shows that 9 complaints were made since the last inspection. 4 were substantiated. 2 partially substantiated. Overall comments received in the CSCI survey about the home’s complaints system were commendable. There had been no instances of reported abuse since for two years. The home had an up-to-date copy of the Surrey Multi-agency procedure for the safeguarding of vulnerable adults in the office. Staff consulted were aware of Tupwood Gate Nursing Home DS0000013363.V329911.R01.S.doc Version 5.2 Page 18 abusive situations such as rough-handling, bruising and physical or verbal abuse and what to do if this was observed. Tupwood Gate Nursing Home DS0000013363.V329911.R01.S.doc Version 5.2 Page 19 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): Standards 19, 21, 22, 23, 24, 25 and 26 were inspected. Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Residents benefited from personalised rooms, a homely, clean, airy environment that was well equipped, tastefully decorated and appreciated by relatives and visitors. EVIDENCE: A tour of the premises and grounds was conducted and residents and staff were consulted about the home that was clean light and airy. The newly decorated rooms had been decorated to enhance the unique features of the home. One comment made by a residents in the CSCI survey stated that; A “Lovely atmosphere”, existed at the home. Resident’s rooms were individually decorated and showed individualised touches specific to each resident. Tupwood Gate Nursing Home DS0000013363.V329911.R01.S.doc Version 5.2 Page 20 New equipment such as a electronically controlled bath was new and it’s design much appreciated by staff due to the ease of use and safety for residents. The home ensured that regular equipment checks were completed. 22 residents completing the CSCI survey agreed that the home was fresh and clean. Other comments made were: “It is the only nursing home that I have visited and know that it smells fresh and is always clean” and “I am always impressed”. A programme of maintainence was in place and including new carpets and furniture. The laundry room was clean tidy and an effective drying room was available were the clothes could be safely and economically dried indoors. Residents were well dressed as a consequence of the efficient laundering system in place. Tupwood Gate Nursing Home DS0000013363.V329911.R01.S.doc Version 5.2 Page 21 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): Standards 27,28, 29 and 30 were inspected. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Staff assisting the nursing staff during the night would benefit from further training. The home supported staff to obtain the National Vocational Qualification however some elements of their recruitment procedure was in need of improvement. EVIDENCE: The evening and day rotas were inspected and staff training compared. The evening rota consisted of a senior nurse and three care staff. There was evidence to suggest that the staff had received induction and manual handling training however the certificates validating this training were not available therefore a requirement was made. Staff were from multicultural backgrounds, had a good command of English and could assist any resident/relative with similar backgrounds. . Relatives commenting in the CSCI survey were satisfied with the standard of care received and healthcare practitioners completing the CSCI survey agreed that; Specialist advice was incorporated in residents care plans; Tupwood Gate Nursing Home DS0000013363.V329911.R01.S.doc Version 5.2 Page 22 Management and staff took appropriate actions when they no longer manage the care needs of the residents and were satisfied with the overall care provided. The manager is a registered nurse and has attained, the Registered Managers Award, the National Vocational Qualification certificate for ‘assessor and verifier’ and a palliative care certificate. The homes pre-inspection questionnaire stated that it is registered with the University of Surrey and Hertfordshire to take student nurses and provided an overseas nursing programme. Relatives/relatives commenting in the CSCI Survey stated that they had; “Total faith and trust in the providers of his care and well being” “Have always been extremely pleased with a very efficiently run home” A sample of six staff files containing new and existing staff members was inspected. Staff files contained the required documentation such as; references, proof of identity and original job applications. Confirmation of Criminal Record Bureau (CRB) certification had been provided however reference numbers, dates and the type of CRB clearance were not in evidence on some files. Proof of CRB checks must be available for inspection therefore a requirement has been made. Employment histories were not all in place and some had gaps. It was recommended that a full employment history is obtained from all staff and that all gaps in employment be accounted for. Please see the requirements and recommendations section of this report to see how the home is to improve in this area. Tupwood Gate Nursing Home DS0000013363.V329911.R01.S.doc Version 5.2 Page 23 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): Standards 31,33 35 and 38 were inspected. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The matron runs the home efficiently with the support of staff, residents, and relatives. Efficient networking and the promotion of health and safety ensure that the home was working in the best interests of the residents. EVIDENCE: Residents, relatives and staff supported the ‘Matron’ of the home. “ Matron and staff are lovely to my Mum” and “ I could not find a better home”. Networks have been made with the hospice local to the home, Marie Currie, the Local Authorities and the Alzheimer’s Association. Tupwood Gate Nursing Home DS0000013363.V329911.R01.S.doc Version 5.2 Page 24 Residents and relatives had regular meetings every month and the manager promoted an ‘open-door’ policy. Feedback from residents and relatives completing the CSCI survey indicated that the home was operating in the best interests of the service users. The home will be required to submit an Annual Quality Assurance Assessment (AQAA) and will be implemented by CSCI in due course. It is the homes policy not to keep residents money or hold pocket money accounts however staff do go shopping with the residents and therefore handle the residents money. Families and advocates act on behalf residents and some CSCI surveys had been completed by them. The home confirmed that it had reviewed it’s management of residents money ‘Policy and Practice’ and residents had access to their own lockable cupboards for valuables. The health, safety and welfare of service users and staff are promoted and protected. The environment safety officer’s report was in place and still relevant and the home had responded by ensuring that new floors to the kitchen were laid. A fire safety officers had recently assessed and as had gas and electrical appliances checks. Staff training was also in place. Residents and their relatives completing the CSCI survey agreed that the home is always fresh and clean. Tupwood Gate Nursing Home DS0000013363.V329911.R01.S.doc Version 5.2 Page 25 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 X 3 X X X HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 4 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 4 3 3 3 3 3 X 4 STAFFING Standard No Score 27 2 28 3 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 3 Tupwood Gate Nursing Home DS0000013363.V329911.R01.S.doc Version 5.2 Page 26 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 OP27 Regulation 18(1)(a) (b) 19 (1) Requirement Timescale for action 01/05/07 2. OP29 The home must ensure that suitably trained staff are available to support residents at all times. The home must make sure that 01/05/07 proof of CRB checks are available for inspection and provide these to the CSCI. 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 OP9 OP9 OP9 OP14 Good Practice Recommendations It was recommended that the home review is medication storage arrangements to ensure that the correct temperature is maintained. That staff should record more detailed information regarding whether medication should be administered before or after meals. The home review the current storage containers used and the recording of the medication to be returned in the containers Resident’s did not have assess to a remote control for the DS0000013363.V329911.R01.S.doc Version 5.2 Page 27 Tupwood Gate Nursing Home 5. OP29 television therefore it is recommended that staff and residents select what programmes are to be viewed on a daily basis. It was recommended that a full employment history is obtained from all staff and that all gaps in employment be filled. Tupwood Gate Nursing Home DS0000013363.V329911.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Oxford Area Office Burgner House, 4630 Kingsgate Cascade Way, Oxford Business Park South Cowley Oxford OX4 2SU 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. Extracts may not be used or reproduced without the express permission of CSCI Tupwood Gate Nursing Home DS0000013363.V329911.R01.S.doc Version 5.2 Page 29 - 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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