Care Home: The Tudors

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What the care home does well Residents living at the home benefit from an experienced manager and stable staff team. Residents comments to us included "staff are "great", "very helpful", "all as good as gold". Staff and management have a good knowledge of individual resident`s needs, preferences and interests. Visitors are made to feel welcome and their comments to us included "I visit frequently and always find a friendly staff "and "I visit once a week and am very happy with everything". Residents told us they enjoy living at the home. Bedrooms are personalised with residents` own possessions. The home offers a range of activities. One resident commented "we have entertainment and lovely afternoon buffets". The home provides a choice of dishes at mealtimes. Residents said "the food is very good", "the choice is very good with lovely Sunday roasts..". The homes policies and procedures protect the health, safety and welfare of residents. The management of the home is committed to improving all areas of the home. The home has met all of the requirements made by CSCI at the last inspection. A number of the good practice recommendations have been met. What has improved since the last inspection? Residents` contracts now include a copy of terms and conditions, room number and fees. The home has updated its complaints policy so that it contains all of the required contacts and information. The home has replaced the carpets in the ground floor communal areas and renewed some fixtures and fittings in bedrooms. The home has introduced a new staff induction training package that meets the Skills for Care guidelines. The home has introduced one to one staff supervision. What the care home could do better: The home should ensure that its Statement of Purpose and Service Users Guide are reviewed when changes take place so that it is up-to-date for residents and prospective residents. The home should further develop its care plans so that up-to-date information is clearly identified and documented for staff to follow. The key to the home`s controlled drugs cabinet should be held by the senior person on duty to ensure that security of the medicines is maintained. The home should consider introducing a file so that the record of complaints, investigation and action taken is maintained in one place. Some of the rooms viewed would benefit from redecoration and refurbishment. The home told us that they have plans to make further improvements to the environment including providing a new dining room, upgrading the kitchen, improvements to bedrooms, and improving the garden. The Registered Provider must undertake a monthly Regulation 26 visit/monitoring of the service being provided, taking account of residents views and review progress of plans for improvement to ensure that the home continues to be run in the best interests of residents. It is recommended that the home obtains two signatures when dealing with financial transactions to protect residents` financial interests. The home should develop the staff supervision system with the aim being for all staff to receive regular formal supervision to ensure staff continue to feel well supported. CARE HOMES FOR OLDER PEOPLE The Tudors Street Road Glastonbury Somerset BA6 9EQ Lead Inspector Alison Philpott Unannounced Inspection 8th January 2009 10:00 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 The Tudors DS0000015996.V373592.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. The Tudors DS0000015996.V373592.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service The Tudors Address Street Road Glastonbury Somerset BA6 9EQ 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) 01458 831524 01458 831608 Mrs Noreen Maria Khan Mrs Wendy Lavinia Weddell Care Home 21 Category(ies) of Old age, not falling within any other category registration, with number (21) of places The Tudors DS0000015996.V373592.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 18th December 2007 Brief Description of the Service: The Tudors provides residential accommodation for adults under the Older Persons category of registration. The home is owned by Mrs N. M. Khan-Mullane. The registered manager is Mrs Wendy Weddell. The home is sited in Street Road, not far from the centre of Glastonbury, sited at the base of a hill and facing an access road to the town. There is a large supermarket just opposite and local facilities nearby. There are patio areas and steps leading to an attractive hill garden at the back of the property. Access to the garden is limited to mobile residents who can manage the stairs but there is easier access to the patio areas. There is car parking space at the front of the property. Residents’ accommodation is on two floors. The first floor is accessed by stair lifts. Some bedrooms of the first floor have nice views of the hill beside it, others of the garden or the front of the house. The home has one double room. All other rooms are single, some with en-suite and all have washing facilities. Communal areas, staff office and the kitchen are sited on the ground floor. The current fee range is from £315.00 to £390.00 per week, depending on the size of the bedroom and facilities. The Tudors DS0000015996.V373592.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this home is two star good service. A quality rating is our assessment of how well a care home is meeting the needs of the people who use it. We give a quality rating following a full assessment of the service. We call this a ‘key’ inspection. This was an unannounced key inspection which took place over a total of 8 hours on 8th January 2009. The inspection was undertaken by Alison Philpott and Jackie Dolan. Although there were two inspectors, throughout the report the term we will be used as it is written on behalf of the Commission. The preferred term for the people who live at the home is residents. This is used throughout the report. As part of this inspection we received four completed surveys from residents and five completed surveys from staff. During the inspection we spoke with residents, management and staff. We viewed the home. We looked at five individual care plans, and looked at records relating to medication, finance and health & safety. The inspectors would like to thank residents, staff and management for their assistance on the day of inspection. The focus of this inspection visit was to inspect the relevant key standards under the CSCI Inspecting for Better Lives 2 framework. This focusses on outcomes for residents living at the home. The quality of the service is measured under four ratings. These are excellent, good, adequate and poor. The following is a summary of the inspection findings and should be read in conjunction with the whole of the report. What the service does well: The Tudors DS0000015996.V373592.R01.S.doc Version 5.2 Page 6 Residents living at the home benefit from an experienced manager and stable staff team. Residents comments to us included “staff are “great”, “very helpful”, “all as good as gold”. Staff and management have a good knowledge of individual resident’s needs, preferences and interests. Visitors are made to feel welcome and their comments to us included “I visit frequently and always find a friendly staff “and “I visit once a week and am very happy with everything”. Residents told us they enjoy living at the home. Bedrooms are personalised with residents’ own possessions. The home offers a range of activities. One resident commented “we have entertainment and lovely afternoon buffets”. The home provides a choice of dishes at mealtimes. Residents said “the food is very good”, “the choice is very good with lovely Sunday roasts..”. The homes policies and procedures protect the health, safety and welfare of residents. The management of the home is committed to improving all areas of the home. The home has met all of the requirements made by CSCI at the last inspection. A number of the good practice recommendations have been met. What has improved since the last inspection? What they could do better: The Tudors DS0000015996.V373592.R01.S.doc Version 5.2 Page 7 The home should ensure that its Statement of Purpose and Service Users Guide are reviewed when changes take place so that it is up-to-date for residents and prospective residents. The home should further develop its care plans so that up-to-date information is clearly identified and documented for staff to follow. The key to the home’s controlled drugs cabinet should be held by the senior person on duty to ensure that security of the medicines is maintained. The home should consider introducing a file so that the record of complaints, investigation and action taken is maintained in one place. Some of the rooms viewed would benefit from redecoration and refurbishment. The home told us that they have plans to make further improvements to the environment including providing a new dining room, upgrading the kitchen, improvements to bedrooms, and improving the garden. The Registered Provider must undertake a monthly Regulation 26 visit/monitoring of the service being provided, taking account of residents views and review progress of plans for improvement to ensure that the home continues to be run in the best interests of residents. It is recommended that the home obtains two signatures when dealing with financial transactions to protect residents’ financial interests. The home should develop the staff supervision system with the aim being for all staff to receive regular formal supervision to ensure staff continue to feel well supported. 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. The Tudors DS0000015996.V373592.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 The Tudors DS0000015996.V373592.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): 1, 2, 3. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Prospective residents have enough information to help them decide whether they would like to live at the home. Residents have a written contract with terms and conditions. The home undertakes pre-admission assessments to ensure it can meet the needs of potential residents. EVIDENCE: We viewed the home’s statement of purpose and service user guide. These have been updated since the last inspection but some information has changed since the update. The home should ensure that this document is reviewed The Tudors DS0000015996.V373592.R01.S.doc Version 5.2 Page 10 when changes take place so that it is up-to-date for residents and prospective residents. The residents who completed surveys all confirmed that they received enough information about the home before they moved in so they could decide it was the right place for them. The home told us on their Annual Quality Assurance Assessment (AQAA) “when we have an enquiry..we make arrangements to meet with the person..to assess the care needs..we invite the person and/or their family to come to the home and see if they think..the home would be suitable for them”. We viewed two residents’ contracts. These now include a copy of terms and conditions, room number and fees. Residents who completed surveys confirmed that they had received a contract from the home. There were no recent admissions to the home. We viewed the last admission. The home had undertaken a pre-admission assessment to ensure that the prospective resident’s needs could be met appropriately. We did not assess Standard 6 as the home does not provide intermediate care. The Tudors DS0000015996.V373592.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): 7, 8, 9, 10. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Each resident has an individual care plan. The care plans need some further development and the manager is committed to improving these. Residents are supported to access health care services. The home’s medication policies and procedures protect residents. EVIDENCE: The home told us in their AQAA that they plan to continue to update care plans and make them more consistent. We viewed five care plans. The care plans did not contain detailed information for all of the identified care needs for each resident. However, daily records are maintained and these contained a good level of detail. On a The Tudors DS0000015996.V373592.R01.S.doc Version 5.2 Page 12 number of occasions, it was evident that care needs were monitored closely and acted on appropriately through the daily records. The care plans contained risk assessments relating to falls, diabetes and vision. Records relating to food intake, fluids and tissue viability were viewed. The home should ensure that the care plans contain detailed information so that staff know how to manage these and when to take action. The home should further develop its care plans so that up-to-date information is clearly identified and documented for staff to follow. We discussed how to obtain guidance and support to do this with the manager. It was evident through observation and talking to staff and residents that residents needs are met appropriately. Staff demonstrated a good knowledge of each resident and knew their individual needs and preferences. Three residents who completed the survey confirmed that they ‘always’ receive the care and support they need. One resident said ‘usually’ but went on to say “if I’m ever unsure about anything I feel I can always ask”. Staff confirmed that they are given up-to-date information on handover about the needs of the residents they care for. We viewed records that confirmed that residents have access to healthcare including Doctors, Optician, and Diabetic Clinic. A relative told us that the home calls the Doctor whenever needed. We viewed the home’s medication and medication records. The medication cupboard was locked. The key to the controlled drugs cabinet was on top of the medication trolley in the cupboard. This should be held by the senior person on duty to ensure that security of the home’s controlled drugs is maintained. The balance of one of the controlled drugs was checked and found to be correct. The home uses Medication Administration Record Sheets. These sheets were fully completed and reasons for administration of ‘as required’ medication was recorded. When a medication was not taken the home records the reason for this. Staff were observed interacting with residents in a respectful manner. Residents confirmed that staff knock on their door before entering their bedroom. The Tudors DS0000015996.V373592.R01.S.doc Version 5.2 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, 15. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are able to enjoy a range of activities within and outside of the home. Visitors are made to feel welcome at the home. Residents benefit from freshly prepared foods and a varied menu. EVIDENCE: The home told us “we have a varied activities programme. During the summer we have trips out”. Residents who completed the survey confirmed that activities include visiting groups; singalongs; talks on countries; bingo; DVD and television. One resident commented “we have entertainment and lovely afternoon buffets”. We viewed posters for activities which also included ‘reminiscence’ on the noticeboard in the hallway. The Tudors DS0000015996.V373592.R01.S.doc Version 5.2 Page 14 We spoke to residents who told us “the staff are great, very helpful..they take you out shopping and took me Christmas shopping”. The home told us that they now obtain reading and talking books from the local library for residents to enjoy. One relative told us “I visit frequently and always find a friendly staff “. Another relative who was visiting on the day of the inspection said “I visit once a week and am very happy with everything” and “staff ask if you would like tea”. Residents have their personal possessions in their rooms. If a resident wishes to contact an advocate to act in their interests, information on how to do this is provided in the home’s service user guide. The home told us “we use a varied menu which is reviewed every three months after the residents have filled in a questionnaire as to any changes they would like”. The home arranges regular food shopping trips so that fresh produce is used. Residents said “the food is very good”, “the choice is very good with lovely Sunday roasts and special Christmas menu”. The lunch menu is on display and has a choice of 3 dishes. We spoke with the cook and viewed information in the kitchen that confirmed residents individual preferences. The Tudors DS0000015996.V373592.R01.S.doc Version 5.2 Page 15 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16, 18. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents feel confident that their concerns will be acted upon. The home’s policies and procedures protect residents from the risk of harm. EVIDENCE: The home has updated its complaints policy since the last inspection and now includes the contact details for the Commission for Social Care Inspection. The home has received one complaint since the last inspection. The home had taken action to rectify the issue. The home should consider introducing a file so that the record of complaints, investigation and action taken is maintained in one place. Residents who completed surveys confirmed that they always knew who to speak to if they were not happy and knew how to make a complaint. One resident said “there is always someone to talk with”. Staff confirmed that they knew what to do if a resident, relative, advocate or friend has concerns about the home. The home has policies relating to whistleblowing and abuse. Staff files viewed contained Protection of Vulnerable Adult checks and Criminal Record Bureau The Tudors DS0000015996.V373592.R01.S.doc Version 5.2 Page 16 checks for staff to protect residents from risk of harm. Staff spoken with had a good understanding of adult protection and what to do. The Tudors DS0000015996.V373592.R01.S.doc Version 5.2 Page 17 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 22, 25, 26 Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. The home continues to make improvements to the environment as part of its ongoing renewal and maintenance programme. Residents are able to personalise their bedrooms to suit their individual taste. Some areas of the home were cold on the day of inspection. The home is clean and fresh. The Tudors DS0000015996.V373592.R01.S.doc Version 5.2 Page 18 EVIDENCE: We viewed the home on the day of inspection. The home has replaced the carpets in the ground floor communal areas and renewed some fixtures and fittings in bedrooms. Bedrooms viewed were personalised with people’s possessions. Some of the rooms viewed would benefit from redecoration and refurbishment. The home told us that they have plans to make further improvements to the environment including providing a new dining room, upgrading the kitchen, improvements to bedrooms, and improving the garden. We viewed a bathroom. A bath seat was available to meet the needs of residents. On the day of inspection, a number of items were stored in the bathroom. This gives an untidy appearance and may reduce the pleasurable experience of bathing for residents. The home told us that they have recently had a new hot water system that has enabled the heating system to work more efficiently. On the day of inspection, some areas of the home felt cold. Residents spoken with commented “rooms can get cold”, and “it can be cold at times”. We discussed this with the manager who told us that the home was currently looking into moving a thermostat to improve warmth. Residents who completed surveys confirmed that the home is always fresh and clean. On the day of inspection the home was clean and free from odours. The Tudors DS0000015996.V373592.R01.S.doc Version 5.2 Page 19 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29, 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home has a stable staff team who have a good knowledge of residents’ needs and preferences. Staff receive the training they need to ensure they can meet residents’ needs and keep up-to-date with good practice. The home’s recruitment procedures protect residents from the risk of harm. EVIDENCE: On the day of inspection, there appeared to be enough staff on duty to meet individual resident’s needs. Residents who completed surveys confirmed that staff are ‘always’ available when they need them. Staff confirmed that staffing levels are adjusted to meet the needs of the residents and staff cover each other when someone takes leave. The home benefits from a stable staff team. Residents comments included staff are “great”, “very helpful”, “all as good as gold”. One resident said “when I came home from hospital, staff could not have been more welcoming”. Staff confirmed that they work well as a team to meet residents’ needs. The Tudors DS0000015996.V373592.R01.S.doc Version 5.2 Page 20 The home has introduced a new staff induction training package since the last inspection. This meets the Skills for Care guidelines. Staff spoken with confirmed that they had undertaken an induction and felt confident in carrying out their role. Staff confirmed that training relevant to their job role is always offered. We looked at the staff training records. Training provided includes food hygiene, infection control, manual handling, fire, health & safety, first aid, dementia awareness, medication, and abuse. We saw posters advertising training updates for Protection of Vulnerable Adults and Fire. The home told us that they have arranged for the local Pharmacist to visit the home to provide further medication training. Six staff have completed an NVQ in Care. The home confirmed that a further four staff are currently undertaking NVQs. We viewed three staff files. Two of the files contained all of the required recruitment checks. One file did not contain two references. Following the inspection, the home sent this information to CSCI. The Tudors DS0000015996.V373592.R01.S.doc Version 5.2 Page 21 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 32, 33, 35, 36, 38. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents benefit from an experienced manager and stable staff team. The home is currently developing its quality assurance systems. Residents’ monies are stored securely. The home has commenced a system for staff supervision. The home protects the health, safety and welfare of residents and staff. The Tudors DS0000015996.V373592.R01.S.doc Version 5.2 Page 22 EVIDENCE: Wendy Weddell is the Registered Manager at the home. She has eleven years’ experience of working in the home. Staff confirmed they feel well supported and the manager is always approachable. Residents told us they enjoy living at the home and feel the home is managed well. The Registered Provider is in regular contact with the manager with regard to the running of the home through visits and by telephone. The Registered Provider must undertake a monthly Regulation 26 visit/monitoring of the service being provided, taking account of residents views and review progress of plans for improvement to ensure that the home continues to be run in the best interests of residents. The report of the visit must be kept at the home. The manager told us that the home is currently developing and introducing a more comprehensive quality assurance system. As the manager spends a lot of time with residents, quality assurance is currently monitored through informal one to one chats with residents, group discussion and formal residents meetings. We viewed the minutes of a residents’ meeting held in 2008. The manager told us that she is considering holding meetings more regularly with residents and their families. The home holds small amounts of money for some of the residents. We viewed the records for one resident. The money was stored in an individual tin and the balance was correct. It is recommended that the home obtains two signatures when dealing with transactions to protect resident’s financial interests. Where possible, the resident and a member of staff should sign. If this is not possible, two members of staff should sign. The home has introduced one to one supervision for staff since the last inspection. We viewed the records for one supervision. These contained a good level of detail. The home should continue to develop the system with the aim being for all staff to receive regular formal supervision. We viewed health & safety records relating to lifts, water temperatures, fire equipment, and electrical safety. We viewed completed accident reports. The home had recently arranged for a consultant to review and update its fire risk assessment. They are currently awaiting the report. Fridge temperature records were recorded daily and food was covered and dated. The Tudors DS0000015996.V373592.R01.S.doc Version 5.2 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 3 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 X X 3 X X 2 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 3 2 X 2 2 X 3 The Tudors DS0000015996.V373592.R01.S.doc Version 5.2 Page 24 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 OP33 Regulation 26 Requirement The Registered Provider must undertake a monthly Regulation 26 visit/monitoring of the service being provided, taking account of residents views and review progress of plans for improvement. This is to ensure that the home continues to be run in the best interests of residents. Timescale for action 08/03/09 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 OP1 Good Practice Recommendations The home should ensure that its Statement of Purpose and Service Users Guide are reviewed when changes take place so that it is up-to-date for residents and prospective residents. The home should further develop its care plans so that upto-date information is clearly identified and documented for staff to follow. The home should ensure that the care plans contain DS0000015996.V373592.R01.S.doc Version 5.2 Page 25 2. 3. OP7 OP8 The Tudors 4. 5. 6. 7. 8. 9. OP9 OP16 OP19 OP33 OP35 OP36 detailed information relating to food intake, fluids and tissue viability so that staff know how to manage these and when to take action. The key to the home’s controlled drugs cabinet should be held by the senior person on duty to ensure that security of the medicines is maintained. The home should consider introducing a file so that the record of complaints, investigation and action taken is maintained in one place. It is recommended that the on going refurbishment of the property continue. It is recommended that the home develop a more complete quality assurance system. It is recommended that the home obtains two signatures when dealing with financial transactions to protect residents’ financial interests. The home should develop the staff supervision system with the aim being for all staff to receive regular formal supervision to ensure staff continue to feel well supported. The Tudors DS0000015996.V373592.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection South West Colston 33 33 Colston Avenue Bristol BS1 4UA National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. 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