Care Home: Tudor House

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What the care home does well In general, people who use the service are well looked after. They are well dressed, live in a clean and well-decorated environment, their medical needs are met and they have good meals provided for them. The appointment of the manager has resulted in a strategic overview of the home. For example, the paperwork within the home is much improved and now in general is up to date and accurate, with evidence that it is reviewed on a regular basis. Medication is audited internally, and there have been no errors or omissions in the recording of medication. The home is decorated and maintained to a high standard, with a rolling programme of refurbishments in place to make sure that this standard is maintained. The home is equipped with good quality domestic style furniture throughout. The library is in need of redecoration, with works undertaken as soon as the plasterwork dries out. The home employs a number of support staff, which allows care staff to concentrate on providing care and enhances the lives of people who use the service. These staff include cleaners, handy man, kitchen staff and two part time activities co-ordinator. These co-ordinators are responsible in part, for the home having a lively and friendly atmosphere, where visitors are welcomed. The appointment of a training co-ordinator on a part time basis has ensured that staff receive the required levels of training. This directly impacts on the level of care received by people who use the service and can only be seen as positive. What has improved since the last inspection? Historically, there has been an issue with supervision of staff within the home. Since the new manager has been in post, supervision of all care staff has been instigated. However, it was noted at the previous inspection that Registered General Nurses were not being supervised as the manager was of the view that they did not need to be. A requirement was made at the previous inspection regarding this; this issue has now been rectified and all staff are receiving the required levels of supervision. All records checked concerning the recruitment of staff now appear to be in order, including the PoVA first for all new staff. This was an outstanding requirement from the previous inspection. What the care home could do better: The senior managers within the home must focus their attention on policies and procedures regarding vulnerable adults. The homes internal policies must be rewritten so that there is greater clarity. In addition, the home must ensure that staff are aware of the rewritten policy and in what circumstances they have a statutory duty to refer to Social Services. In addition, the home senior managers must attend a detailed external course regarding vulnerable adults so that they are aware of the procedures themselves, and what is and is not abuse. CARE HOMES FOR OLDER PEOPLE Tudor House Tudor House Nursing Home 4 Birdhurst Road South Croydon Surrey CR2 7EA Lead Inspector Ms Rin Saimbi Key Unannounced Inspection 27th August 2008 10:30 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 Tudor House DS0000019044.V371353.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. Tudor House DS0000019044.V371353.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Tudor House Address Tudor House Nursing Home 4 Birdhurst Road South Croydon Surrey CR2 7EA 020 8410 3399 020 8 410 6506 tudorhouse@gmail.com 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) Assured Services Limited Mr Nundlallsing Mathoora Care Home 37 Category(ies) of Old age, not falling within any other category registration, with number (37) of places Tudor House DS0000019044.V371353.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 12 nursing 25 which can be either nursing or residential A variation has been granted to allow one specified service user in the Dementia - over 65 [DE(E)] service user category to be accommodated. 4th July 2007 Date of last inspection Brief Description of the Service: Tudor House is a purpose built property in South Croydon, which can accommodate up to 37 elderly people. The accommodation compromises of a lower ground floor with a large lounge/ dining room, a library, further small lounge, conservatory, office space, kitchen and medical room. The ground, first and second floor all have bedrooms, additionally the ground floor benefits from a further lounge. The third floor is used by the proprietors for office space and also has various training rooms. To the rear of the property there is a mature and well-kept garden; to the front there is parking for a number of vehicles. The home has 31 single bedrooms and three double rooms. All the rooms have their own en- suite facilities, wardrobe, chest of drawers, comfortable chairs, natural light and ventilation. The home is situated close to local facilities and transport links. The home’s current charges for the year 2008/09 are in the range of £524.58 to £750 per week. Tudor House DS0000019044.V371353.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating of this service is 2 star. This means the people who use the service experience good quality outcomes. There have been changes in the management details in the last 12 months with a new registered manager of the service. This unannounced inspection was conducted over a two-day period and took approximately eleven hours in total to complete. Prior to the commencement of the inspection, all documentation and contact relating to the home received by the Commission for Social Care inspection was reviewed. This includes the Annual Quality Assurance Assessment which is a self-assessment document completed by the home, this was received in a timely fashion. The inspection itself involved, looking through documentation, which related to the people who use the service and staff; talking to people who use the service and on occasions their relatives observing activities and the care given. There were interviews and discussions with staff, manager and proprietors, and a tour of the building. Three completed questionnaires from people who use the service were received and their views are included in this report. People who use the service were positive about the care that they received. When asked ‘do they look after you’, the replies were ‘yes’; one person said, ‘the staff are very good’. Tudor House has received two other random visits during this inspection year. An anonymous complaint lead to two visits being made in November and December 2007 by CSCI. This complaint had many elements, which were all investigated. Only one of the elements that is to say, someone with an infectious condition did not have an appropriate written care plan. An immediate requirement was made regarding this issue, we checked in December to make sure that it had been completed. Additionally, there was an incident where a person using the service was inappropriately restrained in a chair, this lead to vulnerable adults meetings being convened by Social Services. The outcome of the meeting was that the allegation was unsubstantiated. The incident led to a random visit being undertaken in July by CSCI. Although it appears this was a one off, there was a lack of understanding of the appropriateness of this action. Tudor House DS0000019044.V371353.R01.S.doc Version 5.2 Page 6 We would like to thank the people who use the service and staff members for their time and co-operation during the inspection process. What the service does well: What has improved since the last inspection? Historically, there has been an issue with supervision of staff within the home. Since the new manager has been in post, supervision of all care staff has been instigated. However, it was noted at the previous inspection that Registered General Nurses were not being supervised as the manager was of the view that they did not need to be. A requirement was made at the previous inspection regarding this; this issue has now been rectified and all staff are receiving the required levels of supervision. All records checked concerning the recruitment of staff now appear to be in order, including the PoVA first for all new staff. This was an outstanding requirement from the previous inspection. Tudor House DS0000019044.V371353.R01.S.doc Version 5.2 Page 7 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. The summary of this inspection report can be made available in other formats on request. Tudor House DS0000019044.V371353.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 Tudor House DS0000019044.V371353.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): 1,3,4 and 5 People using the service experience good quality outcomes in this area. We have made this judgement using evidence, including a visit to the service. In general, the home produces sufficient information regarding the services that it provides in order that prospective people coming into the service are equipped with the information they require to make an informed choice about the suitability of the home. EVIDENCE: The home does have a detailed statement of purpose, which outlines their aims and objectives and the facilities that will be provided. This was viewed at previous inspections and was deemed to be satisfactory Prospective new people coming into the service are only admitted on the basis of an assessment completed by the manager. In addition, the manager Tudor House DS0000019044.V371353.R01.S.doc Version 5.2 Page 10 gathers as much information as possible from the people themselves, family and friends, and other involved professionals. Prospective new people are then invited to the home for a trail period, which normally lasts six weeks. After this period there is a meeting with all relevant professionals including the people themselves, which determines whether the placement should go ahead or not Information was viewed regarding four people who use the service, one of whom had recently been admitted to the home. The assessments included details of medication, hearing and vision, next of kin and mobility. Whilst not a comprehensive assessment it was adequate for the purposes required. The home’s manager is in the process of introducing a ‘social history’ for all people who use the service. This document is in the early stages of being developed and will be completed initially for all new people coming into the service, and then gradually for everyone. The manager stated that it will include information about the person, and will move the focus away from the medical aspects of an individual’s care. The introduction of the form is seen as positive and we would expect that there is a move towards ‘person centred planning’ in the longer term. The majority of people who use the service at Tudor House are from a white/European background. There are however, a small percentage of people who use the service who are from differing backgrounds, there is one AfroCaribbean women and a man from Sri Lankan. The manager stated that their needs were similar to other people who use the service, although the woman does attend church on a regular basis. Tudor House does not provide intermediate care and therefore this standard has not been assessed. Tudor House DS0000019044.V371353.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 and 10 People using the service experience good quality outcomes in this area. We have made this judgement using evidence, including a visit to the service. The assessment process and the subsequent care plan does define the care that is given to people who use the service. Care plans are reviewed regularly to reflect the changing needs of the individual. People who use the service in general are treated with respect and their right to privacy is upheld. EVIDENCE: The initial assessment completed by the manager is translated by a senior member of staff into the care plan. This care plan identifies the actual care that is to be given to each individual person using the service. Tudor House DS0000019044.V371353.R01.S.doc Version 5.2 Page 12 Care plans for four people who use the service were viewed and in general they appeared to reflect the care given. For example, for one person who uses the service, there were eleven individual care plans listed ranging from restricted mobility, confusion and the use of bedrails. There was evidence that the care plans are reviewed monthly, they were not however, signed by the person receiving the care or their representatives. A recommendation has therefore been made that consideration be given to doing so in the future. Risk assessments were available for all people who use the service in relation to pressure sores and manual handling. There was also a dependency profile, which again was completed on a monthly basis. The home maintains a daily log for each person who uses the service. There was some inconsistency in the way that staff used it. For some people it was completed on a daily basis, but the entry only stated ‘care given as per plan’. For other people in the home there was no entry in the daily log for a week at a time. We had a discussion with the manager that there needs to be some clarification with staff about the purpose of daily recording, and that once this had been established, some consistency. A recommendation has therefore been made that the home considers the purpose and function of daily recording. At the time of the inspection, there were two people who use the service with bedsores; both had arrived from hospital with them. The home was able to produce body charts and photographs of the bedsores, which indicated that they were being monitored and cared for appropriately. The home has records of health appointments for individual people who use the service. The GP visits the home on a weekly basis, and anyone who needs a health appointment can be seen immediately. A chiropodist and opticians also come into the home on a six monthly basis. Audiologist and a dietician are accessed via the GP if required. A district nurse visits regularly; the home can also provide palliative care if required. People who use the service have their weight monitored on a monthly basis as a matter of course. We checked the records for this and found that they had been completed. Medication is stored in a room, which is kept locked at all times. The medication is only administered by Registered General Nurses (RGN) and there is at least one RGN on duty over the 24-hour period. The records were examined; there was a photograph of each person who uses the service and all known allergies listed on the Medication Administration Records. The records themselves, showed no omissions Tudor House DS0000019044.V371353.R01.S.doc Version 5.2 Page 13 The manager stated that he completes an internal audit of medication on a monthly basis. In addition, there is an external audit on a six monthly basis, the last being completed in June 2008. With regard to peoples privacy and dignity, we observed on the first day of inspection, some practice that appeared poor; a member of staff approached someone from behind and then shouted in their ear, making her jump; a member of staff feeding someone was not focused on the activity that they were undertaking; staff appearing to rush around, but no one sitting and talking to people who use the service. On the second day, staff interaction with the people who use the service was much improved. During discussions with staff they were all able to give appropriate responses to questions we asked about privacy and dignity. The manager stated that he felt his staff were responding to the presence of an inspector and were not acting in their usual manner on the first day of inspection. As it is difficult to clarify this point, a recommendation has been made that staff nonetheless complete a refresher course regarding privacy and dignity. Tudor House DS0000019044.V371353.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): 12,13,14 and 15 People using the service experience good quality outcomes in this area. We have made this judgement using evidence, including a visit to the service. The home does offer a range of activities via the coordinators. Whilst ensuring that independence and choice is maintained wherever possible. The home has a friendly, relaxed atmosphere where visitors are welcome, thus creating a homely environment. EVIDENCE: The home employs two activities co-ordinators who between them work five days a week, 10 – 4 pm. The co-ordinators arrange a number of activities including bingo, quizzes, and craftwork. A hairdresser visits the home on a weekly basis. As well as the routine activities that take place on a weekly basis, the coordinators also arrange for visits from community groups and outings. There are also trips to the theatre and shows, the local park and using the tram for Tudor House DS0000019044.V371353.R01.S.doc Version 5.2 Page 15 outings. Over the summer period, there was a trip to Worthing and a visit to the Bluebell railway. This year the home has also celebrated three 100th birthdays with parties and visits from the mayor. The home is catering for a range of people whose needs vary, in discussions with people who use the service some stated that they like what was on offer in terms of activities, whereas one person said ‘all the activities are too slow for me’. Many of the activities take part in the lounge/dining room; however, there are other rooms available for people who use the service. There is a conservatory; a small lounge adjacent to the large room known as the library. On the ground floor there is a further lounge, which is used for social occasions. The home had a relaxed atmosphere whilst being quite busy with the coming and goings of friends and relatives. People who use the service are able to choose whether to see friends and family in a communal area or in their bedrooms. One of the relatives interviewed on the day of the inspection, stated ‘I’m made to feel welcome, there does not seem to be any restrictions….and all the nurses seem very nice.’ Mealtimes are clearly an important time within the home. People who use the service are provided with a menu from which they have a choice of main two meals at lunchtime. On the day of the inspection, there was a lentil and vegetable soup, fishcakes and semolina. Alternatives were available if you did like what was on offer. Lunch was taken with people who use the service who spoke positively about the quality of the food provided. People who use the service have a choice for breakfast, which includes a cooked breakfast. The lunchtime meal is the main meal, and for tea there is usually something like macaroni cheese, eggs on toast or sandwiches. In general, there is either a cook or an assistant cook on duty for twelve hours of the day. Food that is prepared in the kitchen and needs to be transferred to bedrooms in done so via a ‘dumb waiter’ thus ensuring that it always arrives hot. The cook stated that she attends the residents meetings to find out what people think of the food; she is constantly trying to extend the range of food provided by trying new dishes. Tudor House DS0000019044.V371353.R01.S.doc Version 5.2 Page 16 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16,17 and 18 People using the service experience good quality outcomes in this area. We have made this judgement using evidence, including a visit to the service. The home has a clear complaints policy; and complaints are always taken seriously and acted upon. People who use the service can therefore feel that their views are listened to. There is a lack of clarity and understanding from those within managerial positions regarding vulnerable adults procedures, which could compromise the welfare of people who use the service. EVIDENCE: The home has a complaints policy and a log of the complaints that are made. Since the last key inspection in July 2007, the log indicated that one complaint has been made and that it was resolved within the timescales required. Several people who use the service were asked what they would do if they have a problem, all stated that they would talk to the manager. One person stated ‘he’s done a lot for us, got things sorted’ Tudor House DS0000019044.V371353.R01.S.doc Version 5.2 Page 17 With regard to the vulnerable adult policy, the home has revised its documentation; this was an outstanding requirement from the previous inspection. However, the internal document is unclear, and therefore a recommendation has been made that it is rewritten. Additionally, there was an incident where a person using the service was inappropriate restrained in a chair, this lead to vulnerable adults meetings being convened by Social Services. The outcome of the meeting was that the allegation was unsubstantiated. The incident led to a random visit being undertaken in July by CSCI. Although it appears this was a one off, there was a lack of understanding of the appropriateness of this action. This lack of clarity and understanding of the policies and procedures could compromise the welfare of people who use the service. Therefore a requirement has been made that the manager and deputy (when one has been appointed) attend a detailed external vulnerable adults training. Tudor House DS0000019044.V371353.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19,20,22,24 and 26 People using the service experience good quality outcomes in this area. We have made this judgement using evidence, including a visit to the service. The focus of the home is very much in the main lower ground lounge; other rooms are available however providing quieter areas and privacy. The home is generally decorated and maintained to a high standard throughout. People who use the service are able to bring in their own furniture, which gives the home a pleasant, homely feel. EVIDENCE: The home is purpose built with facilities arranged over four floors. The lower ground area has a large lounge/dining room, which is the main communal area for the home. Via this room there is access to a conservatory and the garden. Tudor House DS0000019044.V371353.R01.S.doc Version 5.2 Page 19 There are further smaller lounges, which provide greater privacy for people. In addition, the manager’s office, medical room and kitchens are located here. The home has thirty-one single bedrooms all with en-suite facilities, arranged over three floors. The home has three double bedrooms. Each floor has its own kitchenette area and a nurse’s station; all the floors are decorated in different colours for ease of identification by people who use the service. We conducted a tour of the home accompanied by a member of staff. The home is decorated and furnished to a high standard with the focus on providing a homely environment. The home has a rolling programme of maintenance to ensure that this high standard is maintained. It was noted that the library was in need of redecoration following a major leak. A requirement has therefore been made in this regard. The home is equipped with suitable aids and adaptations; there is lift, handrails, call bells, ramps and specifically adapted bathrooms. The home was generally clean and hygienic throughout. Bedrooms were well furnished with some degree of personalisation in the choice of ornaments and photographs. Each person had keys to their bedroom and a lockable space. Tudor House DS0000019044.V371353.R01.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29 and 30 People using the service experience good quality outcomes in this area. We have made this judgement using evidence, including a visit to the service. In general, the staffing levels and skill mix meet the needs of the people who use the service to ensure that they are well cared for. In general the recruitment practices within the home are sufficiently rigorous to protect the welfare of the people who use the service from abuse. EVIDENCE: The home aims to have six members of care staff on duty in the mornings, plus an additional person doing breakfasts, this covers their busy period; during the afternoon there would be five members of care staff. In addition, the home has two registered nurses on duty during the day. At night, there is one waking member of staff on duty on each floor, and also a waking nurse. Duty rota were examined following the July inspection and were sampled again at this inspection, they indicated that there were sufficient staff on duty. Tudor House DS0000019044.V371353.R01.S.doc Version 5.2 Page 21 The home also employs various other domestic staff, including cleaners, cooks and a handy man. People who use the service speak warmly of the care that they receive, when asked if they were looked after, all stated ‘yes’. One person commented on their returned questionnaire, ‘the staff are very good’. Staffing records including recruitment were checked, four files were chosen at random including one of a new member of staff and the manager. The files were generally in good order containing the application form, interview questions, references, terms and conditions and Criminal Record Beaux checks (CRB) and where applicable the Protection of Vulnerable Adults check (PoVA). The group of four homes owned by the proprietors employ a trainer on a full time basis. This has greatly improved the training received by the staff who now receive as a minimum three days of paid training per year. There are five statutory courses, which include manual handling and fire safety, which are undertaken on an annual basis by all staff. In addition, the training manager stated that all carers would receive ‘skills for care’ training regardless of how long they have been employed by the home On the first day of the inspection, a number of staff were receiving training on the Disability Discrimination Act. Staff were also able to confirm the levels of training. The manager stated that of the establishment of 38 staff, 70 had already, or were in the process of completing their National Vocational Qualification Level 2 or above. This is positive to note. Tudor House DS0000019044.V371353.R01.S.doc Version 5.2 Page 22 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31,32,33,35,36,37 and 38 People using the service experience good quality outcomes in this area. We have made this judgement using evidence, including a visit to the service. The quality of the care provided by the home is strongly influenced by the calibre of the registered manager. Mr Mathoora has fostered an atmosphere of openness so that people who use the service and staff feel that they are valued and that the service that is being provided is high quality. There are some gaps in knowledge, which need to be addressed to ensure the welfare of all people who use the service. Tudor House DS0000019044.V371353.R01.S.doc Version 5.2 Page 23 EVIDENCE: The current manager, Mr Mathoora has considerable experience and knowledge in the area of older people, he is an RGN and has worked both as a deputy and manager of services for older people; he is qualified to NVQ Level 4 and has his registered managers award. Mr Mathoora became the registered manager of the home following his interview with the Commission for Social Care Inspection. In discussions with staff and people who use the service we asked about the managers approach and style. All were positive, with one comment received summing up with ‘Narvin (the manager) listens well’. It is clear that the home had made many improvements in recent times. In particular there is a systematic approach to record keeping and internal monitoring which ensures that people who use the service are receiving a good standard of care. The area that the manager must focus on however, to ensure the welfare of people within the home is that of protection which is vital to the running of any home. As previously mentioned a requirement has been made in this regard. With regard to quality assurance and monitoring systems, Tudor House has a number of measures in place, which have been reviewed at previous inspections; these include an annual development plan and questionnaires to people who use the service and their families. There is also a residents meeting approximately three times a year, which is facilitated by the activities co-ordinator. The Regulation 26 visits, that is to say, the visits that the registered provider is required to make ever month were available for inspection purposes. The providers have delegated this task to a nominated individual. The reports of these visits were comprehensive, thorough and much improved from previous reports received. A recommendation has been made however, that the time of the visit and any discussions with staff and people who use the service are recorded. Supervision records for staff were chosen randomly, they indicated that supervision was taking place at the required level, that is to say, a minimum of six per year. There was evidence of these sessions having been recorded appropriately and signed by both parties. At the last inspection, supervision had not been taking place for the Registered General Nurses (RGN’s), as the manager was under the misapprehension that they did not need to be supervised. This has now been rectified and therefore the previous requirement is deemed to have been met and is therefore withdrawn. Tudor House DS0000019044.V371353.R01.S.doc Version 5.2 Page 24 With regard to safe working practices, the home has a number of policies and procedures in place to ensure the safe working practices of the home. There are risk assessments in place for the moving and handling, and appropriate equipment in situ. There was an awareness and understanding of infection control amongst the staff, and the provision of gloves and protective clothing; there is a sluice room on every floor of the home. There was evidence of some regular checks taking place, fire alarms were tested weekly and the equipment was last checked on the 4.6.08; Landlords gas certificate was dated 7.8.08; Portable appliance testing was completed on the 25.3.08 and the five year electrical certificate was issued on the 29.11.04. In the kitchen, fridge and freezer checks are completed daily, and the temperature of food at the time of serving taken although not recorded. A recommendation was made that the recording of temperature checks should be made. Tudor House DS0000019044.V371353.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 3 3 X HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 2 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 3 18 1 3 3 X 3 X 3 X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 2 X 3 3 2 3 Tudor House DS0000019044.V371353.R01.S.doc Version 5.2 Page 26 Are there any outstanding requirements from the last inspection? Yes 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 OP18 Regulation 12(1)(a) Timescale for action The home must rewrite their own 27/09/08 internal policies and procedures regarding vulnerable adults so that there is greater clarity. All staff must be aware of the changes made to the policy; this is to ensure the welfare of people who use the service. All those in a managerial position 27/12/08 must attend detailed external vulnerable adults training to ensure the safety and welfare of all people who use the service Requirement 2 OP18 12(1)(a) Tudor House DS0000019044.V371353.R01.S.doc Version 5.2 Page 27 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 5 6 Refer to Standard OP7 OP7 OP10 OP19 OP33 OP37 Good Practice Recommendations Staff should be reminded of the purpose and function of the daily log, so that a consist approach can be maintained People who use the service or their representatives should sign any care plans as evidence that they agree to the care that is to be given All staff should attend a refresher course on privacy and dignity in order to maintain a high level of care for people who use the service The library should be redecorated so that the home maintains a homely environment Regulation 26 visits undertaken should include the time of the visit, and any person spoken to during the visit; this is to ensure that there is an audit trail The temperature of food as it is served should be recorded, this is to ensure the safety and welfare of the people who use the service Tudor House DS0000019044.V371353.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection London Regional Office 4th Floor Caledonia House 223 Pentonville Road London N1 9NG 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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