Inspection on 12/01/07 for Dudbrook Hall

This inspection was carried out on 12th January 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Excellent. 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

Dudbrook Hall 27/02/06

Dudbrook Hall 05/07/05

Dudbrook Hall 21/01/05

Dudbrook Hall 12/10/04

Dudbrook Hall 05/02/04

Similar services:

Claremont House

Oak Ridge

Sun Court Nursing Home

Ashville House

Bilney Hall

Hill Barn

Mabbs Hall Nursing Home

Henrietta House

Extracts from inspection reports are licensed from CQC, this page was updated on 08/07/2008.

CARE HOMES FOR OLDER PEOPLE Dudbrook Hall Dudbrook Road Kelvedon Common Brentwood Essex CM14 5TQ Lead Inspector Mr Trevor Davey Unannounced Inspection 12th January 2007 11:10 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 Dudbrook Hall DS0000018032.V326862.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. Dudbrook Hall DS0000018032.V326862.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Dudbrook Hall Address Dudbrook Road Kelvedon Common Brentwood Essex CM14 5TQ 01277 372095 01277 375297 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) St Michaels Homes Limited Mrs Cecilia Watson Care Home 41 Category(ies) of Dementia - over 65 years of age (20), Old age, registration, with number not falling within any other category (41) of places Dudbrook Hall DS0000018032.V326862.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 27th February 2006 Brief Description of the Service: Dudbrook Hall is a large Country House dating back to 1602 that is set in four acres of parkland gardens. It is registered to provide care for 41 older people, including 20 people who have dementia. There is a choice of communal lounges and a separate dining room. One lounge provides a higher level of supervision for the more dependent service users. All but one bedroom is single and some have en-suite facilities. There is a remembrance garden to Princess Diana in the home with seating areas in the front and rear garden. The rear garden has a new water feature for residents and their families to enjoy. Dudbrook Hall is in a rural setting half a mile from a local bus stop and five miles away from the town of Brentwood. The home provides a mini bus to transport residents.The current rate of fees as shown in the Pre- inspection questionnaire, range from £426.93 to £580.00 per week. Additional charges are made for hairdressing, chiropody, toiletries, newspapers and personal clothing. Dudbrook Hall DS0000018032.V326862.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The Key Inspection site visit went into two days and covered a period of 13.50 hours. The visit focused on the progress the home had made since the last inspection and covered all key standards. The Acting Manager together with other staff, residents and relatives were spoken with doing the site visit. Their comments and contributions received were helpful in assisting the Inspector to compile this report. Although the existing Registered Manager is still on site, her role is now primarily to oversee the business and financial affairs of the company. The Registered Provider is in the process of submitting a new application to the Commission for Social Care Inspection in respect of the Registered Managers post . As part of the site visit, case tracking took place using some of the personal care records and other official records within the home were also assessed. The management of the home had also conducted their own survey and quality assurance exercise with residents and relatives and a summary of the responses received, were made available to the Inspector. Overall, the feedback received by the Inspector was complimentary and positive regarding the standard of care and services provided. The inspection also took into account previous information submitted by the Home including the completed pre- inspection questionnaire. What the service does well: From conversations with residents, relatives and staff as well as feedback from the survey conducted by the home, residents felt well cared for, supported and appreciated the service provided. Staff recognise the importance of Person centred care planning which focuses on choices made by residents and includes liaising with relatives. Staff treat residents with dignity and respect and staff turnover is low. Some of the residents who spoke to the Inspector confirmed that staff were really good, helped with bathing and personal needs. Some of the relatives spoken to during the inspection felt that staff were suitably trained and were able to interact well with residents who were diagnosed with dementia. Staff were said to be supportive and always kept relatives in touch by inviting them to reviews as well as contacting them regarding any issues or changes which occurred. The home has been able to demonstrate its effectiveness in taking appropriate action when issues of concern arise. Personal care records were comprehensively documented and reviewed on a regular basis. Appropriate recruitment procedures were being followed and documentation was available of induction and training courses attended by the staff team. Regular maintenance of services and equipment had taken place which was documented. The home is clean and hygienic. Dudbrook Hall DS0000018032.V326862.R01.S.doc Version 5.2 Page 6 Various social activities and outings are arranged and the management are shortly to introduce life story books to assist with reminiscence and further improve interaction with residents. The spiritual needs and aspirations of residents are well provided for in the home and arrangements are made for clergy of different denominations to make visits as required. Following the quality assurance exercise which the management carried out at the home in June 2006, an action plan had been implemented resulting in further improvements to the services provided. Within the service there was evidence of good awareness and understanding of equalities and diversity which is constantly promoted. What has improved since the last inspection? 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. Dudbrook Hall DS0000018032.V326862.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Dudbrook Hall DS0000018032.V326862.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1&3 Quality in this outcome area is good. Information regarding the home and services provided had been made available to residents and/or relatives but the Statement of Purpose and Service users’ Guide needs to be reviewed and updated. Pre-admission assessment details for care/health needs had been completed to give staff suitable information to determine whether the needs of potential residents could be met by the home. Intermediate care is not provided by the home. This judgement has been made using available evidence including a visit to the service. Dudbrook Hall DS0000018032.V326862.R01.S.doc Version 5.2 Page 9 EVIDENCE: The Statement of Purpose was available but this had not been reviewed or updated since 2003. Information needs to be included regarding the specific arrangements, facilities and services provided by the home relating to dementia care together with any additional social and therapeutic interaction. The Service Users’ Guide also requires updating which should include details of fees, charges and what these cover as appropriate to individual residents, as required by regulation. Copies of this document should be given to individual residents and/or their representatives. A sample check was made regarding pre-admission assessment details, which included information provided by the funding authority, as well as additional details collated by the manager as a result of visiting prospective residents. Personal information and details had been recorded together with health requirements, sensory and practical support. Issues had been highlighted regarding risk of falls, areas of confusion as well as activities and programs needed for mental stimulation. Other health care professionals had also identified nursing needs and a record of current medication had been included. A personal history together with background information, likes and dislikes as well as interests, had been included as part of the pre-admission assessment. A positive response was received to the home’s quality assurance survey which indicated that initial inquiries had been dealt with professionally and the questions raised had been answered in a manner that could be understood and was helpful. Residents and relatives confirmed that they had been invited to visit the home prior to admission. Dudbrook Hall DS0000018032.V326862.R01.S.doc Version 5.2 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8 ,9 & 10 Quality in this outcome area is good. The care and health needs of residents were being met appropriately. Care records were clearly documented, person centred and reflected the involvement of residents in the decision making process. Medication administrative procedures were not always being followed strictly in accordance with guidance provided by the Royal Pharmaceutical Society. Residents are treated with respect and individual privacy is upheld. This judgement has been made using available evidence including a visit to the service. EVIDENCE: A number of personal care records were looked at which included case tracking and the sampling other documented information relating to more recent admissions. Care plans had been prepared as a result of identified needs such as communication site and hearing, nutrition and weight, mobility and dexterity, personal safety/risks and mental state and cognition. The outcomes Dudbrook Hall DS0000018032.V326862.R01.S.doc Version 5.2 Page 11 and action had been documented, signed and dated by staff and regular reviews had been completed which included signatures of residents and/or relatives. In one case, the action to be taken to meet the needs identified, was not recorded in sufficient detail. Risk assessments had also been provided as required which clearly identified the hazards, who may be harmed or how. The controls of risks and measures to be taken were documented and regularly reviewed. Where necessary, the community psychiatric nurse and other health care professionals had also been consulted. Records of annual reviews which had been carried out by funding authorities were also on file. Residents and relatives spoken to, confirmed that they had been kept fully informed of any changes as well as being invited to reviews to discuss needs and ongoing care planning issues. Family communication sheets had been completed and relatives have the opportunity of regularly discussing any issues with management staff should the need arise. Day and night log reports were informative, well documented and regularly completed. The homes quality assurance survey highlighted positive feedback to show that staff respected privacy and are responsive when residents require assistance with personal care. Relatives spoken to, confirmed that they were advised of any issues which arise and fully involved in discussions relating to care planning. Positive comments were made regarding the help and assistance provided by key workers to individual residents and how the home had been reassuring where there were issues of concern. The medication policy and guidance as provided by the Royal Pharmaceutical Society was not always being followed. It was noted that medication administrative records were sometimes being signed prior to residents taking their tablets and where transcribing of medication details had taken place, these had not been supported by two staff signatures on the M.A.R. sheets. Where residents were self-medicating, a risk assessment was in place which had been suitably endorsed and signed by staff and residents concerned. Local doctors visit the home regularly and update as well as signing medical notes. The home is now arranging for this to be cross-referenced on the M.A.R. sheets so far as changes to medication are concerned. During the sample check it was noted for one resident that ‘tranadol’ had prescription details take one or two as directed but no reference was made as to the time of day or in what circumstances this should be administered. Other care plans had been completed relating to the use of P.R.N. (to be taken as required) painkillers which had been regularly reviewed and dated. With all medication policies and procedures, the guidance issued by the Royal Pharmaceutical Society should be followed irrespective of advice received from individual pharmacists. The home receives a good and positive response from other health care professionals in the area and any involvement with residents was clearly documented. Dudbrook Hall DS0000018032.V326862.R01.S.doc Version 5.2 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 & 15 Quality in this outcome area is good. The home provides an activities/recreational programme to meet residents preferences, social, cultural and religious needs. Meals are provided which take into consideration residents choice. Relatives and friends are encouraged to have regular contact with the home. This judgement has been made using available evidence including a visit to the service. EVIDENCE: The home has increasingly given focus to the importance of social stimulation to residents. Care plans sampled during the inspection included social interests, hobbies, religious and cultural needs together with how these should be addressed. Information also included physical limitations as well as the level of prompting and support required to encourage interaction with others. Other input is received on a regular basis by somebody who attends the home who has specific responsibility for craft activities as well as completing details of individual residents’ interest, activities and participation.There are regular group activities and a member of staff was involved with some of the residents Dudbrook Hall DS0000018032.V326862.R01.S.doc Version 5.2 Page 13 in a quiz during the inspection. The home is currently engaged in obtaining from residents preferences relating to individual interests, which they may wish to pursue. The home is also proposing to introduce life books to encourage reminiscence, participation and interaction with residents, particularly those who require greater imput because of dementia. The home has its own vehicle and regular trips are arranged to visit shops, garden centres and the theatre. Positive links have been made with local schools and voluntary organisations who visit the home. It is understood that approximately 90 of families keep in regular contact with the home. Arrangements are in place for clergy of different denominations to visit the home to give spiritual support as required. Information from the home’s own quality assurance survey show a positive response from both residents and relatives to indicate that encouragement is given by the home for residents to join activities, outings and that spiritual needs were being met in accordance with personal choice. Details of social activities were displayed in the main entrance hall at the home and these are also included in the homes own newsletter. The survey also identified a similar positive response regarding the choice and variety of food provided and records were available in the home to show that alternative hot meals are now supplied. Residents spoken to confirmed this had improved the choice available. Meals served in the dining room at lunchtime were of a good quality and staff were observed assisting residents as required. Records of meals prepared for residents were being maintained. Dudbrook Hall DS0000018032.V326862.R01.S.doc Version 5.2 Page 14 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16 & 18 Quality in this outcome area is good. There is an established complaints procedure in place. The home has appropriate reporting procedures for the prevention of harm to vulnerable adults. This judgement has been made using available evidence including a visit to the service. EVIDENCE: The complaints procedure is referred to in the Statement of Purpose and set out in the Service Users Guide. Residents and relatives spoken to were aware of the complaints procedure and to whom they should approach should they have any concerns. One complaint had been recorded since the last inspection and from the documentation and correspondence available, the Inspector is satisfied that this was properly investigated in accordance with the home’s complaint procedure. Appropriate action and improvements had also been taken to address the issues raised. The home’s quality assurance survey also confirmed that apart from a few exceptions, residents and relatives knew whom to contact should they have any concerns. Up to date policies relating to the prevention of harm to vulnerable adults and reporting procedures were in place and the Inspector reinforced the procedures and gave details of the latest contact telephone number of the Adult Protection Unit for Essex social services. Staff have attended P.O.V.A. training. Dudbrook Hall DS0000018032.V326862.R01.S.doc Version 5.2 Page 15 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 22 & 26 Quality in this outcome area is good. The home was clean and hygienic. Ongoing maintenance and servicing of equipment takes place to ensure residents can continue to live in a safe and well maintained environment. This judgement has been made using available evidence including a visit to the service. EVIDENCE: The premises of the home were clean and hygienic and residents spoken to, confirmed that their rooms were kept tidy and clean. Rooms had been personalised to accommodate individual possessions and items of interest belonging to residents. Appropriate furniture, floor coverings, hoisting and lifting equipment was available as required. Because of the layout of corridors and different floor levels in the building, additional signage and symbols should be considered to assist residents who may have dementia or a sensory impairment in order to maximise independence and recognition. Dudbrook Hall DS0000018032.V326862.R01.S.doc Version 5.2 Page 16 The home employs a handyman to carry out all minor repairs and at the time of inspection, some internal decorating of bedroom accommodation was taking place. Records were being maintained showing dates of servicing/maintenance to equipment which was also included on the Pre- inspection questionnaire previously submitted to the C.S.C.I. by the home. There were some shortfalls relating to health and safety issues and these have been identified under standard OP38 of this report under Management and Administration. Dudbrook Hall DS0000018032.V326862.R01.S.doc Version 5.2 Page 17 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. The number of staff on duty together with supervision provided, was sufficient to meet the needs of residents. Recruitment practices are followed as required and staff are trained and competent to do their jobs. This judgement has been made using available evidence including a visit to the service. EVIDENCE: Staff rotas were available and the normal provision of staff allows for the manager and deputy (who are supernumerary), two team leaders, one senior care assistant, seven care staff for the early shift and four for the late shift. In addition, part time staff are available to provide social activities and arm chair exercises. There is also a team of ancillary staff covering domestic, laundry and kitchen duties as well as a handyman and two drivers. There are two administrative staff who cover financial and personnel administration. One senior care assistant and two night carers, all on awake duty, provide night cover. From the sample check made of recruitment records, these included documentation relating to work permits, proof of identification, Criminal Dudbrook Hall DS0000018032.V326862.R01.S.doc Version 5.2 Page 18 Records Bureau checks, references and health declarations as well as contract of employment and staff handbooks. Detailed records were also available of staff induction and ongoing training, which had been completed. As well as course details, certificates were available for inspection. Training included moving/handling, oral hygiene, first aid, tissue viability, M.R.S.A. awareness, dementia care and diabetes/ Parkinsons conditions. Currently, thirteen staff have obtained N.V.Q. Level two or above and others are currently undertaking N.V.Q. course work. On completion, this will represent over 50 of the staff team having achieved N.V.Q. qualifications. The home’s quality assurance survey indicated that the vast majority of residents/relatives considered the staff team to be helpful, kind and approachable. Staff spoken to, had a clear understanding of their roles and responsibilities and of the training they had completed. During the inspection, staff were observed to be interacting sensitively and positively with both residents and relatives. Dudbrook Hall DS0000018032.V326862.R01.S.doc Version 5.2 Page 19 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, 33, 35 & 38 Quality in this outcome area is good. The management operate the home in the best interests of residents. Staff are properly supervised. Although policies and procedures were in place for the safety and welfare of residents, these were not always being followed. This judgement has been made using available evidence including a visit to the service. Dudbrook Hall DS0000018032.V326862.R01.S.doc Version 5.2 Page 20 EVIDENCE: The Acting Manager has successfully completed the N.V.Q Level 4 Registered Manager’s Award, has considerable experience and is competent in discharging her responsibilities fully to her staff team for the day-to-day running of the home. The deputy manager is also in the process of completing this qualification. An application is to be shortly submitted by the home to the Commission for Social Care Inspection for a new Registered Manager. There is very little staff turnover and staff spoken to, enjoyed working in the home. Staff group meetings regularly take place and minutes were available. Staff supervision sessions are undertaken every two and three months for care staff and ancillary staff respectively and these had been recorded. Staff spoken to, found supervision and the feedback received, constructive and positive. The home does not take responsibility for safeguarding personal allowances of residents, which is handled by residents themselves, relatives or representatives on their behalf. Risk assessments had been completed for a safe working environment including spread of infection, power tools, kitchen and use of minibus. These had been reviewed regularly. However some risk assessments were not always being strictly applied in areas of the home. During the inspection the laundry door was found not to be secure and there was no member of staff in attendance. In the kitchen (which was unsupervised at the time), a knife was left on the waste bin which could have been hazardous if residents had gained access into this area. Some food had been left on the worktop without being put back into the fridge and within the fridge itself, not all food had been covered, dated or clearly labelled in accordance with food hygiene regulations. On the first floor, the door to the sluicer disinfectant room had no lock and substances hazardous to health were not securely stored which could pose a risk to residents. The window restrictor in one of the first-floor bedrooms had broken and risk assessments should be completed in respect of doors in bedrooms, which lead immediately on to balconies, to ensure the safety of residents. These matters were pointed out to the Acting manager during the inspection who undertook to arrange for appropriate action to be taken. It was noted that wheelchairs and walking frames, which had been stored in the entrance area to the dining rooms, were causing an obstruction to residents as they were negotiating this area before and after lunch. On the second day of the inspection, these had been removed to a safe area. The home was able to demonstrate its positive and detailed involvement in completing an exercise for quality assurance of the services provided and results from the surveys conducted, were made available to the Inspector. Areas covered included pre-admission enquiries, personal care and activities, Dudbrook Hall DS0000018032.V326862.R01.S.doc Version 5.2 Page 21 accommodation/food as well as a section for representatives on behalf of residents who were unable to take part (e.g. those with dementia). Over 50 of the questionnaires were completed and returned. The outcomes of the service provided were very positive and the home had since produced an action plan to address issues in the home which needed to be improved or clarified. Within the service, there is evidence of a good awareness and understanding of qualities and diversity. Staff are continuously working to develop the service with a view to translating understanding into positive outcomes for residents rather than just meeting needs in a reactive manner. Dudbrook Hall DS0000018032.V326862.R01.S.doc Version 5.2 Page 22 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 2 x 3 x x x HEALTH AND PERSONAL CARE Standard No Score 7 4 8 4 9 2 10 4 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 4 14 4 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 x 18 3 3 x x 3 x x 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 x 4 x 3 x x 2 Dudbrook Hall DS0000018032.V326862.R01.S.doc Version 5.2 Page 23 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 OP1 Regulation 5&6 Requirement Timescale for action 31/03/07 2. OP9 13(2) 3. OP38 13(4) The Registered Person shall keep under review and, where appropriate, revise the Statement of purpose and the Service User’s Guide in accordance with latest legislation. Updated copies must be sent to the C.S.C.I. 28/02/07 The Registered Person shall make arrangements for the recording, handling, safekeeping, safe administration and disposal of all medicines received into the care home in accordance with guidance issued by the Royal Pharmaceutical Society. This refers to clear medication instructions for individual residents, guidance relating to transcribing prescription details and procedures for storing and administering controlled drugs. 28/02/07 The Registered Person shall ensure that all parts of the home to which service users have access are so far as reasonably practicable, free from hazards to their safety and any unnecessary risks to the health or safety of service users are identified and DS0000018032.V326862.R01.S.doc Version 5.2 Dudbrook Hall Page 24 4. OP38 16(2)(j) so far as possible eliminated. This refers to securing doors to areas of the home which may be a hazard to residents, ensuring dangerous substances are locked away, securing dangerous kitchen implements from residents and ensuring wheelchairs & other equipment is stored safely. The Registered Person shall, 28/02/07 after consultation with the Environmental Health Authority, make suitable arrangements for maintaining satisfactory standards of hygiene in the care home. This refers to the correct procedures for storing, protecting and labelling of food. 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 OP22 Good Practice Recommendations Arrangements should be made to provide suitable signage and appropriate symbols throughout the building to assist the needs of all residents, taking account of sensory impairments, dementia or other cognitive impairments, where necessary. Any future quality assurance surveys should also include the opinions/comments of other health care professionals. 2. OP33 Dudbrook Hall DS0000018032.V326862.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection South Essex Local Office Kingswood House Baxter Avenue Southend on Sea Essex SS2 6BG 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 Dudbrook Hall DS0000018032.V326862.R01.S.doc Version 5.2 Page 26 - 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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