Inspection on 12/10/04 for Dudbrook Hall

Care Home For Older PeopleDudbrook HallDudbrook Road Kelvedon Common Brentwood Essex CM14 5TQAnnounced Inspection12th October 2004 Commission for Social Care InspectionLaunched in April 2004, the Commission for Social Care Inspection (CSCI) is the single inspectorate for social care in England. The Commission combines the work formerly done by the Social Services Inspectorate (SSI), the SSI/Audit Commission Joint Review Team and the National Care Standards Commission. The role of CSCI is to: · Promote improvement in social care · Inspect all social care - for adults and children - in the public, private and voluntary sectors · Publish annual reports to Parliament on the performance of social care and on the state of the social care market · Inspect and assess `Value for Money of council social services · Hold performance statistics on social care · Publish the `star ratings for council social services · Register and inspect services against national standards · Host the Childrens Rights Director role.Inspection Methods & FindingsSECTION B of this report summarises key findings and evidence from this inspection. The following 4-point scale is used to indicate the extent to which standards have been met or not met by placing the assessed level alongside the phrase Standard met? The 4-point scale ranges from: 4 - Standard Exceeded (Commendable) 3 - Standard Met (No Shortfalls) 2 - Standard Almost Met (Minor Shortfalls) 1 - Standard Not Met (Major Shortfalls) O or blank in the Standard met? box denotes standard not assessed on this occasion. 9 in the Standard met? box denotes standard not applicable. X is used where a percentage value or numerical value is not applicable. ESTABLISHMENT INFORMATION Name of establishment Dudbrook Hall Address Dudbrook Road, Kelvedon Common, Brentwood, Essex, CM14 5TQ Email address Name of registered provider(s)/company (if applicable) St Michaels Homes Limited Name of registered manager (if applicable) Mrs Cecilia Watson Type of registration Care Home No. of places registered (if applicable) 41 Tel No: 01277 372095 Fax No: 01277 375297Category(ies) of registration, with (number of places) Dementia - over 65 years of age (20), Old age, not falling within any other category (41) Registration number I060000192 Date first registered 30th July 2002 Was the home registered under the Registered Homes Act 1984? Do additional conditions of registration apply ? Date of last inspectionDate of latest registration certificate 7th February 2003 YES YES 5/2/04 If Yes refer to Part CDudbrook HallPage 1 Date of inspection visit Time of inspection visit Name of inspector Name of inspector Name of inspector 1 2 312th October 2004 09:00 am Patricia StantonID Code131052Name of inspector 4 Name of specialist (e.g. Interpreter/Signer) (if applicable) Name of establishment representative at the time of inspectionNone Miss Clare Watson (Deputy Manager)Dudbrook HallPage 2 CONTENTSIntroduction to Report and Inspection Inspection Visits Brief Description of the Services Provided Part A: Summary of Inspection Findings Inspectors Summary Statutory Requirements/Good Practice Recommendations from last Inspection Conditions of Registration Statutory Requirements/ Good Practice Recommendations from this Inspection Part B: Inspection Methods & Findings National Minimum Standards For Older People: Choice of Home Health and Personal Care Daily Life and Social Activities Complaints and Protection Environment Staffing Management & Administration Part C: Part D: D.1. D.2. D.3. Compliance with Conditions (if applicable) Providers Response Providers Comments Action Plan Providers AgreementDudbrook HallPage 3 INTRODUCTION TO REPORT AND INSPECTION Every establishment that falls within the jurisdiction of the Commission for Social Care Inspection (CSCI), is subject to inspection, to establish if the establishment is meeting the National Minimum Standards relevant to that setting and the requirements of the Care Standards Act 2000. This document summarises the inspection findings of the CSCI in respect of Dudbrook Hall. The inspection findings relate to the National Minimum Standards (NMS) for Care Homes for Older People published by the Secretary of State under the Care Standards Act 2000. The Regulations applicable to the inspected service are secondary legislation, with which a service provider must comply. Service providers are expected to comply fully with the National Minimum Standards. The National Minimum Standards will form the basis for judgements by the CSCI regarding registration, the imposition and variation of registration conditions and any enforcement action. The report follows the format of the NMS and the numbering shown in the report corresponds to that of the Standards. The report will show the following: · Inspection methods used · Key findings and evidence · Overall ratings in relation to the standards · Compliance with the Regulations · Required actions on the part of the provider · Recommended good practice · Summary of the findings · Providers response and proposed action plan to address findings This report is a public document. INSPECTION VISITS Inspections are undertaken in line with the agreed regulatory framework with additional visits as required. This is in accordance with the provisions of the Care Standards Act 2000. The report is based on the findings of the specified inspection dates.Dudbrook HallPage 4 BRIEF DESCRIPTION OF THE SERVICES PROVIDED. Dudbrook Hall is a large old Country House dating back to 1602 and is set in four acres of parkland gardens. It caters 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 and seating areas in the front and rear garden. Dudbrook Hall is in a rural setting half a mile from a local bus stop and five miles away from the town of BrentwoodDudbrook HallPage 5 PART A SUMMARY OF INSPECTION FINDINGSINSPECTORS SUMMARY (This is an overview of the inspectors findings, which includes good practice, quality issues, areas to be addressed or developed and any other concerns.)Dudbrook HallPage 6 Summary of Announced Inspection Dudbrook Hall 12th October 2004.Dudbrook Hall has been inspected as required under the Care Standards Act 2000 and the Care Home Regulations 2001 (as amended). Areas to be progressed are listed in the Requirements and Recommendations section of the report. Any breaches in regulations that pose a more immediate risk to service users have been highlighted for urgent action. Records, practices, policies and procedures have only been sampled. At future inspections other issues may come to light when different items are sampled or different people are spoken to. This inspection took place on one 12th October 2004 and during this visit it was found that all of the requirements from the previous inspection had been met and the overall quality of care provided was very good. During this visit the inspector spoke to fifteen service users; three relatives/significant others; five staff members; the deputy manager and the laundry person. All service users spoken to expressed satisfaction with the care they received and with the quality of the food offered. The home accommodates one service user with a dog, which was seen to be very popular with other service users. As part of the inspection pre inspection questionnaires were sent to all service users and their relatives but the inspector received only response from a relative written on behalf of his mother. The inspector would like to take this opportunity of thanking service users, relatives, staff and the deputy manager for their kind hospitality and for their co operation and time during the inspection. Choice of Home (Standards 1-6) Five of the six standards inspected were met. The home has an appropriate pre assessment process to ensure appropriate placements for service users and staff in the home receive training to ensure all service users needs are met. Health and Personal Care (Standards 7-11) Five of the five standards inspected were met. Care plans inspected were comprehensive and detailed the home delivers a good quality of service and service users spoken to at inspection confirmed they were cared for by an established team of staff in the home. Communication between staff and service users was observed to be mutually respective, caring and positive. Daily Life and Social Activities (Standards 12-15) Three of the four standards inspected were met. Social activities in the home are limited in respect of service users abilities and the homes rural location. The home offers a good quality of food and service users are consulted regarding choice. Complaints and Protection (Standards 16-18) Three of the three standards inspected were met. Any complaints received by the home are fully investigated by the registered person and service users are encouraged to vote and make their views with regard to the day-to-day running of the home. Staff are aware of the procedures of reporting abuse and have training in protection of vulnerable adults. Dudbrook Hall Page 7 Environment (Standards 19-26) Seven of the eight standards inspected were met. The home is located in a rural area in beautiful surroundings and maintained to a high standard. The home must ensure the home is maintained to ensure the health and welfare of individual service users. Staffing (Standards 27-30) Three of the four standards inspected were met. The home employs sufficient numbers of staff to meet the needs of service users living in the home but should ensure one member of staff is on duty 24 hours a day who is qualified in first aid. 50 of all care staff should be qualified in NVQ level 2 by 2005. Management and Administration (Standards 31-38) Six of the six standards inspected were met. The home employs an acting manager who appeared at inspection to be very competent and experienced. The home has produced an effective quality assurance and monitoring system to ensure the home continues to seek others opinion and make improvements to the service when required. This is good practice.Dudbrook HallPage 8 Requirements from last Inspection visit fully actioned? If No please list belowYESSTATUTORY REQUIREMENTS Identified below are areas not addressed from the last inspection report which indicate a non-compliance with the Care Standards Act 2000 and accompanying Regulations. The code in Standard is a cross-reference to the Standards described in full in the section Inspection Findings. No. Regulation Standard Required actions Timescale for actionAction is being taken by the Commission for Social Care Inspection to ensure compliance in regard to the above requirements. RECOMMENDATIONS Identified below are recommendations from the last inspection that have not been implemented No. Refer to Good Practice Recommendations StandardCONDITIONS OF REGISTRATION THAT APPLY (OTHER THAN NUMBERS AND CATEGORY OF SERVICE USERS). Dementia 20Met (Yes / No) YESDudbrook HallPage 9 STATUTORY REQUIREMENTS IDENTIFIED DURING THE INSPECTION Action Plan: The Registered Person is requested to provide the Commission with an Action Plan, which indicates how requirements are to be addressed with the time scale within which such actions will be taken. This action plan will be made available on request to the Area Office.STATUTORY REQUIREMENTS Identified below are areas addressed in the main body of the report, which indicate noncompliance with the Care Standards Act 2000, and accompanying Regulations 2001 and the National Minimum Standards. The Registered Provider(s) is/are required to comply within the given time scales. The code in Standard is a cross-reference to the Standards described in full in the section Inspection Findings. No. Regulation Standard * Requirement Timescale for action 1 23 OP24OP2 5 The home must ensure the premises of the home are kept in a good state of repair and kept reasonably decorated. This refers to service users bedrooms, carpets and floors. The registered manager must provide facilities for recreation including regard to needs of service users who wish to go out. 1/1/05216 (n)OP121/12/04RECOMMENDATIONS Identified below are areas addressed in the main body of the report, which relate to National Minimum Standards and are seen as good practice issues which should be considered for implementation by the registered Provider(s). The code in Standard is a cross-reference to the Standards described in full in the section Inspection Findings. No. Refer to Good Practice Recommendations Standard * 50 of care staff should achieve NVQ level 2 in care by 2005. This is a repeat recommendation. The deputy manager evidences she has a qualification in NVQ level 4 in care management or equivalent. It is recommended links be made with local voluntary services to assist in taking service users out weekly.1OP282 3OP31 OP12Dudbrook HallPage 10 4OP26Service users who are incontinent should have suitable flooring or appropriate cleaning of flooring to help prevent offensive odours.* Note: You may refer to the relevant standard in the remainder of the report by omitting the 2-letter prefix e.g. OP10 refers to Standard 10.Dudbrook HallPage 11 PART BINSPECTION METHODS & FINDINGSThe following inspection methods have been used in the production of this report Direct observation Indirect observation Sampling · Pre-inspection questionnaire · Records · Care plans / Care pathways · Meals · Activities · Other (Specify) `Tracking care and support Group discussion with service users Individual discussion with service users Group discussion with staff Individual discussion with staff Discussion with management Service user survey Relatives/significant others survey/feedback Visiting professionals survey / feedback Tour of premises Formal interviews Document reading Additional inspection information: Number of service users spoken to at time of inspection Number of relatives/significant others the inspectors had contact with Number of letters received in respect of the service CRB check for the responsible individual seen CRB check for the manager seen Certificate of registration was displayed at the time of the inspection Certificate of registration accurately reflected the situation in the service at the time of inspection Total number of care staff employed (excluding managers) Total number of staff with nursing qualifications employed Date of inspection Time of inspection Duration of inspection (hrs) YES YES YES YES YES YES YES YES YES YES YES YES YES YES YES YES NO YES NO YES 15 1 0 YES YES YES YES 26 0 12/10/04 09.00 8Dudbrook HallPage 12 The following pages summarise the key findings and evidence from this inspection, together with the CSCI assessment of the extent to which the National Minimum Standards for Care homes for older people have been met. The following scale is used to indicate the extent to which standards have been met or not met by placing the assessed level alongside the phrase Standard met? The scale ranges from: 4 - Standard Exceeded 3 - Standard Met 2 - Standard Almost Met 1 - Standard Not Met (Commendable) (No shortfalls) (Minor shortfalls) (Major shortfalls)0 or blank in the Standard met? box denotes standard not assessed on this occasion. 9 in the Standard met? box denotes standard not applicable. X is used where a percentage value or numerical value is not applicable.Dudbrook HallPage 13 Choice of HomeThe intended outcomes for the following set of standards are: · · · · · · 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.Standard 1 (1.1 ­ 1.3) The registered person produces and makes available to service users an up to date statement of purpose setting out the aims, objectives, philosophy of care, services and facilities, and terms and conditions of the home; and provides a service users guide to the home for current and prospective residents. The statement of purpose clearly sets out the physical environmental standards met by a home in relation to standards 20.1, 20.4, 21.3, 21.4, 22.2, 22.5, 23.3 and 23.10: a summary of this information appears in the homes service users guide. Range of fees charged From (£) 383 To (£) 550Any charges for extras If yes, please state what the extras are:YESCHIROPODY, HAIRDRESSER, NEWSPAPERS, PERSONAL CLOTHING, TOILITRIES. 3 Key findings/Evidence Standard met? The statement of purpose was updated in November 03 and is detailed and informative but needs to be further updated to reflect the changes in staffing numbers in respect of care workers and the registered provider as specified in the pre inspection questionnaire submitted by the deputy manager. The statement of purpose will need to reflect future changes in management in the home. Service users have copies of the statement of purpose in their bedrooms.Dudbrook HallPage 14 Standard 2 (2.1 ­ 2.2) Each service user is provided with a statement of terms and conditions at the point of moving into the home (or contract if purchasing their care privately). 3 Key findings/Evidence Standard met? At inspection the administrations clerk provided the inspector samples of service users statement of terms and conditions with contracts signed by all relevant parties, which are completed at the point of admission.Standard 3 (3.1 ­ 3.5) New service users are admitted only on the basis of a full assessment undertaken by people trained to do so, and to which the prospective service user, his/her representatives (if any) and relevant professionals have been party. 3 Key findings/Evidence Standard met? The registered provider/manager and her deputy are both experienced and trained to assess prospective service users and visit service users in their own home or in hospital to ensure they are involved with their significant others in the assessment process. Service users at inspection confirmed they were visited prior to admission and files evidenced social workers and other care medical professions are involved in assessments. Standard 4 (4.1 - 4.4) The registered person is able to demonstrate the homes capacity to meet the assessed needs (including specialist needs) of individuals admitted to the home. 3 Key findings/Evidence Standard met? The registered provider and her deputy ensures all service users needs are met by ensuring staff receive training in medical diseases relevant to service user accommodated in the home such as Parkinsons, stroke, dementia, bowel cancer and diabetes.Standard 5 (5.1 ­ 5.3) The registered person ensures that prospective service users are invited to visit the home and to move in on a trial basis, before they and / or their representatives make a decision to stay; unplanned admissions are avoided where possible. 3 Key findings/Evidence Standard met? Service user and relatives at inspection confirmed they had visited the home prior to admission to meet other service users and to look around the home prior to admission. One service users stated staff were very nice and two other service users stated we are on holiday in the home although they were permanent residents. Emergency and respite care are not provided at Dudbrook.Dudbrook HallPage 15 Standard 6 (6.1 - 6.5) Where service users are admitted only for intermediate care, dedicated accommodation is provided together with specialised facilities, equipment and staff, to deliver short term intensive rehabilitation and enable service users to return home. 9 Key findings/Evidence Standard met? The homes does not provide intermediate care.Dudbrook HallPage 16 Health and Personal CareThe intended outcomes for the following set of standards are: · · · · · The service users health, personal and social care needs are set out in an individual plan of care. Service users make decisions about their lives with assistance as needed. Service users, where appropriate, are responsible for their own medication, and are protected by the homes 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.Standard 7 (7.1 ­ 7.6) A service user plan of care generated from a comprehensive assessment (see Standard 3) is drawn up with each service user and provides the basis for the care to be delivered. 4 Key findings/Evidence Standard met? The care plans sampled at inspection were found to be very comprehensive and included an excellent social history written by service users next of kin which gave a good insight into childhood and the past life to assist staffs insight and understanding of service users. Care plans sampled also included comprehensive daily notes from staff, diet intake, three monthly weights, urinalysis and blood pressure readings evidence and regular visits from the local doctor plus other medical professionals, dentist opticians, dentist and district nurse. Key workers review care plans monthly and sign the notes. The care plans for a residential home were excellent. Standard 8 (8.1 ­ 8.13) The registered person promotes and maintains service users health and ensures access to health care services to meet assessed needs. No. of incidents where service users have been taken to Accident and Emergency during last 12 months No. of service users with pressure sores at time of inspection (from information taken from care notes) 9 13 Key findings/Evidence Standard met? All service users at inspection appeared to be very well cared for and only one service user had a pressure sore, which was obtained in hospital prior to admission to Dudbrook. The home provides airflow mattresses and the visiting district nurse stated, care staff are proactive in trying to prevent pressure sores. The district nurse stated I have been visiting the home for 8 years and service users are generally very well cared for. The homes hygiene is good and staff are good.Dudbrook HallPage 17 Standard 9 (9.1 ­ 9.11) The registered person ensures that there is a policy and staff adhere to the procedures for the receipt, recording, storage, handling administration and disposal of medicines, and service users are able to take responsibility for their own medication if they wish, within a risk management framework. 3 Key findings/Evidence Standard Met? Medication was not inspected on this occasion as this was inspected earlier in the year and records showed medication and administration was completed appropriately. The deputy manager stated Boots chemist had completed medication inspections for the home recently with nil anomalies found. Since the previous inspection the thermometer to record the medication store room has been moved from the BT exchange box in the store cupboard to the wall surface and temperature recordings since then have been checked weekly and been below 25Centegrade, in line with the royal pharmaceutical and manufactures guidelines. Therefore this standard is met. Standard 10 (10.1 ­ 10.7) The arrangements for health and personal care ensure that service users privacy and dignity are respected at all times, and with particular regard to: personal care giving, including nursing, bathing, washing, using the toilet or commode, consultation with, and examination by, health and social care professionals, consultation with legal and financial advisors, maintaining social contacts with relatives and friends, entering bedrooms, toilets and bathrooms, and following death. 3 Key findings/Evidence Standard met? All service users spoken to at inspection were complementary of the staff and the management of the home and communication between staff and service users was observed to be respectful and very positive. The registered manager and her staff appeared to have a good knowledge of individual service users and the atmosphere was very happy in the home. Service users looked well cared for and dressed appropriately. Privacy is respected and one service user had his own shed in the garden for his own personal use to sit and sleep in during the summer days. Service users have telephone sockets in their rooms and may request a phone to be installed to take calls in private or use the home call box located in the hall.Standard 11 (11.1 ­ 11.12). Care and comfort are given to service users who are dying, their death is handled with dignity and propriety, and their spiritual needs, rites and functions observed. 3 Key findings/Evidence Standard met? Service users and their relatives are asked about their wishes, needs and spiritual needs regarding illness and death when completing initial assessments with records kept on file. Service users have access to any religious or spiritual need and are given full support from staff regarding their needs.Dudbrook HallPage 18 Daily Life and Social ActivitiesThe intended outcomes for the following set of standards are: · · · · 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.Standard 12 (12.1 ­ 12.4) The routines of daily living and activities made available are flexible and varied to suit service users expectations, preferences and capacities. 2 Key findings/Evidence Standard met? The home tries very hard to meet the needs of service users in the home with regard to lifestyles and activities but because of the large number of service users and their range of ability it is understood by the inspector that the range does not please all service users all the time. Many service users were happy with the limited range of activities in the home but a few service users stated they would like to go out more to get fresh air a couple of hours week. The home relies on relatives and volunteers to take service users out, as staffing numbers are not always sufficient to cover escorting and covering care in the home. The home has not had an activities coordinator for some time and this has further impacted on lack of activities arranged for service users, but a new activities coordinator has recently been recruited and will start work following checks. The home has a programme of activities in the home every afternoon which include weekly exercise classes, musical movements, musical quizzes, sing a long, board games and bean bag throwing. During inspection service users enjoyed listening to music and each communal area had a TV installed. The home has registered vehicle to transport service users to the shops and appointments. There is no public transport or shops within walking distance to the home. One relative stated It would be nice if service users could be taken to the shops once a week, so they could purchase items and just get out. One service users stated she had not been outside for three weeks and another stated would like to go out more but wife does not like to go out much another stated I like to go to Southend for the day and one staff member stated we need an activities lady as service user get bored. One gentleman who was a retired tree surgeon was seen to love being in the garden during inspection. The deputy manager ensured he was warm and protected from the weather.Dudbrook HallPage 19 Standard 13 (13.1 ­ 13.6) Service users are able to have visitors at any reasonable time and links with the local community are developed and/or maintained in accordance with service users preferences. 3 Key findings/Evidence Standard met? Relatives and service users confirmed they are able to have visitors at any time but prefer visitors to avoid meal times if possible. At inspection it was noted despite the lack of public transport service users received visitors throughout the day to take them out. The religious minister and priest visit the home weekly but the home does not have many links with the local community. This may be due to the location of the home. Standard 14 (14.1 ­ 14.5) The registered person conducts the home so as to maximise service users capacity to exercise personal autonomy and choice. 3 Key findings/Evidence Standard met? The deputy manager appeared proactive to ensure service users capacity to exercise personal autonomy is upheld and minutes of residents meeting evidenced service users are asked their opinions and wishes which are taken into account. At inspection one gentleman asked the deputy manager to arrange to have his dogs hair cut and groomed. The deputy manager was seen to act on his wishes willingly. Staff were also seen to encourage service users to take part in activities in the afternoon of the inspection and respect their wishes when they refused. This is good practice. Standard 15 (15.1 ­ 15.9) The registered person ensures that service users receive a varied, appealing, wholesome and nutritious diet, which is suited to individual, assessed and recorded requirements, and that meals are taken in a congenial setting and at flexible times. 3 Key findings/Evidence Standard met? The home offers a varied and appealing menu, which includes fresh vegetables. Food served at inspection was nutritious and service users are given a choice. All service users spoken to were complimentary of the food serviced in the home with the exception of one service users who stated she did not like the sandwiches served Saturday, Sunday and Tuesday evening as she would prefer a warm meal. The inspector sat with service users during their meal and one lady enjoyed her meal and took some back to her room to drink with her Guinness. Daily diet intake is recorded for all service users and staff were seen to assist less able service users eat their meal in a dignified and respectful manner. Minutes of residents meeting confirmed service users are consulted about likes and dislikes with regard to menus. The homes midday meals are prepared at Howard Lodge and transported to the home on heated trolleys served in the home by the kitchen assistance.Dudbrook HallPage 20 Complaints and ProtectionThe intended outcomes for the following set of standards are: · · · 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.Standard 16 (16.1 ­ 16.4) The registered person ensures that there is a simple, clear and accessible complaints procedure which includes the stages and time-scales for the process, and that complaints are dealt with promptly and effectively. No. of complaints made to the home during last 12 months No. of these complaints fully substantiated No. of these complaints partly substantiated No. of these complaints not substantiated No. of these complaints not yet resolved No. of complaints sent direct to CSCI Percentage of complaints responded to within 28 days 1 0 1 0 0 0 0 3 Key findings/Evidence Standard met? The deputy manager in a swift and efficient manner responded to one complaint received by the home from a relative. Records evidenced this was dealt with appropriately and followed up with a phone call to ensure the outcome was satisfactory. This is good practice. A copy of the statement of purpose in some service users room included details of how to complain including the appropriate contact details of the CSCI.Dudbrook HallPage 21 Standard 17 (17.1 ­ 17.3) Service users have their legal rights protected, are enabled to exercise their legal rights directly and participate in the civic process if they wish. 3 Key findings/Evidence Standard met? All service users in the home are encouraged to vote and some service users manage their own personal money and finances whilst relatives or next of kin deal with the majority.Standard 18 (18.1 ­ 18.6) The registered person ensures that service users are safeguarded from physical, financial or material, psychological or sexual abuse, neglect, discriminatory abuse or self harm, inhuman or degrading treatment, through deliberate intent, negligence or ignorance, in accordance with written policies. The home has an Adult Protection procedure (including Whistle Blowing) which complies with the Public Disclosure Act 1998 and the Department of Health Guidance No Secrets No. of staff referred for inclusion on POVA lists YES 03 Key findings/Evidence Standard met? The home has an appropriate policy and procedure for protection of vulnerable adults and whistle blowing. Staff spoken to at inspection were aware of the signs of types of abuse and conversant with the procedures of reporting abuse, although they were not all aware of how to contact the CSCI in any event to report an incident although the homes statement of purpose and service users guide included these details.Dudbrook HallPage 22 EnvironmentThe intended outcomes for the following set of standards are: · · · · · · · · 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.Standard 19 (19.1 ­ 19.6) The location and layout of the home is suitable for its stated purpose; it is accessible, safe and well maintained; meets service users individual and collective needs in a comfortable and homely way and has been designed with reference to relevant guidance. 3 Key findings/Evidence Standard met? Dudbrook Hall is a large detached property set in beautiful grounds in a rural area five miles from Bentwood Essex. The home is set in its own grounds and retains many fine original features. The home is maintained internally to a good standard although some parts of the home do require redecoration and repair to wall surfaces and flooring. The home is welcoming, bright clean, comfortable and meets the needs of service users accommodated in the home. The home has beautiful gardens, which are maintained by a full time gardener and one service user has his own shed in the garden. The home has a memorial garden dedicated to Princess Diana. The home is not within easy access to public transport, shops or public amenities but has the benefit of a fully licensed and insured vehicle to transport service users to medical appointments, shops or day trips. Standard 20. (20.1 ­ 20.7) In all newly built homes and first time registrations the home provides sitting, recreational and dining space (referred to collectively as communal space) apart from service users private accommodation and excluding corridors and entrance hall amounting to at least 4.1 sq. metres for each service user. 3 Key findings/Evidence Standard met? All home benefits from ample communal seating areas and a dining room, which are decorated well and conformable. The carpet of the stairs leading to the administrators office was of good quality but stained. Service users do not use this part of the home.Dudbrook HallPage 23 Standard 21 (21.1 ­ 21.8) Toilet, washing and bathing facilities are provided to meet the needs of service users. 3 Key findings/Evidence Standard met? The home has recently added another bathroom to the first floor so now has five bathrooms and seven WC in addition to en suites.Standard 22 (22.1 ­ 22.8) The registered person demonstrates that an assessment of the premises and facilities has been made by suitably qualified persons, including a qualified occupational therapist, with specialist knowledge of the client groups catered for, and provides evidence that the recommended disability equipment has been secured or provided and environmental adaptations made to meet the needs of service users. 3 Key findings/Evidence Standard met? The home has ramps and a passenger lift accessible to wheel chair users with corridors wide enough to allow easy access. At inspection the home appeared adequate to meet the needs of the client group in the home in respect of disability equipment and adoptions. The home has assisted baths, raised toilet seats with handrails. Paintwork in corridors and on doors was in some parts of the home chipped. The home has an effective call bell system, which was seen to be working effectively, and one service user stated staff always come whenever called.Dudbrook HallPage 24 Standard 23 (23.1 ­ 23.11) The home provides accommodation for each service user which meets minimum space as prescribed Total number of single bedrooms with at least 10 sq.m usable space or additional compensatory space Pre-existing homes only (1 April 2003) - single bedrooms below 10 sq.m usable space or additional compensatory space Total number of wheelchair users accommodated for in rooms at least 12sq.m Total number of wheelchair users accommodated for in rooms at less than 12sq.m Total number of shared rooms at least 16 sq.m Total number shared rooms less than 16 sq.m Percentage of places within single rooms: 100 80 - 99 Less than 80 Total number of single bedrooms Total number of single rooms with en suite Total number of double rooms Total number of double rooms with en suite NO YES NO 16 24 1 0 3 36 30 0 1 0Key findings/Evidence Standard met? All the components of this standard were met at inspection. Appropriate screening is provided in a shared bedroom.Dudbrook HallPage 25 Standard 24 (24.1 ­ 24.8) The home provides private accommodation for each service user which is furnished and equipped to assure comfort and privacy, and meets the assessed needs of the service user. 3 Key findings/Evidence Standard met? The home provides private accommodation for service users, which is comfortable and contains good quality furniture, adequate overhead lighting, and soft furnishing. Rooms 27, 7,6,7 and 41 had recently been decorated and room 26 was decorated to a high standard but room 20 was found to have an offensive odour with wallpaper coming away from the wall. The carpet had a small hole in which had been fixed down but was beginning to lift and the potential to be a trip hazard. All bedrooms were personalised and clean and tidy and service users had locks to their rooms.Standard 25 (25.1 ­ 25 8) The heating, lighting, water supply and ventilation of service users accommodation meet the relevant environmental health and safety requirements and the needs of individual service users. 2 Key findings/Evidence Standard met? The home has a maintained and renewal programme and employs two handy persons/ drivers to maintain and carry out relevant work on the home. Staff and the deputy manager record in the maintenance book any work, which need to be completed. The home has adequate heating, lighting and ventilation to meet the needs of service users. The home must ensure the home is maintained to ensure the health and safely requirements and needs of individual service users. This refers to carpets, flooring and the maintenance of individual service users bedrooms. Standard 26 (26.1 ­ 26.9) The premises are kept clean, hygienic and free from offensive odours throughout and systems are in place to control the spread of infection, in accordance with relevant legislation and published professional guidance. 3 Key findings/Evidence Standard met? At inspection all parts of the home were clean, hygienic and free from offensive odours with the exception of one bedroom. Staff were observed to wear appropriate clothing and disposable gloves when dealing with personal care and the laundry. The laundry area was clean and washing machines included a sluice facility. The kitchen was clean and tidy at inspection. It is recommended that suitable flooring be fitted in room 20 to eliminate an offensive odour.Dudbrook HallPage 26 StaffingThe intended outcomes for the following set of standards are: · · · · 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 homes recruitment policy and practices. Staff are trained and competent to do their jobs.Standard 27 (27.1 ­ 27.7) Staffing numbers and skill mix of qualified/unqualified staff are appropriate to the assessed need of the service users, the size, the layout and purpose of the home, at all times. Number of staff /hours in respect of service user needs based on guidance recommended by Department of Health. Personal Nursing Care No. service users High No. staff hours 1 20 X needs allocated No. service users Medium needs No. service users Low needs No. of staff hours required No. of full time equivalent first level registered nurses No. of care staff No. of ancillary staff 2 35 817.9 No. staff hours allocated No. staff hours allocated No. of staff hours provided 36 684 817.9 X X X1 26 143 Key findings/Evidence Standard met? The home at inspection appeared to have sufficient staff numbers to meet the needs of service users in the home. The home employs 8 care staff in the morning five in the afternoon and three care staff at night in addition to domestic staff. The home has an experienced core staff that understand the needs of service users accommodated. The staff were seen to work hard and communicate respectfully and positively towards service users during inspection.Dudbrook HallPage 27 Standard 28 (28.1 ­ 28.3) A minimum ratio of 50 trained members of care staff (NVQ Level 2 or equivalent) is achieved by 2005, excluding the registered manager and/or care manager, and in care homes providing nursing, excluding those members of the care staff who are registered nurses. No. care staff (excluding registered nurses) with NVQ level 2 or equivalent of care staff with NVQ level 2 4 20 3 Key findings/Evidence Standard met? There are currently 9 care staff in the home undertaking training in NVQ level 2 and five care staff have obtained first aid certificates. The home has five staff members who have completed first aid training and ensure there is one member of staff on duty at all times who is qualified in first aid. The home should ensure 50 of care staff have obtained NVQ level 2 by 2005. This is a repeat recommendation. Standard 29 (29.1 ­ 29.6) The registered person operates a thorough recruitment procedure based on equal opportunities and ensuring the protection of service users. 3 Key findings/Evidence Standard met? The homes deputy manager evidenced the home has a thorough recruitment process based on equal opportunities and sampled files confirmed the home seeks appropriate checks and obtains proof of identification for all new staff and appropriate procedures are now in place for checking agency staff employed in the home. Files contained interview notes, checklists, completed and signed application forms and two references. This is good practice. Standard 30 (30.1 ­ 30.4) The registered person ensures that there is a staff training and development programme which meets the National Training Organisation (NTO) workforce training targets and ensures staff fulfil the aims of the home and meet the changing needs of service users. 3 Key findings/Evidence Standard met? Staff files examined evidenced staff receive appropriate induction training although one induction file was not completed for one staff member who was recruited two years ago. The home arrange health and safety and relevant care of the elderly training for staff.Dudbrook HallPage 28 Management and AdministrationThe intended outcomes for the following set of standards are: · · · · · · · · 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 homes record keeping policies and procedures. The health, safety and welfare of service users and staff are promoted and protected.Standard 31 (31.1 ­ 31.8) The registered manager is qualified, competent and experienced to run the home and meet its stated purpose, aims and objectives. 3 Key findings/Evidence Standard met? At inspection the deputy manager appeared very competent and experienced in management and running the home and able to effectively discharge her responsibilities to her staff team. The deputy manager has completed BTEC Advanced Management in Care and may have the equivalent qualification to NVQ level 4 in Care Management. At inspection this was discussed with the inspector and the deputy manager took action to contact her local university or college for further advise. Advice was also given regarding her application for a manager of the home. The deputy manager is currently undertaking the Registered Managers award. The deputy manager was very efficient during inspection and had prepared thoroughly for the inspection. It was noted the deputy manager was kind, caring and of good character respected by service users and her staff. Staff confirmed the deputy manager was very supportive and during discussion it was observed the deputy manager was aware of her limitations but had an excellent network of support from the registered provider, registered manager at Howard Lodge and occasionally from the director of care at the Marillac Brentwood. This is good practice.Dudbrook HallPage 29 Standard 32 (32.1 ­ 32.7) The registered manager ensures that the management approach of the home creates an open, positive and inclusive atmosphere. 3 Key findings/Evidence Standard met? The management approach appeared open positive and inclusive with files examined of minutes of resident and staff meetings confirming opinions are sought from service users and staff and acknowledged by the management.Standard 33 (33.1 ­ 33.10) Effective quality assurance and quality monitoring systems, based on seeking the views of service users, are in place to measure success in meeting the aims, objectives and the statement of purpose of the home. 4 Key findings/Evidence Standard met? The home has produced an effective quality assurance and monitoring system in June 2004, which was clear highlighting issues for improvement in the home. A report was seen at inspection and the deputy manager was congratulated for this piece of work, which included service users, relatives and significant other input.Standard 34 (34.1 ­ 34.5) Suitable accounting and financial procedures are adopted to demonstrate current financial viability and to ensure there is effective and efficient management of the business. 0 Key findings/Evidence Standard met? This standard was not inspected on this occasion.Dudbrook HallPage 30 Standard 35 (35.1 ­ 35.6) The registered manager ensures that service users control their own money except where they state that they do not wish to or they lack capacity and that safeguards are in place to protect the interests of the service user. Number of service users subject to Power of Attorney processes Number of service users subject to Enduring Power of Attorney processes Number of service users subject to Guardianship Orders 18 0 13 Key findings/Evidence Standard met? The home does not look after any service users valuables or personal money. If service users wish to buy items the home will purchase them and bill the service user or relative.Standard 36 (36.1 ­ 36.5) The registered person ensures that the employment policies and procedures adopted by the home and its induction, training and supervision arrangements are put into practice. 3 Key findings/Evidence Standard met? Sampled files confirmed senior care works and the managers provide informal regular supervision and appraisals for all staff working in the home. Staff policies and procedures were sampled and seen to be updated in 2003 which included policies for independent advice i.e. age concern, religious group visits, infection control, including pets in the home, POVA and COSHHE. Standard 37 (37.1 ­ 37.3) Records required by regulation for the protection of service users and for the effective and efficient running of the business are maintained, up to date and accurate. 3 Key findings/Evidence Standard met? Records examined at inspection were well maintained highlighted else where in the inspection report. The home records the number of accidents, incident, infringement, complaints and compliments. Service users records are kept secure in the home and visitors are requested to sign in and out to ensure security and protection.Dudbrook HallPage 31 Standard 38 (38.1 ­ 38.9) The registered manager ensures so far as is reasonably practicable the health, safety and welfare of service users and staff. 3 Key findings/Evidence Standard met? The following files were examined and found to be in order and in date: The homes maintenance schedule, health and safety checks for fire door alarms, fire extinguishers, gas service records, cold water storage, electrical and building service record, yearly asbestos check, monthly pest control check and appropriate certificate of insurance and homes registration displayed, The home has recently had three new fire extinguishes replaced.Dudbrook HallPage 32 PART C(where applicable)COMPLIANCE WITH CONDITIONSCondition Care Home CommentsComplianceYESCondition Old Age not falling within any other category. CommentsComplianceYESCondition Dementia over 65 years of age (20 places only)ComplianceYESComments The home currently accommodates more that 20 service users with dementia as many of the service users in the home have now developed dementia since living in the home.Condition Places 41 CommentsComplianceYESLead Inspector Second Inspector Regulation Manager DatePatricia StantonSignature Signature SignatureDudbrook HallPage 33 Public reports It should be noted that all CSCI inspection reports are public documents.Dudbrook HallPage 34 PART DD.1PROVIDERS RESPONSE TO IDENTIFIED STATUTORY REQUIREMENTSRegistered Persons comments/confirmation relating to the content and accuracy of the report for the above inspection.We would welcome comments on the content of this report relating to the Inspection conducted on 12th October 2004 and any factual inaccuracies: Please limit your comments to one side of A4 if possible Providers comments available at South Essex Local Office on request.Dudbrook HallPage 35 Action taken by the CSCI in response to provider comments: Amendments to the report were necessary YESComments were received from the provider Provider comments/factual amendments were incorporated into the final inspection report Provider comments are available on file at the Area Office but have not been incorporated into the final inspection report. The inspector believes the report to be factually accurateYESYESNONote: In instances where there is a major difference of view between the Inspector and the Registered Provider both views will be made available on request to the Area Office. D.2 Please provide the Commission with a written Action Plan by , which indicates how requirements are to be addressed and stating a clear timescale for completion. This will be kept on file and made available on request. You will also note that the Commission has identified in the inspection report good practice recommendations and it would be useful to have some indication as to whether you intend to take any action to progress these. Status of the Providers Action Plan at time of publication of the final inspection report: Action plan was required YESAction plan was received at the point of publicationYESAction plan covers all the statutory requirements in a timely fashion Action plan did not cover all the statutory requirements and required further discussion Provider has declined to provide an action planYESOther: enter details here Dudbrook HallPage 36 D.3PROVIDERS AGREEMENT Registered Persons statement of agreement/comments: Please complete the relevant section that applies.D.3.1 I of confirm that the contents of this report are a fair and accurate representation of the facts relating to the inspection conducted on the above date(s) and that I agree with the requirements made and will seek to comply with these. Print Name Signature Designation Date Or D.3.2 I of am unable to confirm that the contents of this report are a fair and accurate representation of the facts relating to the inspection conducted on the above date(s) for the following reasons: Registered Provider/Manager 16/11/04 C B WATSONPrint Name Signature Designation Date Note: In instance where there is a profound difference of view between the Inspector and the Registered Provider both views will be reported. Please attach any extra pages, as applicable.Dudbrook HallPage 37 Dudbrook Hall / 12th October 2004Commission for Social Care Inspection 33 Greycoat Street London SW1P 2QF Telephone: 020 7979 2000 Fax: 020 7979 2111 National Enquiry Line: 0845 015 0120 www.csci.org.ukS0000018032.V178814.R01© This report may only be used in its entirety. 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