Inspection on 27/02/06 for Dudbrook Hall

This inspection was carried out on 27th February 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Dudbrook Hall 12/01/07

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 Patricia Stanton Unannounced Inspection 27th February 2006 11.00 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Dudbrook Hall DS0000018032.V265386.R01.S.doc Version 5.0 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.V265386.R01.S.doc Version 5.0 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.V265386.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 5th July 2005 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 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 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. Conditions of registration - Care Home, old age not falling into any other category. Dementia of 65 of age (20 places only) Places 41. Dudbrook Hall DS0000018032.V265386.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The routine unannounced inspection took place on the 27/2/2006. Records and documents were looked at, including the previous requirements and recommendations from the last inspection. Time was spent in the lounge and dining room chatting and taking note of residents daily routine in the home. Eight residents, two staff members, the registered provider and one senior carer were all spoken to and were most helpful in particular the senior carer. This was greatly appreciated. The inspector would like to thank residents and all the staff at Dudbrook Hall for their time and cooperation during inspection. What the service does well: What has improved since the last inspection? What they could do better: The home could offer alternative hot meals to residents who do not wish to eat the meal provided. Medication procedures and care plan information could be improved. Staff recruitment need to be more robust. Dudbrook Hall DS0000018032.V265386.R01.S.doc Version 5.0 Page 6 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. Dudbrook Hall DS0000018032.V265386.R01.S.doc Version 5.0 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.V265386.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6. The home is not registered for respite care. EVIDENCE: No residents were accommodated at inspection for respite care. Dudbrook Hall DS0000018032.V265386.R01.S.doc Version 5.0 Page 9 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9. Residents’ health and social care needs are met. Medication and administration procedures plus care plans could be improved. EVIDENCE: One daily care plan recording was comprehensive including all relevant information regarding care and possible risk but did not give information regarding the resident’s mood or happiness. The care plan described the resident’s day with regard to eating, health, care and sleep only. The same care plan had a dependency assessment completed with no score or details of the resident’s personal history and personal possessions on admission. Care plans evidenced reviews are completed regularly and residents appeared happy, healthy, nourished and well cared for. Medication stocks were examined and the number of controlled drugs for one resident not correct. The medication for Diazepam 5mg prescribed was not recorded in the homes controlled drug book and the MARS sheet number did not correspond to the amount of stock counted at inspection by two persons. Dudbrook Hall DS0000018032.V265386.R01.S.doc Version 5.0 Page 10 One of the residents MARS sheet did not give details of when the medication was to start or finish and stock balance records did not correspond to the amounts dispensed. It was noted the controlled drug book used by the home was not bound with page numbers and pages may be misplaced. Dudbrook Hall DS0000018032.V265386.R01.S.doc Version 5.0 Page 11 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15. Activities in the home have improved and residents maintain good relationships and contact with relatives and friends. The quality of food provided in the home is of good quality but more choice could be offered for main meals. EVIDENCE: Since the last inspection activities in the home have improved for residents. The acting manager had purchased extra games, which stimulate the senses of residents. Staff were observed to participate in activities with residents at inspection. Records evidenced relatives visit frequently to take residents out. Staff take residents for walks and to appropriate appointments and days out. The food in the home is off good quality meals provided at inspection were fresh. Residents appeared to enjoy mealtimes but one lady who refused her meal at the last inspection refused her meal again and was not offered an alternative meal. It was noted the menu contained only one option for residents but the resident stated she could request a sandwich but only wanted a dessert. All other residents appeared happy with the meal provided. Drinks were seen to be readily available to all residents. Dudbrook Hall DS0000018032.V265386.R01.S.doc Version 5.0 Page 12 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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 The home has received no complaints. Residents are protected from abuse. EVIDENCE: Since the last inspection the home has received no complaints but two complements and a donation from a relative in gratitude for the excellent care received. Staff in the home record all incidents comprehensively but records examined confirmed staff do not always number or record the time of incident. All staff undertake protection of vulnerable adults training and aware of the signs of abuse and the procedures for reporting abuse. Dudbrook Hall DS0000018032.V265386.R01.S.doc Version 5.0 Page 13 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19 The home is safe and well maintained. EVIDENCE: The home carries out regular health and safety checks and is maintained to a high standard. Since the last inspection the home has had some redecoration and new windows fitted making it more homely and bright. The home employs a handyman to carry out all minor repairs in the home. Dudbrook Hall DS0000018032.V265386.R01.S.doc Version 5.0 Page 14 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 29. Staff numbers meet the needs of residents but staff recruitments checks could be improved. EVIDENCE: The number of staff on duty matched the numbers of staff working in the home and appeared sufficient to meet the needs of residents. One resident who was unwell at inspection was observed to receive extra attention and care from staff who were very kind and caring. Staff files confirmed one check had not been obtained prior to the person working in the home unsupervised and two references seen were not on headed notepaper with the details of the referees contact details. One file had no application form to evidence staff past employment history or gaps in employment. Dudbrook Hall DS0000018032.V265386.R01.S.doc Version 5.0 Page 15 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 35. The registered manager and acting manager have the appropriate experience and qualification to manage the home. Residents’ financial interests are safeguarded. EVIDENCE: The acting manager is currently undertaking NVQ level 4 registered managers award and is fit to be in charge, experienced of good character able to discharge her responsibilities fully to her staff team. Staff meetings evidenced staff are able to approach the manager to give their views and opinions and low staff turnover demonstrated the stability of the staff team. Staff spoken to stated how they enjoyed working in the home. No evidence was seen to suspect residents’ finances are not safeguarded. Dudbrook Hall DS0000018032.V265386.R01.S.doc Version 5.0 Page 16 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 X X X X X 3 HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 X 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X X X X STAFFING Standard No Score 27 3 28 X 29 2 30 X MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X X X 3 X X X Dudbrook Hall DS0000018032.V265386.R01.S.doc Version 5.0 Page 17 no Are there any outstanding requirements from the last inspection? 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 OP29 Regulation 19 1c Sch2 Requirement The home must ensure staff recruitment is robust. This refers to obtaining suitable checks before staff are employed in the home. The home must ensure suitable arrangements are made for the recording, handling, storage, administration and disposal of medicines in the home. This refers to controlled medication stocks. Senior managers should carry out regular medication audit checks. Timescale for action 01/04/06 2 OP9 13 (2) 01/03/06 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 Refer to Standard OP9 OP16 Good Practice Recommendations The home should obtain a bound book for recording controlled drug stocks. Incidents should be numbered with time of incident. DS0000018032.V265386.R01.S.doc Version 5.0 Page 18 Dudbrook Hall 3 5 OP7 OP29 Records of residents’ emotional mood, past social history, possessions on admission and dependency scoring levels should be completed. All staff files should be updated to include details required by this standard. Dudbrook Hall DS0000018032.V265386.R01.S.doc Version 5.0 Page 19 Commission for Social Care Inspection South Essex Local Office Kingswood House Baxter Avenue Southend on Sea Essex SS2 6BG National Enquiry Line: 0845 015 0120 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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