Inspection on 05/07/05 for Dudbrook Hall

This inspection was carried out on 5th July 2005.

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 27/02/06

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 05 July 2005 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 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 v223179 i56-i06-s18032-dudbrook hall-v223179230505-stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Dudbrook Hall Address Dudbrook Road, Kelvedon Common, Brentwood, Essex, CM14 5TQ Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 01277 372095 01277 375297 Sainthomes.co.uk St Michaels Homes Limited Mrs Cecilia Watson CRH 41 Category(ies) of 41 OP Old age, 20 DE(E) Dementia over 65 registration, with number of places Dudbrook Hall v223179 i56-i06-s18032-dudbrook hall-v223179230505-stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: Care Home, old age not falling into any other category. Dementia of 65 of age (20 places only) Places 41. Date of last inspection 21/1/05 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. Dudbrook Hall v223179 i56-i06-s18032-dudbrook hall-v223179230505-stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The routine unannounced inspection took place on the 5/7/2005. During the inspection a tour of the premises and records and documents were looked at, including the previous requirements and recommendations from the last inspection. Time was spent in the lounge, dining room and residents bedrooms, chatting and taking notes with nine residents about the daily routine in the home. The residents staff and in particularly the acting manager on duty were most helpful, and this was greatly appreciated. What the service does well: What has improved since the last inspection? What they could do better: Dudbrook Hall v223179 i56-i06-s18032-dudbrook hall-v223179230505-stage 4.doc Version 1.30 Page 6 The home does not always ensure a relevant persons complete references for staff and that all checks are on file for staff employed in the home. 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 v223179 i56-i06-s18032-dudbrook hall-v223179230505-stage 4.doc Version 1.30 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 Standards Statutory Requirements Identified During the Inspection Dudbrook Hall v223179 i56-i06-s18032-dudbrook hall-v223179230505-stage 4.doc Version 1.30 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 standard(s) 3,4,5. Residents do not move into the home without having their needs assessed and without knowing the home can meet their needs. Residents and their relatives have the opportunity to visit and assess the quality of the home to ensure the facilities are suitable. EVIDENCE: The acting manager stated she likes to visits residents in their own homes to carry out assessments. Sampled files evidenced a full pre assessment is completed by the managers prior to admission. The assessments included the Strasbourg dependency test to determine dependency levels of residents and details of residents’ wishes in relation to social needs. Files confirmed residents and their relatives are involved in the assessments and residents confirmed they were able to visit the home prior to moving in to test drive the facilities. Dudbrook Hall v223179 i56-i06-s18032-dudbrook hall-v223179230505-stage 4.doc Version 1.30 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 standard(s) 7,8,9,10,11. Residents’ needs in respect of health, personal care and social needs, are set out in detailed individual, care plans. Residents’ are treated with respect and their right to privacy upheld. Care plans included residents wishes in relation to death and dying. The home seeks approved medication inspections to protect the homes residents. EVIDENCE: Daily record evidenced residents have visit from the local general practitioner, district nurse, opticians and other medical specialists. Residents confirmed at inspection how kind, and lovely the staff were in assisting them with personal care. One resident stated “ I had swollen legs and the home took my blood pressure straight away and contacted the doctor. By the evening I had been given extra medication for my blood pressure. You can see I am contented, the carers will do anything for me.” Other residents stated the “staff are very good, you can do as you like, staff are very nice, helpful and kind.” File confirmed the district nurse was attending the home daily to see one resident. Dudbrook Hall v223179 i56-i06-s18032-dudbrook hall-v223179230505-stage 4.doc Version 1.30 Page 10 Staff were observed to treat residents with respect and dignity at inspection and care plans included residents wishes in relation to illness, death and dying including terminal illness and special requests. At inspection the home was undergoing an inspection by a Boots approved pharmacist. The report confirmed no errors were found. Care plans also confirmed residents and their families are included in reviews. Reviews sampled were very informative and confirmed residents and relatives are involved. The acting manager reviews residents care monthly and risk assessments were up to date and relevant to individuals, giving staff clear instructions regarding care needs. Dudbrook Hall v223179 i56-i06-s18032-dudbrook hall-v223179230505-stage 4.doc Version 1.30 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 standard(s) 12,13,14,15. Residents find the lifestyle experienced in the home matches their expectations and satisfies their social, cultural, religious and recreational needs. Residents maintain close contact with their relatives who are included, as much as possible by the homes staff. Staff encourages residents to exercise choice and control over their lives. Residents receive a wholesome appealing balanced diet in pleasing surroundings. EVIDENCE: Residents spoken to at inspection all stated how they enjoyed living in the home and how facilities met their individual needs. Residents are able to visit church of different religions and participate in recreational activities arranged by the home. The home employs a craft person who comes into the home twice a week to encourage residents to participate in craft activities. Residents were seen knitting and reading daily newspapers. Age appropriate music was playing in communal areas and carers encourage residents to engage in activities including going out for walks, playing games, visiting a neighbouring care home and occasional days out. The home arranges fetes, entertainers to visit the home, a visiting petting dog and a mobile library. Dudbrook Hall v223179 i56-i06-s18032-dudbrook hall-v223179230505-stage 4.doc Version 1.30 Page 12 Relatives are encouraged to take residents out for days out and to volunteer to go with staff on trips out. Activities are recorded daily for residents to evidence residents participation. Some residents do not wish to participate so the staff allows residents to make their own decisions. Care plans also evidenced residents are involved in planning care and they are able to give their views and opinions in residents meetings. One resident stated she was not sleeping very well due to her mattress. The home took action to change her mattress and arranged for the resident to see a doctor. Care plans confirmed the resident had slept better since her mattress was changed. Dudbrook Hall v223179 i56-i06-s18032-dudbrook hall-v223179230505-stage 4.doc Version 1.30 Page 13 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 standard(s) 16,17,18. Residents and relatives can be confident their complaints would be listened to and taken seriously. Residents’ legal rights are protected and residents are protected from abuse. EVIDENCE: Care plans confirmed residents and their relatives are advised how to make a complaint as part of the pre assessment process and given information regarding how to make a complaint in the service users guide. Records confirmed the home had not received any complaints this year. Residents are encouraged to vote via the postal system and staff completed protection of vulnerable adults training to ensure residents are protected from any forms of abuse. The home has an appropriate policy regarding protection of vulnerable adults. Files confirmed when one resident informed staff she got on well with most carers but found some not so patient she was advised by the manager to always notify her so she did not become upset. This is good practice. Other residents stated all staff in the home were very kind and caring. Dudbrook Hall v223179 i56-i06-s18032-dudbrook hall-v223179230505-stage 4.doc Version 1.30 Page 14 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 standard(s) 19,20,21,22,23,24,25,26. Residents live in a safe, well maintained home which is clean and hygienic. The home is safe and comfortable with sufficient lavatories and washing facilities. Residents have rooms to suit their needs and live in a safe environment. EVIDENCE: Dudbrook Hall is a beautiful country home set in lovely surroundings and countryside away from the main roads. The home provides transport for the home to take residents out and transports staff. The home is decorated to a good standard and appears conformable with adequate toilets and washing facilities for the number of residents accommodated. The home has adequate communal space and a very pleasant dining area which residents appeared to enjoy dining in. The homes handyperson/gardener maintains the homes gardens. At inspection some residents rooms had been decorated and a programme was planned to decorate others following inspection. Dudbrook Hall v223179 i56-i06-s18032-dudbrook hall-v223179230505-stage 4.doc Version 1.30 Page 15 Residents’ seen in their bedrooms were very happy with their rooms, which were personalised and decorated to a good standard. One resident was able to choose the colour of her room. Other residents’ rooms contained their own furniture and one resident bought in her own bed. The home is clean and hygienic and residents have access to large gardens and grounds which are maintained to a high standard. Residents are provided with suitable specialist equipment to aid mobility. The home had just purchased a new electric hoist to take resident to the bathroom. Dudbrook Hall v223179 i56-i06-s18032-dudbrook hall-v223179230505-stage 4.doc Version 1.30 Page 16 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27,28,29,30. Residents’ needs are met by the number of staff working in the home who are appropriately trained and competent to meet residents needs. EVIDENCE: Staff numbers appeared to meet the needs of residents at inspection and the home was fully staffed. The home ensures staff received appropriate training and records evidence staff complete thorough induction programmes and regular training on fire, health and safety issues. Other staff training included confidentiality, missing persons, aggression, accidents, care of the dying and orientation programmes. Staff files examined evidenced one staff member had not received back a CRB check but the acting manager took immediate action as the checks had been applied for but not on file. The home faxed through a copy of the check following inspection to the CSCI. Five staff members in the home have completed NVQ level 3 or above and another ten staff were undertaking NVQ and VTS training. This is good practice. Dudbrook Hall v223179 i56-i06-s18032-dudbrook hall-v223179230505-stage 4.doc Version 1.30 Page 17 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31,32,33,36,38. Residents live in a home which is run and managed by a person who is fit to be in charge and able to discharge responsibilities fully. The home is run in the best interest of residents who are safeguarded by the homes appropriate record keeping and health and safety checks. EVIDENCE: The acting manager runs the home in a competent and efficient manner and the registered manager/provider oversees all staff training and the homes financial records and attends the home three days per week. The acting manager has appropriate experience and is undertaking the registered managers award NVQ level 4 in September 2005. The acting manager manages the home while working with staff to ensure she is able to keep in touch with all residents needs. At inspection the communication between the acting manager and the residents and staff was mutually respectful positive and very supportive. Dudbrook Hall v223179 i56-i06-s18032-dudbrook hall-v223179230505-stage 4.doc Version 1.30 Page 18 The acting manager carries out all appraisal and supervision for staff but intends to delegate some of this responsibility to a team leader when completed a course in NVQ level 4. Staff files confirmed supervision is carried out regularly and care plans confirmed the acting manager reviews care regularly. Files confirmed an Environmental Health check was completed at the home on 8/6/05. No contraventions were found. Fire extinguishers were found to be in date and all fire safety checks had been carried out each week. Fire evacuations were completed regularly and recorded. The home does not need to complete regulation 26 visits as the registered provider is also the registered manager of the home. The inspector would like to thank residents, staff and the acting manager for their time and cooperation during the visit. Dudbrook Hall v223179 i56-i06-s18032-dudbrook hall-v223179230505-stage 4.doc Version 1.30 Page 19 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score x x 3 3 3 x HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION 3 3 3 3 3 3 3 3 STAFFING Standard No Score 27 3 28 3 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 3 3 3 3 3 x x 3 x 3 Dudbrook Hall v223179 i56-i06-s18032-dudbrook hall-v223179230505-stage 4.doc Version 1.30 Page 20 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 29 Regulation 19(1c) Sch 2 Requirement The home must ensure staff recruitment is robust. Timescale for action 01/07/05 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 31 Good Practice Recommendations The deputy manager who runs the home should apply for the registered managers position. Dudbrook Hall v223179 i56-i06-s18032-dudbrook hall-v223179230505-stage 4.doc Version 1.30 Page 21 Commission for Social Care Inspection 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. Extracts may not be used or reproduced without the express permission of CSCI Dudbrook Hall v223179 i56-i06-s18032-dudbrook hall-v223179230505-stage 4.doc Version 1.30 Page 22 - 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. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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