Inspection on 01/03/08 for Dudley Court Rest Home

This inspection was carried out on 1st March 2008.

CSCI found this care home to be providing an Good service.

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Dudley Court Rest Home 04/03/09

Dudley Court Rest Home 21/09/07

Dudley Court Rest Home 31/01/07

Dudley Court Rest Home 05/06/06

Dudley Court Rest Home 01/11/05

Dudley Court Rest Home 08/06/05

Dudley Court Rest Home 17/12/04

Dudley Court Rest Home 12/05/04

Dudley Court Rest Home 18/02/04

Dudley Court Rest Home 30/10/03

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Maple Lodge

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Bank House

Inspirations

Ashcroft Hollow Nursing Home

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

CARE HOMES FOR OLDER PEOPLE Dudley Court Rest Home 16 Dudley Park Road Acocks Green Birmingham West Midlands B27 6QR Lead Inspector Yvette Delaney Unannounced Inspection 1st 09:30 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Dudley Court Rest Home DS0000016864.V358555.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Dudley Court Rest Home DS0000016864.V358555.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Dudley Court Rest Home Address 16 Dudley Park Road Acocks Green Birmingham West Midlands B27 6QR 0121 706 3087 0121 706 3087 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) Mr Paresh Parmar Mrs Jill Lynette Durrant Care Home 22 Category(ies) of Old age, not falling within any other category registration, with number (22) of places Dudley Court Rest Home DS0000016864.V358555.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 21st September 2007 Brief Description of the Service: Dudley Court is a three storey residential service for twenty-two older adults. The home is situated near to a busy shopping centre in Acocks Green that can be accessed by local bus links to Birmingham and Solihull and Acocks Green Railway Station is within walking distance. It is also close to a variety of local churches of various denominations and the local library. There is a driveway with some space available for off road parking to the front of the premises. The ground floor consists of two lounges, a dining area and a conservatory providing residents with a choice of areas to sit. There are twelve single bedrooms, two of which have en-suite facilities on the ground floor, the first floor consists of seven single bedrooms and there are three bedrooms on the second floor. The remaining rooms have a wash hand basin and all areas have a call bell. There is a separate laundry area on the second floor. Four bathrooms with assisted baths including one that has a hoist are available throughout the premises. There are four toilets and one of these is a designated staff toilet. There is a passenger lift, which gives residents access to all floors. There is a pleasant garden to the rear of the property that has ramped access for residents who use wheelchairs plus seating for when the weather permits. Wheelchair access is also available to the front of the home. The proprietor has information about the services and facilities available in each bedroom. The fees are available on enquiry these do not include, toiletries, newspapers, chiropody or hairdressing. Dudley Court Rest Home DS0000016864.V358555.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 2 Star. This means the people who use this service experience good quality outcomes. The focus of inspections undertaken by us is upon outcomes for people who live in the home and their views of the service provided. This process considers the home’s capacity to meet regulatory requirements, minimum standards of practice and focuses on aspects of service provisions that need further development. A number of questionnaires were issued to residents, their families and staff working in the home on the day of the inspection to ask their views about the home. There was a very good return. Information contained within the surveys is included in this report where appropriate. Three people who were staying at the home were ‘case tracked’. The case tracking process involves establishing an individual’s experience of staying at the home, meeting or observing them, discussing their care with staff and relatives (where possible), looking at their care files and focusing on outcomes. Tracking people’s care helps us understand the experiences of people who use the service. The Owner of the home visited the home during the time of the inspection. Records examined during this inspection, in addition to care records, included staff training records, the Service User Guide, staff duty rotas, complaint records, health and safety records and medication records. Residents were observed during lunchtime to ascertain choices given and to view meals made available. A tour of the home was undertaken to view specific areas and establish the layout and décor of the home. What the service does well: Comments received from residents and relatives on what they felt that the home does well include: Dudley Court Rest Home DS0000016864.V358555.R01.S.doc Version 5.2 Page 6 “Dudley Court has a friendly, welcoming and warm atmosphere that gives the impression of being part of an extended family. On arrival at the door you are rarely not met with a smile and the offer of a cup of tea….” “…(Resident) is quite happy and I as a visitor, can say how good they are when we come. Always a welcome plus tea or coffee and biscuits.” “Staff very helpful, seem to cater for individual needs.” “Very caring staff.” “Dudley Court is a friendly welcome and homely place for the residents and I find the standards are consistent.” “I feel the home meets the needs of my relative.” “Dudley Court has exceeded the expectations of me, my brother and my daughter….” “Dudley Court has enabled my father to grow in confidence….” Residents and family members were very positive about the standard of service provided by the home. Visitors to the home are made to feel welcome. Care staff treat residents respectfully and are very knowledgeable about the people living in the home. There was very good interaction between residents and staff. Residents knew the staff and conversation between them was easy and relaxed. Food provided by the home is of a high standard and caters for resident’s likes and dislikes. A choice is available and staff were seen to provide residents with discrete support when needed. What has improved since the last inspection? The manager has addressed most of the requirements made at the last key inspection visit of September 2007. The management of medication administration has improved in the home, which will ensure residents are protected from harm and help to maintain their wellbeing. The contents of residents care files and care plans have started to improve to identify the specific care needs of individual people living in the home. This includes completion of risk assessments. Action plans provides details for care staff on how these care needs should be met. This will ensure that residents receive care appropriate to their needs. Dudley Court Rest Home DS0000016864.V358555.R01.S.doc Version 5.2 Page 7 The number of care staff that have attended training has increased. Topics covered include fire, manual handling and health and safety as well as other areas related to the specific needs of people living in the home. This will ensure that staff are knowledgeable about the care they are asked to give to people living in the home and help to protect residents from harm. The Statement of Purpose for the home has been reviewed and re-written to identify service provided by the home, this provides people with information on the home and whether they would be able to meet their needs. What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Dudley Court Rest Home DS0000016864.V358555.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Dudley Court Rest Home DS0000016864.V358555.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1 and 3. Standard 6 does not apply, as the home does not admit residents who require intermediate care. Quality in this outcome area is good. People who are considering moving into the home benefit from having their care needs assessed so that they can be sure the home can meet their needs. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The Statement of Purpose and Service User Guide were seen and read at the time of the inspection. Copies of both documents are available in the home and the three residents followed through the case tracking process have their own copy. It was identified at the last inspection that the documents needed to be updated the manager and provider have reviewed both of these. Two relatives of residents spoken with said that they were well informed when making the choice for moving into Dudley Court. One relative commented: “Dudley Court care staff have the ability to inform you fully, honestly and with careful consideration for the resident they are caring for. They are extremely Dudley Court Rest Home DS0000016864.V358555.R01.S.doc Version 5.2 Page 10 supportive but ensure that you are at all times involved in the decision process.” One family member responding on behalf of their relative to the questionnaire we sent out indicates that they did not have a choice of home commenting: “…(Resident was in hospital, they wanted the bed, …(Resident) wasn’t able to go to …own home and they found this home for …(Resident)”. The person completing the questionnaire does not say who ‘they’ are but do say that they love being at the home. The visiting hairdresser said that a copy of our inspection report is always at hand to read. The pre-admission details for all the three residents followed through the case tracking process showed that a thorough assessment had been carried out before they were offered a place in the home. The manager and a senior carer carry out pre-admission assessments. Assessments completed showed that some of the areas assessed related to peoples ability to care for themselves. This information was recorded in terms of strengths, what they could do for themselves and their needs, what would be needed to be carried out to support them in their every day life. Assessments included mobility, eating, dressing and toileting. Additional information related to health, medication, enduring interests and family life was also recorded. Dudley Court Rest Home DS0000016864.V358555.R01.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10 Quality in this outcome area is good. Care plans for some residents show improvement and provide staff with guidance on all aspects of resident’s needs this should result in appropriate care being given to residents. Staff practices when managing medicines in the home is good, this supports the safety of people living in the home. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Residents observed during this inspection visit looked well cared for. Residents living in the home were happy, smiling and talkative. It was evident that the service is meeting their personal care needs. People were well presented and groomed. Resident’s clothes looked well laundered and the clothes they wore were suited to the time of year. Three people were identified for ‘case tracking’. Dudley Court Rest Home DS0000016864.V358555.R01.S.doc Version 5.2 Page 12 Each care file contained a profile about the person’s life history, interests and relationships. This is good practice and should help staff to understand the cultural and social background of individuals and assist them to give ‘person centred’ care. It was identified at the last inspection carried out in September 2007 that residents care plans did not always provide sufficient details for care staff on what action they needed to take to meet the needs of residents in their care. The care plans examined at this inspection show that the manager and care staff have carried out a lot of work to update the care plans. All residents have a care plan and most have been updated to contain a plan of care with information about the actions staff need to take to meet most of their identified needs. Care plans are based on the initial assessment of peoples’ needs and a further assessment when they are admitted to the home. There is evidence that this information is reviewed and updated. The service uses risk assessment tools for identifying the risk of falls and developing pressure sores. A dietary assessment is completed for each person to identify potential risk of poor nutrition. This is good practice and should identify risks to the health and well being of people living in the home. Care plans had been developed to minimise identified risks. Examples of improvements in care planning were identified for one of the residents where they had been assessed as being at high risk of falling. A care plan had been developed and directions for staff include: “To provide a clutter free environment” “Ensure one member of staff is with …(Resident) when transferring or walking.” Another care plan and risk assessment identified a further resident as being at risk of becoming hypoglycaemic (low blood sugar). The care plan read provided staff with details of the signs they need to look out for and the action they need to take to monitor and manage any deterioration in the person’s condition. Information read include: “Test blood sugar levels as prescribed by the doctor.” “Give fruit juice, tea with sugar, milk with sugar or toast with jam or marmalade if blood sugar is low.” “Inform GP” Dudley Court Rest Home DS0000016864.V358555.R01.S.doc Version 5.2 Page 13 Residents considered at risk of developing pressure sores had appropriate care plans in place and equipment or treatment was clearly documented. At present residents at risk, require creams and pressure relieving equipment, which include special pressure relieving cushions. Residents responding to the question in the questionnaire: Do you receive the care and support you need? State: “Could not be better.” “Very well supported indeed.” Records examined showed that people are supported access to GP services, hospital out patient appointments, community nurses and optician. Family member spoken with said that they are called if there is a problem with their relative and that they are kept up to date with important issues affecting them. On the day of the inspection, a family member expressed that they did not feel that their relative looked well. The situation was assessed and the family member reassured that the GP would be called. The systems for the safe management of residents’ medication were examined. A weekly monitored dosage (‘blister packed’) system is used. The senior carer was observed giving the medicines out to residents. Audits of the medication of the people involved in case tracking were undertaken and were found to be accurate indicating that people living in the home have their medicines administered accurately. Staff make appropriate records on the MAR sheets when residents refuse to take their medication. Good practice was observed when staff administered medicines. The medicine round was done safely and the carer checked the Medicine Administration Record (MAR) sheet before administering medicines to each resident. The staff member also made sure that residents took their medicines before preparing medicines for other residents. Medicine administration records (MAR) were completed correctly. Controlled drugs, that should be securely stored was being stored in a locked mental container with the drug trolley, which is taken around the home during the drug round. This was discussed with the manager and a senior carer, as this is not good practise. A suitable location was identified for the drugs to be stored. The locked metal container was locked within a locked medicine Dudley Court Rest Home DS0000016864.V358555.R01.S.doc Version 5.2 Page 14 cabinet, which is securely attached to wall within a locked cupboard. There are a limited number of controlled drugs in the home. The drugs are counted daily by senior care staff working in the home and are again counted by district nurses who visit the home to administer the medication. People living in the home were observed to be treated with respect and their dignity maintained; for example, personal care was provided in private and residents were spoken to respectfully. During observation of working practice, it was evident that staff are knowledgeable about the likes and dislikes of people living in the home and were kind, caring and attentive towards them. A relative commented in a questionnaire returned to us: “As far as my relative is concerned all…(Resident) needs are met and staff are very attentive.” Dudley Court Rest Home DS0000016864.V358555.R01.S.doc Version 5.2 Page 15 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15 Quality in this outcome area is adequate. People living in the home are supported to maintain their independence and interests, which enhances their quality of life. Not all residents are supported to be actively involved in activities taking place in the home, which impacts on their quality of life. People benefit from a varied and nutritious diet. This judgement has been made using available evidence including a visit to this service. EVIDENCE: A programme of activities is displayed in the home and details of planned daily activities are identified separately for residents. Entertainers visit the home during afternoons to provide such things as ‘sing a longs’. People are encouraged if they are able and with the support of care staff or their relatives to go out for walks, shopping or to visit the local church. Comments from residents include: “Sometimes difficult to join in because of being hard of hearing.” “A good time is had by all.” Dudley Court Rest Home DS0000016864.V358555.R01.S.doc Version 5.2 Page 16 A relative commented that an increase in entertainment was needed to improve the care home saying that: “Some weeks seem very quiet with not much stimulation. As my friend is quite deaf and has poor eyesight she may miss out if her needs are not catered for as for as entertainment is concerned.” A completed questionnaire was also received from a local community centre that provides lunch club facilities. Three of the residents in the home are members of the club all of whom have different needs. Staff from the centre say that they are informed when their members are in hospital, have an appointment or have family visiting and therefore are unable to attend. This demonstrates good communication between the home and the centre. The centre comments that: “When clients wish to go out on trips the staff help in every way they can, giving instructions for medication or extra care that is needed.” Care plans read for residents involved in the case tracking process gave details of the resident’s interests, family life and involvement. One care plan identified that a resident liked to go church but felt that they were no longer able to do this, as they feel ‘quite forgetful’. The care plan identified that staff should let the resident know when a representative from the church was in the home as the resident expressed that they would like to have communion. Family members or their representative are made welcome at all times and they are involved in planning their relative care. The home is friendly and welcoming and visitors and residents are able to communicate well with staff. Relatives visiting the home were willing to talk to the inspector Residents received their family in their bedrooms as well as communal areas. Visitors who had travelled a long distance to see their relative had a meal prepared by the home and were able to sit and eat together as a family. This is good practice and supports people to maintain and continue to be part of their family’s life. One relative commented that: “Dudley Court staff have on numerous occasions offered my…(Resident) the facility of using the phone to contact my brother…who unlike me is unable to visit frequently.” Residents have a say in what they do in their daily life in the home. Dudley Court Rest Home DS0000016864.V358555.R01.S.doc Version 5.2 Page 17 The manager said that a local church visits the home on a monthly basis to provide a service. One care plan identified that a resident liked to go church but felt that they were no longer able to do this, as they feel ‘quite forgetful’. The care plan identified that staff should let the resident know when a representative from the church was in the home as the resident expressed that they would like to have communion. The inspector joined the residents for lunch; there was a choice of two meals Chicken Kiev or liver with vegetables. The meal looked appetising and was tasty. Residents spoken with during lunch were seen to enjoy their meals. Resident said the food was “very good”, “lovely” and they had a choice each day. A resident responded in a questionnaire that the food was “excellent”. Dudley Court Rest Home DS0000016864.V358555.R01.S.doc Version 5.2 Page 18 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 Quality in this outcome area is good. Complaints are taken seriously by the home and there are appropriate policies and procedures to safeguard residents. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The complaints procedure is displayed in the reception area of the home. Copies are also available in the Service User Guide. Residents and relatives spoken with said that they were aware of how to complain and whom to complain to. Comments made in questionnaires received by us include: “The complaints procedure is clearly displayed by the front door.” “…(The Manager) is always available if needed.” “There is always a friendly and comforting word.” We have not received any complaints since the last inspection in September 2007. The manager said that the home had not received any formal complaints. It would be good practice for all verbal concerns to be documented with evidence of how these were dealt with and the outcome reached. The policy and procedure detailing the action to be taken by staff to ensure the protection of vulnerable adults were examined. The information guides staff on the procedures to follow if they saw or suspected evidence of abuse. Dudley Court Rest Home DS0000016864.V358555.R01.S.doc Version 5.2 Page 19 Staff were able to confirm that they had attended training related to the protection of vulnerable adults. Two members of staff were able to explain the action they would take if they saw abuse. Both answered appropriately. Training records examined indicates that staff had received training in the protection of vulnerable adults. Dudley Court Rest Home DS0000016864.V358555.R01.S.doc Version 5.2 Page 20 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 21, 22, 23, 24, 25 and 26 Quality in this outcome area is adequate. The environment is generally well maintained providing a clean and homely place for the service users. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Improvements continue in the home, the latest refurbishment has been the replacement of the carpet in some areas of the home, which includes the dining room. The home has sufficient communal areas where residents can sit in private, meet with their own family or pursue their own activities. There is a large conservatory, which residents and relatives say that they like to use. Some of the resident’s bedrooms have a second door, which opens out onto the conservatory. One of the residents spoken to said that she did not mind this but does close the door if the conservatory is being used. A new roofing system, which deflects light, has been fitted to the conservatory. Staff and Dudley Court Rest Home DS0000016864.V358555.R01.S.doc Version 5.2 Page 21 residents report that this has made the conservatory more comfortable to sit in. Residents moved around the home freely. Some residents used walking aids, such as Zimmer frames or walking sticks to help them to mobilise safely. Residents were seen to come and go to their rooms as they choose. Most of the bedrooms were visited and these looked homely, residents and their family had brought some of their own furniture into the home. Resident’s photographs and soft furnishings were also used to help personalise the rooms. This practice would help the resident to settle into the home quicker and promote their comfort. Communal bathroom and shower facilities looked in need of updating and refurbishment. Some furniture and furnishings provided by the home was showing wear and tear and in need of replacement. Various types of chairs are provided for the comfort and safety of residents. On the day of the inspection, the home looked clean, although some bedrooms were dusty. Most residents and relatives responded that the home was always fresh and clean; some gave their response as usually. The laundry in the home is small and is situated on the top floor of the home. The room contained a lot of laundry and was not well organised. Care staff working during the day carry out laundry duties and night staff do the ironing. Protective clothing such as plastic gloves and aprons were available and arrangements are in place for the disposal of waste. Comments received said that clothes are mixed up and they receive clothes that are not theirs. “All clothes are named but problems still arise.” The kitchen was clean, tidy and organised on the day of the inspection. Records for cleaning and checking temperatures of fridge’s, freezers, food brought into the home and cooked foods had been maintained. The cook for the day knew what meals residents had ordered, was well prepared and was ready to serve lunch before residents came to the dining room. Dudley Court Rest Home DS0000016864.V358555.R01.S.doc Version 5.2 Page 22 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30 Quality in this outcome area is good. There are sufficient numbers of staff on duty to meet the needs of people living in the home and robust preemployment checks safeguards people from risk of harm from abuse. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Duty rotas seen evidenced that staffing levels are being maintained. On both days of the inspection, there were three carers plus a senior carer on duty in the morning and two carers plus a senior carer in the afternoon/evening. Two waking staff are on duty each night. A cook was also on duty. The manager is supernumerary. Most care staff have completed a National Vocational Qualification (NVQ) level 2 in care. Staff files examined contained certificates to show that they had completed the training. Senior care staff have completed NVQ level 3. The personnel files of two recently recruited staff members were examined and they contained evidence that satisfactory checks such as Criminal Record Bureau (CRB), Protection of Vulnerable Adult (PoVA) and references are obtained before staff commence employment in the home. Robust recruitment Dudley Court Rest Home DS0000016864.V358555.R01.S.doc Version 5.2 Page 23 procedures and pre-employment checks should protect the vulnerable elderly people living in the home. Staff training records demonstrate that staff complete an induction programme and receive mandatory training in Health and Safety, Infection Control, Fire Training, Moving and Handling, Abuse Awareness and Food Safety. The manager maintains a monitoring system, which identifies staff who require updates in their training, so that training can be arranged. Staff feedback on the running of the home was received through questionnaires they had completed and returned to us. Conversations were also held with care staff. Comments received show that the staff enjoy working at the home. Staff said that they received regular training, supervision and annual appraisals. One staff member commented about the application process before commencing work in the home and said: “…CRB and references were gathered before I was able to commence work.” Staff were all extremely positive and said that they felt that they provided a high standard of care to people living in the home. Dudley Court Rest Home DS0000016864.V358555.R01.S.doc Version 5.2 Page 24 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 and 38 Quality in this outcome area is good. The manager is competent and fit to be in charge of the home. Policies and procedures offer a sound framework and safeguard service users’ interests and safety. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The manager of the home has been in post for a number of years and has the necessary experience and training required to undertake the role. She has a working knowledge of the care needs of people that live in the home. The manager is keen to make improvements and since the last inspection had taken actions to address all of the issues identified in the last report. Dudley Court Rest Home DS0000016864.V358555.R01.S.doc Version 5.2 Page 25 The home has an informal quality system, which looks at ways of gaining the opinions of the people at the home about the service they receive. Evidence was not available to show how the information received is used to develop and improve services provided by the home. Resident’s and relatives commented in conversation about the management of the home to say that: “The manager is always approachable”. A member of staff said: “I feel I can always approach my manager and feel positive with the staff appraisals we receive.” People’s personal monies are stored away safely and a clear record of expenditure is kept so that it is possible to check how people’s money has been spent. Health and safety and maintenance checks had been carried out to ensure equipment in use is safe and in full working order. Electrical equipment used in the home had been tested to ensure us it was safe to use and appropriately wired. The ‘5’ year electrical certificate was available and current. Water temperatures checks had been recorded monthly and this assists in the prevention of people accidentally scolding themselves. Maintenance checks were completed on fire systems and equipment. The complete certificate to confirm the maintenance, up to date servicing of the lift and confirm that it is safe to use was available to be examined. A record is maintained in the home of any accident or incident that happens to person using the service. Dudley Court Rest Home DS0000016864.V358555.R01.S.doc Version 5.2 Page 26 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 3 3 2 3 3 3 3 3 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 2 X 3 3 X 3 Dudley Court Rest Home DS0000016864.V358555.R01.S.doc Version 5.2 Page 27 Are there any outstanding requirements from the last inspection? Yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 6. Standard OP19 Regulation 23(2)(o) Requirement The raised beds in the garden must have a more appropriate wall to retain the earth. Not assessed at this inspection, previous date 15/12/07 Timescale for action 30/04/08 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 OP7 OP12 Good Practice Recommendations All persons living in the care home must have an up to date detailed care plan. This will ensure that they receive person centred care, which meets their needs. Consideration should be given to the needs of all residents living in the home when planning activities. This includes residents with sensory disabilities, which includes those with hearing and sight problems. For example would the fitting of a loop system be beneficial in the home. This will ensure that the needs of all residents are met. All complaints received in the home should be recorded; this includes concerns received by word of mouth. This will ensure that the issues are addressed. A record should be maintained of the action taken by staff and response DS0000016864.V358555.R01.S.doc Version 5.2 Page 28 3 OP16 Dudley Court Rest Home 4 OP21 5 OP26 6 OP33 given to the complainant. People who use the home will then feel confident that the concerns will be acted on. A review of the bathing facilities should be added to the ongoing maintenance and refurbishment programme for the home. This will ensure that there are suitable bathroom and shower facilities, which are accessible by people living in the home. All areas of the home should be kept clean and dusting of furniture and furnishings to include ornaments should be carried out. This will help to ensure that people live in a clean environment. The registered person must ensure a quality assurance system is fully implemented including consultation with stakeholders and draw up an annual development plan based on outcomes for residents. Dudley Court Rest Home DS0000016864.V358555.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection West Midlands Office 3rd Floor 77 Paradise Circus Queensway Birmingham B1 2DT National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. 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