Inspection on 01/11/05 for Dudley Court Rest Home

This inspection was carried out on 1st November 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. 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 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 01/03/08

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 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

Heathlands

Aston Court Nursing Home

Breme

Ravenhurst

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 Joe O`Connor Announced Inspection 1st November 2005 & 2nd November 2005 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.V252367.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. Dudley Court Rest Home DS0000016864.V252367.R01.S.doc Version 5.0 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.V252367.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 4. That the home accommodates 22 persons over the age of 65 for reasons of old age. That telephone points and television aerials are installed in second floor rooms 20, 21 and 22 prior to a service user being admitted to the room. That overhead or bedside lighting is provided in second floor rooms 20, 21 and 22 prior to a service user being admitted to the room. That service users admitted to second floor rooms 20, 21 and 22 have a pre admission assessment to ensure that they have no mental confusion, dementia or Alzheimer’s disease, and that the mental state be kept under review to ensure they are safely able to be accommodated on the 2nd floor. That service users admitted to the second floor rooms 20, 21 and 22 are assessed prior to accepting the room that they have sufficient mobility/dexterity to access the storage space provided for their personal possessions independently. That service users admitted to the second floor, rooms 20, 21 and 22 are assessed as having no sensory impairment that would prevent them hearing the fire alarm system in the event of a fire. That the door to the external fire escape is alarmed to alert staff in the event of the door being opened prior to any service user being admitted to the second floor. That the lockable grid at the top of the second floor stairs is renewed and an alternative method of minimising the risk of falls is installed in consultation with CSCI, prior to any service users being admitted to the second floor. In addition to the care manager or shift leader there are three suitably qualified and experienced care staff on duty during day time hours. At night-time there should be two suitably qualified waking night staff plus a designated person on call within a 20-minute travel distance from the home. That the manager completes Quality Assurance Training by 31st July 2005. 5. 6. 7. 8. 9. 10. Dudley Court Rest Home DS0000016864.V252367.R01.S.doc Version 5.0 Page 5 Date of last inspection 8 June 2005 Brief Description of the Service: Dudley Court is a residential service for 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. Acocks Green Railway Station is within walking distance from the service. It is also close to a variety of church denominations and the local library. The service is currently registered to accommodate twenty two older adults. 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 and a dining area. There are twelve single bedrooms, two are en-suite, and Three bathrooms with assisted baths including one that has a hoist are available throughout the premises. There are five toilets and one of these is a designated staff toilet. There is a kitchen with two food storerooms and a manager’s office. A staircase leads up to the first floor. The first floor consists of six single bedrooms and one double bedroom. There are no en-suite facilities on the first floor. The second floor consists of three bedrooms and a bathroom with assisted bathing facilities. There is a separate laundry area. Access to all floors is provided by a shaft lift. Dudley Court Rest Home DS0000016864.V252367.R01.S.doc Version 5.0 Page 6 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was announced and took place over two days. Five service users were able to convey their views on life in the home. Discussions were also taken with two members of staff. A tour of the premises was undertaken. Service users care plans and risk assessments were inspected. Staff recruitment and training records were examined and a number of health and safety records were also sampled. The Inspector had opportunity to talk to the Registered Manager and the owner. Prior to this inspection eleven comments cards were received from service users, three from health and social care professionals and one from a relative. The Commission’s Pharmacist Inspector was present to undertake an audit of the service’s management of medication for service users. What the service does well: Five of the service users spoken with expressed positive comments about the service. Two service users who had moved from another service that had recently closed said the support and care being provided at Dudley Court was so much better than where they were living before. They felt they had more freedom and that the manager would always talk to them unlike the previous owner. Other comments received included: “We were not allowed to have bacon sandwiches for breakfast where we lived before but we can have them at anytime!” “It’s wonderful, staff put themselves out for you.” Another commented, “Staff know what I like and what I need”. “This is one home that I would personally recommend to my friends”. The atmosphere was relaxed with staff providing a friendly and professional approach to service users. Service users are able to participate in residents meetings every month. There are activities for service users to participate in such as physical exercise, bingo, and musical entertainment and there is a visiting library service. One service user stated she receives Holy Communion from a nun in the privacy of her bedroom. Service users records examined during this inspection indicated they were receiving support from healthcare professionals such as GP, District Nurse. Optician, Dentist and Chiropodist. The service maintains good relationships with visiting District Nurses and the GP who regularly visits the service. Service users expressed satisfaction with the catering arrangements. They stated that a choice was available and that staff would ask them each day for their preferred mealtime choices. Lunch was sampled during this inspection and it was found to be well cooked and presented. Dudley Court Rest Home DS0000016864.V252367.R01.S.doc Version 5.0 Page 7 What has improved since the last inspection? What they could do better: Improvements were required to the cleaning and management of foul odour in two of the bedrooms. Additional call alarm pull cords were required for one of the ground floor bathrooms and main lounge. The light pull cords in the bathroom and toilets were in need of cleaning, as they were dirty. Commode chairs used by service users were in poor condition and needed replacing as a matter of urgency. Some armchairs in service users bedrooms were also worn. Staff had not competed training in adult protection training and care planning and were overdue training in fire safety which should be held every six months. The manager had not developed a policy and procedure for physical intervention. This was a requirement from the previous inspection. The adult protection procedure was unsatisfactory and the manager did not have an up Dudley Court Rest Home DS0000016864.V252367.R01.S.doc Version 5.0 Page 8 to date copy of the adult protection guidelines published by Birmingham Social Care & Health. Service users care plans were found to require improving, as they did not provide full information as to how the needs of service users were to be met. The care plans did not adequately cover how specific healthcare needs should be addressed including diabetes and continence management. Service users risk assessments were incomplete and did not cover issues those who have aggressive behaviour and how this should be managed to reduce the risk of further incidents. Risk assessments were also needed for service users who use steradent tablets. A requirement from the previous inspection for a senior carer to be on duty for each shift had not been addressed since the last inspection. Improvements are required in the recording and management of service users monies and other valuables. 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. Dudley Court Rest Home DS0000016864.V252367.R01.S.doc Version 5.0 Page 9 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.V252367.R01.S.doc Version 5.0 Page 10 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): 1, 2, 3, 4, 5 The statement of purpose and service users guide does not inform prospective service users the range of needs the service intends to meet. Service users needs are assessed prior to admission with needs led assessments and initial care plans on file but not all are up to date. Service users do not have a statement of terms and conditions that informs of what they are contributing towards the cost of their stay. Service users are able to visit the service prior to admission. The needs of the current group of service users are met with positive support provided by staff. EVIDENCE: The service has a Statement of Purpose and a Service User Guide that was found to require some amendments. There was no reference to what the service is registered to accommodate based on the information written on the registration certificate. Three service users’ Statement of Purpose and Service User Guide had their individual bedroom sizes. However, the Registered Provider must ensure there is a “stand alone” statement of purpose document that lists all the bedrooms on a single page for prospective service users and other stakeholders. The service user guide did not provide information such as Dudley Court Rest Home DS0000016864.V252367.R01.S.doc Version 5.0 Page 11 policies and procedures, for fire, accidents, adult protection and missing person. There was no standard form of contract. An examination of four service users records found that one had had an assessment and initial care plan completed by a social worker. Other records examined found only initial care plans had been provided by social workers. In the absence of social work assessments the manager had completed preadmission assessments and a residents assessment shortly after the service user had been admitted. Two service users who had recently been transferred from another service that recently closed did not have up to date care plans completed by social workers. Only one had basic information about their needs from the previous provider. Further sampling of the records found while there were three way agreement (contracts) provided by the local authority, there were no individual statements of terms and conditions with the Registered Provider. Discussion with a number of service users who had recently been admitted to the service stated they were able to look around the home and spend a day their before making their decision. There was evidence of one such daytime visit taking place but the information recorded was not signed and dated by staff. There is an admissions procedure in place, which is available in the Statement of Purpose and Service User Guide. Four service users were able to convey their views on the care and support they were receiving. Two service users who had recently moved from another service that had closed commented, “We get choices here unlike the last place I lived in. “We were not allowed to have bacon sandwiches for breakfast but we can have them at anytime”! “It’s wonderful, staff put themselves out for you.” Another commented “Staff know what I like although I would like someone to take some time to talk to me about my favourite subject which birds”. Comments were received from relatives prior to this inspection and included “ I have always been made to feel welcome here”. “The family greatly appreciate the effort made by the manager and owner to enable my mom to return home after her stay in hospital”. “ One of the few homes I would personally recommend to my friends”. Service users appeared to be well cared for and two staff spoken with were able to demonstrate an understanding the needs of the current group of service users. Dudley Court Rest Home DS0000016864.V252367.R01.S.doc Version 5.0 Page 12 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, 10, 11 Service users care plans do not provide enough evidence as to how their needs are to be addressed, nor are they clear on service users preferences and dislikes. Care plans do not clearly state how specific healthcare needs such as the management of pressure care and diabetes should be managed. Risk assessments do not provide adequate information with regard to concerns around the management of challenging behaviour. Service users are able to access community healthcare services but there are no basic assessment tools for the monitoring of nutrition and pressure care needs. The systems for medicine management have improved since the last inspection. Clear comprehensive arrangements had been installed to ensure service users medication needs are met. Service users privacy and dignity is maintained to an acceptable standard but service users’ final wishes must be ascertained. EVIDENCE: Four service users care records were sampled and there was evidence that each one had a care plan and manual handling assessment. Nocturnal needs assessment was in place were the times service users get up and go to bed. There was information on personal preference sheets but these tended to refer to what service users needed assistance with rather than setting out their preferred choice of how each topic of care should be delivered. The manager Dudley Court Rest Home DS0000016864.V252367.R01.S.doc Version 5.0 Page 13 has introduced a new format for the care plans but it was found that much work was still needed to ensure there were clear statements as to how service users needs were to be met. For example one care plan referred to a service user requiring assistance with showering but did not say in what areas assistance was needed and what could the service user do for themselves. There was no evidence to confirm service users had been involved in the development of the care plans. Further sampling of service users records confirmed service users had access to community healthcare services such as GP, District Nurses, Dentist, Optician and Chiropodist. In discussion with staff and the manager there are good relationships maintained with District Nurses. Comments received from healthcare professionals included one from a GP who stated, “Staff have a good knowledge of their residents and appear responsive to the residents need for dignity and respect.” The home responds well to requests which I make with regard to patient management”. An examination of service users care plans found that much improvement was still required in ensuring how service users needs were to be met. For example a service user’s district nurse care plan stated that the service user needed to have changes in her position every half hour but this was not documented on the individual service user’s care plan. There was also no reference on those service users’ care plans to identify action to be taken when service users with diabetes had hypoglycaemic or hyperglycaemic episodes. As there were a number of service users with diabetes it is recommended that arrangements be made for all staff to receive training in this area. There was also no reference to the management of continence needs and for example what size incontinence pads service users were to wear. The manager must ensure that any pressure equipment referred to in the district nurse care plans are recorded on the individual’s care plan e.g. type of pressure relief mattress and level of pressure sore risk. Assessments for nutrition and the prevention of pressure sores were still not in place. The manager stated that a training session had recently taken place with a district nurse covering topics such as prevention of pressure sores and nutrition. The district nurse stated that they would do assessments for pressure sores. While it was commended the manager had arranged for appropriate training in this area, there is still a need for a basic assessment tool in place that documents any initial concerns before the intervention of a district nurse and dietician for a more comprehensive assessment. Manual handling assessments were in place that were dated meeting a requirement from the previous inspection. These will need some amending to state what action to be taken in the event of a fall. In discussion with a member of staff she spoke about one service user who had recently hit her twice and there was no risk assessment in place to identify how that Dudley Court Rest Home DS0000016864.V252367.R01.S.doc Version 5.0 Page 14 individual’s behaviour was to be managed. One service user record examined found an individual risk assessment sheet had not been completed. Staff had worked hard to implement all the requirements from the last Pharmacist inspection and this is commended. All audits undertaken to demonstrate that the medicines had been prescribed were correct. Regular drug audits had been performed by the staff and these were to be refined to staff drug audits. All prescriptions were seen to prior to dispensing and the dispensed medication checked into the home. A Controlled Drug cabinet had been installed and all Controlled Drug Balances were correct at the time of inspection. A CD register had been purchased and this was completed after each transaction. At the time of this inspection staff were observed to respect service users’ privacy by knocking on their bedroom doors and entering when asked by service users. The interaction between staff and service users was friendly and respectful. A comments book for visitors was examined and there were thanks recorded by district nurses commenting on the staff co-operation regarding one service user who had terminal illness. Discussion with the manager and a member of staff about found that the appropriate care and equipment had been provided in order for the service user to be more comfortable in their final days. The staff member demonstrated a very good understanding of the important factors involved in caring for people who are dying. The manager attended the funeral of the service user. The manager however, must ensure service users records refer to their final wishes and funeral arrangements. Dudley Court Rest Home DS0000016864.V252367.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, 15 Daily routines of service users are not affected by any rigid rules or restrictions. Service users are able to access the local community but care records do not reflect the involvement of service users in organised activities and how they spend their leisure time. Service users are able to receive visitor at various times of the day. Service users records do not state whether service users wish to have a key to their bedroom for privacy. There is a menu available providing service users a variety of nutritious meals catering for various dietary requirements. EVIDENCE: There were no unnecessary restrictions to service users daily routines. Three service users stated they were able to get up and go to bed when they wanted to and had a cup of tea first thing in the morning. One service user commented that she preferred to get up early in the mornings and was able to do this. Observations during this inspection found service users coming down for breakfast at different times during the morning. The service users also spoke of activities such as progressive mobility, Bingo and musical entertainment taking place. There is a visiting library service. Last summer the service users were involved in a garden fete. However, there were no records in place to confirm whether service users had participated in them or not. One service user stated she goes out with her former partner once a week to Northfield shopping centre and the manager stated two service users go out to a lunch Dudley Court Rest Home DS0000016864.V252367.R01.S.doc Version 5.0 Page 16 club. One service user was observed to go out with a relative for lunch. One service user stated she receives a visit from a nun to administer Holy Communion in her bedroom and there is another visitor from another Christian Denomination that also visits regularly. At the time of this inspection service users were observed to receive visitors from family and friends. Service users are able to personalise their bedrooms to their liking with evidence of their own possessions such as pictures, furniture and ornaments. However, it was noted that personal inventories had not been completed for service users newly admitted to the service. An examination of service users care plans did not indicate whether service users had the choice of a key to their bedroom. The pre-inspection questionnaire stated that four service users maintain control of their benefit book and their financial affairs. Three service users expressed satisfaction with the catering arrangements stating that there was a choice of food available. They also said staff would provide an alternative if they declined what was on the menu. Service users stated staff would ask them what they wanted for lunch and tea. Two service users who had recently moved from another service that closed were so pleased that where they had moved to offered cooked breakfasts which they could not have previously. The menus examined indicated there was a variety of meals available with regular portions of vegetables provided as part of a nutritious diet. There is a daily diary to confirm what service users had eaten during the day and whether they had eaten any alternatives. Lunch was sampled which was Roast Lamb, roast and mashed potatoes and vegetables. The meal was well presented and very tasty. One service user who declined the main meal requested an egg sandwich and this was provided. Observations during lunch found the atmosphere to be relaxed with service users being allowed to finish their meals. Condiments were on the table although it was noted that some of the tablecloths had cigarette burns. The refrigerator, freezers and food cupboards were well stocked and the service caters for specific dietary requirements such as diabetes. Dudley Court Rest Home DS0000016864.V252367.R01.S.doc Version 5.0 Page 17 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, 18 There is a complaints procedure available to service users making the process in making a complaint open and clear. The adult protection policy and procedure remains unsatisfactory with no information available and training provided to enable staff to protect service users welfare. EVIDENCE: Neither the CSCI nor the service has received a complaint since the last inspection. There is a complaints procedure a copy of which is given to each service user and is on display in the reception area. Amendments have been made to the complaints procedure since the last inspection. It now states that the CSCI can be contacted at anytime during the complaints process and no one will be victimised for making a complaint. Two service users stated they were aware of the complaints procedure and would be able to raise any concerns with the manager. The adult protection policy and procedure was still in need of development to reflect the spirit of the Department of Health’s Publication No Secrets. It must include reference to POVA and an outline of training for staff and a list of organisations available who provide support. The manager did not have an up to date copy of the multi agency guidelines published by Birmingham Social Care & Health. At the time of publication of this report a new copy was forwarded to the manager. There was a leaflet on display in the dining area published by the Local Authority of who to contact if there was any suspected abuse. A requirement for all staff to receive training to have adult protection had not been addressed. The manager stated that two staff completing NVQ Level 2 & 3 were covering abuse of vulnerable adults as part of their course. Dudley Court Rest Home DS0000016864.V252367.R01.S.doc Version 5.0 Page 18 While this is acknowledged there should still be a separate annual adult protection training course available to staff as part of their induction and foundation training. Staff stated that they would be undertaking training in challenging behaviour. The manager stated that she had not developed an appropriate procedure for the use of restraint and action must now be taken to address this. Dudley Court Rest Home DS0000016864.V252367.R01.S.doc Version 5.0 Page 19 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, 20, 21, 22, 24, 25, 26 The maintenance and cleanliness of the premises require improvement including a more effective management of foul odour. Service users are able to freely access the communal and bathing facilities without any hazards. Service users are able to personalise their bedrooms to their individual tastes. Practices with regard to the control of infection require improvement. Service users do not have full access to emergency call alarms in parts of the premises to summon assistance. EVIDENCE: The premises were found to be clean and reasonably tidy at the time of this inspection. However, there was evidence of foul odour in bedrooms 18 & 19, which needs addressing. It was also noted that parts of the premises including a number of bedrooms had cobwebs hanging from the ceiling. Five service users spoken with stated they thought the premises was clean and tidy. Parts of the wall by the lift on the first floor were found to require some the paintwork to be touched up. There is a maintenance book on the premises and it was evident that the Registered Provider would address any requests for repairs and replacing of equipment. A number of bedrooms had new carpets Dudley Court Rest Home DS0000016864.V252367.R01.S.doc Version 5.0 Page 20 fitted and that bedroom 2 had its vanity unit repaired, a requirement from the previous inspection. New blinds and furniture had been installed in the conservatory another requirement form the previous inspection. A tour of the premises was undertaken and a number of bedrooms were viewed. It was evident that service users were able to bring in their personal possessions including ornaments and photographs. It was noted however, that some of the rooms had commode chairs that were worn and in need of replacing. Some of the armchairs in the bedrooms were also worn. One bedroom was found to have its emergency pull cord in an inaccessible position for the service user. One bedroom door was found to have a mortice type lock that is unsuitable and should be replaced with one that guarantees service users’ privacy but could be accessed by staff in an emergency. There are bathrooms on each floor with assisted bathing facilities. The toilet facilities are close to the lounges and dining area. One bathroom on the ground floor did not have an alarm call by the bath. A number of toilets and bathrooms did not have any lampshades although the Registered Provider started to fit these when this had been pointed out to him. The toilet on the ground floor near the dining room needed a new toilet seat as the one being used was worn. There are two lounges one of which is used as a hairdressing salon by the visiting hairdresser. The garden was well maintained although there were cracks on the slabs along the ramp from the dining room. It was noted that the large lounge only had one call alarm cord and another must be installed to improve access to the alarm for all service users. Staff were generally observed to maintain appropriate infection control practices such as wearing protective clothing. When assisting with personal care and preparing food in the kitchen. However, it was noted that some of the light pull cords in the bathrooms and toilet were dirty and in need of replacing. Incontinence pads were found to be stored in one bathroom on a shelf exposed to the air. The manager had obtained suitable containers for storage to reduce the risk of contamination in the air when this had been pointed out to her. Discussion with the manager advised her of the need to have an infection control audit that can be arranged by the City’s Health Protection Nursing service. Since the last inspection one service user had moved into one of the new bedrooms on the second floor. The Registered Provider requested a review of one the conditions of registration relating to not admitting service users with sensory impairment. He was advised to put his proposal in writing to the Commission. During the inspection it was observed that a service user was being mobilised in a wheelchair that belonged to another service user and the chair was in a Dudley Court Rest Home DS0000016864.V252367.R01.S.doc Version 5.0 Page 21 poorly maintained condition. A member of staff stated that the service user’s family gave permission for the other service user to use the chair. This practice must now cease and the manager must ensure the service users concerned are re-assessed for wheelchairs that meet their needs. Dudley Court Rest Home DS0000016864.V252367.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29, 30 Service users needs are met with appropriate numbers of staff on duty but there is a need for a senior carer to be on duty during each shift. The manager provides training for staff to enable them to undertake their duties effectively but some topics are still outstanding. Improvements have been made to the recruitment procedure and staff records protecting service users interests. EVIDENCE: Two staff were spoken with including a senior carer and both demonstrated an understanding of service users needs. Observations at the time of this inspection found staff to be friendly and respectful towards service users. Staffing levels appeared to meet the needs of the service users with four on duty during the day. A requirement from the previous inspection for an additional senior carer to be on duty had not been addressed. The Manager stated that she was giving the opportunity for two experienced care assistants to train and apply for a new senior carer post. The post had been advertised but there had been no response. While this is acknowledged the manager must resolve this situation or the Commission may consider enforcement action. The service has had a stable team and the manager was recruiting for a second domestic assistant and night carer. The pre-inspection questionnaire stated that out of fourteen care staff employed in the service ten were qualified to NVQ Level 2. Two staff records examined confirmed there were NVQ 2 certificates on file. Two staff were coming to the end of the NVQ Level 3. The manager stated that both would go on to train for the NVQ Assessors Award. Further examination of staff records Dudley Court Rest Home DS0000016864.V252367.R01.S.doc Version 5.0 Page 23 found that staff had completed mandatory training topics such as manual handling, first aid, food hygiene and fire safety although this topic was overdue for an update. Staff had also completed training in communication, eye care from a local optician and had received specific hoist training from the Manual Handling Team provided by Birmingham Social Care & Health. Since the last inspection a member from one of the District Nurse teams provided a training session on the management of pressure care needs. Comments seen from the trainers involved in the use of the hoist and pressure care training were positive about the commitment of staff in taking part in these sessions. A requirement for staff to undertake care planning had not been addressed. The manager had taken action since the last inspection to place the staff recruitment records into a more structured format. Two records sampled of prospective staff found that the manager had completed interview assessment forms but these were not dated. Requests for two references had been made and there were completed job application forms along with proof of identity. The recruitment policy and procedure had been amended to include information that any gaps in previous employment records would be followed up and the appointment of staff would also be subject to enhanced CRB and POVA checks. Dudley Court Rest Home DS0000016864.V252367.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 32, 33, 34, 35, 36, 37, 38 The manager demonstrates her knowledge of the needs of service users to an acceptable standard. Service users and staff are able to raise any concerns with the manager and provider that is open and supportive. There is no verifiable system in place that enables the service to review the care provided for service users at appropriate intervals. Staff receive supervision ensuring staff are able to effectively undertake their duties. Records were generally up to date but the recording and management of service users monies and valuables require a more robust approach protecting the interests of service users. The welfare and safety of service users is maintained with some improvements required. EVIDENCE: The manager has worked hard to address most of the requirements from the previous inspection. She has the Registered Managers Award qualification and had also completed training in quality assurance. She was able to demonstrate her knowledge regarding the needs of the service users. The atmosphere was Dudley Court Rest Home DS0000016864.V252367.R01.S.doc Version 5.0 Page 25 found to be relaxed with service users stating they would be able to approach the manager with any concerns and they could also speak to the owner. Two service users who had moved from another home spoke of how nice it was to be able to talk to the manager and owner where previously they had little say in what was going on in their previous home. Staff spoke positively about the manager and felt she provided excellent support and that support and assistance was available from the owner who regularly visits the premises. There was evidence of regular staff meetings. The Registered Provider visits the premises every month and reports for these visits are forwarded to the CSCI every month. He acknowledges that a quality assurance system must be implemented in order for the service to improve on their current risk assessment category. An examination of the staff records found there had been an improvement in the frequency of supervision. The manager had taken action from the previous inspection to maintain the staff records in a more structured format. Generally the records were found to be up to date and locked in a secure facility. Service users finances were examined and it was found improvements were required to ensure these are managed in a more robust manner. Monies brought in by relatives on behalf of service users had not been issued with receipts to confirm that the staff had entered the monies on the individual service user’s expenditure record. Valuables being held on behalf of service users such as rings did not have evidence of receipts being issued to the service user. The means of recording service users personal monies is recorded on index cards but consideration must be given that these are recorded on appropriate financial ledger books. There was evidence on display in the premises of an up to Employers Liability insurance certificate and the Registered Provider was asked to provide the CSCI with examples of a business plan to confirm the financial viability of the service. Health and safety records were found to be generally satisfactory. There was evidence that equipment for the prevention of fire, electric, gas and the lift had been tested and serviced on a frequent basis. A fire drill had occurred since the last inspection but it was noted fire training for staff was now overdue. A risk assessment was in place for the prevention of fire. A risk assessment was in place for the premises but this will need to cover the grounds. It was noted that there were a number of service users using steradent tablets and the manager must ensure risk assessments are in place confirming service users’ ability to use these. The service had received a visit from an Environmental Health Officer prior to this inspection. There were a number of requirements of which all but one had been addressed. The officer was due to visit the service again within two weeks of his first visit. The main kitchen was found to be clean and tidy. There was evidence to confirm that temperatures for the refrigerators and freezers were being logged on a daily basis. One of the requirements that had been Dudley Court Rest Home DS0000016864.V252367.R01.S.doc Version 5.0 Page 26 addressed included the installation of a new blind for the kitchen window, the setting up of a cleaning schedule and hygienic wipes to clean the probe that is used to check the temperature of cooked meat. The cupboards had also been cleaned and the seal around the sink had been repaired. There had been improvements since the last inspection with regard to the reporting of accidents. An examination of the accident book found the service had been reporting all accidents to the CSCI on Regulation 37 notification forms. Further examination of the accident book found there had been nineteen falls since the last inspection. The manager had started an audit of service users falls but this was still in need of improving to state what action was being taken to address any concerns. Dudley Court Rest Home DS0000016864.V252367.R01.S.doc Version 5.0 Page 27 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 2 2 3 3 2 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 3 10 3 11 2 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 2 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 N/A 18 2 2 3 2 2 N/A 2 3 2 STAFFING Standard No Score 27 2 28 3 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 1 2 2 3 2 2 Dudley Court Rest Home DS0000016864.V252367.R01.S.doc Version 5.0 Page 28 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. 1 Standard OP1 Regulation Requirement Timescale for action 01/01/06 2 OP5 3 OP2 4 OP7 4(1b)Sch1 The Registered Person must 5(1c) ensure the Statement of Purpose states clearly the range of the needs the service is intended to meet as stated on the registration certificate. The service user Guide must have a standard form of contract. 14(1) The Registered Person must 15(1) ensure service users admitted to the service by the Local Authority have an up to date needs led assessment and initial care plan completed by a social worker. 5(1b,c) The Registered Person must ensure all service users have an individual statement of terms and conditions (contract) 15(1) The Registered Person must ensure service users care plans clearly state how their needs are to be met. They must also demonstrate evidence that service users, families or other representatives have been involved in their draft and review. 01/12/05 01/01/06 01/01/06 Dudley Court Rest Home DS0000016864.V252367.R01.S.doc Version 5.0 Page 29 5 OP8 12(2) 6 OP8 15(1) 7 OP7 13(4) 8 OP11 12(2)(3) (4a,b) 9 OP12 12(2)(3) 10 OP14 12(2)(3) The Registered Person must ensure basic assessments are in place for nutrition and the documentation of any pressure sores prior to referring to the dietician and district nurse. Outstanding Requirement. Timescale 8 July not met. The Registered Person must ensure service users’ care plans refer to how the following healthcare needs are being met: Pressure care relief & equipment Diabetes and action to be taken in the event of hypo/hyper episodes and how often blood levels are to be monitored. Continence needs including sizes of incontinence pads to be used. The Registered Person must ensure all manual handling assessments state clearly the action to be taken in the event of a fall and any equipment to be used. Individual risk assessments for service users must be completed and refer to any issues around challenging behaviour and how these should be managed. The Registered Person must ensure a record is maintained to show they have consulted with service users, relatives and other representatives regarding any final wishes and funeral arrangements. The Registered Person must ensure a daily record is maintained of activities participated in by service users to reflect a typical day in the home. The Registered Person must ensure service users care plans state whether they wish to have a key to their bedroom. Personal inventories must be completed DS0000016864.V252367.R01.S.doc 01/01/06 01/01/06 01/01/06 01/01/06 01/01/06 01/01/06 Dudley Court Rest Home Version 5.0 Page 30 11 OP18 13(6) 12 OP18 13(6) for service users admitted to the service. The Registered Person must ensure that all staff undertake training in adult protection. Outstanding Requirement. Timescale 8 July 2005 not met. The Registered Person must ensure the adult protection policy and procedure is within the spirit of the DOH Guidelines No Secrets. Outstanding Requirement. Timescale 8 July 2005 not met. A procedure for Physical intervention must also be developed. The Registered Person must ensure the premises are cleaned to a more acceptable standard. The paintwork on the wall by the lift needs to be made good. Cracked slabs along the ramp need to be repaired. The Registered Person must ensure the toilet seat on the ground floor by the dining room is replaced as it is worn and in poor condition. The Registered Person must ensure additional call alarm cords are required in the following areas: - The main lounge - Ground floor bathroom by the office. The Registered Person must ensure service users are assessed and provided with wheelchairs that meet their mobility needs. The practice of service users sharing other users’ wheelchairs must cease. The Registered Person must ensure service users’ commode chairs are replaced as they are in a poor condition. An audit must DS0000016864.V252367.R01.S.doc 01/01/06 01/01/06 13 OP19 23(2)(b) 01/01/06 13 OP21 23(2)(j) 01/12/05 14 OP22 23(2n) 01/12/05 15 OP22 23(2n) 01/01/06 16 OP24 16(2c) 01/01/06 Dudley Court Rest Home Version 5.0 Page 31 17 OP24 16(2c) 18 OP26 13(3) 16(2k) 19 OP26 13(3) 16(2j) 20 OP27 18(1a) 21 OP27 18(1a) 22 OP30 18(2) 23 OP33 26(1) be undertaken of all furniture provided in service users bedrooms and any items that are in poor condition are replaced. The Registered Person must ensure the mortice lock in the identified service user’s bedroom is replaced with one that can guarantee their privacy but can be accessed by staff in an emergency. The Registered Person must ensure that it addresses the problems of foul odour in bedrooms 18 & 19. The light pull cords in the bathrooms and toilets need replacing, as they are dirty. The Registered Person must ensure the premises are cleaned more thoroughly including the removal of cobwebs particularly in service users’ bedrooms. The Registered Person must ensure the staff rota includes the name of the manager and the hours worked by the manager. The Registered Person must ensure a senior carer is on duty during each shift throughout the day. Outstanding Requirement. Timescales 17 December 2004 & 8 June 2005 not met. The Registered Person must ensure staff receives training in adult protection and care planning. The Registered Person must establish and maintain a system for reviewing at appropriate intervals of improving the quality of care being provided. A system must be developed to ensure a process of continuous self monitoring, through a verifiable method, using preferably a professionally recognised quality DS0000016864.V252367.R01.S.doc 01/12/05 01/12/05 01/12/05 01/12/05 01/01/06 01/01/06 01/02/06 Dudley Court Rest Home Version 5.0 Page 32 24 OP34 25(1)(2a, b,c) assurance system. The Registered Person must provide the Commission a current business plan or statement from a certified accountant to confirm the service’s financial viability. The Registered Person must ensure that the management of service users personal allowances and their property is safeguarded with receipts to be provided for any monies or items of property brought in for safekeeping and enable accurate audit trail. The Registered Person must ensure that all records with regard to service users care plans and personal monies are up to date. The Registered Person must also review its policies and procedures to ensure they reflect current practice. The Registered Person must ensure that all staff undertakes up to date fire safety training. The Registered Person must ensure risk assessments are in place for service users using steradent tablets. The Registered person must ensure improvements are made to the falls audit record so that it identifies the action taken when falls have occurred including any referrals to falls clinic. 01/01/06 25 OP18OP35 13(6) 01/12/05 26 OP37 17(2) Sch 2&4 01/01/06 27 28 OP38 OP38 13(4) 13(4) 01/12/05 01/12/05 29 OP38 13(4) 01/12/05 Dudley Court Rest Home DS0000016864.V252367.R01.S.doc Version 5.0 Page 33 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 3 4 Refer to Standard OP8 OP9 OP25 OP26 Good Practice Recommendations It is recommended that the Registered Person arrange for staff to receive training in the management of diabetes. It is recommended that the Registered Person complete staff drug audits before and after a drug round to demonstrate staff competence in medicine management. It is recommended that the Registered Person give consideration for the lighting in the dining room to be made more domestic in character. It is recommended that when the current washing machine can no longer be repaired, then the Registered Provider replace it with one that has a sluice cycle programme. Dudley Court Rest Home DS0000016864.V252367.R01.S.doc Version 5.0 Page 34 Commission for Social Care Inspection Birmingham Office 1st Floor Ladywood House 45-46 Stephenson Street Birmingham B2 4UZ 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 Dudley Court Rest Home DS0000016864.V252367.R01.S.doc Version 5.0 Page 35 - 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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