Inspection on 21/09/07 for Dudley Court Rest Home

This inspection was carried out on 21st September 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is (sorry - unknown). 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 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

Similar services:

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 Jill Brown Key Unannounced Inspection 21st September 2007 08:15 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.V351126.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.V351126.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 F/P 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.V351126.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. That the home accommodates 22 persons over the age of 65 for reasons of old age. 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 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 nighttime there should be two suitably qualified waking night staff plus a designated person on call within a 20-minute travel distance from the home. 31st January 2007 3. 4. 5. 6. Date of last inspection 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 Dudley Court Rest Home DS0000016864.V351126.R01.S.doc Version 5.2 Page 5 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 that enables access to all floors for residents and there is one mobile hoist for residents who experience difficulties with mobility. 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.V351126.R01.S.doc Version 5.2 Page 6 SUMMARY This is an overview of what the inspector found during the inspection. An inspection took place on a day in September without prior notice. This was a key inspection, which looked at majority of the national minimum standards. The inspection took place over 10 hours. During the inspection 3 residents were case tracked from admission. Case tracking involves talking to the residents looking at all the records and information about them, including their medication and personal rooms. This information was used to make a judgement about the care given. Another five residents were spoken with. Observations were made of the care given. A comment card was received from a relative and three comment cards from staff. The inspector also took into account information we had received from all sources about the home since the last inspection. Services are required to complete an Annual Quality Assurance Assessment (AQAA) on a yearly basis; information from this was used in this report. We have received one complaint about this service since the last inspection. The complaint was about the skin care of residents and it was found the home needed to improve in this area. In the same complaint concerns were raised about the care of a resident and about the attitude of a member of staff. The resident had no concerns about their care. We could find no evidence for concerns about the member of staff’s attitude. What the service does well: Residents that needed aids to assist them with daily living, such as spectacles, dentures, walking aid and pressure relieving equipment had these available to them. Visiting is flexible enabling relatives to visit at a time that suits them. Representatives of residents commented ‘The home needs no improvement and the staff at Dudley court are not only supportive of my friend but also of me.’ And ‘everything is satisfactory at present.’ There were positive comments by visitors in the comments book in the entrance hall. Residents felt they could go to their rooms when they wanted and that they get up and go to bed when they wished. Dudley Court Rest Home DS0000016864.V351126.R01.S.doc Version 5.2 Page 7 Residents said the food was good, one resident commented ‘what dinners you enjoy they try to do again.’ Residents thought that they could have a cooked breakfast if they wanted although none chose this on the day of the inspection. Residents were assisted with eating where necessary and this was done well. What has improved since the last inspection? What they could do better: The statement of purpose needed revision to ensure that people and their representatives considering moving to the home had enough information about the service the home provides to make a decision. The assessment of new residents needed to be more detailed to ensure that residents’ needs are identified and abilities recognised so care is given appropriately. The identification of risk and care needs did not always result in good planning to minimise risk and meet the need. For example a resident that has had pressure areas rated as a low risk for developing them and no measures were in place to prevent them developing. A care plan for a specific sight loss did not detail how the resident may experience that loss and did not have specific measures to deal with this appropriately. Activities are not individually planned for which means residents that are unable to join in-group activities do not have individual time planned with staff and there were no medication care plans. Medication administration needed to be improved in the time of recording and monitoring the stocks. Refusals of medication need to result in action and maintenance of records to monitor the health of the resident. Medicinal creams need to be applied where prescribed to ensure good skin care. The amount of medication received on admission must be recorded. Residents that selfadminister medication must have a lockable storage facility and checks must be made on the appropriateness of all their medication. Dudley Court Rest Home DS0000016864.V351126.R01.S.doc Version 5.2 Page 8 The home needs to ensure that residents can receive the appropriate level of privacy during attention to personal care. The range of activities provided was limited and the home did not record who had joined in activities in a consistent way. This means that some residents can be missed from having a meaningful activity. The raised bed in the garden needs a more suitable wall to retain the earth. A number of bedrooms on the ground floor have offensive odours and remedial action is needed to ensure that this improves. The home should continue with its refurbishment plans throughout the rest of the home and consider the recommendations to improve the environment. The management of the staffing needs to be improved to ensure that staff are not working excessive hours, to improve the access to senior carers, to ensure appropriate risk assessments are undertaken for staff with health conditions and to ensure all appropriate checks are in place. Staff training needs to be consistent for all staff and proof of the staff teams training needs to be kept. The home needs to draw up a development plan for improving the home based on a good quality assurance system. 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.V351126.R01.S.doc Version 5.2 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.V351126.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 1,2 & 3 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Information provided by the home is not in enough detail for residents to make a decision that the home could meet their needs. Information collected about residents is not detailed enough to ensure that all residents needs are met. EVIDENCE: There was information available for relatives and residents however this needed to be revised to give more detail of the service provided. For example further information was needed on the range of care needs the home could meet, the levels and the experience of the staff in the home and the ways in which the service ensured residents could have a say in the running of the home. This information helps residents make a choice about whether the home can meet their needs. Dudley Court Rest Home DS0000016864.V351126.R01.S.doc Version 5.2 Page 11 The care files seen had a contract on file and these had been updated this year. It was noted that the provider does not make any arrangements for insuring any of the residents’ belongings. There had been only one permanent stay admission since the last inspection, this stay started on the day of the preadmission assessment. The assessment information needed some improvement to include all the areas required by the standard. Details of how health conditions were affecting the resident needed to be improved. The home has one member of male staff, which means male residents cannot have the option of a male carer if they wish. Residents religion and was noted and this assists in planning for residents religious needs being met. Dudley Court Rest Home DS0000016864.V351126.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9 &10 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. Care plans did not always reflect how residents’ needs were met in enough detail and this can lead to care being given in an inconsistent way. Risks were consistently identified and planned for and this could lead to residents’ health being compromised. Medication administration needed to be improved to ensure that residents’ health could be assured. Whilst residents felt they were treated with respect and their dignity preserved the environment did not always assist this. EVIDENCE: Upon admission to the home an admission assessment is completed. Risk assessments for manual handling, nutrition and tissue viability are completed on most occasions. There was also a personal preference sheet. The files sampled showed a lack of detail in care plans and the way that risks were Dudley Court Rest Home DS0000016864.V351126.R01.S.doc Version 5.2 Page 13 assessed. This means that residents cannot be guaranteed that assistance is given in a consistent way or that appropriate instructions are in place to minimise risks identified. For example a resident that uses a wheelchair, rests on the bed and has a history of pressure areas was assessed as a low risk of developing pressure areas. As a result no plans were put in place to minimise the risk. Personal hygiene plans and continence plans did not reflect the individual resident’s needs. Care plans did not always give enough direction about how a residents health needs were to be met for example there was a lack of instruction about sight impairments and information about the medication residents were taking. Concerns were raised with us about the number of residents with pressure areas. Records indicated that residents that had pressure areas previously had improved and that appropriate consultations and from district nurses had been sought. A conversation with a district nurse indicated that on occasions referrals of reddened areas needed to be made more promptly. There was a lack of attention to skin care and application of medicinal creams by staff. All residents were said to be refusing administration of medicinal creams. Medicinal creams were not kept near where they needed to be administered. It was also noted on one district nurse records that a resident did not have olive oil drops administered consistently. Medication administration needed improvement. The home uses a monitored dosage system (MDS) of medication that is supplied by the pharmacist on a weekly basis. Three residents’ medication administration was looked at the following found. The medication in the MDS matched the medication administration record (MAR). Copies of the prescription were taken to check medication against when it was supplied. A resident refused medication on one occasion. There was neither record in the care notes or communication book of this refusal nor any instructions to staff about whether to try again later, nor any signs of ill health to look out for caused by the lack of medication. Handwritten medication details had not been countersigned by two members of staff as required. A new resident had no details of the amount of medication at the beginning of their stay so it was not possible to determine if the amount of medication left was correct. Controlled medication was correct with the record, however where it is no longer being used and waiting for return a system of checking the number left should be undertaken until it is returned. A resident was observed to have medication in their hand for several minutes awaiting water to take them with. The medication trolley and records had been cleared away. This indicates that medication had been signed for without the member of staff watching it being taken. A respite resident was self-administering medication and had large amounts of medication in an unlocked cupboard in their Dudley Court Rest Home DS0000016864.V351126.R01.S.doc Version 5.2 Page 14 bedroom. Medication training was being held in the home that day and other homes staff were attending not all care staff that worked in the home had medication administration training or were attending the training that day. Residents were treated with respect at the time of the inspection and appeared to have a good relationship with the staff. Residents spoken to said that when they needed help they activated the alarm and that staff soon came to help. Residents were mostly well presented having their personal care needs met as much as they would allow such as hair and nail care. A number of female residents were wearing jewellery and residents nail care was attended to. Residents that used spectacles, dentures and aids had these available to them. The home has a number of residents’ rooms that have doors and windows on to the conservatory. Residents’ privacy can be compromised by the use of the conservatory for training. One resident said ‘its getting on my nerves I can see him standing there waving his arms around.’ It was also noted that this resident uses a commode in this room. Dudley Court Rest Home DS0000016864.V351126.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 &15 Quality in this outcome area are adequate. This judgement has been made using available evidence including a visit to this service. The meals offered are of a satisfactory standard. There is a lack of stimulation and activities for residents on a regular basis so leading to boredom. EVIDENCE: Residents did not have an individual plan for interests and activities. The plan of activities on display in the reception area showed that the type of activities available was limited. The record of activities undertaken did not show which residents had been involved, so the home could not demonstrate that each resident benefited from some meaningful activity time and the schedule activity on the plan was not often recorded as taking place. Recorded activities undertaken with some residents over the last month were: - eye spy, chatting, music, singing, guess what’s in the bag, guess that name and play your cards right. A local vicar and a hairdresser also visit the home. One resident attends a luncheon club. A resident commented that the singing was ‘excellent’, ‘exercise and vicar visits could be more frequent’ there are ‘sometimes long gaps between activities.’ Relatives were able to visit when they wished a relative commented ‘everything is satisfactory at present.’ A resident said that relatives could stay Dudley Court Rest Home DS0000016864.V351126.R01.S.doc Version 5.2 Page 16 for a meal if needed.’ Another representative said ‘The home needs no improvement and the staff at Dudley court are not only supportive of my friend but also of me.’ Residents spoken with thought they could get up and go to bed when they wished. One resident remained in bed until about 11 am on the day of the inspection. Residents that wished could spend their time in their rooms and three residents were doing this during the inspection. Residents thought the food was good. Although the home employs a cook due to sick leave care staff were taking on this role. The inspector arrived at breakfast to find that the residents were having cereal and toast. All the residents spoken to thought they could have something cooked for breakfast if they wanted. A number of residents were having food supplement drinks. Residents had a choice of main meal of either cheese and potato pie or faggots with mashed potatoes and vegetables. The home provided four weeks of menus for inspection and these were found to provide a range of foods suitable for the residents. Residents that needed assistance to eat were helped appropriately. A resident said ‘what dinners you enjoy they try and provide again.’ Dudley Court Rest Home DS0000016864.V351126.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents’ can be assured that the home listens and responds to complaints. Staffs requires further training in adult protection to ensure that they are fully aware of and would know what to do in the event of an actual or alleged abuse situation. EVIDENCE: The home has received no complaints since the last inspection. There is a comment book kept in the reception area this has numerous comments from professionals visiting since the last inspection but none from residents or relatives. All the comments were good being mainly from training providers. There were three concerns raised by residents two about food, one saying they were given white bread on an occasion rather than brown, one wanting less cheese on their cheese on toast and one wanting to remain in the bedroom when the room needed cleaning and these were dealt with. We received a complaint about the skin care of the residents the outcome of this is reported at standard 8 and the attitude of a staff member according to the information received so far does not demonstrate any action against any residents and no further evidence was found on inspection. The home has policies in respect of adult protection, whistle blowing and restraint in order to safe guard residents from abuse. The staff files sampled Dudley Court Rest Home DS0000016864.V351126.R01.S.doc Version 5.2 Page 18 showed that not all staff had training on the protection of residents from abuse. Dudley Court Rest Home DS0000016864.V351126.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 19,20,21, 23,24, & 26 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. There have been improvements in the decor and furnishings further work was needed to minimise risks and to improve the odour control in the home to make this a pleasant environment for residents. EVIDENCE: It was clear that a large amount of work had been undertaken in the environment since the last inspection. The upper floors of the home had been redecorated. However the ground floor and garden area needed some improvement. The AQAA stated the outside of the home had been painted and the conservatory area varnished. The home is working to a plan of redecoration and refurbishment. Records were kept of maintenance undertaken. Dates of work requiring attention and being attended to were the same on all occasions and this was unlikely. Dudley Court Rest Home DS0000016864.V351126.R01.S.doc Version 5.2 Page 20 A passenger lift gives access to all areas in the home to enable access to all areas plus wheelchair access to the front of the home and from the conservatory to the garden. As previously stated a number of residents’ rooms open up on to the conservatory and this in part restricts the placement of furniture in the rooms. A number of bedrooms do not allow for the bed to be accessed by either side and this may mean that residents with high care needs and some wheelchair users cannot be accommodated appropriately. Residents can access the garden. Due to heavy rains the slabs that are retaining the earth in the raised bed have become unstable and more robust arrangements need to be made. The fire escape that comes into the garden needed a more robust caging on the second floor. The access to the fire escape from the first floor had been improved and no longer necessitates going through a bathroom. The conservatory was in use for training during part of the inspection and the provision of blinds was not looked at. Most of the bathrooms in the home have medibaths that are a step in and sit down type, which may not be suitable for all residents. The ground floor bathing facility was more accessible. A tour of the premises was undertaken and a number of bedrooms were viewed. It was evident that residents had personalised them with possessions including ornaments, photographs etc. providing a homely environment. The bedding and mattresses sampled during the tour found that these were generally of good quality and fit for purpose. Locks had been fitted to doors, but they were of the type that did not have a key to enable residents to lock the door from outside the room and could only be locked from inside the room. Locks should be of the type that residents could lock the door when going out to secure their possessions and these will need to be replaced. Staffs are able to get into rooms in an emergency if locked from the inside. Fire doors were restrained with the appropriate use of door guards on this inspection and this was an improvement from previous inspections. A number of the ground floor rooms had offensive odours on inspection and health professionals also mentioned this was an issue in the home. The home appeared clean and at a comfortable temperature. Hand wash and paper towels were available for staff and residents in shared washing and toilet facilities. The areas where substances hazardous to health were stored were locked. The home’s Annual Quality Assurance Assessment (AQAA) stated that they have acted on ensuring that all dried food is stored in suitable containers. Dudley Court Rest Home DS0000016864.V351126.R01.S.doc Version 5.2 Page 21 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 &30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The levels and the skill mix of staff on duty does not always reflect the needs of the residents and the tasks to be undertaken and this could lead to residents needs not being met. The recruitment of staff is carried out in a way that safeguards residents. Whilst staff receive training it is not shown that is received consistently across the staff group and this means that staff may not be able to give the care residents need in a safe way. EVIDENCE: Four weeks staff rotas were looked at it was found that, as at previous inspections there was not a senior carer available on each day shift. Whilst there was a clear plan to provide 4 carers on a morning shift and 3 on an afternoon shift with support of management hours on several occasions was below this level and this constitutes a risk to residents. The planned level was just sufficient to meet the needs of residents as staff also were undertaking cooking and cleaning duties. Staff were working long hours and in some cases were working more than 48 hours per week. There was no evidence of an assessment by the manager of Dudley Court Rest Home DS0000016864.V351126.R01.S.doc Version 5.2 Page 22 the continuing competence of staff working long hours. Staff with identified health condition did not have a risk assessment to ensure they work safely. The Annual Quality Assurance Assessment (AQAA) completed by the home indicated that 82 of care staff have completed a National Vocational Qualification level 2 in care. Files sampled found certificates in place for this. This is above the required level and means that staff have the training to provide care appropriately. A small sample of staff files were inspected and it was found that the home had a good employment procedure so safeguarding residents. Ensuring that all references are validated could enhance employment records. A new member of staff had started on the Common Induction Standards however it was unlikely that these would be completed in the timescale recommended. Staff have completed training on Food Safety, Abuse, dementia and infection control courses since the last inspection however there was no staff training matrix available to determine the gaps in training. Dudley Court Rest Home DS0000016864.V351126.R01.S.doc Version 5.2 Page 23 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): 31,33,35,36,37 & 38 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Records are not always held in way to ensure that trends of care practice can be identified and improved upon and this affects the service given to residents. Management of staffing issues of training and deployment needed to improved upon to ensure the care to residents. EVIDENCE: The manager has been in post for some time and has completed the Registered Managers Award qualification plus training in quality assurance. There are some quality assurance systems in place to ensure that the home is run in the way that benefits residents. Residents and staff have meetings to discuss how the home can improve. The proprietor visits the premises Dudley Court Rest Home DS0000016864.V351126.R01.S.doc Version 5.2 Page 24 regularly and provides monthly reports on the conduct of the home, which are forwarded to us. However audits of the service provided are not undertaken in a way that minimise risks of infection and falls or the way the home provides activities and so on. Residents are assisted with managing some parts of their personal allowance. Records are kept of money deposited by relatives for hairdressing and so on and receipts are kept. Four residents money was checked and this was accurate to the record held. Staff files looked at had evidence that supervisions were now being undertaken with staff in a routine way and this should mean that staff will meet the required standard of six recorded supervision sessions a year. The fax machine on the day of the inspection was not able to receive incoming faxes this is important as we send information about concerns raised about faulty medical aids and equipment. Records were checked about the health and safety of the building and this included: - Fire Safety, lifting equipment, gas and electrical installation checks and so on. All the maintenance and inspection checks required except for an inspection report of the passenger lift were in place. The fire safety could be improved by ensuring that all staff have the benefit of a fire drill on a six monthly basis, that records of the fire drill contain the outcome of the drill and any learning points. The fire risk assessment needed to consider any issues for individual residents. The West Midlands Fire Service had visited in September and made some requirements the date for these to be done had not expired. Dudley Court Rest Home DS0000016864.V351126.R01.S.doc Version 5.2 Page 25 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 3 2 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 2 10 2 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 1 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 2 2 X 2 X 2 2 X 2 STAFFING Standard No Score 27 1 28 3 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 2 X 3 3 X 2 Dudley Court Rest Home DS0000016864.V351126.R01.S.doc Version 5.2 Page 26 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 OP8 Regulation 13(3) 13(4)(c) Requirement Risk assessments must reflect the actual risks to residents especially in skin care. Plans to minimise the risks to residents must be put in place. Including timely referrals to health practitioners. 2 OP9 13(2) A safe system of medication administration must be put in place to include: A robust system for checking medication into the home. Two members of staff must countersign handwritten medication details. There must be a record of the amount of medication at the beginning of the month to enable auditing. The G.P. must be informed when residents refuse medication. Medication stored in the kitchen fridge must be in a locked Dudley Court Rest Home DS0000016864.V351126.R01.S.doc Version 5.2 Page 27 Timescale for action 15/11/07 15/11/07 container plus the minimum and maximum fridge temperature must be recorded and maintained between 2 and 8 degrees. ( this item was not assessed) Timescale of 27/9/06 and 28/02/07 not met. Medication must not be signed for as given until it the resident has taken it. Residents self administering medication must have a lockable store to keep it in and use it as part of the risk assessment process. Medicinal creams must be administered as prescribed wherever possible and refusals taken up with the GP. All staff that administer medication must have medication training and evidence of this must be retained on their files. 3 OP18 13(6) All staff must undertake training 15/12/07 in respect of adult protection procedures and the prevention of abuse. Timescale of 08/07/05 and 30/04/07 not met. The raised beds in the garden 15/12/07 must have a more appropriate wall to retain the earth. All staff must undertake updated 30/11/07 training in respect of moving and handling and records are retained in the home. Timescale of 30/7/06 and 30/04/07 not met. Evidence of an in date insurers 30/11/07 report for the passenger lift must DS0000016864.V351126.R01.S.doc Version 5.2 Page 28 4 5 OP19 23(2)(o) 13(5) 17(2) OP30 6 OP38 13(4) 23(2)(b) Dudley Court Rest Home be available at all times. Timescale of 30/03/07 not met RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 Refer to Standard OP1 Good Practice Recommendations The Statement of Purpose must be reviewed and enhanced in line with the regulations. Timescale of 01/01/06 and 30/05/07 not met. Except in emergency situations residents must have an assessment of their needs and risks prior to admission into the home. Timescale of 01/12/05 and 30/03/07 not met. Care plans must detail how all of residents identified needs are to met. Timescale of 01/01/06 and 30/04/07 not met. Care plans must also demonstrate evidence that residents, families or other representatives have been involved in their draft On admission you must write to residents confirming that they are able to meet their needs. Not met since last inspection 31/01/07 Staff must be provided with training in respect to drawing up care plans where necessary. Timescale of 30/07/06 not met. An assessment must be undertaken of residents past interests and hobbies, draw up a plan of meaningful activities following consultation with residents and ensure it is implemented maintaining records of activities participated in. Timescale of 01/01/06 and 30/04/07 not met. Blinds or similar to the conservatory roof to ensure that a reasonable temperature in this area can be maintained. Not inspected on this occasion A review of the bathing facilities should be undertaken to ensure there is a suitable bathing facility on each floor that residents can access safely. DS0000016864.V351126.R01.S.doc Version 5.2 Page 29 2 OP3 3 4 OP7 OP7 5 6 OP7 OP7 7 OP12 8 9 OP19 OP21 Dudley Court Rest Home 10 11 12 13 14 OP23 OP26 OP29 OP30 OP30 Timescale of 30/08/06 and 30/07/07 not met. Residents are consulted about holding a key to their door and this is recorded in their records. Timescale of 30/06/07 not met The home should have measures in place to ensure that the home is odour free. All staff references should be validated and evidence retained. The common induction standards for new staff should be completed within the 12 week timescale set and evidence of this retained on the staff’s file. A risk assessment must be undertaken to determine the level of need for first aid of the residents. The staff duty roster must show which staff is the designated first aider for the shift. 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. A fax machine should be available that is able to take incoming faxes. All the requirements made by the fire officer are addressed. All staff must have the benefit of a six monthly fire drill. Timescale of 01/12/05 and 30/03/07 not met. 15 OP33 16 17 18 OP37 OP38 OP38 Dudley Court Rest Home DS0000016864.V351126.R01.S.doc Version 5.2 Page 30 Commission for Social Care Inspection Birmingham Office 1st Floor Ladywood House 45-46 Stephenson Street Birmingham B2 4UZ 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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