Inspection on 31/01/07 for Dudley Court Rest Home

This inspection was carried out on 31st January 2007.

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 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 Ann Farrell Key Unannounced Inspection 31st January 2007 08:30 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.V328315.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.V328315.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.V328315.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 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. 5th June 2006 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 six single bedrooms and one double bedroom and there are three bedrooms on the second floor. The remaining rooms have a wash Dudley Court Rest Home DS0000016864.V328315.R01.S.doc Version 5.2 Page 5 hand basin and all areas have a call bell. There is a separate laundry area on the second floor. 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 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 range from £322 to £398 per week depending on the accommodation. SUMMARY This is an overview of what the inspector found during the inspection. The fieldwork inspection was conducted over one day commencing at 8.30. The manager was not available as she had been on sick leave for approximately six weeks. During the fieldwork a senior carer, two members of staff and six residents were spoken to. The feedback from residents was good in a number of areas they stated they liked living in the home, the staff and food were good, but they got bored at times as there was a lack of stimulation The inspector toured the home, sampled residents files and other documentation. Case tracking was used to determine care for residents from the time of admission to the home plus direct and indirect observation. Information was also utilised from the pre inspection questionnaire, which was provided by the home prior to the fieldwork. A random inspection was conducted in 25th September 2006 to follow up on the requirements from the previous key inspection. At that inspection the home was found to be making progress with the requirements and there were noted to be improvements. The dependency of residents had decreased and as a result staff were better able to meet residents needs. Improvements are continuing however, the manager and senior staff will need to be aware of their limitations and ensure residents whose needs increase are reviewed by professionals and appropriate action taken to ensure their needs are met. What the service does well: Visiting is flexible enabling relatives to visit at a time that suits them. Relatives were observed to be welcomed by staff on visiting and there positive comments by visitors in the comments book in the entrance hall. Dudley Court Rest Home DS0000016864.V328315.R01.S.doc Version 5.2 Page 6 Comments received from residents were generally positive; they stated the staff were good, the food was good and they enjoyed living in the home. One resident stated, “I could not have come to a better place”. The district nurse was visiting at the time of inspection as she stated staff were friendly, referred where necessary and carried out instructions so ensuring residents health care needs were being met. What has improved since the last inspection? What they could do better: The assessment and care planning system needs to be developed and staff training provided to ensure residents needs are identified and met. The medication system needs to be reviewed and improved to ensure a robust system is in place and residents receive the medication they are prescribed. The arrangements for activities needs to be reviewed and enhanced to ensure residents are offered further opportunities for stimulation. The bathing facilities must be reviewed and upgraded to meet resident’s needs. The cleanliness of the home needs improving to ensure residents live a clean hygienic environment. The manager will need to ensure requirements form inspections are met in a timely manner to provide positive outcomes for residents. Dudley Court Rest Home DS0000016864.V328315.R01.S.doc Version 5.2 Page 7 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.V328315.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Dudley Court Rest Home DS0000016864.V328315.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1,2,3,4 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. The information available for prospective residents and their relative’s about the services and facilities needs developing further to enable them to make an informed decision about moving into the home. The admission procedures do not currently identify resident’s needs effectively and therefore it cannot be guaranteed that residents needs will be identified and met prior to admission. EVIDENCE: Information is available in individual bedrooms about the services and facilities. On inspection it was noted that the statement of purpose requires further development, the complaints procedures needs some amendment to clarify the procedure. It is also recommended that copies are made available in the reception area for prospective residents and their representatives. On inspection of resident’s files there was no contract or statement of the terms and conditions of the home. A contract must be provided to all residents Dudley Court Rest Home DS0000016864.V328315.R01.S.doc Version 5.2 Page 10 and a copy retained on their files to ensure they are aware of the terms and conditions of residency. On inspection of a sample of resident’s records it was noted that there were pre-admission assessments. However, some of them were not signed, they were pre-populated and areas had been circled by staff to indicate which aspects was relevant, but no detail had been given and there was no indication of residents strengths. The assessment process will need to be reviewed to ensure a more comprehensive assessment is undertaken so that all residents needs can be identified and appropriate care plans put into place following admission to the home to ensure residents needs are met. There was no evidence that the home write to residents confirming they can meet their needs, which is required under the regulations and this will provide confidence to the resident that their needs will be met. The home currently accommodates some residents with a mental health condition. The home is registered to accommodate residents for reason of old age. Staff individually and collectively do not have the knowledge to meet individuals needs where they have a mental health disorder. Therefore staff will need training in this area. Dudley Court Rest Home DS0000016864.V328315.R01.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9,10 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 medication systems so ensuring residents receive mediation prescribed for them. Care plans are not adequate to provide staff with clear guidance on all aspects of residents needs so that they can be met in a consistent manner EVIDENCE: Upon admission to the home an admission assessment is completed with risk assessments for manual handling, nutrition and tissue viability are completed in some cases. There was also a personal preference sheet. The admission documents gave little further information about residents needs to the preadmission assessments. Following assessments care plans are drawn up for each resident, which outlines how the resident’s needs are to be met by staff following admission to the home. On inspection of a sample of records it was noted they were of a poor standard all areas of need had not been included in the care plans, statements were vague, they were lacking in detail, were difficult to follow and had not been reviewed regularly. The care plans were based on physical care mainly and lacked information about emotional and Dudley Court Rest Home DS0000016864.V328315.R01.S.doc Version 5.2 Page 12 psychological aspects of care. In some cases there was no evidence that the resident or their representative had been involved in the care planning process to ensure their wishes and preferences are taken into consideration. The care plans in respect of diabetes stated staff would monitor blood sugar levels if problems were identified. However, this is an invasive procedure and there was no evidence that staff had undertaken any training in this area. Also staff did not have adequate knowledge about diabetes and normal blood sugar levels. Some training will be required in this area to provide staff with the appropriate knowledge to manage this condition effectively. Generally there had been little development in this area. It appears staff does not have a full understanding of the care planning process and without this it cannot be guaranteed that all residents needs will be met. . This area will need to be reviewed and training provided where necessary. Staff complete daily records in respect of each resident. Although there has been some improvements since previous inspections they did not indicate the type of day residents had experienced, their emotional or psychological state, concerns etc. It one case records indicated that a visiting health professional had identified that a residents was depressed. It was concerning there was no evidence that staff had identified this and taken action. Records of personal care provided by staff indicated that some residents had not had a bath or shower for some time; therefore, their personal hygiene needs were not being met consistently. From discussion it became apparent that the bathing facilities on the first and second floor, which are “sit in” baths, are not used, as residents do not like them. A review of bathing facilities will need to be undertaken and action taken to provide appropriate bathing facilities. All residents are registered with local G.P. and records confirmed visits by them. The senior carer stated residents who had diabetes attended a clinic regularly. The district nurse visits on a regular basis and on discussion with her she stated the staff were welcoming, referred residents appropriately and carried out instructions satisfactorily. Records of visits by other health professionals indicated the chiropodist and optician visited fairly regularly, but there was no evidence of visits by a dentist. On discussion with some residents they stated they had not seen a dentist. Residents are weighed on admission to the home and intermittently to monitor nutritional status. However, on the files sampled there was no evidence of this occurring over the past three months. A call bell is available in all rooms and action has been taken to lengthen cords since the last inspection. However, it was noted that some residents were Dudley Court Rest Home DS0000016864.V328315.R01.S.doc Version 5.2 Page 13 sitting in their bedrooms and the call bell was not accessible in order to summon for assistance if required. The home uses a monitored dosage system of medication that is supplied by the pharmacist on a weekly basis. On inspection it was found that the administration of medication in the cassettes was satisfactory and there had been some improvements since the last inspection. Areas that need attention to ensure a robust system include: • Staff do not have a robust system for checking medication into the home, as they do not have copies of prescriptions to check medication entering the home. A suitable system will need to be developed. • Handwritten medication details had not been countersigned by two members of staff as required. • There were no details of the amount of medication at the beginning of the month to enable auditing in some cases. • The administration of variable dose medication and not been consistently recorded and could not be audited. • Eye drops had not been consistently dated when opened. They must be dated when opened and discarded after one month to due the risk of bacterial infection. • In one case a resident was refusing medication and the GP had not been informed. • There was no evidence of written consent for flu vaccinations. At the time of visiting the hairdresser was present. Many of the ladies had their hair attended to and looked well presented. However, some of the men looked as if they needed shaving, one resident nails required cleaning, and some did not have socks/stocking in place. Some further attention to detail is required to ensure all residents are well presented and their needs met. Staff were noted to be pleasant and polite to residents. Resident’s privacy was respected and staff knocked doors before entering rooms. Residents stated the staff were good. One stated,” I could not have come to a better place”. Dudley Court Rest Home DS0000016864.V328315.R01.S.doc Version 5.2 Page 14 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 is 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: There were no unnecessary restrictions to resident’s daily routines. On discussion with some residents they stated they were able to get up and go to bed when they wanted and had a cup of tea first thing in the morning. One resident stated she was able to walk to the local shops when she wished. Visiting is flexible enabling relatives to visit at a time that suits them to maintain contact. Staff greeted relatives who visited at the time of inspection on entering the building. Residents are able to bring personal items of furnishings etc into the home and some rooms were found to be well personalised by residents; reflecting their individual taste and interest. On discussion with residents it was stated that progressive mobility visited once a month and they had a range of exercises, singers come into the home intermittently. The vicar and priest visits and the home celebrate events such as Christmas and Halloween. On discussion with residents they stated they Dudley Court Rest Home DS0000016864.V328315.R01.S.doc Version 5.2 Page 15 had a good Christmas and there was entertainment coming up to Christmas. Residents were observed to be watching the television or listening to music. One resident goes out regularly to a lunch club. However, residents stated they did is get bored at other times and would appreciate more activities. There was little evidence in residents files of activities undertaken, there was no assessment of their past interests or hobbies and no plan of activities on a daily basis for stimulation of residents. This area will need to be addressed more fully to provide residents with appropriate stimulation to meet their needs and preferences. The home employs separate catering staff who provide three full meals per day. There is a four-week rotating menu, which provides a choice of meals at lunchtime and evening meal. Records of food taken by residents indicated all residents had the same meal at lunch times. On discussion with residents they stated they enjoyed the meals and liked the food. At lunchtime tables were laid with condiments, the atmosphere was relaxed and residents were given time to eat meals at their own pace. The main meal was roast pork and residents enjoyed it. Dudley Court Rest Home DS0000016864.V328315.R01.S.doc Version 5.2 Page 16 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16,18 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The procedures in place and staff knowledge were adequate in respect of complaints and protection of residents. EVIDENCE: The home has a complaints procedure displayed on the notice board on entering the home. However it was a little confusing, as it did not make it clear until the bottom of the notice that complainant could contact the Commission at any stage in the process. It is recommended that this be reviewed and made clearer. On discussion with residents they stated they were not aware of the procedure, but if they had any concerns they would speak to the manager. On discussion with staff they stated that if the residents voiced any complaints they would inform the senior carer or manager verbally. There was no record of any complaints in the home. The Commission had received concerns about the cleanliness of the home. At the time of visiting it was noted that there had been no member of domestic staff for a number of months and a new member of staff had commenced employment the day prior to the inspection. It was found that some areas had not been cleaned effectively and this did not ensure good standards of hygiene. Dudley Court Rest Home DS0000016864.V328315.R01.S.doc Version 5.2 Page 17 The manager must ensure all concerns/informal complaints and formal complaints are recorded to include the nature of the complaint, the investigation, outcome, action taken and resolution. The home has policies in respect of adult protection, whistleblowing and restraint in order to safe guard residents from abuse. However, there was no evidence that staff had received training in these areas. On discussion with some staff they stated they were not allowed to restrain residents. Staff will require training in restraint and techniques of managing difficult behaviours, which remains outstanding from previous inspections to ensure they are aware of how to manage challenging behaviours. On discussion with some staff they were aware of the adult protection procedures, but there was no evidence to indicate that all staff had received training in this area. Staff training will be required to this area to ensure residents are fully protected. Dudley Court Rest Home DS0000016864.V328315.R01.S.doc Version 5.2 Page 18 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): 19,20,21,23,24,25,26 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. There have been some improvements in the decor and furnishings. The bathing facilities are not adequate to meet residents needs. The standard of cleaning and infection control practices were not adequate to meet hygiene standards. EVIDENCE: On arrival at the home it was noted that the exterior of the building requires decorating, a number of window frames were damaged and need replacing. The clinical waste bin was not locked and this poses a risk of infection or injury. There is ramped access to the building for wheelchair access. There is a pleasant garden to the rear of the property, which was tidy and orderly; there is a patio area and seating for when weather permits. 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. Dudley Court Rest Home DS0000016864.V328315.R01.S.doc Version 5.2 Page 19 On entering the home it was warm and odour free. The general standard of cleaning was not adequate, as areas of behind beds, shelving, extractor fan etc were dusty. The home has been without a domestic member of staff for a number of months and a new member of staff has just been employed. This area will need to be addressed to ensure residents live in a pleasant clean environment. Some areas were in need of decoration, walls were stained and paintwork was chipped. A full audit needs to be undertaken and a plan of re-decoration drawn up and implemented to ensure residents live in a well maintained home. There are two pleasant lounges, one of which is a quiet lounge leading from the reception area. Chairs have been replaced since the last key inspection enhancing the environment for residents. There is also a conservatory to the rear of the building that looks out onto the garden, which provides residents with a choice of areas to sit. There are blinds to the windows, but not to the ceiling and during last summer the sun was beating down on residents sitting there, which proved to be uncomfortable. Some type of blinds will need to be fitted for when the weather improves to enable the area to be utilised more comfortable by residents. 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. Bedrooms had a wash hand basin and call bell to summon assistance when required. Other furnishings were present as outlined in the National Minimum Standards, but it was noted that some of the furnishings were damaged and will require replacement. Lockable facilities had been provided in some rooms to enable residents to store valuables or medication, but were not secured. 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 can lock the door when going out to secure their possessions and these will need to be replaced. One bedroom door was found to have a mortise type lock that was in position at the time of the last inspection and it was advised that it should be replaced with a more suitable type. During the inspection it was noted that the recommendations from the fire officer had not been addressed. The proprietor stated the equipment had been purchased and they were waiting to have it fitted. Wedges for propping doors open were in evidence. On discussion with one resident she stated she normally had her door propped open as she gets claustrophobic and she cannot open the door to access the toilet. The proprietor will need to link doors into the fire alarm system where necessary to meet resident’s needs. It was also noted that a double adaptor was in use, which should be replaced with a socket board to meet safety regulations. Dudley Court Rest Home DS0000016864.V328315.R01.S.doc Version 5.2 Page 20 The proprietor replaced some mattresses following the last key inspection, but the springs could be felt through one resident’s mattress. A full audit of all mattresses must be undertaken and damaged or worn mattresses must be replaced. The bathrooms on the first and second floor are a “step in and sit down” type, but are not used as residents do not like them and the inspector did not feel they were the most appropriate for the client group. There is also a second bathroom on the first floor, which is in a poor state, and it is recommended that this be replaced with a suitable bathing facility that can be accessed by residents e.g. flat floor shower. On inspection of the kitchen some areas had not been cleaned effectively, dried foods had been opened and had not been stored in airtight containers and staff were washing crockery by hand. The Chartered Institute of Environmental Health – food safety first principles state that there should be two sinks and the items should be washed in the first sink at 55 degrees centigrade. Items should then be rinsed in hot water 82 degrees centigrade in the second sink leaving them to soak for 30 seconds using a designated basket for the purpose if possible. Items should be left to air dry in a clean dry area. This practice was not observed at the time of inspection and the home will need to review this or provide a suitable dishwasher. Fridge and freezer temperatures were recorded for some of the equipment only. Also medications stored in one of the fridges and minimum and maximum temperature recording is required to ensure medication is stored at the correct temperatures. Dudley Court Rest Home DS0000016864.V328315.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. Satisfactory recruitment procedures are implemented so protecting residents. Staffing levels are adequate, but the skill mix is not always suitable as a senior member of staff is not on duty to ensure resident’s needs are met. Staff training has commenced so providing staff with the skills and knowledge required to meet resident’s needs. EVIDENCE: Staffing rotas indicated there were usually three care staff on duty during the day and two care staff overnight. Currently there are only two senior care assistants which results in times when there is no senior carer on duty during the day and currently the manager is on sick leave. The proprietors must ensure there is a senior member of staff on duty during the day to ensure there is a suitably trained and qualified member of staff to meet resident’s needs and deal with any problems or emergencies. Catering and domestic staff support care staff. It was noted that the member of domestic staff had recently commenced employment and the home had been without a member of domestic staff for several months. However, this was not demonstrated clearly on the duty rotas so giving the impression that a member of domestic staff had been working in the home. The proprietor or manager must ensure the duty rotas are accurate and reflect the staff who are on duty. Dudley Court Rest Home DS0000016864.V328315.R01.S.doc Version 5.2 Page 22 A small sample of staff files were inspected and it was found that the home had a robust employment procedure so safeguarding residents. The file for the new member of domestic staff demonstrated the homes induction training had been undertaken. The manager has not employed any new carers since the last inspection; therefore the induction training could not be inspected. However, at previous inspections it was identified that the induction training given did not meet the standards of the Social Skills Council so providing the staff with the necessary knowledge initially. Therefore, the requirement will be carried forward. The information provided indicated that 50 of care staff have completed NVQ level 2 training, which meets the standards and provides them with the skills and knowledge to meet residents needs. Records in respect of other training demonstrated that some staff have completed training recently in respect of infection control, manual handling and first aid ensuring they are updated in the basic areas. This training will need to be undertaken by the remainder of the staff. Training in respect of fire prevention and basic food hygiene will also be required for all staff to ensure they have the skills and knowledge to work safely and meet residents needs. It was stated that further training has been arranged for later in the year. Dudley Court Rest Home DS0000016864.V328315.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): 31,33,35,36,38 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Management systems are not sufficiently developed to ensure resident’s benefit from living in a well managed home. EVIDENCE: The manager has been in post for some time and has completed the Registered Managers Award qualification plus training in quality assurance. At the time of inspection she had been on sick leave for some time and a senior carer was taking charge. There is no quality assurance system in place to audit systems and identify areas that require development etc. The proprietor visits the premises regularly and provides monthly reports on the conduct of the home, which are forwarded to the Commission. Dudley Court Rest Home DS0000016864.V328315.R01.S.doc Version 5.2 Page 24 Examination of staff files demonstrated that formal staff supervision was not undertaken six times a year as required by the National Minimum Standards. This area will need to be addressed in order to monitor staff progress; training needs and identify any areas of concern. The proprietor stated they did not act as appointee or agent for any residents. They do hold some money on behalf of residents in a secure facility and records of transactions and balances were accurate. Receipts were available for all withdrawals, but not consistently available for deposits. It is recommended that this area be addressed to ensure a fully robust system. A sample of maintenance and servicing records were inspected to ensure aspects of health and safety were met. It was found that the majority of equipment had been serviced as required; so ensuring they were safe for use. It was noted there had been 23 call outs to the passenger lift during the last year, but there was no evidence of servicing. The proprietor has now provided evidence to demonstrate it has been serviced, but an insurers report remains outstanding. There were no records in regarding maintenance/servicing of wheelchairs to ensure they are safe for use and this will need to be followed up. Water had been tested for legionella and was found to be satisfactory. However, there had been no treatment of the tanks such as chlorination. Where chlorination or other treatment is not undertaken the home must demonstrate that water is stored and circulating at the correct temperatures and records maintained to demonstrate this. Also records must be retained to indicate that water is run regularly from taps that are not used regularly to demonstrate adequate precautions in respect of legionella. The records of water temperatures from hot taps indicated it was 43 degrees almost every time. When this was checked with the bath thermometer it was found the temperature ranged from 28 to 41degrees. The system will need to be reviewed to ensure accuracy and water from outlets is maintained at 43 degrees plus or minus 1 degree to reduce the risk of scalding. Dudley Court Rest Home DS0000016864.V328315.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 1 2 2 X N/A HEALTH AND PERSONAL CARE Standard No Score 7 1 8 2 9 2 10 3 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 2 1 x 3 2 2 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 X 2 X 2 2 X 2 Dudley Court Rest Home DS0000016864.V328315.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 OP1 Regulation 4 Requirement Timescale for action 30/05/07 2 OP2 5(1)(b) The Registered Person must review and enhance the Statement of Purpose in line with the regulations. Timescale of 01/01/06 not met. The Registered Person must 30/03/07 ensure all residents have an individual statement of terms and conditions (contract) and a copy is retained on their files Timescale of 01/01/06 not met. Dudley Court Rest Home DS0000016864.V328315.R01.S.doc Version 5.2 Page 27 3. OP3 1418(1) 4 OP4 12(1) 5. OP7 1518(1) The registered person must 30/03/07 ensure: • All residents admitted to the home have a comprehensive preadmission assessment undertaken by a competent person. Timescale of 01/12/05 not met. • Must write to residents confirming that they are able to meet their needs. • The admission assessment must be comprehensive and include aspects such as tissue viability. • Where necessary staff should receive training in competing assessment. Timescale of 01/7/06 not met. The registered person must 30/06/07 ensure all staff undertake training in caring for residents with mental health problems who are residing in the home. The Registered Person must 30/04/07 ensure: • Care plans are comprehensive, holistic and outline in detail how resident’s needs are to be met by staff. • They must also demonstrate evidence that residents, families or other representatives have been involved in their draft and review. Timescale of 01/01/06 not met. • Staff must be provided with training in respect to drawing up care plans where necessary. Timescale of 30/07/06 not met. Dudley Court Rest Home DS0000016864.V328315.R01.S.doc Version 5.2 Page 28 6. OP7 17(2) 12(1)(2) 7 OP7 17(2) 8. OP7 15 9. OP8 12(1) 10 OP8 12(1) 18(1) The registered person must ensure residents are consulted about their preferences in respect of bathing, record it in the care plan and ensure systems are in place to meet their requests. Timescale of 30/11/06 not met. The registered person must ensure daily records clearly demonstrate details about residents day, the care provided and any concerns. 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. Timescale of 01/01/06 not met. The registered person must ensure: • A nutritional risk assessment is undertaken for all residents entering the home and it is reviewed on a regular basis. • Ensure that all residents are weighed when they enter the home and this is reviewed on a regular basis. Timescale of 30/06/06 not met. The registered person must review: • The care plans and arrangements in place for dealing with residents with diabetes especially if the blood sugar is too high or too low. • Ensure all staff receive training in respect of caring for residents with diabetes. 30/03/07 28/02/07 30/03/07 30/03/07 30/04/07 Dudley Court Rest Home DS0000016864.V328315.R01.S.doc Version 5.2 Page 29 11. OP8 12(1) 13(4) 12(1) 13(318(1) 12. OP8 13 OP8 13(1) 12(1) 13(7) 18(1) 14. OP8 15 OP8 12(1) 18(1) The registered person must ensure call bells are accessible to all residents when in their bedrooms. The registered person must ensure there is a consistent approach to catheter care and all staff are aware of it, providing training where required. Carried forward from 30/06/06 as not assessed The registered person must ensure there are systems for residents to see a dentist on a regular basis. The registered person must ensure: Staff are provided with training in respect of managing difficult situations and the appropriate use of restraint. Timescale of 30/6/06 not met. The registered person must ensure all staff are provided training in respect to continence management, the correct use of barrier creams and pads and prevention of pressure sores. Timescale of 01/7/06 not met. 25/02/07 30/06/07 30/06/07 30/06/07 30/05/07 Dudley Court Rest Home DS0000016864.V328315.R01.S.doc Version 5.2 Page 30 16. OP9 13(2) 17. OP9 13(2) 28/02/07 The registered person must ensure a fully auditable and safe medication system 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 amount of medication administered when variable doses are prescribed must be recorded. • Eye drops must be dated when opened and discarded after one month. • The G.P. must be informed when residents refuse medication. • Written consent must be obtained for vaccinations. • Medication stored in the kitchen fridge must be in a locked container plus the minimum and maximum fridge temperature must be recorded and maintained between 2 and 8 degrees. Timescale of 27/9/06 not met. The registered person must 30/07/07 ensure the medication policy is reviewed and updated to include the ordering, checking, storage, administration and disposal of medication. Also homely remedies and selfadministration. Carried forward from 30/07/06 as not assessed Dudley Court Rest Home DS0000016864.V328315.R01.S.doc Version 5.2 Page 31 18 OP12 12(2)(3) 19. OP16 22 20. OP18 13(6) 21. OP19 16(2)(j) 22 OP19 16(2)(j) 22 OP19 13(3)(4) The Registered Person must ensure an assessment is 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 not met. The registered person must ensure: • All residents and relatives must be made aware of the complaints procedure. • Review the procedure to ensure it clearly informs people of their right to contact the Commission at any stage. Timescale of 12/6/06 not met. The Registered Person must ensure that all staff undertake training in respect of adult protection procedures and the prevention of abuse. Timescale of 08/07/05 not met. The registered person must ensure a suitable method for washing the dishes is in place. Timescale of 30/6/06 not met. The registered person must ensure: • All dried food items are stored in sealed containers. • The temperature of all refrigeration equipment is monitored regularly. The registered person must ensure the yellow clinical waste bin is kept locked. 30/04/07 30/03/07 30/04/07 30/06/07 01/03/07 28/02/07 Dudley Court Rest Home DS0000016864.V328315.R01.S.doc Version 5.2 Page 32 23. OP19 23(2)(b) 24. OP20 23(2)(a)( b) 23(2)(n) 13(4) 25. OP21 26. OP24 16(2c) 27. OP24 16(2(c) 23(2)(m) 12(3) The registered person must ensure: • The exterior of the home is decorated and windows in a poor state of repair are replaced. • An audit is undertaken of the interior and a programme of redecoration is undertaken. Timescale of 30/12/06 not met. The registered person must provide blinds or similar to the conservatory roof. Timescale of 20/07/06 not met. The registered person must: Undertake a review of the bathing facilities and ensure there is a suitable bathing facility on each floor that residents can access safely. Timescale of 30/08/06 not met. The Registered Person must ensure an audit of all furniture and mattresses is undertaken and any items that are in poor condition are replaced. Timescale of 01/01/06 not met The Registered Person must ensure the mortice lock on the bedroom door is replaced with a more suitable system that guarantees their privacy but can be accessed by staff in an emergency. Timescale of 1/12/05 not met. 30/08/07 30/04/07 30/07/07 30/03/07 30/03/07 Dudley Court Rest Home DS0000016864.V328315.R01.S.doc Version 5.2 Page 33 28. OP24 16(2(c) 23(2)(m) 12(3) 29. OP24 23(4) 30. OP25 23(2)(p) 31 OP26 23(2)(d) The registered person must ensure: • All bedroom doors are provided with a suitable locking system that enables residents to lock it when they are in or out of their room, but can be accessed in the case of an emergency. • Residents are consulted about holding a key to their door and this is recorded in their records. • Lockable facilities are provided for all residents in their bedrooms and they are consulted about holding a key and this is recorded in their records. Timescale of 30/10/06 not met. The registered person must ensure: • All fire doors are kept closed. If there is a need to keep them open they must be linked in to the fire alarm system. Timescale of 7/6/06 not met. • All the requirements made by the fire officer are addressed. The registered person must ensure: • There is adequate lighting in all areas of the home at all times. Timescale of 20/07/06 not met. • Double adaptors are not used with electrical appliances. The registered person must ensue all parts of the home are kept clean at all times 30/06/07 28/02/07 28/02/07 28/02/07 Dudley Court Rest Home DS0000016864.V328315.R01.S.doc Version 5.2 Page 34 32. OP26 13(3) 33. OP26 13(4) 34. OP27 18(1a) 35. OP30 18(1) 17(2) 36 OP30 23(4)(d) (e) 17(2) 37 OP30 13(5) 17(2) The registered person must ensure adequate infection control procedures to include: • Staff hand washing facilities must be provided in resident’s rooms where staff provide personal care. Timescale of 20/6/06 not met. The registered person must ensure the areas to the staff toilet and COSHH cupboard is kept locked at all times when not in use. Timescale of 7/6/06 not met. The Registered Person must ensure a senior carer is on duty during each shift throughout the day. Timescales 17/12/04, 08/06/05 and 01/01/06 not met. • The duty rota must accurately demonstrate staff who are on duty The registered person must review the induction training to ensure it provides staff with the relevant knowledge to undertake their role competently, it meets recognised standards and records are available in the home to demonstrate it has been completed and staff are competent to undertake the duties required of them. Timescale of 30/7/06 not met. The Registered Person must ensure all staff undertake up to date fire safety training and fire drills are least twice a year and records are retained in the home. Timescale of 01/12/05 not met. The registered person must ensure all staff undertake updated training in respect of moving and handling and records are retained in the home. Timescale of 30/7/06 not met. DS0000016864.V328315.R01.S.doc 30/06/07 28/02/07 28/02/07 30/05/07 30/03/07 30/04/07 Dudley Court Rest Home Version 5.2 Page 35 38 OP30 16(2)(j) 17(2) 39 OP30 13(4) 17(2) 40. OP33 25 41. OP36 18(2) 42. 43. OP38 OP38 13(4) 23(2)(b) 13(4) 23(2)(c) The registered person must ensure all staff undertake training in respect of basic food hygiene and records are retained in the home. Timescale of 30/8/06 not met. The registered person must ensure all staff undertake training in respect of first aid and records are retained in the home. Timescale of 30/8/06 not met. 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 selfmonitoring, through a verifiable method, using preferably a professionally recognised quality assurance system. Timescale of 01/2/06 not met. The registered person must ensure all staff receive formal supervision at least six times a year and the process is reviewed to include all aspects of practice, philosophy of care plus career development needs. Timescale of 30/8/06 not met. The registered person must provide evidence of an insurers report for the passenger lift. The registered person must ensue: • Wheelchairs are serviced on a regular basis and records are retained in the home. Timescale of 20/6/06 not met. • Put systems in place to demonstrate adequate controls in respect of legionella. Timescale of 30/10/06 not met. DS0000016864.V328315.R01.S.doc 30/05/07 30/06/07 30/06/07 30/04/07 30/03/07 30/04/07 Dudley Court Rest Home Version 5.2 Page 36 44. OP38 13(4)(a) The registered person must ensure the record of water temperatures from hot taps clearly indicates the actual temperature of the water. The water must be maintained at 43 degrees or - 1 degree and action must be taken where temperatures are not maintained. Timescale of 30/07/06 not met. 30/03/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. Refer to Standard OP25 OP26 Good Practice Recommendations It is recommended that the Registered Person give consideration for the lighting in the dining room to be made more homely. (Carried forward) It is strongly recommended that Health protection unit be contacted for advise and support in respect of infection control measures in the home. (Carried forward) It is recommended receipts be given for all deposits of money and valuables. 3 OP35 Dudley Court Rest Home DS0000016864.V328315.R01.S.doc Version 5.2 Page 37 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. Extracts may not be used or reproduced without the express permission of CSCI Dudley Court Rest Home DS0000016864.V328315.R01.S.doc Version 5.2 Page 38 - 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. 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