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Inspection on 05/06/06 for Dudley Court Rest Home

Also see our care home review for Dudley Court Rest Home for more information

This inspection was carried out on 5th June 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Poor. 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.

What follows are excerpts from this inspection report. For more information read the full report on the next tab.

What the care home does well

Four of the residents spoken with expressed positive comments about the service. They stated they enjoyed the food and the staff were good. Relatives who were visiting confirmed they could visit at any time and found the staff welcoming and friendly and were kept informed of any changes in their relatives condition. They had no complaints, but stated that if there were any concerns they would speak to the manager or proprietors. Visiting health professionals stated the staff were very pleasant Residents stated they were able to get up, go to bed and spend time as they wished. The atmosphere in the home was relaxed and friendly and staff stated they enjoyed working in the home.

What has improved since the last inspection?

The inspector could evidence no improvements at the time of inspection.

What the care home could do better:

There has been little development since the last inspection and many of the requirements still need to be addressed. The proprietors will need to take more positive action to address these issues in a timely manner and demonstrate the home is being well managed. Re-decoration and refurbishment with replacement of windows and attention to the garden area is required to enhance the surroundings and provide a homely environment for residents. Improvements in infection control procedures are required with staff training, practices and equipment to ensure the risk of cross infection is reduced. Arrangements for the cleanliness and management of odour needs to be addressed with some haste to ensure residents have a clean and pleasant environment to live. The call bell system needs to be extended to ensure that residents have access to a call bell in all areas. The management need to further develop the recruitment procedures before staff commence employment to ensure residents are adequately protected. Staff training is required to ensure staff have the appropriate skills and knowledge to care for residents and fully meet their needs. Records of the training completed by staff must be available to demonstrate the training has been completed. The assessment and care planning process needs to be enhanced to ensure resident`s needs are identified and appropriate plans of action put into place to address all needs. There needs to be a more pro-active approach to care with monitoring, early identification of any concerns plus appropriate follow up and referrals to health professionals where required. Staff need to provide more attention to detail when care is provided to residents to ensure their dignity is respected and maintained. Adequate staffing levels must be maintained at all times with a senior care assistant on duty during the day and a formal on call system that all staff are aware of.The quality assurance system needs to be reviewed and developed further and where any issues are identified by residents or stakeholders action must be taken to address them. The systems for dealing with concerns and complaints needs to be reviewed and a more pro-active approach taken to ensure residents are listened to, concerns addressed and they are adequately protected. The arrangements for resident`s finances need to be reviewed and a robust record keeping system in place. A number of areas in respect of the maintenance and servicing of equipment need to be addressed with some urgency, to ensure a safe environment for residents. The arrangements for activities and stimulation of residents need to be reviewed and enhanced to ensure resident`s needs are being met.

CARE HOMES FOR OLDER PEOPLE Dudley Court Rest Home 16 Dudley Park Road Acocks Green Birmingham West Midlands B27 6QR Lead Inspector Ann Farrell Unannounced Inspection 5th June 2006 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.V298344.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.V298344.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.V298344.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. 1st November 2005 3. 4. 5. 6. Date of last inspection Brief Description of the Service: Dudley Court is a three storey residential service for older adults. The home is situated near to a busy shopping centre in Acocks Green that can be accessed by local bus links to Birmingham and Solihull. Acocks Green Railway Station is within walking distance from the service. It is also close to a variety of local churches of various denominations and the local library. The service is currently registered to accommodate twenty-two older adults. There is a driveway with some space available for off road parking to the front of the premises. The ground floor consists of two lounges, a dining area and a conservatory providing residents with a choice of areas to sit. There are twelve single bedrooms, two of which are en-suite 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 hand basin and all areas have a call bell. There is a separate laundry area on the second Dudley Court Rest Home DS0000016864.V298344.R01.S.doc Version 5.2 Page 5 floor and access to all floors is provided by a shaft lift. 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 also a passenger lift that enables access to all floors for residents. There is a pleasant garden to the rear of the property with seating for residents to use when the weather permits Dudley Court Rest Home DS0000016864.V298344.R01.S.doc Version 5.2 Page 6 SUMMARY This is an overview of what the inspector found during the inspection. This was the first key inspection for 2006-2007 and was undertaken on an unannounced basis over two full days commencing at 8.30am on 5th June 2006. The manager was on annual leave and the senior carer and one of the proprietors were present for the duration of the inspection. The senior carer, four members of staff, approximately eight residents and one relative were spoken to and feedback was mixed with some positive and some negative comments. The inspection process included a tour of the home, inspection of records and documents relating the management of the home and staff. Case tracking of resident’s records was undertaken to determine care from the time of admission. The inspection identified many areas that need to be addressed in order to meet the regulations and residents needs effectively. As a result of the inspection a significant number of requirements have been made of the home that will need to be addressed in order for the home to meet the minimum requirements. A number of them have been carried forward from previous inspections. The proprietor has assured the inspector that they will be addressed. These assurances have been made previously and must now be complied with to avoid enforcement action as the home is failing to provide positive outcomes for residents. What the service does well: Four of the residents spoken with expressed positive comments about the service. They stated they enjoyed the food and the staff were good. Relatives who were visiting confirmed they could visit at any time and found the staff welcoming and friendly and were kept informed of any changes in their relatives condition. They had no complaints, but stated that if there were any concerns they would speak to the manager or proprietors. Visiting health professionals stated the staff were very pleasant Residents stated they were able to get up, go to bed and spend time as they wished. The atmosphere in the home was relaxed and friendly and staff stated they enjoyed working in the home. Dudley Court Rest Home DS0000016864.V298344.R01.S.doc Version 5.2 Page 7 What has improved since the last inspection? What they could do better: There has been little development since the last inspection and many of the requirements still need to be addressed. The proprietors will need to take more positive action to address these issues in a timely manner and demonstrate the home is being well managed. Re-decoration and refurbishment with replacement of windows and attention to the garden area is required to enhance the surroundings and provide a homely environment for residents. Improvements in infection control procedures are required with staff training, practices and equipment to ensure the risk of cross infection is reduced. Arrangements for the cleanliness and management of odour needs to be addressed with some haste to ensure residents have a clean and pleasant environment to live. The call bell system needs to be extended to ensure that residents have access to a call bell in all areas. The management need to further develop the recruitment procedures before staff commence employment to ensure residents are adequately protected. Staff training is required to ensure staff have the appropriate skills and knowledge to care for residents and fully meet their needs. Records of the training completed by staff must be available to demonstrate the training has been completed. The assessment and care planning process needs to be enhanced to ensure resident’s needs are identified and appropriate plans of action put into place to address all needs. There needs to be a more pro-active approach to care with monitoring, early identification of any concerns plus appropriate follow up and referrals to health professionals where required. Staff need to provide more attention to detail when care is provided to residents to ensure their dignity is respected and maintained. Adequate staffing levels must be maintained at all times with a senior care assistant on duty during the day and a formal on call system that all staff are aware of. Dudley Court Rest Home DS0000016864.V298344.R01.S.doc Version 5.2 Page 8 The quality assurance system needs to be reviewed and developed further and where any issues are identified by residents or stakeholders action must be taken to address them. The systems for dealing with concerns and complaints needs to be reviewed and a more pro-active approach taken to ensure residents are listened to, concerns addressed and they are adequately protected. The arrangements for resident’s finances need to be reviewed and a robust record keeping system in place. A number of areas in respect of the maintenance and servicing of equipment need to be addressed with some urgency, to ensure a safe environment for residents. The arrangements for activities and stimulation of residents need to be reviewed and enhanced to ensure resident’s needs are being met. Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Dudley Court Rest Home DS0000016864.V298344.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.V298344.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 3, 4, 6 Quality in this outcome area is poor. The judgement has been made using available evidence including a visit to this service. The home has available for prospective residents and their relative’s information about the services and facilities, but they require some development with further detailed information to ensure they can make an informed decision about moving in to the home. The admission documents had not all been completed appropriately and without these residents cannot be confident that their needs will be identified and met by staff. EVIDENCE: The service has a Statement of Purpose and a Service User Guide that was available in resident’s bedrooms. It was found to be lacking in detail and there was no evidence of a standard form of contract. In the one that was taken from an empty bedroom to inspect it was found that a residents care plan from Social Care and Health was also in the document. This raises concerns about confidentiality in the home. Dudley Court Rest Home DS0000016864.V298344.R01.S.doc Version 5.2 Page 11 Since the time of inspection some guidance in respect of drawing a Statement of Purpose has been forwarded to the proprietor. On inspection of resident’s files there was no document in respect of the terms and conditions of the home and there was no standard contract for a privately funded resident. This area will need to be addressed and used for all residents entering the home to ensure they are aware of what to expect with a copy retained on their files. 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 and dated, in one instance it had been dated and it was the same day as the admission assessment, which calls into question the validity of the preadmission assessment. 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 admission assessment was completed and included a handling assessment, but there was no indication of the action to be taken in the event of a fall and this was identified at the last inspection. Assessments for nutrition and the prevention of pressure sores, which were outstanding at previous inspections, were still not in place despite the manager informing the inspector at the last inspection that a training session had taken place with a district nurse covering topics such as prevention of pressure sores and nutrition. There was information on personal preference sheets, but these tended to refer to what residents needed assistance with rather than setting out their preferred choice of how each topic of care should be delivered. In one case it was recorded that a resident liked to get up at 8am. However, it was noted that they were washed, dressed and sitting at the breakfast table at 8am and on discussion with them it was stated they were up early in the morning before 8am. In one case a resident was talking about their preferred drink at night to help with sleeping. This was not recorded and staff stated they were not aware of it and therefore this aspect was not being addressed. The assessment process will need to be reviewed to ensure a more comprehensive assessment is undertaken on admission to the home to enable a comprehensive care plans to be drawn up to meet residents needs and preferences. Where necessary training should be given to ensure there is a consistent approach. 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 skills or competencies to meet individuals needs where they have a mental health disorder. Dudley Court Rest Home DS0000016864.V298344.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9, 10 Quality in this outcome area is poor. The judgement has been made using available evidence including a visit to this service. The care planning system, records and communication of good practice need development to ensure that residents’ needs are being met adequately. There needs to be a more pro-active approach to care with attention to detail to ensure residents health care needs are being met and their dignity is being respected. Medication systems need to be more robust to ensure residents receive the medication prescribed in a safe manner. EVIDENCE: The manager had introduced a new format for the care plans. Staff develop the care plan, 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 areas of need had been identified in assessment, but specific details had not been put in the plan of care. There were vague instructions e.g. check regularly aspects in respect of catheter care had not been documented clearly and on discussion with some staff they were not aware of the appropriate care of urinary catheters. Dudley Court Rest Home DS0000016864.V298344.R01.S.doc Version 5.2 Page 13 There was also no reference to the management of continence needs and for example what size incontinence pads were required or that pressure relieving equipment was in use. The care plans were based on physical care mainly and lacked information about emotional and psychological aspects of care. There was no evidence that the residents or their representative had been involved in the care planning process and some were not aware of the contents of the care plan. Much work is required to ensure comprehensive care plans are in place that includes all residents’ needs. The manager will also need to ensure systems are in place to ensure that all staff are aware of the contents of the care plans and how to meet residents individual needs in a consistent manner. Training in this area should be provided where required. Staff complete daily records and it was found that the great majority of them gave details of the meals taken. There was little in respect of the type of day residents had experienced, their emotional or psychological state, concerns etc. On two occasions it was noted that issues had been raised, but there was no evidence in the records to demonstrate they had been followed up. The full details of meals are a duplication of work as the cook is recording the food that residents eat each day. In addition, there were some inappropriate comments in the daily records and staff will need training in this area. Records of personal care provided by staff were not up to date. 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 and some residents did not have a bath for a number of weeks and, therefore, their personal hygiene needs were not being met consistently. During the inspection it was noted that a night urinary catheter bag, which had been in use was in the bath on the first floor to be re-used later. On discussion with members of staff they were not aware of the principles of catheter care. This are will need to be addressed through training to ensure good practice to reduce the risk of ascending urinary tract infections. Further sampling of resident’s records confirmed residents had access to community healthcare services such as GP and district nurse when required plus the chiropodist, optician and dentist. However, records did not demonstrate these visits were occurring on a regular basis. On discussion with the proprietor it was stated that residents refused the service, but there was no evidence that it had been offered and refused. On discussion with some residents they stated they had not seen a dentist. It was found that the dentist attended one resident when called and there was no evidence of oral hygiene check ups. On the residents file it was noted the dentist had visited as an emergency. The record indicated that following a course of antibiotics further treatment would be required, but there was no evidence to demonstrate that this had occurred. Dudley Court Rest Home DS0000016864.V298344.R01.S.doc Version 5.2 Page 14 During and following the inspection it came to light that staff were encountering some difficulties with managing a residents behaviour, there had been an incident of restraint and relatives instigated a review by the Social Care and Health department. It was concerning that the home had not been more pro-active in seeking help and a review prior to this incident occurring. The manager must review the current systems in place and ensure there is a more pro-active approach to care contacting professionals and seeking reviews of care when experiencing difficulties. At the last inspection the manager was advised of the need to develop an appropriate procedure for the use of restraint. This was not inspected, but this area will need to be reviewed and all staff will need to have some training in respect of the correct use of restraint and managing difficult situations. On inspection of resident’s files there was evidence that some residents were not weighed on admission to the home and there was no evidence that residents weight was monitored on a regular basis. On discussion with one relative she stated that her father “was fading away”. Feedback from residents was variable, some of the more independent residents stated they found staff very good. Others stated they found staff could be harsh, call bells were not answered on occasions and assistance was not provided as requested. During the inspection a resident requested some assistance and the response from the member of staff was rather abrupt and unhelpful. Other interactions between staff and residents were found to be helpful. Visiting health professionals provided positive feedback about the staff attitude stating they were pleasant. On touring the home some residents had not been given assistance with their hair, were not wearing stockings, socks, slippers/shoes and clothing was stained. It was stated that this was because some resident’s feet and legs were swollen and a pressure-relieving cushion was put on the floor. This does not appear to be a good use of resources and advise was sought from the tissue viability nurse. It is recommended that the district nurse be contacted regarding an alternative such as Benefoot universal postoperative shoes or similar, which can be obtained through NHS logistics. Staff were observed to be moving residents in wheelchairs without floor rests in place, which is a potential risk of accidents. Also some residents use wheelchairs and have not been assessed to determine that they are appropriate for their use. One resident stated that they needed a new wheelchair and staff were advised of this. It was also noted that some of the rubbers on walking frames had worn down and required replacement. Staff were also observed to be using inappropriate handling techniques to move Dudley Court Rest Home DS0000016864.V298344.R01.S.doc Version 5.2 Page 15 resident and on discussion with some staff they confirmed that such techniques would be used in other situations. These practices place residents at risk. During the inspection it was noted that staff were wearing latex gloves most of the time including the administration of medication. On discussion with some staff they stated they had been informed to use them for everything. This is not appropriate use of disposable gloves and latex gloves should not be used routinely due to problems with latex allergies. Staff will need to be provided with training in respect of the correct use of disposable gloves and vinyl gloves should be used with latex gloves being used for blood spills. The home records accidents and have a book for auditing them. It was noted that one resident had sustained six accidents over a two-month period. Staff stated the resident had been referred to the falls clinic, but there was no evidence of this and there was no evidence of any strategies that had been put in place to reduce the risk of further falls. During the inspection this resident was noted to be sitting in the quiet lounge and could not access a call bell and had to bang a cup on the table to get attention from staff. A call bell is available in all rooms, however they are not always accessible to residents especially those whose mobility is restricted. It was also noted that staff were cancelling the call bell from the dining room where the panels are located. This is not acceptable practice in case the member of staff is distracted and does not respond to the call. Calls bells must be cancelled at the area where it originates from and action must be taken to ensure residents are able to summon help in all areas of the home. 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. However, the medication in boxes or bottles could not be audited in a number of instances. The following areas need attention: • 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 with. • Handwritten medication details had not been countersigned by two members of staff as required. • There were no carry forward details for medication from the previous months to enable auditing. • The administration of variable dose medication and not been consistently recorded and could not be audited. • Medication was being held in the trolley that was not prescribed. • Eye drops had not been dated when opened and some were in use that had been dispensed in March. They must be discarded after one month to due the risk of bacterial infection. • There were a number of bottles of medication for one resident from previous months suggesting that it had not been administered. Dudley Court Rest Home DS0000016864.V298344.R01.S.doc Version 5.2 Page 16 • • • • • • • • There was in excess of one month’s stock for some items. Inhalers were in use and there was no evidence of the use of spacers, which are used with some types of inhalers to improve the effect of the medication. Stocks of insulin for one resident were not stored in a fridge. The record of controlled drugs was poorly maintained and it could not be audited. Some residents who were self-administering medication had not been risk assessed. Oxygen was in use and there was no sign to indicate the use of it and the oxygen cylinder was not secured. A nebuliser was in use; the machine required cleaning and it was noted that fluid was remaining in the dispenser, which increases the risk of legionnaires disease. Creams that were in use had not been dated and some had been prescribed several months. Creams should be dated when opened and discarded after one month due to the risk of bacterial contamination. Whilst inspecting the medication it was noted that staff for use had written up a barrier cream once every three days. This was queried with them and they stated the instructions came from the district nurse. On discussion with the district nurse the second day of the inspection she stated the cream should be used every 2nd or 3rd time of washing the affected areas. This was clarified with the senior carer. Care must be taken by senior staff to ensure correct instructions are followed at all times. On discussion with some residents who were independent it was stated that they were not consulted about administering their own medication when they entered the home. On touring the home one first aid box was found in the kitchen, but it was not adequately stocked with blue plasters, which will need to be addressed. Also an additional box should be available for general use. Dudley Court Rest Home DS0000016864.V298344.R01.S.doc Version 5.2 Page 17 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, 15 Quality in this outcome area is poor. The judgement has been made using available evidence including a visit to this service. The meals offered are of an adequate standard, but areas in respect choice need to be addressed to ensure residents individual preferences are met. Arrangements for stimulation of residents are poor on a day-to-day basis. The system needs to be reviewed and developed further to ensure residents are stimulated and motivated. 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 residents stated” I like getting up early, you get a nice cup of tea and I can go to bed when I want.” Visiting is flexible and this was confirmed on discussion with relatives. Residents are able to bring personal items of furnishings etc into the home and some rooms were found to be well personalised by residents and reflected their individual taste and interest. Dudley Court Rest Home DS0000016864.V298344.R01.S.doc Version 5.2 Page 18 On discussion with residents and relatives it was stated that progressive mobility visited once a month and singers come into the home intermittently. The vicar visits and the home celebrates events such as Christmas and Halloween. Residents were observed to be writing letters, watching the television and one resident stated, “ I enjoy listening to my music and sitting in the garden” another stated, “ I do a lot of puzzles.” One resident stated they visited the local hairdresser on a regular basis and they were soon to go on holiday with their daughter. Another resident goes out regularly to a lunch club. On discussion with residents some stated they would appreciate more activities. There were posters indicating progressive mobility and singers to the home, but there was no 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. However, on discussion with residents they stated they were offered a choice for the evening meal. This area will need to be reviewed to ensure all residents are offered a choice at all mealtimes. A number of residents stated they enjoyed the meals and they received adequate portions, but some stated the food could be better. One lady who was on a soft diet was complaining about the consistency of the food. This was being given on the instructions of a speech and language therapist due to a past history of swallowing problems. However, staff were asked if they could ensure that this resident could be reviewed to determine if there was a need to continue with the diet. Another resident stated “ the food id good, you get a nice variety and you have a choice at tea time.” At lunchtime tables were laid with condiments, the atmosphere was relaxed and residents were given time to eat their meals at their own pace. During breakfast a comment was made about the “soapy cups” and it was noted that staff used the same type of aprons for use in the kitchen as for personal care. It is recommended the blue aprons are available for kitchen use to distinguish between roles and reduce any risk of cross infection. The refrigerator, freezers and food cupboards were well stocked. Dudley Court Rest Home DS0000016864.V298344.R01.S.doc Version 5.2 Page 19 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16, 18 Quality in this outcome area is poor. The judgement has been made using available evidence including a visit to this service. The procedures in place for complaints and adult protection failed to demonstrate that concerns had been addressed fully; therefore, residents may not be fully protected or confident that their concerns are listened to. 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 made clearer. On discussion with relatives they stated they were not aware of the procedure, but if they had any concerns they would speak to the manager. There was no record of any complaints in the home and the Commission have not received any complaints in respect of the home. However, on general discussion with residents a number of issues were raised including the laundry system, lack of response to call bells etc. It appeared to the inspector that concerns are raised, but the staff in the home do not consider them to be complaints. The approach to complaints needs to be reviewed as they may range from minor concerns to more serious complaints and a system needs to be in place that demonstrates a more pro-active approach. The manager will need to ensure all staff are aware that any concerns/informal complaints and formal complaints must reported and appropriate action taken. All complaints Dudley Court Rest Home DS0000016864.V298344.R01.S.doc Version 5.2 Page 20 must be recorded to include the nature of the complaint, the investigation, outcome, action taken and resolution. Following the last inspection a copy of the multi agency guidelines published by Birmingham Social Care & Health were forwarded to the home as they did not have an up to date copy. The whistle blowing procedure was inspected and needs to be developed further. At the time of arriving for inspection it was stated that their had been an allegation of abuse from a resident which had occurred the previous morning. Action was taken during the course of the morning following a telephone call from Social Care and Health Department. However, it was concerning that no action had been taken the previous day following the incident, which was on a Sunday. This issue has raised concerns about actioning events outside the main working hours and it became apparent that the home does not have a formal on call system. The manager will need to review this area and ensure that action is taken to prevent any such re-occurrences. Also staff will need to be provided with training in respect of prevention of adult abuse, the procedures to follow in the event of any allegation and the whistle blowing policy to ensure appropriate action is taken in future. Dudley Court Rest Home DS0000016864.V298344.R01.S.doc Version 5.2 Page 21 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 21, 22, 23, 24, 25, 26 Quality in this outcome area is poor. The judgement has been made using available evidence including a visit to this service. The home is furnished to basic standards and a considerable amount of redecoration and maintenance is required. There are many requirements that need to be addressed in order to provide a more homely and safe environment for residents. Systems in respect of cleaning, odour control, infection control and bathing facilities need to be reviewed, as they do not currently meet residents’ needs. EVIDENCE: On arrival at the home it was noted that the exterior of the building requires decorating, a number of window frames need replacing and the clinical waste bin was not locked. There is ramped access to the building for wheelchair access. On entering the home there was noted to be a foul odour and on touring the home it was found that there was a poor standard of cleaning throughout. On Dudley Court Rest Home DS0000016864.V298344.R01.S.doc Version 5.2 Page 22 discussion with some residents and visitors to the home they also made comment about the odour in the home. A number of areas were found to be 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. There is a pleasant garden to the rear of the property with patio area and seating for when weather permits. It was noted that there is a green house with broken panes of glass that need to be addressed as this poses a risk to residents who use the garden. There is also a shed, which had a few chemicals in. However it was not locked and there was a piece of wood hanging by a nail from over the door. This will need to be repaired and kept locked when not in use. There are two pleasant lounges, one of which is a quiet lounge leading from the reception area. However the door to the quite lounge does not close properly into the rebate when released from the fire system. 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. At the last inspection new blinds had been fitted to the side windows and furniture had been installed in the conservatory. However, there were no blinds to the ceiling and the sun was beating down on residents sitting there and one resident had a flannel on their head to protect it from the sun and the furniture still had plastic covers on. Blinds or similar will need to be fitted to the ceiling of the conservatory and the plastic removed from the chairs to make it more homely and comfortable for residents to sit in. It was also noted that some of the floor tiles were damaged at the entrance and these will need replacing. 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. Rooms have a wash hand basin and call bell, but call bells were not always accessible to beds. This area will need to be addressed. It was also noted that some of the did not have a comfortable chair to sit in and some did not have adequate furniture. In some instances clothing had been put in the top of wardrobes and when they were opened the clothing fell out. A number of the doors were propped open with wedges. Fire doors must not be propped open. If there is a need to keep them open they must be linked into the fire alarm system. The rooms were not cleaned to a satisfactory standard; e.g. dust on wardrobes, plus commodes and toilets were dirty. The portable hoist was stored in one resident’s bedroom. The manager will need to arrange more suitable storage for the hoist. There is a passenger lift to enable access to all areas plus wheelchair access into the home and from the conservatory to the garden. Dudley Court Rest Home DS0000016864.V298344.R01.S.doc Version 5.2 Page 23 Some of the mattresses and pillows were stained and the springs could be felt through one resident’s mattress. Also one of the pressure reduction mattresses was hanging over the end of the bed base. A full audit of mattresses and pillows must be undertaken and any stained, damaged or worn items must be replaced and bed bases must be of sufficient length to support mattresses. Some rooms did not have lockable facilities for residents to store valuables or medication and the locks to doors did not enable residents to have a key to lock the door when they were out of the room. One bedroom door was found to have a mortice 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. All residents must have access to a lockable facility in their rooms and have a lock that enables them to lock their bedroom door when they are out, but can be accessed by staff in an emergency. 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. Dudley Court Rest Home DS0000016864.V298344.R01.S.doc Version 5.2 Page 24 There are two bathrooms on the ground floor, one of which has a bath seat and it was noted the armrest was damaged and had been repaired with some type of tape. Toilets are situated around the home and it was noted that some of the toilet/bathing facilities did not have a call bell accessible to enable residents to summon assistance. At the top of the stairs on the second floor a grid had been fitted as a safety measure. One of the conditions of registration was that it should be replaced with an alternative method in consultation with the Commission before any residents were admitted to the second floor. However, on inspection it was still in place and there was a resident residing on that floor. The proprietor stated that it had been discussed with the Commission and the current arrangements had been agreed. However, there was no evidence of this on the file and the previous inspector stated they did not have any discussion with the proprietors about this issue. The fire exit on the second floor should be alarmed, but on the day of inspection there was no alarm when the door was opened. The laundry is situated on the second floor and there are two washing machines and one dryer. At the time of inspection there was no evidence that there was a sluice cycle on either of the washing machines. There is a hand washing sink and Belfast sink. It was stated that staff sluice cloths in the sink. This is not appropriate practice in respect of infection control and practices must be reviewed. On discussion with staff it was stated that items for laundering were taken to the laundry in a black bag and there were no alginate bags or similar for soiled items. It is recommended that the home liaise with the Health Protection Unit regarding advice and support in respect of infection control. It was also noted that there is no lock on the door. The laundry area should be kept locked when not attended by staff to reduce the risk of accidents. Other aspects noted that require attention in respect of infection control include: • Disposable gloves were found in the household rubbish. • Bar soap was found in a bathroom. • A washbowl was found on the floor in a bathroom. • Bowls that are used for washing residents in bed are collected up after use and stored in the laundry. Ideally each resident should have his or her own bowl. • A number of residents are given a wash in the bedrooms and there was no hand washing facilities for staff e.g. liquid soap and paper hand towels. Dudley Court Rest Home DS0000016864.V298344.R01.S.doc Version 5.2 Page 25 All areas are individually and naturally ventilated, but windows on the ground floor are not restrained. It is recommended that they be restrained for security reasons and risk assessments must be undertaken. Radiators are covered with guards, but some of the radiator controls in resident’s rooms could not be adjusted and at the time of inspection the temperature from hot water taps was only tepid on the second floor. When the temperature was measured from a ground floor tap it was 41 degrees. Testing is undertaken on a regular basis, but records were vague and stated all outlets were 43 degrees. This recording is not adequate and temperatures must be recorded for each individual outlet. The level of lighting appeared adequate at the time of inspection with the exception of the second floor corridor. During inspection it was noted that the area to the staff toilet and the cupboard where cleaning products were stored was not kept locked. This area should be kept locked when not in use to reduce the risk any accidents to residents who may wander in. The kitchen area was satisfactory, but it was noted that there was no mesh to the windows. It was stated that new windows had just been fitted and the mesh had not been replaced yet due to cleaning. Chopping boards were not stored properly and mops were found in dirty water. On discussion with the cook she stated the mop heads were cleaned once a week. This is not adequate, as they should be cleaned with a sanitizer solution at the end of each shift and stored properly. There is no dishwasher in the kitchen and the cook stated that in order to achieve 82degress, which is required for rinsing crockery she pours boiling water over them when they are on the draining board. This is a very dangerous practice and may result in a serious accident. Also they are required to soak in hot water of 82 degrees or over for at least 30 seconds. The manager will need to review the current arrangements and ensure a suitable and safe system for washing and rinsing all crockery is in place that meets the requirements of environmental health. Dudley Court Rest Home DS0000016864.V298344.R01.S.doc Version 5.2 Page 26 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29, 30 Quality in this outcome area is poor. The judgement has been made using available evidence including a visit to this service. Further development of the recruitment procedure are required to ensure a robust system that safeguards residents. Staffing levels need to be maintained at all times to ensure needs of residents are being met and the induction programme needs to be reviewed to ensure it is robust enough to provide newly employed staff with the appropriate knowledge and skills required to care for residents. EVIDENCE: The manager was not available at the time of inspection due to annual leave, but the rotas did not indicate the times she was available. The Regulations require that there is a duty roster, which indicates the times staff are working, and a record of whether it is worked. The proprietors stated they wanted that manager hours to be flexible. This is acknowledged, however a system will have to be developed to demonstrate the hours worked by the manager. On the first day of inspection there was a senior carer and two care staff on duty plus the cook. It was stated that there was no domestic staff as they had recently left employment. Care staff were responsible for the care of residents, cleaning and laundry duties. This is not acceptable. Dudley Court Rest Home DS0000016864.V298344.R01.S.doc Version 5.2 Page 27 Inspection of staffing rotas indicated that adequate staffing levels are not always maintained in line with the conditions of registration and there are times during the day when there is no senior carer on duty as was found on the evening of the first day of inspection. At the time of the last inspection the manager was advised that she must resolve this situation or the Commission may consider enforcement action. This matter will now be discussed formally with the provider. Some new staff had been employed since the time of the last inspection. On viewing a small sample of staff files it was noted that an application form and medical form are completed. On one file a member of staff had changed their name and there was no evidence to demonstrate this, in another there was no indication of the date employment commenced, where an offence had been committed there was no evidence of a risk assessment, there was no evidence that a new member of staffs job history had been explored, there was only one document for proof of identity for one member of staff and the home had not undertaken a POVA check or CRB for some newly employed staff relying on checks from previous employers. This is not acceptable practice as CRB checks are not portable. Each home must undertake the relevant checks before any member of staff commence work in the home. On some of the files checked there was no evidence of induction training and on discussion with some new staff they stated they read the policies for the first day and worked with another member of staff for a few weeks. The inspector viewed the induction package and it did not appear to meet the standards from the Social Skills Council. This area will need to be addressed in order to ensure all new staff have the appropriate knowledge and skills to undertake their role. On discussion with residents there was a mixed response about staff approach indicating that some staff were very good and helpful “ the girls are wonderful” but other comments included “ they can be harsh.” The information provided indicated that over 50 of care staff have completed NVQ level 2, which meets the standard. Dudley Court Rest Home DS0000016864.V298344.R01.S.doc Version 5.2 Page 28 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35, 36, 38 Quality in this outcome area is poor. The judgement has been made using available evidence including a visit to this service. The manager needs to review systems and implement appropriate monitoring and auditing systems to ensure areas of good practice are being followed at all times. A quality assurance system needs to be developed and an annual development plan drawn up outlining outcomes for residents. Action needs to be taken to in respect of resident’s monies in order to demonstrate robust systems are in place. The prompt servicing of equipment and provision of training to staff in basic areas would enhance Resident’s health safety and well-being. EVIDENCE: The manager has been in post for some time and has completed the Registered Managers Award qualification and training in quality assurance. Dudley Court Rest Home DS0000016864.V298344.R01.S.doc Version 5.2 Page 29 There is no quality assurance system in place. The Registered Provider visits the premises regularly and provides monthly reports, which are forwarded to the Commission. However, the reports are very brief and do not provide feedback on the quality of the home, experiences of residents or comments on the environment. It is recommended that these be developed further along with the introduction of a quality assurance system to in order to develop an approach of continuous improvement and to meet the regulations. Examination of staff files demonstrated that formal staff supervision was not being undertaken six times a year as required and they did not cover the philosophy of the care and aspects of care in sufficient detail. The home holds monies and valuables on behalf of a number of residents. On inspection it was found that this was not included in the plan of care, there was no record of valuables held on the inventory or care plan in addition: • Receipts were not consistently provided for money deposited • Receipts were not consistently available for monies spent. • Where money was given directly to residents to go out there was no evidence that the resident had signed for it. • The safe facility was not secure. • One resident goes out to lunch on a regular basis and pays for this herself. However, the fees include three meals a day and the home should make some allowance for this. A sample of maintenance and servicing records were inspected. Records for servicing of some items were available, but the following areas need addressing: • The electrical wiring system had been visually inspected, but there was no evidence of testing. • There was evidence of testing for Legionella a year ago, but no evidence of chlorination of the tanks. • There was no record of serving and through examination of the passenger lift. • The bath seat had been serviced, but there was no evidence of thorough inspection. • The gas safety certificate identified an issue that required attention. • There was no evidence of servicing for the hoist or wheelchairs. • There was no evidence of servicing the heating system. • A letter dated December 2005 indicated liability insurance, but there was no certificate in place. • There were no COSHH risk assessments and the risk assessments in respect of the environment need to be more comprehensive. Information has been forwarded to the home following the inspection. Dudley Court Rest Home DS0000016864.V298344.R01.S.doc Version 5.2 Page 30 • Records indicated that all staff had not undertaken two fire training sessions and fire drills over the past year and some staff lacked knowledge of the fire procedures or location of extinguishers. All these matters place residents at risk Examination of some staff files indicated that some staff had not received training in moving and handling since December 2004 and fire safety in 2004/2005. There was no evidence in respect of infection control training whilst other staff who have been employed more recently there was no indication of any training undertaken. The manager will need to undertake a training audit and develop an individual training and development profile ensuring that all staff undertaken up dated core training. Dudley Court Rest Home DS0000016864.V298344.R01.S.doc Version 5.2 Page 31 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 2 2 1 1 X N/A HEALTH AND PERSONAL CARE Standard No Score 7 1 8 1 9 1 10 1 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 1 13 3 14 3 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 1 17 X 18 1 2 2 1 2 3 1 2 1 STAFFING Standard No Score 27 2 28 3 29 2 30 1 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 1 2 2 2 X 1 Dudley Court Rest Home DS0000016864.V298344.R01.S.doc Version 5.2 Page 32 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 The Registered Person must ensure the Statement of Purpose is enhanced and states clearly the range of the needs the service is intended to meet as stated on the registration certificate and it must be a stand alone document Timescale of 01/01/06 not met. The service user Guide must have a standard form of contract. The Registered Person must 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. The registered person must ensure that all residents admitted to the home have a pre-admission assessment undertaken by a competent person. Timescale of 01/12/05 not met. The registered person: • Must write to residents confirming that they are able to meet their needs. DS0000016864.V298344.R01.S.doc Timescale for action 30/09/06 2 3 OP1 OP2 5 5(1)(b) 30/07/06 30/07/06 4 OP3 14 18(1) 30/07/06 Dudley Court Rest Home Version 5.2 Page 33 5. OP4 CSA 6. OP7 15 18(1) 7 OP7 17(2) 18(1) 8 OP7 15 The admission assessment must be comprehensive and include aspects such as tissue viability. • Where necessary staff should receive training in competing assessment. The registered person must ensure residents outside there category of registration are not admitted to the home without applying for a variation to the Commission. The Registered Person must 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 service users, 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. The registered person must: • Review the daily recording and ensure it is meaningful providing accurate and factual information about the resident’s day, care provided, concerns etc. • Staff must be provided with training in this area where required. 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. DS0000016864.V298344.R01.S.doc • 10/06/06 30/07/06 30/06/06 30/06/06 Dudley Court Rest Home Version 5.2 Page 34 9 OP8 12(1) 10 OP8 13(1) 11 OP8 13(4) 12(1) Ensure a nutritional risk assessment is undertaken for all residents entering the home and it is reviewed on a regular basis. • Ensure that all resident are weighed when they enter the home and this is reviewed on a regular basis. • Undertake a review of all current residents weight and where they are of low weight or lost weight the relevant health professional contacted for advice. The registered person must ensure that all resident have opportunity to see the dentist, chiropodist and optician on a regular basis and records are retained in the home to demonstrate this. Where residents refuse the service this should be documented. The registered person must ensure: • A call bell is accessible to residents at all times in their rooms and lounge areas to enable them to summon for help. • Ensure the call bell is cancelled at the point of origin. • Systems are in place for prompt responses to call bells at all times. • Footplates are used on wheelchairs unless a risk assessment demonstrates otherwise. • All residents are assessed for their own wheelchair. • An audit of all walking frames is undertaken and DS0000016864.V298344.R01.S.doc • 30/06/06 30/06/06 19/06/06 Dudley Court Rest Home Version 5.2 Page 35 12 OP8 13(5) 13. OP8 12(2) 14 OP8 12(1)(2) 13(4) 15 OP8 12(1) 13(3 18(1) 13(3) 16 OP8 17 OP8 13(7) 18(1) any damaged or worn rubbers are replaced. The registered person must ensure: • Correct moving and handling procedures are used at all times. • Undertake a review to determine the need for moving and handling equipment and provide the necessary equipment. The Registered Person must: • Ensure basic assessments are in place for nutrition and the documentation of any pressure sores prior to referring to the dietician and district nurse. Timescale of 08/07/05 not met. The registered person must implement appropriate strategies for the resident who has been experiencing a number of falls and refer to an appropriate health professional. The registered person must ensure there is a consistent approach to catheter care and all staff are aware of it, providing training where required. The registered person must ensure: • All staff use disposable gloves appropriately. • Latex gloves are only used for blood spills. • Vinyl gloves are used for dealing with incontinence and infected materials. The registered person must ensure: • No resident is subject to any form of restraint unless of the kind employed is the only means of securing the welfare of the resident or DS0000016864.V298344.R01.S.doc 30/06/06 30/06/06 12/06/06 30/06/06 30/06/06 30/06/06 Dudley Court Rest Home Version 5.2 Page 36 18 OP8 12(1) 19 OP8 15(1) 20 OP8 12(1) 18(1) 21 OP9 13(2) any other resident and there are exceptional circumstances. • There is clear guidance for staff in the home about the use of restraint. • Staff are provided with training in respect of managing difficult situations and the appropriate use of restraint. The registered person must ensure there is a more proactive approach to care with monitoring of residents conditions, early identification of any concerns, follow up of any concerns and referral to health professionals as required. The Registered Person must ensure residents’ care plans refer to how the following healthcare needs are being met: Pressure care relief & equipment Diabetes and action to be taken in the event of hypo/hyper episodes and how often blood levels are to be monitored. Continence needs including sizes of incontinence pads to be used. Timescale of 01/01/06 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. The registered person must ensure a fully auditable and safe medication system to include: • A robust system for checking medication into the home. • Correct administration of all medication. • Handwritten medication details must be DS0000016864.V298344.R01.S.doc 30/06/06 30/06/06 30/07/06 12/06/06 Dudley Court Rest Home Version 5.2 Page 37 22 OP9 13(2) countersigned by two staff. The correct recording of variable dose medication. • The correct recording, administration and disposal of controlled medication • Ensure there is a record of any medication carried forward from previous months. • All medication held in the home must be prescribed on the current MAR chart. • Eye drops must be dated when opened and discarded after one month. • Creams must be dated when opened and discarded after one month. • There should only be one month’s supply of medication held in the home. • Liaise with the pharmacist regarding the storage of stock insulin vials. • Review the need for spacers with inhalers. • Ensure a risk assessment is undertaken for all residents who undertaken self-administration of medication. • Obtain a statutory notice for use with oxygen. • Ensure the oxygen cylinder is secured. • Ensure the nebuliser is cleaned on a regular basis. • Ensure the use of any homely remedies is agreed with the relevant G.P’s and a record is retained in the home. The registered person must 30/07/06 ensure the medication policy is reviewed and updated to include the ordering, checking, storage, • DS0000016864.V298344.R01.S.doc Version 5.2 Page 38 Dudley Court Rest Home 23 OP9 13(4) 24 OP10 12(4) 18(1) 25 OP10 12(1) 26. OP11 12(2)(3) (4a,b) 27 OP12 12(2)(3) 28 OP15 12(3) administration and disposal of medication. Also homely remedies and selfadministration. The registered person must ensure there is a fully stocked first aid box in the kitchen and for general use within the home. The registered person must ensure that all staff are providing with training in customer care and adopt an empathetic approach to residents. The registered person must ensure staff provide more attention to detail and enhance residents dignity when attending to personal care to include: • Combing hair. • Providing socks/stockings, shoes/slippers or a suitable alternative. The Registered Person must ensure a record is maintained to show they have consulted with residents, relatives and other representatives regarding any final wishes and funeral arrangements. This area was not assessed and has been carried forward from 01/01/06 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 there are systems in place for residents to be offered a choice at all meals. DS0000016864.V298344.R01.S.doc 20/06/06 15/07/06 12/06/06 30/06/06 30/07/06 20/06/06 Dudley Court Rest Home Version 5.2 Page 39 29 OP15 13(3) 30 OP16 22 31. OP18 13(6) 32. OP18 13(6) The registered person should ensure there are suitable systems in place for staff to change aprons when going into the kitchen area and this is clearly recognisable e.g. blue aprons The registered person must ensure there is a pro-active system in place for all concerns or complaints to be taken seriously. • Staff must be provided with the appropriate training. • All complaints must be recorded indicating the nature of the complaint, the investigation, findings, outcome and resolution. • 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. 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 the adult protection policy and procedure is within the spirit of the DOH Guidelines No Secrets. Timescale 08/07/05 not met. The registered person must ensure the whistle blowing policy is reviewed and clearly indicates contact details for staff to raise concerns at any time of day or night. 20/06/06 12/06/06 30/06/06 30/07/07 Dudley Court Rest Home DS0000016864.V298344.R01.S.doc Version 5.2 Page 40 33 OP18 12(1) 10(1) 34 OP19 16(2)(j) 35. OP19 23(2)(d) 36 OP19 23(2)(b) 37 OP19 13(3)(4) 38 OP19 16(2)(k) 39. OP19 13(4) The registered person must ensure there is a formal on call procedure in the home and this is clearly documented on the duty rota for all staff The registered person must ensure: • The mesh is replaced to the kitchen windows. • The chopping boards are replaced. • A suitable method for washing the dishes is in place. The Registered Person must ensure the premises are cleaned to a satisfactory standard at all times. Timescale of 01/12/05 not met The registered person must ensure: • The exterior of the home is decorated and windows in a poor stated of repair are replaced. • An audit is undertaken of the interior and a programme of redecoration is undertaken. • Forward plan to the Commission The registered person must ensure the clinical waste bin to the front of the house is kept locked. The registered person must ensure that all areas in the home are kept odour free at all times. Timescale of 01/12/05 not met The registered person must ensure the garden is safe at all times for residents to include: • Removal/repair of the greenhouse with safety glass. • Repair the shed and provide a lock to the door. DS0000016864.V298344.R01.S.doc 12/06/06 30/06/06 12/06/06 20/07/06 07/06/06 12/06/06 12/06/06 Dudley Court Rest Home Version 5.2 Page 41 40 OP19 13(4) 41 OP20 23(2)(a) (b) 42 OP21 23(2)(n) 13(4) 43. OP22 23(2n) 44. OP22 23(2n) 45. OP24 16(2c) 46. OP24 OP10 16(2(c) 23(2)(m) 12(3) The registered person must provide a suitable alternative to the grid at the top of the stairs on the second floor in consultation with the Commission. The registered person must: • Provide blinds or similar to the conservatory roof. • Remove plastic from the chairs. • Replace damaged tiles 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. • Repair the arm on the bath seat or replace the bath seat. The Registered Person must ensure a call bell is accessible: • To all bathing and toilet facilities. • To residents in their bedrooms at all times. • Residents in communal areas. The Registered Person must ensure residents are assessed and provided with wheelchairs that meet their mobility needs. The practice of service users sharing other users’ wheelchairs must cease. Timescale of 01/01/06 not met The Registered Person must ensure an audit must be undertaken of all furniture provided in service users bedrooms 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 DS0000016864.V298344.R01.S.doc 30/07/06 20/07/06 30/08/06 20/06/06 30/06/06 30/07/06 30/07/06 Dudley Court Rest Home Version 5.2 Page 42 47 OP24 16(2(c) 23(2)(m) 12(3) 48 OP24 16(2)(c) 49 OP24 23(4) more suitable system that guarantees their privacy but can be accessed by staff in an emergency. Timescale of 1/12/05 not met. The registered person must 30/10/06 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. The registered person must 20/07/06 ensure: • All residents have a comfortable chair to sit on in their bedroom. • All residents have adequate furniture to store their belongings in their bedroom. • An audit of all mattresses and pillows are undertaken and any damaged, stained or worn items are replaced. • Bed bases are of an adequate size to support pressure reduction mattresses The registered person must 07/06/06 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 DS0000016864.V298344.R01.S.doc Version 5.2 Page 43 Dudley Court Rest Home 50 51 OP24 OP25 23(2)(l) 13(4) 52 OP25 23(2)(p) 53 OP26 13(3) 54 55 OP26 OP26 13(4) 13(4) system. The registered person must provide suitable storage facilities for the portable hoist. The registered person must undertake a risk assessment in respect of all windows and provide restrainers where required. The registered person must ensure there is adequate lighting in all areas of the home at all times. The registered person must ensure adequate infection control procedures to include: • The correct use of disposable gloves. • The correct disposal of gloves. • Bar soap must not be used in communal toilets or bathrooms. • Staff hand washing facilities must be provided in resident’s rooms where staff provide personal care. • Washbowls should be for individuals use only. • The washing machine should have a sluice cycle. • Sluicing of clothes must not be undertaken by hand. • Use alginate bags or similar for soiled items of laundry. • Mops are cleaned, sanitised and stored properly after use. The registered person must ensure a suitable lock must be provided to the laundry door. The registered person must ensure the areas to the staff toilet and COSHH cupboard is kept locked at all times when not in use. DS0000016864.V298344.R01.S.doc 20/07/06 30/07/06 20/06/06 20/06/06 30/06/06 07/06/06 Dudley Court Rest Home Version 5.2 Page 44 56. OP27 17(2) Sch4 18(1a) 57. OP27 The Registered Person must ensure the hours worked by the manager are recorded. Timescale of 01/12/05 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 registered person must ensure there are adequate care staff and ancillary staff on duty at all times. The registered person must ensure a robust recruitment procedure to include: • Check employment history and any gaps in employment ensuring a record is retained from the interview. • A POVA and CRB check are undertaken for all new staff before they commence employment. • Undertake an audit of all staff files and ensure a CRB check is completed fro all staff by the home and they are not utilising one from a previous employer, as they are not transferable. • A written risk assessment must be undertaken where any offence is identified The registered person must ensure all staff records include the full name, address, date of birth, qualifications, experience, a copy of birth certificate and passport, the date employment commenced and ceased, the position held in the home, the number of hours worked, the DS0000016864.V298344.R01.S.doc 30/06/06 07/06/06 58. OP29 19 30/06/06 59 OP29 17(2) Sch4 30/07/06 Dudley Court Rest Home Version 5.2 Page 45 60 OP30 18(1) 61. OP33 25 62 OP33 26 63. OP34 25(1)(2a, b,c) 64. OP35 13(6) work that is preformed and any other correspondence. A review of the induction training must be undertaken 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. 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 01/02/06 not met The responsible individual must ensure the report completed as a result of his monthly visits is more detailed in respect of the findings to provide confidence in these reports The Registered Person must provide the Commission a current business plan or statement from a certified accountant to confirm the service’s financial viability. Timescale of 01/01/06 not met The Registered Person must ensure that the management of residents personal allowances and their property is safeguarded with receipts provided for any monies or items of property brought in for safekeeping, receipts and two signatures (one being the resident where possible) for DS0000016864.V298344.R01.S.doc 30/07/06 30/09/06 30/07/06 30/08/06 14/06/06 Dudley Court Rest Home Version 5.2 Page 46 money spent on behalf of residents or given to them to enable an accurate audit trail. Timescale of 01/12/05 not met The registered person must ensure the safe facility is secure and there is a suitable system in place for residents to access money when ever they wish. The registered person must ensure all staff receives staff 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. The Registered Person must ensure that all records with regard to service users care plans and personal monies are up to date. The Registered Person must also review its policies and procedures to ensure they reflect current practice and include aspects of clinical care. Timescale of 01/01/06 not met The Registered Person must ensure that all staff undertakes 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. • Systems are in the home to ensure correct moving and handling procedures are used at all times. The registered person must ensure all staff undertake DS0000016864.V298344.R01.S.doc 65 OP36 18(2) 30/08/06 66. OP37 17(2) Sch 2&4 30/07/06 67. OP38 23(4)(d) (e) 30/06/06 68. OP38 13(5) 30/07/06 69 OP38 16(2)(j) 20/08/06 Page 47 Dudley Court Rest Home Version 5.2 70 OP38 13(4) 71 OP38 13(4) 23(2)(b) 72 OP38 13(4) 23(2)(c) 73 74 OP38 OP38 13(4) 10(1) 13(4)(a) training in respect of basic food hygiene and records are retained in the home. The registered person must ensure all staff undertake training in respect of first aid and records are retained in the home. The registered person must ensure: • The electrical wiring system is tested. • Ensure chlorination of water tanks following testing for legionella. • Ensure the passenger lift is maintained on a regular basis and there is a thorough examination by an accredited individual • Ensure the bath seat is thoroughly examined by an accredited individual. • Address the outstanding issues in respect of the gas safety certificate. • Ensure the heating system is serviced and a record is retained in the home The registered person must ensue: • The hoist is serviced on a regular basis and records are retained in the home. • Wheelchairs are serviced on a regular basis and records are retained in the home. The responsible individual must provide evidence of public liability insurance. The registered person must ensure the record of water temperatures form hot taps clearly indicates the actual temperature of the water. The water must be maintained at 43 degrees or – 1 degree and DS0000016864.V298344.R01.S.doc 30/08/06 20/06/06 20/06/06 30/06/06 30/07/06 Dudley Court Rest Home Version 5.2 Page 48 75 OP38 13(4)(c) 76 OP38 23(4) 77 OP38 13(3) action must be taken where temperatures are not maintained. The registered person must ensure risk assessments are undertaken in respect of all chemicals used in the home and the risk assessment for the environment are reviewed and enhanced. The registered person must ensure the fire alarm system to exterior doors is activated at all times. The registered person must ensure all staff undertake training in respect of infection control, records are retained in the home and systems are in place to ensure good practice is followed. 20/08/06 12/06/06 30/07/06 Dudley Court Rest Home DS0000016864.V298344.R01.S.doc Version 5.2 Page 49 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 OP8 OP9 Good Practice Recommendations It is recommended that the Registered Person arrange for staff to receive training in the management of diabetes. (Carried forward) It is recommended that the Registered Person complete staff drug audits before and after a drug round to demonstrate staff competence in medicine management. (Carried forward) It is recommended that the Registered Person give consideration for the lighting in the dining room to be It is strongly recommended that Health protection unit be contacted for advise and support in respect of infection control measures in the home. It is strongly recommended that communication systems in the home be reviewed to enable senior staff to be aware of all aspects in the absence of the manger. 3 4. 5 OP25 OP26 OP32 Dudley Court Rest Home DS0000016864.V298344.R01.S.doc Version 5.2 Page 50 Commission for Social Care Inspection Birmingham Office 1st Floor Ladywood House 45-46 Stephenson Street Birmingham B2 4UZ National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Dudley Court Rest Home DS0000016864.V298344.R01.S.doc Version 5.2 Page 51 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!