Inspection on 08/06/05 for Dudley Court Rest Home

This inspection was carried out on 8th June 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

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

Other inspections for this house

Dudley Court Rest Home 04/03/09

Dudley Court Rest Home 01/03/08

Dudley Court Rest Home 21/09/07

Dudley Court Rest Home 31/01/07

Dudley Court Rest Home 05/06/06

Dudley Court Rest Home 01/11/05

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 B27 6QR Lead Inspector Joe OConnor Unannounced 8 June 2005 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 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 E54 S16864 Dudley Court Rest Home V231684 080605 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Dudley Court Rest Home Address 16 Dudley Park Road Acocks Green Birmingham B27 6QR 0121 706 3087 0121 706 3087 Telephone number Fax number Email 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 Older People registration, with number of places Dudley Court Rest Home E54 S16864 Dudley Court Rest Home V231684 080605 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: 1. That the home accommodates 22 persons over the age of 65 for reasons of old age. 2. That telephone points and television aerials are installed in second floor rooms 20,21 and 22 prior to a service user being admitted to the room. 3. That overhead or bedside lighting is provided in second floor rooms 20,21 and 22 prior to a service user being admitted to the room. 4. 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. 5. 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. 6. 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. 7. That the door to the external fire escape is alarmed to alert staff in the event of the door being opened prior to any service user being admitted to the second floor. 8. 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. 9. In addition to the care manager or shift leader there are three suitably qualified and experienced care staff on duty during day time hours. At nighttime there should be two suitably qualified waking night staff plus a designated person on call within a 20-minute travel distance from the home. 10. That the manager completes Quality Assurance Training by 31st July 2005 Date of last inspection 17 December 2004 Dudley Court Rest Home E54 S16864 Dudley Court Rest Home V231684 080605 Stage 4.doc Version 1.30 Page 5 Brief Description of the Service: Dudley Court is a residential home for older adults. The home is situated near to a busy shopping centre in Acocks Green that can be accessed by the local bus service. Acocks Green Railway Station is within walking distance from the service. It is also close to a variety of church denominations and the local library. The service is currently registered with the Commission for Social Care Inspection for 22 older people. There is a driveway and parking space to the front of the premises. The ground floor consists of two lounges and a dining area. A conservatory leads off from the dining area. There are twelve single bedrooms, two are en-suite, there are three bathrooms, and one is assisted bathroom with hoisting facilites. There are five toilets and one of these is a designated staff toilet. There is a kitchen with two food storerooms and a managers office. A staircase leads up to first floor where service users can use a stairlift. The first floor consists of six single bedrooms and one double bedroom. There are no en-suite facilites on the first floor. There is a large well maintained garden. Since the last inspection The Registered Person has opened up the second floor and there are now three new bedrooms and an assisted bath, along with a laundry on the second floor. A shaft lift has been installed. There are no ensuite facilities. Dudley Court Rest Home E54 S16864 Dudley Court Rest Home V231684 080605 Stage 4.doc Version 1.30 Page 6 SUMMARY This is an overview of what the inspector found during the inspection. The inspection was unannounced and took place over one day. Four service users were able to convey their views on life in the home. Discussions were also taken with a relative of one service user and two members of staff. A limited tour of the premises was undertaken. Service users care plans and risk assessments were inspected. Staff recruitment and training records were examined and a number of health and safety records were also sampled. The Inspector had opportunity to talk to the Registered Manager. What the service does well: Four of the service users spoken with expressed positive comments about living in the home. These ranged from “staff are courteous and helpful”. “We can do what want”. “ I can go to the manager if there were any concerns”. A relative visiting the service stated that the manager always takes time to listen and “I have recommended Dudley Court to some of my friends”. The atmosphere was found to be relaxed and friendly. Staff were observed to provide a friendly and positive approach to service users. Service users are able to participate in residents meetings every month. Service users are able to participate in a range of activities such as musical entertainment, progressive mobility and Bingo. On occasions staff will take service users out to the local Bingo hall in the evening. Service users were recently involved in celebrations for VE day. A number of service users received visitors at different times of the day. Two service users confirmed they received Holy Communion from the local parish priest. A sample of service users records indicated that they were receiving support from healthcare professionals such as GP, District Nurse, Optician, Dentist and Chiropodist. Service users expressed satisfaction with the catering arrangements. They stated that a choice was available and that staff would ask them each day for their preferred mealtime choices. Lunch at the time of this inspection consisted of roast beef, mashed potato and vegetables. The meal appeared to be well presented and cooked to an appropriate temperature. Dudley Court Rest Home E54 S16864 Dudley Court Rest Home V231684 080605 Stage 4.doc Version 1.30 Page 7 What has improved since the last inspection? What they could do better: Service users care records require significant improvement. Care plans did not provide enough information as to how the health and welfare of service users were to be met. Service users needs assessments should be reviewed and updated to reflect any changes. There were no systems in place to assess and monitor areas such as nutrition and the prevention of pressure sores highly dependent service users. Given the level of dependency the service will need to review its manual handling practices of service users and ensure appropriate lifting equipment is being used other than lifting belts. Information regarding service user’s hobbies and areas of special interest should be more detailed in service users care plans with clear recording to confirm the activities they have been participating. The care staff within the home have received accredited training in the safe handling of medicines and knowledge gained must now be implemented. There are outstanding requirements relating to the physical environment. Suitable blinds or curtains must be fitted to the conservatory along with replacement cushions for the chairs. An audit is required of all furniture and furnishings on the premises as a number of armchairs and tables are worn. While the premises were found to be clean and tidy there was evidence of foul odour in two of the bedrooms and main lounge which needs addressing. Staff training requires further improvement and a number of staff were in need of updated training in areas such as food hygiene, adult protection and manual handling. The need for updated manual handling training was a requirement from the previous inspection. Staff must have training in other areas such as Dementia Awareness, Nutrition and Pressure Care relief. Staff recruitment records needs to be developed Dudley Court Rest Home E54 S16864 Dudley Court Rest Home V231684 080605 Stage 4.doc Version 1.30 Page 8 Health and safety records were found to require improvements. The accident book found that there had been a significant numbers of falls involving service users and most of these had not been reported to the Commission. There is a need for the development of a monthly falls audit to ensure appropriate strategies are in place to prevent further falls. Monthly visits from the Registered Person must have more evidence of service users comments about the service they are receiving. The Registered Manager while demonstrating a good understanding of the needs of service users still has much work to do in ensuring the service is fully meeting the health and welfare of service users. 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 E54 S16864 Dudley Court Rest Home V231684 080605 Stage 4.doc Version 1.30 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 Standards Statutory Requirements Identified During the Inspection Dudley Court Rest Home E54 S16864 Dudley Court Rest Home V231684 080605 Stage 4.doc Version 1.30 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 standard(s) 3, 4, 5 Service users assessments are incomplete and do not provide a full picture their needs. Service records do not reflect how the needs of service users are to be met. Pre-admission visits are undertaken but the assessments during the pre-admission process are incomplete. EVIDENCE: Three service users care records were sampled and it was found that there was evidence that pre-admission assessments had been completed but two were found to be incomplete with no date or signature of the staff member involved. There was evidence that one service user had been admitted with an assessment and care plan and initial care plan completed by a social worker. It was also noted that the assessments had not been reviewed to ensure any changes were documented. A number of service users stated that they were happy with the care and support being provided by staff and the manager. Comments ranged from, “The staff are very good and nothing is too much trouble for them”. “ Staff are friendly and if you ask for something they will get it straight away”. Staff were observed to provide positive and friendly support to service users. A relative visiting commented he thought that as well as his own mother the other Dudley Court Rest Home E54 S16864 Dudley Court Rest Home V231684 080605 Stage 4.doc Version 1.30 Page 11 service users appeared to be well cared for and there was a good atmosphere. Despite these comments it is evident that a great deal of improvement is required with regard to the development of service users records that clearly state how the needs of service users are to be met. There are a number of service users who are highly dependent and staff need to have wider range of training covering specific areas such as nutrition and the prevention of pressure sores and dementia. Dudley Court Rest Home E54 S16864 Dudley Court Rest Home V231684 080605 Stage 4.doc Version 1.30 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 standard(s) 7, 8, 9 Service users care plans do not provide adequate evidence as to how their needs are to be addressed nor are they clear on service users preferences and dislikes. Service users are able to access community healthcare services but there are no systems in place for the assessment and monitoring of concerns around nutrition and pressure care relief. At the time of the inspection the medication records did not reflect accurately what had been administered to the service users in all instances. EVIDENCE: Three service users records were sampled and there was evidence that each one had a care plan and a manual handling assessment. The information recorded did not provide a clear indication of how the needs of individual service user were being met and much of the information was around what the needs were. It was noted that one care plan stated that the service user liked listening to music but there was no information as to what exactly was that individual’s preferences. Another care plan had a written daily routine completed by a relative setting out the service user’s preferred time of getting up and going to bed. There was no evidence to confirm that the care plans were being reviewed on a monthly basis. Manual handling assessments were in place again there was no evidence to confirm that these were dated and that they too had been reviewed. Dudley Court Rest Home E54 S16864 Dudley Court Rest Home V231684 080605 Stage 4.doc Version 1.30 Page 13 When sampling service users records there was evidence they had community healthcare services such as GP, District Nurses, Dentist, Optician and Chiropodist. One file sampled contained information that a service user had not been eating and drinking regularly but there was no evidence to confirm whether specialist input from a Dietician had been sought. It was also noted that some of the daily recording entries referred to the need for “fluids to be pushed” but there was no evidence of any fluid intake charts to confirm these concerns were being monitored. There were no assessments in place for the prevention of pressure sores and nutrition and discussion was held with the manager to address these matters through consultation with the district nurse and community dietician. There was no system installed to check the prescriptions and medication received into to the home for accuracy. Quantities of medicines received or balances carried over were not routinely recorded so accurate audits to demonstrate medicines had been administered as prescribed could not be undertaken. Unlabelled medicines were available for administration. Inadequate steps had been taken to ensure medication bought into the home by new service users was their current drug regime as prescribed by the doctor. The Medicine Administration Record (MAR) chart recorded medication that was no longer prescribed and medicines that had been discontinued were still available for administration, as they had not been returned to the pharmacy for destruction. Medication was available for administration for one service user but there were no supporting records to support this. The manager was keen to improve practice. All staff have received accredited training in the safe handling of medicines. Dudley Court Rest Home E54 S16864 Dudley Court Rest Home V231684 080605 Stage 4.doc Version 1.30 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12, 13, 15 Daily routines of service users are not affected by any rigid rules or restrictions. Service users are able to access the local community but care plans must include more information with regard to service users’ leisure interests and hobbies. Service users are able to receive visitors at various times of the day. Activities are offered to service users but evidence to confirm their participation must be clearly recorded. Service users do not regularly receive a varied choice of meals. Records stating choices available and the meals to confirm what service users have eaten are not written on a daily basis. EVIDENCE: There were no unnecessary restrictions to daily routines. Three service users stated they were able to get and go to bed when they pleased. They also stated there were activities such as progressive mobility, bingo and musical entertainment. However, records to confirm that such activities were taking place were not always clear. One service user attends a lunch club every Thursday. A member of staff stated that service users have the opportunity to go out to the local Bingo hall in the evening. Recently there was a celebration commemorating VE day, which the service users enjoyed. Two service users stated that they receive Holy Communion from a priest or a member of the local congregation at the local Catholic Church. Service users were receiving visitors during the day. Dudley Court Rest Home E54 S16864 Dudley Court Rest Home V231684 080605 Stage 4.doc Version 1.30 Page 15 Service users expressed satisfaction with the catering arrangements stating that there was a choice of food available and that staff would go out of their way to provide an alternative meal. Service users stated that staff would ask about their preferred choices for lunch and tea. There is a daily diary to confirm the meals service users had eaten for each day. However, this was found to be not recorded consistently especially at the weekends Where no records were being made. It was also noted that there was a repetition of meals being prepared at lunchtime such as sausages and fish appearing on the weekly food records twice during that period. Observations were made of service users having lunch, which they appeared to enjoy. The atmosphere was relaxed with some service users given time to finish their meal. There were no condiments available on the tables. Since the last inspection The Registered Person has purchased food from a well known supermarket and the cupboards, refrigerator and freezers were found to be well stocked. However, it was noted that much of the tinned food being provided was of the basic value brands and the Registered Manager and Registered Person must be mindful of their responsibilities in ensuring that service users are receiving food that is nutritious in content. Dudley Court Rest Home E54 S16864 Dudley Court Rest Home V231684 080605 Stage 4.doc Version 1.30 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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 22, 23 There is a complaints procedure available to service users but this will require some amending to ensure the process in making a complaint is open and more clear. The adult protection policy and procedure is unsatisfactory and does not confirm the service’s ability to protect service users from abuse. EVIDENCE: There is a complaints procedure in place that is on display on the premises and is available to service users. This will need some amending to provide assurances that no victimisation will occur when a complaint is made and it must also state that the CSCI can be contacted at anytime during the complaint process. Neither the service nor CSCI have received a complaint since the last inspection nor it is noted that a comments book is available to visitors in the reception area. The adult protection policy and procedure was unsatisfactory and did not reflect the spirit of the Local Authority Multi Agency Guidelines. This is a requirement from the previous inspection and must now be addressed. In discussion with staff they provided satisfactory responses to questions with regard to issues around poor practice and felt able to raise any concerns with the manager. A sample of staff training records found that only one had completed training in adult protection. The procedure for whistle blowing did not have an up to date telephone number. There was no policy and procedure with regard to physical intervention. It was also noted that service users files sampled did not have completed personal inventories a requirement from the previous inspection. Dudley Court Rest Home E54 S16864 Dudley Court Rest Home V231684 080605 Stage 4.doc Version 1.30 Page 17 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 standard(s) 19, 26 Work has been undertaken to develop new facilities within the premises with improved access to all floors. Improvements have been made in ensuring service users safety with regard to the prevention of fire. There are still outstanding requirements that do not provide service users with furnishings and fittings to improve their quality of life. Practices with regard to the control of infection require improvement. EVIDENCE: The premises were found to be clean and reasonably tidy at the time of this inspection. Two service users commented their approval of the cleanliness of the premises. Despite these comments there was evidence of offensive odour in the main lounge and bedroom 12. A maintenance book was examined and there was evidence that the Registered Person had replaced the windows in bedroom 13 &14 and new curtains had been fitted to the new lounge. A new radiator had been fitted to the new conservatory. It was pleasing to see that the outstanding requirements from the last fire officer’s visit had been addressed such as linking the fire exits to the alarm system. It was evident that any repairs requested by staff were addressed quickly. Dudley Court Rest Home E54 S16864 Dudley Court Rest Home V231684 080605 Stage 4.doc Version 1.30 Page 18 Since the last inspection the Registered Provider has made an extension to the premises and opened up the second floor. There are now three bedrooms with call alarms, wash hand basin, an assisted bathing facility and all the minimum requirements for furniture, including telephone points. A shaft lift has been installed to enable access to all floors. The laundry is now located on the second floor and this was found to be clean and tidy. A number of outstanding requirements from the previous inspection with regard to the premises were still in need of addressing. First the damage to the vanity unit in bedroom 2 was had not been repaired. It was also noted that no action had been taken to replace the missing cushions from the chairs in the conservatory. No curtains or blinds had been fitted in the conservatory to make it more homely and provide privacy for service users. A requirement form the previous inspection was for the installation of suitable ventilation in the conservatory. A number of bedrooms lead off the conservatory and previously smokers had been using the conservatory. Despite assurances from the manager that service users who smoke go outside, there was still evidence of the odour from these blowing back into the bedrooms by the conservatory. The lack of suitable ventilation means that in hot weather, as was the case during this visit; the conservatory is not a comfortable area to sit in. It was further noted that it still being used as a storage area. Some of the furniture in the lounge and a number of bedrooms were found to be worn and an audit must be undertaken to check problems with wear and tear and replace any items as required. During a conversation with one service user it was noted her bedroom wallpaper was covered in brown“ dribble stains” and action must be taken to address this. Staff were generally observed to maintain appropriate infection control practices such as wearing protective clothing when working in the kitchen. However, It was noted that commode pots were found left in the bath on the ground floor and the manager was asked to remove these and review practice. Dudley Court Rest Home E54 S16864 Dudley Court Rest Home V231684 080605 Stage 4.doc Version 1.30 Page 19 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27, 28, 29, 30 Service users needs are met with appropriate numbers of staff on duty but there is a need for a senior carer to be on duty during each shift. The manager provides training for staff but much of the topics covered require updating to enable staff to undertake their duties effectively. The staff recruitment policy and procedure does not demonstrate that the service is protecting service users interests. EVIDENCE: Two staff were spoken to and both demonstrated an understanding of service users needs. Staff approach to service users was found to be friendly and respectful. Staffing levels appeared to meet the needs of the service users at the time of this inspection with four on duty during the day, but it was noted on the staff rota that there was only one senior carer on shift when the requirement from the previous inspection stated there should be two. The manager stated that she was having difficulties recruiting for this position and in the meantime was training a care assistant for this position. Two members of staff had left since the last inspection but the manager had recruited to the vacancies. Staff training records indicated that three care staff had completed were training towards NVQ Level 2 and two were completing NVQ Level 3. Further sampling found that staff had completed training in areas such as first aid, food hygiene, manual handling, and fire safety, However it was evident that updated training was required in topics such as manual handling, fire and food hygiene. One staff file showed that they completed training in the awareness of dementia and diabetes. Given the level of dependency of the service users, Dudley Court Rest Home E54 S16864 Dudley Court Rest Home V231684 080605 Stage 4.doc Version 1.30 Page 20 it is important that staff training is widened to cover areas such as nutrition and the prevention of pressure sores. Dementia and care planning training should also be pursued. Staff recruitment records were found to require improvement and structure Two files sampled were found to have the required documents such as proof of ID, Passport, photo, birth certificate, CRB check, job application form and two references. However, the files will need to include the relevant job descriptions and evidence of staff’s NVQ qualifications. One staff file included an interview assessment format completed by the manager for a prospective candidate a requirement from the previous inspection. The staff recruitment policy and procedure had been amended by the manager a requirement from the previous inspection, but this was found to require additional information to include that any gaps in employment will be followed up by the manager and that a POVA check will be undertaken in the process of a CRB application being made. Dudley Court Rest Home E54 S16864 Dudley Court Rest Home V231684 080605 Stage 4.doc Version 1.30 Page 21 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31, 32, 33, 36, 37, 38 The manager demonstrates her knowledge of the needs of service users to an acceptable standard. Service users and staff are able to raise any concerns with the manager that is open and supportive. Service users views are sought but improvement is required to ensure there are examples of service users comments on life in the Home. Staff supervision is not frequent enough in ensuring staff are able to effectively undertake their duties. Records were generally found to be up to date but improvement is still required in ensuring staff records are up to date. The welfare and safety of service users require further improvement through more robust monitoring systems with regard to falls and manual handling practices. EVIDENCE: The manager had recently been registered with the CSCI and at the time of this inspection demonstrated knowledge about the needs of the service users in her care. However, the manager acknowledged that there is still considerable work to be completed on order that the home is run and managed Dudley Court Rest Home E54 S16864 Dudley Court Rest Home V231684 080605 Stage 4.doc Version 1.30 Page 22 to a position where there are no significant requirements left to address and the service demonstrates it meets the needs of service users. She also was keen to improve practice and received comments in a positive manner. The atmosphere was relaxed and those service users spoken with stated they would be able to raise concerns with the manager. Staff spoke positively about the manager feeling supported and able to raise any issues in an open forum such as staff meetings. One member of staff commented that the manager gave her confidence to undertake training and achieve qualification to NVQ Level 2. The Registered Provider visits the premises every day and there was evidence that monthly reports were written of his visits. However, there needs to be more evidence as to specific comments made by service users and staff about the management of the service. Service users have monthly meetings and minutes are written up. It was noted that staff would consult service users on a one to one basis about what had been discussed but not every month. A sample of staff records found that one to one supervision was not being undertaken every two months and action is required to address this. Generally records were found to be up to date but work is still required to ensure staff records are up to date and maintained in a clear structured format. As previously mentioned action had been taken to address many of the health and safety requirements, including outstanding matters following the visit of the fire officer. A sample of health and safety records found there was evidence that equipment for the prevention of fire, electric, gas and the lift had been tested and inspected on a frequent basis. Risk assessments had been completed for the premises including the use of the gas cooker in the kitchen. There was also a risk assessment for the prevention of fire. It was noted that a fire drill had taken place prior to this inspection and that the manager was rearranging training in fire safety as the trainer had previously cancelled it. A smoke detector had been installed in Bedroom 15 a requirement from the previous inspection. A record for the temperatures of water outlets used by service users were being carried out every month as were the temperatures for the probing of cooked meat, refrigerators and freezers. It was noted that the freezers were in need of de-frosting. The accident book was examined and it was noted that there were a high number of falls involving service users since the last inspection. The manager will need to develop a monthly audit of falls on the premises to ensure appropriate action is being taken to address specific concerns. It was noted that many of the accidents that had occurred were not notified to the CSCI under Regulation 37 notification. It was of concern to note of certain practices with regard to manual handling of service users. Many are transferred with lifting belts, as there is not a mobile hoist on the premises. The manager must review these practices to ensure Dudley Court Rest Home E54 S16864 Dudley Court Rest Home V231684 080605 Stage 4.doc Version 1.30 Page 23 appropriate equipment is being used particularly for those service users who are permanent wheelchair users and mobility difficulties. Action must be taken to ensure staff receive up to date manual handling training. Dudley Court Rest Home E54 S16864 Dudley Court Rest Home V231684 080605 Stage 4.doc Version 1.30 Page 24 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score x 2 2 x 2 x HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 1 10 x 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 x 15 2 COMPLAINTS AND PROTECTION 2 x x x x x x 2 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 Standard No 16 17 18 Score 2 x 2 2 3 2 x x 1 2 1 Dudley Court Rest Home E54 S16864 Dudley Court Rest Home V231684 080605 Stage 4.doc Version 1.30 Page 25 YES Are there any outstanding requirements from the last inspection? 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 1 Regulation 14(1) Requirement The Registered Person must ensure service users assessments are detailed in identifying the needs of the individual and that these have been dated and signed by the individual completing the assessment. The Registered Person must review service users assessments to ensure they reflect the needs of the current group of service users living in the home. The Registered Person must ensure that service users needs are kept under review to ensure that their needs are met and changes in health and ability taken to account. Outstanding Requirement Timescale 31 December 2004 not met. The Registered Person must ensure that pre-admission provide more detailed information of prospective service users. They must be signed by staff and dated. The Registered Pesron must ensure that service users care plans show how the service Timescale for action 8 August 2005 2. 3 14(2) 8 August 2005 3. 4 14(2) 15(2)(b) 8 August 2005 4. 5 14(1) 8 August 2005 5. 7 15(1) 8 August 2004 Page 26 Dudley Court Rest Home E54 S16864 Dudley Court Rest Home V231684 080605 Stage 4.doc Version 1.30 6. 8 12(1)(a) (b) 13(1)(b) 12(1)(a) (b) 7. 8 8. 9 13(2) 9. 9 13(2 17(1)(a) 10. 9 13(2) 11. 9 13(2) 12. 9 13(2) users needs in respect of their health and welfare are to be met. Outstanding Requirement. Timescale 31 December 2004 The Registered Person must ensure that assessments are introduced for nutrition and the prevention of pressure sores. The Registered Person must ensure that where there are concerns with regard to service users not eating or drinking that food and fluid intake charts are in place and appropriate professional advice is sought without delay. The Registered Person must rewrite the medication policy to reflect new systems that must be introduced into the home for the safe handling of medicine The Registered Person must ensure the quantities of all medicines received into the home must be recorded to enable accurate audits to be undertaken to demonstrate staff competence in medicine management The Registered Person must ensure all medicine received into the home must be checked and recorded on the Medicine Administration Record (MAR) chart The Registered Person must ensure prescriptions must be seen prior to dispensing, checked and a system installed to check the dispensed medication and the Medicine Administration Record (MAR) chart for accuracy upon receipt The Registered Person must ensure all medication that is no longer required must be returned to the pharmacy for destruction 8 July 2005 8 July 2005 8 July 2005 and ongoing From 8 June 2005 and ongoing From 8 June 2005 and ongoing 8 July 2005 and ongoing From 8 June 2005 and ongoing Page 27 Dudley Court Rest Home E54 S16864 Dudley Court Rest Home V231684 080605 Stage 4.doc Version 1.30 13. 9 13(2) 14. 12 16(2)(m) 15. 15 16(2)(i) 16. 15 17(2) Schedule 4 (13) 17. 15 12(3) 18. 16 22(1) 19. 18 13(6) The Registered Person must ensure it purchases a Controlled Drug cabinet that complies with the Misuse of Drugs (safe custody) Regulations 1973 must be purchased and installed. The Registered Person must ensure that daily recording of service users records reflect the activities participated by service users. Their care plans must provide more information with regard to their hobbies and interests. The Registered Person must ensure that service users have a nutritious wholesome diet that does not depend on the use of tinned supermarket Value brands The Registered Person must ensure that the records of food provided for service users are completed daily and they must demonstrate a varied choice of meals on offer and avoid repetition of meals prepared during the week. The Registered Person must ensure that during mealtimes condiments are placed on tables for service users. The Registered Person must ensure that the complaints procedure is amended to state that the CSCI can be contacted at any time during the complaints process, with an assurance that no one will be victimised as a result of a complaint being made. A copy is to be forwarded to CSCI. The Registered Person must ensure that systems are put into place that safeguard service users and their property e.g. personal inventories of service users belongings. Outstanding 8 July 2005 8 July 2005 8 July 2005 ongoing From 9 June 2005 ongoing From 8 June 2005 and ongoing 8 August 2005 8 July 2005 and ongoing Dudley Court Rest Home E54 S16864 Dudley Court Rest Home V231684 080605 Stage 4.doc Version 1.30 Page 28 20. 18 13(6) 21. 18 13(6) 22. 18 13(7) 23. 19 16(2) (c ) 24. 19 16(2) (c ) 25. 19 23(2) 26. 19 16(2)(k) 27. 19 16(2) (c ) Requirement. Timescale 18 December not met. The Registered Person must ensure the adult protection policy and procedure reflect the spirit of the Local Authoritys Multi Agency Guidelines. The Registered Person must ensure that all care staff have received up to date training in adult protection. The Registered Person must ensure that it develops a policy and procedure with regard to physical intervention. The Registered Person must ensure that curtains and or blinds are fitted to the conservatory. Outstanding Requirement. Timescale 31 December 2004 not met. The Registered Person must ensure that the chairs in the conservatory have cushions and appropriate coverings to meet the needs of service users. Outstanding Requirement. Timescale 24 Decemeber 2004 not met. The Registered Person must ensure that the conservatory and lounge area is not used as a storage facility. The Registered Person must ensure that it addresses areas of foul odour in bedroom 12 and the main lounge. A hinged bracket must be fitted for the TV set in Bedroom 13 to enable service user to watch in comfort. The Registered Person must ensure that the formica around the vanity unit in bedroom 2 is repaired or replaced as it is peeling. Outstanding Requirement. Timescale 31 December 2004 not met. 8 July 2005 8 July 2005 8 August 2005 8 July 2005 8 July 2005 8 June 2005 8 July 2005 1 July 2005 Dudley Court Rest Home E54 S16864 Dudley Court Rest Home V231684 080605 Stage 4.doc Version 1.30 Page 29 28. 19 23(2)(p) 29. 26 13(3)(4) 30. 27 18(1)(a) 31. 29 19(1)(a) Schedule 2 19(1)(a) 32. 29 33. 30 18(2) 34. 31 10(1)(2) (a) The Registered Person must ensure that additional ventilation is provided in the conservatory as the smoke is impacting in the bedrooms leading off it. There must also be adequate ventilation in place during hot weather for the comfort of service users. Outstanding Requirement. Timescale 31 December 2004 not met. The Registered Person must ensure that commode pots are not left in baths used by service users. They should be stored in the appropriate facilities for sluicing. The Registered Person must ensure there is a senior member of staff on each shift. Outstanding Requirement. Timescale 17 December 2004. The Registered Person must ensure that all the documents required by Schedule 2 are available in the home for inspection. The Registered Person must ensure that its recruitment policy and procedure is amended to ensure that employment practices in the home are robust and protect the interests of service users. The Registered Person must ensure that staff receive training in the following topics: Manual Handling Food Hygiene Adult Protection Dementia Awareness Nutrition Prevention of Pressure Sores Care Planning The Registred Manager must complete training towards Quality Assurance training 8 July 2005 8 June 2005 From 8 June 2005 8 July 2005 8 July 2005 8 August 2005 31 July 2005 Dudley Court Rest Home E54 S16864 Dudley Court Rest Home V231684 080605 Stage 4.doc Version 1.30 Page 30 35. 33 26(1) 36. 37. 36 37 18(2) 17(2) Schedule 2 13(4) 37(1) 13(4) 18(1)(a) 13(4) 38. 38 39. 40. 38 38 41. 38 13(4)(5) 23(2)(n) 42. 38 13(4) The Registered Person must ensure that written reports of monthly visits provide more detailed information regarding service users and staff comments about life in the home The Registered Person must ensure that staff receive supervision every two months. The Registered Person must ensure that staff recruitment records are maintained in structured divided files to enable clear tracking of records. The Registered Person must ensure that it reports any accident in the care home without delay. The Registered Person must ensure that all staff up to date training in manual handling. The Registered Person must ensure that it develops a monthly audit of service users falls that demonstrates appropriate action is being taken to address specific concerns. The Registered Person must review its current working practices with regard to the lifting and transferring of service users. A mobile hoist must be available on the premises. The Registered Person must ensure that action is taken to defrost the freezers. 8 July 2005 and ongoing 8 July 2005 and ongoing. 8 July 2005 8 June 2005 and ongoing 8 June 2005 8 July 2005 and ongoing. 8 July 2005 and ongoing. 9 June 2005 and ongoing. 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. Dudley Court Rest Home E54 S16864 Dudley Court Rest Home V231684 080605 Stage 4.doc Version 1.30 Page 31 Refer to Standard Good Practice Recommendations Commission for Social Care Inspection Birmingham & Solihull Local 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 E54 S16864 Dudley Court Rest Home V231684 080605 Stage 4.doc Version 1.30 Page 32 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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