Inspection on 23/01/06 for Dudley House Care Home

This inspection was carried out on 23rd January 2006.

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 House Care Home 10/12/07

Dudley House Care Home 03/07/07

Dudley House Care Home 23/10/06

Dudley House Care Home 04/04/06

Similar services:

Ashlong House

Henry Nihill House

Birchwood

The Infirmary

Orchard House Nursing Home

St Josephs Rest Home

Red Court Nursing Home

Spinney (The)

Extracts from inspection reports are licensed from CQC, this page was updated on 08/07/2008.

CARE HOMES FOR OLDER PEOPLE Dudley House Care Home The Grove Isleworth Middlesex TW7 4JF Lead Inspector Clare Henderson Roe Unannounced Inspection 23rd January 2006 09:45 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 House Care Home DS0000064752.V277558.R01.S.doc Version 5.1 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 House Care Home DS0000064752.V277558.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Dudley House Care Home Address The Grove Isleworth Middlesex TW7 4JF 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) 020 8560 9560 020 8568 7082 Dudley House Care Home Ms Lynette Maggs Care Home 40 Category(ies) of Old age, not falling within any other category registration, with number (40), Physical disability (40), Physical disability of places over 65 years of age (40) Dudley House Care Home DS0000064752.V277558.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. One named service user who has a terminal illness can be accommodated, as agreed by the Commission for Social Care Inspection, on the 25th July 2005. The home must advise CSCI when the service users no longer reside at the home. Date of last inspection Brief Description of the Service: Dudley House Nursing Home is a large detached house in Isleworth. The home has a combination of single and double rooms with some en suite facilities. Significant changes are being made to the building which will result in more single rooms, some with en suite facilities, being provided to replace some of the double rooms. The home has installed a new larger passenger lift. There are three floors in the home and service users accommodation is provided on all three floors. There are also bathroom facilities on all three floors. The home has a lounge/dining area and another small sitting room with access to the rear garden. New offices have been built onto the rear of the building. The home is located nearby to Isleworth train station and is also a short walk from the London Road served by several bus routes. There are several shops in Isleworth itself and the home is a short bus ride from Hounslow Town Centre. Dudley House Care Home DS0000064752.V277558.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection carried out as part of the regulatory process. A total of 22 hours was spent on the inspection process. One Inspector carried out a tour of the home, and service user plans, staff records, financial records, management records, administration records, maintenance and servicing records were viewed. 8 service users, 5 staff and 4 visitors were spoken with as part of the inspection process. For some of the last inspection carried out in August 2005 the Registered Manager was unable to be present. As a result requirements from the inspection prior to August 2005 could not be reviewed. What the service does well: What has improved since the last inspection? What they could do better: This inspection highlighted a number of serious concerns in relation to medication management and employment procedures. The Inspectors were concerned that requirements from previous inspections had not been met. There appeared to be a poor knowledge of the National Minimum Standards for Older People and associated legislation. The Statement of Purpose and Service User Guide documentation was out of date. The service user plans were very general and did not identify the service users individual needs adequately. Shortfalls in the completion of several areas of the service user plans were identified. Healthcare needs of service users were not always being met. Food choices are not offered to service users. Building work is in progress, however there is no clear management of how the work is undertaken what has been done to minimise any risk to service users and staff during this time. There are still outstanding issues with regard to the environment. A programme for the replacement of divan beds with adjustable beds was not available. The quality Dudley House Care Home DS0000064752.V277558.R01.S.doc Version 5.1 Page 6 of some of the furniture and furnishings is poor and does not create a homely environment. A programme of building works, redecoration and refurbishment had not been formulated. Radiators in service user areas were not all guarded, and could pose a burn risk to service users. Systems for infection control needed reviewing. Evidence of induction and foundation training to meet the Skills for Care core standards was not available. Systems for monitoring the quality of care and management were not in place. There was no business and financial plan available to view. Staff supervision records were very out of date and it was not clear if supervision was taking place. The systems for the management of health & safety are very poor and risk management is not in place. The majority of these findings have been identified in past inspection reports, and it is of grave concern that they have not been addressed. 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 House Care Home DS0000064752.V277558.R01.S.doc Version 5.1 Page 7 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 House Care Home DS0000064752.V277558.R01.S.doc Version 5.1 Page 8 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 and 5. The home does not provide intermediate care. Service users and their representatives are not provided with up to date information about the home, therefore they do not have an accurate view of the facilities provided. Contracts are completed for service users. Service users are assessed prior to admission to ensure the home can meet their needs. Staff have received training to meet service users needs. Prospective service users and their representatives are encouraged to visit the home in order to allow them to make an informed choice. EVIDENCE: The Statement of Purpose and Service User Guide had not been updated to reflect the current changes within the home. There was no evidence at the time of the inspection that service users and/or their representatives had received copies of the Statement of Purpose or the Service User Guide. It was discussed with the Registered Manager that the required information from Standard 1 of the National Minimum Standards (NMS) for Older People plus Regulation 4 and Schedule 1 of the Care Homes Regulations 2001 must be included in the Statement of Purpose. In addition, the Service User Guide must Dudley House Care Home DS0000064752.V277558.R01.S.doc Version 5.1 Page 9 contain the information required under Standard 1 of the NMS for Older People plus Regulation 5 of the Care Homes Regulations 2001. The Registered Manager stated that all service users accommodated at the home have a contract either privately or with Social Services or the Primary Care Trust (PCT). Pre-admission assessments had been carried out and those viewed were comprehensive. In addition copies of the Social Services needs led assessment or PCT assessment is obtained by the home prior to admission. The home is registered to care for older people with nursing care needs. Staff receive training to include topics relevant to the needs of the service user group. Representatives spoken with said that they made a pre-admission visit to the home. The Registered Manager stated that she would receive a referral or request via Social Services and she would encourage the family to visit the home prior to any pre-admission assessment being undertaken. The Registered Manager said that prospective service users are encouraged to visit the home, but this rarely happens due to frailty. Dudley House Care Home DS0000064752.V277558.R01.S.doc Version 5.1 Page 10 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 and 11 Service user plans were not always up to date and did not accurately reflect the condition and needs of the service user. Shortfalls in the medication management could place service users at risk. Staff are courteous to service users and personal support is provided in such a way as to promote and protect the service users privacy and dignity. Management of service users needs during their final days is good, thus respecting service users wishes with sensitivity and respect. EVIDENCE: 3 service user plans were viewed as part of the inspection process. Overall the content of the care plans was very general and was not fully personalised to the service user. Care plans had not always been formulated for all the service users identified needs. There was evidence of input from the service user and/or their representative when the service user plan was formulated. Risk assessments for falls had not been formulated for all service users. Risk assessments for other risks identified, for example, use of the stair lift were in place. For one service user with some bruising there was no explanation or information recorded regarding the occurrence of this. The service user was able to clearly explain to the Inspector about it and the Registered Manager said that the service user had explained it to staff also. Monthly reviews had Dudley House Care Home DS0000064752.V277558.R01.S.doc Version 5.1 Page 11 been recorded but actual updates of some areas of the service user plans had not been carried out. Documentation for wound care was in place. In one instance information for 3 wounds was recorded on one care plan. The Inspector recommended that separate documentation be completed for each wound for clarity. Some of the wound information was out of date. Pressure relieving equipment was seen in use in the home but the specific equipment in use for each service user had not been clearly identified in the service user plan. For one service user it was recorded that they had lost over 10 kilograms in weight over a period of two months. There was no evidence that any action had been taken to address this finding. Nutritional assessments were in place. Continence assessments provided by the PCT had been completed, but the need for ongoing continence assessment was discussed. Care plans for continence care needs had not always been formulated. Moving & handling assessments had been carried out. The equipment in use to aid with moving & handling was not clearly identified in some cases. Bedrail risk assessment documentation was available, but this had not always been filled in fully, so a complete assessment was not done. Consents for the use of bedrails had been obtained. The CSCI Pharmacist Inspector carried out an inspection on 23/01/06 and a separate report is available. The requirements and recommendations resulting from that inspection have been incorporated into this report. An immediate requirement was set at the time of inspection. Staff were seen to be speaking with service users in a courteous manner. Service users clothing is individually labelled. Several of the bedrooms viewed were personalised. Care plans for death and dying are available for each service user. Some had not been completed. The Registered Manager explained that some service users and their representatives were reluctant to provide information of this sensitive nature. The changing needs of service users in relation to death and dying are addressed and representatives are able to stay with loved ones during this stage. Dudley House Care Home DS0000064752.V277558.R01.S.doc Version 5.1 Page 12 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): 15 The food provision is satisfactory but mealtime alternatives are not being offered, thus service users are not making their own choices. EVIDENCE: Service users spoken with said that the food provision is good. However, all those asked said that they are not offered a choice at mealtimes. The menus were viewed and choices are available. Records of service users meals were viewed and there is documentation available for each service users’ choice to be recorded. The need to educate the staff to speak with service users and ascertain their meal choices each day was discussed. The Inspectors sampled the lunchtime meal and it was tasty and well presented. In the kitchen one storeroom had been removed in order to create space for a stairway to the cellar to be installed. Documentation was in disarray and cleaning schedule records could not be found. Fridge, freezer and food temperatures had been recorded. Items in the dry store viewed were in date. Dudley House Care Home DS0000064752.V277558.R01.S.doc Version 5.1 Page 13 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, 17 and 18 The home has a complaints procedure in place and there was evidence that service users and representatives concerns are listened to and acted upon. Service users rights are protected and service users are able to exercise their legal rights directly. Staff have knowledge of and have received training in adult protection issues which protect service users from abuse. EVIDENCE: The home has a complaints procedure, which includes stages and timescales for complaint investigation progress. However the procedure did not identify that service users and their representatives could refer complaints to the CSCI at any stage. Two complaints had been received by the home since the last inspection. Both had been investigated and the outcomes recorded. The Registered Manager stated that service users could access advocacy services via Age Concern in Hounslow. It was suggested that contact information for advocacy services be provided in the Service User Guide. At the last election held locally 6 service users were taken to the local polling station and other service users chose to send a postal vote. The home had copies of the Ealing and Hounslow Adult Protection procedures. The Hounslow POVA team had provided training in the protection of vulnerable adults. There had been no adult protection issues since the last inspection. Staff spoken with said that they would report any concerns of this nature. Dudley House Care Home DS0000064752.V277558.R01.S.doc Version 5.1 Page 14 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, 23, 24, 25 and 26 Building and refurbishment works are in progress. A full programme of the work being carried out is required to show the progress being made and the aims and objectives being attained. A redecoration and refurbishment plan is also required to show how the shortfalls in the furnishings and fittings are to be addressed, to meet service users needs. Shortfalls in some infection control systems could potentially place service users at risk. EVIDENCE: At the time of inspection there was ongoing refurbishment work taking place. Several of the double rooms are being converted into single rooms, some with en suite facilities being provided. A full environmental audit must be carried out. A programme of redecoration and refurbishment was not available and this was discussed with the Responsible Individual and the Registered Manager, as a programme to identify the work done, in progress and planned, with timescales for completion, must be available. During the tour of the home the Inspectors observed that service users were present in bedrooms near to where building works were taking place, some of which necessitated loud noise Dudley House Care Home DS0000064752.V277558.R01.S.doc Version 5.1 Page 15 levels. There did not appear to have been any assessment or consultation with service users regarding the most appropriate management of service users needs to cause them minimum disruption whilst the works take place. The rear garden was untidy and had building materials in some areas. The grassed area was damaged and overall the garden looked neglected. Action is required to bring the garden up to a safe, usable standard for service users. The home has a large communal lounge/diner. The additional small sitting room was not in use. The new offices and clinical room have been built as an extension off the small sitting room. The need to ensure that systems are in place for all communal areas to be used for service users was discussed. Some of the new single rooms are being provided with en suite facilities to include a shower area. Some of the original bathing facilities are being incorporated into the new single rooms with en suite shower facilities. The Registered Manager said that one bathroom was not in use and was to be refurbished with an assisted bath. The toilet facilities near the communal rooms on the ground floor need some refurbishment to include new flooring. The information regarding refurbishment of the bath, shower and toilet facilities must be included on the redecoration and refurbishment plan. Several of the previously double rooms are being converted into single bedrooms. The Responsible Individual said that once the building works are completed the home would have one double room only. Several of the bedrooms were viewed at the inspection. In most cases the beds are divan beds, and some of these were damaged. The need to provide a rolling programme of replacement of beds with adjustable beds has been discussed on several occasions in the past and no action has been taken. The Responsible Individual said that he would look at this and provide a programme to meet it. The wardrobe facilities were old and some were damaged. Some of the bedrooms have non-slip flooring of the type often used in bath and toilet facilities. This is somewhat impersonal and institutional in appearance and needs to be reviewed so that appropriate flooring is provided. Each room viewed had a lockable top drawer in the chest of drawers, plus suitable door locks to allow emergency access to staff. The office by the front door has been converted into a single room with an en suite shower facility. The radiators in both the bedroom and the en suite were unguarded and very hot. There was an additional free-standing radiator in the room, which was also very hot and for which no risk assessment had been carried out. Before the Inspectors left the home, guard covers had been placed over the fixed radiators and the free-standing radiator removed from the room. The need to ensure all pipe work and radiators in areas accessible to service users are appropriately guarded was discussed. Hot and cold water temperature checks on outlets accessible to service users were being undertaken by the handyman. The records were completed with a ‘tick’ rather Dudley House Care Home DS0000064752.V277558.R01.S.doc Version 5.1 Page 16 than the actual temperature at the time of testing, and information as to whether any remedial action had been required was not recorded. Hot water storage and distribution temperatures were not being recorded. Legionella testing had been carried out. Draughts were apparent in several rooms to include the day room, and in some bedrooms the windows did not fit properly and window restrictors were not in place. The Responsible Individual explained that there are some issues because the home is in a preservation area, however action must be taken to ensure that the windows in all areas are appropriate and in full working order. The laundry room was viewed. One of the washing machines had a build up of lime scale on the door. One of the tumble dryers was marked as out of order. Information regarding the liquid detergent and fabric conditioner in use was out of date. The documentation in the laundry was old and faded. The Responsible Individual explained that the laundry room is to be relocated to the cellar. The home was clean and the home smelled fresh throughout. Gloves and aprons were available. Personal toiletries and brushes and combs were seen in one bathroom. Dudley House Care Home DS0000064752.V277558.R01.S.doc Version 5.1 Page 17 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 and 30 The home is appropriately staffed to meet the current needs of the service users. The arrangements for the Induction and foundation training are not in place and staff potentially doe not have a clear understanding of their roles. The standard of vetting and recruitment practices is poor with appropriate checks not being carried out, potentially leaving service users at risk. EVIDENCE: The home had 30 service users accommodated at the time of inspection and the Registered Manager explained that she had adjusted the staffing levels accordingly. In addition to the employed rostered staff on duty, the home has supervised practice students plus student nurses from Thames Valley University on placement. 4 of the care staff are trained to NVQ in care level 2 or above, and 6 care staff are currently undertaking NVQ in care training. Two staff employment record files were viewed. These did not contain the required information as per Schedule 2 of the Care Homes Regulations 2001, a copy of which was given to the Registered Manager at the time of inspection. The Registered Manager was unaware that Schedule 2 had been amended in July 2004. Both files viewed did not contain full employment histories and the application forms did not detail the reasons for leaving previous employment. For one staff member there was no Criminal Records Bureau or POVA First check in place. For another staff member a Criminal Records Bureau Dudley House Care Home DS0000064752.V277558.R01.S.doc Version 5.1 Page 18 undertaken at another nursing home had been accepted. The portability of Criminal Records Bureau checks had ceased in July 2004, and the Registered Manager was not aware of this. The need for the Registered Manager to keep herself up to date will all procedures to include employment procedures was discussed. The gaining of a POVA First and Criminal Records Bureau check for all persons working at the home, to include any volunteers or non-contract workers was also discussed. An immediate requirement in respect of shortfalls identified in the staff employment records was issued. There was no evidence seen regarding the induction and foundation training programmes for the home. The Registered Manager said that induction training was available but she could not produce the documentation to show it met Skills for Care (formerly TOPSS) standards. Dudley House Care Home DS0000064752.V277558.R01.S.doc Version 5.1 Page 19 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, 34, 35, 36, 37 and 38 The Registered Manager is experienced to manage the home. The completion of a management qualification would update and enhance her management skills and thus facilitate current management practice in the home. The home does not review aspects of its performance through a programme of selfreview and consultation and seeking the views of, service users, staff and relatives. The Health & Safety systems in place in the home need to be reviewed to ensure that the safety of the service users, staff and visitors to the home is maintained at all times. Systems for office administration were poor and need to be reviewed. EVIDENCE: The Registered Manager is a first level registered nurse with post-graduate qualifications in teaching & assessing and care of the dying and their families. She has commenced the Registered Managers Award and is near completion. The Inspectors were concerned at the number of Standards with shortfalls identified at this inspection, and the Registered Manager needs to ensure she Dudley House Care Home DS0000064752.V277558.R01.S.doc Version 5.1 Page 20 has a clear knowledge of the NMS for Older People and Care Homes Regulations 2001, so that she can manage the home in accordance with this legislation. Effective quality assurance and quality monitoring systems were not in place. This has been discussed at previous inspections. There was no annual development plan for the home and there is no evidence of self-monitoring or internal audit systems in place. Service user surveys had not been undertaken for the year 2005 and requirements identified in the CSCI reports had not all been met. The home has a suggestion box located at the front entrance. The Responsible Individual stated that he has been carrying out the Regulation 26 inspections, however copies of the reports have not been forwarded to the CSCI. Draft, audited accounts were available for the financial year ending 31/05/05 and these showed that the home is financially viable. A business and financial plan was not available for inspection and the Responsible Individual said that the various sections required collating. There was evidence of employers liability insurance being in place. A solicitor with Power of Attorney manages three service users monies. The Registered Manager stated that no service users monies are managed by the home. Staff supervision records were not up to date. In the sample viewed the last recorded supervision took place in November 2003. The Registered Manager said that supervision is taking place, but she was not able to evidence this. The Registered Manager needs to ensure that all staff providing care receive supervision every 2 months from people trained and competent to do. There is a system for annual appraisals within the home. Records were being stored securely. Records required by regulation and for the efficient running of the business were not up to date. Details of these are recorded under Standards 7, 8, 9, 29, 30, 33, 34 and 38. The systems in place for office administration were poor. For example, out of date information was still being stored in the current files and needed archiving. One Inspector viewed some servicing and maintenance records at random. These were generally up to date. A fire risk assessment was available and was dated November 2004. It appeared that there had been no review of this assessment following a fire in the home. Fire drill and fire alarm records were viewed. Fire drill records did not detail the name of the staff attending, at what time the drill took place and what action, if any, was required. For the weekly fire alarm test, the individual call points actually tested had not always been identified. These issues had been identified at the last inspection. During the Dudley House Care Home DS0000064752.V277558.R01.S.doc Version 5.1 Page 21 tour of the premises the Inspectors noted that a fire alarm sounder on the first floor had been removed. Fire detection was not available in some of the new single bedrooms viewed. It was suggested at the time of inspection that the Inspectors request a visit to the premises by the LFEPA. Risk assessments on safe working practices, the premises and the home were not available. Risk assessments to include the building works had not been formulated. During the tour of the premises one Inspector found that the builders had left their tools unattended at the top of the stairs. These were removed following discussion with the Registered Manager. The systems for the management of health and safety were poor and did not safeguard the service users and the staff working in the home. The handy man and the Registered Manager have not undertaken health and safety and risk management training. The Registered Manager stated that there is a member of staff trained in First Aid on duty on each shift. A full audit of health & safety management, within the home, needs to be undertaken. Dudley House Care Home DS0000064752.V277558.R01.S.doc Version 5.1 Page 22 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 2 3 3 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 1 8 1 9 1 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 X 14 X 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 3 18 3 1 2 2 X 3 1 1 2 STAFFING Standard No Score 27 3 28 3 29 1 30 1 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 1 2 3 2 1 1 Dudley House Care Home DS0000064752.V277558.R01.S.doc Version 5.1 Page 23 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 Statement of Purpose must be updated so that it reflects the current management of the home. A copy must be forwarded to the CSCI. The Service User Guide must be updated and copies distributed to service users and/or their representatives and the CSCI. The service user plan must accurately reflect all the individual needs of the service user. They must be reviewed and updated monthly and whenever the service users condition changes. Risk assessments for falls must be in place for all service users and must be updated following any falls. Any incidents of unexplained injury to include bruising must be clearly recorded and investigated. Wound care documentation must be up to date and clearly reflect the condition and progress of each wound. Pressure relieving equipment DS0000064752.V277558.R01.S.doc Timescale for action 01/03/06 2 OP1 5 01/03/06 3 OP7 15, 17 01/03/06 4 OP7 13(4) 01/03/06 5 OP7 12 01/03/06 6 OP8 17 01/03/06 7 OP8 17 01/03/06 Page 24 Dudley House Care Home Version 5.1 8 OP8 13(1)(b) 17 9 OP8 17 10 OP8 13(5) 11 OP8 13(4)(7) 12 OP9 13(2) 13 14 15 16 17 OP9 OP9 OP9 OP9 OP9 13(2) 13(2) 13(2) 13(2) 13(2) 18 OP9 13(2) used for a service user must be clearly identified and recorded in the service user plan. Any incidents of marked weight loss must be reported to the relevant healthcare professional and appropriate action taken to address this finding. Continence assessments for all service users must be in place. Care plans for continence care needs must be formulated. reviewed monthly and when there are any relevant changes. The specific moving & handling equipment to be used must be identified in the service users individual service user plan. Prior to their use, risk assessments for the use of bedrails must be carried out in full and the appropriateness of their use clearly identified. Prescription medicines must be stored securely in the home. Medicines requiring storage in a fridge must be stored appropriately. Tippex must not be used on The MAR. Staff must sign the MAR with their full specimen initials. Medicines must be recorded accurately when administered Dates of opening must be written on all liquids particularly those with a short shelf life The fridge must be defrosted and the minimum/maximum temperature recorded daily The home must obtain a professional finger-pricking device or lancing device for taking blood samples. The home must not use one service users lactulose for another person. If they wish to continue with the current DS0000064752.V277558.R01.S.doc 03/02/06 01/03/06 01/03/06 01/03/06 01/02/06 01/02/06 23/01/06 01/02/06 01/02/06 14/02/06 01/03/06 Dudley House Care Home Version 5.1 Page 25 19 OP9 13(2) 20 OP9 13(2) 21 OP9 13(2) 22 OP9 13(2) 23 24 OP15 OP15 12(3) 13(3) 25 OP19 23(2)(b) 26 OP19 13(4) 27 OP19 23(2)(b) 28 OP21 23(2)(b) practice of sharing then they must obtain a bulk prescription. Medicines must be recorded when received into the home either on the MAR or in separate ledger. Immediate requirement notice issued. Medicines must be recorded when disposed of. They must be disposed of via a licensed waste carrier. Immediate requirement notice issued. Medicines must be kept for 7 days when a service user dies. Immediate requirement notice issued. All staff must have training in current best practice in the safe handling of medication. Date of training to be notified to CSCI. Immediate requirement notice issued. Service users must be offered a choice at mealtimes and this must be recorded and respected. Kitchen records must be maintained in good order. Cleaning records must be available for inspection. A full environmental audit of the home must be carried out. There must be in place a programme of redecoration and refurbishment with timescales for completion. A copy of the both documents must be forwarded to the CSCI. Risk assessments in relation to the work being carried out must be in place. Clear systems for managing the works must be in place to minimise any risk or disruption to service users. The garden must be reviewed and action taken to maintain it in good condition, suitable for the use of service users and their visitors. The toilet, bath & shower DS0000064752.V277558.R01.S.doc 24/01/06 25/01/06 25/01/06 01/04/06 01/03/06 01/03/06 01/04/06 17/02/06 01/04/06 01/04/06 Page 26 Dudley House Care Home Version 5.1 (j) 29 OP24 13(5) 16(2)(c) 30 OP24 16(2)(c) 31 32 OP24 OP25 16(2)(c) 13(4) 33 OP25 13(4) 34 OP25 13(4) 23(2)(p) 35 OP26 23(2)(c) 36 37 38 OP26 OP26 OP29 13(4) 13(3) 17 facilities must be reviewed as part of the environmental audit and included on the redecoration and refurbishment programme, with timescales for completion. Adjustable beds must be available for all service users with moving & handling needs. Confirmation of this must be forwarded to the CSCI. The flooring in the bedrooms must be reviewed and where necessary replaced to provide suitable flooring for bedroom areas. The furnishings in the bedrooms to include the wardrobes must be reviewed and replaced. All radiators and pipe work in areas accessible to service users must be of a guaranteed low surface temperature type or must be guarded. There must be clear records of actual water temperature readings available. These must also include any remedial action required. As part of the environmental audit, all windows must be reviewed. Action must be taken to ensure all windows close fully and that window restrictors are in place. All equipment used by service users or persons working at the home must be maintained in good working order. The instructions for the use of any COSHH products must be up to date and accurate. Personal toiletries must not be left in communal areas. Staff records must include all the information required under Schedule 2 of the Care Homes Regulations 2001. Immediate requirement notice issued. DS0000064752.V277558.R01.S.doc 01/04/06 01/05/06 01/05/06 01/02/06 01/02/06 01/03/06 01/02/06 10/02/06 01/02/06 03/02/06 Dudley House Care Home Version 5.1 Page 27 39 OP30 18 40 OP31 9 41 OP31 10 42 OP33 26 43 OP33 24 44 OP34 25 45 OP36 18(2) 46 OP37 17 47 OP38 23(4) 48 OP38 23(4) Induction and foundation training to meet the Skills for Care core standards must be in place and implemented. The Registered Manager must complete a management qualification to NVQ level 4 or the equivalent. The Registered Manager and Responsible Individual must ensure that they have a working knowledge of the National Minimum Standards for Older People, the Care Homes Regulations 2001 and all associated legislation. The home must be managed with sufficient, competency and skill. Regulation 26 visits must be carried out in accordance with the regulation and copies of the reports forwarded to the CSCI. An annual development plan for quality assurance, relevant to the size of the home, must be formulated and available in the home. A copy must be forwarded to the CSCI. A business and financial plan must be formulated and available for inspection in the home. Formal supervision in line with Standard 36 must be ongoing. Supervision records must be kept up to date. The Registered Manager must ensure that records required by regulation and for the efficient running of the business are up to date, available and accurate. The fire risk assessment must be reviewed annually and whenever there are any relevant changes within the home or its grounds. Records regarding fire safety equipment checks and fire drills DS0000064752.V277558.R01.S.doc 01/03/06 01/04/06 17/02/06 10/02/06 01/04/06 01/04/06 01/04/06 01/04/06 03/02/06 10/02/06 Page 28 Dudley House Care Home Version 5.1 49 50 OP38 OP38 23(4) 13(4) 51 OP38 12, 13(4) must be kept up to date and in order. Previous timescale of 01/11/05 not met. Fire drill records must identify the staff attending each drill, the time of each drill and what action, if any, was required. Any shortfalls identified at the Fire Officers visits must be addressed. Risk assessments must be available for equipment and all safe working practices. These must be available for inspection. A full audit of health & safety systems must be carried out. All staff to include management must be up to date with training in all health & safety topics. 10/02/06 01/03/06 01/04/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2 3 4 Refer to Standard OP8 OP9 OP9 OP9 Good Practice Recommendations It is strongly recommended that individual care plans be formulated for each wound identified. The allergy section should be completed on the MAR. If there is no allergy then no allergy known should be stated. That the evidence of the current dose of warfarin is kept with MAR The manager must audit at least monthly the handling of medication in the home Dudley House Care Home DS0000064752.V277558.R01.S.doc Version 5.1 Page 29 Commission for Social Care Inspection West London Area Office 58 Uxbridge Road Ealing London W5 2ST 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 House Care Home DS0000064752.V277558.R01.S.doc Version 5.1 Page 30 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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