Inspection on 03/07/07 for Dudley House Care Home

This inspection was carried out on 3rd July 2007.

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

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

Other inspections for this house

Dudley House Care Home 10/12/07

Dudley House Care Home 23/10/06

Dudley House Care Home 04/04/06

Dudley House Care Home 23/01/06

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 Mrs Rekha Bhardwa Key Unannounced Inspection 10:15 3rd July 2007 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.V339198.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Dudley House Care Home DS0000064752.V339198.R01.S.doc Version 5.2 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 Dementia (0), Dementia - over 65 years of age registration, with number (0), Old age, not falling within any other of places category (40), Physical disability (40), Physical disability over 65 years of age (40), Terminally ill over 65 years of age (1) Dudley House Care Home DS0000064752.V339198.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. As agreed on 02/05/2006, one named service user over the age of 65 with Terminal Illness can be accommodated within the home. Service users who already have a diagnosis of Dementia may not be admitted. Service users who develop Dementia after being admitted, may be accommodated, as long as their needs can be met and they do not detrimentally affect the wellbeing of the other service users. 23rd October 2006 Date of last inspection Brief Description of the Service: Dudley House Nursing Home is a large detached house in Isleworth. There are 38 single bedrooms, 11 of which are en suite, plus one double bedroom. The home has installed a new larger passenger lift. There are three floors in the home and resident 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, which is served by several bus routes. There are shops in Isleworth itself and the home is a short bus ride from Hounslow Town Centre. There were 38 residents accommodated at the home at the time of inspection. The fees range from £530 to £600 per week. Dudley House Care Home DS0000064752.V339198.R01.S.doc Version 5.2 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 15 hours was spent on the inspection process. A tour of the home was carried out, and service user plans, management records, medication systems, training records, staff employment records, administration records, maintenance and servicing records were viewed. The pre-inspection questionnaire and comment cards from people living at the home and representatives/visitors and healthcare professionals have also been used to inform this report. 7 residents, 2 visitors and 8 staff were spoken with as part of the inspection process. On the day of inspection the Registered Manager was not present. The Responsible Individual and the Deputy Care Manager assisted the Inspectors. What the service does well: What has improved since the last inspection? There has been an improvement in the completion of bedrail risk assessments. A record of all medication received in the home is now being maintained and there have been no drug errors reported. Medication fridge temperatures are being maintained within a safe range. An activities co-ordinator has been appointed to commence work and further developments in this area have been planned for. The management of complaints has improved and the complaints procedure has been updated. POVA training had been undertaken by staff and staff spoken with were clear about POVA and whistle blowing procedures. An environmental audit has taken place and the home has in place a redecoration and refurbishment plan. Bedroom door locks have been changed and these allow staff access in an emergency. Shower facilities have improved. Improvements have been made to the laundry facilities and plans are in place to replace the flooring. Dudley House Care Home DS0000064752.V339198.R01.S.doc Version 5.2 Page 6 What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Dudley House Care Home DS0000064752.V339198.R01.S.doc Version 5.2 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.V339198.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 3. The home does not provide intermediate care. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are fully assessed prior to admission to the home, to ascertain that the home is able to meet their needs. EVIDENCE: A sample of pre-admission and assessments on admission were viewed during the course of the inspection. These were comprehensive and gave a clear picture of the residents needs. A copy of the Social Services ‘Needs Led’ Assessment for each resident had also been obtained prior to admission. Dudley House Care Home DS0000064752.V339198.R01.S.doc Version 5.2 Page 9 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9, 10 and 11. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Overall the service user plan documentation to include wound care documentation was poorly completed, thus placing residents at risk of not having their needs identified and met. Shortfalls in medication management and recording place residents at risk. Staff care for residents in a courteous and professional manner, however by not using a preferred term of address this is not showing respect to each individual. Shortfalls in identifying end of life care needs place residents at risk of not having there needs fully met. EVIDENCE: 4 service user care plans were viewed during the course of the inspection. Apart from one viewed, these were very general and were not personalised to reflect the individual residents needs. This is a repeat finding. For one resident a care plan headed mobility and dexterity was in place. Upon checking the detail in this care plan the resident was immobile and cared for in bed. There was evidence of monthly reviews however there was no evidence that the care plans were actually being updated to reflect any changes. For example, where the personal circumstances of residents had changed, their service user plans Dudley House Care Home DS0000064752.V339198.R01.S.doc Version 5.2 Page 10 had not been updated to reflect this. The admission assessments viewed by the Inspectors provided good information on the needs of the residents this information however was not always transferred into the care plan. Risk assessments for falls had been completed. In one instance where the resident had fallen there was no evidence that the falls risk assessment had been updated. This is a repeat finding. There was no evidence of involvement from residents and representatives with the exception of some assessments and/or consents being signed. Wound care documentation was viewed. For one resident the documentation had not been reviewed to fully reflect the current condition of the wound. The daily log indicated that the wound had deteriorated. It was not clear what action had been taken to address this with the GP. Prior to the deterioration a new wound product had been advised by the GP and was being used by the Nurses, however this had not been reflected in the wound care plan. Dressing changes are recorded in the daily log. These did not always detail the condition of the wound. Monthly wound assessments are undertaken. A pain care plan was in place for this resident. This did not detail that pain relief should be offered prior to a dressing change. Pressure relieving equipment was seen in use in the home and is identified in the service user plan. There was evidence of input from the Tissue Viability Nurse specialist. Nutritional assessments were in place, and care plans had been formulated for service users with any identified problems. Monthly weights were being carried out and where problems with eating and drinking or weight loss had been identified referrals made to the Dietician. Moving and handling assessments viewed did not identify the type of hoist in use, the care plan for one resident did not identify the fact that a hoist was in use. For some other residents the moving and handling assessments were incomplete. Continence and pressure sore risk assessments were available. For some residents with skin breaks this had not been included in the risk scores for pressure sore risk assessments. There was evidence of input from healthcare professionals to include GP, chiropodist and optician. One Inspector viewed the medication management for the home. All receipts, administration and disposals had been clearly recorded and signed for, and the correct method of medication disposal was in use. Whilst auditing the medication the Inspector noted that in some instances medication had been signed for however when counting the remaining stock there was a discrepancy in the amount that should be left in the box and actually was left in the box. This was brought to the attention of the Deputy Manager at the time of the inspection and the need to carry out a stock check of the boxed medications and put systems in place to aid stock control in the future was discussed. Stocks of some creams were high and it was suggested that there be a full stock check before further items are ordered. The medication fridge temperature records are within safe range. Controlled drugs records were up to date and the register was being completed correctly. Medications are being Dudley House Care Home DS0000064752.V339198.R01.S.doc Version 5.2 Page 11 securely stored in the home. All prescribed creams are stored in the clinic room. The Inspector noted that home was not using ‘professional use’ lancets for blood glucose monitoring. Information regarding the correct lancing devices to be used has been sent to care homes on more than one occasion and evidence of this was available on file in the home. For one resident being fed via a naso-gastric tube this had not been recorded on the Medication Administration Record (MAR). Some information was available on the fluid chart, however clear records of start times, batch numbers and the person responsible for setting up the feed were not available. Following the inspection the Inspectors were informed that the home had contacted Boots the pharmacist and that they are putting in place a monitored dosage system. Staff were seen caring for residents in a gentle, caring and professional manner. Each bedroom has a telephone extension for receiving incoming calls and residents can choose to have their own private telephone if they so wish. Comment was received in a questionnaire that “many residents in their 80’s and 90’s would prefer not be called by their given names but “Mrs” – they don’t have that option. Also “darling” used all the time and whilst showing affection is also infantilising”. It was also noted that staff refer to the residents as ‘patients’ and this is not an appropriate term for people living in a care home. Clothing is labelled and residents were well dressed, expressing individuality. Bedrooms were personalised and residents are encouraged to bring in personal possessions in line with fire safety. The service user plans contained information regarding individual wishes in respect of health deterioration and end of life care, in some instances this information was brief and for one resident who was receiving end of life care there was no care plan in place to reflect this. Dudley House Care Home DS0000064752.V339198.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home has recruited an activities co-ordinator, and work is to take place to ascertain residents’ individual interests in order to plan to provide activities to cater for residents’ individual and group interests. The home has an open visiting policy, thus encouraging residents to maintain contact with family and friends. Information regarding advocacy services is available, thus ensuring residents right to independent representation is respected. The food provision in the home is good, offering variety and choice, thus meeting the resident’s individual needs. EVIDENCE: “My mother is always given choices with regard to coming downstairs or staying in her room, what to eat for meals, whether to join in activities etc.” “The home has a family atmosphere, friendly and caring along with efficiency” “Dudley House is a happy caring establishment where everyone is made to feel special and visitors made welcome” Dudley House Care Home DS0000064752.V339198.R01.S.doc Version 5.2 Page 13 A new activities co-ordinator has been recruited and is due to commence employment at the end of July 2007. In the interim period a member of staff on duty take responsibility for arranging activities and outings. Comments received in the feedback questionnaires included that residents enjoyed the activities provided and that there could be more outings arranged. In some of the service user plans viewed life history information had not always been completed and this did not allow for clear information in relation to hobbies and interests. A weekly activities programme was on display in the man entrance of the home. Once the activities co-ordinator commences further work will be undertaken to provide individual and group activities. This standard will be assessed in further detail at the next inspection. The home has an open visiting policy and visiting is encouraged. Visitors spoken with confirmed that they are made welcome at the home and are offered refreshments. Residents can choose to receive visitors in their own bedrooms or in one of the communal rooms. Details of advocacy services available are displayed in the main hallway, and are therefore freely available to residents and their representatives. One Inspector viewed the kitchen. Following the last inspection a new chef has been recruited. There was a good supply fresh, frozen, tinned and dried foodstuffs available and those viewed were in date. Kitchen records to include fridge, freezer and food temperatures and cleaning records were available and up to date. The menus viewed indicated that meal choices were available. Staff were observed assisting residents in a sensitive manner at the lunchtime meal. One Inspector noted that no condiments were available at the dining tables, and on investigation it appeared only one set was available in the home. This needs to be addressed so that residents are provided with condiments at each meal unless there is a medical reason not to do so. Varying comments were received about the quality of food provided in the feedback questionnaire. These included not enough choice, meals not always hot, very good meals, good-sized portions and good choice. Hot and cold drinks and snacks are available throughout the 24 hour period. Dudley House Care Home DS0000064752.V339198.R01.S.doc Version 5.2 Page 14 Complaints and Protection The intended outcomes for Standards 16 – 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home has policies and procedures in place for the management of complaints and adult protection issues, and these are followed, thus safeguarding the residents. EVIDENCE: The home has a clear complaints procedure with timescales for completion. There have been no complaints since the last inspection. There is a detailed complaints log maintained with outcomes recorded. Residents and visitors spoken with said that any issues raised are promptly addressed. Staff spoken with said that they had received training in safeguarding adults and those questioned were clear that they would report any concerns of this nature. There have been no POVA issues since the last inspection. The home has policies and procedures for POVA in place and also follows the Borough of Hounslow Safeguarding Adults procedures. Dudley House Care Home DS0000064752.V339198.R01.S.doc Version 5.2 Page 15 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 21 and 26. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Overall the internal and external environment is of a fair standard, thus providing a clean, comfortable and homely environment for residents to live in. Plans are in place to address any shortfalls in the environment in order to maintain a good standard throughout. The bath and shower facilities have been improved and bathing facilities are now available to meet the needs of the residents. Infection control procedures are in place, however some shortfalls in infection control practices could place residents, staff and visitors at risk. EVIDENCE: One Inspector carried out a tour of the home. An audit of the environment has been carried out and shortfalls identified have been included in the redecoration and refurbishment plan. Some bedrooms had been personalised to meet individual needs. The carpets in the corridors, particularly the ground floor, are very marked and the Responsible Individual reported that plans are Dudley House Care Home DS0000064752.V339198.R01.S.doc Version 5.2 Page 16 in place to provide alternative flooring in the corridor areas. Plans are in place to replace all divan beds with adjustable beds. Several adjustable beds are have been purchased since the last inspection. The home has a rear garden with seating available for the residents to use. The home employs a full time maintenance person and external companies undertake larger areas of redecoration and refurbishment. There are assisted bath and shower facilities on each floor and some of the bedrooms have en suites to include shower facilities. Since the last inspection the ground floor shower room has been refitted with new flooring and fittings. The home was clean and fresh throughout. Improvements have been made to the laundry facilities and further plans are in place to have non-slip flooring fitted. Protective clothing to include gloves and aprons was available. It was not clear from the training information provided whether staff had received training in infection control (see Standard 38). Personal clothing is labelled with a marker pen. The laundry staff are very aware of the importance of caring for individuals personal clothing correctly. Dudley House Care Home DS0000064752.V339198.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is appropriately staffed to ensure that the needs of the residents can be met at all times. Systems for vetting and recruitment practices are in place and protect residents. Staff have received appropriate induction training to provide them with the basic skills and knowledge to meet the needs of the residents, however shortfalls in wound care training placed residents at risk and staff therefore are not being kept up to date with current good practice. EVIDENCE: At the time of inspection the home was being staffed to meet the needs of the residents. The Responsible Individual has a clear understanding that staffing is determined according to the assessed needs and dependency needs of the residents. Where additional care needs are identified, staffing is reviewed to address this. Domestic, maintenance and administrative staff are employed in appropriate numbers to meet the needs of the home. A duty roster was available. The pre-inspection questionnaire detailed that 35 of the care staff had completed their NVQ level 2 or have an equivalent qualification. Ten more care staff had commenced their NVQ Level 2 in April 2007. Dudley House Care Home DS0000064752.V339198.R01.S.doc Version 5.2 Page 18 Staff employment records were sampled and those viewed contained the information required by the Care Homes Regulations 2001. The home has in place a training plan, which is based on the training needs of the staff employed at the home. One Inspector viewed the Workforce Development Training Plan, which had been completed in February 2007. Staff spoken with confirmed that they receive regular training. Induction and Foundation training in the home meets the Skills for Care Common Induction Standards. The pre-inspection questionnaire detailed that staff had received training in several areas to include diabetes, nutrition in the elderly, prevention of falls, asthma, naso gastric feeding and Parkinson’s disease. There was no evidence that the staff had received training in wound care from the information provided in the training matrix. Comment was also received in a healthcare professional survey that staff required more training in wound care and management. The need for effective communication between staff, relatives and residents was discussed following comments received in one feedback questionnaire. One Inspector had difficulty in finding training information and systems for managing training information appeared to be chaotic. Dudley House Care Home DS0000064752.V339198.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 and 38. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The Registered Manager has the qualifications and experience to manage the home. Systems for quality assurance are in place, however audits are not identifying issues, thus undermining the effectiveness of the auditing process. The home does not hold any personal monies for residents. Good systems are in place for the management of health & safety, however gaps in staff training could place residents at risk due to out of date practices. 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 completed the Registered Managers Award. The Registered Manager was on leave on the day of inspection. This standard will be assessed in detail at the next inspection. Dudley House Care Home DS0000064752.V339198.R01.S.doc Version 5.2 Page 20 A system for auditing care plans and medication is in place. The Inspectors were concerned that several shortfalls identified in these areas at the inspection had not been found during the audits. A tick box system is used for care plan audits and this does not allow for a thorough detailed audit. Monthly Regulation 26 unannounced visits by the Responsible Individual are not being undertaken and the need to undertake these visits was discussed with the Responsible Individual. There must be effective systems in place for the auditing and review of all care provision. The home is looking to attain and implement the ISO Quality Assurance System. A business and financial plan was available. Resident questionnaires were completed at the end of 2006 and an annual survey is planned for later this year. The home also has a suggestion and comments box in the main entrance. Residents and relatives meetings take place and minutes of these meetings were viewed. Staff meetings take place and minutes of these meetings were available. 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. The Responsible Individual said that no service users monies are managed or held by the home. A sample of servicing and maintenance records were viewed and these were found to be up to date. The home employs a full time maintenance man and a maintenance book is maintained. The training matrix viewed did not detail that all staff had received moving & handling and infection control health and safety training. A fire risk assessment was available and was in the process of being reviewed. The Responsible Individual has since confirmed that the updating has been completed. Risk assessment for equipment and safe working practices are in place. Fire drills to include night and day staff were taking place at the required intervals. Dudley House Care Home DS0000064752.V339198.R01.S.doc Version 5.2 Page 21 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 X X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 2 10 2 11 2 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X 3 X X X X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 2 X 3 X X 2 Dudley House Care Home DS0000064752.V339198.R01.S.doc Version 5.2 Page 22 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 OP7 Regulation 17 Requirement Service user plans must be specific to the individual for whom they are being formulated. Previous timescale of 01/12/06 not met. Risk assessments for falls must be updated following any falls. Previous timescale of 01/11/06 not met. Input from the resident and/or their representative must be sought for the formulation and review of the service user plans, unless it is impracticable to carry out such consultation. This will ensure the needs and wishes of the resident are clear and can be respected. All service user plan documentation to include assessments must be complete, accurate, up to date, signed and dated. Previous timescale of 17/11/06 partially met. All wound care documentation must be up to date in order to show the progress of each wound. Any associated care plans, such as controlling pain DS0000064752.V339198.R01.S.doc Timescale for action 24/08/07 2. OP7 13, 17 01/08/07 3. OP7 15 24/08/07 4. OP8 17 24/08/07 5. OP8 17 20/07/07 Dudley House Care Home Version 5.2 Page 23 6. 7. OP9 OP9 13(2) 13(2) 8. OP9 13(2) 9. OP10 12 10. OP11 12 11. OP12 16 12. OP30 18 13. OP33 24 14. OP33 26 15. OP38 18 associated with a wound, must fully reflect the action to be taken to meet this need. Lancing devices for professional use must be used when taking samples for testing blood sugar. A clear system of auditing must be introduced for stock control, both for boxed medication and also for reserves of medications being held in the home to ensure stocks are being well managed. All Entral feeds must be entered on the MAR chart and clear records maintained to demonstrate the setting up and administration of the feed in line with the dieticians instructions. Residents living at the home must be spoken with using their preferred term of address, showing them respect. The wishes of residents and their families in respect of end of life care must be discussed and clearly recorded, to ensure these wishes are met. Information regarding individual hobbies and interests must be available so that activities can be planned in accordance with this information. Staff involved in wound care must receive training in this area to provide them with up to date knowledge and skills. The auditing processes must be reviewed to ensure that all audits to include service user plans and medications effectively identify any shortfalls so that these can be promptly addressed. Regulation 26 visits must be carried out in accordance with the regulation in order to keep the home under review. All staff must undertake training DS0000064752.V339198.R01.S.doc 20/07/07 20/07/07 20/07/07 20/07/07 20/07/07 01/08/07 01/09/07 01/08/07 01/08/07 01/09/07 Page 24 Dudley House Care Home Version 5.2 and updates in health & safety topics to include moving & handling and infection control, so that practices are up to date in line with current legislation and guidance. RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard OP15 Good Practice Recommendations Residents should have condiments available on the table to use unless there is a medical reason to contraindicate this. The filing systems in the home be reviewed and old information either archived or disposed of, depending on the legal requirements to maintain some documentation. 2. OP33 Dudley House Care Home DS0000064752.V339198.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection West London Local Office 11th Floor, West Wing 26-28 Hammersmith Grove London W6 7SE National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Dudley House Care Home DS0000064752.V339198.R01.S.doc Version 5.2 Page 26 - 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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