Inspection on 04/04/06 for Dudley House Care Home

This inspection was carried out on 4th April 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. 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 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 Unannounced Inspection 4th April 2006 10:00 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.V286666.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.V286666.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.V286666.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 23rd January 2006 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 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, 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. Dudley House Care Home DS0000064752.V286666.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 15 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. The CSCI Pharmacy Inspector carried out an inspection on 12/04/06. 6 service users, 5 staff, 3 visitors and a visiting healthcare professional were spoken with as part of the inspection process. The pre-inspection questionnaire, given to the home at the time of inspection, was also used to inform this report. What the service does well: What has improved since the last inspection? What they could do better: The home is accommodating service users who are outside the homes categories of registration. Staff do not have the specialist training and skills to meet the needs of these service users. There is evidence that some of the behaviour could be impacting on other service users. This issue needs to be addressed promptly and appropriately. Whilst requirements have been made in Dudley House Care Home DS0000064752.V286666.R01.S.doc Version 5.1 Page 6 this report, the shortfalls identified are minor and should be easy to address. The home must ensure that improvements made are maintained, and that any issues that occur are promptly and effectively addressed in the future to prevent any regression in standards. 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.V286666.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.V286666.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, 3, 4 and 5. The home does not provide intermediate care. Draft documentation providing information about the home is available, and once finalised will be distributed to service users and their representatives. Service users are assessed prior to admission to ensure the home can meet their needs. Service users with specialist needs outside the homes categories of registration are accommodated at the home. This can impact on other service users and staff do not always have the skills to meet these 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 home has a draft Statement of Purpose, which was viewed by one Inspector, and some changes are to be made before producing the final document. The Service User Guide has been produced and copies are available in all the service users rooms. Pre-admission assessments had been completed, and those viewed were comprehensive and gave a clear picture of the service users needs. In some Dudley House Care Home DS0000064752.V286666.R01.S.doc Version 5.1 Page 9 instances copies of the Social Services needs led assessments were also available. The home is registered to provide general nursing care. When observing and speaking with service users in the communal room, two service users were noted to be very confused and have a diagnosis of dementia. This was discussed with the Registered Manager and the need to review the placements and ensure that staff have relevant training and the home is able to meet their dementia care needs was identified. The home does have a second communal room, and it may be beneficial for the service users to sit in this room during the day so that their specialist care needs can be catered for and any behavioural impact on other service users is minimised. If it is found that the home is able to continue to accommodate these service users, the home must apply to the CSCI for a variation to their conditions of registration. Service users and their representatives are encouraged to visit the home prior to admission to see if it meets their needs and expectations. Copies of the new Statement of Purpose will be made available to prospective service users and their representatives. Dudley House Care Home DS0000064752.V286666.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 and 10 The service user plans were up to date and identified the needs of the service users, thus providing staff with clear information of how the service users needs are to be met. Shortfalls should be easy to address. The management of medications is generally good, thus safeguarding service users. Shortfalls should be easy to address. Staff treat service users with courtesy and respect. EVIDENCE: Four service user plans were viewed. There had been an improvement in the formulation and updating of the service user plans since the last inspection. Care plans for identified needs are in place. Risk assessments for falls had been completed and reviews were seen. Wound care documentation is in place, and there was evidence of input from the Tissue Viability Nurse Specialist. Care plans for wounds were seen, and the Inspector recommended that a separate care plan be formulated for each wound. Continence assessments are now in place, and in all but one instance had been completed, and this was discussed with the Registered Manager. Moving & handling assessments had been carried out and equipment to be used identified. Nutritional assessments were in place and monthly weights are recorded, and where it is not possible to weigh a service user this is also recorded. Action had been taken to ensure any marked Dudley House Care Home DS0000064752.V286666.R01.S.doc Version 5.1 Page 11 weight loss is recorded and appropriate action taken. Risk assessments for bedrails are in place, but had not always been completed. This was discussed at the time of inspection. The CSCI Pharmacist Inspector carried out an inspection on 12/04/06 and a separate report is available. The requirements and recommendations resulting from that inspection have been incorporated into this report. Staff were seen caring for service users in a gentle and courteous manner, assisting them as required with daily activities. Service users spoken with expressed their satisfaction with the home and said that they are well cared for. Visitors to the home said that they are made welcome and are happy with the care their relative receives. There was a healthcare professional visiting the home at the time of inspection and feedback regarding service user referrals was satisfactory. Dudley House Care Home DS0000064752.V286666.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): 13 & 15 Visiting is encouraged and this enhances the service users lives and keeps them in touch with their families and friends. The meals provided offer both choice and variety to meet the service users preferences. EVIDENCE: Visiting is encouraged and visitors spoken with said that they are made welcome at the home. Service users can receive visitors in the day room or in their own rooms. Action has been taken to organise the kitchen records since the last inspection, and these are now easy to follow and in order. These include cleaning schedules and work carried out, a record of food hygiene training for kitchen staff, safe working practice risk assessments and daily temperature recordings. Records of service users meal choices were available and service users spoken with confirmed that they are offered a choice of meals and this is respected. Staff were available to assist service users at mealtimes, and were seen to do so in a discreet and gentle manner. Dudley House Care Home DS0000064752.V286666.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 & 18 The home has a satisfactory complaints system in place and concerns are listened to and acted upon. Staff have an understanding of adult protection issues, thus safeguarding service users from abuse. EVIDENCE: The home has a clear complaints and adult protection procedures. There have been no complaints or POVA concerns since the last inspection. Staff spoken with had a clear knowledge of POVA and said that they would report any concerns of this nature. POVA procedure documentation is in place. Dudley House Care Home DS0000064752.V286666.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 & 26 There have been marked improvements to the environment to provide service users with a homely environment, and respect their privacy and dignity. EVIDENCE: The recent redecoration and room alterations had been completed. The Responsible Individual has carried out an environmental audit. The Inspectors asked for an up to date redecoration and refurbishment plan to identify works completed and works to be done, with dates for completion to be included. One Inspector toured the home and it was clear that a lot of work had taken place throughout the home. The rear garden had been cleared and made safe for service users to use. The Responsible Individual said that the area is also to be landscaped to provide an attractive garden for service users to sit out in. Single bedrooms with en suite toilet, shower and wash hand basin facilities have been created from double bedrooms. New assisted shower facilities for general use are also in place, with plans for a new assisted bath facility in the near future. Dudley House Care Home DS0000064752.V286666.R01.S.doc Version 5.1 Page 15 The Responsible Individual said that new carpets for the corridors had been purchased, and were to be fitted in the near future. The home is looking at ways of providing necessary storage areas within the home. New bedroom furniture to include adjustable beds is still required, and the Responsible Individual said that he is planning for this to be addressed at the rate of refurbishing one room per month. This information is to be included in the redecoration and refurbishment plan. The home was pleasantly warm and ventilation was appropriate. Water temperature records were viewed and actual temperature recordings were available, however the entries had not been dated. The need for this was discussed. Window restrictors are in place and work had been done to ensure the windows fit properly, although one ground floor room window needed to be replaced as a priority and this was discussed. The Responsible Individual said that he was exploring avenues to have the other windows replaced. The laundry room is to be relocated to the cellar in the near future. The Responsible Individual confirmed that this has been discussed and agreed with the Fire Safety Officer who recently inspected the home. There had been an improvement in the condition of the laundry room, which was clean and tidy. The broken dryer had been removed. The home was clean and there were no infection control issues identified. Dudley House Care Home DS0000064752.V286666.R01.S.doc Version 5.1 Page 16 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, 29 & 30 The home was adequately staffed to meet the needs of the service users. Systems for vetting and recruitment practices are in place and protect service users. Induction and foundation training is in place, thus providing new staff with the knowledge to care for service users. EVIDENCE: At the time of the inspection there were 32 service users accommodated at the home and the home was appropriately staffed to meet the needs of the service users. The need to ensure that staffing levels are reviewed on an ongoing basis in line with service users changing dependency levels was discussed. Since the last inspection a full audit of all staff files has taken place. Two staff employment files were viewed during the course of the inspection. These contained all the information required under Schedule 2 of the Care Homes Regulations 2001 with the exception of a recent photograph, and the Registered Manager said that this would be addressed. The Registered Manager has implemented induction and foundation training in line with the Skills for Care core standards. Information requested and provided by the Registered Manager evidenced that staff have undertaken statutory training and training in topics relevant to the service users needs. Dudley House Care Home DS0000064752.V286666.R01.S.doc Version 5.1 Page 17 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 & 38 The Registered Manager has a greater awareness of the Standards and Regulations applying to Older People, and is working within these to provide a good quality service. Systems for quality assurance are in place, thus providing an ongoing process of review and feedback. Staff receive supervision, thus promoting communication and review of practice. Records are better maintained for the protection of service users and the running of the home. Systems for the management of health and safety throughout the home are good, thus safeguarding service users, staff and visitors. 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 stated that she was due to complete her Registered Managers Award, NVQ level 4, by the end of April 2006. Staff spoken with said that the Registered Manager is supportive and approachable. Dudley House Care Home DS0000064752.V286666.R01.S.doc Version 5.1 Page 18 The home is putting systems in place for quality assurance. Questionnaires for service users and their representatives have been completed, and a copy of the results was given to the Inspectors. The home is looking to attain and implement the ISO Quality Assurance System. Medication, service user plan, health & safety and environmental audits are taking place monthly and these were viewed. Monthly Regulation 26 unannounced visits by the Responsible Individual are being undertaken and copies of the reports of these visits have now been received by the CSCI. The need to forward these each month was discussed. A business and financial plan was available. Audited accounts for the business were also available. The Registered Manager said that no service users monies are managed or held by the home. Records of staff supervision were available, and staff spoken with confirmed that this is taking place. There was a marked improvement in the standard of the record keeping in the home. Some further work is required, and the improvements made must be maintained. Generic risk assessments for safe working practices are now in place, and these are comprehensive. A health & safety audit had been carried out and any shortfalls identified had been addressed. Servicing and maintenance records were viewed at random and were up to date. The Registered Manager and Responsible Individual are going to undertake training in health & safety and risk management. Fire drill records were up to date and the Fire Risk Assessment had been reviewed and updated. It is acknowledged that a lot of work had been done to improve the standard of health & safety within all areas of the home. Dudley House Care Home DS0000064752.V286666.R01.S.doc Version 5.1 Page 19 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 X 3 2 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 2 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 3 14 X 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 3 3 X 3 3 2 3 STAFFING Standard No Score 27 3 28 X 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 3 3 3 3 3 Dudley House Care Home DS0000064752.V286666.R01.S.doc Version 5.1 Page 20 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, 5 Requirement The Statement of Purpose and Service User Guide must be amended in line with the Care Homes Regulations 2001. A copy must be forwarded to the CSCI. (repeat requirement that has been partially addressed) For those service users with a diagnosis of dementia, whose behaviour does not impact on other service users, a variation to conditions of registration must then be submitted to the CSCI together with the evidence that staff have the training and skills and the home is equipped to meet the specialist care needs of service users with dementia. The risk assessments for the use of bedrails must be completed in full and the appropriateness of their use clearly identified. Medicines must be recorded accurately when administered. Staff must use their full specimen initials when recording administration of medicines. The fridge temperature must be monitored closely to ensure that DS0000064752.V286666.R01.S.doc Timescale for action 01/07/06 2. OP4 12 12/05/06 3. OP8 13(4)(7) 01/05/06 4. 5. 6. OP9 OP9 OP9 13(2) 13(2) 13(2) 12/04/06 01/05/06 01/05/06 Dudley House Care Home Version 5.1 Page 21 7. OP9 13(2) 8. 9. OP9 OP19 13(2) 23(2)(b) 10. 11. 12. OP25 OP25 OP29 13(4) 23(2)(b) 17 it is maintained between 2 and 8 degrees. It may be necessary to consider an alternative location. The home must not use one service users lactulose for another person. All staff must be reminded that this is poor practice. Controlled drugs must be kept in the CD cupboard until disposed of. A record of planned and completed redecoration and refurbishment to include dates for completion must be available. The water temperature records must be dated at the time of completion. The damaged window frame must be made good. Staff records must include all the information required under Schedule 2 of the Care Homes Regulations 2001, to include a recent photograph. (repeat requirement that has been partially addressed) 01/05/06 12/04/06 01/06/06 01/05/06 01/07/06 01/05/06 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. Refer to Standard OP8 OP9 Good Practice Recommendations It is strongly recommended that individual care plans be formulated for each wound identified. The manager should continue to audit at least monthly the handling of medication in the home Dudley House Care Home DS0000064752.V286666.R01.S.doc Version 5.1 Page 22 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.V286666.R01.S.doc Version 5.1 Page 23 - 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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