Inspection on 26/02/07 for Richmond Court Dudley

This inspection was carried out on 26th February 2007.

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

Richmond Court Dudley 26/09/07

Richmond Court Dudley 28/03/06

Richmond Court Dudley 07/09/05

Richmond Court Dudley 16/11/04

Richmond Court Dudley 25/06/04

Richmond Court Dudley 02/12/03

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Inspirations

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Extracts from inspection reports are licensed from CQC, this page was updated on 09/07/2008.

CARE HOMES FOR OLDER PEOPLE Richmond Court Dudley 16 St James Road Dudley West Midlands DY1 3JD Lead Inspector Chris Lancashire Key Unannounced Inspection 26th February 2007 09:00 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 Richmond Court Dudley DS0000047902.V329871.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. Richmond Court Dudley DS0000047902.V329871.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Richmond Court Dudley Address 16 St James Road Dudley West Midlands DY1 3JD 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) 01384 254442 Mr Dharam Pal Sahni Mrs Sangeeta Sahni Care Home 14 Category(ies) of Dementia - over 65 years of age (5), Old age, registration, with number not falling within any other category (13), of places Physical disability over 65 years of age (6) Richmond Court Dudley DS0000047902.V329871.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. Service Users to include up to 13 OP, 6 PD(E) and up to 5 DE(E) That the service user named in the variation report dated 3 June 2004 must be moved to a room that meets the requirements of the National Minimum Standards as soon as the new extension is registered. That the room is used solely for the purpose of accommodating the service user named in the variation report dated 3 June 2004. When that person is re-accommodated the room must not be used until it meets National Minimum Standards. One service user identified in the variation report dated 14 June 2005 who is 61 years and over may be accommodated at the home in the category OP. This will remain until such time that the service users placement is terminated. 28th March 2006 4. Date of last inspection Brief Description of the Service: Richmond Court is located in a residential area, close to the centre of Dudley, and benefits from a variety of services and amenities, including shops, library, post office, religious facilities and the main bus terminal providing access to neighbouring towns and places of interest. The Home is a traditional style, detached house, with extensions which offers twelve single bedrooms, one double bedroom, lounge, dining room, two bathrooms, seven WCs, kitchen and laundry. There are no en-suite rooms but all bedrooms have wash-hand basins. Richmond Court has a large garden to the rear of the property, but, at the present time, this is not easily accessible to residents, as it is much lower than the house and the connecting steps are steep. However, residents have a view over the garden and there are well-advanced plans for an extension to the property, which will provide a net increase of seven new single bedrooms with en-suite facilities, a new laundry, enlarged and up-graded kitchen, new shower room and improved access to the garden. At present there is some car parking space to the front of the Home, but the proposed extension should increase this facility and provide extra office space and storage. Fees: £343 Richmond Court Dudley DS0000047902.V329871.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was undertaken by two inspectors, on an unannounced basis. The aim was to inspect against the key standards and to assess progress made towards meeting requirements made at the previous visit. The inspectors viewed records, spoke with staff, the manager and proprietor and toured the building. What the service does well: What has improved since the last inspection? There are improved systems for recording assessments of residents’ needs and daily progress. Staff have received additional training in several areas so that they are now better qualified and more aware of how to meet the needs of the residents. There have been improvements in the arrangements for storing and handling of medication. Richmond Court Dudley DS0000047902.V329871.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. Richmond Court Dudley DS0000047902.V329871.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 Richmond Court Dudley DS0000047902.V329871.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. Quality in this outcome area is good. Prospective residents’ needs are assessed and they are assured that they will be met. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Sampled care files contained evidence of pre-admission assessments, completed by the manager, in addition to the information provided by other professionals. These covered the necessary areas and included nutritional assessments, dependency checklists, continence and tissue viability assessments. The Residents and their representatives had been assured that these would be met by the home. Richmond Court Dudley DS0000047902.V329871.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. Quality in this outcome area is good. The residents’ needs are set out in a plan of care and health needs are met. There are suitable arrangements for the storage and administration of medication. The privacy of residents is respected and their dignity is upheld. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Sampled records included care plans which cover the necessary areas. The various assessments carried out at the time of admission are supplemented by other information which provides staff with guidance about how to care for each resident. Information is reviewed and updated on a regular basis by the manager and deputy. There is also a detailed summary care plan which provides details of each resident’s social history. Plans are signed by residents or relatives. There are detailed daily record sheets where staff record the care which has taken place. Richmond Court Dudley DS0000047902.V329871.R01.S.doc Version 5.2 Page 10 Care plans include the health needs of residents and records show that the services of GPs and other relevant health professionals are used on a regular basis. There are appropriate arrangements for the storage and administration of medication and staff who administer this are suitably trained to do so. The administration sheets were completed appropriately with no gaps. Staff were observed treating residents with dignity and respecting their privacy. Residents expressed the view that they were treated well by staff. Richmond Court Dudley DS0000047902.V329871.R01.S.doc Version 5.2 Page 11 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): 12,13,14,15 Quality in this outcome area is good. Residents are consulted about the lifestyle which they prefer to follow in the home and staff enable them to do so. Contact with relatives, friends and the local community is encouraged. Residents receive a varied and balanced diet, which provides choice. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The social history, needs and preferences of residents are sought prior to admission and at regular intervals so that they can be enables to continue to pursue interests and activities which they enjoy. The manager and staff described a range of activities which take place. Staff are aware that several residents have a limited concentration span and this is taken into account. Social events and activities take place in the home and relatives and friends are encouraged to attend. Notice of these events is provided on a notice board in the entrance hall. Some residents are able to go out for short walks with the staff or their families and use is made of local clubs, where appropriate. Richmond Court Dudley DS0000047902.V329871.R01.S.doc Version 5.2 Page 12 On the day of the inspection, residents were engaging in an activity with a large ball. Staff encourage residents to chat and sing. There are also seasonal craft related activities. Photographs were available of staff and residents engaging in social events at the home and also enjoying meals out with the owners. Residents confirmed that they were happy with the activities on offer. There are no rigid routines. When the inspectors arrived at the home, the majority of residents had finished their breakfast, but others came down at various times and all were offered a full choice of items. One resident informed the inspectors that she prefers to get up late. Residents also choose when they retire at night. It is difficult to arrange consultation meetings of residents, as some have a limited attention span and others would not make their opinion known in a large group. However, the manager and her husband, who is the co-owner, regularly consult residents on an informal basis, in addition to using service user feedback questionnaires. The menus show a variety of food which appears to be well balanced in terms of nutrition. There are two choices at each meal and alternatives are also available. There is information about specific dietary needs. Daily sheets are completed and these contain details of the food served and the choices made by each resident. This form is also used to record the temperature of the food. Richmond Court Dudley DS0000047902.V329871.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 16,17,18 Quality in this outcome area is good. There are good arrangements for handling complaints and protecting residents from abuse. This judgement has been made using available evidence including a visit to this service. EVIDENCE: There is information available for residents and their relatives in respect of the action to be taken should they be dissatisfied with any aspect of the home. This is included in the Statement of Purpose and the service user guide, which are both displayed for visitors. The manager prefers to be informed of any complaint at an early stage, so that efforts can be made to resolve the difficulty. The manager confirmed that all residents were registered on the electoral roll and would receive postal votes that they could use at election time. A record of this was in sampled files. There are policies and procedures in place intended to provide protection for vulnerable people. These meet the requirements of this standard and staff training records demonstrated the topic is covered at induction and through on-going staff training. Richmond Court Dudley DS0000047902.V329871.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 19,23,25,26. Quality in this outcome area is adequate. Residents live in a well-maintained home which is clean and pleasant. However, improvements are needed to ensure that the laundry and garden facilities are fully suitable and accessible. Staff also need to ensure that they always follow procedures in relation to infection control. This judgement has been made using available evidence including a visit to this service. EVIDENCE: A tour of the Home confirmed Residents live in accommodation, which meets their needs and is generally comfortable, clean and safe. Residents’ rooms are personalised. Richmond Court Dudley DS0000047902.V329871.R01.S.doc Version 5.2 Page 15 Several ‘Requirements’ were issued at the previous inspections and these relate to various aspects of the accommodation, i.e. improvement in sluicing and laundry arrangements and improvement in storage provision for equipment, e.g. wheelchairs. At present, no staff or residents are able to use the garden as the access is dangerous and there are items in the garden which could be trip hazards. The planned extension should address these issues, as there will be a new kitchen and laundry, additional storage space and improved access to the garden area, including a conservatory and decking. The inspectors were informed by the manager that the planning permission for this work has been obtained, so the work should take place in the near future. There are policies and procedures in relation to infection control and staff are trained in this area. Staff were able to describe the correct procedure for handling laundry. Gloves, aprons and laundry bags are available. However, during the tour of the building, the inspector witnessed laundry being handled in an inappropriate way. This was brought to the attention of the manager and staff. Staff must ensure that they follow safe handling procedures for laundry at all times. Richmond Court Dudley DS0000047902.V329871.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29,30. Quality in this outcome area is good. Residents are supported and protected by the home’s recruitment policies and practices and their needs are met by adequate numbers of staff who are suitably trained to do their jobs. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home has standard procedures for the recruitment of staff and these include interviews, taking up two references and checking staff through the Criminal Records Bureau. Sampled files provided evidence that these had been followed. Once employed, staff undergo the home’s induction training in addition to Skills for Care and records are maintained of this process. The rotas show that there are sufficient numbers of care staff on each shift and these are supported by cooks and a cleaner. There are two members of waking staff each night. 64 of staff currently hold an NVQ level 2. I member of staff is currently undertaking level 3 and the deputy is undertaking level 4. Staff also receive training in other relevant areas of care and the owners also undertake this training so that they are fully aware of what is expected of staff. The manager showed the inspectors the arrangements for training which has been booked ad this included dementia training for 8 members of staff the week after the inspection. Richmond Court Dudley DS0000047902.V329871.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 31,33,35,38 Quality in this outcome area is good. The Home has excellent leadership from the Manager, who is appropriately qualified. The managerial ambience of the Home is warm, friendly and inclusive with lines of accountability being clearly defined and observed. Staff are supported effectively. The health, safety and welfare of residents and staff are promoted and protected. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The manager is suitably qualified to undertake her role and she also attends training sessions with staff in order to keep up to date and to know what advice staff have been given. She is fully committed to ensuring that the home meets the needs of the residents. Richmond Court Dudley DS0000047902.V329871.R01.S.doc Version 5.2 Page 18 There are very good systems for monitoring the quality of care provided, including an audit against the standards and service user feedback forms, which were last completed in December 2006. There are detailed plans for the future development of the home, which ensure that any shortfalls identified by the audit and the Commission for Social Care Inspection inspections are addressed. The core staff team is settled and there appear to be very relaxed and friendly relationships between staff and between staff and residents. The home does not administer the finances of any residents. Only small amounts of personal money are looked after on behalf of some residents and there are appropriate systems to safeguard residents’ interests. The home has good systems for ensuring that regular checks are made on services to and equipment in the home. Where hazards have been identified, such as the access to the garden, there are risk assessment, the results of which are made known to staff and residents. Plans are put in place to ensure that risks are minimised. Richmond Court Dudley DS0000047902.V329871.R01.S.doc Version 5.2 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 X X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 3 18 3 3 X X X 3 X 2 2 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 4 X 4 X 3 X X 3 Richmond Court Dudley DS0000047902.V329871.R01.S.doc Version 5.2 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 OP22 Regulation 23.-(2)(l) Requirement Arrangements must be made for large pieces of equipment to be appropriately stored, e.g. wheelchairs, in order that there are no obstructions to the use of bathroom facilities. This may be completed as part of the new extension programme. (Plans for the extension have progressed) 2 OP25 23.-(2)(p) The necessary changes to the radiators in all bedrooms thus enabling Residents to adjust heating to meet their individual needs must be completed at the same time as the building of the new extension. (Plans for the extension have progressed) 31/12/07 Timescale for action 31/10/07 Richmond Court Dudley DS0000047902.V329871.R01.S.doc Version 5.2 Page 21 3 OP26 23.-(2)(k) Adequate sluice facilities must be 31/12/07 provided for the Home in the extension, preferably a sluicing disinfector. This must also be completed as part of the new extension programme. (Plans for the extension have progressed) OP26 13(3) The manager must ensure that staff always follow procedures in relation to infection control. 30/04/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Richmond Court Dudley DS0000047902.V329871.R01.S.doc Version 5.2 Page 22 Commission for Social Care Inspection Halesowen Record Management Unit Mucklow Office Park, West Point, Ground Floor Mucklow Hill Halesowen West Midlands B62 8DA 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 Richmond Court Dudley DS0000047902.V329871.R01.S.doc Version 5.2 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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