Care Home: Dudbrook Hall

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What the care home does well The management team are committed to promoting high quality care and ongoing improvements have taken place in the home since the last inspection. The home has a quality assurance system in place, which demonstrates that the registered provider listens to people who use the service. A summary of findings and feedback from completed questionnaires was made available to the Inspector as well as action taken to improve the service. Information had been provided by residents, relatives and one health care professional. Overall, comments were positive with a high percentage of the feedback expressing satisfaction that personal choice, daily routines and wishes of residents were being respected. Residents and relatives spoken with during the site visit also felt that the care and support provided by staff was good. A number of the residents spoken with had a good working relationship with their key workers who were said to be friendly and supportive. Positive comments were also made indicating that staff were approachable and whenever concerns had been expressed, these had been dealt with promptly. From comments received and observation during the site visit, staff were seen to be supportive of residents who were in need of personal assistance, which was handled with dignity and respect. Sample checks were made of personal care records, pre- admission assessment information as well as the recording of care plans and risk assessments. Recorded information was clear, regularly updated and easy to follow. There was evidence to show that the views of residents and/or relatives had been taken into consideration when reviews have taken place. Within the service, there was evidence of increasing awareness and understanding of equality and diversity issues and for these to be promoted in the home. The spiritual needs and aspirations of residents are taken into account, which includes arrangements for church services to take place in the home. A detailed recording system covering recruitment procedures was in place as well as staff training records. Records were available to show the home continues to review on a regular basis, health and safety procedures as well as updating maintenance servicing contracts. The home is clean in hygienic. What has improved since the last inspection? Since the last inspection, requirements and recommendations have been addressed including improvements to the safety and security of residents and minimising the risk of potential hazards. Medication practices have also been improved which now includes a regular internal audit to ensure medication has been administered safely in accordance with agreed policies and procedures. Refurbishment and improvements have taken place to the main dining room and serving areas. This includes new flooring, dining-room and lounge furniture. Arrangements for the preparation and provision of meals has been improved. A new hairdressing and chiropody room has also been created. With the help of relatives, staff have compiled "life books" to encourage reminiscence so that a better understanding and knowledge of residents is available to staff. Both the registered manager and deputy have obtained the National Vocational Qualification (NVQ) Level 4 Registered Manager`s Award and a range of training courses continues to be provided for the staff team. The Statement of Purpose and Service User`s Guide have been updated. What the care home could do better: The home acknowledge in their self-assessment (AQAA) form that they intend improving dementia care for residents by adapting the home to provide improved recognition of key areas by signs and pictures. Some of these improvements have begun to take place. Individual assessments should take into account specific social and recreational interests so that appropriate stimulation can be provided to encourage all residents to lead a fulfilled life style so far as this is possible. The Statement of Purpose and Service User`s Guide should be made available in suitable formats for the benefit of prospective and existing residents with a sensory impairment. CARE HOMES FOR OLDER PEOPLE Dudbrook Hall Dudbrook Road Kelvedon Common Brentwood Essex CM14 5TQ Lead Inspector Mr Trevor Davey Unannounced Inspection 11th January 2008 10:30 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 Dudbrook Hall DS0000018032.V357626.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. Dudbrook Hall DS0000018032.V357626.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Dudbrook Hall Address Dudbrook Road Kelvedon Common Brentwood Essex CM14 5TQ 01277 372095 01277 375297 stmichaelshomes@btconnect.com 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) St Michaels Homes Limited Mrs Cecilia Watson Care Home 41 Category(ies) of Dementia - over 65 years of age (20), Old age, registration, with number not falling within any other category (41) of places Dudbrook Hall DS0000018032.V357626.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 12th January 2007 Brief Description of the Service: Dudbrook Hall is a large Country House dating back to 1602 that is set in four acres of parkland gardens. It is registered to provide care for 41 older people over 65 years of age, including 20 people who have dementia. There is a choice of communal lounges and a separate dining room. One of the lounges provides a higher level of support for the more dependent residents where meals are also provided. All but one bedroom is single and some have en-suite facilities. There is a remembrance garden to Princess Diana in the home with seating areas in the front and rear garden. The rear garden has a water feature for residents and their families to enjoy. Dudbrook Hall is in a rural setting half a mile from the local bus stop and five miles away from the town of Brentwood. Car parking facilities are available. The home provides a mini bus to transport residents. The current range of fees is £483 to £580 per week. Additional charges are made for hairdressing, chiropody, toiletries, newspapers and personal clothing. Information about the home is made available to prospective residents in the Statement of Purpose and Service Users Guide. Dudbrook Hall DS0000018032.V357626.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The Key Inspection site visit covered a period of 7.50 hours and covered all key standards. The registered manager together with staff, residents, relatives and other people involved with the home, were available during the site visit and were spoken with. Their comments and contributions received were helpful in assisting the Inspector to prepare the report. As part of the site visit, a tour of the premises took place. Personal care records and other official records within the home were inspected. The information included in the annual quality assurance assessment form (AQAA) which had been submitted to the Commission for Social Care Inspection, was also used in compiling the inspection report. This form gives homes the opportunity of recording what they do well, what they could do better, what has improved as well as future plans for improving the service. Feedback from survey information, which the home itself had obtained as part of their quality assurance exercise, was also inspected. Matters relating to the outcome of this inspection were discussed with The registered manager. Full opportunity was given for discussion and/or clarification both during and at the end of the site visit. What the service does well: The management team are committed to promoting high quality care and ongoing improvements have taken place in the home since the last inspection. The home has a quality assurance system in place, which demonstrates that the registered provider listens to people who use the service. A summary of findings and feedback from completed questionnaires was made available to the Inspector as well as action taken to improve the service. Information had been provided by residents, relatives and one health care professional. Overall, comments were positive with a high percentage of the feedback expressing satisfaction that personal choice, daily routines and wishes of residents were being respected. Residents and relatives spoken with during the site visit also felt that the care and support provided by staff was good. A number of the residents spoken with had a good working relationship with their key workers who were said to be friendly and supportive. Positive comments were also made indicating that staff were approachable and whenever Dudbrook Hall DS0000018032.V357626.R01.S.doc Version 5.2 Page 6 concerns had been expressed, these had been dealt with promptly. From comments received and observation during the site visit, staff were seen to be supportive of residents who were in need of personal assistance, which was handled with dignity and respect. Sample checks were made of personal care records, pre- admission assessment information as well as the recording of care plans and risk assessments. Recorded information was clear, regularly updated and easy to follow. There was evidence to show that the views of residents and/or relatives had been taken into consideration when reviews have taken place. Within the service, there was evidence of increasing awareness and understanding of equality and diversity issues and for these to be promoted in the home. The spiritual needs and aspirations of residents are taken into account, which includes arrangements for church services to take place in the home. A detailed recording system covering recruitment procedures was in place as well as staff training records. Records were available to show the home continues to review on a regular basis, health and safety procedures as well as updating maintenance servicing contracts. The home is clean in hygienic. What has improved since the last inspection? Since the last inspection, requirements and recommendations have been addressed including improvements to the safety and security of residents and minimising the risk of potential hazards. Medication practices have also been improved which now includes a regular internal audit to ensure medication has been administered safely in accordance with agreed policies and procedures. Refurbishment and improvements have taken place to the main dining room and serving areas. This includes new flooring, dining-room and lounge furniture. Arrangements for the preparation and provision of meals has been improved. A new hairdressing and chiropody room has also been created. With the help of relatives, staff have compiled life books to encourage reminiscence so that a better understanding and knowledge of residents is available to staff. Both the registered manager and deputy have obtained the National Vocational Qualification (NVQ) Level 4 Registered Manager’s Award and a range of training courses continues to be provided for the staff team. Dudbrook Hall DS0000018032.V357626.R01.S.doc Version 5.2 Page 7 The Statement of Purpose and Service User’s Guide have been updated. 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. Dudbrook Hall DS0000018032.V357626.R01.S.doc Version 5.2 Page 8 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 Dudbrook Hall DS0000018032.V357626.R01.S.doc Version 5.2 Page 9 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 (standard 6 is not applicable in this home) People who use the service experience good quality outcomes in this area. Residents can expect to have their care needs assessed by the home to ensure that the proposed placement is suitable. This judgement has been made using available evidence including a visit to the service. EVIDENCE: A sample check was made of pre-admission information, which was available for two of the residents admitted since the last inspection. This included an enquiry form containing information of care needs together with details of information gathered when visiting the prospective residents home. Prospective residents also had the opportunity of visiting Dudbrook Hall. Information had been recorded relating to feeding, washing and dressing, continence, mobility and medical intervention. Other information regarding behaviour, dementia, medication and social activities/interests had also been included. Where appropriate, a history of falls was available. From this and Dudbrook Hall DS0000018032.V357626.R01.S.doc Version 5.2 Page 10 other information gathered, an interim risk assessment and care plan had been completed. Where funded by the local authority, and assessment completed by the social worker had also been taken into account. Residents spoken with confirmed that they had settled into the home well and relatives confirmed that they were satisfied with the care being provided. In one case relatives had visited several homes before deciding that Dudbrook Hall was the most suitable. In some cases, the home and its location meant a lot to residents because they had lived and worked nearby in the local community and had chosen to be admitted because of additional personal support required. Residents spoken with confirmed that their likes and dislikes had been taken into account and they were supported by staff in pursuing their own chosen lifestyle. Twenty-two questionnaires were completed as a result of the quality assurance survey conducted by the home in August 2007. All responses confirmed that their initial inquiry had been dealt with professionally and that the home had been helpful. All of them had been invited to visit the home apart from one perspective resident who arrived at the home to view for themselves. Information packs had been given to enquirers and all apart from four people, were aware that the Service User’s Guide was available in their bedroom. Although the home’s Statement of Purpose and Service User’s Guide have been updated, the management have stated in their self-assessment (AQAA) form, that they intend to review this document to ensure that it properly reflects the correct services provided. Other formats should also be made available of these documents for prospective and existing residents who may have a sensory impairment. Dudbrook Hall DS0000018032.V357626.R01.S.doc Version 5.2 Page 11 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 and 10 People who use the service experience good quality outcomes in this area. Residents can expect to have a plan of care drawn up by the home that details all their assessed needs and the management of risk and can expect to receive the services of health care professions. This judgement has been made using available evidence including a visit to the service. EVIDENCE: Four sets of personal care records were inspected which included care plans, risk assessments, reviews and daily record sheets. Other care records were also sampled. Care plans had been drawn up which showed identified needs as they related to individual residents. Team leaders and senior staff have the responsibility for setting up care plans and risk assessments. These are then allocated to key workers who carry out monthly reviews. Examples of care plans inspected included personal care and physical well-being, diet, nutrition and weight, carer and other social relationships, social interests, hobbies, religion and cultural needs. Monthly reviews had taken place and were Dudbrook Hall DS0000018032.V357626.R01.S.doc Version 5.2 Page 12 recorded. Care plans had been dated and signed by members of the staff team and wherever possible, by the resident or their representative. Monthly reviews had taken place and were recorded. Examples of changes which had occurred included medication and rest patterns. In addition, medical treatment provided by local doctors and other health care professionals had been recorded. Where appropriate, moving and handling assessments had been completed together with other risk assessments. This included risk assessments where bed rails had been provided although in one case, this had been omitted. This was mentioned to the registered manager at the time. Day and night log reports were being maintained but it was suggested to the registered manager, that the times of checks carried out and when assistance had been provided to residents, should also be recorded by night staff. Annual reviews had been carried out by funding authorities although the registered manager advised the Inspector that in some cases, these are carried out by telephone which includes contacting relatives. A check was made of the medication administrative arrangements in the home. From the sample checks made, the medication administrative records (M.A.R.), were being completed in accordance with agreed procedures. Entries made corresponded with prescriptions instructions. A record was available of discontinued drugs, which had been returned to the pharmacist. Since the last inspection, the deputy manager carries out an audit every two months and any concerns regarding medication administrative procedures, are brought to the attention of staff. Where residents are able to self medicate, evidence was available of reviews which had taken place and the resident concerned was able to sign the medication administrative records each month as required. Reviews had taken place which recorded changes in medication as required by local doctors. At the time of the site visit, there were no controlled drugs being used. The Inspector spoke with five residents and positive comments were made regarding the support, assistance and care provided by staff. Doctors were available when required and district nurses provided treatment when necessary. One resident said that before coming into the home they had experienced a number of falls but this had greatly reduced since being admitted some time ago. Residents spoke of a good and supportive relationship with their key workers who were aware of their personal needs but at the same time, allowed residents to maintain independence so far as possible. Some of the residents spoken with confirmed that their care plans were discussed with them and that staff were good and supportive. At the same time they were allowed to maintain their independence. During the site visit, positive comments were made by relatives who said that staff were approachable and that whenever concerns had been raised, these had been dealt with. Relatives acknowledge that some residents could be quite demanding at times but they felt confident that staff had the skills to meet these needs and that personal dignity, respect and choice were not being compromised. Another relative told the Inspector that their mother had Dudbrook Hall DS0000018032.V357626.R01.S.doc Version 5.2 Page 13 recently died after having been in the home for a number of years. The care was said to be excellent as they had observed staff acting appropriately and sensitively in the way personal care had been given. Twenty people replied to the home’s questionnaire regarding the standard of care in the home. Where residents were unable to complete these themselves, either staff or relatives had assisted. The majority of people were aware that care plans were in place. Again the majority of responses were positive regarding the standard of care provided although one issue had been raised about toileting procedures. The responses received also indicated that the majority of people were satisfied with the feedback received regarding treatment provided by other health care professionals. One comment was made that information received was not always consistent depending on different staff who were on duty. The home have since drawn up an action which includes reminding relatives that they are invited to attend monthly care reviews and that any concerns should be raised with the management at any time so that these can be promptly addressed. The management intend to continue with intensive staff training in all aspects of care as part of their improvements for the next twelve months. Dudbrook Hall DS0000018032.V357626.R01.S.doc Version 5.2 Page 14 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14 and 15 People who use the service experience good quality outcomes in this area. Residents can expect to receive a balanced diet and assisted in maintaining family/friend/community contact. Residents can be assured of a meaningful activities/recreational programme that meets their needs and interests. This judgement has been made using available evidence including a visit to the service. EVIDENCE: Care plans sampled during the site visit, included social interests, hobbies religious and cultural needs. The home is able to demonstrate that through assessment, positive day- to- day relationships with key workers, individual and group conversations, that preferred lifestyles and social needs are being met. Some of the residents spoken with confirmed that craft sessions take place on Tuesday and Thursday afternoons and recently residents had made individual place mats and had the opportunity of colouring pictures. Various quizzes and bingo sessions also take place on a regular basis. It is understood from the manager, that an activities organiser is employed on a part-time basis by the home although not all of the residents seemed to be aware of this. Some of the residents spoken with confirmed that meetings are Dudbrook Hall DS0000018032.V357626.R01.S.doc Version 5.2 Page 15 arranged where there is opportunity to discuss issues related to the home and any possible changes. Minutes of these meetings were displayed on the notice board. There had also been outings arranged to shopping centres and church services are held in the home twice a month. Other activities arranged included music and cabaret and a winter sale and clothes party. Some relatives spoken with during the site visit, thought there could be more entertainment arranged and in the survey which they had completed, suggested that residents could be taken into the grounds on a more regular basis when the weather was suitable. The home have introduced life books and have begun putting together a background and social history of residents with the assistance of their families. This is to encourage reminiscence and further interaction with staff. The home is registered to provide dementia care and particular focus should be made by the home to review the provision of occupational and appropriate social activities that can provide additional individual stimulation to promote improved quality lifestyles. Two of the hairdressers were spoken with who said how they enjoyed the opportunity of talking and engaging with residents particularly those with dementia who they were able to meet on a regular basis. Residents also expressed satisfaction that they were allowed to enjoy their own preferred daily routines and could spend time in the lounges as well as in their own rooms where they could see visitors. Residents appreciated the assistance of key workers who helped them to find personal belongings and arranging flowers in their rooms. ‘Talking books’ had also been provided and a radio belonging to one resident who was partially sighted, had been adapted with special coloured controls. This enabled residents to retain a measure of independence and control over their lives. Relatives spoken with confirmed that residents were nicely dressed and their clothes had been regularly laundered and kept clean. Residents spoken with confirmed that they had a choice of meals which included cereals, fruit or porridge for breakfast as well as a menu of alternative meals for lunch. Overall, residents’ comments regarding the standard and variety of food provided was positive. The more highly dependent residents had their meals served in the smaller dining room and staff were observed assisting people who required additional help. The main dining room had been refurbished and residents spoken with said they enjoyed the meals provided. There was a choice of savoury mince, chips, peas and gravy or fish chips and peas. Other alternative meals were available should residents request these . Residents spoken with appreciated the new dining room and the furniture. On each table large print menus were available. A record of meals provided to individual residents had been maintained. Since the last site visit, arrangements have been made for food contractors to deliver the main meals and new storage facilities and serving areas had been installed. The registered manager advised the Inspector that the Environmental Health Officer had visited and approved the food hygiene arrangements. Records were available of refrigerator and freezer temperatures but it was noted that fruit which had been stored in one of the fridges for breakfast had not been dated. Apart from one response, residents and relatives who completed the homes Dudbrook Hall DS0000018032.V357626.R01.S.doc Version 5.2 Page 16 questionnaire, expressed their satisfaction with the standard of food being served and that appropriate assistance was given at mealtimes. Dudbrook Hall DS0000018032.V357626.R01.S.doc Version 5.2 Page 17 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 People who use the service experience good quality outcomes in this area. Residents can expect to have their complaints taken seriously and be assured that they will be protected by the home’s safeguarding adults from harm procedures. This judgement has been made using available evidence including a visit to the service. EVIDENCE: The Statement of Purpose and Service User’s Guide clearly explains the complaints procedure. Copies of the Service User’s Guide are given to residents and/or their relatives. There has only been one recorded complaint since the last inspection and the Commission has been notified and kept informed of the investigation and of the outcomes. Where appropriate, relatives had also been kept informed and involved in this process. The Commission is satisfied that the home has used its own complaints procedures effectively to ensure issues are properly investigated and any appropriate action is taken should this be necessary. Policies and procedures on safeguarding adults from harm were in place and some of the staff spoken with, were aware of the reporting procedures to be used should they consider residents to be at risk. All staff are trained annually in the prevention of abuse to vulnerable adults and his topic is also included in the induction of new staff. Dudbrook Hall DS0000018032.V357626.R01.S.doc Version 5.2 Page 18 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 and 26 People who use the service experience good quality outcomes in this area. Residents can expect to live in a clean, safe and comfortable environment. This judgement has been made using available evidence including a visit to the service. EVIDENCE: The premises were clean and hygienic and no concerns were expressed by residents regarding the cleanliness of their rooms. One response from the survey completed by a health care professional stated that there were no offensive odours in the home. Other comments from relatives confirmed that the home was always kept clean. Provision of protective gloves and aprons together with appropriate disposal facilities were available. The laundry assistant confirmed that they had completed infection control training as well as instruction on the control of substances hazardous to health. Contracts were in place for the collection of clinical waste. There was evidence from a tour of Dudbrook Hall DS0000018032.V357626.R01.S.doc Version 5.2 Page 19 the premises that all areas of the home were regularly cleaned and hygiene standards maintained. Responses from the survey conducted by the home, showed that the majority of people were satisfied with the cleanliness of the home and the premises were comfortable and homely. Issues raised about furniture that needed replacing have been dealt with and where there were cleaning issues, these have been addressed. Since the last inspection, new armchairs had been provided in the lounge, a previous lounge had been converted to a new dining room with servery. New flooring, chairs and tables have also been provided in this area. The kitchen had been modified with new food storage facilities and a separate hairdressing/chiropody room had been created. Appropriate signs have also being installed around the home to assist all residents particularly those with a sensory impairment and dementia, to be able to more easily access all parts of the building. Dudbrook Hall DS0000018032.V357626.R01.S.doc Version 5.2 Page 20 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 People who use the service experience good quality outcomes in this area. Residents can expect to be cared for by suitable numbers of staff on each shift, which meets their needs. Residents can be assured that records will be an able to demonstrate that the home has followed robust recruitment and employment procedures. This judgement has been made using available evidence including a visit to the service. EVIDENCE: The provision of staff allows for the registered manager and deputy, two team leaders and a senior care assistant. In addition, six care assistants cover the early shift and four the late shift. Other ancillary staff includes four domestics who cover different areas of the home and a laundry assistant as well as kitchen assistants. Other people cover maintenance and driving duties. Night cover is provided by one senior care assistant and two carers, all on awake duty. As already referred to in this report, there is no longer an activities organiser in post. It is recommended that given the size of the home and the diverse needs of residents, further consideration be given by the management for somebody to be appointed specifically to take on this responsibility. Dudbrook Hall DS0000018032.V357626.R01.S.doc Version 5.2 Page 21 Recruitment records were checked for recent members of staff who had been appointed. Records inspected included Criminal Record Bureau checks, residence permit, application form and two references, proof of identification, contract of employment and health questionnaire. Other documentation was also available. Detailed records were also available of staff induction and ongoing training, which had been completed. In addition, updated training had been provided for Parkinsons condition and oral hygiene. Staff had also received falls prevention training and one of the team had attended a course on providing care for the dying. Some of the staff spoken with confirmed that they had attended training related to moving and handling,’safeguarding adults from harm’ as well as health and safety. Training related to dementia care had also been provided. Information received as a result of the questionnaire distributed by the home, confirmed that the majority of people were satisfied that adequate staff were on duty throughout the day and night although one comment was made by a relative that staff are not always on hand at break times. All people who took part in the survey felt that staff were courteous and polite and that when visiting the home, they were able to speak to a responsible person. As a result of this feedback, the home has, as part of their action plan, undertaken to address the issue of staffing levels during break times. Many of the staff team are trained to National Vocational Qualification (NVQ) Levels 2 and 3 and new staff are encouraged and guided through level 2 by the home’s N.V.Q. Assessor. One of the senior staff from a nearby home which is also registered with the same provider, is now a manual handling trainer and is able to give input to the staff team. Dudbrook Hall DS0000018032.V357626.R01.S.doc Version 5.2 Page 22 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 People who use the service experience good quality outcomes in this area. Residents can expect to live and be supported in a home where the management and administration of the service is good. This judgement has been made using available evidence including a visit to the service. EVIDENCE: The registered provider and registered manager have continued to develop the service to ensure that it is run in the best interests of residents. Evidence is available to show that residents meetings have taken place and the home has also included survey questionnaires as a means of obtaining the views of residents, their relatives and other health care professionals regarding the service provided. This demonstrates the home is actively involved in quality Dudbrook Hall DS0000018032.V357626.R01.S.doc Version 5.2 Page 23 assurance to improve the quality of life for users of the service. The registered manager and deputy have both successfully completed the National Vocational qualification (NVQ) Level 4 Registered Manager’s Award. There is very little staff turnover and members of the team were observed to be actively engaged with residents with an awareness of their duties and responsibilities in meeting individual needs of residents. There is a clear organisational structure and staff supervision normally takes place every two months. Supervision records and appraisal notes were available. Maintenance checks regarding health and safety regularly take place throughout the building and general work place risk assessments had been reviewed every six months. Records were available to demonstrate that servicing of equipment had taken place and certificates were available. This included maintenance of the lift, mechanical aids and hoists, gas and electricity safety certificates. A new storage area for wheelchairs has been created since the last inspection to reduce the risk of any hazard and obstruction. The safeguarding of residents’ personal allowances are handled by the residents, relatives or their representatives. The home have stated in their self-assessment (AQAA) form that they intend to improve in the next twelve months by providing ongoing training and supervision of all staff particularly regarding health and safety issues. Dudbrook Hall DS0000018032.V357626.R01.S.doc Version 5.2 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 x x x x N/A HEALTH AND PERSONAL CARE Standard No Score 7 4 8 4 9 3 10 4 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 4 14 4 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 x 18 3 3 x x x x x x 3 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 Dudbrook Hall DS0000018032.V357626.R01.S.doc Version 5.2 Page 25 Are there any outstanding requirements from the last inspection? NO 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. Standard Regulation Requirement Timescale for action 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 OP1 Good Practice Recommendations The Statement of Purpose and Service User’s Guide should be made available in alternative formats. This is to ensure that all prospective and existing residents are able to be aware of the services provided by the home. Night reports should include times of checks and when assistance is provided. This is to provide more specific detail should queries arise concerning the provision of night care. Alternative occupational activities should be considered in order to stimulate individual residents who may have specific identified needs. This is to ensure that the quality of life for all residents is maximised as much as possible. Closer monitoring should take place to ensure food hygiene standards are always maintained regarding storing, and dating of all food. This is to minimise any possible risk of infected food being used. 2. OP7 3. OP12 4. OP38 Dudbrook Hall DS0000018032.V357626.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Eastern Regional Contact Team CPC1 Capital Park Fulbourn Cambridge CB21 5XE 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. 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