Care Home: Dudley House Care Home

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What the care home does well Prospective residents are fully assessed prior to admission to ensure the home is able to meet their needs. Pre-admission visits to the home are encouraged in order that the prospective resident and their representatives can meet staff and other residents. Service user plans are well completed and provide clear information about each residents needs and how these are to be met. Staff care for residents in a gentle and professional manner, respecting their privacy and dignity. The activity provision in the home, to include the obtaining of comprehensive life history information for each resident so that activities can be tailored to individual interests, is of a high standard. The home has an open visiting policy and visiting is encouraged. Contact information regarding advocacy services is available in the home. The food provision at the home is good, offering variety and choice. The home has clear procedures for the management of complaints and safeguarding adult issues, and these are adhered to. The home provides a good standard of accommodation and is clean and fresh. Procedures are in place and being followed for infection control. The home is being appropriately staffed to meet the needs of the residents and this is kept under review. There is an induction and training programme for all staff. The Manager is approachable and listens to people, and works with the staff to maintain standards throughout. There is a good system in place for quality assurance to maintain the quality of the service. Residents` monies are well managed. Overall there are good procedures and practices in place for the management of health & safety in the home. Some shortfalls have been identified in the recording of water temperatures and this should be easy to address. Overall the comments received via the CSCI comment cards were positive. Examples of these are: `I have nothing but praise for the staff at Dudley House for the way they care for my (relative)`. `The staff are very friendly, kind and supportive`. `They are providing an excellent service and care for the people who live in the home`. What has improved since the last inspection? Risk assessments for falls were in place and had been updated following any falls. Risk assessments for risks associated with bedrails had been completed. The bedrail assessment to ascertain suitability of their use was put back into place during the time of the inspection, and the Manager is to do more work in this area. Records for accidents and incidents are up to date and clearly identify the action taken to address such findings. What the care home could do better: Medications are being generally well managed, however one shortfall identified at this inspection should be easy to address. The home provides end of life care and this area must be further improved, with the wishes of the resident and their representative being ascertained and clearly recorded, so that these are known and can be respected. Systems for the recruitment and vetting of staff must be improved in order to safeguard the residents. Water temperature records must clearly record the actual temperature of the water. CARE HOMES FOR OLDER PEOPLE Dudley House Care Home The Grove Isleworth Middlesex TW7 4JF Lead Inspector Mrs Rekha Bhardwa Key Unannounced Inspection 13:20 8 , 9 & 12 September 2008 th th th 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.V364569.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Dudley House Care Home DS0000064752.V364569.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Dudley House Care Home Address The Grove Isleworth Middlesex TW7 4JF Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 020 8560 9560 020 8568 7082 dudleyhouse@eurotelonline.com Dudley House Care Home Care Home 40 Category(ies) of Dementia (0), Dementia - over 65 years of age registration, with number (0), Old age, not falling within any other of places category (40), Physical disability (40), Physical disability over 65 years of age (40), Terminally ill over 65 years of age (1) Dudley House Care Home DS0000064752.V364569.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. As agreed on 02/05/2006, one named service user over the age of 65 with Terminal Illness can be accommodated within the home. Service users who already have a diagnosis of Dementia may not be admitted. Service users who develop Dementia after being admitted, may be accommodated, as long as their needs can be met and they do not detrimentally affect the wellbeing of the other service users. 10th December 2007 Date of last inspection Brief Description of the Service: Dudley House Nursing Home is a large detached house in Isleworth. There are 38 single bedrooms, 11 of which are en suite, plus one double bedroom. There is a passenger lift. There are three floors in the home and resident accommodation is provided on all three floors. There are also assisted bathing facilities on all three floors. The home has a lounge/dining area and another small sitting room with access to the rear garden. The home is located nearby to Isleworth train station and is also a short walk from the London Road, which is served by several bus routes. There are shops in Isleworth itself and the home is a short bus ride from Hounslow Town Centre. There were 37 residents accommodated at the home at the time of inspection. The fees range from £540 to £680 per week. Dudley House Care Home DS0000064752.V364569.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 2 star. This means the people who use this service experience good quality outcomes. This was an unannounced inspection carried out as part of the regulatory process. A total of 23 hours was spent on the inspection process. We carried out a tour of the home, and service user plans, medication management & records, staff rosters, staff records, financial & administration records and maintenance & servicing records were viewed. 12 residents, 10 staff and 4 visitors were spoken with as part of the inspection process. The Annual Quality Assurance Assessment (AQAA) document completed by the home, plus comment cards from residents and staff have also been used to inform this report. There were no equality and diversity issues identified at this inspection. What the service does well: Prospective residents are fully assessed prior to admission to ensure the home is able to meet their needs. Pre-admission visits to the home are encouraged in order that the prospective resident and their representatives can meet staff and other residents. Service user plans are well completed and provide clear information about each residents needs and how these are to be met. Staff care for residents in a gentle and professional manner, respecting their privacy and dignity. The activity provision in the home, to include the obtaining of comprehensive life history information for each resident so that activities can be tailored to individual interests, is of a high standard. The home has an open visiting policy and visiting is encouraged. Contact information regarding advocacy services is available in the home. The food provision at the home is good, offering variety and choice. The home has clear procedures for the management of complaints and safeguarding adult issues, and these are adhered to. The home provides a good standard of accommodation and is clean and fresh. Procedures are in place and being followed for infection control. The home is being appropriately staffed to meet the needs of the residents and this is kept under review. There is an induction and training programme for all staff. The Manager is approachable and listens to people, and works with the staff to maintain standards throughout. There is a good system in place for quality assurance to maintain the quality of the service. Residents’ monies are well managed. Overall there are good procedures and practices in place for the management of health & safety in the home. Some shortfalls have been identified in the recording of water temperatures and this should be easy to address. Overall the comments received via the CSCI comment cards were positive. Examples of these are: Dudley House Care Home DS0000064752.V364569.R01.S.doc Version 5.2 Page 6 ‘I have nothing but praise for the staff at Dudley House for the way they care for my (relative)’. ‘The staff are very friendly, kind and supportive’. ‘They are providing an excellent service and care for the people who live in the home’. What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Dudley House Care Home DS0000064752.V364569.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Dudley House Care Home DS0000064752.V364569.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 & 4. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Prospective residents are fully assessed prior to admission, thus the home ensures they are able to meet each persons needs. Residents and their relatives are encouraged to visit the home prior to admission, thus allowing them to make an informed choice. EVIDENCE: The home has a comprehensive pre-admission assessment document that provides a good picture of the resident and their needs. This is completed for all prospective residents in order to ascertain if the home is able to fully meet their needs. Completed assessments were viewed and had been well completed. The home also obtains a copy of the assessment undertaken by social services. We spoke to relatives of a recently admitted resident. They said that they had been able to visit the home at any time in order to look around, and were Dudley House Care Home DS0000064752.V364569.R01.S.doc Version 5.2 Page 9 made welcome. Residents and relatives spoken with said that they had been able to visit the home prior to admission, to decide if they liked the home and it met their needs. A comment made on one of the residents surveys said ‘the welcome I received on a visit I made, made me want to stay’. Dudley House Care Home DS0000064752.V364569.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9, 10 & 11. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Overall the service user plan documentation is well completed to provide staff with the information to meet each resident’s needs. Medications are being well managed at the home, however a shortfall identified could place residents at risk. Staff care for residents in a gentle and professional manner, respecting their privacy and dignity. The home provides good end of life care, however information needs to be documented to ensure that residents and their families have their wishes and needs discussed, recorded and met. EVIDENCE: We viewed 5 service user plans as part of the inspection process. For each resident a long term needs assessment had been completed, and this contains information identifying the care needs of the resident and how these are to be met. Care plans had been formulated for significant areas relating to the findings on the long term needs assessment, and the Manager said that he is in the process of reviewing the service user plans to ensure that a more comprehensive, individual care plan is available for each identified need. There was also evidence that the Responsible Individual had carried out his own Dudley House Care Home DS0000064752.V364569.R01.S.doc Version 5.2 Page 11 audits of the service user plans and had identified the same issues, so it was clear the home were aware of these and action is being taken to address them. Risk assessments for falls were in place and there was evidence of updates following a fall. The service user plan documentation had been reviewed monthly and whenever a resident’s condition had changed. There was evidence of input from residents and representatives in the service user plans and comments received evidenced that representatives are always kept up to date with their relatives progress. Documentation in relation to wound care was viewed. Wounds had been identified and there was a clear record of dressing changes and the progress being made by each wound. In one instance one care plan included more than one wound, and we recommended that individual care plans be formulated for each wound, and these were available in the other wound care documentation viewed. There was evidence of regular input from the Community Matron with regards tissue viability, and where dressing regimes had been changed, the registered nurses had implemented these changes. Pressure sore risk assessments were in place and a record is maintained of the turning regime followed for those residents who are at risk. There was evidence of pressure relieving equipment in use throughout the home. One resident spoken with was very clear on the reason for having the pressure relieving equipment in place. There was evidence that residents are given analgesia prior to dressings being carried out, and that effective pain control is in place for residents requiring it for other conditions. Pain assessments had not always been carried out and this was addressed during the inspection, with care plans being formulated to evidence how pain is being individually managed. Assessments for moving & handling and nutrition were also viewed. The home uses the Primary Care Trust continence assessments and these were shown to the inspectors at the time of the inspection. The home is to find out if the Standex system provides a continence assessment document for inclusion with the other documentation. Risk assessments for risks associated with the use of bedrails were in place, however the assessment document previously used to initially assess the appropriateness of the use of bedrails for each individual could not be found. This was addressed during the inspection and more work is taking place to review the documentation in use. Written consents for the use of bedrails were in place. There was evidence of input from healthcare professionals to include GP, tissue viability nurse, chiropodist, optician, occupational therapist, physiotherapist, dietician and speech and language therapist. Each healthcare professional makes a written entry in the residents’ records when they visit. Residents healthcare needs are being well met. We viewed the medication management within the home. A list of registered nurses signatures and initials was available. The home uses the monitored dosage system. An identification sheet was available for each resident with their name, photograph, allergy information and other relevant details. The medication administration records (MAR) were viewed and all receipts and administration had been signed for. The appropriate codes had been recorded Dudley House Care Home DS0000064752.V364569.R01.S.doc Version 5.2 Page 12 for any omitted medication. Medications were being disposed of in accordance with current legislation. Liquid medications had their date of opening recorded on them. Where medications had been received in a box instead of a blister pack, the date of opening had been written on the box. Fridge and room temperatures were being recorded and were within safe range. Supplement drinks and liquid feeds were being appropriately stored. The correct lancing devices for professional multi-use were in place, and we recommended that a bulk prescription for the lancets be obtained. The controlled drugs register was viewed and this was complete and up to date. Balances of controlled drugs checked were correct. No residents were self-medicating. For residents on entral feeds these had been recorded on the MAR and signed for when commenced. Entries are also made on the fluid and food intake charts. One resident spoken with was able to explain how they are fed via this process. Care plans for entral feeding were also seen. With one exception where the dosage of a medication had been changed the MAR had been altered accordingly. The one instance where this had not occurred was for a dietary supplement, and this was discussed with the Manager and was addressed during the inspection. The home has 2 residents on oxygen therapy and this was not recorded on the MAR. The Manager discussed this with the GP and by the end of the inspection action had been taken to address this issue. Signage alerting people to the fact oxygen is in use was placed on the bedroom doors at the time of inspection. During the inspection it was discovered that on occasion there is a time delay between the dispensing pharmacist receiving the prescription and the medication being dispensed to the home. The Manager has since spoken to the pharmacist and is also aware to make an arrangement with a local dispensing pharmacist to have such prescriptions dispensed without delay in future. Overall the medications are being well managed at the home and the shortfalls identified should be easy to address. Staff were seen caring for residents in a gentle, caring and professional manner and excellent interaction between residents, relatives and staff was observed during the inspection. Bedrooms had been personalised and there was a very homely feel throughout. Residents can have their own telephone, either mobile or landline. Personal clothing is labelled with either the residents name or room number and residents were well groomed and dressed to reflect individuality. Residents spoken with said that they were being very well cared for by the staff. ‘I could not wish for better care and support. Everyone is cheerful and lots of smiles and chats.’ ‘absolutely everything is spotless, well managed and all the staff are fantastic.’ ‘they are providing an excellent service and care to the people who live in the home and we are really happy.’ On the admission sheet for some residents there was brief information regarding their wishes in the event of health deterioration and end of life wishes. The home has contacted the Macmillan nurses for input in this area and some training has been carried out. The importance of introducing a Dudley House Care Home DS0000064752.V364569.R01.S.doc Version 5.2 Page 13 system for ensuring that all residents and their representatives are given the opportunity to express their wishes in relation to this sensitive subject was discussed, and the Manager and Responsible Individual were very aware of the need for progress to be made in this area. Dudley House Care Home DS0000064752.V364569.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 & 15. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The activity provision for the home is excellent, providing a variety of activities, outings and entertainments to meet residents’ individual needs. The home has an open visiting policy, thus encouraging residents to maintain contact with family and friends. Information regarding advocacy services is available, thus ensuring the residents’ right to independent representation is respected. The food provision in the home is good, offering variety and choice, to meet residents individual dietary needs. EVIDENCE: The home employs a full-time activity person. The activities programme for the week was displayed throughout the home. Residents were seen partaking in individual and group activities. There are regular outside entertainers arranged and also outings from the home. The activity records for each resident were up to date and detailed the activities that the resident had taken part in. There is also a ‘life story’ section of the service user plan and the majority of these viewed had been completed and gave a good picture of each person. The residents also have an activities journal with pictures of those residents who wish to be photographed undertaking various activities and outings. Where Dudley House Care Home DS0000064752.V364569.R01.S.doc Version 5.2 Page 15 residents choose not to attend group activities or are bed bound the activities co-ordinator undertakes individual activities with them. Representatives from various religious denominations visit the home regularly and the activities coordinator holds a prayer meeting every two weeks. We were informed that where residents express a wish to go on holiday, wherever possible this is arranged. It was clear that the activities co-ordinator provides activities, outings and entertainments following discussion with residents in order to meet their individual needs and interests. Activities are seen as an integral part of the residents’ day. One comment received was: ‘My relative does not like to join in all the activities, preferring to be left quiet. Their requests are always respected, and they are not forced to join in when they do not want to. My relative is not left isolated and staff come and talk to them.’ The home has an open visiting policy and visiting is encouraged. Visitors spoken with said that they are made welcome at the home and representatives are kept up to date with any issues. Residents can choose to receive visitors in one of the communal rooms or in their bedrooms, as they so wish. Information regarding advocacy services was available and on display in the main entrance. Leaflets regarding advocacy services in relation to financial issues were available. We viewed the kitchen and it was clean and tidy, with all the records being up to date. The home has attained a 3 star rating for food hygiene from the Food Standards Agency. Good food stocks were available to include fresh fruit and vegetables. Residents spoken with said that the food is good and that they are offered a choice. Records of meal choices were available in the kitchen. We viewed the lunch and suppertime serving and meals to include liquidised meals were well presented and looked appetising. Staff were available to assist residents with their meals and did so in a discreet and professional manner. Drinks and snacks are available throughout the 24-hour period. Dudley House Care Home DS0000064752.V364569.R01.S.doc Version 5.2 Page 16 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. This judgement has been made using available evidence including a visit to this service. The home has clear complaints procedures in place to address any concerns raised by residents and their visitors. There is a robust system in place for the safeguarding of residents from abuse. EVIDENCE: The home has a clear complaints procedure and this is on display in the main entrance of the home. The home has had 5 complaints in the last 12 months, and had been recorded and addressed under the homes complaints procedure. Complaints records were sampled, and documentation was available to evidence that complaints had been appropriately investigated and responded to. We suggested that the home keep a monthly summary of any complaints received. During the recent London Mayoral elections residents had discussed this topic and postal voting documentation was obtained in order that they could participate in the voting process. The home has safeguarding adult policies and procedures in place that dovetail with the Hounslow Safeguarding Adults documentation. Staff spoken with said that they had received POVA training to include whistle blowing and were clear to report any concerns. Any incidents or issues that may involve safeguarding adults are reported to the Hounslow safeguarding adults team as well as to us. Dudley House Care Home DS0000064752.V364569.R01.S.doc Version 5.2 Page 17 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 & 26. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is being well maintained, thus providing a clean, homely and safe environment for residents to live in. Procedures are in place for infection control and these are practiced, thus minimising the risk of infection. EVIDENCE: We were informed that several areas of the home have been redecorated to include residents’ bedrooms. The home has a redecoration and refurbishment plan and timescales for completion are recorded. New furniture to include wardrobes and drawers have been purchased for several bedrooms. Profiling beds have been purchased and the second floor corridor has been re-carpeted. The garden is well maintained and there is a good supply of garden furniture for residents and their visitors to use. The London Fire Emergency and Planning Authority (LFEPA) visited the home on 20/08/08 and the home is in the process of addressing the shortfalls identified at this visit. Dudley House Care Home DS0000064752.V364569.R01.S.doc Version 5.2 Page 18 The home has a separate laundry room in the basement with 2 washers and 2 dryers, all of industrial standard. There are clear laundry programmes on display and the washing machines have appropriate wash programmes to manage soiled or infected laundry. The flooring in the laundry has been replaced. Protective clothing to include disposal gloves and aprons was available in the home. The home uses the Otex Ozone cleaning system that filters the air to remove bacteria and manage odour control. The home was clean and fresh throughout, and infection control was being well managed. Dudley House Care Home DS0000064752.V364569.R01.S.doc Version 5.2 Page 19 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. This judgement has been made using available evidence including a visit to this service. The home is appropriately staffed to ensure that the needs of the residents are met. Systems for vetting and recruitment practices are in place, however shortfalls could place residents at risk. There is an ongoing training programme, providing staff with the knowledge and skills to meet the needs of residents. EVIDENCE: At the time of inspection the home was being staffed appropriately to meet the needs of the residents. From discussions with staff, residents and relatives, the one concern raised regarding a staff shortage had already been identified and action taken to address this. The home is being well maintained and the numbers of kitchen, domestic, administration and maintenance staff are appropriate to meet the needs of the home. The majority of care staff are qualified to NVQ in care level 2 or 3 or the equivalent. More of the care staff are currently undertaking NVQ training. We viewed 3 sets of staff employment records and these did not contain all the information required under the Care Homes Regulations 2001. For one file no references were available and in the other 2 files only 1 reference was available. POVA First and CRB checks had been carried out, however the importance of ensuring the CRB check is obtained prior to employing a Dudley House Care Home DS0000064752.V364569.R01.S.doc Version 5.2 Page 20 member of staff was discussed. We recommended that all the staff employment files be audited to ascertain that all required information is available for each employee. The home has an induction programme that meets the Skills for Care common induction standards. Completed booklets were seen. Staff said that they receive training and updates in topics relevant to the needs and care of the residents, to include specialist care needs. Dudley House Care Home DS0000064752.V364569.R01.S.doc Version 5.2 Page 21 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. This judgement has been made using available evidence including a visit to this service. The Manager has the skills and experience to manage the home effectively and has an open approach with staff, residents and relatives. Systems for quality assurance are in place, thus providing an ongoing process of review and feedback. Resident’s monies are well managed and securely stored. Systems for the management of health and safety throughout the home are good, thus safeguarding residents, staff and visitors. Shortfalls identified should be easy to address. EVIDENCE: The Manager is a first level nurse with many years experience in management, much of it in the care of the elderly field. He had only been in post for 3 weeks. Staff spoken with said that the Manager and Responsible Individual are approachable and listen to what they have to say. The Manager is in the Dudley House Care Home DS0000064752.V364569.R01.S.doc Version 5.2 Page 22 process of applying to undertake the Registered Managers Award. He has degrees in social science and healthcare. The Manager is to apply to CSCI for registration. The home has a detailed quality assurance system in place, which dovetails with each of the National Minimum Standards for Older People, so that progress in each area can be monitored. Regulation 26 visits take place every month and reports were available to view. Annual satisfaction surveys are sent out for resident feedback and the results are collated and available to all by the signing in register at the main entrance. Regular staff and management meetings take place, with minutes being taken and available to read. Regular audits of medication, care planning, wound care and accidents are undertaken, and where a shortfall is identified then action is taken to address this. The home holds clear records of income and expenditure for residents for whom monies are held on their behalf. Receipts were available for all expenditure and the records were accurate and up to date. Maintenance and servicing records were sampled and these were up to date. We noted that for the hot water temperature record checks, the actual temperature was not being recorded, and ‘ok’ had been recorded instead. The importance of recording the actual temperatures was discussed. The Fire risk assessment was last updated in June 2008 along with a comprehensive health & safety assessment. Fire drills are carried out on a regular basis and we were informed that the home has internal rotation for all staff. The timings of the drills need to be recorded. Risk assessments for equipment and safe working practices were in place and in the process of being reviewed. The training records show that staff receive training and updates in health & safety topics to include moving & handling, fire safety, food hygiene, infection control, safeguarding adults and First Aid, and staff spoken with confirmed this. The training matrix for 2007 had been lost due to computer problems, and the Responsible Person confirmed that staff had received training in health & safety topics at the required intervals. Overall health & safety is being well managed at the home. Dudley House Care Home DS0000064752.V364569.R01.S.doc Version 5.2 Page 23 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 3 X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 10 4 11 2 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 3 18 3 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 2 Dudley House Care Home DS0000064752.V364569.R01.S.doc Version 5.2 Page 24 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. 1. Standard OP9 Regulation 13(2) Requirement All medications must be accurately administered in accordance with the prescriber instructions. Where oxygen is in use this must be recorded on the MAR and safety signage displayed in the area where it is in use. Information regarding the wishes of each resident in the event of a deterioration in their health, plus their care in their final days must be ascertained and recorded, so that their wishes are respected. All required staff employment checks and records must be in place before staff are employed at the home in order to safeguard the residents. Water temperature records must record the actual temperature for each hot water outlet accessible to residents, to protect them from the risk of scalds. Timescale for action 12/09/08 2. OP9 13(2) 12/09/08 3. OP11 12 01/11/08 4. OP29 19(1) Schedule 2 13(4) 01/10/08 5. OP38 01/10/08 Dudley House Care Home DS0000064752.V364569.R01.S.doc Version 5.2 Page 25 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 A separate care plan should be formulated for each wound for ease of identification and so that once a wound is healed the related documentation can be archived. A bulk prescription should be obtained for the lancing devices for professional use for blood glucose monitoring. Dudley House Care Home DS0000064752.V364569.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection London Regional Office 4th Floor Caledonia House 223 Pentonville Road London N1 9NG National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Dudley House Care Home DS0000064752.V364569.R01.S.doc Version 5.2 Page 27 - 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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