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Inspection on 09/08/05 for Catherine Dalley House

Also see our care home review for Catherine Dalley House for more information

This inspection was carried out on 9th August 2005.

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

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

What follows are excerpts from this inspection report. For more information read the full report on the next tab.

What the care home does well

Catherine Dalley provides good quality care for residents, supported by care plans and record keeping, a staff group who are accessible and caring and a committed management team. Environmentally the home is clean, tidy and welcoming. Staff receive a high level of training incorporating health and safety, adult protection, and care practices which includes training in mental health and medical conditions. A high proportion of staff has achieved a National Vocational Qualification. There are good relationships between staff and residents, and the residents feel that they are well cared for and supported by staff. Resident`s of Catherine Dalley benefit from specialist equipment, which includes hoists and adjustable height baths. Catherine Dalley rehabilitation unit offers a good quality service with dedicated care staff, who work closely with health care professionals.

What has improved since the last inspection?

Environmental improvements to the home have taken place, which includes the provision of specialist equipment and a flat screen television, in the main lounge of the home.

What the care home could do better:

Care plans could further be developed to contain greater detail as to the resident`s mental health, and how this impacts on their daily lives, and the role of care staff in supporting them. Care plans could further be improved by incorporating social interest, hobbies and recreational pursuits of residents. Residents could benefit from staff being able to access training at a higher level with regards to a National Vocational Qualification; in particular those care staff that undertake Relief Officer duties.

CARE HOMES FOR OLDER PEOPLE Catherine Dalley House Scalford Road Melton Mowbray Leicestershire LE13 1JZ Lead Inspector Linda Clarke Unannounced 9 August 2005, 9:30am th 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 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. Catherine Dalley House C51 C01 S32860 Catherine Dalley V242445 090805 Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Catherine Dalley House Address Scalford Road Melton Mowbray Leicestershire LE13 1JZ 01664 562487 01664 462487 None Leicestershire County Council Social Services Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Mrs Marian Hovell Care Home 31 Category(ies) of Dementia - over 65 years of age (20), Learning registration, with number disability over 65 years of age (4), Mental of places Disorder, excluding learning disability or dementia - over 65 years of age (6), Old age, not falling within any other category (31), Physical disability over 65 years of age (10), Sensory Impairment over 65 years of age (4) Catherine Dalley House C51 C01 S32860 Catherine Dalley V242445 090805 Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: No person falling within category DE(E) may be admitted to the home when 20 persons who fall within category DE(E) are already accommodated within the home No person falling within category MD(E) may be admitted to the home when 6 persons who fall within category MD(E) are already accommodated within the home No person falling within category LD(E) may be admitted to the home when 4 persons who fall within category LD(E) are already accommodated within the home No person falling within category PD(E) may be admitted to the home when 10 persons who fall within category PD(E) are already accommodated within the home No person falling within category SI(E) may be admitted to the home when 4 persons who fall within category SI(E) are already accommodated within the home Service users between 55-65 years who fall within the above categories and were resident in the care home at the date of registration may continue to reside there Date of last inspection 17th March 2005 Catherine Dalley House C51 C01 S32860 Catherine Dalley V242445 090805 Stage 4.doc Version 1.40 Page 5 Brief Description of the Service: Catherine Dalley is a care home providing personal care and accommodaiton for upto thirty one older persons. Catherine Dalley as part of its provision offers four rehabilitation beds and two respite beds. The home has twenty five single bedrooms and three shared rooms (one of which is for indivdiuals accessing respite) and are without en-suite facilitites. The home has a garden surrounding the property including a secure garden with a seating area. The premise is owned by Leicestershire County Council Social Services Department and is siutated in the town of Melton Mowbray, which is an historic market town. The home is a large Victorian house with an extension. The home is easily accessible by private or public transport. Accommodation is provided over two floors with access between the floors being via stairs or a passenger lift. Catherine Dalley is fully accessible. Catherine Dalley House C51 C01 S32860 Catherine Dalley V242445 090805 Stage 4.doc Version 1.40 Page 6 SUMMARY This is an overview of what the inspector found during the inspection. This Inspection took place between 9.30am and 1.45pm. The opportunity was taken to look around the home, spend time with residents, view records and policies which, included viewing the care plans of three residents residing at the home and two individuals accessing rehabilitation services. Information recorded on the pre-inspection questionnaire has been incorporated into the Inspection Report, along with relative comment cards. The Registered Manager facilitated the Inspection, spending time with the Inspector; the Inspector also interviewed three members of care staff. What the service does well: What has improved since the last inspection? Environmental improvements to the home have taken place, which includes the provision of specialist equipment and a flat screen television, in the main lounge of the home. Catherine Dalley House C51 C01 S32860 Catherine Dalley V242445 090805 Stage 4.doc Version 1.40 Page 7 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. Catherine Dalley House C51 C01 S32860 Catherine Dalley V242445 090805 Stage 4.doc Version 1.40 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 Standards Statutory Requirements Identified During the Inspection Catherine Dalley House C51 C01 S32860 Catherine Dalley V242445 090805 Stage 4.doc Version 1.40 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 1, 3 and 6. The admission process is well managed with residents needs being assessed ensuring staff have the appropriate information to meet individual needs. EVIDENCE: The home has a detailed Statement of Purpose for both prospective and existing residents with separate information for those individual accessing the rehabilitation unit. The admission procedure is adequate in that assessments of individuals are carried out by a Social Worker as part of the referral process. For individuals accessing the rehabilitation unit, assessments of need are carried out by social and/or health care professionals; these include Social Workers, Occupational Therapist and Physiotherapists. As part of the assessment process residents and relatives are asked to provide a history of an their life prior to admission, this provides additional information to help in the delivery of care and activities provided. Catherine Dalley House C51 C01 S32860 Catherine Dalley V242445 090805 Stage 4.doc Version 1.40 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 7, 8, 9, 10 and 11. Residents are looked after well in respect of their health and personal care needs. EVIDENCE: The care plans and records of three residents were viewed, care plans were well written and were presented to a high standard. Care plans detailed information as to resident’s health care needs, including specific information pertaining to illness and death, where indicated by residents and/or relatives. Information as to a resident’s mental health was also incorporated; however further detail would enable staff to have a higher level of awareness as to how the mental health of an individual affects their daily lives, and how staff could offer appropriate support. Consideration should also be given to incorporating daily activities in the care plan providing a holistic approach to care. Catherine Dalley House C51 C01 S32860 Catherine Dalley V242445 090805 Stage 4.doc Version 1.40 Page 11 Daily records give a brief summary of the resident’s day consistent with their care plan. Contact with relatives and friends, and excursions into the community were also recorded. Activities accessed within the home could also be recorded, consistent with their care plan. The records of two individuals accessing rehabilitation were viewed, all contained assessments and individual plans of care, which detailed goals, needed to be achieved, consistent with independent living. Records highlighted the progress and achievement of individual goals, along with the involvement of Physiotherapists and Occupational Therapists. The medication and administration records of those residents whose records were viewed were inspected and found to be in good order. The Inspector received one completed Comment Card from relatives; which stated they were satisfied with the overall care provided. Catherine Dalley House C51 C01 S32860 Catherine Dalley V242445 090805 Stage 4.doc Version 1.40 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12, 13, 14 and 15. Residents experience a homely life style and visitors are encouraged to visit. Various formal and informal activities meet the individual and collective needs of residents. EVIDENCE: Records evidenced that residents were offered a variety of activities within the home, this is currently being provided by care staff, as the position of Activity Organiser is currently vacant. Activities include music, bingo, exercises, talks and hymn singing. External entertainers visit the home offering a variety of entertainment. Residents spoke about the recent day trip to Skegness, and how much they enjoyed the day. The records of all residents evidenced contact with relative and friends, some of which incorporated relatives and friends supporting resident to access community resources such as going to Church or to the local shops. Records also detailed as to who was responsible for the handling of residents financial affairs. Catherine Dalley House C51 C01 S32860 Catherine Dalley V242445 090805 Stage 4.doc Version 1.40 Page 13 Residents were offered a choice as to the main meal of the day, residents sat within various dining rooms, the meal time was relaxed and unhurried, residents using this time to converse with each other. Residents spoken to stated that the meals at Catherine Dalley were enjoyable. Catherine Dalley House C51 C01 S32860 Catherine Dalley V242445 090805 Stage 4.doc Version 1.40 Page 14 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) Standards within this section were not inspected on this occasion. EVIDENCE: Catherine Dalley House C51 C01 S32860 Catherine Dalley V242445 090805 Stage 4.doc Version 1.40 Page 15 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 19, 20, 21, 22, 23, 24, 25 and 26. A comfortable and safe standard of accommodation is provided for the resident’s including a garden area, which individually and collectively meets the resident’s needs. EVIDENCE: Catherine Dalley House is well maintained and is suitable to the needs of residents; it is decorated and furnished to a standard that creates a comfortable and homely environment. Communal areas are provided on the ground floor offering lounge and dining areas including a small ‘bar’ which is used for parties and functions. The rehabilitation has dedicated bedroom, living and kitchen space these areas are used in the promotion and regaining of independent living skills for those individuals accessing the service. Catherine Dalley House C51 C01 S32860 Catherine Dalley V242445 090805 Stage 4.doc Version 1.40 Page 16 Residents have access to equipment such as hoists and adjustable height baths, which assist them and staff in the delivery of personal care. The bedrooms of the three residents and the individuals accessing the rehabilitation unit were viewed and found to be homely, and contained personal affects which met individual need. Catherine Dalley is surround by a garden area and in addition has a secure garden area, which provides seating for residents. Catherine Dalley House C51 C01 S32860 Catherine Dalley V242445 090805 Stage 4.doc Version 1.40 Page 17 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27, 28, 29 and 30. Staff at the home are well trained and supported, and employed in sufficient numbers to meet the needs of residents. EVIDENCE: Catherine Dalley employs twenty members of care staff, of which fourteen have attained a level 2 National Vocational Qualification; this level of achievement is to be commended. The Inspector spoke with three members of staff, two of which work with residents of the home, whilst the third works within the rehabilitation unit. The members of staff spoken with have attained level 2 National Vocational Qualification. The staff members said they wish to attain level 3, however the Local Authority will not fund the costs of the course. Staff spoken with had a clear understanding of resident needs, and confirmed they were responsible for the devising and reviewing of care plans. Staff had not received formalised training in care plan writing. The member of staff working within the rehabilitation unit said although they did not use care plans, they worked with the care plans and goals as identified by health care professional assessments. Staff have received training in a variety of topics, including fire awareness, moving and handling, first aid to name some. Staff have also received training in specialist areas such as Alzheimer’s, Dementia, Parkinson’s and Stroke Awareness. Catherine Dalley House C51 C01 S32860 Catherine Dalley V242445 090805 Stage 4.doc Version 1.40 Page 18 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31, 32, 33, 35, 36, 37 and 38. The Registered Manager offers a clear sense of leadership, which reflects on the day-to-day delivery of care practices of residents and running of the home. EVIDENCE: The Registered Manager is a qualified Social Worker and has attained a Certificate in Counselling and Psychotherapy, and is currently working towards a level 4 National Vocational Qualification and Registered Managers Award. The pre-inspection questionnaire completed by the Registered Manager detailed the regular maintenance and checks pertaining to the environment, which includes fire equipment and fire drills. Catherine Dalley House C51 C01 S32860 Catherine Dalley V242445 090805 Stage 4.doc Version 1.40 Page 19 Quality Assurance questionnaires are sent to those individuals who have accessed the rehabilitation unit, the Inspector viewed completed questionnaires and thank you cards, all contained positive comments as to their stay of rehabilitation. The three members of staff spoken with confirmed that they receive regular one to one supervisions with a member of the management team, this provides an opportunity to review residents needs and discuss issues affecting them, including training. Staff were positive as to the training they received, however were disappointed that they could not undertake further National Vocational Qualification training. Catherine Dalley House C51 C01 S32860 Catherine Dalley V242445 090805 Stage 4.doc Version 1.40 Page 20 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score 3 x 3 x x 3 HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION 3 3 3 3 3 3 3 3 STAFFING Standard No Score 27 3 28 3 29 4 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score x x x 3 3 3 x 3 3 3 3 Catherine Dalley House C51 C01 S32860 Catherine Dalley V242445 090805 Stage 4.doc Version 1.40 Page 21 Yes Are there any outstanding requirements from the last inspection? 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 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 7 Good Practice Recommendations It is recommended that care plans contain additional information, evidencing an holistic approach to care. 1. Mental Health and its affects on the individual to be more detailed. 2. Recreational and activities form part of the care plan. 3. Daily records contain more detailed information, indicative of their care plan. It is recommended that the Registered Person considers the funding of care staff to undertake National Vocational Qualifications at level 3, for care staff demonstrating an eagerness to develop professionally, with particular reference to those undertaking Relief Officer duties. 2. 30 Catherine Dalley House C51 C01 S32860 Catherine Dalley V242445 090805 Stage 4.doc Version 1.40 Page 22 Commission for Social Care Inspection 5 Smith Way Grove Park Enderby Leicestershire LE19 1SX National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Catherine Dalley House C51 C01 S32860 Catherine Dalley V242445 090805 Stage 4.doc Version 1.40 Page 23 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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