Inspection on 18/08/06 for Dalecroft

This inspection was carried out on 18th August 2006.

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

The inspector found no outstanding requirements from the previous inspection report, but made 2 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Dalecroft 23/07/07

Dalecroft 21/02/06

Dalecroft 30/08/05

Dalecroft 03/11/04

Dalecroft 16/06/04

Dalecroft 19/01/04

Similar services:

Snydale Care Home

Staveley Birk Leas Nursing Home

Fairmount Nursing Home

Currergate Nursing Home

Brookfield

Castlethorpe Care Home

Elmleigh Convent

Woodlands Respite Care Centre

Extracts from inspection reports are licensed from CQC, this page was updated on 08/07/2008.

CARE HOME ADULTS 18-65 Dalecroft 94A Keighley Road Illingworth Halifax HX2 8DN Lead Inspector Cheryl Stovin Unannounced Inspection 18th August 2006 11:00 Dalecroft DS0000051646.V300756.R01.S.doc Version 5.2 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 Dalecroft DS0000051646.V300756.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 Adults 18-65. 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. Dalecroft DS0000051646.V300756.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Dalecroft Address 94A Keighley Road Illingworth Halifax HX2 8DN 01422 246646 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) Holly Bank Trust Miss Sarah O`Sullivan Care Home 6 Category(ies) of Physical disability (6) registration, with number of places Dalecroft DS0000051646.V300756.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. Care for up to six adults with a physical disability who may also have a learning disability or sensory impairment. 21st February 2006 Date of last inspection Brief Description of the Service: Dale Croft is owned and managed by the Holly Bank Trust and is registered to provide accommodation and care for six young adults who have physical and learning disabilities. The accommodation comprises of an adapted bungalow and an adjacent self contained flat, which provides accommodation for a service user which promotes independence . Service users are included in decisions about their lives, through person centred approaches in the home. Dale Croft is located in the Illingworth area of Halifax and is within close proximity of the main Keighley Road and public transport links. The home is a detached property, designed over a single floor. Adaptations have been undertaken to promote wheelchair access and meet the mobility and personal care needs of service users. The accommodation offers spacious communal areas and a private, landscaped and accessible garden, where service users are able to spend time in the warmer weather. A pre-inspection questionnaire was returned accurately completed which indicated that service users are individually assessed as to the weekly charges. Dalecroft DS0000051646.V300756.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This report refers to a Key Inspection of Dalecroft which was undertaken on 18th and 23rd of August 2006 by an inspector from the Commission for Social Care Inspection. A total of 9 hours was spent on the visit. In addition to the visit to the home, when service users were consulted, relatives/visitors were invited as to their opinions of the services and facilities provided within the home by the completion of a comment card. Four replies were received. In April 2006 the Commission for Social Care Inspection (CSCI) made some changes to the way in which care services are inspected. Care services are now judged against outcome groups. The inspection report is divided into separate sections for each outcome group for example Choice of Home. An overall judgement is made for each outcome group based on the findings of the inspection. The judgements reflect how well the service delivers outcomes to the people using the service. The judgements categories are “excellent”, “good”, “adequate” and “poor”. The judgements are recorded within the main body of this report. More detailed information about these changes is available on our website – www.csci.org.uk What the service does well: The home has a warm and welcoming atmosphere with staff and service users working together as a team. All of the residents at Dalecroft have detailed and holistic individual support plans which ensures that they receive personal and health care support in line with their wishes. The home is fully equipped with aids and adaptations to promote the residents independence and all areas of the home, both internally and externally are accessible for wheel chair users. Individual bedrooms are highly personalised reflecting the service users interests and tastes and fully equipped to meet their needs. Residents are actively encouraged to influence the way the home is run and to participate in the drawing up of policies and procedures. Service users live active and varied lives and make use of a wide range of community social and recreational activities. Residents stated that they are treated with respect at all times and that staff protect their dignity. The staff team is well trained and highly motivated and committed to providing a high standard of care and attention to the service users. Relationships between staff and residents was relaxed and friendly with appropriate use of informality and humour. Dalecroft DS0000051646.V300756.R01.S.doc Version 5.2 Page 6 All of the respondents to the relatives/visitors comment cards indicated that they were satisfied with the overall care provided. One made the following additional comment “My daughter has been with Holly Bank Trust since she was 11 years old, school, younger disabled unit and now Dalecroft, and has had excellent care and I don’t think there would be anywhere better for her in this country”. 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. Dalecroft DS0000051646.V300756.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Dalecroft DS0000051646.V300756.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 2,5 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users needs are fully assessed prior to admission. Each service user has an individual contract and statement of terms and conditions. EVIDENCE: All of the service users needs are fully assessed prior to moving into the home. The assessment process is detailed and holistic with input from the service user and their family and relevant health professionals. Prior to moving into the home the service users visited several times and were fully involved in the design and décor of their bedrooms and communal areas. Each service user has a contract stating the terms and conditions of residence. Dalecroft DS0000051646.V300756.R01.S.doc Version 5.2 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7,8,9 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users needs are thoroughly assessed and the home has a good approach to promoting the service users health care. Service users make decisions about their lives and are fully involved in the day to day running of the home. EVIDENCE: Each service user has an individual personal support plan, which is detailed and holistic and covers activities of daily living as well as social and emotional needs. Each service user signs to say they are in agreement with the content of the care plan, and the aims and objectives set All service users are routinely assessed by a Physiotherapist and an Occupational Therapist and have detailed manual handling plans and risk assessments. The home uses a person centred planning approach and the personal support plans are reviewed on a regular basis. A daily record is kept which clearly details how the service user has spent their day. Dalecroft DS0000051646.V300756.R01.S.doc Version 5.2 Page 10 Service users are encouraged and enabled to be fully involved in the day to day running of the home and participate in all activities of daily living. Staff were observed to be offering service users choices during the day and service users were seen to be exercising choice in when to get up and where and with whom to spend their time. Dalecroft DS0000051646.V300756.R01.S.doc Version 5.2 Page 11 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 11,12,13,14,15,16,17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Daily routines within the home are flexible to enable the service users to follow their preferred lifestyle. A wide range of social and recreational activities are enjoyed by the service users, who make use of a wide range of local community facilities. Service users are encouraged and enabled to maintain contact with family and friends. A varied and nutritious diet is taken by the service users. EVIDENCE: The atmosphere within the home was noted to be relaxed and homely with service users and staff appearing to work together as a team in the day to day running of the home. Dalecroft DS0000051646.V300756.R01.S.doc Version 5.2 Page 12 Service users are encouraged and enabled to participate in a wide range of community social and recreational activities. Recent activities have included going swimming, visiting the local pub, cinema, bowling and theatre and art gallery visits. Some service users attend adult education courses. Service users regularly make use of local community facilities and are very much part of the local community.. Holidays are enjoyed by the service users, this years destinations have included Disneyland Paris and an activity holiday. Service users are actively encouraged to maintain relationships with family and friends, with key dates of birthdays and special occasions of recorded in their individual support plan Visitors are welcomed into the home and all respondents to the relatives/visitors comment cards indicated that the staff welcome them into the home when they visit and that they are kept informed of important matters affecting their relative/friend. The staff were observed to be treating the service users with respect at all times and relationships were observed to be relaxed and friendly with appropriate use of informality and humour. Relationships between fellow residents was also noted to be cordial and relaxed. Records seen indicated that a varied and healthy diet is taken by the service users. The main meal of the day is served in the evening. Mealtimes were observed to be a relaxed and social occasion with service users choosing what they wanted to eat. On the day of the inspection service users and staff prepared lunch together and the service users chose to have spaghetti and scrambled eggs on toast. Any service user requiring assistance to eat was treated in a dignified and sensitive manner. . Dalecroft DS0000051646.V300756.R01.S.doc Version 5.2 Page 13 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18,19,20 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users personal and health care support needs are met and support is given in accordance with their wishes. Medication practices within the home are safe, however, care should be taken to ensure the medication is taken from the correct section of the blister pack. EVIDENCE: Service users personal and physical and emotional health care support needs are assessed and form part of their plan of care. All personal care is given in private and in accordance with the service users preferences. Service users physical and psychological health care needs are assessed and detailed in their personal support plan. Service users have access to Physiotherapy and Occupational Therapy support on an on-going basis. The home is designed and equipped with aids and equipment to maximise independence and to ensure personal care is carried out safely. The establishment uses the Boots MDS (Monitored Dose System) for the administration of medication. All staff, responsible for administering medication, receive appropriate training. The medicines are securely and Dalecroft DS0000051646.V300756.R01.S.doc Version 5.2 Page 14 appropriately stored. Stocks of medication held and Medication Administration Records were inspected. It was found that one morning dose of medication had been taken from the wrong day of the blister pack. The records tallied with the medication held, however, care must be taken to ensure that the correct day is selected when administering medication. One service user is responsible for handling their own medication. A risk assessment is in place with an effective monitoring system. Dalecroft DS0000051646.V300756.R01.S.doc Version 5.2 Page 15 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22,23 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users views are acted upon. Service users are protected from abuse and neglect. EVIDENCE: The establishment holds a complaints procedure which is displayed and provides information of the procedure to follow and the correct contact details. All of the respondents to the relatives/visitors comment cards indicated that they were aware of the homes complaints procedure, although none had had the occasion to make a complaint. One respondent made the following comment “Dalecroft is an excellent placement for my daughter and staff deal with her needs very well. As such I have got no complaints whatsoever”. The establishment holds a ‘whistle blowing’ procedure which is displayed in the staff room. The procedure details the responsibilities and obligations of the staff to report any instances of bad practices observed or suspected. All of the staff team have received training in the Protection of Vulnerable Adults and all staff spoken to were aware of the procedures to follow. Dalecroft DS0000051646.V300756.R01.S.doc Version 5.2 Page 16 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24,25,26,27,28,29,30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is well maintained, with high standards of cleanliness throughout, providing a pleasant, fully accessible and safe environment for service users. Individual bedrooms are spacious and equipped with aids and equipment to meet the individually assessed needs of the service user, which maximise independence. In addition to the en-suite facilities appropriate assisted bathing facilities are provided. Communal areas are spacious and comfortable and furnished and fitted in a contemporary manner to meet the needs of the residents. EVIDENCE: Dalecroft is located in the Illingworth area of Halifax and is within close proximity of the main Keighley Road and public transport links. The home is a detached property, designed over a single floor. Adaptations have been undertaken to provide wheelchair access and meet the mobility and personal care needs of service users. The accommodation offers spacious communal areas and a private, landscaped and accessible garden, where service users are able to spend time in the warmer weather. All bedrooms are for single Dalecroft DS0000051646.V300756.R01.S.doc Version 5.2 Page 17 occupancy and highly personalised to reflect the individuals interests and hobbies. The bedrooms have been designed to meet the individually assessed needs of the service users to promote independence. The service users are obviously proud of their bedrooms and staff respect their wishes in the choice of décor and layout of the rooms. In the grounds of the establishment is a self contained flat occupied by a less dependent service user. In addition to the en-suite facilities provided there are assisted bathing facilities provided, which are warm and welcoming. There is a routine programme of redecoration and refurbishment of the home which was observed to be clean and hygienic throughout. Dalecroft DS0000051646.V300756.R01.S.doc Version 5.2 Page 18 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31,32,33,34,35 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The establishment is staffed in sufficient numbers by a well trained and motivated workforce. Service users are protected by the home’s robust recruitment practices. EVIDENCE: From records examined and following observation and discussion during the inspection sufficient staff are deployed to meet the needs of the service users. There are three care staff plus the manager on duty during day time hours and one waking night staff plus a senior sleeping in during the night. The staff team work flexibly to meet the social and recreational needs of the service users. The staff appeared to work together as a team and relationships with service users was observed to be relaxed and friendly. All of the respondents to be relatives/visitors comment cards felt that in their opinion there are always sufficient numbers of staff on duty. There is a commitment to training within the organisation and all new staff receive induction training to Skills Council specification. Staff training records were examined which indicated that the following training had recently been undertaken: caring for the bereaved, assertiveness and confidence skills, Dalecroft DS0000051646.V300756.R01.S.doc Version 5.2 Page 19 infection control, adult protection, disability awareness, first aid, good practices in intimate care and Rett syndrome awareness. There is a programme of NVQ training in place and six members of staff have completed the award. The establishment is working towards the requirement for 50 of the care staff to be qualified to NVQ II or equivalent. The staff spoken to during the inspection displayed a thorough understanding of the needs of the service users. They appeared motivated and committed to providing a high standard of care and attention, and were observed to be meeting their needs in a sensitive and dignified manner. The service users are protected by the establishments robust recruitment procedure. Evidence was seen that all staff are subject to the necessary CRB and POVA checks. An application form is completed and two written references are taken up prior to an offer of employment being made. All staff receive job descriptions and statements of terms and conditions. Dalecroft DS0000051646.V300756.R01.S.doc Version 5.2 Page 20 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. 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 are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37,38,39,42 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is well run and managed with the Registered Manager demonstrating a clear sense of leadership. Health and safety policies and procedures are in place, however, one member of staff has not received food hygiene training. Service users are routinely consulted about the way the home is run. EVIDENCE: The Registered Manager of the home is experienced and competent to run the home. She has completed the NVQ IV Registered Managers Award, and is committed to ensuring an open and positive atmosphere is prevalent within the home, and demonstrates a clear sense of leadership. The home adheres to health and safety policies and procedures and all staff receive training in safe working practices, moving and handling, first aid, fire Dalecroft DS0000051646.V300756.R01.S.doc Version 5.2 Page 21 safety and infection control. One member of staff has not received training in food hygiene and must do so. The home routinely consults with the service users and their representatives about how the home is run. The home holds and adheres to detailed policies and procedures which are up to date and freely available to staff and service users. Dalecroft DS0000051646.V300756.R01.S.doc Version 5.2 Page 22 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 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 X 2 3 3 x 4 x 5 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 3 26 3 27 3 28 3 29 3 30 3 STAFFING Standard No Score 31 3 32 2 33 3 34 3 35 3 36 x CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 3 3 x LIFESTYLES Standard No Score 11 3 12 3 13 3 14 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 x 3 3 3 3 x 2 x Dalecroft DS0000051646.V300756.R01.S.doc Version 5.2 Page 23 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 YA32 Regulation 19 Requirement 50 of care staff to be qualified to NVQ II. The previous timescale of 30/08/06 was not met. All staff must receive training in food hygiene. Timescale for action 31/01/07 2 YA42 13 31/10/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard YA20 Good Practice Recommendations Care should be taken to ensure that medication is taken from the correct day stated on the blister pack. 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