Inspection on 01/02/06 for The Dales

This inspection was carried out on 1st February 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 there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 4 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

The Dales 01/06/09

The Dales 12/02/09

The Dales 22/02/07

The Dales 22/11/05

The Dales 10/03/05

The Dales 13/09/04

The Dales 24/02/04

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Polesworth Group Pooley Heights

Polesworth Group 32 Station Road

Polesworth Group 70 Long Street

Breme

Polesworth Group 64 Long Street

Polesworth Group 68 Long Street

10 Whitfield Avenue

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

CARE HOME ADULTS 18-65 Dales, The 137 Gillott Road Edgbaston Birmingham West Midlands B16 0ET Lead Inspector Susan Scully Unannounced Inspection 1st February 2006 09:30 Dales, The DS0000016945.V281851.R01.S.doc Version 5.1 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 Dales, The DS0000016945.V281851.R01.S.doc Version 5.1 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. Dales, The DS0000016945.V281851.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Dales, The Address 137 Gillott Road Edgbaston Birmingham West Midlands B16 0ET 0121 454 0197 0121 454 0197 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) Ms Mary Slammon Ms Mary Slammon Care Home 7 Category(ies) of Learning disability (7) registration, with number of places Dales, The DS0000016945.V281851.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. Residents must be aged under 65 years with a learning disability. The home may accommodate one named service user over the age of 65 for reasons of learning disability. That the home periodically reviews that it can continue to meet the individuals needs and a record of these reviews are maintained. 22nd November 2005 Date of last inspection Brief Description of the Service: The Dales is situated close to Edgbaston Reservoir and Summerfield Park, being within easy reach of local amenities. The large Victorian property has front off street parking and is well presented. Facilities are provided on ground, first and second floor reached by a main staircase. Each resident has a bedroom with wash hand basin. There is a large front lounge, rear dining/kitchen area and laundry facility. One ground floor bedroom is available. The house is well maintained. Furniture, carpets and décor are well maintained. The garden has been developed to include two seating areas with comfortable garden furniture. Paving around the garden allows for short walks. The home has regard to previous home care experiences of service users, it acknowledges them as individuals who are seeking support and care as opposed to independence training. The Statement of Purpose states the home will Provide service users with secure, relaxed, homely environment in which their care, well-being and comfort are of prime importance. Dales, The DS0000016945.V281851.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. An unannounced visit took place by two inspectors over a one-day period. Records pertaining to resident’s Healthcare needs, daily activities, Health and Safety and Polices and Procedures were sampled. What the service does well: 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. Dales, The DS0000016945.V281851.R01.S.doc Version 5.1 Page 6 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 Dales, The DS0000016945.V281851.R01.S.doc Version 5.1 Page 7 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): 4 Residents have sufficient information to make the decision to accept a placement or decline. EVIDENCE: The Dales provides each resident with a Statement of Purpose and Service User Guide before admission. Information contained in these document’s enable residents to make a choice whether to accept a placement or to decline. There have been no admissions to the home since the last inspection, however there is an Admission Procedure that includes details of visit to the home and a settling in period. Dales, The DS0000016945.V281851.R01.S.doc Version 5.1 Page 8 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, 9 Information contained in care plans gave detailed information for staff to follow and have improved significantly. Additional information is required to ensure staff are working with a comprehensive care plan. Risk assessments are completed in most areas, but further information is required in care plans sampled and specific areas pertaining to residents needs. EVIDENCE: Care plans have improved significantly with a new format being introduced. Some additional information is required to complete the process of providing care to residents. Information is available to staff to show how resident’s needs are met and the way care is to be provided. Risk assessments have been completed in most areas and include Manual Handling and Fire. Other risk assessments were being developed for specific aliments pertaining to residents. The manager said she has additional support from other professionals to support her in completing the new format with all the relevant details. This would ensure all aspects of the residents care, social and physical needs are met. Those risk assessments identified during the visits must be completed Dales, The DS0000016945.V281851.R01.S.doc Version 5.1 Page 9 and include a risk assessments for one service users who regularly goes out on his own, and for one service user who may self harm. Dales, The DS0000016945.V281851.R01.S.doc Version 5.1 Page 10 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): 13, 16, 17 Residents are consulted about social and recreational activities. Participation depends on the level of interest and ability of the residents. Menu planning and choice of food include ethnic and religious options where appropriate. EVIDENCE: Resident’s records show how resident are consulted on a daily basis about leisure activities. One resident goes to a luncheon club each day at the local church, one resident attends a day centre, and all residents regularly go out to peruse their own interests. The manager said every week they go out either to the clubs or have planned activities such as going to the theatre. The routine is flexible. The manager said the purpose of the Dales is to enable residents to achieve their full potential. The meals provided are fresh. Menus are not strictly followed. This depends on the choice of the resident on any particular day. Dales, The DS0000016945.V281851.R01.S.doc Version 5.1 Page 11 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 Residents Healthcare needs are monitored and reviewed. Other professionals are involved in the care of residents when required. EVIDENCE: All residents are registered with a local GP, optician and dentists. Residents also receive a chiropodist when required. Support from staff is provided when residents attend Healthcare Appointments. Records sampled indicated when necessary other Healthcare Professionals were contacted for further advice or assistance. Reviews are completed on a regular basis and care plans are changed according to the resident needs. Dales, The DS0000016945.V281851.R01.S.doc Version 5.1 Page 12 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): 23 Residents are encouraged to voice their concerns. Complaints are taken seriously and recorded. The Adult Protection Procedure is in line with the Birmingham Multi Agency Guidelines for the Protection of Vulnerable Adults. EVIDENCE: A complaints procedure that outlines how to make a complaint and the time scale for a response was seen. Residents have a copy of the procedure on file. A record is kept of any complaints received, investigated and the outcome. On going training to safeguard residents from abuse, neglect or harm is monitored. Policies and Procedures relating to this area are in line with the Protection of Vulnerable Adults Guidelines. Training is an ongoing topic and the Manager ensures training is given in the related areas to enable staff to meet the resident’s needs. Dales, The DS0000016945.V281851.R01.S.doc Version 5.1 Page 13 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, 26 Residents live in a safe comfortable environment with their own personal possessions. Residents receive support when required and their individuality is respected. EVIDENCE: All residents’ bedrooms are decorated to their preference with personal possessions and certificates of achievements clearly displayed on bedroom walls. The Dales on this visit and previous visits was clean and fresh. The communal lounge was nicely maintained with good communally space. The Manager and owner promote independent living for residents. It was apparent from daily records that residents enjoy freedom of choice and have support when required. When speaking with the Manager individuality and respect was foremost. Dales, The DS0000016945.V281851.R01.S.doc Version 5.1 Page 14 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): 32 Appropriately trained staff are on duty each day to supports residents. There are clear lines of accountability. EVIDENCE: From sampling records pertaining to staff it was clear staff were appropriately trained in mandatory areas such as Food Hygiene, First Aid, and Manual Handling. Not all training records were sampled. Staff demonstrated their knowledge and experience and gave examples of how the resident’s needs were met. Training is ongoing and the manager ensures training is given to staff to enable them to meet resident’s needs. There is a clear line of accountability with support from management when required. Dales, The DS0000016945.V281851.R01.S.doc Version 5.1 Page 15 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, 42 Health and Safety is maintained to a satisfactory standard ensuring action is taken when required. Risk assessments for the environment must be completed, regularly updated and reviewed to ensure the safety of residents. The manager is experienced and operates an open door policy ensuring residents and staff have the support when needed EVIDENCE: The Registered Manager has considerable experience in management and supervision. Evidence was seen of the manager knowledge and experience in the documentation that had been implemented by her. In general, Health and Safety checks are completed to a satisfactory standard. Fire regulations are maintained with the testing of all fire safety equipment, fire drills and weekly testing of fire alarms. Risk assessments for the environment are not completed. Dales, The DS0000016945.V281851.R01.S.doc Version 5.1 Page 16 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 X 3 X 4 3 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 X 23 3 ENVIRONMENT Standard No Score 24 3 25 X 26 3 27 X 28 X 29 X 30 X STAFFING Standard No Score 31 X 32 3 33 X 34 X 35 X 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 X X 2 X LIFESTYLES Standard No Score 11 X 12 X 13 3 14 X 15 X 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 X X 3 X X X X 2 X Dales, The DS0000016945.V281851.R01.S.doc Version 5.1 Page 17 Are there any outstanding requirements from the last inspection? Yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard YA6 Regulation 14(2)(a)(b) Requirement Care plans must contain information to ensure all aspects of the residents physical needs are met. Detailed risk assessments must be completed for any specific aliments of residents that may place them at risk. A quality assurance system must be introduced to ensure a consistent monitoring system. Not assessed. Risk assessments must be completed for the environment. Timescale for action 01/04/06 2 YA9 13(4) 01/04/06 3 YA39 24(1) 01/04/06 4 YA42 13(4) 01/04/06 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 YA6 Good Practice Recommendations It is recommended the manager and staff receive training in the implementation and recording of information in care plans. DS0000016945.V281851.R01.S.doc Version 5.1 Page 18 Dales, The Commission for Social Care Inspection Birmingham Office 1st Floor Ladywood House 45-46 Stephenson Street Birmingham B2 4UZ 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 Dales, The DS0000016945.V281851.R01.S.doc Version 5.1 Page 19 - 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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