Inspection on 22/02/07 for The Dales

This inspection was carried out on 22nd February 2007.

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 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 01/02/06

The Dales 22/11/05

The Dales 10/03/05

The Dales 13/09/04

The Dales 24/02/04

Similar services:

Polesworth Group Friary Road

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 Brenda O’Neill Key Unannounced Inspection 22nd February 2007 09:30 Dales, The DS0000016945.V328172.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 Dales, The DS0000016945.V328172.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. Dales, The DS0000016945.V328172.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Dales, The Address 137 Gillott Road Edgbaston Birmingham West Midlands B16 0ET 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.V328172.R01.S.doc Version 5.2 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. 1st February 2006 Date of last inspection Brief Description of the Service: The Dales is situated close to Edgbaston Reservoir and Summerfield Park, and within easy reach of local amenities. The large Victorian property has front off street parking and is well presented. Facilities are provided on the ground, first and second floor reached by a main staircase. Each resident has a bedroom with wash hand basin and four bedrooms also have showers. 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 a secure, relaxed, homely environment in which their care, well-being and comfort are of prime importance. Fee at the home ranged from £326.44 to £432.54 per week at the time of the inspection. Dales, The DS0000016945.V328172.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. One inspector carried out this key unannounced inspection over one day in February 2007. During the course of the inspection a tour of the premises was carried out, two resident and two staff files were sampled as well as other care and health and safety documentation. The inspector spoke with the manager, one staff member and five of the six residents. Prior to the inspection a completed pre inspection questionnaire had been returned to the Commission with additional information about the home. The home had not logged any complaints since the last inspection and none had been raised with the Commission. What the service does well: There was a service user guide available at the home and all the residents had received a copy of this. The document included all the necessary information and it was written in a format that residents could understand which included pictures to help those unable to read. Residents were encouraged and enabled to make decisions about their lives on an ongoing basis. Residents spoke avidly about their regular holidays which they clearly enjoyed. All the residents spoken with were happy with the day placements they attended and the activities they took part in with staff at the home. Residents were clearly satisfied with their lifestyles and participated in daily life at the home as well as pursuing their personal leisure pursuits. All the residents spoken with were very happy with the food provided at the home. They were quite clear that staff knew their likes and dislikes and that these were catered for. Food records were being kept and these showed residents had very varied meals. Residents’ health and personal care needs were met in a way that suited them. The medication system was well managed and ensured the residents received their prescribed medication appropriately. Residents were confident that their views were listened to and that if any issue arose they would have no difficulty raising it with the manager who would ‘do something about it.’ The staff team were made up of family members. There had been no staff turnover for a considerable amount of time which was very good for the continuity of care of the residents. Residents spoken with were very positive about the staff at the home and saw them as their friends. Staffing levels were Dales, The DS0000016945.V328172.R01.S.doc Version 5.2 Page 6 appropriate for the needs of the residents and they received all the required training to enable them to undertake their roles. The home provided residents with a safe, comfortable and well maintained environment in which to live. The home was very well managed. The manager/owner of the home demonstrated her knowledge and understanding of the needs of the residents in her care. She was very friendly with the residents and they were very comfortable in her presence. It appeared that the home had successfully balanced the aims to provide a family type environment with the requirements of a large 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. Dales, The DS0000016945.V328172.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 Dales, The DS0000016945.V328172.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. JUDGEMENT – we looked at outcomes for the following standard(s): 1 and 2 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. There is adequate information available for prospective residents to enable them to make a decision as to whether the home can meet their needs. Systems are in place to ensure that the needs and aspirations of prospective residents are fully assessed prior to admission. EVIDENCE: There was a service user guide available at the home and all the residents had received a copy of this. The document included all the necessary information and it was written in a format that residents could understand which included pictures to help those unable to read. There had been no new residents admitted to the home for a number of years. There were policies and procedures on site in relation to admission. The home did have a vacancy at the time of the inspection and the manager was very clear about the home’s assessment and admission procedure. She discussed with the inspector that a referral had been made to the home, she had met the individual and they had visited the home. The manager was very clear and able to detail that the home could not meet the needs of the individual and why. Dales, The DS0000016945.V328172.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. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 and 9. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Care plans and risk assessments had been further developed ensuring staff knew how to meet the identified needs and minimise any risks for the residents. Residents were encouraged and enabled to make decisions about their lives on an ongoing basis. EVIDENCE: Two residents’ files were sampled. Both files included comprehensive information about the individuals. There was information about their past history, social and medical needs, their likes dislikes and preferences and their abilities. There were details included on the files of any issues identified and the aims for the future. Areas covered in the care plans included, personal hygiene, communication, relationships and behaviour, personal safety and hobbies and education. Any actions needed by staff to help the residents in these areas were detailed. It was clear from the plans that residents were encouraged to Dales, The DS0000016945.V328172.R01.S.doc Version 5.2 Page 10 make decisions about their lives, for example, ‘does not want a key worried they may lose it’ and ‘no longer attends church says it is boring’. The care plans in place had been further developed since the last inspection to include details of all the residents personal care needs. The assistance with personal care required by the residents varied significantly for example, ‘uses the shower every night, washes hair, no assistance is needed in doing these tasks. For another resident it was quite different, ‘will need to be told to clean his teeth, staff will need to clean his nose, very dry skin cream to be applied every night.’ One resident had very limited verbal communication this was clearly detailed in his care plan that he had a picture book to enable him to indicate to staff what he wanted/needed. The inspector saw the book and found it to be very extensive. He also had a book at his day placement. Residents had been involved in drawing up their plans and they included lists of ‘I like’ and ‘I don’t like’. These included statements such as ‘I like sitting quietly, a glass of wine, watching T.V.’ and ‘I don’t like staying up late,’ ‘ my things being touched by others.’ Care plans were reviewed in house at least every six months. Any specific risks identified for the residents were detailed with details of how the risks were to be minimised. Some of the risks detailed involved some limitations being put on the residents movements but these were for health and safety reasons and had been discussed with the individuals involved. For example, one resident was very vulnerable when they went out drinking, another was unable to go out alone due to not understanding the dangers of crossing the road. Other risks identified were refusing dental appointments and self harming. Dales, The DS0000016945.V328172.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. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15, 16 and 17. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Each resident is encouraged to participate in activities of their choice. Residents’ rights and choices are respected. Residents take responsibility with support for the decisions they make. The catering arrangements in place at the home met the needs of the residents. EVIDENCE: All the residents living at the home went out to various day placements on the day of the inspection. On their return the inspector spoke to them about what they had been doing. Some detailed their placements as going to work for which they received a nominal payment. Another resident spoke of doing drawings and going to an arts centre. All those spoken with were happy with their placements. Residents also spoke of going out with staff to the theatre, shopping, out for meals and to the manager’s family celebrations. Two of the residents were able to go out independently. One regularly went out on Dales, The DS0000016945.V328172.R01.S.doc Version 5.2 Page 12 Saturdays for a drink another spoke of going out for a walk and spending time in the park in the better weather. Residents spoke avidly about the holidays they have with the manager and staff. A trip to Blackpool for Easter had been planned for this year and the manager also planned to take the residents abroad later in the year. One of the residents spoke to the inspector about going to America last year with the manager and her son and that this was something he had always wanted to do. During discussions with the manager it was evident that she was very keen for all residents to achieve something they really wanted. Residents accessed all the local community facilities either independently or with staff support including health care facilities, shops, parks and pubs. All the residents had friends at their day placements. Some of the residents had regular family contact others had none. Wherever possible the manager and staff ensured family contact was maintained. Residents were free to visit their families and friends or have them visit them at the home. Residents took some responsibility for some daily household tasks. They spoke to the inspector about helping with washing up, putting out the rubbish, tidying their rooms and making their beds. Where necessary residents were supported with budgeting their money but all managed their own to some degree. All the residents spoken with were very happy with the food provided at the home. They were quite clear that staff knew their likes and dislikes and that these were catered for. Food records were being kept and these showed residents had very varied meals. During the week residents generally had cereals and toast for breakfast but liked a cooked breakfast at weekends. Records also detailed the residents’ packed lunches during the week that they took to their day placements. The manager discussed with the inspector that one resident only liked jam sandwiches for lunch and although she had tried to vary this she had been contacted by the day centre to say that if there was anything else on the sandwiches they were not eaten. Residents were clearly satisfied with their lifestyles and participated in daily life at the home as well as pursuing their personal leisure pursuits. The daily diaries being kept for the residents needed to be further developed to reflect how residents were spending their time both inside and outside the home and the tasks they took part in. Dales, The DS0000016945.V328172.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. 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. Residents’ health and personal care needs were met in a way that suited them. The medication system was well managed and ensured the residents received their prescribed medication appropriately. EVIDENCE: The personal care needs of the residents varied considerably. Their needs were clearly detailed in their care plans and these included details of where staff were to provide support. Wherever possible residents were encouraged to maintain their own personal hygiene to an acceptable level. Residents were all well dressed and their appearance reflected their personalities. There was only one female resident at the home at the time of the inspection. There were both female and male staff employed at the home therefore gender sensitive care was provided. All residents had health action plans in place which included a pen portrait of the individuals and any issues they had in relation to their health. Residents were all registered with a local G.P. and had a yearly health check. Health care records showed that residents received regular check ups with dentists and Dales, The DS0000016945.V328172.R01.S.doc Version 5.2 Page 14 opticians and that where necessary other health care professionals were contacted, for example, psychiatrists and psychologists. Residents refusals to health care were also clearly documented, for example, ‘refused flu vaccination.’ One of the residents had been having specialist health care input but had been discharged as considerable progress had been made. The discharge letter stated ‘considerable progress with the issues identified at referral have been made. This was due to your own hard work and the support of the carers at The Dales.’ Residents were being weighed on a regular basis. The manager was trying to ensure the residents ate a healthy diet wherever possible. The medication at the home was administered via a 28 day monitored dosage system and this was very well managed. All staff had received some training in the administration of medication. One resident was not having any medication and none of the other residents were able to self administer their medication. All the medication received at the home was acknowledged and signed for and all the MAR (medication administration records) charts were signed appropriately. There was no boxed medication at all in the home and no controlled medication was being administered. Dales, The DS0000016945.V328172.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. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are protected and their views are listened to. EVIDENCE: A complaints procedure that outlined how to make a complaint and the time scale for responses was seen. Residents had a copy of the procedure on file. This was written in a format suitable for them. The home had not had any complaints since the last inspection and none had been logged with the Commission. When asked who they would raise any issues with the residents stated ‘Mary’ (manager of the home) and that ‘she would do something about it’. There were comprehensive procedures on site for adult protection. No issues had been raised at the home since the last inspection. Staff had received training in adult protection and managing challenging behaviour. The manager supported the residents where necessary with managing their money. All of the residents managed some of their money on an ongoing basis. The records for the management of money were sampled. For three of the residents all their money was paid into the home’s account and although this is not an ideal situation it was a long standing arrangement at the home. Every week the manager drew the residents’ personal allowance for them and they signed to say they had received it. One of the residents had help from a family member to manage his money and another had his paid into the post office and managed part of this himself. The manager needed to ensure that where Dales, The DS0000016945.V328172.R01.S.doc Version 5.2 Page 16 residents’ monies were being paid into the home’s account and this was being documented in the resident’s personal records the amount of the money being taken for fees was also detailed to ensure a complete audit trail for all money. Residents were satisfied that they had access to their money and spoke to the inspector about being encouraged to save for the things they ‘really wanted’. Dales, The DS0000016945.V328172.R01.S.doc Version 5.2 Page 17 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. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 25, 27, 28, 29 and 30. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home provides residents with a safe, comfortable and well maintained environment in which to live. EVIDENCE: The Dales is very like a large family home and is furnished and decorated as such. Furnishings and fittings were domestic in character and the home was very well decorated and well maintained. Since the last inspection several improvements had been made to the environment. The house had been rewired, there had been a lot of redecoration, several new carpets had been fitted, bed linen and curtains had been purchased. The bathroom had been retiled and carpeted and one bedroom had had a new sink. Bedrooms at the home varied in size and all the residents spoken with were very happy with their rooms. All the rooms reflected the individuals’ personal preferences and personalities. The manager spoke of taking the residents to the DIY shops to choose their own wallpaper. Residents had their own Dales, The DS0000016945.V328172.R01.S.doc Version 5.2 Page 18 televisions, DVDs and music systems and some had very large collections of videos and CDs. Some of the rooms had en suite showers and all had wash hand basins. There were adequate bathing, showering and toilet facilities in the home. The home has a large lounge and a large combined kitchen/diner. Residents were seen to be very comfortable in the home and all had their preferred seats. The garden at the rear of the home was well maintained and furniture was available for the residents to use in the better weather. The current resident group did not require any special aids and adaptations but the home did have an emergency call system. The home would not be suitable for residents with mobility difficulties as all but one of the bedrooms are on the first and second floors with no lifts in place. The home was very clean, tidy and hygienic. The environmental health officer had recently visited the home and the report was very positive. Dales, The DS0000016945.V328172.R01.S.doc Version 5.2 Page 19 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. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34 and 35. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Appropriate numbers of competent staff were on duty who could meet the needs of the residents. Recruitment procedures were robust and safe guarded the residents. EVIDENCE: The staff team at the home is made up of family members. There had been no staff turnover at the home for a considerable amount of time. Residents spoken with were very positive about the staff at the home and saw them as their friends. The manager and her son were on duty at the time of the inspection and demonstrated quite clearly during discussions that they had a very comprehensive knowledge of the residents and their needs. Residents were very comfortable in the presence of the staff and friendly relationships were evident. There were two staff on duty throughout the waking day and one staff member on night duty. If additional staff were required for activities they were provided. Dales, The DS0000016945.V328172.R01.S.doc Version 5.2 Page 20 Recruitment procedures had been checked at previous inspections for the existing staff and were found to be appropriate with all the required checks in place. Training records for the staff were sampled and it was evident staff had the required regulatory training including fire, food hygiene, first aid, adult protection and moving and handling. Other training topics also covered by staff included, diabetes, challenging behaviour, dementia and risk assessment. All staff had completed their NVQ level 2 and two were undertaking level 3. Dales, The DS0000016945.V328172.R01.S.doc Version 5.2 Page 21 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. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 and 42. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The manager ensured the smooth running of the home in a competent manner. The health and safety of the residents and staff were well managed. The home needed a system in place for the continuous monitoring of the quality of the service on offer with a view to continuous improvement. EVIDENCE: The manager of the home is also the owner and has many years experience of running a home and caring for people with a learning disability. Throughout the course of the inspection she demonstrated her knowledge and understanding of the needs of the residents in her care. She was very friendly with the residents and they were very comfortable in her presence. It was clear from conversations with both residents and the owner/manager Dales, The DS0000016945.V328172.R01.S.doc Version 5.2 Page 22 there were very clear standards by which the home should run, and this ensured that high standards were maintained. It appeared that the home had successfully balanced the aims to provide a family type environment with the requirements of a large home. The home did not have a formal quality assurance system. Resident and staff meetings did take place and clearly residents were listened to at all times. Quality Assurance was discussed with the manager and the need to have a system in place that continually monitors the service on offer with a view to continuous improvement that results in a yearly development plan for the home. Health and safety at the home were very well managed. Staff had received training in safe working practices. There was evidence on site that all equipment, with the exception of the emergency call system, had been serviced. All the in house checks on the fire system were up to date and fire drills were carried out as required. The few requirements made by the fire officer at his last visit had been met. Dales, The DS0000016945.V328172.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 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 3 2 3 3 X 4 X 5 X 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 X 27 3 28 3 29 3 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 3 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 3 X 2 X X 3 X Dales, The DS0000016945.V328172.R01.S.doc Version 5.2 Page 24 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 YA12 Regulation 12(1)(a) Requirement Residents’ daily diaries must include detail of how residents are spending their time both in and outside of the home. The manager must ensure that the fees deducted from the residents’ income are detailed in their records. A quality assurance system must be introduced to ensure a consistent monitoring system is in place with a view to continuously improving the service. (Previous time scale of 01/04/06 not met.) There must be evidence on site that the emergency call system has been serviced. Timescale for action 01/05/07 2. YA23 17(2) schedule 4(9) 24(1) 14/04/07 3. YA39 01/07/07 4. YA42 13(4) 01/05/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Dales, The DS0000016945.V328172.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection Birmingham Office 1st Floor Ladywood House 45-46 Stephenson Street Birmingham B2 4UZ 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 Dales, The DS0000016945.V328172.R01.S.doc Version 5.2 Page 26 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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