CARE HOME ADULTS 18-65
Dales, The 137 Gillott Road Edgbaston Birmingham West Midlands B16 0ET Lead Inspector
Susan Scully Announced Inspection 22nd November 2005 10:00 Dales, The DS0000016945.V260236.R01.S.doc Version 5.0 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.V260236.R01.S.doc Version 5.0 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.V260236.R01.S.doc Version 5.0 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.V260236.R01.S.doc Version 5.0 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. 10th March 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.V260236.R01.S.doc Version 5.0 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. An announced visit took place over a one-day period. Records were sampled pertaining to residents’ daily records, care plans, risk assessments and healthcare needs. Other records seen included staff files, Health and Safety, Complaints, Policies and Procedures and records pertaining to staffing levels. The manager was present throughout the inspection and comments have been included in the report. What the service does well: What has improved since the last inspection? What they could do better:
Care plans do not reflect the needs of resident. Risk assessments are completed but do not show how the risk is incorporated into the care plan. There appears to be some confusion as to what a care plan is. It was evident that the residents are well looked after, but recording is poor. The manager and staff do themselves no justice in not maintaining sufficient information to show how the resident’s needs are met. Three residents said the home is like a family home and they were well looked after, there was nothing staff and the manager would not do for them. Dales, The DS0000016945.V260236.R01.S.doc Version 5.0 Page 6 Care plans must be developed to show what personal tasks and assistance is given to residents on a daily basis and the long-term goals and aspiration of each individual. Care plans must also show activities, healthcare appointments and any other healthcare professionals involved. The manager said “ Resident have been at the home for so long they are part of the family’’. “Staff know them so well’’. This was demonstrated during the visit. However in order to ensure the needs of residents are met information must be recorded of how the initial assessment is incorporated into every day life. It is not acceptable based on staff knowing the resident that there is no need to record information. Significant improvement is required in this area. 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.V260236.R01.S.doc Version 5.0 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.V260236.R01.S.doc Version 5.0 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 The identified needs of residents before admission are not incorporated into the care plans. All residents have a contract of terms and conditions of residency. EVIDENCE: Pre admission care plans that are completed by the manager include objectives, measures of success and daily living tasks. This information is not incorporated into the care plan to identify what support is required and who will provide it. Assessed needs of residents from the initial assessment must be included in the care plan and reviewed as required. It is acknowledged this may not be possible for the residents living at The Dales as they have been living in the home for a number of years. This process must be applied to any new admissions in the future. Contracts are in place for all service users, these are stored on file. Dales, The DS0000016945.V260236.R01.S.doc Version 5.0 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 The care planning system is not clear and consistent to provide staff with the information they need to meet the resident’s needs. The care needs, wishes, preferences and personal goals are not recorded. While information is not recorded of how residents make daily decisions about their life, residents confirmed they do. Regular meetings take place that involve residents in discussions about the home. Risk assessments are completed giving details of how the risk is managed and monitored. EVIDENCE: Care plans were not adequate. Information of how the resident needs were met was not recorded. They did not contain information pertaining to what personal care is given. Reviews were completed based on risk assessments. There was some confusion of what a care plan is. The manager said “ staff know the residents well, what they like and dislike, how they are supported with personal care and what activities they participate in’’. “The residents are
Dales, The DS0000016945.V260236.R01.S.doc Version 5.0 Page 10 part of the family and treated as such’’. The residents confirmed this. While it was evident, the needs of resident are met. The recording of information was poor. Residents spoken to gave a very high opinion of the care they receive and what it was like to live at The Dales. Other information contained in the residents file included aliments, healthcare appointments and Social Worker reviews. The manager and staff must record what tasks are completed on a daily basis for each resident to ensure consistency, autonomy and choice. Records were not available to show how residents make decisions each day or long term. One resident said, “all of us make decisions and are given the support when required, we have regular meetings and discuss what we would like to do’’. “I have been here for years and would not want to live anywhere else’’. Staff and the manager have been good to me’’. Two other residents agreed with what was being said. Risk assessments are completed and reviewed every six months. One risk assessment required more information as to how staff ensure the resident or staff is not placed at risk when assisting with manual handling. Dales, The DS0000016945.V260236.R01.S.doc Version 5.0 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): 13, 14, 16 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. EVIDENCE: Each resident’s individual requirements are well catered for. Some residents enjoy the experience of attending day care placements and work opportunities. One resident chooses to enjoy the freedom and flexibility of a lifestyle, which is akin to that of retirement. He enjoys watching TV and videos, and takes regular exercise in the garden with the support of staff. The home has no set activity plans presently, but all residents expressed satisfaction with the arrangements in place currently, which allow flexibility and choice of activities whether individually or as a group. Residents access a range of leisure activities. Each resident enjoys an annual holiday either in Britain or abroad. There has been no change to the routine or consultation with residents about holidays. Dales, The DS0000016945.V260236.R01.S.doc Version 5.0 Page 12 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 Significant documentation concerning the support, healthcare, and needs of residents is not adequately completed. There is not sufficient information to show how residents achieve their full potential, capacity, physical, and intellectual needs. EVIDENCE: Care plans sampled did not give a clear indication of what personal care is given or what healthcare needs the residents has. This was discussed with the manager during the visit. Information is contained in risk assessments that should be contained in care plans. As those need areas identified present no risk. One resident’s health has deteriorated. There was no information to show how this residents needs was monitored with regard to mobility and the feedback given to the physiotherapist that had given instruction for this residents to regularly take exercise. The resident said he took regular excise with support form staff, this must be recorded of the progress this residents is making. Dales, The DS0000016945.V260236.R01.S.doc Version 5.0 Page 13 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 Residents are protected and their views are listened to. Records pertaining to healthcare needs could have a detrimental effect on the wellbeing of residents. EVIDENCE: Meetings take place where residents can air their views. The minutes of these meeting were not examined in detail. When a complaint is made, information is recorded. 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. The Dales operates in line with the Birmingham Multi Agency guidelines including whistle blowing. Insufficient information contained in care plans could place residents at risk. Dales, The DS0000016945.V260236.R01.S.doc Version 5.0 Page 14 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, 30 The Dales is very well maintained comfortable clean and well decorated. Bedrooms are personal and show the individuality of each resident. The Dales at this visit and previous visit was clean and fresh. EVIDENCE: The home is very well maintained, clean and fresh. The home has domestic style furnishings and decoration, with bedrooms reflecting the individual tastes and interest of service users. Recently the home has been extensively redecorated and additional bathing facilities fitted, fire doors replaced and radiators replaced and covers provided. Access to the first and second floors is via a steep staircase. Resident said they are comfortable and their bedrooms are to their liking clean and fresh at all times. Dales, The DS0000016945.V260236.R01.S.doc Version 5.0 Page 15 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, 34, 35, 36 Feedback from residents indicates The Dales provide a homely and relaxed environment. The necessary checks are completed to ensure the safety of residents. Training is completed in mandatory areas and updated as required. Supervision is held regularly. EVIDENCE: The staffing is made up of family members. Records of training and CRB checks were seen. Two staff files were sampled that contained information and certificate of training that had been completed. It was clear from conversations with both residents and the owner/manager there are very clear standards by which the home should run, and thus ensures that high standards are maintained. It appears that the home has successfully balanced the aims to provide a family type environment with the requirements of a large home. Supervision is completed on a regular basis. Information contained in supervision files shows topics discussed, such as Policies and Procedures, and any concerns they may have concerning the residents and training. Dales, The DS0000016945.V260236.R01.S.doc Version 5.0 Page 16 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): 38, 42 The routine in the home is flexible and residents gave positive comments about the manager and staff. Records pertaining to resident’s healthcare needs are not recorded in sufficient detail and this could potentially place residents at risk. EVIDENCE: The manager demonstrated her knowledge regarding the residents’ needs. Residents said the manager and staff were always polite and cared for them well. Care plans were not maintained to a satisfactory standard to ensure the residents are not placed at risk. A risk assessment is required for manual handling for one resident. A risk assessment is required for the environment; this must be reviewed on a regular basis. Weekly fire safety checks are completed including fire drills and risk assessments. Dales, The DS0000016945.V260236.R01.S.doc Version 5.0 Page 17 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score X 2 X X 3 Standard No 22 23 Score 3 2 ENVIRONMENT INDIVIDUAL NEEDS3 AND CHOICES3 Standard No 6 7 8 9 10 3Score 1 3 3 2 X Standard No 24 25 26 27 28 29 30
STAFFING Score 3 X 3 X X X 3 LIFESTYLES Standard No Score 11 X 12 X 13 3 14 3 15 X 16 3 17 Standard No 31 32 33 34 35 36 Score X X X 3 3 3 CONDUCT AND MANAGEMENT OF THE HOME X PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21
Dales, The Score 1 1 X X Standard No 37 38 39 40 41 42 43 Score X 3 X X X 2 X DS0000016945.V260236.R01.S.doc Version 5.0 Page 18 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 2 Standard YA2 YA6 Regulation 14(1)(a) Requirement Timescale for action 31/12/05 31/12/05 3 4 5 6 YA9 YA18 YA19 YA23 7 YA39 8 YA42 9 YA42 Needs identified at the initial assessment must be incorporated into care plans. 15(1) Care plans must give detailed (2)(a,b) information to show how the needs of residents are being met. 13(4) A risk assessment must be completed in manual handling for one resident. 15(1)(2) Care plans must show what personal support is given to residents. 12(1)(a,b) The healthcare needs of residents must be documented in sufficient detail. 12(1)(a) Records pertaining to the health 13(4) and welfare of residents must be recorded in detail to prevent residents being placed at risk. 24(1) A quality assurance system must be introduced to ensure a consistent monitoring system. Not assessed. 13(4) Manual handling assessments must be completed on all residents. Not assessed. 13(4) Risk assessments must be completed for the environment.
DS0000016945.V260236.R01.S.doc 31/12/05 31/12/05 31/12/05 31/12/05 31/12/05 31/12/05 31/12/05 Dales, The Version 5.0 Page 19 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. Dales, The DS0000016945.V260236.R01.S.doc Version 5.0 Page 20 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
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