Inspection on 01/02/06 for Dingle Meadow Care Centre

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 but made no statutory requirements on the home.

Other inspections for this house

Dingle Meadow Care Centre 20/10/08

Dingle Meadow Care Centre 06/12/06

Dingle Meadow Care Centre 21/10/05

Dingle Meadow Care Centre 16/03/05

Dingle Meadow Care Centre 27/08/04

Dingle Meadow Care Centre 24/02/04

Similar services:

Maple Lodge

Heathlands

Aston Court Nursing Home

Breme

Ravenhurst

Bank House

Inspirations

Ashcroft Hollow Nursing Home

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

CARE HOMES FOR OLDER PEOPLE Dingle Meadow Care Centre Goldencrest Drive Oldbury West Midlands B69 2DR Lead Inspector Mrs Mandy Beck Announced Inspection 1st February 2006 09:30 X10015.doc Version 1.40 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 Dingle Meadow Care Centre DS0000038425.V274877.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 Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Dingle Meadow Care Centre DS0000038425.V274877.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Dingle Meadow Care Centre Address Goldencrest Drive Oldbury West Midlands B69 2DR 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) 0121 552 9355 0121 544 2442 Southern Cross Care Homes No 2 Limited Ms Anette Mole Care Home 46 Category(ies) of Dementia - over 65 years of age (12), Old age, registration, with number not falling within any other category (34) of places Dingle Meadow Care Centre DS0000038425.V274877.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. One service user (female) identified in the variation report dated 8 August 2005 may be accommodated at the home in the category SI(E). This will remain until such time that the identified service users placement is terminated. 21st October 2005 Date of last inspection Brief Description of the Service: Dingle Meadow Care Centre is a purpose built care establishment which is situated in a residential area within easy access to Oldbury town centre. It is close to public transport routes to local areas, Birmingham, Dudley and Wolverhampton and within easy access of the M5/M6 motorway network. There is a car park at the front and rear of the premises. The garden is situated at the rear of the property. There is level access to the front and entrance is via a keypad system. Service users accommodation is en-suite and on three floors that are accessed via passenger lift or stairs. There are fortyone single and two double rooms. Communal space consists of two lounge/dining areas on the ground floor. There are a number of bathrooms with assisted bathing facilities and toilets situated through the premises. Balmoral unit has provision for 12 service users who have dementia, it has a communal lounge and separate dining room. All of the bedrooms are en-suite and located within the unit. The home provides activities for service users and has an open visiting policy Dingle Meadow Care Centre DS0000038425.V274877.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an announced inspection carried out between the hours of 09:30 and 16:30. The judgements made in this report are based on information from a pre inspection questionnaire, 32 comments cards from service users and relatives and assessing the progress made in meeting previous requirements from the last inspection. Residents files were looked at, as were staff files to ensure all necessary documentation was available. A tour of the premises was also undertaken. The manager and the deputy manager were present throughout the inspection. The inspector would like to thank all of the staff and residents at Dingle Meadow for their hospitality, this was a positive inspection What the service does well: What has improved since the last inspection? The home has taken positive steps to meet most of the requirements form the last inspection. The laundry walls have been tiled making them impermeable to reduce the risk of cross infection for residents. The unpleasant odours that was identified in three bedrooms at the last inspection has been addressed and the rooms are now odour free making them a more inviting place to be. The manager and deputy manager have made excellent progress in their documentation of risk assessments and care plans making it easier to identify residents individual needs. Dingle Meadow Care Centre DS0000038425.V274877.R01.S.doc Version 5.1 Page 6 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. Dingle Meadow Care Centre DS0000038425.V274877.R01.S.doc Version 5.1 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Dingle Meadow Care Centre DS0000038425.V274877.R01.S.doc Version 5.1 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 2 Each service has a copy of the terms and conditions indicating the conditions of their residency whilst in the home EVIDENCE: Some of the residents files seen had a copy of the terms and conditions located within them, each resident had signed them indicating their understanding of the contract they were entering into. At present some of the residents are reviewing their contracts as part of the transfer of ownership from Highfield care to Southern Cross Care Homes this is why the contract was absent from their files. Dingle Meadow Care Centre DS0000038425.V274877.R01.S.doc Version 5.1 Page 9 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,11 All of the residents have a care plan indicating what needs they have and how they are going to be met. Residents can be assured that their health needs will be fully met and that at the time of their death they will be treated with respect and dignity. EVIDENCE: Residents files were seen and there is evidence of risk assessments for falls, nutritional screening, pressure sore risk development and moving and handling. The risk assessments were generally completed and provided an accurate picture of the health of the resident. It was noted that where risk had been identified a care plan had been introduced to manage or reduce the risk. This was pleasing to see as it assures the resident there needs can be managed. The care plans are reviewed at least monthly and where possible residents have signed them to indicate their involvement. Some residents have indicated that they are not happy about doing this because they trust the staff to carry out their care and don’t want to be bothered with signing papers. “I Dingle Meadow Care Centre DS0000038425.V274877.R01.S.doc Version 5.1 Page 10 can’t see what the fuss is, I know they look after me, I don’t like signing paper” other residents commented that “the girls tell me what they are doing for me if I don’t agree I tell them” “I have no complaints about the care I get it’s what I need”. There was clear evidence that residents are referred to specialist services such as community psychiatry, dietetics and district nurses, all residents are visited by the chiropodist and optician. Every resident has their weight recorded regularly giving the staff a record that easily identifies whether or not residents are loosing weight and that action may need to be taken. A previous requirement regarding medication was that the staff were not recording when they were administering creams and lotions for residents, it was pleasing to see that this practice has now stopped and all medications administered are being recorded appropriately. It was also noted that the build up of stock medicines previously identified had also been addressed. Staff are taking steps to talk to residents and record their individual wishes at the time of their death, the home are aware that this is a sensitive area for many of their residents and have not rushed them into making decisions about their needs. At present there is a core care plan in place that attempts to identify what residents want at the time of their death but this needs to be more individualised for each resident. Dingle Meadow Care Centre DS0000038425.V274877.R01.S.doc Version 5.1 Page 11 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): These standards were not assessed at this inspection EVIDENCE: Dingle Meadow Care Centre DS0000038425.V274877.R01.S.doc Version 5.1 Page 12 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16,18 Residents can be assured that their complaints will be dealt with in a timely manner and acted upon. Residents are protected from abuse through robust policies and procedures. EVIDENCE: The home has not received any complaints within the last twelve months, it has a robust policy that identifies who will be dealing with the complaint and the timescale in which the complaint will be dealt with. Residents spoken to said “I never complain about anything it’s lovely here”, ”I’d tell Annette if I wasn’t happy she would sort it out for me”. Other residents were not quite sure about who to talk to “I don’t know who to tell”, “I wouldn’t tell anyone I’d keep it to myself”. There are policies and procedures in place that protect the residents from abuse and there is evidence that the staff are taking part in training to ensure they have the necessary skills to identify potential abuse and how to report it. All of the staff files seen contained appropriate safety checks including POVA/CRB disclosures thereby reducing the risks to residents. The home has a financial policy in place for the safekeeping of residents money this ensures that monies placed in the home are kept safe and residents can be assured that there individual monies are secure. Dingle Meadow Care Centre DS0000038425.V274877.R01.S.doc Version 5.1 Page 13 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19,26 Residents live in an environment that is clean, tidy and well maintained EVIDENCE: Since the last inspection there have been changes to the decoration within the home. Three bedrooms have been redecorated and residents were encouraged to choose their décor including carpets and wallpaper. The offensive odours identified in some rooms has been addressed and there was a great improvement. The laundry wall has been tiled making it impermeable so the risk of cross infection is reduced and laundry staff were seen to be wearing disposable gloves whilst handling the soiled laundry. The ceiling tiles have been replaced where they were damaged. On Balmoral unit there have been changes to the environment, the relaxation room has been developed and now provides a quiet haven for those residents wanting to sit and relax and listen to music. There are plans in motion to decorate the “nursery” where the dolls are kept and there are prams there for residents to use. Dingle Meadow Care Centre DS0000038425.V274877.R01.S.doc Version 5.1 Page 14 All of the resident’s rooms are decorated with their personal belongings and this makes the home feel very welcoming. One resident commented that “I wanted to bring my three piece in they tried really hard but in the end I only got a chair but at least they tried”, “I would’ve bought all the house in if I could get it through the door”. Dingle Meadow Care Centre DS0000038425.V274877.R01.S.doc Version 5.1 Page 15 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 28,29,30 There is a shortfall in the number of staff that have completed their NVQ 2, residents cannot therefore feel assured that staff have had the appropriate training to meet their needs. All staff are recruited in a safe manner that protects residents. EVIDENCE: At present there is a shortfall in the numbers of staff that have completed their NVQ level 2. Currently there are 22 care staff employed at the home with only 5 care staff having completed NVQ level2, a further 9 care staff are working towards the completion of either NVQ level 2 or 3. The manager needs to explore ways in which to improve this number and ensure that staff have the appropriate qualifications. Staff files were looked at to ensure that the relevant information is being kept, generally these were satisfactory with only minor shortfalls. The files seen were all missing a recent photograph of the employee. All of the other required information was present in each file. New employees are registered on an induction and foundation programme and are supervised by staff when carrying out their duties to ensure their competence. Records of this supervision were seen, care needs to be taken to ensure that staff sign these documents as proof of their participation within the process. Staff supervision is being carried out for members of staff but on an informal basis, at present only the manager has received training around Dingle Meadow Care Centre DS0000038425.V274877.R01.S.doc Version 5.1 Page 16 supervision consideration should be given to arranging training for the senior care staff who are currently involved in providing supervision for care staff. This will help clarify their role within the process and give them an understanding of the process of supervision. All staff have mandatory training and this is recorded on the training matrix, copies of certificates were seen in some staff files, the manager should ensure that all certificates of training are kept within the individual staff files as proof of training. Some of the staff are about to embark upon the yesterday, today and tomorrow training with the Alzheimer’s society to further enhance their knowledge and understanding of the condition. Dingle Meadow Care Centre DS0000038425.V274877.R01.S.doc Version 5.1 Page 17 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31,33,35,38 The home is run in the best interests of the residents by a manager who is competent and confident in her role. Residents financial interests are safeguarded and the health, safety and welfare of residents is promoted and protected. EVIDENCE: The registered manager is qualified, competent and experienced to run the home, she has completed the NVQ 4 and now wants to complete the registered managers award. The home needs to expand upon it’s current process of quality assurance, it needs to develop a annual development plan and ensure that there is a system of continuous self monitoring that involves the residents. the views of relatives and stakeholders in the community should also be sought. The results of residents surveys should be published and made available prospective Dingle Meadow Care Centre DS0000038425.V274877.R01.S.doc Version 5.1 Page 18 residents and their relatives. established. Action plans for improvements can then be The home has arrangements to keep small amounts of residents monies for safe keeping. The records were seen and all transactions were accounted for and receipts provided, this helps residents feel safe knowing that their money is in safe hands. In addition to money the home keeps some valuables for residents, it was noted during the inspection that there are a lot of items kept for safe keeping of residents no longer at the home the manager needs to explore ways of dealing with this problem so that current residents are able to store their items if required. The home is well maintained, records were seen indicating all appropriate checks, servicing and maintenance had been carried out. The training matrix indicates that all staff are receiving appropriate mandatory training on at least a yearly basis. All accidents are reported and logged appropriately and provide an audit trail for an action plan to be managed, for example recent episodes of falls indicated that residents were tripping over their handbags, measures have now been put in place to reduce this risk, with some residents choosing to have a net bag attached to their zimmer frame or leaving their handbag in their rooms with the door locked. Some of the residents spoken to about this said “I wasn’t happy at first but I can see why they asked us to do it”, “I think that it’s not as good as my handbag but then again I don’t want a broken leg do I” Dingle Meadow Care Centre DS0000038425.V274877.R01.S.doc Version 5.1 Page 19 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X 3 X X X X HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 X 10 X 11 2 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 X 14 X 15 X COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X X X 3 STAFFING Standard No Score 27 X 28 1 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 2 X 3 X X 3 Dingle Meadow Care Centre DS0000038425.V274877.R01.S.doc Version 5.1 Page 20 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 OP7 Regulation 13 Requirement To establish and introduce a written prevention of falls management policy and procedure which complies with national policy frameworks and good practice guidelines (previous timescale 16/04/05 not met) The registered manager must put in place a quality monitoring system and ensure that all the requirements of this standard are met. (previous timescale not met 16/05/05) 3 OP11 3 The registered manager must 01/04/06 take steps to record the individual wishes of each resident in relation to their needs around dying and their care upon their death The registered manager must 01/05/06 take steps to increase the number of staff enrolled to complete NVQ 2 qualifications in order to meet minimum DS0000038425.V274877.R01.S.doc Version 5.1 Page 21 Timescale for action 30/01/06 2 OP33 24 01/05/06 4 OP28 18 (a) Dingle Meadow Care Centre 5 OP29 19(1)(b) sch 2 requirements The registered manager must ensure that all employees have a recent photograph on their staff files 01/03/06 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 2 Refer to Standard OP7 OP30 Good Practice Recommendations The home should consider training in Dementia Care Mapping as part of their quality assurance system and improvements in dementia care The registered manager should give consideration to training for senior staff in the theory and delivery of supervision. Dingle Meadow Care Centre DS0000038425.V274877.R01.S.doc Version 5.1 Page 22 Commission for Social Care Inspection Halesowen Record Management Unit Mucklow Office Park, West Point, Ground Floor Mucklow Hill Halesowen West Midlands B62 8DA 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 Dingle Meadow Care Centre DS0000038425.V274877.R01.S.doc Version 5.1 Page 23 - 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. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!