Inspection on 16/02/06 for Hall Lane Resource Centre

This inspection was carried out on 16th February 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. 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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Hall Lane Resource Centre 27/04/07

Hall Lane Resource Centre 29/01/07

Hall Lane Resource Centre 09/09/05

Hall Lane Resource Centre 16/12/04

Hall Lane Resource Centre 18/06/04

Hall Lane Resource Centre 29/03/04

Hall Lane Resource Centre 20/01/04

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

CARE HOMES FOR OLDER PEOPLE Hall Lane Resource Centre 157 Hall Lane Baguley Wythenshawe Manchester M23 1WD Lead Inspector Helen Dempster Unannounced Inspection 10:00 2 March 2006 nd 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 Hall Lane Resource Centre DS0000033105.V279197.R02.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. Hall Lane Resource Centre DS0000033105.V279197.R02.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Hall Lane Resource Centre Address 157 Hall Lane Baguley Wythenshawe Manchester M23 1WD 0161 945 7609 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) Manchester Children, Families and Social Care James William Gabrielides Care Home 10 Category(ies) of Dementia (0), Dementia - over 65 years of age registration, with number (0), Mental Disorder, excluding learning of places disability or dementia - over 65 years of age (0), Old age, not falling within any other category (0) Hall Lane Resource Centre DS0000033105.V279197.R02.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. The home provides respite care only for a maximum of 10 service users at any one time within the following categories: old age (OP), older people who require care by reason of dementia (DE(E)), older people who require care by reason of their mental ill health (MD(E)) or adults, aged 60 years and over, who require care by reason of early onset dementia (DE). The Statement of Purpose must be maintained in line with the requirements of Schedule 1 of Regulation 4(1) of the Care Homes Regulations. The Statement must be kept under review and updated. Any changes to the home’s purpose must be agreed with the National Care Standards Commission prior to implementation. The staffing arrangements at the home must be maintained in line with the minimum levels set out in the guidance published by the Residential Forum, `Care Staffing in Care Homes for Older People`. This must be reflected in the Statement of Purpose. The home must be managed at all times in accordance with the guidance and regulations issued in respect of homes for older people by the Secretary of State for Health under Sections 22 and 23(1) of the Care Standards Act 2000. The organisation must, at all times, employ a suitably qualified and experienced manager who is registered with the Commission for Social Care Inspection. The matters detailed in the schedule of requirements attached to the Notice of Registration must be completed within the stated timescales. 9th September 2005 2. 3. 4. 5. 6. Date of last inspection Brief Description of the Service: Hall Lane Assessment/Respite/Outreach (ARO) Unit provides care for a maximum of ten residents at any one time. The unit accommodates older people who suffer from mental ill health. The average stay for each resident is two weeks. Residents in receipt of rotational care are accommodated for approximately 40 nights within a 12 month period. However, this arrangement is flexible to meet the changing needs of those who use the service. The unit is located on the first floor of a large two storey building, which was originally a purpose built residential home for older people. A covered walkway known as the link has been built to connect this building to a large single storey centre for older people, which provides day care facilities for adults with mental health problems, and staff teams who provide a variety of outreach domiciliary services within the community. Residents at Hall Lane have access Hall Lane Resource Centre DS0000033105.V279197.R02.S.doc Version 5.1 Page 5 to the day centre. The Assessment/Respite unit takes up approximately half of the two storey building. Hall Lane Day Hospital for older people with mental health is also located in the ARO Unit, but this does not directly affect the unit’s services. The centre is located in Baguley, directly opposite a new development of shops and apartments next door to Baguley Hall. The area has a good range of all the usual services, including shops, public houses, health services etc. A large hypermarket is located approximately 35 minutes away. Wythenshawes main shopping centre is 10 minutes drive away. The centre is surrounded by gardens and there are parking facilities for approximately 20 cars. Hall Lane Resource Centre DS0000033105.V279197.R02.S.doc Version 5.1 Page 6 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was the second unannounced inspection for the year. It was carried out on 2nd March 2006 from 12pm to 4.30pm. Time was spent talking with a senior manager (Team Manager), the duty coordinator, staff and residents. This included discussing welfare matters relating to the residents the home supported and examining documentation in relation to the running of the home, the management arrangements, staffing, care planning and the residents’ satisfaction. The term of address preferred by the users of the service was confirmed as “residents”. It was felt that this best reflected the function and purpose of the service. The inspection only looked at a limited number of standards, so this report should be read together with the earlier report to get a full picture of how the home is meeting the needs of the residents. What the service does well: The residents’ care and health needs were well documented by the home. Day to day records were clear and detailed and reflected the staffs’ work in assessing the needs of individual residents, including observing them making a drink and sandwich independently. This is commendable. Residents said that staff treated them with respect and respected their right to privacy. They were able to give examples of how the staff did this, including knocking on doors and the way they were helped to bathe. Residents benefited from being provided with a nutritious diet and being encouraged to make choices about food and daily living routines, including what clothes to wear and who they want to talk to. Good staff awareness of the home’s adult protection policies and procedures and staff training protected residents from abuse. Residents benefited from the commitment of the manager and staff to improve the environment and make it attractive and safe. Residents said that the staff were “smashing” and that they worked hard to look after them. Infection control measures, including the use of alcohol gel, were in place to protect residents. Hall Lane Resource Centre DS0000033105.V279197.R02.S.doc Version 5.1 Page 7 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. Hall Lane Resource Centre DS0000033105.V279197.R02.S.doc Version 5.1 Page 8 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 Hall Lane Resource Centre DS0000033105.V279197.R02.S.doc Version 5.1 Page 9 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): N/A EVIDENCE: These standards were assessed at the previous inspection and will be assessed again at future inspections. Hall Lane Resource Centre DS0000033105.V279197.R02.S.doc Version 5.1 Page 10 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, 9 and 10. The residents’ care and health needs were well documented by the home and residents were treated with respect. However, some aspects of the monitoring of residents’ nutritional needs/weight compromised this good practice. EVIDENCE: Since the previous inspection, the home had implemented a complete new care plan package/template. Four of these care plans were sampled. Overall, the new care plan format was enabling staff to record information about residents’ needs, by providing triggers/headings for staff on the specific areas of needs that they needed to make records about. Care plans were completed during the stay of the resident, so the care plans of people who had been at the unit for longer than others were more detailed. In two of the four care plans sampled; it was evident that there were issues about the nutritional requirements of the residents. In particular, one resident’s record noted, “recent weight loss, but still eats well”. This person was said to have “no preferences” about food. Another resident was noted to be “underweight” and the care plan later notes a need to “monitor weight”. Hall Lane Resource Centre DS0000033105.V279197.R02.S.doc Version 5.1 Page 11 However, there was no baseline weight taken on admission to draw comparisons with and a nutritional assessment had not been completed, despite the identified need. Through discussion with the senior manager and duty coordinator, it was evident that staff had an awareness of the importance of nutritional assessments and were also aware of recent research evidence about this subject. A requirement was made concerning the need to complete nutritional assessments and wherever possible, and with residents’ permission, to take baseline weights of residents on admission. Overall, risk assessments were in place, but these were in need of consistent audit/monitoring to ensure that they assess all risks applicable to an individual resident and are subject to consistent review to take account of any changes. Some good practice was noted. In particular, day to day records viewed were clear and detailed and reflected the staffs’ work in assessing the needs of individual residents, including observing certain tasks, e.g. making a drink and sandwich independently. This is commendable. At the previous inspection, requirements were made concerning medication practice. This included ensuring that records contained a photograph of the resident, providing evidence of a record of the receipt of medication received into the home, providing accurate records of the receipt and disposal of all medication and providing a detailed description of each medication in the monitored dosage packs. All these issues had been addressed appropriately by the manager and staff. When viewing care plans it was noted that information about the medication administration issues concerning individuals was noted. This good practice needed to be extended to include information about the administration of “when required” medication, including Paracetamol, which needed to confirm why medication is prescribed and in what circumstances and for what conditions, PRN medication is given. The home also needed to obtain a controlled drugs book. A requirement was made accordingly. Residents said that staff treated them with respect and respected their right to privacy. They were able to give examples of how the staff did this, including knocking on doors and the way they were helped to bathe. Hall Lane Resource Centre DS0000033105.V279197.R02.S.doc Version 5.1 Page 12 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): 14 and 15. Residents benefited from being provided with a nutritious diet and being encouraged to make choices about food and daily living routines. EVIDENCE: At the time of inspection, the residents were enjoying the lunchtime meal of fish, chips and peas or steak and kidney puddings with chips and peas followed by jam roly-poly and custard. Alternative desserts included fruit salad, yogurts or bananas and custard. Residents said that the food is “very good” and that they enjoyed their meals. Residents have their lunchtime meal and some tea time meals in the day centre. Residents who expressed a view said that this was fine and that they get to meet other people because of this. Residents said that staff ask them about their choice of menu and records were in place to record these choices. The home has a four-week rotating menu and special diets, including diabetic diets are catered for. Residents said that they can choose what clothes to wear and who they want to talk to. Care plans contained details of individual resident’s preferences and routines. Hall Lane Resource Centre DS0000033105.V279197.R02.S.doc Version 5.1 Page 13 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): 18. Good staff awareness of the home’s robust adult protection policies and procedures protected residents from abuse. EVIDENCE: Manchester Social Service’s Protection of Adults from Abuse Policy was readily available at the home and staff demonstrated good awareness of this issue. This included staff making 2 referrals appropriately since the previous inspection. Staff had received briefing in “No Secrets” and adult protection is covered in the staff induction process. Hall Lane Resource Centre DS0000033105.V279197.R02.S.doc Version 5.1 Page 14 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 and 25. Residents benefited from the commitment of the manager and staff to improve the environment and make it attractive and safe. EVIDENCE: The staff at the unit were committed to making the environment an attractive place for residents. One member of staff personally paints attractive pieces of art work for the home and staff demonstrated pride in the environment and commitment to improving it. This is commendable. At the previous inspection, requirements were made to the effect that an audit of the interior and exterior of the building must be completed and arrangements made to carry out any necessary work, the fire escape must remain free from obstruction at all times and records of water temperatures must be maintained and be available for inspection. The senior member of staff said that the manager had completed the audit and that some work, including redecoration of bedrooms and fitting some new carpets, had been done. The home was recording water temperatures in response to a requirement made. Hall Lane Resource Centre DS0000033105.V279197.R02.S.doc Version 5.1 Page 15 These temperatures did, at times, exceed safe maximum temperatures. Following the inspection, the manager confirmed, in writing, that the plumbers were on site fitting water temperature regulators on these taps. At the time of inspection, the fire escape was free of obstructions. A requirement was made to the effect that the work identified in the previous report and the manager’s audit is completed. It was acknowledged that the manager and staff had worked hard to address the above issues and were committed to ensuring that any outstanding work identified in the audit was completed. Hall Lane Resource Centre DS0000033105.V279197.R02.S.doc Version 5.1 Page 16 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): 29 The home has an appropriate recruitment policy. However, the lack of recruitment information held at the home concerning checks on new staff has the potential to undermine this good practice. EVIDENCE: Residents said that the staff were “smashing” and that they worked hard to look after them. The unit has a recruitment policy and staff files, which included evidence, which demonstrated that induction and training were in place. It was not possible to fully assess this standard as application forms, references and CRB checks are held at the organisation’s personnel department. A discussion took place with the team manager about the need to photocopy this information for new recruits before forwarding it to the personnel section and holding this information securely at the home. A requirement was made accordingly. Hall Lane Resource Centre DS0000033105.V279197.R02.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): 35 and 38. Residents benefited from appropriate arrangements for safeguarding money and the manager and staff working hard to maintain their health and safety. EVIDENCE: The records of money held for safekeeping on behalf of residents were viewed. The duty coordinator said that the unit does not handle money for residents’ fees, as this is invoiced by the organisation. When residents are admitted the home can place valuables in the safe and a record is made of this. Receipts were also held for transactions made on behalf of residents. Health and safety information, including fire safety checks were viewed. The outcome of some safety checks, which could not be readily located at the time of inspection, were forwarded to the CSCI following the inspection and it was evident that safety tests were being undertaken as required. Hall Lane Resource Centre DS0000033105.V279197.R02.S.doc Version 5.1 Page 18 Infection control measures, including the use of alcohol gel, were in place. Through discussion, it was agreed that the infection control policy was in need of amendment to reflect changes in practice. A recommendation was made accordingly. Hall Lane Resource Centre DS0000033105.V279197.R02.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 X X X X X HEALTH AND PERSONAL CARE Standard No Score 7 2 8 X 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 X 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 X 17 X 18 3 2 X X X X X X 3 STAFFING Standard No Score 27 X 28 X 29 2 30 X MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X X X X 3 X X 3 Hall Lane Resource Centre DS0000033105.V279197.R02.S.doc Version 5.1 Page 20 Are there any outstanding requirements from the last inspection? No. 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 and 15 Requirement Residents’ nutritional assessments must be detailed and clear and wherever possible, baseline weights of residents should be taken on admission. The home must also have recorded strategies where any concerns/risk about a resident’s weight exist. Risk assessments must be in place to assess all risks applicable to an individual resident, including the risk of falls. These must be subject to consistent review to take account of any changes. The care plan for the administration of “when required” medication, including Paracetamol, must confirm why medication is prescribed and in what circumstances and for what conditions, PRN medication is given. The home must also obtain a controlled drugs book. Timescale for action 15/04/06 2. OP9 13 15/04/06 Hall Lane Resource Centre DS0000033105.V279197.R02.S.doc Version 5.1 Page 21 3. OP19 23 4. OP29 18 Necessary work and repairs identified in the audit of the interior and exterior of the building must be completed. This includes ensuring that water temperatures are consistently monitored for safety. Evidence of the required preemployment checks relating to the recruitment of staff must be retained in the home and made available for inspection by officers of the Commission. 15/04/06 15/04/06 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 OP38 Good Practice Recommendations It is strongly recommended that the infection control policy be amended to reflect changes in practice. Hall Lane Resource Centre DS0000033105.V279197.R02.S.doc Version 5.1 Page 22 Commission for Social Care Inspection CSCI, Local office 9th Floor Oakland House Talbot Road Manchester M16 0PQ 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 Hall Lane Resource Centre DS0000033105.V279197.R02.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. 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