CARE HOMES FOR OLDER PEOPLE
Hall Lane Resource Centre 157 Hall Lane Baguley Wythenshawe Manchester M23 1WD Lead Inspector
Val Bell Unannounced Inspection 27th April 2007 10:00 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.V338939.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 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.V338939.R01.S.doc Version 5.2 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.V338939.R01.S.doc Version 5.2 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. 16th February 2006 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. One bed is allocated for emergency placements. Hall Lane Resource Centre DS0000033105.V338939.R01.S.doc Version 5.2 Page 5 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 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.V338939.R01.S.doc Version 5.2 Page 6 SUMMARY
This is an overview of what the inspector found during the inspection. This report is based on information gathered by the Commission for Social Care Inspection (CSCI) since the last inspection on 29th January 2007. Site visits to the home form part of the overall inspection process and the lead inspector conducted a visit during daytime hours on Friday 27th April 2007. The opportunity was taken to look at the core standards of the National Minimum Standards (NMS) This inspection will also be used to decide how often the home needs to be visited to make sure that the required standards are being met. During the visit time was spent talking to one of the four people living in the home and discussions were held with one support worker, two senior staff and the registered home manager. Relevant documents, systems and procedures were assessed and a tour of the home was undertaken. What the service does well:
From conversations held with support staff and management it was evident that the needs of people using the service were being put first. Staff spoke enthusiastically about their work and how they support people to be valued members of their local community and maintain their chosen lifestyles. This is achieved by providing people with a variety of stimulating and interesting activities that promote peoples individuality. Of particular note was the focus on community presence and the opportunities people had to engage in community based projects. This was in addition to a varied programme of inhouse activities that aimed to improve peoples physical and mental health and reduce the prevalence of falls. People using this service can be confident that their health needs will be met as the home has good links with community services. People were receiving support to attend planned appointments during their stay in the home and prompt referrals were made where health concerns had been identified. One of the four people staying in the home said that the staff were respectful, kind, caring and discreet and that he always looked forward to his planned respite care. He added that he couldn’t ask for anything better. This person was also very impressed with the recent redecoration and replacement of furniture in the lounge. Staff agreed that the management approach provides leadership and support and that the ethos of the home is open, honest and transparent. Hall Lane Resource Centre DS0000033105.V338939.R01.S.doc Version 5.2 Page 7 What has improved since the last inspection? What they could do better:
Three good practice recommendations were made during the site visit. Cigarettes and batteries were being stored in the medication cabinet, which should only be used for storage of the medicines prescribed to people using the service. Staff recruitment records are held centrally for this home so the inspector was not able to assess if the required pre-employment checks had been undertaken for the people employed to work there. The manager stated that the required checks such as Criminal Record Bureau disclosures and two written references had been obtained prior to new staff being confirmed in post. However, it was recommended that some written evidence of this be held in the home so that
Hall Lane Resource Centre DS0000033105.V338939.R01.S.doc Version 5.2 Page 8 inspectors can assess if people of good character and with suitable employment histories are employed to work with people using the service. The homes certificate of public liability insurance was displayed but this had expired during March 2007. It was recommended that a current insurance certificate be displayed at all times. The manager said that the new certificate was expected in the near future. 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. Hall Lane Resource Centre DS0000033105.V338939.R01.S.doc Version 5.2 Page 9 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.V338939.R01.S.doc Version 5.2 Page 10 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. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 3 and 6 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People admitted to the home have a thorough assessment of needs and are provided with the relevant information for them to decide if the home will be the right place for them. EVIDENCE: Since the last inspection the homes Statement of Purpose and Service User Guide had been reviewed and updated as required. These documents had been distributed in draft form for consultation. The manager said that when these had been ratified it was intended that people using the service would be asked to sign to confirm that they had received copies. People admitted to the home had received an assessment of their needs and this assessment process continued during their stay in the home. This meant that peoples changing needs were being recorded and updated on a continual basis. This home did not offer an intermediate care service.
Hall Lane Resource Centre DS0000033105.V338939.R01.S.doc Version 5.2 Page 11 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. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People are treated with respect and their privacy and dignity are maintained. Their assessed needs are being consistently met in a way that suits their preferences. EVIDENCE: The four people receiving respite care at the time of this site visit had up to date care plans in place. It was pleasing to note that the recommendation for staff to receive training in care plan documentation had been taken on board. This had resulted in a marked improvement in the quality of information recorded in care plans. People’s needs and preferences about how their care was to be delivered were very detailed and meaningful outcomes of individuals’ experiences were being recorded. This was recognised as an area of good practice. Risks identified from peoples assessments of need had been assessed and risk management plans were in place. Hall Lane Resource Centre DS0000033105.V338939.R01.S.doc Version 5.2 Page 12 The home had forged close links with health services and peoples physical and mental health needs were given high priority as a means to maintaining their wellbeing. Staff provided support for people to attend scheduled appointments and health needs were constantly under review. The system for administration of medication was audited during the site visit. Shortfalls identified at the last inspection had been addressed and a weekly internal audit had been implemented to ensure that a safe system was in operation. Additionally, staff had received refresher training in medication administration as recommended. One minor shortfall was noted. Cigarettes and batteries were being stored in the medication cabinet. A good practice recommendation was made that items other than current medication should not be stored in the medication cabinet. One of the men admitted for respite care was asked if staff were respectful and if his privacy and dignity was maintained. He said, “The staff are wonderful. I couldn’t ask for better. They are all kind, caring and very discreet. They have a difficult job to do but are always cheerful and ready to have a laugh and a joke. I have no complaints at all.” Hall Lane Resource Centre DS0000033105.V338939.R01.S.doc Version 5.2 Page 13 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15. Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. People are treated as valued members of their local community and the home provides a varied programme of stimulating and interesting activities that maintain peoples’ wellbeing. EVIDENCE: The home received a commendation for the variety of stimulating and interesting activities it provided. Links had been forged with health day care services and this had extended the range of opportunities for people to engage in. Of particular note was the priority given to enabling people to have a high level of community presence through regular trips out and involvement in community group activities. This included intergenerational activities with local school children. A theatre project had recently been undertaken and people using the service had written and performed their own music and play. Similarly, the service had participated in the Lord Mayor’s games and photographic evidence on display depicted people receiving the winning award. Family and friends are encouraged to become involved in the activity programme and people using the service had formed a committee with its own
Hall Lane Resource Centre DS0000033105.V338939.R01.S.doc Version 5.2 Page 14 constitution. All people using the resource centre become members and their hard work had seen successes in raising grants for additional facilities such as a raised garden that aims to improve peoples mobility. Regular exercise classes are held with the focus on improving health, mobility and falls reduction. In-house activities include pool, arts and crafts, music and singing and dancing. One of the people spoken to said, “I went on a trip to Bury market the other day and really enjoyed it. There is always something interesting going on.” The main meal at lunchtime is provided by the resource centre’s kitchen. This offers people a choice of two main meals. Meetings with the caterers were held every four weeks and individuals’ preferences are recorded. Light meals are provided in the evenings. There was a good stock of food available to provide variety of diet for people and fresh fruit was always available. Good health and safety practice was observed in the home’s kitchen including the daily recording of fridge and freezer temperatures. Hall Lane Resource Centre DS0000033105.V338939.R01.S.doc Version 5.2 Page 15 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. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home listens and responds to concerns and systems are in place to protect the safety and wellbeing of people using the service. EVIDENCE: Significant progress had been made to the way in which the outcome from complaints investigations was being recorded. A complaints tracking form had been introduced and this clearly detailed the progress of action taken to resolve complaints. The home followed Manchester’s multi-disciplinary policy and procedures for safeguarding adults from abuse. Two staff spoken to had received training in abuse awareness and in conversation they were able to confidently explain the correct procedure to follow if abuse was suspected or alleged. There were no current complaints or safeguarding adult issues at this home. Hall Lane Resource Centre DS0000033105.V338939.R01.S.doc Version 5.2 Page 16 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. JUDGEMENT – we looked at outcomes for the following standard(s): 19 and 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. A rolling programme of redecoration and refurbishment provides a pleasant, comfortable and safe environment for people to live in. EVIDENCE: A tour of the homes communal and private space was undertaken and the environment was found to be clean and hygienic and no unpleasant odours were present. The re-decoration work required to the two bedrooms identified in the last inspection report had been undertaken. It was pleasing to learn from the manager that rooms were being inspected every six weeks to ensure that a high standard of décor and facilities was maintained. Furthermore, daily visual checks were carried out on the building and fire escapes etc were checked weekly. The lounge had been redecorated and refurbished to a very high
Hall Lane Resource Centre DS0000033105.V338939.R01.S.doc Version 5.2 Page 17 standard. One of the people staying in the home said, “Have you seen the lounge? I couldn’t believe it when I came in last week, it’s top book!” This person added, “We have everything we need here for our comfort and we can bring some of our own possessions with us to make it feel like home. I look forward to my visits here.” Staff had been instructed to keep all fire doors shut and the appropriate signage had been affixed to storeroom doors. The home was taking action to ensure that the anti-smoking legislation being introduced on 1st July 2007 would be complied with. Staff had received mandatory health and safety update training to ensure that safe working practices were being observed. Hall Lane Resource Centre DS0000033105.V338939.R01.S.doc Version 5.2 Page 18 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. JUDGEMENT – we looked at outcomes for the following standard(s): 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. Staff receive the necessary training and support to understand and meet the assessed needs of people using the service. EVIDENCE: One member of staff had been recruited since the last inspection and the manager confirmed that the required pre-employment checks had been undertaken. Recruitment records are staff working at the home, are held centrally by Manchester Local Authority. Consequently, the records were not examined during this site visit. It is recommended that the manager requests written evidence from the human resources department that Criminal Record Bureau disclosures and the two references obtained for staff recruited are satisfactory. The manager confirmed that staff have access to current copies of their job descriptions, which were held in the office. Six members of the senior staff team had achieved a National Vocational Training (NVQ) certificate at level 4 in care and a seventh person was about to begin this course of study. Twelve support workers had achieved NVQ level 2 in care and three were currently working towards this qualification. Two domestic staff had achieved NVQ level 1 in Cleaning and Support Services and Building Support.
Hall Lane Resource Centre DS0000033105.V338939.R01.S.doc Version 5.2 Page 19 Staff had received the training that had been required and recommended following the last inspection and the details of this are recorded elsewhere in this report. Two staff confirmed that they have access to training courses that update their skills and knowledge in meeting the needs of people using this service. Hall Lane Resource Centre DS0000033105.V338939.R01.S.doc Version 5.2 Page 20 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. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 34, 35 and 38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The management approach is open and inclusive and this ensures that people staying in the home are valued as individuals for their contribution to the future development of the service. EVIDENCE: Three members of staff were asked about the support that they receive from management. The three staff confirmed that the manager is approachable and communicates a clear sense of leadership and direction. The ethos of the home was found to be open and transparent and the professional manner in which the manager and staff had approached dealing with shortfalls identified at the last inspection was commended as an area of best practice.
Hall Lane Resource Centre DS0000033105.V338939.R01.S.doc Version 5.2 Page 21 The manager provided written evidence that staff had received two job consultations (supervision sessions) since the last inspection and a schedule was in place for future planned sessions at six to eight week intervals. Since the last inspection in January 2007 the manager had introduced a quality assurance monitoring system and records provided evidence that regular audits of systems and procedures were being undertaken. Satisfaction surveys were being issued to all people on discharge from the service. Feedback contained in completed surveys was positive. Appropriate systems were in place for the management of peoples’ personal finances while staying in the home. Bedrooms were fitted with lockable space for people to securely store money and valuables. The homes registration certificate was displayed along with a certificate of public liability insurance, which had expired in March 2007. The manager confirmed that the insurance was current, although the new certificate had not been received. A sample of health and safety records provided evidence that the maintenance and periodic checks of the homes equipment was up to date. The fire risk assessment had been reviewed and updated in April 2007. Fire safety checks, including fire drills, had been carried out at the required intervals since the last inspection. Hall Lane Resource Centre DS0000033105.V338939.R01.S.doc Version 5.2 Page 22 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 3 X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 4 14 4 15 3 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 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 4 X 3 3 3 X X 3 Hall Lane Resource Centre DS0000033105.V338939.R01.S.doc Version 5.2 Page 23 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. Standard Regulation Requirement Timescale for action 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 OP9 Good Practice Recommendations Unnecessary items should be removed from the medication cabinet to ensure that medication administration is administered safely in a clutter-free environment. The registered person should consider requesting confirmation that pre-employment checks for staff recruited are satisfactory. This will provide evidence that staff with suitable employment histories are employed to safely meet the needs of people using the service. The registered person should ensure that a current certificate of public liability insurance is on display at all times to demonstrate that the rights of people using the service are protected. 2. OP29 3. OP34 Hall Lane Resource Centre DS0000033105.V338939.R01.S.doc Version 5.2 Page 24 Commission for Social Care Inspection Manchester Local Office 11th Floor West Point 501 Chester Road Manchester M16 9HU 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
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