Inspection on 09/09/05 for Hall Lane Resource Centre

This inspection was carried out on 9th September 2005.

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 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 16/02/06

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 Ann Connolly Unannounced 09 September 2005 10.00 am 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 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 f55 f05 s33105 hall lane v248335 090905 stage 2.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Hall Lane Resource Centre Address 157 Hall Lance Baguley Wythenshawe Manchester M23 1WD 0161 945 7609 Telephone number Fax number Email 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 City Council Social Services Department James William Gabrielides CRH Care Home PC PC Care Home only 10 Category(ies) of OP Old age, not falling within any other category registration, with number of places DE (E) Dementia - over 65 years of age MD (E) Mental Disorder, exluding learning disability or dementia over 65 yrs of age DE Demetia Hall Lane Resource Centre f55 f05 s33105 hall lane v248335 090905 stage 2.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: 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. Date of last inspection 16 December 2004 Hall Lane Resource Centre f55 f05 s33105 hall lane v248335 090905 stage 2.doc Version 1.40 Page 5 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 story building, which was originally a purpose build 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, 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 unit.The Assessment/Respit unit takes up approximately half of the two storey building. Hall Lane Day Hospital for older people with mental health, are also located in the ARO Unit, but this does not directly affect the Unit 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 approximately 35 minutes away. Wythenshawes main shopping centre is 10 minutes dirve away. The cetre is surrouned by cardens and there are parking facilities for approximately 20 cars. Hall Lane Resource Centre f55 f05 s33105 hall lane v248335 090905 stage 2.doc Version 1.40 Page 6 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was unannounced and took place over 5 hours on the 9th September 2005. During the inspection, time was spent talking to all of the 10 residents who receive care and respite services in the home. The senior coordinator and members of staff were spoken to in order to find out their views of the service. Time was also spent examining medication, the care plan files, health and safety issues and meals. A tour of the building also took place. During this inspection only a selection of the National Minimum Standards were assessed. In order to gain a full picture of how the home meets the needs of the residents, this report should be read together with the previous and any future reports. What the service does well: The manager and staff team have worked hard to provide residents with a comfortable place to live, and have focused on encouraging residents to make their own choices about how they want to be supported and how they want their care needs to be met. Staff actively encourage residents to be involved in all aspects of their care. During the inspection, there was evidence of good communication between staff and residents. One resident said, ‘Its great here, the staff are so friendly and there are flexible living arrangements’. There was further evidence of residents being encouraged to maintain independence levels and to be involved in their own care planning. Another resident said, ‘ It’s wonderful here, the food is excellent, you can make yourself as many cups of coffee or horlicks as you like, and you can have as many baths as you like, I love it here.’ It was evident from comments made by residents that they felt confident in raising concerns with the staff . One resident said,’ It’s great here, the staff are so friendly. If I had a complaint I would make sure that I told someone here like a member of staff’. Since Hall Lane is used primarily for respite care, where people return to their own homes, the staff appear well briefed on the importance of providing support in a manner which does not reduce the independence levels of residents using the service. The service focuses on developing links with the community to assist residents in the transition from residential accommodation back into their own homes. Hall Lane Resource Centre f55 f05 s33105 hall lane v248335 090905 stage 2.doc Version 1.40 Page 7 Staff seemed very motivated and well supported by the open management style. There was considerable emphasis on ongoing staff development and training. There was a good range of activities available including, gentle exercise, Tai Chi, art and craft, with good links with voluntary community services. 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 f55 f05 s33105 hall lane v248335 090905 stage 2.doc Version 1.40 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 Standards Statutory Requirements Identified During the Inspection Hall Lane Resource Centre f55 f05 s33105 hall lane v248335 090905 stage 2.doc Version 1.40 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 standard(s) 3 and 6 Prospective residents needs were assessed prior to admission to ensure that the home could support these needs. EVIDENCE: The files examined contained an assessment carried out by the care manager and a pre-admission assessment carried out by staff from the home. The information contained in the assessments was used to develop the care plan, and there was evidence on files that ongoing assessments were being carried out to reflect any changes in care needs and to establish if additional input was required from other services within the multidisciplinary framework. Observations of interaction between the residents and staff in the home and day care unit provided evidence that the home was meeting the needs of residents. One resident said, ‘ Staff are very good, they help you to do things. They came to me with a note pad and asked me how I felt about all the falls I had been having, and how they could help me.’ Records indicated that residents had access to other health care professionals as required. Hall Lane does not offer intermediate care services. Hall Lane Resource Centre f55 f05 s33105 hall lane v248335 090905 stage 2.doc Version 1.40 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 standard(s) 7,8 and 9 Information with regards to residents identified care needs was available to show how health and social care needs were being met. Some shortfalls were identified in the systems for administering, recording and safe keeping of medication, which may potentially place residents at risk. EVIDENCE: Care plans were detailed and comprehensive and included the care manager assessment, a profile of the resident, with details about individual care needs, and the interventions required to meet those needs. There was evidence that care plans were regularly reviewed and updated to detail interventions necessary for residents to achieve their agreed goals. Senior staff said that plans were scheduled to review the care planning system in the home. Hall Lane has been issued with a complete new care plan package/template and the home was in the process of implementing the system, which was to be phased in over a period of time. This should be available at the next inspection. Hall Lane Resource Centre f55 f05 s33105 hall lane v248335 090905 stage 2.doc Version 1.40 Page 11 Systems were in place for the handling of medication in the home. Medication was administered appropriately, however, on a previous recording, the Medication Administration records (MAR) showed that medication had been administered but had not been signed for. The importance of signing for medication immediately after administration was reinforced. Medication Records did not contain a photograph of the resident. Photographs of each resident must be held on the MAR sheets in line with good practice. There was no evidence of a record of the receipt of medication received into the home. Accurate records of the receipt and disposal of all medication must be maintained. Some medication in the blister packs was in multiple quantities with no description of the individual tablets. Where the pharmacist has dispensed quantities of multiple medications in the blister pack, a detail description of each medication must be provided. Hall Lane Resource Centre f55 f05 s33105 hall lane v248335 090905 stage 2.doc Version 1.40 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 standard(s) 12 and 13 Residents were encouraged to maintain contact with family, friends and the local community. Care planning ensured that the expectations and preferences of residents reflected the social, cultural, religious and recreational needs of each individual resident. EVIDENCE: A client centred approach was used in the delivery of services to residents in the home. Care plans detailed residents individual preferences, social, cultural, religious and recreational needs. During the inspection staff were observed in positive interaction with residents, and it was seen that all activities were arranged following individual consultation, discussion and agreement. Regular activities were available in the day centre and there were sufficient staff on duty to co-ordinate one to one and group activities. Activities included Tai Chi, armchair activities, dancing and music, afternoon film sessions and art classes provided by the local community group- The Tree Of Life. Residents spoke well of the flexible living and lifestyle they enjoyed whilst staying in the home. The home had an open visiting policy and residents confirmed that they were able to receive visitors at any time. Hall Lane Resource Centre f55 f05 s33105 hall lane v248335 090905 stage 2.doc Version 1.40 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 standard(s) 16 The home had policies, procedures and systems in place to enable and encourage residents to express their views and concerns. EVIDENCE: The home had a complaints policy in place, which was made available to all residents in the home. Since the last inspection the home had received one complaint, which had been appropriately investigated and recorded. All residents who were spoken to expressed confidence in approaching the manager or the staff with any issue of concern. One resident said, ’It’s great here, the staff are so friendly. If I had a complaint I would make sure that I told someone here, like a staff member’. Hall Lane Resource Centre f55 f05 s33105 hall lane v248335 090905 stage 2.doc Version 1.40 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 standard(s) 19 and 26 Some shortfalls were identified in the safety standards within the home. Housekeeping was not consistently maintained to a satisfactory standard in all areas of the buildings. The home did not fully provide residents with a clean and hygienic, wellmaintained and safe environment at all times. EVIDENCE: On a tour of the home some shortfalls were identified in the fabric of the building. Some areas of the home required decorating, particularly in the lounge area. All exterior paintwork required attention. Some window frames appeared to be rotten. The lounge window was rotten and in a poor state of repair, this must be replaced. A full audit of the exterior of the building is required and work to be scheduled as necessary. One bedroom did not contain the required amount of furniture as detailed in the standards. Basic items of furnishings were missing, for example, a bedside Hall Lane Resource Centre f55 f05 s33105 hall lane v248335 090905 stage 2.doc Version 1.40 Page 15 light. The senior staff said that the manager was in the process of completing an audit of the home’s interior, including all bedrooms. The fire escape was dirty and included items of furniture, which were inappropriately stored, causing a potential hazard in the event of a fire. One of the windows was damaged and broken glass was found on the stairs. The outside of the fire escape was overgrown with weeds which must be removed in order to make the area safe and accessible to residents in the event of a fire or an emergency. Arrangements were made to tidy this area at the time of inspection. Although most areas of the home were reasonably clean and tidy, odours were detected in some bedrooms, which were identified at the time of inspection. These areas must be cleaned to a satisfactory standard. Some of the window restrictors were missing from the windows. In the case of the lounge window, this was as a result of rotten wood. An assessment of all windows must be made to determine safety, and where required, window restrictors must be fitted. The hot water temperature in some of the bedrooms exceeded the recommended safe level of forty-three degrees centigrade. The senior staff on duty reported this to building control at the time of inspection and arrangements were made to undertake the necessary work to maintain safe temperature levels. There was no evidence available of any records to monitor and check water temperatures. The home must maintain a record of temperature checks throughout the home and ensure they are available for inspection. Hall Lane Resource Centre f55 f05 s33105 hall lane v248335 090905 stage 2.doc Version 1.40 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27 and 30 . The resident’s needs were being met by a staff team with sufficient numbers who have the required skills, experience and training. EVIDENCE: Rotas and observations at the time of inspection provided evidence that staffing levels were sufficient to meet the assessed needs of residents in the home. There was evidence of ongoing training and development, which was available for all staff. On this inspection, six staff had completed NVQ Level 2, a further two staff were near to completion of their Level 2. One member of staff said that there were lots of opportunities for staff to access and participate in training. It was evident from talking to a number of the staff that here was an emphasis placed on training and development of staff skills. Staff confirmed that they had received service specific training in a number of topics, including dementia care, health and safety and mental health. Staff were aware of the importance of maintaining links with the community enabling those residents on respite care to maintain strong links with families, neighbours or community services. One staff said, ‘ I feel the centre has moved in a positive direction to meet needs of residents when they are in the home or move back to the community’. Other staff made reference to Hall Lane Resource Centre f55 f05 s33105 hall lane v248335 090905 stage 2.doc Version 1.40 Page 17 maintaining links with other health care professionals and liaising appropriately in order to meet the needs of service users who will return to living in their own homes. Residents spoken to expressed satisfaction and confidence in the way that staff provided care to them. Hall Lane Resource Centre f55 f05 s33105 hall lane v248335 090905 stage 2.doc Version 1.40 Page 18 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31,32, 33, Residents in the home benefit from having a manager with skills and management approach to provide a good quality service and has the procedures and systems in place to promote their interests. EVIDENCE: The manager confirmed that all Health and Safety policies had been reviewed and updated. Risk assessments were in place and found to be appropriate. The manager was off duty on the day of the inspection. Senior staff were in post to provide managerial support in the manager’s absence. From discussions with staff there was evidence of an open and transparent management style. Staff said that the manager was very supportive and always available to discuss any issues of concern. One member of staff said that there was a good relationship between the staff and manager and went on to say, ‘ We are a team and can talk and communicate to each other, and help each other out’. Staff on duty confirmed that they were in receipt of regular Hall Lane Resource Centre f55 f05 s33105 hall lane v248335 090905 stage 2.doc Version 1.40 Page 19 supervision and attended staff meetings. There was evidence of the manager taking an active role in developing the learning and training programme for staff in the home. Hall Lane Resource Centre f55 f05 s33105 hall lane v248335 090905 stage 2.doc Version 1.40 Page 20 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score x x 3 x x x HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 10 x 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 x 15 x COMPLAINTS AND PROTECTION 2 x x x x x x 2 STAFFING Standard No Score 27 3 28 x 29 x 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x x 3 3 3 x x x x x Hall Lane Resource Centre f55 f05 s33105 hall lane v248335 090905 stage 2.doc Version 1.40 Page 21 no Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. 2. Standard 9 9 Regulation 13 13 Requirement Medication must be signed for immediantly following administration 1.Records must be kept of the receipt and disposal of medciation. 2.Records must include a photograph of the individual resident. 3.The description of individual medication must be recorded where blister packs contain multiple medication. An audit of the interior and exterior of the building must be completed and arrangements made to carry out any necessary repairs and cleaning work as detailed in the main body of the report. The fire escape must remain free from obstruction at all times Records of water temperatures must be maintained and be available for inspection. Timescale for action 12/11/05 12/11/05 3. 19 23 21/11/05 4. 5. 19 25 13 13 9/10/05 9/10/05 Hall Lane Resource Centre f55 f05 s33105 hall lane v248335 090905 stage 2.doc Version 1.40 Page 22 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 Good Practice Recommendations Hall Lane Resource Centre f55 f05 s33105 hall lane v248335 090905 stage 2.doc Version 1.40 Page 23 Commission for Social Care Inspection 9th Floor Oakland House Talbot Road Manchester M16 OPQ 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. 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