Inspection on 18/03/06 for Kersal Dale

This inspection was carried out on 18th March 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 found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Kersal Dale 28/11/07

Kersal Dale 05/07/07

Kersal Dale 31/10/06

Kersal Dale 03/11/05

Kersal Dale 08/02/05

Kersal Dale 19/05/04

Similar services:

Chirnside House

Keer Sands Residential Home

Ruskin Lodge

Bushell House

Langrigg House

Parkside

Dystlegh Grange

Thornton Lodge

Extracts from inspection reports are licensed from CQC, this page was updated on 09/07/2008.

CARE HOMES FOR OLDER PEOPLE Kersal Dale 48 Vine Street Salford Gtr Manchester M7 0PG Lead Inspector Lynne Lynch Unannounced Inspection 18th March 2006 8:00 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 Kersal Dale DS0000008347.V281613.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. Kersal Dale DS0000008347.V281613.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Kersal Dale Address 48 Vine Street Salford Gtr Manchester M7 0PG 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) 0161 792 3166 Mrs N Akram Mr U Akram Miss Chrisden Williams Care Home 35 Category(ies) of Old age, not falling within any other category registration, with number (35) of places Kersal Dale DS0000008347.V281613.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. The home provides accommodation to a maximum of 35 service users who require care by reason of old age, not falling within any other category. The home must at all times employ a suitably qualified and experienced manager who is registered with the Commission for Social Care Inspection. 11th November 2005 Date of last inspection Brief Description of the Service: Kersal Dale is a residential care home for 35 older people. The building is set in its own grounds with landscaped gardens to the front and rear of the property. There is a drive in drive out route to the home and parking area to the side. The home is situated in a residential area of Salford. Internally there is a large lounge and dining area running down the centre of the building leading to a large glazed patio style lounge. Accommodation comprises of twenty-five single rooms, and five double rooms, on the ground and first floor. The home has good disabled access at the front of the property and both floors are accessible via a passenger lift, which also goes to basement level. Kersal Dale DS0000008347.V281613.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This announced inspection took place over two days on the 18th and 27th March 2006 over 7 hours. At the time of the inspection there were 24 residents living at the home. The inspector spoke with six service users, two staff, the provider and the registered manager of the home. Documentation in respect of resident’s care planning, medication, protection, staff records and Health and Safety were viewed. Key standards not assessed at this inspection will have been addressed at the previous inspection on the 11th November 2005. 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: What has improved since the last inspection? There home has continued it’s clear commitment to the training and development of all staff with currently 54 of the care staff employed at the home having either a nursing or NVQ qualification. The home continues to develop care plans and daily records under the supervision of the new manager. Kersal Dale DS0000008347.V281613.R01.S.doc Version 5.1 Page 6 The manager has further developed the induction training for new staff members. There is planned training in place for staff in respect of Adult Protection. The manager has developed a policy and procedure in respect of the receipt, recording, storage, handling and administration of medication. What they could do better: The homes statement of purpose and service user guide, require amending to ensure they reflect the current situation in the home. All care plans must record the date the plan was drawn up and the proposed review date. Internal assessments and reviews of care plans must be conducted on a monthly basis. Staff must be more attentive to ensure that residents are assisted with their dietary needs, especially during times of illness when fluid only is being given this should be recorded and monitored. A criminal records bureau check must be requested for new staff employed to work at the home before they start work. The manager must evidence that structured and formal supervision is provided to all staff, to a minimum of 6 sessions per year. The manager should also retain formal evidence of supervision provided to her by the registered owners. The manager must further develop quality assurance and quality monitoring systems, based on seeking the views of service users and stakeholders to measure success in meeting the aims and objectives of the home. An immediate requirement was served during this inspection in respect of the homes infection control procedures and the manager was reminded that she must ensure suitable arrangements are in place to prevent the spread of infection and must also notice to the Commission for Social Care Inspection without delay of all occurrences of death, illnesses or other events, which adversely affect the well being, or safety of any resident. Please contact the provider for advice of actions taken in response to this Kersal Dale DS0000008347.V281613.R01.S.doc Version 5.1 Page 7 inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Kersal Dale DS0000008347.V281613.R01.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 Kersal Dale DS0000008347.V281613.R01.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): 1&6 The Statement of Purpose and Service User Guide require reviewing and updating to provide prospective service users with clear current information. EVIDENCE: The Statement of Purpose and Service User Guide were evidenced at the time of inspection and were noted to require reviewing and updating to reflect the homes current position. People are not admitted to Kersal Dale solely for intermediate care. Kersal Dale DS0000008347.V281613.R01.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): 10 Residents right to privacy is upheld by staff. EVIDENCE: Discussion with residents and staff, confirmed that the maintenance of resident’s privacy and dignity is given high priority at Kersal Dale and upheld at all times. All staff receive training in respect of these topics during the process of induction and through a variety of other training opportunities. Residents spoken with said, “ staff are very good, they knock on my door, they appreciate when I want privacy” “I saw my social worker in private the other day”, “I have privacy in my own room, I have sky TV”. Information contained within two residential placement reviews provided evidence that family contact is maintained and confirmed that privacy is maintained in the home. Although only one of the above standards was fully inspected, the following observations were made in respect of the other standards. Care plans continue to be developed to comply with the requirements made at the last inspection. Each resident has a plan of care however these still require further development to ensure good guidance is given to staff. Each plan requires a review date to ensure monitoring of care needs takes place on a Kersal Dale DS0000008347.V281613.R01.S.doc Version 5.1 Page 11 monthly basis. Daily records are being maintained by staff on all shifts, however these are very basic and uninformative and need to be expanded for example one lady’s plan stated on 16 separate daily entries that she was fine with no indication of her daily living activities. One ladies daily entries contained information regarding her epilepsy and seizures that she had. The manager was informed that such information should be recorded separately to ensure that her condition could be monitored effectively. During the inspection it was noted through reading daily entries made by staff that several of the residents had sickness and diarrhoea. Staff had placed these people on fluid only and made arrangements for these residents to be isolated from the other residents. There was no evidence of each individual’s fluid intake being recorded. The staff were advised that this must be monitored and recorded. It was noted that not all of the residents GP’s had been contacted nor had the local authority for Environmental Health or The Commission for Social Care Inspection as is required in these instances. An immediate requirement was issued to ensure this was rectified and that a complete infection control process was implemented. The home has now developed a medication policy and procedure, however this needs to contain information regarding resident’s self-administration. On examination of the medication records it was found that records for the receipt and return of medication by the home were not completed appropriately, in that, the monitored dosage cassettes for the following week were in stock at the home but there was no record of their receipt, nor was their a record of medications being returned. This shows that the record of receipt/return of medication is not being completed on the actual day that medication is received into the home or returned back to the pharmacy. Kersal Dale DS0000008347.V281613.R01.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): 13 Contact with family and friends is actively encouraged relevant members of the local community are welcomed in the home. EVIDENCE: A number of residents were spoken to and all commented that everything possible is done in order that they can retain relationships with family and friends. Relatives were observed throughout the day coming and going freely and were obviously welcome to visit at any time. The staff were observed to be supportive of these visits, one resident was brought downstairs from his room to meet a relative who couldn’t manage to go up to his room and a quiet area was provided for them to meet. The inspector witnessed good relationships between staff and relatives. Two of the residents were enabled to visit their relatives by taxi, which is arranged by the home. There was evidence in the home of local clergy coming into the home to conduct services for the residents and two residents are encouraged to maintain links with the local Jewish community and receive visits from the local Rabbi. Kersal Dale DS0000008347.V281613.R01.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): None of the above standards were inspected at this visit. EVIDENCE: Although none of the above standards were inspected, the following observations were made. Training has been planned for all staff in respect of Adult Protection. Kersal Dale DS0000008347.V281613.R01.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): None of the above standards were inspected at this visit. EVIDENCE: Kersal Dale DS0000008347.V281613.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): 29 & 30 Suitable measures for the protection of residents are not in place. Staff training, although improving, still requires some work to meet agreed national standards and targets. EVIDENCE: All the staff files were viewed in respect of recruitment practice. Two suitable references were viewed on each file, however not every file contained a Criminal Records Disclosure; neither did these files contain a Pova First clearance. The registered manager was requested to contact the umbrella body at once to obtain Pova First clearances for these staffed and informed that all staff without a full Criminal Record Bureau (CRB) check must be supervised at all times. The manager was also advised that the Commission for Social Care Inspection should be advised of any staff that she wished to commence employment for, prior to the receipt of a CRB. The inspector advised that the full record supplied by the Criminal Record Bureau should be available for inspection by a representative of the Commission for Social Care Inspection. Progress has been made with NVQ training. Seven staff have gained the level 2 awards, which means that 54 of the staff team are now qualified the remaining members of the staff team are currently undergoing the level 2 Kersal Dale DS0000008347.V281613.R01.S.doc Version 5.1 Page 16 training. The manager should continue to monitor the progress of NVQ training. The manager is working hard to provide a thorough induction for new staff. Each staff file has an induction checklist, which records when important information about working at the home has been discussed with a senior member of staff. The manager needs to ensure that the induction package meets national training organisation induction standards. Staff undertake a programme of training, which includes moving and handling, first aid, the protection of vulnerable adults, food hygiene, health and safety and working and operating safely, medication and dementia. Evidence of completion of these courses was seen on staff files. A clear training matrix needs to be developed to show what courses have been completed by each staff member. Kersal Dale DS0000008347.V281613.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): None of the above standards were fully inspected. Appropriate contact is not maintained with appropriate authorities. Resident’s health and safety is compromised due to infection control procedures not being followed. EVIDENCE: Although none of the above standards were fully inspected, the following observations were made. The provider of the home still needs to provide the manager with a comprehensive job description. The homes policies and procedures require reviewing and updating, these documents should be dated and signed by staff to show that they have read and understood them. Kersal Dale DS0000008347.V281613.R01.S.doc Version 5.1 Page 18 During the inspection it was noted through reading daily entries made by staff that several of the residents had sickness and diarrhoea. Staff had placed these people on fluid only and made arrangements for these residents to be isolated from the other residents. It was noted that not all of the residents GP’s had been contacted nor had the local authority for Environmental Health or The Commission for Social Care Inspection as is required in these instances. An immediate requirement was issued to ensure this was rectified and that a complete infection control process was implemented. During the inspection staff were observed entering the dining area during breakfast still wearing their protective aprons that are worn whilst carrying out personal care tasks. The inspector advised that this posed a risk of the spread of infection throughout the home and was not good practice. The inspector met the registered manager on the second day of the inspection and advised that she must give notice to the Commission for Social Care Inspection without delay of all occurrences of death, illnesses or other events, which adversely affect the well being, or safety of any resident. Kersal Dale DS0000008347.V281613.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 2 X X X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 3 14 X 15 X COMPLAINTS AND PROTECTION Standard No Score 16 X 17 X 18 2 X X X X X X X X STAFFING Standard No Score 27 X 28 1 29 1 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X 2 X X X X X 1 Kersal Dale DS0000008347.V281613.R01.S.doc Version 5.1 Page 20 Are there any outstanding requirements from the last inspection? Yes Kersal Dale DS0000008347.V281613.R01.S.doc Version 5.1 Page 21 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 OP1 Regulation 6 Requirement The homes statement of purpose and service user guide, require amending to ensure they reflect the current situation in the home. (Previous timescale 16/02/06 not met). All care plans must record the date the plan was drawn up and the proposed review date. (Previous timescale 16/02/06 not met) Internal assessments and reviews must be conducted on a monthly basis. (Previous timescale 16/02/06 not met) Staff must be more attentive to ensure that residents are assisted with their dietary needs, especially during times of illness when fluid only is being given this should be recorded and monitored. The homes medication policy and procedure must include a section on self administration. The registered manager must ensure that an accurate dated record is maintained of all medication received/returned by the home in order to maintain a complete audit trail of medication. Timescale for action 30/04/06 2. OP7 15 30/04/06 3. OP7 15 30/04/06 4. OP8 12 18/03/06 5. 6. OP9 OP9 13(2) 13 (2) 17 (1) a Sch 3 3i 30/04/06 31/03/06 Kersal Dale DS0000008347.V281613.R01.S.doc Version 5.1 Page 22 Kersal Dale DS0000008347.V281613.R01.S.doc Version 5.1 Page 23 7. OP18 13(6) 8. OP29 19 9. OP31 8 10. OP36 18(2) 11. OP33 24 12. OP38 13(3) 13. OP38 23(5) 14. OP38 37 Kersal Dale The home must ensure that 31/05/06 planned training in Adult Protection Procedures for all staff takes place and evidence is maintained. (Previous timescale 16/02/06 not met) A criminal records bureau check 31/03/06 must be requested for new staff employed to work at the home before they start work. The job description of the 31/05/06 manager had not changed from the time she was employed as Deputy manager. This issue must be addressed by the home. (Previous timescale 16/02/06 not met) The manager must evidence that 30/04/06 structured and formal supervision is provided to all staff, to a minimum of 6 sessions per year. The manager should also retain formal evidence of supervision provided to her by the registered owners. . (Previous timescale 16/02/06 not met) The home must further develop 31/05/06 quality assurance and quality monitoring systems, based on seeking the views of service users and stakeholders to measure success in meeting the aims, objectives of the home. The manager must ensure 18/03/06 suitable arrangements are in place to prevent the spread of infection. The registered manager must 18/03/06 undertake consultation with the appropriate authority responsible for environmental health for the area in respect of infection control. The registered person must give 18/03/06 notice to the Commission for Social Care Inspection without delay of all occurrences of death, illnesses or other events, which DS0000008347.V281613.R01.S.doc Version 5.1 Page 24 adversely affect the well being, or safety of any resident. 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. 3. Refer to Standard OP8 OP31 OP37 Good Practice Recommendations Records in respect of specific health needs should be maintained separately and not made within daily notes. The manager should complete the NVQ Level 4 award. Policies and procedures for the home should be regularly reviewed and updated. Kersal Dale DS0000008347.V281613.R01.S.doc Version 5.1 Page 25 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 Kersal Dale DS0000008347.V281613.R01.S.doc Version 5.1 Page 26 - 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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