Inspection on 03/11/05 for Kersal Dale

This inspection was carried out on 3rd November 2005.

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 18/03/06

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 Joe Kenny Unannounced Inspection 3rd November 2005 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 Kersal Dale DS0000008347.V262672.R01.S.doc Version 5.0 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.V262672.R01.S.doc Version 5.0 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.V262672.R01.S.doc Version 5.0 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. 8th February 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. Ms Chrisden Williams has been registered as manager of the home in the period since the last inspection. Kersal Dale DS0000008347.V262672.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection of Kersal Dale was carried out unannounced on 3 November 2005. During the course of the inspection time was spent talking to residents, members of staff and the registered owners of the home. Time was spent examining records, residents and staff files and a tour of the home was conducted. At the time of the inspection there were 31 residents in the home. The home had taken action to positively address requirements and recommendations made at the last inspection. In the period since the last inspection Ms Chrisden Williams had been registered as manager of the home. Discussions were held with the owners and the manager in relation to the arrangements for management of the home, as Ms Willams continued to work part of her contracted hours as cook, covering in the absence of the fulltime cook. The inspection identified a need to recruit an additional cook so as to enable the registered manager to carry out her day-to-day management duties. Residents spoke positively about the care and support offered at the home. A selection of the key 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 recording procedures relating to care plans continue to be reviewed and developed by the newly appointed registered manager. Standards of cleanliness and décor continue to be well maintained and a homely environment is maintained. The arrangements for communal space, offer residents large lounge settings to the front and rear of the property. Catering arrangements are well established and residents spoke highly of the meal and menu plans in the home. Kersal Dale DS0000008347.V262672.R01.S.doc Version 5.0 Page 6 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. Kersal Dale DS0000008347.V262672.R01.S.doc Version 5.0 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Kersal Dale DS0000008347.V262672.R01.S.doc Version 5.0 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 2,3 and 4 Residents are given appropriate information to assist them in making a decision about moving to the home. EVIDENCE: Procedures relating to admission to the home ensure residents are give information about the home and can visit prior to moving there. The preadmission visit can be taken as a day visit or involve an overnight stay. The home’s statement of purpose clearly states that residents will be given the opportunity to take up trial visits to the home. This was confirmed by a number of residents spoken to on the day. The homes statement of purpose and service user guide will require amending to reflect change in registered manager for the home. All residents are issued with a contract and statement of terms and conditions at the time of admission to the home. A number of residents were spoken to; all indicated that they were happy with the support offered to them and that they are free to arrange how they spent their day in the home. No intermediate care is provided in the home. Kersal Dale DS0000008347.V262672.R01.S.doc Version 5.0 Page 9 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8 and 9 Residents’ health, personal and social care needs were met and regularly reviewed by staff working in the home. EVIDENCE: Residents’ personal and health care needs are detailed in their individual files. The manager had taken the lead in reviewing care plans leading to completion of individual folders for named residents. The manager is again advised to encourage all staff to be proactively involved in contributing to residents’ records and to ensure all files evidence such reviews. The records for morning and afternoon shifts are held as two separate recording systems. These should be brought together to ensure continuity and consistency in written information. All care plans must record the date it was drawn up and also record the proposed review date. This is essential when reviewing the outcomes of intervention. One plan was drawn up in March 04 with no indication of a review. A further plan indicated that the resident should be turned hourly during the night as part of strategy in relation to pressure management. This Kersal Dale DS0000008347.V262672.R01.S.doc Version 5.0 Page 10 was not always recorded as completed in the night reports. This must be monitored by the manager and supervision and training provided where identified. Staff were observed to support residents in a caring manner and enabled residents to be as independent as possible. Care is offered in the privacy of residents’ bedrooms and all visiting professionals and relatives are offered the opportunity to meet residents in the privacy of bedrooms. The manager must work toward monthly reviews of care in line with standard 7 of the National Minimum Standards. None of the residents self medicated. Designated staff administers all medication. Medication is received from the pharmacist in weekly dossette boxes. A policy statement and procedure relating to the administration of medication must be devised by the home. On inspection of the locked cabinet used to store medication it was noted that amounts of medication were being held but not currently prescribed for use. An inventory should be taken and excess medication should be returned to the pharmacist for disposal. The manager was also advised to confirm the dispensing arrangement for an anti-biotic as there was a query as to the dosage and amount to be dispensed. Kersal Dale DS0000008347.V262672.R01.S.doc Version 5.0 Page 11 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 14, and 15 The preferred and chosen daily living arrangements and social interests of residents is respected and responded to by the management and staff team working in the home. EVIDENCE: Residents confirmed in discussions that they are free to determine their own daily living arrangements such as when they go to bed and when to get up. Residents were observed to freely move between communal facilities. Communal facilities offer ample space and seating arrangements to allow resident to pursue personal interests, quiet place to read and facility to watch television. Residents confirmed they freely access their own rooms. A selection of rooms were viewed as part of the tour of the home, rooms were found to be clean and reflected interests of residents. The home operates an open policy on visiting times to the home; visitors can be received in the lounges or in residents’ bedrooms. Kersal Dale DS0000008347.V262672.R01.S.doc Version 5.0 Page 12 Residents stated that they were appreciative of the support they received and confirmed that activities are held in the home. There was evidence of a range of activities and resources, such as board games and audio equipment. A wholesome and balanced diet was provided. There were ample provisions available in the home at the time of the inspection. Kersal Dale DS0000008347.V262672.R01.S.doc Version 5.0 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): 16 and 18 The homes’ complaints procedures informed residents and relatives of the process to raise concerns about the service. Procedures relating to protection of vulnerable adults required additional training in order to ensure residents are protected from risk of abuse. EVIDENCE: The homes complaints procedure contains information about who to contact if there is a concern about the service. No complaints had been received by the home or by the Commission in the period since the last inspection. The home must access the complete policy guidelines in relation to the local authority procedures relating to Adult Abuse procedures. The manager was advised to develop training programmes for staff and to retain evidence that all staff had been given the opportunity to read the document and sign the tracking form to confirm they had read the document and understood its principles. Kersal Dale DS0000008347.V262672.R01.S.doc Version 5.0 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 26 The home is well maintained comfortable and provides residents with a safe and homely environment in which to live. EVIDENCE: The home continues to be well maintained in terms of décor, cleanliness and was free of odours. The communal areas are suitably furnished and are located on ground floor. Lounges are well maintained and offer extensive space for resident to move about in. Bedrooms are suitably furnished and personalised by residents. There are extensive grounds to the home. Discussions were held with residents regarding their accommodation and a tour of the home was undertaken and led by one of the residents. Permission had been sought from residents regarding entering their rooms. Kersal Dale DS0000008347.V262672.R01.S.doc Version 5.0 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): 27 and 28 The home was well managed and residents benefited from a staff team that were skilled, trained and supervised. The staff team were stable and offered residents the support necessary to address and meet their needs. EVIDENCE: The staffing levels for the period covering the inspection were assessed and were maintained in accordance with the needs of residents. The manager’s hours do however need reviewing to address issues relating to other duties undertaken by her such as catering duties. The hours worked by the manager must be dedicated to the management and development of the service. In addition to this the manager must be given responsibility for all aspects of management as currently some tasks, such as issues relating to residents’ finances are overseen by the owner of the home. The manager must be involved in this process. The manager works a total of 40 hours per week, 10 of which are taken up with catering duties. The staffing arrangements for the time of the inspection, 7 to 13 November a total of 319 day care hours were provided. The rota did highlight that some staff were working 13-hour shifts. The manager should monitor this. The staffing arrangements at night are for two staff to be on waking duty. The manager is also required to evidence that structured and formal supervision is provided to all staff. Records should be retained of such Kersal Dale DS0000008347.V262672.R01.S.doc Version 5.0 Page 16 sessions and each member of staff should have a minimum of 6 sessions per year. The manager should also retain formal evidence of supervision provided to her by the registered owners. Kersal Dale DS0000008347.V262672.R01.S.doc Version 5.0 Page 17 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31,32, 33, 35, and38 The manager must be given full responsibility to discharge her duties in relation to all aspects of the day-to-day management of the home. EVIDENCE: The registered manager had the relevant experience of care of older people, in a residential setting. The manager is currently completing NVQ level 4 and was advised to complete the Registered Managers Award. During discussions, she demonstrated a commitment to developing and keeping her knowledge current and to supporting staff on development issues. As indicated in the previous section this should be evidence through staff supervision. However, some aspects of the management of the home continued to be undertaken by the registered owner and previous manager of the service. This related to issues such as resident finances and vetting of new staff. The current registered manager must be involved in this process. The job Kersal Dale DS0000008347.V262672.R01.S.doc Version 5.0 Page 18 description of the manager had not changed from the time she was employed as Deputy manager. This issue must be addressed by the home. The home is again advised to develop quality assurance and quality monitoring systems, based on seeking the views of service users and to measure success in meeting the aims, objectives of the home Kersal Dale DS0000008347.V262672.R01.S.doc Version 5.0 Page 19 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X 3 2 3 X X HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 X 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 3 X X X X X X 3 STAFFING Standard No Score 27 2 28 2 29 X 30 X MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 2 3 X 3 X X 2 Kersal Dale DS0000008347.V262672.R01.S.doc Version 5.0 Page 20 Are there any outstanding requirements from the last inspection? YES STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP2 Regulation 5 Requirement The homes statement of purpose and service user guide, require amending to reflect change in registered manager for the home. The home must develop systems to support all staff in recording on daily care plans. All care plans must record the date the plan was drawn up and the proposed review date. All health monitoring charts must be complied with to evidence support offered. Internal assessments and reviews must be conducted on a monthly basis. The home must develop a medication policy and procedure and ensure all staff adheres to the procedures for the recording, storage, handling administration and disposal of medicines. An inventory must be taken of excess medication. Any excess medication must be returned to the pharmacist for disposal. Timescale for action 16/02/06 2 3 4 5 6 OP7 OP7 OP7 OP7 OP9 19 19 19 15 13 16/02/06 16/02/06 16/02/06 16/02/06 16/02/06 7 OP9 13 16/02/06 Kersal Dale DS0000008347.V262672.R01.S.doc Version 5.0 Page 21 8 OP9 13 9 10 OP18 OP27 12 18 11 OP28 18 12 OP32 8 13 OP38 15 The manager must ensure the dispensing arrangement for all medication is clear and understood in terms of the dose and amount to be dispensed. The home must retain evidence of training in Adult Protection Procedures for all staff. The hours provided to the manager must be reviewed in relation to other duties undertaken. The home must monitor staffing levels to ensure that the needs of residents are being met. 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 job description of the manager had not changed from the time she was employed as Deputy manager. This issue must be addressed by the home. The home must develop quality assurance and quality monitoring systems, based on seeking the views of service users and to measure success in meeting the aims, objectives of the home. 16/02/06 16/02/06 16/02/06 16/02/06 16/02/06 16/02/06 Kersal Dale DS0000008347.V262672.R01.S.doc Version 5.0 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 OP7 Good Practice Recommendations The records for morning and afternoon shifts are held as two separate recording systems. These should be brought together to ensure continuity and consistency in written information. Kersal Dale DS0000008347.V262672.R01.S.doc Version 5.0 Page 23 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.V262672.R01.S.doc Version 5.0 Page 24 - 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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