Inspection on 05/07/07 for Kersal Dale

This inspection was carried out on 5th July 2007.

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 31/10/06

Kersal Dale 18/03/06

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 3PG Lead Inspector Helen Dempster Unannounced Inspection 5th July 2007 11:00 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.V338011.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. Kersal Dale DS0000008347.V338011.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Kersal Dale Address 48 Vine Street Salford Gtr Manchester M7 3PG 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 none 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.V338011.R01.S.doc Version 5.2 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. 23rd March 2007 Date of last inspection Brief Description of the Service: Kersal Dale is a residential care home which has thirty-five places for older people. The home has extensive grounds with landscaped gardens to the front and rear of the property and a parking area to the side of the building. 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, which leads to a large glazed patio style lounge. There are 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. The range of fees is between £364.41 and £373.54 per week, with additional charges for hairdressing, personal toiletries, newspapers and magazines. Kersal Dale DS0000008347.V338011.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was conducted by gathering lots of information about how well the home was meeting the National Minimum Standards. This included the owner of the home filling in a questionnaire about the service, which gave information about the residents, the staff and the building. The inspection also included carrying out an unannounced visit to the home on 5th July 2007 from 11am to 7.30pm. During this visit, lots of information about the way that the home was run was gathered and time was taken in talking with residents, the manager and the staff team about the day-to-day care and what living at the home was like for the residents. Other information was also used to produce this report. This included reports about things and events affecting residents that the home’s staff had informed the Commission about. The main focus of the inspection process was to understand how the home was meeting the needs of the people who use the service and how well the staff were themselves supported by the home to make sure that they had the skills, training and support to meet the needs of the residents. The term preferred by the people consulted during the visit was “residents”. This term is, therefore, used throughout the report when referring to those people living at the home. What the service does well: The home has a friendly atmosphere and residents, visitors and staff find the manager to be approachable. The manager was competent and caring. One resident said that the manager was “very nice” and was “very helpful”. A visiting religious minister talked about how welcome visitors were made at the home by the owner, manager and staff. This person talked about being “encouraged to visit any time” and talked about having a “very good relationship with the owner and manager”. Residents’ health needs are met and detailed records of visits from doctors, chiropodists, nurses etc are held. Residents have a choice of meals each day and residents spoken to expressed satisfaction with the food, including one resident who said that “the food is good”. Kersal Dale DS0000008347.V338011.R01.S.doc Version 5.2 Page 6 Meals were served in a relaxed and unhurried way. Soft, age appropriate music was played throughout the day in the home and residents said that they liked this. One person, who completed a questionnaire, said that respecting choices about activities gives their relative “the dignity and respect that is important in later life”. Residents live in clean and homely surroundings. Lounges are big and were well furnished and decorated and all residents’ rooms seen were clean and personalised. A visiting religious minister said that “the home is always clean and has no bad smells” and that “it smells like an ordinary house”. This is good for the residents. The standard of kitchen hygiene was high and the home has been awarded with Salford Council’s 5 star rating (Gold award) for kitchen hygiene. Staff spoken to said that they were happy at the home, liked the manager and had good access to training. A visitor to the home said that staff were “kind” and “make a personal effort with people”. Residents’ relatives and friends, who filled in questionnaires, said that the staff were “brilliant”, “always pleasant and caring” and were “dedicated and hard working and always have a smile”. One resident’s relative said “I see, almost daily, acts of kindness from the staff that is far beyond their remit”. This is good for the residents. What has improved since the last inspection? What they could do better: The owner needs to provide the Commission with more detailed information about how the home is run, areas for improvement at the home and any planned development. The assessment and planning process for a resident’s admission needed to be improved to make sure that the home could meet individual needs and to provide residents with more information to allow them choice. Care plans and risk assessments needed development so that they guided staff on how residents wanted to be cared for and reduced risks to residents. Kersal Dale DS0000008347.V338011.R01.S.doc Version 5.2 Page 7 Staff needed training, support and guidance in writing records. Medication administration and records needed to be improved. Each resident should have their individual need for activities assessed. One resident said that there was “not much entertainment” and that they “would like more”. The way that complaints are dealt with and recorded should be reviewed so that residents are confident that any issue they raise will be dealt with promptly. Staff hand hygiene needed to improve. Residents are not fully safeguarded by the staffs’ knowledge of adult protection policies and because of poor staff recruitment practice. The manager needed to be given more time to do management tasks, including supervision and induction of staff. There needed to be a clear system in place for getting the views of residents, relatives and visiting professionals about how to improve the home. Inadequate fire safety checks could put people at risk. 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. Kersal Dale DS0000008347.V338011.R01.S.doc Version 5.2 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.V338011.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 1 and 3. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents benefited from having their needs assessed by a Social Worker before admission. However, the home needed to improve their pre admission assessment and planning process to make sure that they can meet individual needs and to provide residents with more information to allow them choice. EVIDENCE: Copies of the Statement of Purpose and Service User Guide were held in the office. Both documents would benefit from review and updating. The manager said that new residents are given a copy of the Service User Guide. However, these were not held on residents’ files, or in their rooms, and residents spoken to did not remember seeing this document. It was recommended that these documents are updated and that each resident, and/or their relative, is given a Kersal Dale DS0000008347.V338011.R01.S.doc Version 5.2 Page 10 personal copy of the Service User Guide and that it is adapted so that residents can access the information easily. The files of the five residents who had been admitted to the home most recently were seen. Two of these residents had been admitted to the home as an emergency and the remaining three had been admitted from hospital, or from their home in the community. All five residents’ needs had been assessed by a Social Worker, but the home’s staff had not visited these residents prior to admission, to complete their own assessment of whether the home could meet each person’s needs. The manager said that the social workers’ assessments did not always reflect the needs of each individual, yet the home’s staff did not complete their own assessments. The manager agreed that prospective residents would benefit from having their needs assessed by the home’s staff. Although in some cases, members of the residents’ family had visited the home before their admission, the residents had not had the opportunity to visit. It was recommended that wherever possible, that residents be given the opportunity to visit the home before admission. Kersal Dale DS0000008347.V338011.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 poor. This judgement has been made using available evidence including a visit to this service. Failure to consistently base care plans on assessment of residents’ needs, to have up to date risk assessments and to maintain safe medication practices puts residents at risk. EVIDENCE: The files of five residents were seen. As noted earlier, the home’s staff did not complete their own pre admission assessment of residents’ individual needs. Copies of social work assessments were made available to staff on some of the files seen. However, some aspects of needs referred to in the social work assessments were not addressed in the care plans. Care plans were in place for all five residents. These comprised a tick list of skills followed by more detailed care plans about some areas of need. There Kersal Dale DS0000008347.V338011.R01.S.doc Version 5.2 Page 12 was some good practice, including a reference to a resident being “proud” and providing details of how residents should be given choice, including preferred clothes, and how staff should explain what they are doing and reassure residents when helping them with personal care. However, care plans did not address all areas of assessed need and many included vague statements including “full assistance”, without providing specific details of the staff assistance needed. Another example was reference to a resident having a “toileting programme”, but there were no specific details of this programme on file to guide staff. Residents and/or their relatives were not signing care plans to demonstrate that they had been consulted about the plan. Risk assessments were in need of development, as they did not address all known risks for individuals. One example was a resident whose nursing assessment noted that this person had high blood pressure and was complaining of being unsteady when mobilising, yet there was no falls risk assessment. Another example was a resident whose assessment noted that this person had “postural hypertension” but there was no care plan or risk assessment in place to explain how staff could minimise any risks, including the risk of falls, that low blood pressure can cause. When risk assessments had been completed, they did not advise staff of the things they needed to do to reduce the risk. One example was a resident who was said to be at risk of falls, was taking “sedative medication”, had “dementia” and “challenging behaviour” and had environmental risks in their bedroom. The risk assessments did not include practical ways in which these serious risks may be reduced, which did not fully protect the resident. Care plans were being reviewed each month, but risk assessments were not adequately reviewed. One example was the falls risk assessment for a resident, reviewed on 8/05/07, and said to be no longer applicable. This resident’s record noted “several falls” in April 2006 and the use of an alarm mat. The care plan review on 8/05/07 noted “mobility deteriorated” and on 31/05/07, the record notes a fall and that “mobility has not improved” and the resident was “sometimes assisted in a wheelchair”. The dangers of not having an up to date falls risk assessment for this resident were discussed. Daily records about residents were made twice daily. There was some good practice, including good staff observation of residents who had poor verbal communication, which noted the resident’s mood and body language. This included a reference to a resident “giggling all day”. However, many of the records had statements including “personal care needs met” without any further detail. The manager said that she was aware of this and was heard to discuss this with staff during a staff handover. One resident’s relative who filled in a questionnaire, stated “the care that the patients receive is, in my opinion, excellent.” This person talked about Kersal Dale DS0000008347.V338011.R01.S.doc Version 5.2 Page 13 residents having “regular visits” from doctors and being warm and clean, with clean clothes every day and help that they needed. There were examples of positive ways in which the staff sought to maintain the privacy and dignity of residents. However, care staff needed further guidance in recording in a more respectful way. One example was a record which described a resident as “usually quite placid, but can for no reason be very verbally abusive and shout, scream and curse”. This was discussed with the manager, who said that she does monitor records, but that staff needed more guidance in how to record appropriately. The need to address this through staff supervision was also discussed (See staffing for details). The manager held detailed records of visits from doctors, chiropodists, nurses etc. It was also evident that the manager made sure that residents were assessed by health care professionals, including a speech and language therapist and dietician, when a resident became frail and was at risk of choking. This resident and some others had a nutritional risk assessment and a detailed weight record. Medication was stored in a locked trolley, secured to the wall in a communal area. Medication was dispensed from dossette boxes, which did not have security seals to prevent medication falling out of the cassette. The manager was aware that this was a problem and was considering changing the supplying pharmacy. All the senior carers and the manager had undertaken an advanced medication course in May 2007. Despite this, there were lots of examples of inaccuracy on the medication administration records (MARS). These included gaps in the records, where it was not clear whether medication had been administered or not. The need to have more detailed care plans for each resident about their support needs concerning medication administration, including in what circumstances ‘when required’ medication is given, was discussed. Kersal Dale DS0000008347.V338011.R01.S.doc Version 5.2 Page 14 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 adequate. This judgement has been made using available evidence including a visit to this service. Residents social needs and choices are respected, but activities needed to be based on individual assessments to meet residents’ diverse needs. EVIDENCE: The manager said that the service offers activities, but that it is hard to motivate people. She said that residents enjoy visiting singers and that residents also enjoy watching television and videos, playing bingo and taking part in the healthy hips and hearts class on Tuesday each week. One resident said that there was “not much entertainment” and that they “would like more”. The manager said that one Asian resident was about to attend a day centre for Asian people and that this person is provided with Halal food. A religious minister talked about how welcome visitors were made at the home by the owner, manager and staff. This person talked about being “encouraged Kersal Dale DS0000008347.V338011.R01.S.doc Version 5.2 Page 15 to visit any time” and said that a church representative does visit every week. This minister says mass and gives communion to residents who wish to take part. The relative of a resident, who completed a questionnaire, noted that the home offered activities to residents, but also respected the rights and choices of his relative to “do their own thing”. This person said that this gives their relative “the dignity and respect that is important in later life”. Some residents’ files contained details of their previous likes and hobbies and current needs. However, there was no assessment of preferred activities for some residents. One resident’s file noted that this person was “incapable of joining in on any activities due to cognitive impairment and limited movement”. Another resident ‘s record noted that this person was “not cooperative when doing activities, needs encouraging”. This resident’s nursing assessment noted that this person “finds it difficult in groups”. The need to assess each individual’s specific needs and to provide one to one activities, e.g. just communicating with a resident, or offering a hand massage was discussed. Menus showed that the main meal at lunchtime is soup and a main course and residents have a cooked meal and pudding at teatime. The manager holds a record of residents’ daily choices and residents spoken to expressed satisfaction with the food, including one resident who said that “the food is good”. Three staff were seen to be serving the lunchtime meal of battered fish or shepherds pie to residents. Staff were heard to be offering choices and were familiar with residents’ preferences. The meal was served at the table, rather than being placed on plates in advance, to enable portion control to be considered. This attention to detail is good for the residents. Food was not served from a hot trolley and the manager agreed that food temperatures could drop. It is recommended that a hot trolley be purchased. The meal was served in a relaxed and unhurried way. Soft, age appropriate music was played throughout the day in the home and residents said that they liked this. Residents’ care plans had details of their needs and preferences about food, although some were more detailed than others. One resident’s care plan noted that this person was accustomed to eating all meals with their partner prior to admission, and stressed the need for staff to understand this and support and encourage this person to adapt to this change and eat. Kersal Dale DS0000008347.V338011.R01.S.doc Version 5.2 Page 16 Kersal Dale DS0000008347.V338011.R01.S.doc Version 5.2 Page 17 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 poor. This judgement has been made using available evidence including a visit to this service. Practice in dealing with complaints needs to be reviewed so that residents are confident that any issue they raise will be dealt with promptly. Residents are not fully safeguarded by the staffs’ knowledge of adult protection policies. EVIDENCE: The complaints policy in held in a policy file in the office. It was very detailed and was not easy to understand. It appeared to be aimed at staff and professionals and was not displayed anywhere in the home. Residents spoken to were not aware of the policy but said that they would tell people if they had a problem. One resident said that the manager “would sort out any problems”. The complaints records are held in a hard backed book. This does not meet data protection guidelines, as complainants would not be able to see the record of investigation of their complaint, without seeing details of other peoples’ complaints. A recommendation was made about the need for staff guidance in writing records that meet Data Protection guidelines. The last recorded complaint was made in January 2005. The manager said that residents’ dayto-day concerns tend to be dealt with verbally. She agreed that residents would benefit from their concerns being recorded to demonstrate what the Kersal Dale DS0000008347.V338011.R01.S.doc Version 5.2 Page 18 manager does to address these. The manager agreed to record all complaints and outcomes and a requirement was made about the need to review the complaints procedure. The home has a copy of the Salford Council’s Protection of Vulnerable Adults Policy. There have been no referrals under this policy to date. Although some staff have had training in the implementation of the Protection of Vulnerable Adults Policy, the manager has not had this training. This needs to be addressed so that the manager and all staff know what to do in the event of a disclosure of abuse. This lack of recent training and knowledge, along with unsafe recruitment processes, does not help to safeguard residents. (See Staffing for details). Kersal Dale DS0000008347.V338011.R01.S.doc Version 5.2 Page 19 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. Residents live in clean and homely surroundings. Overall, there is good attention to environmental safety issues, but more detailed risk assessments of some bedrooms, and better hand hygiene, would benefit residents. EVIDENCE: The home was clean, homely and free from unpleasant odours. Communal areas were very spacious and were well furnished and decorated. All residents’ rooms seen were clean and personalised. One resident’s relative said that “the outside and gardens are lovely”. Kersal Dale DS0000008347.V338011.R01.S.doc Version 5.2 Page 20 A visiting religious minister said that “the home is always clean and has no bad smells” and that “it smells like an ordinary house”. Relatives and friends of residents, who filled in questionnaires, were also pleased with the standard of hygiene. This included on relative who said that the home is “well maintained and cleanliness is of a high standard”. This is good for the residents. Radiator safety in residents’ rooms had been addressed by covering radiators. One resident did not have the skills to use a call bell, so this person was checked regularly and a pressure mat, attached to the call system, was used. One resident was very frail and was cared for in their bedroom. The room was a double room, but was being used as a single room. Portable screens were being used around this resident’s bed. The manager said that having the second bed in the room restricted the opportunities to reposition this resident’s bed to aid staff support and moving and handling. The need to complete a risk assessment about this issue and to minimise risks was discussed. The standard of kitchen hygiene was high. On 15/06/07 the home achieved Salford Council’s 5 star rating (Gold award) for kitchen hygiene. However, the kitchen, toilets, bedrooms, bathrooms and the staff toilet, all had bar soap and cloth towels. This carries a risk of cross infection and a requirement was made about the need to obtain the advice of the local environmental health department about this issue. Kersal Dale DS0000008347.V338011.R01.S.doc Version 5.2 Page 21 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 poor. This judgement has been made using available evidence including a visit to this service. The arrangements for training care staff ensure that the needs of residents are met. But, poor recruitment practice puts residents at risk. EVIDENCE: The manager holds a staff-training audit, which was being updated at the time of the visit. Training undertaken since the previous inspection included the Protection of Vulnerable Adults (Four staff), Equality and Diversity (two staff), Person Centred Planning (1 staff member) and First Aid Appointed Person (6 staff). In addition, all the senior carers and the manager had undertaken an Advanced Medication Course in May 2007 and all staff did Moving and Handling Training in June 2007 and Fire Safety training in May 2007. Some staff induction records were seen and the manager was about to introduce the Skills for Care programme. Staff spoken to said that they were happy at the home, liked the manager and had good access to training. A visitor to the home said that staff were “kind” Kersal Dale DS0000008347.V338011.R01.S.doc Version 5.2 Page 22 and “make a personal effort with people”. Residents’ relatives and friends, who filled in questionnaires, said that the staff were “brilliant”, “always pleasant and caring” and were “dedicated and hard working and always have a smile”. One resident’s relative said “I see, almost daily, acts of kindness from the staff that is far beyond their remit”. This is good for the residents. The recruitment files for the three most recently recruited members of staff were seen. Appropriate police checks had been made for all three staff. However, recruitment practice was very poor. This included one application form, which noted that the person had no experience in care work, and no references had been taken. Another file contained a character reference from somebody who stated that they had only known the person for six months. The second reference for this person, and one of the other employees, were said to be from a previous employer, yet these employers were not noted on the application form employment history. References were not always clear, and did not carry any proof of origin e.g. a company stamp. Employment histories were incomplete and had not been checked for gaps. One example was a file where the only record on the employment history was “2 years care work”, with no details of where this experience was gained. This practice puts residents at risk. Kersal Dale DS0000008347.V338011.R01.S.doc Version 5.2 Page 23 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, 35, 37 and 38. Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. The manager is competent and caring, but is not fully supported to manage the home in the best interests of residents; inadequate fire safety practice puts residents at risk. EVIDENCE: The owner completed a document as part of the inspection, which provides the Commission with information about how the home is run, areas for improvement at the home and any planned development. This form did not provide sufficient information and needs to be completed more fully. Kersal Dale DS0000008347.V338011.R01.S.doc Version 5.2 Page 24 It was clear from discussions and observations that the manager fosters an open and friendly atmosphere in the home, and that residents, visitors and staff find her approachable. One resident said that the manager was “very nice” and was “very helpful” and a visiting clergyman described a “very good relationship with the owner and manager”. There was also evidence that the manager continually seeks to make improvements in the home for the benefit of residents and had a very good knowledge of their individual personalities and preferences. However, the manager discussed the things that prevent her from raising standards. The main problem was that of her forty contacted hours, only 10 of these hours were used for managing the home, because for the other thirty hours the manager provided personal care to residents. This issue was discussed with the owner of the home in the context of the manager not having time to do management tasks, e.g. supervision, induction, health and safety, monitoring and review. A specific example discussed was the fact that the manager had not been able to meet a requirement made at the previous inspection concerning the need to provide staff with regular supervision. The manager did not have a planner in place and had only supervised two staff since the previous inspection. There was no clear system in place for obtaining the views of residents, relatives and visiting professionals, and using these to identify improvements for residents. This needed to be addressed so that these peoples’ views may be taken into account in future plans. Written information provided by the owner of the home demonstrated that most appliance and equipment tests at the home were up to date, but fire safety practice was poor. In particular, fire safety checks of the fire alarm were not up to date and the home was not undertaking regular checks of the means of escape and emergency lighting. This was discussed with the owner and manager and a requirement was made. All staff had received fire safety training in February 2007. However, the manager and staff were not familiar with the fire risk assessment. The manager said she had “never read it” and that staff had not seen it. This puts residents at risk and a requirement was made. Kersal Dale DS0000008347.V338011.R01.S.doc Version 5.2 Page 25 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 2 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 1 8 3 9 2 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 x 18 2 2 X X X X X X 2 STAFFING Standard No Score 27 2 28 2 29 1 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 2 X X 2 2 2 Kersal Dale DS0000008347.V338011.R01.S.doc Version 5.2 Page 26 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 OP3 Regulation 14 Requirement Timescale for action 05/08/07 2. OP7 13 and 15 Pre admission assessments must be undertaken and the outcomes of these assessments must be recorded to ensure that the service is able to meet the needs of the prospective resident. Care plans must address all 05/08/07 areas of assessed need and must provide specific details of the staff assistance needed to support residents. 3. 4 OP9 OP16 13(2) 22 5. OP18 13 Risk assessments must be in place to assess all risks applicable to an individual resident, including the risk of falls. These must be subject to consistent review to take account of any changes so that residents are protected. Medication administration and 05/08/07 record keeping must be reviewed so that it protects residents. A record of the investigation and 05/08/07 outcomes of all complaints must be held, so that residents know that their concerns are addressed. The manager and all staff must 05/11/07 DS0000008347.V338011.R01.S.doc Version 5.2 Page 27 Kersal Dale 6. OP19 23(4) 7. OP26 16 8. OP27 18 9. 10. OP29 OP33 19 24 11. OP36 18(2) 12. OP38 13 have training/guidance in the implementation of Salford Council’s Protection of Adults from Abuse Policy. Environmental safety must be clearly risk assessed, with strategies put in place to reduce identified risks to residents and staff. To protect residents from cross infection, the guidance of the local environmental health department must be sought and adhered to concerning hand hygiene. In order that residents can be assured that the home is being managed, the provider must provide the Commission with a plan which provides sufficient staffing to release the manager from the care staffing rota duties, so that she can fulfil her management role. Recruitment and selection procedures must ensure the protection of the residents. The quality assurance system must be reviewed and developed to allow residents views to be heard and taken account of. The manager must evidence that supervision is provided to all staff to support them to care for residents. (Previous timescale of 01/04/07 had not been met). Fire safety checks must be undertaken in line with Fire Department Guidelines and the fire risk assessment must be a working tool, that all staff are familiar with, which is updated regularly to ensure the safety of residents and staff. 05/08/07 05/08/07 05/08/07 05/08/07 05/11/07 05/08/07 05/08/07 Kersal Dale DS0000008347.V338011.R01.S.doc Version 5.2 Page 28 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 OP1 Good Practice Recommendations It is recommended that the statement of Purpose and Service User Guide are updated and that each resident, and/or their relative, is given a personal copy of the Service User Guide and that it is adapted so that residents can access the information easily. It is recommended that wherever possible, the manager arrange for prospective residents be given the opportunity to visit the home before admission. It is recommended that a care plan for the administration of “when required” medication, including Paracetamol, confirms why medication is prescribed and in what circumstances and for what conditions, medication is given. It is recommended that a hot trolley be purchased, to ensure that food remains hot when being served. It is recommended that care staff be given training in record keeping which respects residents’ dignity and meets Data Protection requirements. 2. 3. OP3 OP9 4. 5. OP15 OP37 Kersal Dale DS0000008347.V338011.R01.S.doc Version 5.2 Page 29 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 © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. 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