Inspection on 06/03/07 for The Dales

This inspection was carried out on 6th March 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

The Dales 11/06/09

The Dales 09/02/09

The Dales 09/02/06

The Dales 26/07/05

The Dales 14/03/05

The Dales 14/01/05

Similar services:

Abbey The

Snydale Care Home

Hawkhills

Larchfield Manor

Beeches The - North Yorkshire County Council

The Grove Waltham

Carentan House

Ravensworth Lodge

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

CARE HOMES FOR OLDER PEOPLE The Dales Woodhall Road Off Gain Lane Bradford BD3 7DY Lead Inspector Karen Westhead Key Unannounced Inspection 08:30 6th March 2007 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 The Dales DS0000029150.V326716.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. The Dales DS0000029150.V326716.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service The Dales Address Woodhall Road Off Gain Lane Bradford BD3 7DY 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) 01274 656110 01274 665800 walkerdo@bupa.com www.bupa.co.uk BUPA Care Homes (GL) Ltd Judith Lister (not yet registered) Care Home 108 Category(ies) of Dementia (1), Dementia - over 65 years of age registration, with number (108), Old age, not falling within any other of places category (108) The Dales DS0000029150.V326716.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. That the category of DE be used for the service user named on the application signed on 03/03/05 9th February 2006 Date of last inspection Brief Description of the Service: The Dales is owned by BUPA. It is in a central position on the Leeds/Bradford border. The main road, Gain Lane, is well served by public transport. Visitors on foot then have a reasonable walk up Woodhall Road to reach the main reception area. The site is know collectively as The Dales, but is split into five separate units. Four units provide nursing care to residents who have a diagnosis of dementia or related conditions. One unit is used for residents who may not need to be in a nursing home but can be looked after in a residential setting. Each unit is self-contained with a range of lounges, dining areas, kitchenettes and bathrooms, some of which have specialist equipment. A lot of the bedrooms have en-suite facilities. Residents are encouraged to bring personal items such as ornaments, pictures and small pieces of furniture with them when moving in. On 3rd January 2007 the fees were between £439.50 and £650.00 per week. Additional charges are made for hairdressing, newspapers and private chiropody treatment. The Dales DS0000029150.V326716.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This visit was done by one inspector and had not been prearranged with the Manager. This meant the inspector was able to observe how the home is run on a day-to-day basis, without any changes being made to the usual routines of residents and staff. The reason for the visit was to make sure the home was being run for the benefit and well being of the residents and in line with the standards. The inspector arrived at 8.30am and left at 4.30pm. The inspector rang the manager the following day and told her how well the home was being run and what needed to be done to make sure the home meets the required standards. Before the inspection, information already known about the home was reviewed. This included looking at the number of reported incidents and accidents, the action plan provided following the last inspection and information from other agencies such as the fire safety officer’s report. This information was used to plan the inspection visit. Comment cards were left at the home for relatives and visitors to complete. At the time of writing this report three comment cards had been returned. The comments made on these cards and what was said to the inspector during the visit is included in this report. Most of the day was spent talking to residents, visitors, staff and the manager, to find out what it is like to live and work at The Dales. Two of the five units were inspected in detail. The inspector visited the other units during the course of the day and spoke to staff and residents. What the service does well: The Dales has a welcoming and relaxing atmosphere. Staff are proud of the care they give and are knowledgeable and professional in their work. Staff put the welfare of residents first and routines are flexible enough to give staff time to work around the needs of the residents and respond to situations when they arise. Staff will make it possible for residents to remain ‘at the home’ for as long as they can, as long as they can meet their needs. Plans of care and supporting records are satisfactory. New documentation is to be implemented in July and staff are working with the existing format until then. Residents, who were able to give a view, said The Dales was their home. They talked positively about their surroundings and the staff looking after them. The Dales DS0000029150.V326716.R01.S.doc Version 5.2 Page 6 Those residents who could not give a view looked comfortable and were seen to move around the home freely. Residents are happy and well looked after. Staff are trained, so that they can look after the residents properly. Training is ongoing and the manager keeps a record of what training staff need and provides the opportunity for them to attend courses. The complaints procedure is displayed and appropriate action is taken if a complaint is received. This means residents are safe. 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. The summary of this inspection report can be made available in other formats on request. The Dales DS0000029150.V326716.R01.S.doc Version 5.2 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 The Dales DS0000029150.V326716.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 3, 4 and 5 (Standard 6 - N/A, the home does not provide intermediate care) Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents and their relatives have enough information about the home to decide if it will meet their needs. EVIDENCE: One visitor said they had visited the home before their relative had moved in. They had chosen the home in preference to others they had visited. All the plans of care seen included a pre admission assessment, which had been carried out by a senior member of staff. This meant staff had met with the prospective resident, had discussed their care needs with those involved with this prior to admission and they were able to get a good idea about the type of care the resident needed. A judgement was then made about whether the home could provide the appropriate care. Prospective residents are then given the opportunity to spend time in the home. An individual member of staff is The Dales DS0000029150.V326716.R01.S.doc Version 5.2 Page 9 allocated to give them information, special attention, help them to feel welcome and comfortable in their surroundings, and enable them to ask any questions about life in the home. Eight residents, four from two of the units were selected for case tracking. These included the most recent admissions and those residents who had either high dependency needs or had been ill. Each resident receives a contract of terms and conditions on admission. Those residents case tracked were having their fees paid by the local authority and contracts were held in the home to show this. The Statement of Purpose and Service User Guide provides enough information for residents and their relatives to make an informed choice about whether they think The Dales might be a suitable home. The staff on duty thought it could be produced in larger print on request, for those with poor sight. At the time of the visit, because some double bedrooms were being used as singles, the maximum number of residents being looked after amounted to 100. This meant residents could be given maximum privacy whilst being attended to in their own bedroom and were able to make use of a larger room for their own furniture and belongings. The staff team are qualified and experienced to work with the needs of the residents. Residents from different cultural or ethnic backgrounds have come to live at The Dales. Staff who understand the cultural expectations of those residents are also employed. For example residents who have a different first language to English have contact with staff on the day and night shifts, who can converse with them in their own language. Residents also have access and use the advocacy service, particularly Age Concern to make sure they have a representative if they are not able to make their own wishes known. The Dales DS0000029150.V326716.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9, 10 and 11 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Health, personal and social care needs are met. However staff must record if a change in residents conditions are followed up and what action is taken to monitor this. EVIDENCE: A selection of care plans were examined before meeting the residents they referred to. During the visit a doctor called to visit residents. Each resident was seen in private. Therefore respecting the residents right to privacy and dignity. Staff said they stayed with a resident during a consultation so that they could give the doctor a current account about their condition and record any changes in medication or treatment. The home provides the necessary aids and equipment to support both staff and residents in daily living and these are maintained according to the manufacturers instructions. The Dales DS0000029150.V326716.R01.S.doc Version 5.2 Page 11 Staff are clear about their roles and responsibilities. However, they will make it possible for a resident to stay in the home whilst receiving treatment if they can continue to meet their needs and are able to call on additional resources. The manager and staff team are well informed about current good practice and use their knowledge in their daily work. The home is run in a way, which reinforces the importance of treating residents with respect, and dignity and these values were seen during the visit in the way staff responded to residents. However additional training for some staff may be necessary to make sure this is carried through during mealtimes. The care plans seen provide staff with clear guidelines on how to meet each residents needs. There is a strong belief that it is essential to involve residents where possible in the planning of care that affects their lifestyle and quality of life. However, staff are good at working with relatives and those who have known the resident before admission to gather information which can inform the way the resident would like to be looked after. There was written evidence that care plans are being evaluated and altered as the needs of the resident change. Staff have made sure they know exactly what the resident wants in the event of their death and this is clearly documented. In most cases a relative has provided key information if the resident is not able to give their view. Staff also us a variety of ways to get to know the resident they are looking after for example key workers are appointed who can build up special relationships with the resident and their family and work on a one to one basis with them. The records written by staff can be cross-referenced to the care plans and gave a good description of how each resident was. If there are any changes in the care required, this is added to the care plan and a verbal instruction is given between staff during the handover period. It is expected that there is an entry on a residents daily records at least once a day. However, it was not clear, from one entry on a daily record, if a symptom, picked up during the day, had been followed up and what, if any action had been taken to safe guard the health of one resident. Risk assessments had been done where required. Staff spoken to on duty had a good working knowledge of when to involve other professionals and they were able to give examples of how they would treat pressure sores and what steps would be taken to minimise any risk to those residents who may go on to develop them. Comments from two relatives showed they were very happy with the care provided and they said their relative was ‘well cared for’. It was not possible to watch a full medication round. However, only the staff who have received training and are competent, give out medication. Records were checked and had been filled in correctly and matched the medication held The Dales DS0000029150.V326716.R01.S.doc Version 5.2 Page 12 in the trolleys. None of the current group of residents take care of their own tablets. The Dales DS0000029150.V326716.R01.S.doc Version 5.2 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Resident’s lifestyle in the home matches their expectations and they are encouraged to exercise choice and control over their lives as far as possible. EVIDENCE: The routines in the home are planned around the resident’s needs and wishes and are flexible enough to be changed to meet individual wishes. Family and friends feel welcome and know they can visit the home at any time. Notices stating this were seen around the home. An administrator is employed who offers support to those residents who need help in financial matters, this is overseen by the manager. They work to a clear robust policy that protects the residents from financial abuse and clearly directs staff in their practice. The home employs four activity organisers who work across the five units. The amount of time available for each resident is significantly limited when The Dales DS0000029150.V326716.R01.S.doc Version 5.2 Page 14 considering the amount of time needed for residents who are better suited to one to one attention or for staff to be able to take residents out. Additional hours are required to make sure residents are able to take part in purposeful activities which will be of benefit to them. Staff said they made good use of the local facilities, however the home is off the main road and is not part of the local community. One relative said they felt the activity programme could be improved to include outings to the local shops for example. The manager said it was difficult to engage some residents in activities, and this is where the one to one time is of maximum benefit. Residents meetings are not used as a way to get residents views at the moment, although the manager is in the process of asking relatives and families if they would be interested in forming a relatives group who could meet and take an active role in decisions, which affect the residents directly. If this is successful it will be a good example of staff seeking the views of people to improve services for residents in the home. Since the last inspection there has been additional training to kitchen staff to improve the quality of food. Staff are aware of the need to make meal times an event in the day. High calorific meals are provided and snacks are available throughout the day and night, especially for those residents who are at risk of loosing weight or are reluctant to eat regular meals. The main meal of the day is served at teatime, with a hot snack at lunchtime. The inspector sat and observed the snack meal being provided, in one of the units. The residents in the unit had a variety of needs. Some residents were able to sit in the dining area and with little help from staff were able to eat their meal with discrete prompts and supervision. Other residents required full staff assistance. The meal did not look appetising as the pie served was overcooked. However, some residents managed to finish their meal. Residents who were not sat at a dining table were left to eat their meal in the lounge, in an easy chair. For three residents the meal was taken to them and the member of staff cut the food up using a spoon whilst walking towards the resident. The plate was then put on a coffee table to the side of the resident. Who had already been served with a cup of tea whilst they waited. The three residents were able to use the cutlery but because of their seating position and the position of the coffee table had difficulty in reaching their meal. Some residents, who needed full assistance with their meal, were also sat in an easy chair in the lounge. The member of staff attending to them pulled up a coffee table and sat on this in front of the resident. In this position they were sat higher that the resident so there was no eye contact and only one member of staff engaged the resident they were helping with any conversation or explanation about what was happening. To adopt a more individualised approach when serving drinks to residents at the table, staff should not be serving milk directly from a four-pint plastic carton. This practice could be viewed as undignified by some residents. The Dales DS0000029150.V326716.R01.S.doc Version 5.2 Page 15 The menu allows for choices at all meal times and alternatives are offered if residents do not want what is on the menu. Nutritional risk assessments had been carried out for all residents and if there were any concerns about weight loss or lack of appetite residents were being referred to dieticians and doctors to make sure they were being provided for adequately. Meals are cooked in a central kitchen on site and food is delivered to the five units in hot boxes and transferred to hot trolleys in each kitchenette. Staff said this worked well and that they had a routine, which meant there was always one member of staff to serve the food and all other staff were then available to give their attention to residents. The Dales DS0000029150.V326716.R01.S.doc Version 5.2 Page 16 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, 17 and 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The level of staff understanding gives assurance that complaints will be taken seriously and residents will be protected from abuse. EVIDENCE: The manager keeps records of all compliments and complaints. There have been twenty-seven complaints over the last twelve months, one of which was referred to Commission for Social Care Inspection (CSCI) and involved meetings with the manager, relative, social services officers and adult protection. All the others were dealt with internally by the manager. Of all the complaints ten had been upheld and seven had been partially upheld. Action had been taken to make sure the person making the complaint was satisfied. Where necessary practices and procedures had been changed. Only one complaint had been referred to the adult protection unit. This is because there are not many serious incidents, rather than there being a lack of understanding when incidents should be reported. Relatives said they knew who to complain to if they were unhappy and the complaints procedure was displayed for visitors and residents to see. The Dales DS0000029150.V326716.R01.S.doc Version 5.2 Page 17 Some staff spoken to said they had not received training on adult protection, others said they had been on a course. Copies of the adult protection procedures and the local authority adult protection procedures are kept in the manager’s office, and available for staff to read. Evidence was seen to show that training courses had been planned and staff had been informed when they were due to attend. Despite the lack of training staff showed an awareness of what they should do if they thought residents might have been subject to any form of abuse and were able to identify the different types of abuse possible. The Dales DS0000029150.V326716.R01.S.doc Version 5.2 Page 18 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, 20, 21, 22, 23, 24, 25 and 26 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The standard of decoration and maintenance of the home is generally satisfactory. However, some requirements have been made to make the units more comfortable and appropriate for the residents. EVIDENCE: The company employs a maintenance worker, who is responsible for the site, both in terms of the upkeep of each unit and the grounds. There are plans to develop the garden areas directly outside each unit. Some have an enclosed garden area which residents are able to use. Some of the décor is now showing signs of wear and tear. However, there is evidence to show that routine redecoration is planned on a rolling programme. Two of the units are listed buildings and little can be done to alter the layout of the corridors and The Dales DS0000029150.V326716.R01.S.doc Version 5.2 Page 19 rooms. However, staff work well with the space they have and try to make it easier for residents to find their way about. They have done this by using simple signage to show where toilets and bathrooms are and each bedroom has a ‘memory box’ outside to remind residents it is their bedroom. The ‘memory box’ is a display frame, attached to the wall, and items belonging to the resident are kept in it. For example a framed photograph or ornament, which they have cherished and know from the past. This is familiar to them and prompts their memory so they recognise this is their bedroom. Resident’s bedrooms are individually decorated and furnished giving the feeling of individuality and ownership. Each unit is self-contained. Only one unit, which has two floors, has a passenger lift. The remaining units are on one level. There are a range of bathrooms and toilets for communal use, some bedrooms have en-suite facilities. There are dedicated cleaning, catering and laundry staff. All the units were clean and tidy. All areas smelt fresh. Staff work together to achieve this and were seen to be well organised and committed to the task in hand without overlooking any attention residents might need. Requirements: • All windows need to be fitted with a blind or curtains to make sure residents are attended to in private. • Toilet roll holders and bins should be correctly fitted with lids to reduce the risk of cross infection. • Pipe work in toilets and bathrooms should be boxed in to prevent residents from possible harm if hot pipes are exposed. • Cleaning solutions, which pose a risk, should not be kept in areas, which are accessible to residents. • Lino in one storeroom (identified) used for soiled linen is lifting and makes it difficult for staff to clean properly. • All bathrooms should be fitted with appropriate equipment to allow residents to get in and out of the bath with ease. • The lack of storage space for laundry bins means some bathrooms are being used for this purpose. (This was highlighted at the last inspection.) • The pathways, leading from a final exit fire door, must be kept free of moss and dead leaves. Presence of moss could make the path slippery. Despite the list of requirements, the home continues to provide a pleasant and comfortable environment for residents. Staff work hard to keep the home looking and smelling nice. Each unit has its own unique atmosphere and staff work hard to overcome some of the limitations of the building. The Dales DS0000029150.V326716.R01.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Staff are well trained and are competent to look after the residents. Only staff who are suitable to work with older people are employed. EVIDENCE: The staff rota shows a minimum of four staff during the day and evening. This includes a senior member of staff. The manager is not included in the rota as part of the overall number of staff. She works set hours through the week to support the staff team. If there is a shortfall in the rota then the manager has access to a number of ‘bank’ staff who are employed by the company. These staff are used when required. It was noted that this is used only rarely, as existing staff are happy to work additional shifts if required. No agency staff are used. Most of the staff have now completed their National Vocational Qualification or are working towards this. Staff are encouraged to attend a wide variety of courses relevant to the care provided in the home. The training programme is given a high priority and the manager keeps a record of all the training staff have done. All the required background checks are done before staff are appointed. The inspector looked at four staff files in detail. All of them contained detailed The Dales DS0000029150.V326716.R01.S.doc Version 5.2 Page 21 application forms, two references and the results of a criminal records bureau check. The company clearly defines the roles and responsibilities of staff by providing them with a job description. Positive remarks were made by visitors and residents about the staff looking after them. Staff spoken to did not report having any difficulties meeting the needs of the residents they were looking after. There is a good mix of staff with a range of ages, experience, cultural backgrounds and skills. All staff on duty were spoken to and were seen carrying out their duties. They were polite and respectful of each other and the residents. There was a good rapport between residents and staff. Staff supervision sessions are held routinely and staff spoken to confirmed they had attended staff meetings. The Dales DS0000029150.V326716.R01.S.doc Version 5.2 Page 22 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, 32, 35, 36, 37 and 38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is managed and run in the best interests of residents. EVIDENCE: The manager has a lot of experience and holds relevant qualifications for running a home of this size. She is well thought of by her staff at The Dales. She is not yet registered with CSCI but is due to complete this before the end of March. The registration process will assess her ‘fitness’ to run the home. Residents’ looked well cared for and were seen moving around the home freely. Those residents who were able to share their views said The Dales felt The Dales DS0000029150.V326716.R01.S.doc Version 5.2 Page 23 like home and this was because of the way the manager and staff treated them. The manager confirmed in the pre inspection questionnaire that some resident’s finances were dealt with by her. Three residents are subject to Power of Attorney. Otherwise resident’s relatives or a third party dealt with any financial arrangements if residents cannot do this for themselves. If the home pays for anything over and above the weekly fee, the family is invoiced for the expense and charged accordingly. There are sound policies and procedures, which the manager effectively reviews and updates, in line with current thinking and practice. All records are kept in a locked filing cabinet in the office when not being used by the staff. There were no concerns regarding health and safety. The Dales DS0000029150.V326716.R01.S.doc Version 5.2 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 X 3 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 2 9 3 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 3 18 3 2 3 2 3 3 3 3 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 X X 3 3 3 3 The Dales DS0000029150.V326716.R01.S.doc Version 5.2 Page 25 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 OP12 Regulation 16 Requirement The registered person must make sure the home provides suitable activities for residents. This requirement is outstanding from May 2006. The registered person must make sure the home provides sufficient storage space in for linen trolleys to stop these being stored in the bathrooms. Timescale for action 29/06/07 2 OP19 23 16/06/07 3 OP8 4 OP15 5 OP19 This requirement is outstanding from June 2006. 17(1)(a) The registered person must 09/04/07 Schedule make sure that staff record any 3 3(k) action they have taken if a residents condition changes. 12(4)(a) The registered person must 09/04/07 & 16(2)(i) make sure that residents are assisted in an appropriate way when dining. This includes the delivery of food and the presentation of drinks. 13(4)(b), The registered person must carry 09/04/07 13(4)(c), out the necessary work to make 16(2)(c) & sure: 23 That all windows are fitted with a DS0000029150.V326716.R01.S.doc Version 5.2 Page 26 The Dales blind or curtains to make sure residents are attended to in private. That all cleaning solutions, which pose a risk, are not kept in areas, which are accessible to residents. That all pathways, leading from a final exit fire door, be kept free of moss and dead leaves. The registered person must carry 24/04/07 out the necessary work to make sure: That all toilet roll holders and bins are fitted with lids to reduce the risk of cross infection. That pipe work in toilets and bathrooms are boxed in to prevent residents from possible harm if hot pipes are exposed. That all bathrooms are fitted with appropriate equipment so that residents can get in and out of the bath with ease. 6 OP21 13(4)(a), 23(2)(j) & 23(2)(m) RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations The Dales DS0000029150.V326716.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Aire House Town Street Rodley Leeds LS13 1HP 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. Extracts may not be used or reproduced without the express permission of CSCI The Dales DS0000029150.V326716.R01.S.doc Version 5.2 Page 28 - 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. 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