Inspection on 14/12/05 for Abbeyfield The Dynes

This inspection was carried out on 14th December 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

Abbeyfield The Dynes 05/09/07

Abbeyfield The Dynes 10/10/06

Abbeyfield The Dynes 28/06/05

Abbeyfield The Dynes 28/09/04

Abbeyfield The Dynes 19/05/04

Similar services:

The Shelley

Springfield House

Sutton Lodge Nursing Home

St Helier`s Residential Hotel

St Joseph`s

Ridgemount

Wingham Court

Old Hastings House

Extracts from inspection reports are licensed from CQC, this page was updated on 08/07/2008.

CARE HOMES FOR OLDER PEOPLE Abbeyfield The Dynes Nightingale Road Kemsing Sevenoaks Kent TN15 6RU Lead Inspector Jo Griffiths Unannounced Inspection 14th December 2005 11:30 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 Abbeyfield The Dynes DS0000024033.V264128.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. Abbeyfield The Dynes DS0000024033.V264128.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Abbeyfield The Dynes Address Nightingale Road Kemsing Sevenoaks Kent TN15 6RU 01959 523834 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) The Abbeyfield Medway Valley Society Mrs Susan Mary Gray Care Home 34 Category(ies) of Old age, not falling within any other category registration, with number (34) of places Abbeyfield The Dynes DS0000024033.V264128.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 28th June 2005 Brief Description of the Service: The Dynes is a purpose built home for the elderly situated in a quiet part of Kemsing village. The home is in close proximity to local shops and there is a bus service to the village connecting with Sevenoaks. Residents are currently all accommodated in single bedrooms although there is the provision of a double bedroom if requested. All bedrooms have an alarm call system and service users are encouraged to personalise their rooms and may bring in small items of furniture subject to Fire Safety Regulations. A shaft lift provides access to all areas of the home. Abbeyfield The Dynes DS0000024033.V264128.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was unannounced and was conducted by Jo Griffiths, Regulatory Inspector, on 14th December 2005 between 11.30 – 15.00. The inspection included a tour of the premises, discussion with staff and the Manager, discussion with some service users and inspection of some records. What the service does well: 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. Abbeyfield The Dynes DS0000024033.V264128.R01.S.doc Version 5.0 Page 6 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 Abbeyfield The Dynes DS0000024033.V264128.R01.S.doc Version 5.0 Page 7 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, 4, 5 Service users have their needs assessed and are able to visit the home before moving in. Most service users feel their needs are well met by the home. Service users have a contract for their care with the home. EVIDENCE: Service users have a contract with the home for their care. The service user or their relative has signed this. Each service user has a full assessment of their needs completed before they move to the home to ensure their needs can be adequately met. They have the opportunity to visit the home to help them make their decision. The other service users formally welcome new service users moving into the home when they arrive. Service users said that they felt their needs were generally well met at the home, although it was acknowledged that there are not always enough staff available for some service users to have a bath as often as they would like. Abbeyfield The Dynes DS0000024033.V264128.R01.S.doc Version 5.0 Page 8 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, 10 Service users have a care plan, but this does not always ensure their needs are met. Service users’ primary health needs are met, but they are not always supported with their personal care needs as stated in the care plan. Service users feel they are treated with respect by staff. EVIDENCE: Each service user has an individual plan of care. This is based on their assessed needs and is kept under review. However, it was noted that some areas of the care plan are not followed consistently. This was in particular relation to bathing. Where a service users care plan stated they would be supported to have a bath weekly or twice weekly, the records of baths taking place did not support this in every instance. In some cases some service users had not been supported to have a bath for 3 weeks. Staff spoken with said that there was not always enough time to offer baths to each service user each week as there are increasing pressures with staff sickness, domestic duties and vacancies. One service user had not been supported to have a bath for 2 weeks as he prefers a male carer and the home only employs one male carer who happened to be on leave at this time. Arrangements should be made in future for another male carer to be available for this gentleman. Abbeyfield The Dynes DS0000024033.V264128.R01.S.doc Version 5.0 Page 9 Service users spoken with said that they would like to be able to have more flexibility in when they can have a bath and some were concerned that if they refused their bath they would not have another opportunity for some time. Most service users said they like to use the assisted bath downstairs and one bathroom upstairs is not used, as it is not accessible to people with mobility difficulties. It is required that the unused bathroom be converted to provide assisted bathroom facilities. Service users said that the staff respect their privacy and they feel they are treated with respect. The previously broken lock on the toilet door has been replaced. Abbeyfield The Dynes DS0000024033.V264128.R01.S.doc Version 5.0 Page 10 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 Service users benefit from some activities in the home, but these can be sporadic and they would benefit from regular activities and accurate advertising of these. Service users enjoy the types of activities available. EVIDENCE: Records show that activities have improved since the last inspection and a new way of recording is being introduced. However, it was noted that the home is reliant on one carer to arrange activities. This member of staff is allocated to activities and has 2 shifts a week for this task, although this does not always happen. Rotas and activity records show that when there is a shortage of care staff activities do not take place. On the day of the inspection the activity worker was on shift as a carer and there were no domestic staff on duty. This meant that the majority of the morning was taken up with making beds and other domestic tasks and no planned activities took place. It is recommended that a member of staff dedicated to activities be employed. It is also recommended that the activity board for service users accurately display the planned activities for the week. For example, it said a church service was due but this had not occurred. This could be confusing to service users and should be kept up to date. Service users were positive about the types of activities available. Abbeyfield The Dynes DS0000024033.V264128.R01.S.doc Version 5.0 Page 11 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 Service users know how to make a complaint and know they will be listened to. EVIDENCE: There has been one complaint received by the home recently and the Management team have carried out a full investigation. The complaints procedure is clearly displayed for service users and visitors to use and all complaints are logged accurately and responded to quickly by the Manager. Service users said they know who to talk to if they have any concerns and feel they are listened to. Abbeyfield The Dynes DS0000024033.V264128.R01.S.doc Version 5.0 Page 12 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, 20, 21, 22, 25, 26 Service users live in a comfortable, clean, safe and well maintained home. They have access to plenty of communal space and sufficient toilets. Service users would benefit from more assisted bathrooms. EVIDENCE: The home is generally well maintained. It is planned that the hallway carpets will be renewed in the new financial year and some further decoration of hallways will take place. Service users have a number of communal areas they can use and comfortable furniture to relax in. The television set in one lounge was broken and did not show a clear picture. The handyman said this would be replaced. Service users have sufficient toilets near to their bedrooms and communal areas. Some residents have ensuite facilities and there are 3 bathrooms and 1 shower for general use. Most service users prefer to use the assisted bathroom downstairs and there is one bathroom upstairs that is not used, as it is not accessible to people with mobility difficulties. It is required that this bathroom Abbeyfield The Dynes DS0000024033.V264128.R01.S.doc Version 5.0 Page 13 be adapted in light of the changing mobility needs and the wishes of the service user group. Some radiators have been covered or replaced throughout the home, but some in hallways were very hot to touch. The surface temperature of these must be lowered to prevent risk of scalding to service users. This is particular risk for people with mobility difficulties who may fall or grab onto the radiators. The Manager stated that all the requirements from the last EHO report had now been met. The kitchen was not inspected on this occasion. The home was clean and hygienic on the day of the inspection. Abbeyfield The Dynes DS0000024033.V264128.R01.S.doc Version 5.0 Page 14 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, 29 Service users are not supported by sufficient numbers of staff to meet their needs. Staff recruitment procedures are safe and protect service users. EVIDENCE: Observation, discussion with staff and inspection of the rotas showed that there was not sufficient staff on duty to meet the needs of the service users on the day of the inspection. No domestic or laundry staff were on duty and care staff were having to complete these tasks. This meant that there were long periods of time when service users were left unsupported and no activities took place. As reported under standard 8 above, the records of bathing showed that service users’ care plans were not always being carried out. Some staff files were inspected and evidenced that robust recruitment procedures are in place. Abbeyfield The Dynes DS0000024033.V264128.R01.S.doc Version 5.0 Page 15 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): 33, 36, 37, 38 Service users are consulted on their views of the home. They are supported by supervised staff and protected by good record keeping in their care plans. Service users’ health and welfare are protected. EVIDENCE: A recent quality assurance exercise had been carried out with surveys being issued to service users. There was a good response and the comments were mostly positive. The Manager said Abbeyfield will publish the results and produce an action plan. Records of staff supervision showed that sessions are taking place more frequently now. Records within service users’ care plans were detailed and an entry made every few hours. Records in relation to the running of the home are kept up to date and the PAT records for testing appliances are now held at the home. Abbeyfield The Dynes DS0000024033.V264128.R01.S.doc Version 5.0 Page 16 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 3 2 3 X HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 X 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 X 14 X 15 X COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 X 2 3 2 2 X X 2 3 STAFFING Standard No Score 27 2 28 X 29 3 30 X MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X X 3 X X 3 3 3 Abbeyfield The Dynes DS0000024033.V264128.R01.S.doc Version 5.0 Page 17 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 OP4OP7OP 8 Regulation 12(1)(a) Requirement The registered person shall ensure that the care home is conducted so as to promote and make proper provision for the health and welfare of service users. In that, Service users must be offered a bath at the times of their choosing and as agreed in their care plan to maintain their personal hygiene. Arrangement must be made for suitable staff to be available to support service users with bathing when their regular carer is off duty. 2 OP21OP22 23(2)(n) The registered person must ensure that suitable adaptations are made, and such support, equipment and facilities, as may be required, are provided, for service users who are old, infirm or physically disabled. In that, the unused bathroom must be adapted to an assisted bathroom to suit the Abbeyfield The Dynes DS0000024033.V264128.R01.S.doc Version 5.0 Page 18 Timescale for action 31/12/05 31/03/05 3. OP19 23(2)(c) needs of the service users at the home. The registered person shall, 31/12/05 having regard to the numbers and needs of the service users, ensure that equipment provided at the care home for use by service users or persons who work at the home are maintained in good working order. In that, the television set in the lounge must be repaired or replaced. 4. OP25 13(4) The registered person shall ensure all parts of the home to which service users have access to, are so far as reasonably practicable, free from hazards to their safety. In that, radiators around the home must be covered or have a guaranteed low surface temperature. 31/03/06 5. OP27 18(1)(a) The registered person shall, having regard to the size of the care home, the Statement of purpose and the numbers and needs of service users, ensure that at all times suitably qualified, competent and experienced persons are working at the care home in such numbers as are appropriate for the health and welfare of service users. In that, the Manager must provide evidence that sufficient staff, excluding domestic staff, are employed to meet the personal, social and emotional needs of service users each day. 31/01/06 Abbeyfield The Dynes DS0000024033.V264128.R01.S.doc Version 5.0 Page 19 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. 3. Refer to Standard OP12 OP12 OP19 Good Practice Recommendations The planned programme of activities should be advertised accurately to service users. It is recommended that an activity worker, separate from care staff, be employed to ensure activities take place. It is recommended that the carpets that are worn in the hallways are replaced. Abbeyfield The Dynes DS0000024033.V264128.R01.S.doc Version 5.0 Page 20 Commission for Social Care Inspection Maidstone Local Office The Oast Hermitage Court Hermitage Lane Maidstone ME16 9NT 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 Abbeyfield The Dynes DS0000024033.V264128.R01.S.doc Version 5.0 Page 21 - 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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