Inspection on 28/09/05 for Donisthorpe Hall

This inspection was carried out on 28th September 2005.

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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Donisthorpe Hall 07/04/08

Donisthorpe Hall 05/12/06

Donisthorpe Hall 07/03/06

Donisthorpe Hall 17/01/05

Donisthorpe Hall 22/09/04

Donisthorpe Hall 11/02/04

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Snydale Care Home

Hawkhills

Larchfield Manor

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Ravensworth Lodge

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

CARE HOMES FOR OLDER PEOPLE Donisthorpe Hall Shadwell Lane Leeds LS17 6AW Lead Inspector Michael Smithson Announced 9.30am 28 September2005 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 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. Donisthorpe Hall J52_S1337 Donisthorpe Hall V243848 280905 Stage 2.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Donisthorpe Hall Address Shadwell Lane Leeds LS17 6AW Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 0113 2684248 0113 2370502 Donisthorpe Hall Company Limited Mrs Lynne Dunderdale Care Home 163 Category(ies) of Old Age (163) Dementia -over 65 (45) Mental registration, with number Disorder -over 65 (45) Terminally Ill (1) of places Donisthorpe Hall J52_S1337 Donisthorpe Hall V243848 280905 Stage 2.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: The place for TI(E) is for the named service user only. Date of last inspection 17/01/05 Brief Description of the Service: Donisthorpe Hall is a large care home, which also provides nursing care. The original house was converted in 1956 and extended over time to become what it is today. The last extension, named, Silver Lodge, provides accommodation for forty service users. This area offers facilities including a kitchen; lounges; dining areas and bathrooms. All bedrooms are for single occupancy and are fitted with an en-suite. The organisation continues to improve facilities and accommodation. There is a long-term refurbishment programme, which is organised in set phases. Current work includes improved staff facilities. There are two passenger lifts available in the home, which allow service users to access all areas of the home. There are a number of communal areas including a synagogue, cinema (seating capacity for up to forty two), coffee shop, reception, physiotherapy area, sensory room and a range of sitting rooms. The overall effect is very pleasing and has made a significant impact on the entrance area. The home is situated in extensive private grounds, in a residential area of Leeds. There is ample parking for visitors and staff. The area is well served by public transport. Within the registered numbers, fortyfive people may be accommodated who are suffering from dementia or a mental disorder. Donisthorpe Hall accommodates predominantly Jewish adults and offers a strictly kosher environment. Donisthorpe Hall J52_S1337 Donisthorpe Hall V243848 280905 Stage 2.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection was announced and took place over the morning and afternoon of the 28 September 2005. A team of 3 inspectors undertook the inspection. This was the first of 2 inspections for this year, the second will be unannounced. The inspectors spent time on 3 of the units. The Specialist Dementia unit, Unit 1 and Silver Lodge. The inspection focused on the outcomes for service users, records, meals and activities. The staff recruitment procedure was checked together with staff training. Time was spent on each of the units inspected and discussion took place with service users, visitors and staff. A poster had been displayed informing service users of the inspection. Feedback questionnaires were provided and a significant number were returned prior to the inspection. The feedback cards included very positive comments about the home and the care provided. What the service does well: The home provides very good information about the facilities offered and the service provided. The information is contained in the statement of purpose, service user guide and welcome pack. The environment for service users is geared to meet their needs. Parts of the premises are still in the process of refurbishment. The completed work has been done to a very high standard. An excellent range of activities and entertainment facilities are provided. Service users said that they felt they had a very good choice of activities. They particularly enjoyed using the cinema and the coffee bar area. Many service users enjoy organising their own activities with friends and family. The cultural needs of service users are met. The home specialises in providing a service for Jewish service users and provides a kosher diet and a Synagogue is on site. The home always celebrates the Jewish festivals. The feedback regarding the food was mixed, however the majority of the service users felt they were offered a good choice and the food provided was of a good quality. The dinning experience in Unit 1 and the main dinning area was very positive. The tables were attractive and staff were on hand to offer any assistance required. Donisthorpe Hall J52_S1337 Donisthorpe Hall V243848 280905 Stage 2.doc Version 1.40 Page 6 What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Donisthorpe Hall J52_S1337 Donisthorpe Hall V243848 280905 Stage 2.doc Version 1.40 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 Standards Statutory Requirements Identified During the Inspection Donisthorpe Hall J52_S1337 Donisthorpe Hall V243848 280905 Stage 2.doc Version 1.40 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 1, 3 and 4. Service users are provided with information to enable them to make an informed choice about the home. The admission process is good and includes introductory visits. EVIDENCE: The statement of purpose and service user guide are available and are updated. The information can be produced in large print. An additional brochure regarding the services provided is also provided. Copies of the information are included in the Welcome Packs for new admissions. In addition to the statement of purpose and service users guide a Care Strategy document has been produced which provides all staff with information regarding the aims and objectives for the establishment. This is good practice. Service users are admitted following a pre-admission assessment. The organisation has its own pre-admission assessment form and a member of staff within the organisation has the responsibility for undertaking all the assessments. Donisthorpe Hall J52_S1337 Donisthorpe Hall V243848 280905 Stage 2.doc Version 1.40 Page 9 Donisthorpe Hall J52_S1337 Donisthorpe Hall V243848 280905 Stage 2.doc Version 1.40 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 7, 8, 10 and 11. A new care planning system is being implemented at the home. The records provide good information regarding service user care and health needs. The care records on the Specialist Dementia Unit need to be reviewed to make sure the health care needs are up to date. EVIDENCE: Each of the 3 inspectors carried out case tracking on 3 of the units. These included Unit 1, Silver Lodge and the Specialist Dementia Unit. The care records for Unit 1 and Silver Lodge provided evidence of good attention to all aspects of life – health care, personal care & support, emotional care and social care. There were specific care plans in place for areas assessed as being high risk, e.g., pressure relief and wound care. Risk assessments are routinely in place for moving and handling, nutrition, Bed safety rails and individual lifestyle risks. The care seen matched the care that was written about in the plans. Two service users were seen in their rooms, one whilst having specific nursing Donisthorpe Hall J52_S1337 Donisthorpe Hall V243848 280905 Stage 2.doc Version 1.40 Page 11 intervention for a P.E.G. feed. Good practice was observed with plenty of communication between service user and nurse. There was evidence that the staff have tried hard to accommodate individual preferences for the timing of events, even to the extent of training more staff to handle the P.E.G. feed. There was widespread approval about the staff. All the service users felt the staff were cheerful, hard working and were appreciative of the help and support they provide. Some of the more independent service users in Silver Lodge were asked if they knew whether they had a care plan. Most were unaware. Evidence must be available that service users and relatives have been included in the production and review of the care plans. Good communication was observed between care staff and the Unit Manager on Unit 1, regarding a service user who was feeling unwell that day. The GP service is good. The home deals mainly with 3 practices, all of which have doctors with a special interest in older people. Some surgeries hold “clinics” twice or three times a week within the home and pick up on minor health problems promptly. The tailor made electronic programme for care plans is in it’s introductory phase and looks as though it will be a good addition to the recording system. On the EMI unit four service users files were examined. Each file showed that a comprehensive assessment is taken on each individual. A “Pen Picture” is also taken of the resident, which includes a history of the individual’s life. From this information, a plan of care is developed using the Roper Logan and Tierney nursing care model. Each care file examined was in good order and the care plans were reviewed on a monthly basis. No evidence was found to show that the resident or a representative was involved when developing their care plans. The assessments identified that each individual had complex dementia needs but the plans of care did not reflect that these needs were being met. Examples of this were, constant wandering, aggressive behaviour and communication difficulties. Two care plans indicated that their pressure care and nutritional needs were not being met appropriately. A nutritional assessment must be available for all service users who are at risk. The care documentation of one service user with wounds was examined. The wound care plan did not present a correct picture of the service user needs. It only referred to one wound when there were Donisthorpe Hall J52_S1337 Donisthorpe Hall V243848 280905 Stage 2.doc Version 1.40 Page 12 three, there was no indication of how the wounds should be treated or how often. The records showed that there were gaps of up to fifteen days before the wounds were being redressed. Another service user was identified as having severe blistering of the toes and needed an urgent referral to a chiropodist. There was no care plan in place to deal with this issue. The records did show that service users were seen by other health care professionals when needed. There was no evidence that consultation has taken place with the provision of bed safety rails. Air mattresses are put on top of ordinary mattresses, which reduces the height and effectiveness of the bed safety rails. This poses a risk to the health and safety of services users. Donisthorpe Hall J52_S1337 Donisthorpe Hall V243848 280905 Stage 2.doc Version 1.40 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12, 13, 14 and 15. Donisthorpe Hall provides a very good range of activities and entertainment geared to both individuals and small groups. The cultural needs of service users are very well met. The dining experience on the Specialist Dementia Unit differed from that of the other units and must be reviewed. EVIDENCE: Silver Lodge service users did have comments to make about the food. Some of the comments were positive and some were not. However they did praise the home for providing plenty of social events and companionship. One woman said a relative had told her that it was one of the best homes in the country and she agreed with that. Lots of evidence was noted of people exercising choice over their own lives. A lot of the service users could self-advocate. The service users were not afraid to approach management, but some had feelings that action was not always taken. The Senior Care had been on an Activities Course at Thomas Danby College. Donisthorpe Hall J52_S1337 Donisthorpe Hall V243848 280905 Stage 2.doc Version 1.40 Page 14 A volunteer present on the unit described what she did. She ran errands for service users, organises card games and compiles the Donisthorpe Magazine. There are 5 volunteers that visit service users on Unit 1, which helps to expand their existing social contacts. A number of computers are available and a volunteer provides training and support for service users wishing to use the facilities. The computers are linked to the Internet, which allows service users to e-mail family and friends. There was plenty of evidence of family involvement, also the involvement of the Jewish community in the area. The home was very busy and provides a lively environment. Relevant special events celebrated are observed, e.g., Jewish New Year. There was good information for staff so they can understand the culture and help service users to observe in the traditional ways if they wish. On the Specialist Dementia Unit Service users files showed that their interests are recorded as part of their admission assessment. An activities coordinator works with the service users on the unit and the files seen showed records of activities. Some service users recently went out for a fun walk, which was planned by the Alzheimer’s society. A room on the unit has been developed as a “calm room” for service users to use as a form of relaxation. This is good practice. The mealtime was chaotic and appeared rushed. It was not viewed as a pleasurable social experience. Carers did not appear to be aware of the assistance service users required with eating their meals, with the result that some of the meals went cold. Carers stood over service users and gave them a few mouthfuls of food and then walked away with no explanation. The communication between carers and residents during the mealtime was very minimal. The dining areas were very bare with no condiments, knives and forks or napkins. Service users were observed using tablecloths and blue plastic napkins to clean their mouths. The meal taken in the main dinning room was a very positive experience. The tables were very attractive and contained all the required condiments. The meal was very enjoyable and was very well presented. The staff were on hand to provide assistance where required and offer second helpings. A choice was offered and fresh fruit was provided to finish the meal. The feedback from the service users in this area was very positive. They felt the home offerered an excellent choice and they had the opportunity to discuss the menu with the catering staff that served the meal. Donisthorpe Hall J52_S1337 Donisthorpe Hall V243848 280905 Stage 2.doc Version 1.40 Page 15 Donisthorpe Hall J52_S1337 Donisthorpe Hall V243848 280905 Stage 2.doc Version 1.40 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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 16 and 17. A robust adult protection and complaints policy and procedure ensures that service users are listened to and are protected from abuse. EVIDENCE: The organisation demonstrated a positive attitude to dealing with complaints. The complaints procedure is available for both service users and visitors. The last 3 complaints received were assessed. The complaints were fully investigated and an outcome determined. A written response was provided for all the complainants. The Local Ombudsmen is no longer applicable to the CSCI complaints procedure. The contact information for the Ombudsmen must be removed from the homes complaints procedure. Service users rights are protected and they have the opportunity to vote. The home has established links with Advocacy Services. Donisthorpe Hall J52_S1337 Donisthorpe Hall V243848 280905 Stage 2.doc Version 1.40 Page 17 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 standard(s) These standards were not inspected. EVIDENCE: The refurbishment plan is still underway and a significant number of improvements have been made. Further major refurbishment is currently underway and should be completed by late October. Donisthorpe Hall J52_S1337 Donisthorpe Hall V243848 280905 Stage 2.doc Version 1.40 Page 18 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27, 29 and 30. The staffing levels were adequate to meet the needs of the service users. A very good level of training has been provided to ensure staff had appropriate skills to meet their needs. EVIDENCE: Each unit is staffed independently with the units managers having responsibility for the staffing budget and the organisation of the duty rota. This allows the unit managers to determine the appropriate numbers required for each unit and have staff available at key times. An induction training programme is in place for care staff which usually allows between 3 and 4 days to complete depending on previous knowledge and experience. The catering staff organise their own induction training. The organisation has made good progress in achieving the required 50 of care staff completing NVQ level 2. An annual training plan has been produced based on the required mandatory training and feedback from staff meetings and staff supervision. Much of the training is organised internally by the training officer. However some courses are sourced externally. The Records for the last 3 members of staff employed at the home were checked. All the information required was available including, 2 written Donisthorpe Hall J52_S1337 Donisthorpe Hall V243848 280905 Stage 2.doc Version 1.40 Page 19 references and CRB check. A number of staff from Eastern European Countries are currently being employed through an established agency. Donisthorpe Hall J52_S1337 Donisthorpe Hall V243848 280905 Stage 2.doc Version 1.40 Page 20 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31, 32, 33, 37 and 38. The home is very well run and staff are involved in the decision making process. Detailed and up to date records, policies and procedures are available to support the staff in their daily duties. EVIDENCE: The Registered Manager and a team of senior managers with a range of responsibilities within the organisation manage the home. Good systems are in place to provide a quality audit of the services provided. The views of service users have been sought using questionnaires. The results have been analysed and the outcomes discussed. The management team are now in the process of completing a similar exercise with relatives and visitors. The records seen during the inspection were found to be well organised and kept up to date. The accident records were well recorded and are analysed to Donisthorpe Hall J52_S1337 Donisthorpe Hall V243848 280905 Stage 2.doc Version 1.40 Page 21 determine trends. Action is then taken to reduce the incidents where appropriate. Detailed policies and procedures are available to cover all aspects of the work undertaken within the organisation. The policies and procedures are kept up to date and this was confirmed in the pre-inspection information. All the policies and procedures were not assessed during this inspection. Donisthorpe Hall J52_S1337 Donisthorpe Hall V243848 280905 Stage 2.doc Version 1.40 Page 22 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score 3 x 3 3 x N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 x 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 4 14 3 15 2 COMPLAINTS AND PROTECTION x x x x x x x x STAFFING Standard No Score 27 3 28 x 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 3 x 3 3 3 x x x 3 3 Donisthorpe Hall J52_S1337 Donisthorpe Hall V243848 280905 Stage 2.doc Version 1.40 Page 23 No Are there any outstanding requirements from the last inspection? 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 OP 7 Regulation Reg 12(1)(a) Requirement The care plans must include up to date information regarding pressure care treatment and monitoring. Turning charts must be provided where required. Evidence must be provided that service users and relatives have been involved in the care planning and review process. A nutritional assessment must be provided for all service users on the Specialist Dementia Unit. The risk assessments for use of bed safety rails must be reviewed. Only the correct mattress must be used. Timescale for action 01/12/05 2. OP 7 Reg 15(1) 01/12/05 3. 4. OP 7 OP 8 Reg 16 (2)(1) Reg 12(10(a) 01/12/05 Immediate Action. 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 OP 15 Good Practice Recommendations The meal times on the Specialist Dementia Unit should be reviewed. The staffing should be re-organised so more staff time is available for service users who need more assistance. The more able service users should be provided with the same standards and facilities that are J52_S1337 Donisthorpe Hall V243848 280905 Stage 2.doc Version 1.40 Page 24 Donisthorpe Hall 2. 3. OP 16 available in the other dinning areas in the home. The contact number for the Local Government Ombudsmen should be removed from the complaints procedure. Donisthorpe Hall J52_S1337 Donisthorpe Hall V243848 280905 Stage 2.doc Version 1.40 Page 25 Commission for Social Care Inspection Aire House Town Street Rodley Leeds LS13 1HP 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 Donisthorpe Hall J52_S1337 Donisthorpe Hall V243848 280905 Stage 2.doc Version 1.40 Page 26 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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