Inspection on 05/12/06 for Donisthorpe Hall

This inspection was carried out on 5th December 2006.

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 07/03/06

Donisthorpe Hall 28/09/05

Donisthorpe Hall 17/01/05

Donisthorpe Hall 22/09/04

Donisthorpe Hall 11/02/04

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 08/07/2008.

CARE HOMES FOR OLDER PEOPLE Donisthorpe Hall Shadwell Lane Leeds Yorkshire LS17 6AW Lead Inspector Sue Dunn Key Unannounced Inspection 5th December 2006 09:30 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 DS0000001337.V313294.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. DS0000001337.V313294.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Donisthorpe Hall Address Shadwell Lane Leeds Yorkshire LS17 6AW 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) 0113 2684248 0113 2370502 maria@donisthorpehall.org Donisthorpe Hall Company Limited Mrs Maria Lyn Dunderdale Care Home 163 Category(ies) of Dementia - over 65 years of age (45), Mental registration, with number Disorder, excluding learning disability or of places dementia - over 65 years of age (45), Old age, not falling within any other category (163), Terminally ill over 65 years of age (1) DS0000001337.V313294.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The place for TI(E) is for the named service user only Date of last inspection 7th March 2006 Brief Description of the Service: Donisthorpe Hall is a large care home, which provides residential and nursing care, primarily for Jewish people, but also accommodating the needs of people from a range of cultural and religious backgrounds. The original house was converted in 1956 and extended over time to become what it is today. The last extension, Silver Lodge, provides accommodation for forty service users. The facilities in this area include a kitchen, lounges, dining areas and bathrooms. All bedrooms are for single occupancy and have en-suite facilities. A long-term and ongoing refurbishment programme is gradually improving the facilities and services in all parts of the home. Two passenger lifts allow service users to access all areas of the home. Communal areas include 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, forty-five people may be accommodated who are suffering from dementia or a mental disorder. DS0000001337.V313294.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The purpose of the inspection visit was to ensure the home was operating and being managed for the benefit and well being of the service users. Three inspectors undertook the inspection, which was unannounced. The inspection started at 9.30am and finished at 5.15pm. The report is based on information received from the home since the last inspection in March 2006. A pre inspection questionnaire had been completed and returned by the manager. This, and 14 questionnaires, inviting service users to comment on the care, had been returned at the time of writing and were used to support judgements made during the inspection The inspectors looked at units 3, 5 and Silver Lodge. One inspector spent two hours observing the care experiences of a small group of people on unit 3, which provides care for people with dementia. The care of a random selection of service users was looked at in more depth by an examination of records and discussion with the managers, care workers, visitors and where possible the people themselves. The weekly fees range between £389 - £655. The fee does not cover hairdressing, physiotherapy or chiropody, personal toiletries, clothing or newspapers. The home uses internal and external systems to evaluate the services and facilities, the findings of which contribute to action plans for development and improvement. Annual Quality Assurance Reports are made available. The home has been involved in research projects, some ongoing, with the Primary Care Trust and Leeds University. This has been judged as an excellent home with a management team who continue to work towards raising standards and improving the quality of life for people who live in the home. The inspectors would like to thank all the people who provided assistance and information, which allowed a judgement to be made. What the service does well: The home was spotlessly clean and free from any unpleasant odours, giving visitors a good impression as soon as they walked into the building. This same standard was seen throughout the home. Prospective service users and their relatives were provided with good written information about the services and facilities to enable them to make an informed choice about moving into the home. Care files included background history, which showed staff the uniqueness of each persons life and helped them to make care more person centred. The care files examined included detailed guidance for staff so that they could be consistent in giving service users care in the way they preferred. DS0000001337.V313294.R01.S.doc Version 5.2 Page 6 Overall, staff communicated well with service users, including those who were mentally impaired, and attended to their needs with tact and understanding. Health care needs were well documented with good back up support from other health care professionals. A range of aids and adaptations were in use based on assessed needs. Service users, relatives and visiting health care professionals described staff as kind and caring. The home offered a range of social and recreational opportunities to suit most tastes and abilities. Relatives and friends were made welcome and seen as partners in care. The home was sensitive to the cultural and spiritual needs of Jewish and none Jewish service users. Staff had access to advice and information on Jewish life and culture. The majority of people were satisfied with the meals. Those people who needed assistance to eat and drink were helped to do so with dignity and at a pace to suit their needs. Staff were alert to each person’s dietary intake and food supplements were given where required. The home’s training programme provided staff with the knowledge they needed to do the job and opportunity for personal development. It was apparent that service users were benefiting by being cared for by staff who were putting their training into practice and appeared relaxed and confident. The home was well managed by a professional team of managers who had acted on information raised during previous inspections and from their quality audits. What has improved since the last inspection? A manager, with training and experience in dementia care, had been appointed to manage the dementia unit. She was observed to work alongside staff, setting a good example by her own practices and approach. There had been some refurbishment, redecoration and development work on the unit to improve standards and make the environment more visually appealing and stimulating. Themed décor and pictures prompted memories and conversation to make it easier for people with dementia to differentiate between one room and another. Tactile boards gave service users a focus for activity and diversion. Approval had been given for the open screening between the main communal area on the dementia unit and an adjoining dining area to be filled in to increase privacy and reduce noise levels. Staff were seen to respond to service users in a calm and understanding way helping to reduce noise and other factors, which can lead to service users becoming agitated. Staff facilities had been improved which was said to have improved morale The standard of cleanliness, hygiene and odour control in the home was excellent. An ongoing building and maintenance programme ensure the home keeps apace and exceeds environmental standards. DS0000001337.V313294.R01.S.doc Version 5.2 Page 7 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. DS0000001337.V313294.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection DS0000001337.V313294.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 3, 4 and 5 (6- the home does not provided intermediate care) Quality outcomes in this area were good. This judgement was based on all the available evidence including information received from the home before the inspection and gathered during the inspection visit. The information for prospective residents and the pre admission process allows people to make an informed choice about the home. Assessment documentation could be improved by ensuring all the information is signed and dated. EVIDENCE: Several residents and their families in Silver Lodge and unit 2 were spoken with. They said they were provided with sufficient information to enable them to make a decision to move into the home. A Statement of Purpose and Service User Guide gave clear information about the level of care that could be provided by the home to both current and prospective residents. The needs of all prospective residents were assessed before admission to the home so that all concerned could be assured that needs could be met. However, it was noted that some copies of the preadmission assessments had not been signed and dated. DS0000001337.V313294.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9, 10 and 11 Quality outcomes in this area were good. This judgement was based on all the available evidence including information received from the home before the inspection and gathered during the inspection visit. Care plans were detailed and gave information about more than physical care needs. There was evidence to show service users and their families had been part of the process and able to express their wishes for end of life care. The care files on Silver Lodge should be fully completed to bring them up to the standard seen elsewhere. EVIDENCE: A selection of care files was examined on the 4 units inspected. Service users had their own individual records with care plans which included details about their physical, social and emotional needs which were clear and easily understood. The care files on the dementia unit included some life history information to assist staff in their understanding of each person’s individuality. An excellent example of this was seen in a life storybook, compiled by the family of one person, which included photographs from all phases of her life with captions. DS0000001337.V313294.R01.S.doc Version 5.2 Page 11 This provided staff with a good background to enable them to give person centred care. A two-hour period of close observation on this unit and examination of the care files of two of the people observed showed, overall, care plans were being followed. For example, staff were seen to follow the guidance in one care plan on how to communicate with the person by getting down to her level and making eye contact. Some staff and the manager were very good in speaking to people and used every opportunity. One particular carer carried out tasks with hardly any verbal input and on several occasions was overheard shouting across the room to one person who was becoming agitated and banging on the table rather than attending to her needs. Other staff approached promptly and with tact as stated in the care plan and used methods to divert. None of the dependant, seated residents were seen to be encouraged/assisted to stand or move during the period of observation. Two people were case-tracked on Unit 5, which provides nursing care. Care records were looked at in depth and where possible the individuals were spoken with. Care records showed that nursing care plans were in place, supplemented by appropriate wound care plans, dietary intake charts and specific risk assessments. General Practitioners provided health care support. One visiting doctor said that staff were very, very kind and the standard of care good. There was evidence that one person had received treatment from the in-house physiotherapist. Computerised daily records were being introduced and were at different stages on each unit. A paper copy of the information was transferred to the files each day. This was leading to a build up of paperwork in each file. On one unit staff were trying to work with a mixture of electronic and hand written records. Most of the files looked at were detailed and informative describing personal preferences. On one unit however two of the files had no photo of the service users and the weight chart, nutrition chart and personal belonging/inventory were not completed. There was evidence to show that where appropriate and safe people were supported to maintain some control over their own medication administration. Where medication administration was observed good practice was demonstrated throughout the process, with particular regard to checking the condition of the service user before specific drugs were given. Recording was done at the time that the drugs were given. Service users who were spoken to said they felt well cared for by the staff. Some relatives were also spoken to and were asked their opinions about the standards of care given. All said that they felt this was of a very good standard. One of the files inspected gave detailed instructions about the person’s wishes for end of life care. DS0000001337.V313294.R01.S.doc Version 5.2 Page 12 One person was receiving end of life care, using the Liverpool Care Pathway document to guide staff in meeting her assessed needs. There was a record that the doctor had had a discussion with the family and included their wishes in the decisions reached. DS0000001337.V313294.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15 Quality outcomes in this area were excellent. This judgement was based on all the available evidence including information received from the home before the inspection and gathered during the inspection visit. The home provided a range of facilities for recreational, intellectual and social stimulation. Staff supported people to lead fulfilling lives. The distribution of staff on the dementia unit however could have been better organised to ensure all service users received a better balance of time for social contact. EVIDENCE: Time was spent talking with and observing a number of the residents who currently live at the home. Those who could all spoke highly of the care and support given to them by the managers and staff. Many of the service users on Unit 5 were frail, but efforts were made to assist them to join in the communal activities on the ground floor. Families who were able to visit at any time were an important part of this and were seen on the day of inspection to take their relatives down to the coffee shop or to the entertainment in the main area. Some people go out and the staff on the dementia unit were making plans for one person to go to the Caribbean Association in order to maintain contact with people of his own culture. DS0000001337.V313294.R01.S.doc Version 5.2 Page 14 The staff on the dementia unit talked about how none Jewish people had their spiritual needs met. A local priest visits the home and it was suggested that individual bedrooms could be decorated for Christmas. There were a lot of visitors on the day of the inspection, most of whom were spoken to. They clearly felt comfortable about the home and said they had good relationships with the staff and were kept informed about their relatives’ progress. Various people came in to the home from the wider community to lead activities; individual service users enjoy reminiscence, listening to an organist, chair exercises and quizzes. One visitor said that he felt his wife did not have sufficient conversation and mental stimulation on the unit she was on and would prefer it if she could move to another unit with more able residents. The manager and nursing staff were aware of this. An Activity organiser employed on the dementia unit was spending 1:1 time with a group of approx 10 people seated in circle in entrance lounge area. Less mobile people were positioned to allow them to observe. The distribution of staff to assist with this could have been better organised as during the two hour period of observation it became apparent that certain members of the group received more staff input whilst others just sat passively. For example one person sitting on a couch communicating with another service user was approached by two separate staff who carried out hand care and a manicure whilst others had no contact at all with staff or other service users during the 2 hour period. During the activities a maintenance person arrived and started hammering without any warning to service users or consultation with staff. He was asked to stop by a member of staff, as there was an inspection. Whilst it is appreciated that essential work needs to be carried out this should, whenever possible, be coordinated to fit around the needs of the people living in the home. Staffing levels were sufficient to assist people to go to bed and get up at times of their choosing. Several residents seen in their bedrooms in bed looked comfortable and clean. Bedroom doors were open so they could see passers by. Residents said that the meals were generally very good, with the exception of one or two who said the quality varied. Time was spent with the residents over lunchtime and all enjoyed their meal. Fluids and fortified drinks were available throughout the day and staff assisted those who required help in an appropriate and unhurried way. Some staff were better than others at using this time as an opportunity to talk to the people they were assisting. DS0000001337.V313294.R01.S.doc Version 5.2 Page 15 One person concerned about having to rely on staff to maintain his orthodoxy was reassured by the discussion with the inspector, that the home’s kitchen was confirmed as being completely kosher. The cultural and dietary preferences of none Jewish people were seen to be respected and catered for in a person centred way. DS0000001337.V313294.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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 Quality outcomes in this area were good. This judgement was based on all the available evidence including information received from the home before the inspection and gathered during the inspection visit. People felt confident (with one exception) that action would be taken to deal with their concerns. Adult protection information and training had been introduced though not all staff had had training. EVIDENCE: People were aware of the complaints policy and procedure and those living in the home said that they felt safe and well cared for. Service users and relatives spoken with felt confident that they could speak to the manager about any concerns. One person however, who returned a questionnaire, felt they were met with an unsympathetic response when they complained. Other people spoken with said they had never really had anything to complain about. One person said, “I don’t like to grumble about little things, because the staff are doing a very hard job.” At the time of the visit there were a number of leaflets around the home asking for residents comments and suggestions on how to improve the service. Service users welcomed this but stated it would be have been more helpful if the leaflets were in larger print and explained by staff. The home has accessed some information about adult protection, however two care staff spoken to said they had not had any adult protection training. Another member of staff had received written information about adult DS0000001337.V313294.R01.S.doc Version 5.2 Page 17 protection and spoke of in house training by the local authority adult protection team. She was able to describe a case, which confirmed her understanding of an abusive situation. DS0000001337.V313294.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 21, 22, 23, 24, 25 and 26 Quality outcomes in this area are excellent. This judgement is based on all the available evidence, which included information received from the home before the inspection and gathered during the inspection visit. The organisation has a rolling programme of refurbishment and rebuilding which has brought most areas of the home up to, and in some cases exceeding, current standards. Progress has been made to improve the environment in the specialist dementia unit. Odour control and cleanliness is of a high standard. EVIDENCE: An ongoing programme of refurbishment has brought most areas of the home up to a high standard. Work was underway to improve the environment on the dementia unit to make it more interesting and stimulating for the people who live there. The size of the unit allows space for people to move about freely but as it is on the top floor there is no access to outdoor areas without the assistance of staff. The management have responded to comments made on previous inspectors about the open screening between this area and the DS0000001337.V313294.R01.S.doc Version 5.2 Page 19 adjoining dining room and are to increase the privacy for the people on both units. A team of maintenance staff is responsible for routine maintenance and repairs. Skirting boards were being replaced involving a lot of banging at a time when people were involved in activities in the same area. Better communication could have allowed this to be done at a time when residents were not using the area, as their needs should be the first consideration. Two service users who were case tracked on the nursing unit were seen in their rooms and there was evidence that appropriate aids to mobility, safety and pressure relief were in place, as described on their plan of care. The home was comfortable, clean and well decorated. The residents’ rooms were welcoming and they were able to bring small personal items to help personalise their rooms. The majority of rooms in the home had en-suite facilities and there were sufficient and suitable communal lavatories and washing facilities for residents and guests. The domestic members of the staff told how they managed their workload to ensure the home is kept clean and tidy. One of the housekeeping staff described the routines for collection of clinical waste, which occurs three times a day, thus preventing bad odours from building up. There was an excellent standard of cleanliness and odour control seen on all the units inspected. Unit 5 was awaiting refurbishment; therefore some of the rooms and bathroom facilities do not meet current standards. Nevertheless, the bedrooms seen were all nicely carpeted and furnished and decorated to a good standard. All of the equipment required to care for that person was seen in the rooms of those who were case tracked; this included pressure-relieving aids, mobility aids and protective gloves, soap and paper towels to maintain good hygiene. The care staff spoken to said that they had enough equipment to move service users safely, including hoists, handling belts and slide sheets. They were seen using the hoists with different service users and it was evident that they were well trained in safe practice; a young carer offered assistance with one manoeuvre, which was politely declined, as he had not yet received training in the correct use of the hoist. Service users said they did not have to wait long for staff to respond when they used the call bell. Staff were seen to respect peoples’ privacy by knocking on doors before entering bedrooms. Work was underway and had been undertaken on the dementia unit to improve the environment and provide interest, prompts and stimulation. Themed décor and pictures in communal rooms helped people to differentiate between the different areas. Tactile boards were being introduced in corridor areas to provide interest and diversion. One seen had a door-fastening theme, with locks bolts handles, knockers and a bell. A music/reminiscence area was being planned. DS0000001337.V313294.R01.S.doc Version 5.2 Page 20 The open screening between the dementia unit and the adjoining dining room, raised as an area of concern on past inspections, is to be filled in to reduce the agitation and noise levels between the two areas. As the environment can have a significant impact on the well being of people with dementia this imaginative approach is encouraging and should be ongoing to maintain a positive outcome for people living and working in the unit. All people were appropriately dressed in well cared for clothing. Staff carry out the task of labelling clothing if families are unable or unwilling to do so, this however takes time away from direct care of service users. DS0000001337.V313294.R01.S.doc Version 5.2 Page 21 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28 and 30 Quality outcomes in this area were good. This judgement was based on all the available evidence including information received from the home before the inspection and gathered during the inspection visit. The staff were confident and relaxed with senior staff seen to lead by example. Comments made by residents and visitors were very positive about the staff and they complimented their care and kindness in meeting personal needs. Overall, staff practices observed during the time spent on the different units was good. EVIDENCE: The pre inspection questionnaire submitted by the manager gives a total staff group of 24 nurses and 85 care workers with 53 of the care staff having a National Vocational Qualification (NVQ). Nursing staff receive updates on clinical topics. There is an annual staff training programme for care staff which includes fire safety, infection control, manual handling, health and safety, adult protection, food hygiene, NVQ 2 and 3, managing stress, individual person planning, back care, and an introduction to Jewish culture. The dementia strategy programme for the coming year shows more emphasis is to be placed on specialist dementia training. The new manager of the dementia unit, who is a Registered Mental Nurse, has already introduced some in house training for staff on person centred care. DS0000001337.V313294.R01.S.doc Version 5.2 Page 22 A member of the care staff confirmed she had received a good range of training in the two years she had been employed. Other staff spoken to had worked at the home for a long time and said they had seen many changes for the better, mainly better accommodation and facilities for the service users. One unit manager felt satisfied that the delivery of care on her unit was good; some moving and handling issues still arise, where best practice slips, but this was spotted and dealt with. Methods of staff team working had been reviewed. The changes had been beneficial to the smoother running of the units and improved understanding of residents needs. There was a good ratio of 2 nurses and 7 care staff working 8am – 8pm shifts for 36 residents on the dementia unit, where people were observed to need 1:1 assistance with eating and drinking. Service users on this unit would benefit from a more balanced deployment of staff time and tasks to ensure everyone on the unit had some 1:1 contact. The home has a diverse staff team, many coming from mid Europe. One manager felt that as English was not their first language some may, at times, lack confidence to interact verbally with service users. Staff spoken to and observed during the inspection appeared relaxed and confident. Systems were in place for sharing information about care needs between shifts. The comments made by residents and visitors were very positive about the staff and they complimented their care and kindness in meeting personal needs. Overall staff practices observed during the time spent on the different units was good. DS0000001337.V313294.R01.S.doc Version 5.2 Page 23 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 32, 33, 34, 35, 36, 37 and 38 Quality outcomes in this area were excellent. This judgement was based on all the available evidence including information received from the home before the inspection and gathered during the inspection visit. The home is well managed with opportunities for people living and working in the home to express their views and make suggestions. The standard of record keeping was high overall with a minor shortfall due to omissions on one of the units A recommendation was made to provide regular financial statements for people whose personal allowances were managed by the home. EVIDENCE: There was a professional approach to the management of the home with each section of the home’s operation having its own manager. The managers of each section of the home attended the feedback and were receptive to the inspectors’ findings and comments. DS0000001337.V313294.R01.S.doc Version 5.2 Page 24 The home was having an external quality audit at the time of the visit. Health and Safety was well managed and safety checks documented. Nothing was seen at the inspection that could cause a hazard to service users or visitors. The home manages the finances for several service users. Records were available and up to date for all transactions. It was suggested by the inspectors that as good practice each person be given a statement of their financial transactions each month. This would enable people to keep track of their balance each month. On one unit there was evidence that staff have an annual staff appraisal as well as regular staff supervision. Records showed that service users and staff were able to make a contribution to the operation of the home through resident and staff meetings. The home has an ongoing improvement and development plan as detailed elsewhere in the report. Managers explained how an investment in improving staff facilities had raised morale throughout the staff team. The registered manager had a good knowledge of each of the units. Those units inspected were well managed. The manager of the dementia unit was seen to set an excellent example of good practice for staff to follow. The atmosphere on the unit was calm and tranquil in comparison to the atmosphere reported during previous inspections. A copy of the inspection report was said to be available in the reception area for anyone who wished to read it. DS0000001337.V313294.R01.S.doc Version 5.2 Page 25 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 x 3 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 4 8 4 9 3 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 4 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 x 18 3 4 3 3 3 3 3 3 4 STAFFING Standard No Score 27 3 28 3 29 x 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 4 4 3 3 3 3 2 4 DS0000001337.V313294.R01.S.doc Version 5.2 Page 26 Are there any outstanding requirements from the last inspection? NO STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP3 OP8 OP37 Regulation Reg 12(1)(a) Requirement All documentation in care files must be signed dated and fully completed Timescale for action 28/02/07 DS0000001337.V313294.R01.S.doc Version 5.2 Page 27 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 OP8 Good Practice Recommendations Less mobile and or motivated service users should be encouraged to change position and stand periodically to reduce the risk of pressure ulcers. Staff should make better use of mealtimes as an opportunity to talk to less able service users Maintenance staff should liaise with staff to minimise the disruption to service users when work is being carried out. Work to separate the dining areas on Unit 3 and Unit 5 to reduce the level of noise and distraction should be completed as soon as possible. Service users suggested that leaflets asking them to express their views about the home would have been better in larger print and with some explanation from staff. Service users should be given a monthly statement of their finances. 2 3 4 OP15 OP19 OP33 OP20 5 6 OP32 OP32 OP37 DS0000001337.V313294.R01.S.doc Version 5.2 Page 28 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. 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