Inspection on 18/10/05 for Dyneley House

This inspection was carried out on 18th October 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

Dyneley House 24/01/07

Dyneley House 21/02/06

Dyneley House 11/01/05

Dyneley House 22/09/04

Similar services:

Snydale Care Home

Abbey The

Larchfield Manor

Hawkhills

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 Dyneley House 10 Allerton Hill Leeds West Yorkshire LS7 3QB Lead Inspector Ann Stoner Announced Inspection 18th October 2005 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 Dyneley House DS0000001445.V258888.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. Dyneley House DS0000001445.V258888.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Dyneley House Address 10 Allerton Hill Leeds West Yorkshire LS7 3QB 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 268 1812 0113 266 7356 Greendown Trust Limited Mrs Pamela McGown Care Home 21 Category(ies) of Old age, not falling within any other category registration, with number (21) of places Dyneley House DS0000001445.V258888.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 11th January 2005. Brief Description of the Service: Dyneley House is owned by Greendown Trust and is a registered charity. The home provides care, without nursing, to 21 people of both sexes over the age of 65. It was originally set up to provide care and support specifically to members of the Christian Science Church, but now people of all faiths are welcome. The home is set in mature well-tended gardens, and is situated in a suburb of Leeds, close to local shops, and restaurants. There are 21 single bedrooms, all with an en-suite facility, and spacious communal space includes a lounge, dining room and 2 conservatories. There is a no smoking and no alcohol policy in the home. Dyneley House DS0000001445.V258888.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. Over an inspection year from April until March, care homes have a minimum of two inspections a year; these may be announced or unannounced. The last inspection was unannounced and took place on the 11th January 2005. There have been no further visits until this announced inspection. The people who live in the home prefer the term resident, therefore this will be the term used throughout this report. This inspection was carried out between the hours of 9.30am and 5.15pm. During the inspection, I looked at records, saw care staff carrying out their work and spoke with residents, visitors, staff, a committee member of the trust and the manager. Comment cards/questionnaires are left for residents, visitors and other professionals at each inspection. These provide an opportunity for people to share their views of the home with the Commission for Social Care Inspection (CSCI). We discuss any comments received with the manager without revealing the identity of those completing them. None have been returned. Copies of previous inspection reports are available via the Internet at www.csci.org.uk. What the service does well: The home is very well maintained, and furnished and decorated to a high standard. The atmosphere within the home is relaxed and homely. One resident said, ‘I call this home, and it is just like home’. All residents were complimentary about the home and the staff. Comments include, “I couldn’t live anywhere better’, ‘We are very well looked after’, ‘You could never get a better home’, ‘Everybody is nice’, ‘The food is gorgeous’. One person said that the small touches made a difference, such as having the opportunity to have the ‘right kind of sauce’ as an accompaniment to the meal, such as parsley, cranberry, apple, and mint. The staff are smart, look professional and receive a high level of training. The home offers exceptional facilities for visitors, such as providing accommodation for overnight stays and encouraging visitors to stay and have a meal with their relative. The beliefs and values of all residents are respected and nobody is made to feel different. One resident said, ‘This is a home for Christian Scientists, but I follow another religion, and my views are respected.’ Staff recruitment and selection is rigorous to make sure that the people appointed are sympathetic to, and respect, the needs, beliefs and values of all individuals. The home views inspections in a positive way and uses them as a means of improving practice, which is excellent. Dyneley House DS0000001445.V258888.R01.S.doc Version 5.0 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. Dyneley House DS0000001445.V258888.R01.S.doc Version 5.0 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Dyneley House DS0000001445.V258888.R01.S.doc Version 5.0 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 the following standard(s): 1, 3 & 5. Standard 6 does not apply to the home. People thinking about moving into the home are given written information, and have the chance to visit before making any decisions about admission. Staff carry out a pre-admission assessment to make sure that the home can meet the needs of the person. EVIDENCE: There is a statement of purpose on display in the home, and residents and visitors said that they were given both written information and had a look round the home before making any decisions about moving in. One visitor said that she chose the home on behalf of her mother, who was incapable of making an informed choice, because of two factors. One was the ethos of the home, and the second was that the home was well managed. Three pre-admission assessments were sampled. Some contained more information than others. One assessment had some good information as to the level of assistance the resident needed with dressing, whilst another contained information that conflicted with the person’s actual plan of care. From speaking to the manager it was clear that information is gathered from a Dyneley House DS0000001445.V258888.R01.S.doc Version 5.0 Page 9 variety of sources during the assessment process. It is recommended that this be documented on the assessment form, along with more detailed information about the person’s actual needs. For example if a person is suffering from memory loss, there should be information on how this affects his/her ability to function at all levels. The assessments did not have any outcome of the assessment or justification of how the home was able to meet assessed need. Dyneley House DS0000001445.V258888.R01.S.doc Version 5.0 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 & 11. Resident’s needs are met, but care plans do not always provide detailed instructions for staff. Safe practices are followed when handling medication. Residents are treated with dignity and respect, and death is handled with sensitivity. EVIDENCE: From discussions with staff it was clear that they have a good knowledge of the individual needs of residents, and of the care that is required, based on need and individual choice. Residents confirmed that their needs are met. In the care plans sampled, some contained more information than others. There was excellent information recorded for one resident who has diabetes. This person’s care plan gave specific instructions for staff on monitoring blood sugar levels. Other plans were more basic and did not include specific instructions such as how often the resident has a bath, the person’s preferred time for having a bath, and any preference of toiletries. One person’s plan stated that he had some degree of memory loss, but there was no information on how staff should manage this. Another person’s plan said that she had her own teeth, but there was no information as to whether she needed assistance to clean them, such as whether staff had to put toothpaste on her toothbrush, or whether she was able to do this herself. Her plan stated that she enjoyed reading newspapers, listening to music and watching television, but there was Dyneley House DS0000001445.V258888.R01.S.doc Version 5.0 Page 11 no information as to whether staff should give her a newspaper, where she preferred to watch television and listen to her music, and whether she needed any assistance, such as making sure the remote control for her television was within easy reach. This person has Parkinson’s disease, but there was no information about how this affected her functioning on a daily basis. It was clear that another resident suffered from depression but there was no plan on how to manage this. Residents and visitors were aware of the existence of the care plan, and said that they are involved in a monthly review and evaluation. Signatures of residents and relatives were seen in the care plans reviews confirming this. This is commendable. There were good records of GP visits, and the manager said that she could contact the community dietician independent of the GP. Nutritional assessments were not seen in all care plans, and there was no evidence of a review or management plan for one person whose weight had dropped to 40kg. The medication records of residents who have recently completed courses of antibiotics were checked and found to be correct. Where handwritten entries are made on MAR (Medication Administration Records) these are not signed and dated by staff and are not checked and countersigned by a second person. Staff were seen knocking on doors before entering, some residents have telephones in their room, and residents said that they could see visitors in the privacy of their own room. A member of staff said that privacy and dignity was included in her induction programme. A visitor said the home had handled his father’s death with sensitivity and he described the level of support given to members of the family. Dyneley House DS0000001445.V258888.R01.S.doc Version 5.0 Page 12 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. Residents are able to live their lives according to their beliefs and personal choices. They are able to maintain contact with family and friends and excellent facilities are provided for visitors. EVIDENCE: Residents spoke of the degree of flexibility and choice they have in the home. They said that they could choose what time to go to bed, and what time to get up in the morning. They also spoke about how their individual beliefs and values are respected. At the time of this inspection a Christian Science reading was taking place in the conservatory. These readings take place on a weekly basis and are integral to the way of life of the Christian Scientists who live in the home. Residents not of this faith said that there is no obligation or pressure put on them to join in the readings, but anyone from any domination may listen and join in. It was noted that two residents not from the faith were listening to the reading. One person said there is no discrimination within the home and that the beliefs and values of all are respected. Residents said that their visitors are always made to feel welcome. One resident said, ‘Staff always make a point of saying hello to visitors, and they are always offered a drink’. One resident said that his daughter always visits on Sunday and stays for lunch with him. The wife of a resident explained how her husband has a large room. Another bed has been placed in the room so Dyneley House DS0000001445.V258888.R01.S.doc Version 5.0 Page 13 that she can stay with him for a long weekend. She said she appreciates this and regularly stays with her husband. This is commendable. Dyneley House DS0000001445.V258888.R01.S.doc Version 5.0 Page 14 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 & 18. Complaints are taken seriously and residents are protected from abuse. EVIDENCE: Residents said that they would have no hesitation in making a complaint should the need arise, and one person said she had seen a notice on a board near the front entrance saying the manager should be made aware of, and would deal with, any complaint. A care worker was able to describe the different types of abuse and was aware of the more subtle kinds of institutional abuse such as leaving residents waiting for assistance. Senior staff were able to explain how they would deal with any suspicion of abuse and were aware of the policies and procedures relating to adult abuse. The home has a copy of the Multi-Agency Adult Protection Procedures, but the home’s policy and procedures does not refer staff to these procedures. Dyneley House DS0000001445.V258888.R01.S.doc Version 5.0 Page 15 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): These standards were not assessed. EVIDENCE: Dyneley House DS0000001445.V258888.R01.S.doc Version 5.0 Page 16 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, 29 & 30. Staff are well trained and the staffing levels are appropriate for the home. Overall the home’s recruitment policies and procedures are robust. EVIDENCE: The staffing rotas were reviewed and there were sufficient staff on duty. The home places much emphasis on staff training and development. The manager explained how she has sourced various organisations that provide fast track access to NVQ (National Vocational Qualifications). From a care team of thirteen, five have completed a NVQ and two are working towards completion. The housekeeping staff have an NVQ level 1, and two team leaders have recently completed a 28 week management course in Health and Social Care. Senior staff described the induction programme for new staff, which is based on the TOPSS (Training Organisation for Personal Social Services) standards, and a member of staff confirmed that she completed this. It was noted that at least two residents suffer from Parkinson’s disease. It is recommended, because this is a very individual condition and each person will have different features that need to be managed in different ways, care staff access training on this disease. All staff said they were happy with the level of training available. The recruitment and selection of four members of staff was sampled. On the whole the required checks had taken place, but one person was appointed before two written references were returned. The photograph held on staff files is a photocopy of a passport photograph rather than an original, and a minimum of two people do not always carry out the recruitment and selection Dyneley House DS0000001445.V258888.R01.S.doc Version 5.0 Page 17 interview. A full employment record was not seen on all of the application forms. The terms and conditions of employment do not state that any new convictions (including motoring offences) must be reported to the manager. Dyneley House DS0000001445.V258888.R01.S.doc Version 5.0 Page 18 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, 33, 36 & 38. The home is well managed, and there is a good system of staff supervision in place. Quality assurance systems are in place, and the health and safety of residents is promoted. EVIDENCE: The manager has completed both the Registered Manager’s Award and an NVQ in Care at level 4. She has many years experience in management and caring for older people, and from discussions with staff, residents and visitors it was evident that she is well respected. In addition to managing the home she continues to provide an overview for two sheltered housing schemes, owned by the Greendown Trust. She described how this additional responsibility has a positive impact on the home. Two team leaders, who have recently completed a course in health & social care management, support the manager. All described the close relationship between each other, but there are clear lines of accountability within the management structure. The manager delegates some responsibilities such as staff supervision to the team leaders, but then supervises the team leaders herself. Staff confirmed the structure of the Dyneley House DS0000001445.V258888.R01.S.doc Version 5.0 Page 19 supervision system and said that they felt that supervision was a worthwhile and valuable process. The manager hosts regular meetings for other home managers, she said that these meetings provide the opportunity to share experiences and practices as well as providing a safe haven to voice opinions. The manager described the quality monitoring processes used in the home. These include staff and residents’ meetings and satisfaction questionnaires, distributed annually to residents, relatives, and other professionals such as district nurses and GPs. She was able to show how results from questionnaires are analysed, and are used to improve practices within the home. The manager completed a pre-inspection questionnaire, which states that all the required service and health and safety checks have been completed as required. Three members of staff are trained as moving and handling trainers, and after their annual training update they then deliver and update moving and handling training to other staff. Staff within the home have also completed training given by the Fire Department, so they are qualified to deliver fire training at intervals of no longer than 6 months to all staff in the home. There is a qualified first aider on duty at all times, a fire risk assessment is in place, and health and safety risk assessments have been commissioned by a management consultant and are in place. Accidents not involving any injury or treatment are not routinely recorded in the home’s accident book. Where an accident is not witnessed there is no record kept of when the person was last seen and by whom, and accidents are not analysed on a monthly basis to identify any trends or patterns. Dyneley House DS0000001445.V258888.R01.S.doc Version 5.0 Page 20 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 X 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 4 14 3 15 X COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 X X X X X X X X STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 4 X 3 X X 3 X 3 Dyneley House DS0000001445.V258888.R01.S.doc Version 5.0 Page 21 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 OP7 Regulation 15 (1) Requirement Care plans must set out in detail the action which needs to be taken by staff to make sure that all aspects of the resident’s health, personal and social care needs are met. Timescale for action 31/12/05 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 OP3 Good Practice Recommendations A record should be kept on the home’s pre-assessment form as to where the assessment was carried out, and who provided the information. More detailed information should be recorded about the person’s specific needs. The outcome of the assessment should be recorded along with justification of how the home is able to meet assessed need. Nutritional assessments should be undertaken on admission and reviewed as and when necessary, DS0000001445.V258888.R01.S.doc Version 5.0 Page 22 2 OP8 Dyneley House 3 OP9 4 5 OP18 OP29 particularly if the resident is losing weight. All handwritten entries on Medication Administration Records should be signed and dated by the person making the entry, and should be checked and countersigned by a second person. The home’s policy and procedures relating to adult abuse should refer staff to the Multi Agency Adult Protection Procedures. A recent original photograph, rather than a photocopy of the passport photograph, should be held on the staff file. Wherever possible, a minimum of two people should carry out the recruitment and selection interview. Both should sign and date the interview record. The home should make sure that a full employment history is obtained from leaving school to the present time. The terms and conditions of employment should state that any new convictions (including motoring offences) must be reported to the manager. Care staff should access training on Parkinson’s disease. All accidents should be recorded in the home’s accident book. Where an accident is not witnessed a record should be kept of when the person was last seen and by whom. A monthly analysis should be made of all accidents, so that any trends or patterns can be identified. 6 7 OP30 OP38 Dyneley House DS0000001445.V258888.R01.S.doc Version 5.0 Page 23 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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