Inspection on 09/03/06 for Ghyll Court

This inspection was carried out on 9th March 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

Ghyll Court 08/03/07

Ghyll Court 05/10/05

Ghyll Court 18/02/05

Ghyll Court 01/09/04

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

CARE HOMES FOR OLDER PEOPLE Ghyll Court The Wells Walk Ilkley West Yorkshire LS29 9LH Lead Inspector Sughra Nazir Unannounced Inspection 9th March 2006 11:00 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 Ghyll Court DS0000001279.V283804.R01.S.doc Version 5.1 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. Ghyll Court DS0000001279.V283804.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Ghyll Court Address The Wells Walk Ilkley West Yorkshire LS29 9LH 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) 01943 607059 01943 607059 Mrs Jane Mary Verfuerth Mrs Jane Mary Verfuerth Care Home 14 Category(ies) of Dementia - over 65 years of age (3), Old age, registration, with number not falling within any other category (11) of places Ghyll Court DS0000001279.V283804.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 5th October 2005 Brief Description of the Service: Ghyll Court is a converted, extended property situated close to Ilkley town centre. It was first registered in November 1989 and bought by the present owner in 2001. Mrs Verfuerth, the owner, also manages the home on a day-today basis. The home provides personal care and support for 14 older people who do not require nursing care. There are twelve single bedrooms and one double room, most with en-suite facilities. The home stands in attractive gardens and is within easy reach of Ilkley Moor, the railway station and public transport links to Leeds, Bradford and Skipton. Ghyll Court DS0000001279.V283804.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection took place over the morning and early afternoon of the 9th March 2006. It was the second and final inspection for this year and was carried out again without prior announcement. Copies of reports for this and previous inspections are available to read at the home and on the CSCI website. www.csci.org.uk The focus of the visit was to look at progress made since the last inspection and to spend time with service users. Time was spent speaking to service users and observing care provided over lunch and afternoon periods. What the service does well: What has improved since the last inspection? What they could do better: Recording of medication administered needs to improve to comply with standards and the Royal Pharmaceutical Society of Great Britain guidelines. There should be a record of staff signatures/initials for identication and all medication administration records should be fully completed to record when medication has been administered. Ghyll Court DS0000001279.V283804.R01.S.doc Version 5.1 Page 6 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. Ghyll Court DS0000001279.V283804.R01.S.doc Version 5.1 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 Ghyll Court DS0000001279.V283804.R01.S.doc Version 5.1 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): Not assessed on this occasion. EVIDENCE: Ghyll Court DS0000001279.V283804.R01.S.doc Version 5.1 Page 9 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, 9 and 11 Care plans are thorough and promote individualised care. Recordkeeping of medication administered needs to be improved. EVIDENCE: Service user care plans have improved significantly and now provide a lot more detailed information including risk assessments, recording of monthly reviews and the wishes in relation to end of life care. Minor improvements to the layout and contents of service user files, care plans and daily records could be made so that information is easier to find. Service users who are able to do so have signed their care plans. Every service user’s care plan contains very detailed information about their preferences in relation to getting up, having a bath, drinks and night time routines such as preferred number of pillows, preferred time for retiring. This is good practice. Ghyll Court DS0000001279.V283804.R01.S.doc Version 5.1 Page 10 The home uses the Boots chemist service for medication supply. All staff have received training and senior staff are now undertaking a distance learning course to develop their awareness of medication. Medication administration records were inspected and there were some gaps in recording making it unclear whether medication had been administered or not. The home was advised that this was unsafe practice. There was no list of usual /approved signatures of staff administering medication. Service users who are able to self-administer are encouraged to do so and their medication is handled safely. Ghyll Court DS0000001279.V283804.R01.S.doc Version 5.1 Page 11 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): 15 Service users receive well-balanced meals in pleasant surroundings. EVIDENCE: Service users enjoyed a three-course meal consisting of chicken soup, shepherds pie with accompanying seasonal vegetables, followed by fruit strudel or ice cream. Food was served in a formal dining room and also made available to service users in the lounge and their bedrooms. The meal was enjoyed and two service users said that the food is always good. Food likes dislikes and preferences are identified and recorded on individual files. Menus are changed regularly. Ghyll Court DS0000001279.V283804.R01.S.doc Version 5.1 Page 12 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 Service users are protected by a clear complaints process. EVIDENCE: The home’s complaints procedure includes timescales for response and all the details needed for contacting the Commission. The information is available to service users and their representatives in a folder prominently displayed in the foyer. The policy states that any complaints received will be taken seriously, acknowledged and fully investigated. Ghyll Court DS0000001279.V283804.R01.S.doc Version 5.1 Page 13 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): Not assessed on this occasion. EVIDENCE: Ghyll Court DS0000001279.V283804.R01.S.doc Version 5.1 Page 14 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28 29 and 30 Service users receive care from staff who understand their needs. EVIDENCE: There is a strong commitment to training for all staff including night staff. The training programme in place ensures that all training needs are identified and planned and budgeted. All staff have had training on health and safety, adult protection, moving and handling etc. Individual staff records provide evidence of additional training such as challenging behaviour. Two staff are undertaking training on palliative care, the manager has just updated learning on dementia and will also undertake a distance-learning course on medication planned for staff. All staff have been encouraged to undertake National Vocational training courses. Staff files inspected were complete containing all the required information, including two written references, completed application form, confirmation of identity, job description and signed contracts. The recruitment policy includes verifying references and checking gaps in employment history. Ghyll Court DS0000001279.V283804.R01.S.doc Version 5.1 Page 15 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 38 Service user and staff safety is promoted through robust policies and procedures. EVIDENCE: Health and safety procedures and the home’s policies for safe working are documented and regularly revised. The manager and senior staff have up-todate training on Health and Safety, fire safety and first aid. Risk assessments are in place for the environment. The manager is aware of responsibilities to report any accidents or incidents to appropriate organisations. Ghyll Court DS0000001279.V283804.R01.S.doc Version 5.1 Page 16 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X X X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 X 9 2 10 X 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 X 14 X 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 X X X X X X X X X STAFFING Standard No Score 27 3 28 2 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X X X X X X X 3 Ghyll Court DS0000001279.V283804.R01.S.doc Version 5.1 Page 17 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 OP9 Regulation 13 Requirement All medication records must be fully completed. Timescale for action 01/04/06 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 OP28 Good Practice Recommendations The home should continue implementing the NVQ training programme to ensure that 50 of care staff are qualified to level 2 or equivalent. Ghyll Court DS0000001279.V283804.R01.S.doc Version 5.1 Page 18 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 Ghyll Court DS0000001279.V283804.R01.S.doc Version 5.1 Page 19 - 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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