Inspection on 01/09/05 for Ghyll Royd House

This inspection was carried out on 1st 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

Ghyll Royd House 05/06/07

Ghyll Royd House 06/03/06

Ghyll Royd House 11/03/05

Ghyll Royd House 15/09/04

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

CARE HOMES FOR OLDER PEOPLE Ghyll Royd House New Ghyll Royd Guiseley Leeds LS20 9NE Lead Inspector Mary Bentley Announced 1 September 2005, 10.00am st 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. Ghyll Royd House J52 J03 S1340 Ghyll Royd House V196885 010905 Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Ghyll Royd House Address New Ghyll Royd Guiseley Leeds LS20 9NE 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) 01943 870720 0113 871212 ghyllroyd@lineone.net Ghyll Royd Nursing Home Ltd Mrs Ann McGregor Care Home with Nursing 76 Category(ies) of Old age (61) Dementia (15) Mental disorder registration, with number (15) Terminally Ill (3) of places Ghyll Royd House J52 J03 S1340 Ghyll Royd House V196885 010905 Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: None. Date of last inspection 11/03/05 Brief Description of the Service: Ghyll Royd House is a 76 place care home for older people, it provides nursing care and has a 15 bed unit dedicated to the care of people with dementia. The home also has a number of places dedicated to the care of people with termial illnesses. It was purpose built as a care home and was first registered in 1995. The home is situated in Guisley, a short walk from local shops and facilities including good transport links to Otley, Ilkley, Leeds and Bradford. The building is well maintained and has pleasant gardens. Accommodation is on two floors, there are 72 single and 2 shared rooms and the majority have ensuite facilities. The home is internally divided into 3 units, Yew and Rowan provide general nursing care and Beech is the specialist dementia unit. Each unit has a designated manager who is accountable to the Registered Manager, the Registered Manager is responsible for all aspects of the day-to-day running of the entire home. Ghyll Royd House J52 J03 S1340 Ghyll Royd House V196885 010905 Stage 4.doc Version 1.40 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 March 2005. There have been no further visits until this announced inspection. This inspection was carried out between 10.00am and 5.00pm by two inspectors and before the visit time was spent planning the day. The people who live in the home prefer the term resident; therefore this will be the term used throughout this report. During the inspection, we looked at records, saw care staff carrying out their work and spoke with residents, visitors, staff, and the deputy manager. The Registered Manager was on leave. Comment cards/questionnaires for residents and visitors were sent to the home before the inspection. These provide an opportunity for people to share their views of the home with the Commission for Social Care Inspection. Comments received in this way are shared with the provider without revealing the identity of those completing them. Forty-three comment cards were returned to the CSCI. What the service does well: Ghyll Royd House provides a clean, pleasant and safe home for residents. The home has a friendly atmosphere and all the relatives who returned comment cards said they are always welcomed. All parts of the home are decorated and furnished to a good standard and there are plenty of communal rooms for residents to use. On the day of the inspection several residents spent part of their day on the patio at the front of the home. The bedrooms are suitably equipped and furnished to meet residents’ needs and have good natural light and ventilation. In the bedrooms seen residents had their personal belongings around them. The home has wide corridors and this creates a feeling of spaciousness. Residents are supported and protected by good recruitment practices and there is a strong commitment to staff training and development. Residents are treated with respect and dignity and are consulted about how their care needs will be met. The relatives of less able residents are involved in planning care and all the relatives who completed comment cards said they were kept informed by the home. Ghyll Royd House J52 J03 S1340 Ghyll Royd House V196885 010905 Stage 4.doc Version 1.40 Page 6 The following are some of the comment received by the CSCI “excellent place, full confidence in the care they give”, “fantastic place, could not ask for better”, “I bless the day I went there”, “the staff are truly wonderful”. 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. Ghyll Royd House J52 J03 S1340 Ghyll Royd House V196885 010905 Stage 4.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 Ghyll Royd House J52 J03 S1340 Ghyll Royd House V196885 010905 Stage 4.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) 3. Standard 6 does not apply to this service. Residents are not admitted to the home until their needs have been assessed and they have been assured that these will be met. EVIDENCE: Pre-admission assessments done by the home were seen in the care records examined, copies of assessments done by other health and social professionals were also available. Residents and/or their relatives are encouraged to visit the home before admission. Ghyll Royd House J52 J03 S1340 Ghyll Royd House V196885 010905 Stage 4.doc Version 1.40 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 standard(s) 7, 8, 10 and 11. The personal and health care needs of residents are met in a way that respects their privacy and dignity. Care plans do not give detailed instructions on how care needs will be met and this creates the opportunity for care needs to be overlooked. EVIDENCE: We looked at the care records of six residents, two from each unit. There were care plans in place setting out how personal, health and social care needs would be met. The care plans were reviewed monthly and there was evidence of involvement by residents and/or their representatives. Some of the care plans were not detailed enough to reflect peoples day-to-day care needs, an example of this is the use of phrases such as “regular toileting” and “needs full assistance” which do not give clear instructions to staff. Individual risk assessments were in place dealing with all areas of risk including nutrition, falls, moving and handling, the use of bed rails and the risk of developing pressure sores. The moving and handling risk assessment had good instructions for staff but did not clearly show how the risk had been identified. The risk assessment for bed rails did not have the necessary detail to show that all the issues relating to the use of bedrails had been considered and that consultation with all the relevant people had taken place. Ghyll Royd House J52 J03 S1340 Ghyll Royd House V196885 010905 Stage 4.doc Version 1.40 Page 10 The care records showed that residents have access to a range of health and social care staff including GPs, physiotherapists, Community Psychiatric nurses and Tissue Viability nurses. The deputy manager is the palliative care link nurse, training has been provided in the home by Macmillan Nurses and three senior care assistants spent a week working in a local hospice. The wishes of residents and/or their representatives in relation to their care before and after death are recorded and respected. Residents said they are treated with respect and their right to privacy is respected, staff were seen to be patient and kind in their dealings with residents. Ghyll Royd House J52 J03 S1340 Ghyll Royd House V196885 010905 Stage 4.doc Version 1.40 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 standard(s) 12, 13, 14 & 15. Residents are encouraged to take part in social and leisure activities, to keep in contact with their family and friends and to exercise choice and control over their lives. The choice and quality of food does not always reflect the tastes and preferences of residents and this creates the risk that nutritional needs will not be met. EVIDENCE: The home offers a range of social activities both inside and outside the home. Most residents said they were satisfied with the activities offered. One resident said how much he enjoyed going to the local pub and the activities organiser was seen playing “snakes & ladders” with a resident. It was evident that residents could choose how and where to spend their time, some were outside, some were in their own rooms and others were in the lounges. One resident said, “I have a nice life here”. The records about residents’ participation in social activities were not up to date in all the care plans seen. Visitors were seen to come and go freely, they said they are always welcome and are offered refreshments, one visitor said she often has lunch at the home with her relative. Ghyll Royd House J52 J03 S1340 Ghyll Royd House V196885 010905 Stage 4.doc Version 1.40 Page 12 A number of residents were not happy about the food provided, one said it was not as good as it used to be, another said that you do not always get what you ordered and several commented on the lack of fresh fruit and vegetables. Other people said the presentation was often poor and some people felt it was worse at weekends when basic things like juice and salads were not available. Other people spoke about the poor quality of the bread, the lack of butter and said there was too much pasta. This information was shared with the deputy manager who said she would deal with it. Ghyll Royd House J52 J03 S1340 Ghyll Royd House V196885 010905 Stage 4.doc Version 1.40 Page 13 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, 18 Residents and their relatives have their views listened to, taken seriously and action is taken to resolve issues. Residents are protected and feel safe living in the home. EVIDENCE: The home has not had any complaints since the last inspection. The complaints procedure is available in the home and the majority of residents and relatives said they were aware of how to raise concerns. One relative said there is always someone available to deal with any questions. The home recently received an allegation of abuse, appropriate action was taken to protect residents and the management team showed that they have a good understanding of the multi-agency approach to adult protection. As a result of this incident the home has made some changes to their policies and procedures relating to the protection of vulnerable adults. Ghyll Royd House J52 J03 S1340 Ghyll Royd House V196885 010905 Stage 4.doc Version 1.40 Page 14 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) 19 and 24. Residents live in a home that is clean, safe and well maintained. EVIDENCE: The home was clean and tidy and there were no unpleasant odours. It was evident that there is an ongoing programme of decoration and maintenance. The grounds are kept well and there is a seating area at the front of the home that is used by residents. The garden area leading off the patio outside Beech is not level. This means that residents cannot use this area unless staff accompany them. The door connecting Beech unit to the rest of the home is controlled by a keypad, one relative had been concerned that this was not working properly; the lock had been damaged and has now been replaced. The bedrooms seen were nicely decorated and residents had their own belongings around them, all bedroom doors are fitted with door locks and risk assessments have been done for those residents who do not have a key. Ghyll Royd House J52 J03 S1340 Ghyll Royd House V196885 010905 Stage 4.doc Version 1.40 Page 15 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, 28, 29 & 30. The numbers and skill mix of staff were sufficient to meet the needs of the residents’. Residents are supported and protected by good recruitment procedures. The home supports staff in meeting residents’ needs by providing a programme of training that reflects the needs of the people living in the home. EVIDENCE: The duty rosters show that during the day the ratio of staff to residents is 1:5 on the general nursing units and on the dementia care unit the ratio is between 1:3.75 and 1:5. Overnight the home has 10 staff on duty. The manager’s hours are not included in these numbers and the deputy manager has 12 hours a week supernumerary time. In addition the home employs activities organisers, domestic, laundry, catering, maintenance and administrative staff. Some relatives said that they did not think there were always enough staff on duty and particular reference was made to staffing on Beech unit at weekends. The duty rosters show that the same numbers of staff are on duty every day, the deputy manager said there had been some problems with staffing on Beech earlier in the summer but that the unit is now fully staffed. The staff files showed that all the required checks are done before new staff start work in the home. As well as mandatory training, which includes moving & handling, fire safety and health & safety training provided in the last 12 months has covered Ghyll Royd House J52 J03 S1340 Ghyll Royd House V196885 010905 Stage 4.doc Version 1.40 Page 16 subjects such as palliative care, infection control, dementia care, catheter care and effective communication. Approximately 40 of care staff have an NVQ (National Vocational Qualification) level 2 and 33 of the staff have been trained in First Aid. Some senior care staff spent a week working at a local hospice and the home is now trying to arrange placements with Community Psychiatric Nurses for staff working on the dementia unit. The training programme is ongoing and the next priority is for all staff to attend adult protection training. Ghyll Royd House J52 J03 S1340 Ghyll Royd House V196885 010905 Stage 4.doc Version 1.40 Page 17 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) 38 The health, safety and welfare of residents and staff are protected. EVIDENCE: The pre-inspection questionnaire completed by the home manager showed that all the required health and safety and maintenance checks have been carried out. The training records showed that staff are up to date with mandatory training. Ghyll Royd House J52 J03 S1340 Ghyll Royd House V196885 010905 Stage 4.doc Version 1.40 Page 18 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 x x 3 x x N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 x 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 2 COMPLAINTS AND PROTECTION 3 x x x x 3 x x STAFFING Standard No Score 27 3 28 2 29 3 30 4 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x 3 x x x x x x x 3 Ghyll Royd House J52 J03 S1340 Ghyll Royd House V196885 010905 Stage 4.doc Version 1.40 Page 19 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 7 Regulation 15 Requirement The care plans must set out in detail how the personal, health and social care needs of residents will be met. The food provided for residents must be varied, nutritous and well presented and as far as possible must suit their tastes and prefernces. Timescale for action 31 December 2005 30 November 2005 2. 15 16(2)(i) RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. Refer to Standard 8 19 Good Practice Recommendations The risk assessment documentation in relation to falls, moving and handling, nutrition and bed rails should be reviewed. The garden area outside Beech should be made safe for residents to use. Ghyll Royd House J52 J03 S1340 Ghyll Royd House V196885 010905 Stage 4.doc Version 1.40 Page 20 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 Royd House J52 J03 S1340 Ghyll Royd House V196885 010905 Stage 4.doc Version 1.40 Page 21 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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