CARE HOMES FOR OLDER PEOPLE
Gills Top Scar Street Grassington Skipton North Yorkshire BD23 5AF Lead Inspector
Mrs Irene Ward Unannounced Inspection 7th November 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 Gills Top DS0000007960.V260559.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. Gills Top DS0000007960.V260559.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION
Name of service Gills Top Address Scar Street Grassington Skipton North Yorkshire BD23 5AF 01756 752699 01756 753804 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) Anchor Trust Mrs Judith Gibbs Care Home 27 Category(ies) of Old age, not falling within any other category registration, with number (27) of places Gills Top DS0000007960.V260559.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION
Conditions of registration: Date of last inspection 15th September 2005 Brief Description of the Service: Gills Top provides personal care and accomodation for up to 27 older people and is owned and managed by Anchor Trust. The home is a detached property within a short walk of Grassington village centre. The accomodation is purpose built and is spaced over two floors and all areas are accessed by a vertical passenger lift. The home is set in its own grounds. There is car park to the front of the home. Gills Top DS0000007960.V260559.R01.S.doc Version 5.0 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This report relates to an unannounced inspection carried out on the 7th November 2005, which started at 09.45 hrs and finished at 15.00hrs. A tour of the home was carried out which included the service users private accommodation, a selection of records were looked at and time was spent observing activity in the home, talking and listening to service users, relatives and staff. The focus of the inspection was a number of key standards, inspecting the care records of four service users in detail to establish if they corresponded with service users experiences in the home. There were also discussions with two visitors and Judith Gibbs registered manager of the home. What the service does well: What has improved since the last inspection?
The management of records has improved, such as daily records on service users plans are now dated and signed. Service users care plans have now all been reviewed. Quality Assurance systems are now also in place. One health and safety requirement made at the last inspection regarding the fire system is be implemented with a new fire alarm system being installed in the next few weeks. Gills Top DS0000007960.V260559.R01.S.doc Version 5.0 Page 6 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. Gills Top DS0000007960.V260559.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 Gills Top DS0000007960.V260559.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): 3 and 6 In most cases prospective service users can be confident before moving into the home that their needs can be met. EVIDENCE: A number of service users files inspected held copies of assessments carried out prior to admission into the home. However files for two new admissions into the home did not have any evidence that an assessment had been carried out, prior to service users being admitted into the home. The organisation has an assessment format but this had not been used. The homes manager confirmed that the home does not provide intermediate care. Gills Top DS0000007960.V260559.R01.S.doc Version 5.0 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): 7,8,9 and 10 The health care needs of service users are well met. EVIDENCE: Four-service users case files were inspected, which contained comprehensive plans of care. Risk assessments covering areas of daily living were available and up to date. The health care needs of service users were recorded on their individual care plans. All service users care plans had been recently reviewed and updated as required. For those service users that are unable to self medicate the home operates a monitored dosage system, which was inspected and was appropriately stored and records were accurately maintained. Senior staff have all completed the Safe Handling of Medication training and certificates had been obtained. Visitors to the home stated that they were always made to feel welcome by the staff. Gills Top DS0000007960.V260559.R01.S.doc Version 5.0 Page 10 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 Service users’ lifestyle within the home reflects their wishes and satisfies all of their recreational and social needs. EVIDENCE: Visiting arrangements are flexible throughout the day as this was confirmed by the comments made by relatives and visitors. All service users confirmed that they are able to get up and go to bed as and when they wish. One service user stated that she liked to regularly walk into Grassington, weather permitting. Service users stated that they had a really good time on Bonfire night, with toffee apples, parkin and sherry being provided and they had all enjoyed the fireworks. Mealtimes at Gills Top are flexible. Choices are available each mealtime and all service users spoken with commented that the food at the home was very good. One service user stated, “the food was very good indeed and that they are very keen on providing a good table” Another service user said that when she had been ill that the chefs had visited her daily to see what she could eat. Special diets are catered for. Staff was observed helping service users in the dinning room who needed assistance in a respectful manner. Service users were all asked by staff what they would prefer to eat and drink.
Gills Top DS0000007960.V260559.R01.S.doc Version 5.0 Page 11 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 Service users are confident that their complaints and concerns are dealt with and are acted upon. EVIDENCE: The home’s complaints procedure is available to service users and visitors. Service users commented that if they had a complaint or a concern that they would speak directly with staff on duty or to the registered manager. It then would be acted upon. Service users were also confident that the registered manager would always put things right. Gills Top DS0000007960.V260559.R01.S.doc Version 5.0 Page 12 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): 19,20,23 and 26 The standard of the environment of the home is good and provides service users with a clean and homely place in which to live. EVIDENCE: The home is a large building with an entrance hall with corridors running off. Service users accommodation is over two floors, which is serviced by a passenger lift. There is a dinning room and small lounge area on the ground floor and a large communal lounge on the first floor, which also has a small kitchen attached for service users’ and relatives’ use. There is a main bathroom and toilet on each floor. Service users’ bedrooms all have en-suite facilities with toilet and shower. The home was decorated to a good standard. The home was very clean and tidy throughout; there were no offensive odours present. Gills Top DS0000007960.V260559.R01.S.doc Version 5.0 Page 13 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 are protected by the home’s vigorous recruitment procedures. EVIDENCE: Staff records showed that the registered manager undertakes thorough checks before staff commence working at the home. CRB checks have been carried out and staff have been checked against the POVA first list. All staff complete application forms. Two written references are obtained. The rota showed that there are two care staff and one senior staff on duty each morning and three care staff in the afternoon. Two staff are on waking duty each night with a senior staff member on call. In discussions held with the registered manager the home has experienced some difficulties in recruiting staff and continues to employ regular agency staff until this can be resolved. The home has commenced a recruitment drive and some vacancies have now been filled. Gills Top DS0000007960.V260559.R01.S.doc Version 5.0 Page 14 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): 31,33,35 and 38 Service users’ health safety and welfare are promoted and protected, although some attention is required to some health and safety procedures. EVIDENCE: Throughout the day from discussions held with service users and staff and through observation, Gills Top continues to be managed well with a committed staff team. Finances for two service users were inspected and were accurately maintained with receipts kept for all purchases made. A number of health and safety records were inspected most of which were up to date and accurately maintained. However fire drills had not been carried out in line with the requirements made by North Yorkshire Fire and Rescue Service. The accident book was inspected and was maintained in line with the requirements of the Data Protection Act.
Gills Top DS0000007960.V260559.R01.S.doc Version 5.0 Page 15 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 1 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 3 X X 3 X X 3 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 3 X 3 X 3 X X 1 Gills Top DS0000007960.V260559.R01.S.doc Version 5.0 Page 16 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 Regulation 14 Timescale for action Full assessments must be carried 07/11/05 out prior to any admission into the home and records maintained. Fire drills must be carried out in 07/11/05 line with North Yorkshire Fire and Rescue Service guidelines. Requirement 1 OP38 23(4)(e) RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Gills Top DS0000007960.V260559.R01.S.doc Version 5.0 Page 17 Commission for Social Care Inspection York Area Office Unit 4 Triune Court Monks Cross York YO32 9GZ 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 Gills Top DS0000007960.V260559.R01.S.doc Version 5.0 Page 18 - 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. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!
