Inspection on 14/12/05 for 10 Spennithorne Road

This inspection was carried out on 14th December 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. 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 found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 8 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

10 Spennithorne Road 10/08/07

10 Spennithorne Road 08/06/06

Similar services:

Clover House

Parkside

Park Lodge

Mere Hall View

St Bonaventures

Hudson Road

Whitewalls

Home Farm

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

CARE HOME ADULTS 18-65 10 Spennithorne Road 10 Spennithorne Road Urmston Manchester M41 3BY Lead Inspector Michelle Moss Unannounced Inspection 14th December 2005 12 pm 10 Spennithorne Road DS0000064119.V258422.R01.S.doc Version 5.0 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 10 Spennithorne Road DS0000064119.V258422.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 Adults 18-65. 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. 10 Spennithorne Road DS0000064119.V258422.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service 10 Spennithorne Road Address 10 Spennithorne Road Urmston Manchester M41 3BY 0161 748 6414 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) sandra.hodgins@calderstones.nhs.uk Calderstones NHS Trust Sandra Hodgins Care Home 4 Category(ies) of Learning disability (4) registration, with number of places 10 Spennithorne Road DS0000064119.V258422.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. All service users have a learning disability and may in addition have an associated physical disability. The home should at all times employ a suitably qualified and experienced manager who is registered with the Commission for Social Care Inspection. 14th December 2005 Date of last inspection Brief Description of the Service: Spennithorne Road is a home for 4 service users with complex and multiple health and personal care needs. The home is located within easy reach of Urmston town centre, where service users are supported in taking part in community activities and the pursuit of individual leisure interests. The home is on one level, with access points in the cellar, kitchen and the front of the property. Ramps accommodate wheelchair users. There is off road parking to the front of the property and the large rear garden is accessed from French doors, leading off the lounge. 10 Spennithorne Road DS0000064119.V258422.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was the home’s second unannounced visit for the year and took place over one weekday in December. The visit lasted approximately 2 hours. Three residents were met and two members of staff and the assistant manager were spoken with about practices of care within the home. In addition, a range of records including care plans, medication charts and health and safety and fire records were examined. The term of address preferred by the users of the service was confirmed as ‘residents’. It was felt that this best reflected the function and purpose of the service. The inspection only looked at a limited number of standards, so this report should be read together with the earlier report to get a full picture of how the home is meeting the needs of the residents living there. What the service does well: What has improved since the last inspection? The home had improved their manual handling assessments and risk assessments for pressure sore care. The home was continuing to move towards person centred planning. 10 Spennithorne Road DS0000064119.V258422.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. 10 Spennithorne Road DS0000064119.V258422.R01.S.doc Version 5.0 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection 10 Spennithorne Road DS0000064119.V258422.R01.S.doc Version 5.0 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 2 The residents’ changing needs were assessed and recorded. EVIDENCE: The home had a static resident group, which had not changed for several years. Parts of ongoing care of the residents included updating the residents’ care assessments when changes in their needs were identified. 10 Spennithorne Road DS0000064119.V258422.R01.S.doc Version 5.0 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6 and 9 Residents’ needs were assessed and recorded in a care plan that was individual to the specific resident. However, these were not in a format which allowed updated information to be easily accessed. This had the potential to compromise care practices within the home. EVIDENCE: The care planning records of two residents were examined. The plans had risk assessments, including manual handling assessments. The home was moving towards a more person centred approach through the use of essential life style plans. On reviewing the current main service user plan some confusion emerged over the care plans and risk assessments that were being used and those that were no longer in use. In discussion with the assistant manager, it was identified that the way records were being maintained had changed, which had caused some confusion over which forms and assessments were now to be used. There was a need for a formal review to be undertaken of all records used and a decision reached over which type staff were to use to record and assess the everyday care needs of residents. 10 Spennithorne Road DS0000064119.V258422.R01.S.doc Version 5.0 Page 10 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 15 and 17 All residents were supported well by the home to maintain positive family links. The practices and records for confirming that residents were receiving a healthy and varied diet could not be confirmed. EVIDENCE: The residents were supported to maintain positive links with families. The dietary needs of residents could not be formally confirmed, either in the staff practices or records. A menu was examined, which gave one meal choice. When the staff team were asked about how the menus were written, it was explained that the night staff did them. When asked how did the night staff make sure the menu reflected residents’ choices, the staff could not confirm the consultation process used. On looking at the weeks menu, no information could be seen which indicated that residents were getting a nutritional diet, including having vegetables served with meals. For example was an entry which stated ‘Yorkshire pudding’. The Staff on duty were asked what would be included in this meal. It was suggested that it would be roast beef. However, without a formal record of the meals served, it was not possible to confirm what was actually served. Furthermore, when examining 10 Spennithorne Road DS0000064119.V258422.R01.S.doc Version 5.0 Page 11 the nutritional assessments of the residents, the record gave very limited information. For example, a section for likes and dislikes had no record of meals and food known to be liked by the resident, which could be matched against the menu. In addition, the assessment failed to inform about how their food needed to be served, including the types of crockery and utensils that needed to be used and the consistency food needed to be served at. When the staff on duty were asked about choice at a previous inspection, it was explained that choice was determined by the residents through staff offering a small sample of food. However, on talking to the staff on duty during this inspection, this was not suggested as the method used. Instead, the staff explained that if the residents refused a meal, then they would make something else. 10 Spennithorne Road DS0000064119.V258422.R01.S.doc Version 5.0 Page 12 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 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 and 20 Arrangements for maintaining good health of residents were in place. EVIDENCE: The medication charts were examined and overall, they provided a good audit trail. The only minor shortfall raised with the assistant manager was that when the staff were administering ‘as and when required medication’ (PRN) such as Paracetamol, the time the medicine was administered needed to be added to the record. One other area advised on was not to use a label on medication charts in line with current guidance/good practices. All residents had included in their service user plan a health action plan. This was examined and found to be an informative document. 10 Spennithorne Road DS0000064119.V258422.R01.S.doc Version 5.0 Page 13 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 23 The residents were protected from abuse through daily care practices. However, this could be compromised as not all the staff team had received training in adult protection and were not familiar with procedures. EVIDENCE: The staff team on duty were asked about their awareness as to the protection of residents from abuse, including asking if they had received training. Some staff could confirm receiving training and others could not. All the staff team are required to receive training in this area of practice. 10 Spennithorne Road DS0000064119.V258422.R01.S.doc Version 5.0 Page 14 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 27 and 30 The overall quality of the furnishing and fittings was satisfactory. However, some aspects of the premises posed risks to the health and safety of residents and staff. EVIDENCE: A partial tour of the premises was completed, including the living area and bathroom. It was noted that the space within the home was becoming increasingly restricted due to the use of essential specialised equipment and medical supplies to meet residents’ health needs. Risk assessments of the environment needed to consider the impact of these factors on the safety of residents and staff. Two requirements from the home’s previous inspection were still outstanding. The first being the necessity to have the incline at the front of the house assessed to ensure that it did not compromise the health and safety of the staff team when they were assisting residents that use a wheelchair. This requirement was repeated and must be addressed within the set time scale given during this inspection. The second area was a requirement that damaged enamel on the bath needed repairing. On examining the bath, concerns were raised about the poor condition of the bath, with several areas 10 Spennithorne Road DS0000064119.V258422.R01.S.doc Version 5.0 Page 15 notably damaged with rust evident. This required some degree of urgency to be addressed, as it posed a health and safety risk to residents, especially if they had broken skin and came in contact with the rust area in the bath. Action must be taken within the set time by either recovering the bath enamel or replacing the bath. On checking the water temperature records, it was found that the last time the temperatures were checked was April 2005. Furthermore, the assistant manager said that there had been a problem with the heating and hot water supply after the boiler had broken over the weekend. To provide warm water to meet the residents’ personal care needs, the staff team were boiling the kettle and carrying it through to the bedroom or bathroom. In addition, heating was being supplied by the use of portable heaters. Some safety concerns were raised with the assistant manager about the practices of staff walking through the house with boiling water and portable heaters that could be accessed by residents. No contingency plan had been set up for such an emergency and no risk assessments had been undertaken to ensure that the steps taken were not posing an unsafe environment for the residents and staff. 10 Spennithorne Road DS0000064119.V258422.R01.S.doc Version 5.0 Page 16 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 35 The staff team were receiving training that gave them the skills required to meet the residents’ needs. EVIDENCE: Three staff members were on duty to care for four residents. All staff had received training in aspects of the residents’ needs including Gastrostomy Care, Person Centred Planning, First Aid and Manual Handling. Further training was confirmed by the staff team, which exceeded the required minimum levels of 5 paid training days in a 12-month period. 10 Spennithorne Road DS0000064119.V258422.R01.S.doc Version 5.0 Page 17 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. 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 are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 39 & 42 The health, safety and welfare of residents were not promoted and protected in areas of fire safety and securing the views of residents through the homes self–monitoring of the service. EVIDENCE: When following up the outcome of a previous requirement, the assistant manager was asked about the development of the home’s quality assurance, including obtaining the views of the residents and stakeholders about the service. The assistant manager was unable to confirm that any survey had been completed. On examining the fire safety records concerns were raised that no fire safety checks, including testing the fire alarms, had been completed since 24th September 2005. This weakness was discussed with the assistant manager. A daily fire safety check sheet was shown which had three headings Checked – Fault – Reported. Firstly, the record did not explain what was being checked and secondly a tick was being used. In the majority of entries the staff member filling the form was putting a tick in all three columns. This caused 10 Spennithorne Road DS0000064119.V258422.R01.S.doc Version 5.0 Page 18 confusion, which was discussed with the assistant manager. For instance a tick had in nearly all cases been put in the fault column. Did this mean there was a fault and if so what was the fault and did this pose a risk to the safety of the residents and staff? The assistant manager confirmed that a test of the fire alarm system would be completed following the inspection. 10 Spennithorne Road DS0000064119.V258422.R01.S.doc Version 5.0 Page 19 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score X 3 X X X Standard No 22 23 Score X 2 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 2 X X 3 X Standard No 24 25 26 27 28 29 30 STAFFING Score 2 X X 1 X X 2 LIFESTYLES Standard No Score 11 X 12 X 13 X 14 X 15 3 16 X 17 Standard No 31 32 33 34 35 36 Score X X X X 3 X CONDUCT AND MANAGEMENT OF THE HOME 2 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 10 Spennithorne Road Score X 3 3 X Standard No 37 38 39 40 41 42 43 Score X X 2 X X 1 X DS0000064119.V258422.R01.S.doc Version 5.0 Page 20 Yes 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 YA6 Regulation 15 Requirement The service user plan must be reviewed to ensure that it contains the most up to date information and assessments that staff are required to follow to ensure that residents’ needs are met. The home must ensure that the health and well-being of residents is secured by ensuring that they are provided with a nutritious, varied and balanced diet including having: • A record of actual meals served. • All nutritional assessments sufficiently detailed to inform staff about likes and dislikes and the way foods should be served. • Evidence of how choice is promoted. • A system in place that wherever possible, enables residents to be consulted over meals, including the formatting of the menu. All staff must receive training in adult protection. DS0000064119.V258422.R01.S.doc Timescale for action 31/01/06 2 YA17 16 & 17. 28/02/06 3 YA23 13 31/03/06 10 Spennithorne Road Version 5.0 Page 21 4 YA24 13 The premises and sources of 31/01/06 heating must not create risks to the health and safety of the residents. This includes: • Carrying out a risk assessments of the environment, which takes into account the restriction on space being caused by the equipment and medical supplies needed to meet residents’ needs. • There must be a contingency plan in place when things like heating break down for more than 24 hours. • When different sources of heating and transporting of hot water have to be used, risk assessments must be put in place and staff informed over safety procedures that must be followed. The damaged bath enamel must be repaired or the bath replaced. (not met in previous timescale 30/09/05) Water temperatures must be regularly checked to ensure that the welfare and safety of residents is not compromised. The home’s quality assurance system must include undertaking a satisfaction survey of residents, families and other stakeholders. This should then be linked with other monitoring systems and an annual report published of which a copy must be provided to CSCI. (not met in previous timescale 30/10/05) The home must carry out weekly fire safety checks and tests, including maintaining a record of the test. DS0000064119.V258422.R01.S.doc 5 YA27 23 15/01/06 6 YA30 13 31/01/06 7 YA39 24 28/02/06 8 YA42 23 31/01/06 10 Spennithorne Road Version 5.0 Page 22 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 10 Spennithorne Road DS0000064119.V258422.R01.S.doc Version 5.0 Page 23 Commission for Social Care Inspection CSCI, Local office 9th Floor Oakland House Talbot Road Manchester M16 0PQ 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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