Inspection on 13/12/05 for 18 Spindlebury

This inspection was carried out on 13th December 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 found no outstanding requirements from the previous inspection report, but made 1 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

18 Spindlebury 25/05/07

18 Spindlebury 04/05/05

18 Spindlebury 25/11/04

18 Spindlebury 08/07/04

Similar services:

The Vicarage

7 Hyde Road

5 Seafield Road

Trevaylor Manor

12 Orchard Mews

Stallcombe House

Stepping Stones

Cornerstones

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

CARE HOME ADULTS 18-65 18 Spindlebury 18 Spindlebury Padbrook Cullompton Devon EX15 1SY Lead Inspector Louise Delacroix Unannounced Inspection 2.30pm 13 December 2005 th 18 Spindlebury DS0000036966.V259151.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 18 Spindlebury DS0000036966.V259151.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. 18 Spindlebury DS0000036966.V259151.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service 18 Spindlebury Address 18 Spindlebury Padbrook Cullompton Devon EX15 1SY 01444 239123 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) Brain Injury Rehabilitation Trust Mrs Penny Jean Blackmore Care Home 2 Category(ies) of Physical disability (2) registration, with number of places 18 Spindlebury DS0000036966.V259151.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 4th May 2005 Brief Description of the Service: Spindlebury provides rehabilitation care and support for two residents with an acquired brain injury. The home is part of the Brain Injury Trust and works closely with the professionals within the Trust. The professionals based at The Woodmill Brain Injury Unit carry out all rehabilitation and therapeutic assessments/programmes for the service users living at the home in conjunction with the carers and House Leader working at Spindlebury. The home is a bungalow situated in a modern housing estate in Cullompton. Minor adaptations have been made to the house to meet the current service users physical needs. The home is within walking distance to the local amenities, including public transport. The emphasis in the home is to support the service users to become more independent, in and out of the home, to seek employment and training opportunities, and maintain regular contact with relatives and friends. 18 Spindlebury DS0000036966.V259151.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection took place in the afternoon over several hours and was unannounced. Both residents were at home and during the inspection both had visitors. Prior to their visitors arriving, both residents contributed to the inspection. The atmosphere was relaxed and the house had been decorated for Christmas. As part of the inspection, care plans, fire records and medication sheets were looked at. Unfortunately, due to illness neither the manager nor a staff member from the usual staff team were available and although the carer on duty knew both the residents, some questions about the running of the home could not be answered. This was resolved during a telephone call with a permanent member of staff and the manager on 22nd December 2005. The majority of standards were inspected on 4th May 2005 and therefore this report should be read in conjunction with the previous inspection report. What the service does well: What has improved since the last inspection? What they could do better: Improvements are needed to create a more robust recruitment process, and a risk assessment for an uncovered radiator is needed to ensure that a resident is not put at risk of burns. 18 Spindlebury DS0000036966.V259151.R01.S.doc Version 5.0 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. 18 Spindlebury DS0000036966.V259151.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 18 Spindlebury DS0000036966.V259151.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): 2,4 Prospective residents are actively involved in moving to the home, which enables them to make decisions about whether the service will suit them. EVIDENCE: Full assessments are carried out prior to admission to the home. The Woodmill team, which is another BIRT unit and based close by, completes these. The assessments are detailed, and cover all issues in a holistic manner as well as recognising the individuality of the person concerned. Care plans are then generated from these assessments. Rehabilitation and therapeutic needs are assessed by a multi-disciplinary team based at The Woodmill and are incorporated into the plan of care. Records evidence that relatives/representatives and residents are involved in the process. Good evidence was seen of prospective residents visits to the home. 18 Spindlebury DS0000036966.V259151.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): 7 The ethos of the home promotes the rights of residents to make choices in their lives. EVIDENCE: Records evidence the views of residents. Residents are provided with opportunities to make decisions about their lives either through reviews or informally on a day to day basis i.e. choosing meals or the decoration of the home. Residents’ care plans focus on encouraging residents to express themselves i.e. writing their own daily notes, and the plans acknowledge that the success of support relies on the resident being in agreement with the approach. Both residents have chosen to improve their general fitness and there was evidence of them making decisions about how often they went to the gym. 18 Spindlebury DS0000036966.V259151.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): 17 Residents decide what they would like to eat, and meals cater for their likes and dislikes. EVIDENCE: Residents are actively involved in planning meals through joint discussion, normally on a daily basis, and go shopping for the ingredients. A staff member confirmed that records are kept of each meal and that staff members are aware of likes and dislikes, and ensure that alternatives are offered. Staff support residents with preparation. 18 Spindlebury DS0000036966.V259151.R01.S.doc Version 5.0 Page 11 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, 20 Residents are protected by good medication practice, and there is recognition in assessments and guidance for staff to work towards meeting residents’ emotional needs EVIDENCE: Records showed an appreciation of the importance of residents’ sense of self worth and body image. Clear guidance was given for recognised risks/reactions regarding support with personal care, and reviews take place to ensure the guidance is working both for staff and the resident. The medication records were checked against the medication, which tallied. Medication records are appropriately completed with medication securely stored. Clear records are kept about the systems in place for residents when they take medication away from the home for holidays etc. 18 Spindlebury DS0000036966.V259151.R01.S.doc Version 5.0 Page 12 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): EVIDENCE: These standards were inspected and met on the previous inspection. Neither resident wished to raise any concerns during the inspection. No complaints have been received by CSCI about the service. 18 Spindlebury DS0000036966.V259151.R01.S.doc Version 5.0 Page 13 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 The maintenance and décor of the home is well maintained, and provides a clean and homely atmosphere for residents living there. EVIDENCE: The home was clean and odour free. Since the last inspection, the living room and dining room have been attractively decorated, one of the residents chose the colour and the other resident confirmed that they were happy with the choice. Recently both bedrooms have also been decorated to the residents’ individual tastes. The furnishings are of good quality and the home is well maintained. It is close to local amenities and the look of the home fits in with the other homes in the close. Standards27, 28, 29 and 30 were inspected and met on the last inspection. 18 Spindlebury DS0000036966.V259151.R01.S.doc Version 5.0 Page 14 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): 34,35,36 There is a small committed staff team whose training opportunities benefit the residents. However, minor improvements to staff recruitment would ensure the process is more robust and potentially offer greater protection to residents. EVIDENCE: Staff benefit from a good range of training provided by the Brain Injury Trust and an audit is kept at The Woodmill of staff training needs, which was seen. Training covers mandatory courses, as well as more specific training relating to the needs of the client group, which is also part of the induction. One member of staff has their induction planned, which includes a comprehensive workbook to promote good practice. The staffing group is currently stable; although illness has meant staff from other BIRT homes have stepped in to provide cover when necessary. Three staff files were checked. All had appropriate ID. Photographs are currently being placed in each staff member’s file. However, one person did not have an application form for their current position, had started one day prior to their CRB being received and only had one written reference as opposed to two. A second person had their CRB and POVA clearance in place before they started their job but there were gaps in their employment history, and no record of the reasons for these gaps. 18 Spindlebury DS0000036966.V259151.R01.S.doc Version 5.0 Page 15 A staff member confirmed that they had supervision with the house leader, and the manager said that they supervised the house leader on an eight weekly basis with recorded notes. The manager said they visited the home on a weekly basis to over see practice. 18 Spindlebury DS0000036966.V259151.R01.S.doc Version 5.0 Page 16 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 Fire training for staff is now happening at the required intervals and other health and safety issues are generally well managed. EVIDENCE: Staff explained that house issues that affect residents are discussed informally with the outcome discussed by the house leader with the clinical team based at The Woodmill. The house leader will then feedback the responses/action. Residents have said on previous inspections that they prefer this informal approach. Review minutes also evidence that residents can put forward their viewpoint or ask for a representative to do this on their behalf. A new system is now in place to monitor health and safety issues around the home, which shows that checks to protect residents are up to date and now the responsibility of all staff. These include fridge/ freezer temperatures, the fire alarm and water temperature. Qualified staff from the multi-disciplinary team review moving and handling techniques used with residents and staff, and changes are recorded in the care plans. Regulation 26 visits, which monitor the service of the home, occur at appropriate intervals. Mandatory fire 18 Spindlebury DS0000036966.V259151.R01.S.doc Version 5.0 Page 17 training for care staff has now taken place at the required intervals. However, a risk assessment is not in place for an unguarded radiator despite the resident having recent falls. 18 Spindlebury DS0000036966.V259151.R01.S.doc Version 5.0 Page 18 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 3 x Standard No 22 23 Score x x ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score x 3 x x x Standard No 24 25 26 27 28 29 30 STAFFING Score 3 x x x x x x LIFESTYLES Standard No Score 11 x 12 x 13 x 14 x 15 x 16 x 17 Standard No 31 32 33 34 35 36 Score x x x 1 3 3 CONDUCT AND MANAGEMENT OF THE HOME 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 18 Spindlebury Score x 3 3 x Standard No 37 38 39 40 41 42 43 Score x x 3 x x 2 x DS0000036966.V259151.R01.S.doc Version 5.0 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 YA34 Regulation 19 Schedule 2 (1-9) Requirement Staff records must require all the information required in paragraphs 1-9 of Schedule 2 i.e. two references and CRB in place. Timescale for action 31/01/06 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 YA34 Good Practice Recommendations Gaps in employment history should be discussed and the outcome/reason recorded and followed up, if necessary. An application form should be completed for new employees. A risk assessment for uncovered radiators in the home should take place and action taken to guard the radiator if the risk is medium or high. 2 YA42 18 Spindlebury DS0000036966.V259151.R01.S.doc Version 5.0 Page 20 Commission for Social Care Inspection Exeter Suites 1 & 7 Renslade House Bonhay Road Exeter EX4 3AY 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 18 Spindlebury DS0000036966.V259151.R01.S.doc Version 5.0 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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