Inspection on 15/11/05 for Bury Metro - Spurr House

This inspection was carried out on 15th November 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 but made no statutory requirements on the home.

Other inspections for this house

Bury Metro - Spurr House 07/05/08

Bury Metro - Spurr House 02/11/06

Bury Metro - Spurr House 21/03/06

Bury Metro - Spurr House 19/01/05

Bury Metro - Spurr House 11/08/04

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

CARE HOMES FOR OLDER PEOPLE Bury Metro - Spurr House Spurr House Residential Care Home Pole Lane Unsworth Bury Lancs BL9 8SA Lead Inspector Diane Gaunt Unannounced Inspection 15th November 2005 09:00 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 Bury Metro - Spurr House DS0000008468.V264918.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. Bury Metro - Spurr House DS0000008468.V264918.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Bury Metro - Spurr House Address Spurr House Residential Care Home Pole Lane Unsworth Bury Lancs BL9 8SA 0161 253 7505 0161 2536106 c.hesketh@bury.gov.uk 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) Bury M.B.C. Mrs Christine Hesketh Care Home 36 Category(ies) of Old age, not falling within any other category registration, with number (36) of places Bury Metro - Spurr House DS0000008468.V264918.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. The home is registered for a maximum of 36 service-users to include: Up to 36 service-users in the category OP (Older People, who do not fall in to any other category). The service should employ a suitably qualified and experienced Manager who is registered with the Commission for Social Care Inspection. 19th January 2005 Date of last inspection Brief Description of the Service: Spurr House provides provides residential care for up to 36 older people, within this number respite care can be provided for up to 5 residents at any one time. The home also provides a day care service for up to 10 older people each day. It is situated close to local shops and offers easy access to the local motorway system. Car parking facilities are available. The home is a single storey building with ample wheelchair access. The building is divided into four units; each unit has its own lounge, dining room and kitchen where residents and visitors to the home can make drinks and snacks. The home also has a conservatory and a large lounge with wide screen TV, video facilities, and a CD music system. Thirty six en-suite bedrooms, four assisted bathrooms and 1 assisted shower are provided. Hoists, aids and adaptations are available for residents’ use. Bury Metro - Spurr House DS0000008468.V264918.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection took place over a period of 7¾ hours. The home had not been told beforehand that the inspector would visit. The inspector looked around the building and looked at paperwork about the running of the home and the care given. Five residents, two visitors, five care assistants, the laundry assistant and the registered manager were spoken with. Carers were watched as they went about their work. Requirements listed at the end of the report include two which have not been fully met since the last two inspections. What the service does well: What has improved since the last inspection? What they could do better: Bury Metro - Spurr House DS0000008468.V264918.R01.S.doc Version 5.0 Page 6 The home must make sure up to date information is written down about residents when they are assessed before moving in. More information should be written down about residents’ food likes/dislikes, pressure sore care and assessments for their safety in bed. Safety locks must be fitted to bedroom doors so residents can be as private as they wish in their rooms, but able to leave their rooms quickly in an emergency. More electric sockets must be provided in bedrooms so residents have somewhere to plug in their electrical equipment. Improvements should be made to the appearance of corridors and bathrooms to make them more homely, and bedroom furniture should be replaced. Staff must have refresher training in how best to help residents to move, how to make and serve food safely and what to do if there is a fire. Water must be provided at a safe temperature and hot enough for residents to wash in. Bleach must be locked away when it is not being used. The manager should check how long it takes for staff to answer call bells so residents aren’t left waiting for the toilet. 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. Bury Metro - Spurr House DS0000008468.V264918.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 Bury Metro - Spurr House DS0000008468.V264918.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 Residents were assessed prior to admission to ensure the home could meet their needs, but the assessment was not always recorded which could result in staff having outdated information when initially providing care. EVIDENCE: Individual records were kept for each resident and three were inspected with regard to pre-admission assessment. All residents were care managed and copies of needs assessments undertaken by a social worker were held on each file. However, it was noted that with regard to the two most recently admitted residents, the assessments were not current (April 2000 and December 2004 respectively). The manager explained that staff at the home were familiar with one resident’s needs as she regularly attended the home for day care. The other resident had been visited by the manager prior to admission but assessment documentation was not completed. With regard to emergency admissions, basic information was requested from the duty social worker prior to admission and more detailed assessment undertaken once the person moved in. The manager said that if the home was unable to meet the person’s needs then an alternative placement would be requested. Bury Metro - Spurr House DS0000008468.V264918.R01.S.doc Version 5.0 Page 9 Bury Metro - Spurr House DS0000008468.V264918.R01.S.doc Version 5.0 Page 10 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, and 10 Residents’ health and personal care needs were being met. Residents were treated with respect by a staff team who understood the need for privacy, but the lack of safety locks to bedroom doors meant their privacy was at times compromised. EVIDENCE: Four individual plans of care were inspected. They encompassed all health and social care needs and recorded action to be taken to meet the needs. In the main, the care plans had been regularly reviewed by staff on a monthly basis and evidence of resident or relative involvement was seen on file. Residents and relative interviewed confirmed that they were consulted by staff regarding meeting of care needs. They also said they would raise issues with the manager as necessary and these would be addressed. Care plans recorded the involvement of GPs and other healthcare professionals, although one file inspected did not record District Nurse involvement and treatment of pressure sores. The inspector was advised this information was recorded on District Nurse files. None of the residents had pressure sores at the time of the inspection but District Nurses called to check one resident’s skin on a regular basis. The home provided pressure relieving equipment i.e. cushions and mattresses, and were loaned additional mattresses from the District Nursing service when required. Residents said the home called their GP when they Bury Metro - Spurr House DS0000008468.V264918.R01.S.doc Version 5.0 Page 11 needed them and the services of opticians, dentists, chiropodist and audiologist were accessed either at the home or in the community as and when necessary. Residents and visitors described problems in accessing audiology services as they had to travel to the local hospital. The manager had requested home visits but had been advised they were no longer available. Continence advice was sought from the local Primary Care Trust (PCT) advisor and implemented. Staff described good practice with regard to monitoring continence needs in order to ensure suitable aids were provided. Detailed risk assessments were held on file with regard to moving and handling, and were regularly reviewed. Nutritional screening tools were seen to be used as and when necessary, although it was noted residents’ food likes and dislikes were not always recorded. Risk assessments were not always completed when considering whether bedrails or other safety arrangements should be made for a resident, and one relative commented they had not been involved in such process. The activities organiser provided regular exercise sessions for residents, those interviewed considered they had sufficient exercise in moving around the home and attending the sessions as and when they wished. Residents interviewed considered their health and care needs were met. This was supported by comment cards completed by one GP and three care managers 4 months prior to this inspection. They described the service as ‘excellent’, and ‘well managed’. Each considered that staff demonstrated an understanding of residents needs, and expressed overall satisfaction with the care provided. Residents interviewed considered their privacy and dignity was respected by staff at the home. Staff interviewed were able to describe good practice in this area. However, some residents expressed concern that other residents wandered into their bedrooms both during the day and night. An outstanding requirement is in place with regard to the provision of safety locks to bedroom doors. Bury Metro - Spurr House DS0000008468.V264918.R01.S.doc Version 5.0 Page 12 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): None of these standards were assessed. EVIDENCE: Bury Metro - Spurr House DS0000008468.V264918.R01.S.doc Version 5.0 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 the following standard(s): 16 and 18 Residents were confident that complaints would be listened to, taken seriously and acted upon. Appropriate systems were in place to protect residents from abuse. EVIDENCE: The home had a complaints procedure which was displayed on the notice board and included in the Service User Guide. It included contact details of CSCI. Residents/relative spoken with said they would speak to staff or the manager if they had a concern and that issues were generally resolved at this point. Residents saw the manager on a daily basis and most said they would raise issues with her then. They could also do so at residents meetings. Staff interviewed were familiar with the complaints procedure and knew to inform managers of issues raised with them. The complaints log was inspected and recorded four complaints since the last inspection. The log recorded the complaint, the action taken to investigate and the outcome. Each was seen to have been satisfactorily resolved. The CSCI had received no complaints during this period. A procedure for responding to allegations of abuse was available as was the Bury Inter-agency Protection of Vulnerable Adults (POVA) procedure. Staff spoken with understood the importance of reporting malpractice and were conversant with the different types of abuse. The manager, deputy and 4 carers had attended POVA training linked to Bury Inter-agency procedure. Other staff had received some POVA training as part of induction or NVQ level 2. Further training had been arranged in order to ensure all staff were conversant with the Inter-agency procedure. Bury Metro - Spurr House DS0000008468.V264918.R01.S.doc Version 5.0 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 the following standard(s): 19 and 26 An ongoing refurbishment programme ensured the environment was upgraded and maintained; a safe, clean and hygienic home was provided for residents to live in. EVIDENCE: A refurbishment programme, which began in November 2004, was ongoing at the time of the inspection. The first phase of this programme was due to be completed by the end of December 2005. Improvements were seen in the provision of new PVC windows, doors, fascia boards, guttering and roofing. Asbestos had been removed from the building. Inside the building improvements had been made through decoration of the kitchen and lounges, provision of new curtains and some new lounge chairs, carpets and rise and fall beds. New flooring, a dishwasher, and microwave had been provided in the kitchen. Recommendations regarding provision of carpets in corridors and improved appearance of bathrooms were to be addressed in December 2005 and by June 2006 (the second phase of refurbishment) respectively. The path around the building had been widened making it safe for residents to walk on, and fences had been erected around the home creating safe, enclosed Bury Metro - Spurr House DS0000008468.V264918.R01.S.doc Version 5.0 Page 15 spaces. One garden area had been prepared in readiness for a sensory garden to be planted. Residents interviewed spoke positively of the refurbishment and considered the building had been ‘done up lovely’. They said their bedrooms were comfortable and were pleased that they had been able to bring their own furniture, pictures etc for their rooms. They also said the building was safe and easy to get around as good flat surfaces were provided throughout. Observation showed that appropriate safety precautions were taken by builders and domestic staff as they went about their work. Residents all considered the home was kept clean and odour free. Observation and discussion with staff and residents confirmed there were satisfactory infection control practices. In line with good practice, paper towels and liquid soap were used for hand washing in communal areas. Disposable gloves and colour-coded aprons were provided and staff said these were always readily available. The inspector observed staff making use of this provision. Inspection of the laundry and discussion with the laundry assistant showed that sufficient equipment was provided. A sluice was also provided. Laundry facilities were sited away from food storage and preparation areas. Residents’ clothing was individually named and the majority of residents spoken with considered the laundry arrangements were satisfactory with minimal problems experienced. The manager agreed to investigate one resident’s lost laundry. Bury Metro - Spurr House DS0000008468.V264918.R01.S.doc Version 5.0 Page 16 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 Sufficient numbers of staff, with an appropriate skill mix, were provided to meet the needs of residents. EVIDENCE: A recruitment drive had taken place since the last inspection in order to build a stable team and reduce the number of agency staff used. This had been achieved although a number of vacancies remained. In particular, a 25 hour post for a day care worker was vacant, and staff on the unit were covering the post. On occasion this reduced the staffing in the units. The inspector was advised that when this occurred the manager or deputy would cover the unit. The vacancy had been advertised and managers were hopeful it would be filled in the near future. If the present situation continues, agency staff must be used to fill the vacancy. With this exception, inspection of rotas showed that sufficient staff were provided to meet the needs of residents and day care clients. Feedback from staff, and the majority of residents and visitors interviewed supported this view, although two residents said that on occasion they sometimes had to wait for staff to respond to call bells when they had rung for assistance to the toilet. Residents said staff were generally ‘very helpful’ and ‘approachable’. The manager and the deputy had an NVQ level 4 in Care and Management and had achieved the Registered Manager’s Award. 13 care staff had achieved their NVQ level 2 and one had NVQ level 3. A further 14 had been nominated to take the course. All care staff had attended or were due to attend training in dementia care. Those interviewed who had already attended the course Bury Metro - Spurr House DS0000008468.V264918.R01.S.doc Version 5.0 Page 17 commented upon how valuable it was to them. Other courses e.g. dental care, continence care and care planning were provided in-house. Bury Metro - Spurr House DS0000008468.V264918.R01.S.doc Version 5.0 Page 18 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 Whilst health and safety of residents and staff was generally promoted and protected, training was not always updated within recommended timescales and bleach was not stored safely. EVIDENCE: A training matrix displayed in the office showed that an ongoing health and safety training programme was provided. The induction programme showed that staff were introduced to this training shortly after appointment, although not all staff had renewed their training within recommended timescales. Sufficient staff had been trained in 1st Aid to ensure one per shift was on duty. Fire precaution checks and drills were undertaken on a regular basis but not as frequently as recommended by GM Fire Officers. Induction included fire training, and staff were required to attend an annual fire lecture, although only 19 of the 40 staff had done so. Fire drills/practices were held but a record of those attending was not kept. The manager could not therefore monitor whether each staff member had attended at least one fire drill during the last Bury Metro - Spurr House DS0000008468.V264918.R01.S.doc Version 5.0 Page 19 12 months. Dorgards had been fitted on a number of doors since the last inspection enabling residents to safely keep their bedroom doors open during the day. Building, fire and COSHH risk assessments were written as required. With the exception of the Legionella and annual thermostatic mixer valve service, regular maintenance checks were undertaken in line with legislation. A resident commented that the temperature of the water in her bedroom was too cool to wash in and staff had to boil a kettle to get hot enough water. On testing the water temperature it was seen to run at 30°C, the flow was also intermittent. Staff interviewed were aware of their responsibilities with regard to health and safety although it was noted bleach was kept in an unlocked cupboard in the laundry. No health and safety hazards were noted during the inspection. Residents and staff considered it a safe place to live and work. Bury Metro - Spurr House DS0000008468.V264918.R01.S.doc Version 5.0 Page 20 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 2 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 X 10 2 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 X 14 X 15 X COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 X 29 X 30 X MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X X X X X X X 2 Bury Metro - Spurr House DS0000008468.V264918.R01.S.doc Version 5.0 Page 21 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 2 Standard OP3 OP10OP24 Regulation 14 16 Requirement Up to date assessments must be completed prior to admission. Safety locks must be fitted to all bedrooms doors and keys provided to residents unless risk assessment indicates otherwise. (Previous timescale of 30/12/04 not met) Two accessible double electric sockets must be provided in each bedroom. (Previous timescale of 30/12/04 not met) All staff must receive refresher training in moving and handling and food hygiene at recommended intervals. All staff must attend an annual fire lecture and have an annual fire drill/practice. Legionella and thermostatic mixer valve tests must be undertaken on an annual basis to ensure the delivery of water at a safe and satisfactory temperature (40°C - 43°C). Bleach must be kept in a locked cupboard whenever it is not in use. Timescale for action 31/12/05 31/12/05 3 OP24 16 31/03/06 4 OP38 13 31/03/06 5 6 OP38 OP38 23 13 28/02/06 31/12/05 7 OP38 13 15/11/05 Bury Metro - Spurr House DS0000008468.V264918.R01.S.doc 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. 1 2 3 4 5 6 7 8 9 10 Refer to Standard OP3 OP8 OP8 OP8 OP19 OP21 OP27 OP27 OP24 OP38 Good Practice Recommendations Assessment documentation should be completed by staff prior to admission. District Nurse involvement and treatment for pressure sores should be recorded on care plans. Residents food likes and dislikes should be recorded on care plans. Signed and agreed risk assessments should be held on file with regard to use of bedrails or other arrangements made for a residents’ safety. Corridors should be fitted with non-slip flooring i.e. carpets The ambience/appearance of bathrooms and toilets should be improved. Agency staff should be employed to cover the vacant day care worker post. The manager should monitor response time to call bells to ensure residents’ needs are met when necessary. Bedroom furniture should be upgraded. The fire precautions register should be completed at intervals recommended by GM Fire Officers. Bury Metro - Spurr House DS0000008468.V264918.R01.S.doc Version 5.0 Page 23 Commission for Social Care Inspection Bolton, Bury, Rochdale and Wigan Office Turton Suite Paragon Business Park Chorley New Road Horwich, Bolton BL6 6HG 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 Bury Metro - Spurr House DS0000008468.V264918.R01.S.doc Version 5.0 Page 24 - 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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