Inspection on 07/05/08 for Bury Metro - Spurr House

This inspection was carried out on 7th May 2008.

CSCI found this care home to be providing an Adequate service.

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Bury Metro - Spurr House 02/11/06

Bury Metro - Spurr House 21/03/06

Bury Metro - Spurr House 15/11/05

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 27/09/2008.

CARE HOMES FOR OLDER PEOPLE Bury Metro - Spurr House Spurr House Residential Care Home Pole Lane Unsworth Bury Lancs BL9 8SA Lead Inspector Julie Bodell Unannounced Inspection 7th May 2008 07:00 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.V363848.R01.S.doc Version 5.2 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.V363848.R01.S.doc Version 5.2 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 253 6106 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. Post Vacant 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.V363848.R01.S.doc Version 5.2 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. 2nd November 2006 Date of last inspection Brief Description of the Service: Spurr House is owned by Bury Council and is run by the Social Services Department. The home provides residential care for up to 36 older people. Within this number respite care can be provided for up to 7 residents at any one time. A day care service is also provided for up to 10 older people each day. The home is situated in Unsworth and is 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, bathroom 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 single en-suite bedrooms, four assisted bathrooms and two assisted showers are provided. Hoists, aids and adaptations are available for residents’ use. A Service User Guide (Residents Information Guide) describing the home’s services is available and the provider gives other information about the home to new and prospective residents and their families verbally. A copy of the latest inspection report is available in the entrance area of the home. At the time of writing this report the basic charge for accommodation and services is £305:00 per week with this being subject to negotiation to allow for individual circumstances. Additional charges are made for hairdressing, personal newspapers, preferred toiletries and outings. Bury Metro - Spurr House DS0000008468.V363848.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 1 star. This means the people who use this service experience adequate quality outcomes. The inspection took place over one day starting at 7.00am in the morning. The home had not been told that the inspector would visit. We (the commission), spoke with the acting manager, the acting deputy manager, an acting senior carer, a night carer and some support staff members, as well as people living at the home. We looked around parts of the building, looked at some paperwork and watched what was happening around the home. We asked for information from the service before the visit, which we received. We also received four survey forms from people using the service, one from a relative and five from members of the staff team. Following a recent review of the service we decided to visit the service earlier than planned. This was because we had concerns that the registered manager had moved to another service and the acting manager was also leaving. Concerns had also been raised about staffing levels at the home, by relatives and members of the staff team. What the service does well: To ensure that the home can fully meet people’s needs an assessment is undertaken before an admission is agreed. It was clear from watching what went on that there were good relationships between the people living at the home and the staff team. The atmosphere was very relaxed and friendly. The home has a very enthusiastic activities organiser who provides a varied activities programme that helps to keep people stimulated and motivated. People were happy with the food provided at the home and they were given choices at each meal and generous portions. The home provides comfortable and homely surroundings for the people living there. Attention was given to good control of infection practices by the staff team. The home exceeds the minimum standard for having more than 50 of the permanent staff team trained to NVQ Level 2 and above. Bury Metro - Spurr House DS0000008468.V363848.R01.S.doc Version 5.2 Page 6 The permanent staff team are properly recruited and criminal records checks are undertaken to ensure that they are suitable to work with vulnerable people. An external manager undertakes monthly quality assurance visits to the home, to make sure that everything is in order. What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Bury Metro - Spurr House DS0000008468.V363848.R01.S.doc Version 5.2 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.V363848.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 1 3 and 4 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People had enough information and were properly assessed before agreeing to move so that they could be assured that the home was able to meet their needs. EVIDENCE: The home has an up-to-date service user guide, which ensures that people considering using the service have the information they need to make an informed choice about where they live. The home is currently working towards becoming a specialist dementia unit as part of an integrated service with other health and social care professionals. They work closely with the Older People’s Co-ordinator, who is also the home’s external line manager and are building good links with the new Irwell Unit and the older people’s mental health team. The acting manager said that steady Bury Metro - Spurr House DS0000008468.V363848.R01.S.doc Version 5.2 Page 9 progress was being made towards the development of the new service but more work was still to be done. We looked at the care records of two people and found copies of a community care assessment on each file undertaken by a qualified social worker. An experienced manager from the home also meets the prospective service user prior to the person moving in to ensure the home can meet the needs. Some people use the respite service prior to a permanent admission so they and their relatives have the opportunity to make their own assessment about the home. We had no concerns that the home was not able to meet the needs of any of the people living at the home, at the time of this inspection. A review of the placement is undertaken six weeks after by Adult Care Services. This is done to check that the person using the service, where able, their relatives and the home were happy that the placement was meeting the person’s needs. Bury Metro - Spurr House DS0000008468.V363848.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 7 8 9 and 10 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Care planning and the safety of the medication system were good but ways to improve the healthcare risk assessments need to be considered to ensure that people are cared for effectively and safely. EVIDENCE: The care files of two people were looked at. These contained detailed care plans, which in the main had been kept up to date and reviewed monthly. One care plan needed to be updated following a recent hospital admission. General and specific risk assessments were in place. These included moving and handling and workplace activity. The risk assessment format used is the local authority corporate risk assessment. Although the risk assessments were being reviewed regularly it was not always clear how staff members determined the level of risk. Risk assessments need to support staff in making judgements around the level of risk e.g. high, medium and low level and Bury Metro - Spurr House DS0000008468.V363848.R01.S.doc Version 5.2 Page 11 prompt them to request support from relevant healthcare professionals depending on the outcome. It is required that the present arrangements for healthcare risk assessments be reviewed to ensure they are adequate and whether improvements could be made by introducing specialist health care risk assessments formats for nutrition, MUST, Waterlow, falls etc and if training for staff from health care professionals for example the tissue viability nurse, is needed. The home has a satisfactory medicines policy and procedure that includes guidance for the self-administration of medicines and the use of homely remedies. No homely remedies are used at the home. Medicines are safely and securely stored in two medication trolleys. The home has recently changed the pharmacist who supplies medication to the home. Medication is supplied in pre-filled blister packs with pre-printed MAR sheets. Records were found to be properly completed and to be up to date. Identification photographs of each person are kept with the medication administration records. Only manager’s and senior carer staff members, who have been trained, administer medication. There is a list of authorised signatories. Managers and seniors audit the medication system. The last audit was undertaken on 13.04.08. Creams are kept in each person’s bedroom and records kept on a card. These were not checked at this inspection. One person had recently returned from hospital to the home following a review of their medication with a positive outcome. People were observed being treated in a courteous manner throughout this inspection. Good relationships were observed between people living at the home and the care staff on duty. Care staff members were relaxed and friendly in their approach. Care was taken to ensure that people’s privacy and dignity was maintained whilst involved in personal care tasks. Bury Metro - Spurr House DS0000008468.V363848.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12 13 14 and 15 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. People who live at the home have many opportunities to participate in stimulating activities and maintain contact with their family and friends. EVIDENCE: The home employs a very enthusiastic part time activities co-ordinator. There is a programme of social and recreational activities. A record is kept of each session and of who participated in them. A wide range of both individual and group activities are offered at the home including manicures, games, crafts, quizzes, sing-a-longs, reminiscence sessions, exercises and baking. In addition, musical entertainers visit the home and outings are arranged to various venues. There were many pictures and photographs around the home of different events and art work such as “Lets talk Safari…” as well as collages, old newspaper cuttings from the local newspaper and yesteryear pictures of Bury. One picture shows one of the resident’s working in a mill. The cuttings are laminated for people to handle and talk about. Bury Metro - Spurr House DS0000008468.V363848.R01.S.doc Version 5.2 Page 13 On the day of the inspection it was a very warm and sunny day. People were outside in the enclosed garden area with the activities co-ordinator, under shades and with hats and sun cream on. They sat chatting, listening to music or reading the paper with hats on with flowers that people had made. The activities programme flexible. The activities co-ordinator likes to take every opportunity for people to get out into the fresh air. The previous day some people went for a walk to the nearby cricket club. Minutes from the last Residents Meeting that took place on 22.04.08 were available in large font and had involved the activities co-ordinator. Activities discussed were the reading club that was due to meet on 23.04.08 and the Astral Players due to visit 20.05.08. People suggested they would like trips out to Southport, St Anne’s and to see the local Carnival. Other people who did not want to join in with organised activities were seen to be singing along to old and war-time songs and reading newspapers and books. Some people preferred to spend time in their bedrooms watching television. Two people were receiving Holy Communion. The hairdresser was also visiting the home. The pace at the home was very relaxed and people who were able appeared to have choice and control over the day-to-day lives. Where people had limited ability to make decisions and choices about their day-to-day living arrangements, carer’s assisted them by offering choices about what clothing to wear and helping them to choose from the menu. People are able to bring personal items into the home such as televisions, radios, photographs, pictures and ornaments. The home has a four weekly menu that offers a choice. The main meal is served at lunchtime and a lighter meal at teatime. Warm food is always offered at midday. Some people have special diets for diabetes or they needed their food liquidised to help them to swallow food easily. The inspector joined people for lunch. A substantial amount was served and everything was eaten. Where liquised, the portions of food were served separately on the plate. Staff were observed offering people choices and encouraging people to eat as much as possible and as independently as they were able. Meals were served in the dining rooms that are situated in each of the four living units. There was a new crockery service being used. There were enough cooks and kitchen assistants available in the kitchen to prepare meals and to keep it clean. Bury Metro - Spurr House DS0000008468.V363848.R01.S.doc Version 5.2 Page 14 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. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People were encouraged to raise any concerns and most of the staff team had received safeguarding training to ensure that they are aware of what action they must take to protect people from abuse. EVIDENCE: Complaints information is displayed in the home and this information is also included in the Service User Guide (residents’ information guide). No formal complaints have been made to the CSCI about the service. There have been eleven internal complaints. The acting manager said that all complaints were treated seriously and were viewed as a means of improving the quality of the service provided. At the residents meeting people were encouraged by the acting manager to bring any concerns they had to her attention. The home has a copy of the Bury Local Authority inter-agency safeguarding policy and procedure. Records show that most of the staff team have received training in vulnerable adult protection procedures. As part of the inspection we undertook a thematic probe and we discussed safeguarding with the manager and three members of the staff team. All those we spoke with had received training, were aware of the different sorts of abuse and they also understood what they should do if they suspected that someone was being abused. Bury Metro - Spurr House DS0000008468.V363848.R01.S.doc Version 5.2 Page 15 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. JUDGEMENT – we looked at outcomes for the following standard(s): 19 21 24 and 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home provides a good, safe, well-adapted, clean and comfortable environment for people to live in. EVIDENCE: Spurr House is well maintained. Most areas of the home were refurbished two years ago, which included a new roof and new window frames and doors being fitted. Corridors were redecorated, new lights fitted and new carpets laid. Two bathrooms and two shower rooms were also fully renovated. There is good accessibility around the building with ramps, assisted baths and other equipment provided. The home has a full time handyman. There is a very pleasant enclosed garden and courtyard area in the centre of the home, which was safe for people to use. This area was attractive, with a Bury Metro - Spurr House DS0000008468.V363848.R01.S.doc Version 5.2 Page 16 nice water feature and was well used throughout the day by people living at the home and relatives. The conservatory is currently being used as the smoking area, which limits it’s use to those people who do not smoke. Consideration is being given to provide another area for people who smoke, due to changes in the law. We checked the water to a number of baths, which were set at safe temperatures. Thermometers were found in the bathrooms to enable care staff to check water temperatures were safe, before giving a person a bath. Some bedrooms had been upgraded during the refurbishment programme. However, we looked at eight bedrooms at random during the visit and it was clear that some bedrooms were very tired in appearance and in need of attention. We were also informed that some people with dementia were struggling to use the concertina type doors to the en-suite facilities in their bedrooms. Ways to improve this situation need to be looked at. The building was clean and tidy throughout and was free from malodour. We saw that staff adhered to good control of infection procedures at all times throughout this visit. The home has a properly equipped laundry. We were informed that sometimes people did not get their belongings back from the laundry. A relative stated in a returned survey that “My mother sometimes has other people’s clothes and her own clothes seem to disappear but usually turn up several weeks later.” A person using the service stated that, “Sometimes they take my clothes away and forget to bring them back the next morning.” Ways to improve this situation need to be looked at. Bury Metro - Spurr House DS0000008468.V363848.R01.S.doc Version 5.2 Page 17 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. JUDGEMENT – we looked at outcomes for the following standard(s): 27 28 29 and 30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Staffing levels need to be kept under review to ensure care needs of people living at the home are not compromised. EVIDENCE: In January this year we undertook an annual service review of the home. We looked at the information the home had sent to us as well as surveys we received. The “Have your say about….” surveys made some very positive comments about the staff team. One relative stated that the care home, makes people feel cared for and wanted. Also provides a home with a happy atmosphere and very sociable and helpful. I feel that the staff here give 100 Another relative stated that the care home could improve by, providing more staff as they are pushed to the limit to care for all the people in the home. Another stated, The only thing is that there are not enough staff. Staff are run off their feet doing more than their best. A staff member stated, we have been promised more staff for months and still it has not happened. There is no sign of new staff and a lot of staff are off sick through stress. Because of this information and that the registered manager was seconded elsewhere, we decided to return to the home earlier than we had planned. Bury Metro - Spurr House DS0000008468.V363848.R01.S.doc Version 5.2 Page 18 In surveys received for this inspection from four people using the service, three ticked no for the question “Do the staff listen and act on what you say?” In answer to the question “Are the staff available when you need them? Three people said usually and one said sometimes. One person said “not always when needing the toilet.” When people were asked at the recent resident’s meeting if they had any concerns it was commented that it often took a long time for carers to answer the buzzer. One person stated in a returned survey, “when I ring the bell it takes a long time for someone to answer.” In surveys returned from staff members answering the question, “Are there enough staff to meet the individual needs of all the people who use the service? One staff member ticked usually, three ticked sometimes and one ticked never. One staff member stated, “I feel that there isn’t always enough staff at our home. Sometimes (more often than not) we can’t sit down with our service users and have a chat with them and for them to get to know the people who care for them. I feel it is really vital so that the service users can trust us and just have a familiar face to talk to.” Another commented, “A lot of the time agency staff are used, which can mean a lot of different people who do not know the home or service users.” We were informed at this visit that there had been a high incident of sickness and maternity leave, though members of the staff team were now returning to work. The acting manager said that there were usually five care staff on duty in the morning, one person to each lounge and a carer floating between the units and a senior staff member. There are two carer’s covering the night period with on call support being provided. We observed all care staff to be very busy throughout the day, particularly between 7am and 8am. Looking at staff rotas for a four-week period the above figures are usually achieved although this often requires carer’s working overtime and the use of agency staff. Staffing levels need to be kept under review to ensure ratios are sufficient to meet not only the physical needs but also the social and emotional needs of all people living at the home, many who have dementia. The local authority carries out the required range of background checks on all staff including a Criminal Records Bureau (CRB) check. We have previously inspected employment files at Bury Adult Care Services human resources section and found the recruitment process to be robust, safe and promote equality and diversity. The home is required to have 50 of the care staff with NVQ level 2 qualifications or above by the end of 2005. We were informed that all permanent care staff at the home holds an NVQ at Level 2, which exceeds the standard. The staff team have access to relevant training to carry out there roles safely and effectively. The acting manager has produced a training matrix, which shows any shortfalls in training. Mandatory training includes, fire safety, food Bury Metro - Spurr House DS0000008468.V363848.R01.S.doc Version 5.2 Page 19 hygiene, infection control, health and safety, first aid, moving and handling and medication training. Some staff member’s mandatory health and safety training is dated and requires refresher training, particularly in moving and handling around the use of a hoist. Not all staff team have received training in equality and diversity and the Mental Capacity Act. Most of the staff team receive training in dementia awareness in 2005. Bury Metro - Spurr House DS0000008468.V363848.R01.S.doc Version 5.2 Page 20 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. JUDGEMENT – we looked at outcomes for the following standard(s): 31 33 35 and 38 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. To ensure that the service is well run and complies with the law, we must receive an application from a competent and suitably qualified person to become the registered manager of the home. EVIDENCE: The registered manager for the home was seconded to work in another service run by the local authority in July 2007 and has since been successful in securing the post for that service. In the interim period the deputy manager has acted up into the manager position. The acting manager is qualified and has many years experience working with older people, but she too moving on to a new job in the very near future. Both people living at the home and staff Bury Metro - Spurr House DS0000008468.V363848.R01.S.doc Version 5.2 Page 21 spoken with spoke highly about the acting manager, stating that she was very approachable, supportive and sorted out any problems that arose. The Older People’s co-ordinator has kept us fully informed about what action has been taken by the local authority to replace the registered manager and the deputy manager. The registered manager post has been advertised but a suitable candidate had not been forthcoming. The registered manager post has now been re-advertised along with the deputy post. A deputy manager from another home will take responsibility for the home until these posts are filled. There are clear lines of accountability within the home and with external management. The Older Peoples Co-ordinator visits the home regularly to audit records and speak to people living at the home and staff. A written report is then produced of the findings. Regular resident and staff meetings take place and minutes are kept. The local authority has recently produced a range of quality assurance questionnaires for services users, their relatives and members of the staff team. It is intended that the findings of the questionnaires will be used as a means of improving the service. We discussed with the acting manager the Inspecting for Better Lives process including AQAA’s, KLORA, inspection reports and judgements and quality ratings system and the impact the ratings will have on services. The home holds money for a number of people for safekeeping. We checked the money and records for two people and found them to be in order. Secure storage is available for the safekeeping of money and of any valuable items. We looked at maintenance of equipment service checks including gas safety, and portable electrical appliances, which were in order. We were informed that the hoisting equipment and the hydraulic bath were recently serviced and that the home was waiting for the invoice. We could not however find confirmation that the home had a valid certificate for the electrical fittings and fitments. We have requested a copy of this certificate to be sent to us. Fire safety records were examined and found to be in order. At the last inspection it was required that the staff team receive fire safety training to ensure that they know what to do in the event of a fire. No action appears to have been taken to address this matter. The staff team training needs analysis shows that only seven members of the staff team have received fire safety training and this was between 2000 and 2003. Action is needed to resolve this matter with some urgency. Bury Metro - Spurr House DS0000008468.V363848.R01.S.doc Version 5.2 Page 22 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 3 X 3 3 X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 2 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 3 X 3 X X 2 X 3 STAFFING Standard No Score 27 2 28 4 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 3 X 3 X X 1 Bury Metro - Spurr House DS0000008468.V363848.R01.S.doc Version 5.2 Page 23 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 OP8 Regulation 15 Requirement Timescale for action 31/07/08 2. OP18 3. 4. OP24 OP27 5. OP30 6. OP31 The present risk assessment format must be reviewed to ascertain whether or not it is suitable for people’s healthcare needs and whether specialist healthcare risk assessments would support staff better in making judgements about the level of risk. 13 That all members of the staff team receive training in safeguarding procedures to ensure that they know what action they should take to protect people in the event of such an incident. 23 That where identified as needed bedrooms that are tired in appearance, are decorated. 18 Care staffing levels should be reviewed in order to ensure that the assessed needs of the people, can be met, at all times of the day, including night time. 18 That support workers receive mandatory health and safety training and refresher training as and where they need it. Section 11 To ensure that the home is well DS0000008468.V363848.R01.S.doc 30/09/08 30/09/08 31/07/08 30/09/08 30/09/08 Page 24 Bury Metro - Spurr House Version 5.2 Care Standards Act 2000 7. OP38 23 8. OP38 13 run and complies with the law, we must receive an application from a competent and suitably qualified person to become the registered manager for the home. The registered person must ensure that all staff members are provided with fire safety training to ensure that they know what to do in the event of a fire. (Outstanding 31/12/06) That a valid copy of the homes electrical fittings and fitments certificate that confirms that the system is safe if sent to us. 30/06/08 30/06/08 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 Bury Metro - Spurr House DS0000008468.V363848.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection Manchester Local office 11th Floor West Point 501 Chester Road Manchester M16 9HU National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 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.V363848.R01.S.doc Version 5.2 Page 26 - 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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