Inspection on 26/04/05 for Lady Spencer House

This inspection was carried out on 26th April 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 there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Lady Spencer House 20/10/08

Lady Spencer House 18/06/08

Lady Spencer House 06/02/08

Lady Spencer House 05/06/07

Lady Spencer House 22/11/06

Lady Spencer House 13/10/05

Lady Spencer House 15/11/04

Lady Spencer House 29/09/04

Lady Spencer House 30/03/04

Lady Spencer House 23/10/03

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Oak Ridge

Sun Court Nursing Home

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Bilney Hall

Hill Barn

Mabbs Hall Nursing Home

Henrietta House

Extracts from inspection reports are licensed from CQC, this page was updated on 09/07/2008.

CARE HOMES FOR OLDER PEOPLE Lady Spencer House 52 High Street Houghton Regis Beds LU5 5BJ Lead Inspector Dragan Cvejic Announced 26 April 2005 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 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. Lady Spencer House I51 s14923 LADY SPENCER HOUSE v215767 260405 stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Lady Spencer House Address 52 High Street Houghton Regis Beds LU5 5BJ 01582 868516 Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Resicare Jean Flanagan Care Home 24 (24) (24) (24) Category(ies) of DE(E) - Dementia over 65 registration, with number OP - Old Age of places PD(E) - Physical Disablilty over 65 Lady Spencer House I51 s14923 LADY SPENCER HOUSE v215767 260405 stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection Brief Description of the Service: Lady Spencer is a residential home for older people, specialising in care for people with mental and physical disabilities. The home was situated in a walking distance from the centre of Houghton Regis and provided easy access to the town’s amenities A new modern, purpose built house on three floors offered accommodation in 24 single rooms. The communal space included 3 comfortable lounges for service users to sit together, and the staff were able to spend time with them, paying attention to all individuals. A lift was used for access to the first and the second floor. A number of toilets and washing facilities were located throughout the building allowing easy access. The parking space behind the building and a small garden was sufficient for staff and visitor’s cars. Lady Spencer House I51 s14923 LADY SPENCER HOUSE v215767 260405 stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an announced inspection. It was carried out during one working day. A trainee manager and the mentor –current manager, provided information necessary for the evidence for this report. The inspector used a case tracking methodology covering all procedures and records for 3 service users. In addition, the inspector observed staff helping service users. The inspector spoke to 5 service users in detail and had personal contact with 9 service users in communal areas in the home. The inspector spoke to 2 staff and attended a handover. What the service does well: Lady Spencer house was home to 24 service users and provided a very homely atmosphere. Staff were friendly and supportive to service users. They knew service users individually and supported them and helped them in a way that they liked. The home had the written information to give to new service users, their relatives, and anyone who wanted to learn more details about the home. The manager and staff were admitting new service users only when they were sure that the home could properly look after them and help them. They invited potential new service users to visit the home a few times before they were asked to make a decision about coming in as permanent service users. Staff were very friendly and understood the problems and difficulties that service users had as a result of their age, conditions or illnesses. The staff treated service users with respect and were available when service users needed their help. The manager and trainee manager were continuously present “on the floor” to see if the number of staff on duty guaranteed a fast response when service users needed help. The home kept nicely organised records that showed how they met the service users’ needs. The environment was pleasant, homely and helped to create a very homely feeling. Most service users were mobile and walked through the home freely, talking to each other and to staff. On the first floor, where mobility was not so good, 3 members of staff were in the lounge to assist service users if they needed help. A hundred year old service user who did not speak showed to the staff that she wanted to draw something, and staff brought her crayons and stayed with her for company while she was drawing. Another service user was helped by two staff to go where he wanted. One floor up, two staff gently helped a service user to move by use of a hoist. A service user in the Lady Spencer House I51 s14923 LADY SPENCER HOUSE v215767 260405 stage 4.doc Version 1.30 Page 6 conservatory spoke to the inspector about his history and said that he liked to sit there until 3pm and to socialise after that time. At three that afternoon, the staff who was there called another colleague to help her assist to move the service user closer to another, so that he could socialise with them. Three service users in the lounge told to the inspector: “All is fine here. I can’t see what can be better. The girls are so nice, they care about us.” Five service users stated to the inspector that they “felt very safe and cared for here” and one added “...I do feel safe here when I see what’s going on in the world.” One service user said: “We change things to make them better. There is one thing we cannot change – the weather”, as at that time it had started raining. He also said that he used the garden when the weather was nice. The home was clean and being purpose built, had all the necessary equipment and facilities that helped service users to stay independent. Those that needed help were helped as was recorded in their care plans. Many nice pieces of furniture, both in communal areas and in service users’ rooms, made the home so homely. Staff that spoke to the inspector stated that they “felt happy working here”, that they were supported and that “service users were nice old people”. They also said that “the manager was always accessible and supportive”. Both managers, a trainee and a mentor stated that the staff atmosphere was good and friendly, but professional. The trainee manager said that she was getting excellent support and induction to her new post. The inspector had lunch with staff and the food was tasty and nice. The cook stated that she catered for a service user from a different cultural background as well as for a diabetic and a strict vegetarian. There was a choice of nice food available for service users. They had their say in their three monthly meetings. The home was run by the manager who was providing mentoring to a proposed new manager. In the open atmosphere, staff were working as a team, felt supported and could attend various training. What has improved since the last inspection? Although one requirement – to register the manager – was not met, the arrangement and mentoring a new person for the manager’s position was ongoing. The kitchen ceiling was redecorated. At least one staff trained in first aid was working in the home at any one time. The home had got a new metal medication box to keep controlled drugs safely. The home was given 3 walkietalkies and used them to allow staff to talk to the kitchen from the office, or to the office from a bathroom etc. The management team had started a quality assurance review and had given some questionnaires to relatives, but the response was not as expected. Lady Spencer House I51 s14923 LADY SPENCER HOUSE v215767 260405 stage 4.doc Version 1.30 Page 7 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. Lady Spencer House I51 s14923 LADY SPENCER HOUSE v215767 260405 stage 4.doc Version 1.30 Page 8 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 Standards Statutory Requirements Identified During the Inspection Lady Spencer House I51 s14923 LADY SPENCER HOUSE v215767 260405 stage 4.doc Version 1.30 Page 9 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 standard(s) 1,2,3,4,5 The home provided sufficient written information about the home. The assessment of new service users was appropriate and detailed. The home was meeting the needs of service users. EVIDENCE: The statement of purpose had been reviewed, but the details of the regulation and registration authority was not changed from NCSC to CSCI in the complaints procedure. Although the service user’s guide was simple and written in plain language (that was appropriate for service users), it did not have all the required details. Staff details presented were general; no names, roles or staff positions and qualifications were available. There was nothing to refer to another place, where this information would be available if needed. New service users and their relatives were given 3 documents: the statement of purpose, the service user’s guide and the contract. When looked at together, these three documents provided all the required information. The contract was detailed and clearly explained terms and conditions, what was offered, the fees and what was included in fees and other relevant information. Lady Spencer House I51 s14923 LADY SPENCER HOUSE v215767 260405 stage 4.doc Version 1.30 Page 10 The admission assessment was carried out by the senior staff members: a manager, a trainee manager, the owner and one senior staff member that was trained for a more senior role of duty. Their expertise was noticeable in the details recorded on these assessment forms. The senior staff were quite clear about the home’s capacity to meet a range of needs and carried out admission assessments so that prospective service users could be reassured that the assessed needs would be met. The home was meeting the service users’ needs and service users documentation, satisfaction and progress were confirming the homes’ effective work. The home did not offer intermediate care and at the time of the inspection there were no respite beds either. Lady Spencer House I51 s14923 LADY SPENCER HOUSE v215767 260405 stage 4.doc Version 1.30 Page 11 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 standard(s) 7-11 The home completely met the health care needs of service users. They could demonstrate with various evidence and through inspectors’ observation that service users’ needs were met. EVIDENCE: The documents from the initial assessment were comprehensive and demonstrated that a full assessment was carried out prior to admission. There were four senior people assessing potential service users: the owner, the manager and trainee manager, and one more senior staff member. A care plan was written in a descriptive format, describing the main features for each individual. The manager stated that this format was the best workable document for staff, as it provided an excellent picture of a service user. A suggested care agreement was another good document that was used to collect service users’ preferences, likes, dislikes and give a picture of their history. It was filled in the form of answers to prepared questions. Each file contained a risk assessment. Lady Spencer House I51 s14923 LADY SPENCER HOUSE v215767 260405 stage 4.doc Version 1.30 Page 12 The care plans did not have an allocated space for service users or their representatives to sign the plan. Where a service user declined to take part in the care planning process, the care plan indicated that. These documents were regularly reviewed and the dates and signatures of the reviewing person were recorded on a separate review sheet. Any change was also recorded on the same sheet and incorporated into the care plan. The file contained daily record sheets where different practical care elements, such as bath, weight, nutrition or other identified needs were recorded on a daily basis with entries made three times a day. In addition, fluid charts and toilet charts were kept in the lounges, where most service users spent the daytime. This allowed staff to accurately and easily record the events affecting service users. The observation of care practices, such as moving and handling, assisting to eat, communicating, according to service users ability etc, also demonstrated that the home and staff met the service users’ needs. The staff communicated with a deaf service user by writing questions, and she wrote the answers or her questions. A medication policy was in place and the procedures were appropriate. The records of administered medication as well as the observed process demonstrated that the procedure was appropriate. In the homely environment, privacy and dignity were respected and promoted. Lady Spencer House I51 s14923 LADY SPENCER HOUSE v215767 260405 stage 4.doc Version 1.30 Page 13 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 standard(s) 12,14,15 The home offered appropriate social activities based on identified needs. Service users’ preferences, wishes, aspirations and abilities were taken into account in relation to the activities and daily routine in the home. EVIDENCE: The statement of purpose addressed the activities offered in the home. A service user’s file contained recorded preferred activities for each individual. A service user confirmed that she was taken out for a day trip. Another service user explained his preferences for his daily routine that was respected. Staff knew about service users’ preferred routines. Service users had their meetings three monthly when they could discuss any suggestions and bring new ideas for sharing with others. Lady Spencer House I51 s14923 LADY SPENCER HOUSE v215767 260405 stage 4.doc Version 1.30 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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 16, 17, 18 The home had the appropriate complaints procedure and measures in place to protect service users. EVIDENCE: The complaint procedure was displayed and had a clearly set time scale for response. The address for the regulation authority was not up-dated. The home had a whistle blowing policy and staff signed all major policies during their induction. A policy on gifts was also signed and prohibited staff receiving gifts from service users. The home did not keep any service users’ money and recorded who was responsible for each individuals’ finances in order to offer protection, if needed. The service users’ properties were recorded on a property list in their files. Lady Spencer House I51 s14923 LADY SPENCER HOUSE v215767 260405 stage 4.doc Version 1.30 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 19-26 The purpose built, well equipped home, arranged in a domestic style and well maintained, offered a comfortable, pleasant and safe environment. EVIDENCE: The home was designed for it’s purpose and grab rails, raised toilet seats, specialist beds, special baths and 2 hoists helped the staff meet the service users’ needs. A service user stated that he was using the nice garden in good weather. Maintenance was organised and recorded in the Maintenance man’s book. The requirement to improve the kitchen ceiling was responded to. Shared facilities, conservatory, lounges and dining room, were clean, warm and service users stated that they enjoyed being there. Toilets and bathrooms were accessible and appropriately marked. The home had equipment and adaptations that helped staff support service users and service users could retain their independence much longer with these provisions. The staff were observed during the inspection using the hoist appropriately and a service user stated that he felt comfortable during the hoisting process. Individual bedrooms were comfortable, appropriate in size and contained personal items that created a homely atmosphere. Radiators were guarded, and the water Lady Spencer House I51 s14923 LADY SPENCER HOUSE v215767 260405 stage 4.doc Version 1.30 Page 16 supply was in accordance with regulations. The laundry room was on the top floor and ensured infection control measures were respected. Lady Spencer House I51 s14923 LADY SPENCER HOUSE v215767 260405 stage 4.doc Version 1.30 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27, 29, 30 Staff had the skills and experience necessary to meet the service users’ needs. A minimal turnover, proper induction, and appropriate training ensured consistency and effectiveness in the staff’s work. There was space for improving the recruitment procedure. EVIDENCE: The staff were skilled, experienced and appropriately deployed through the rota made on the principles of service users’ needs. A trainee staff member, younger than 18, was clearly marked on the rota and worked supervised. None of the sampled staff files contained two written references. Training certificates demonstrated that varied and appropriate training was arranged and carried out. Lady Spencer House I51 s14923 LADY SPENCER HOUSE v215767 260405 stage 4.doc Version 1.30 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31,32, 33, 34,35,36,37 and 39 The home was well managed in an open, creative and inclusive atmosphere. EVIDENCE: There were two managers at the time of the inspection. A new, trainee manager was being mentored through the process of delivering service. Staff felt supported and were clear about their roles. Questionnaires were dispensed to service users, families and some visiting professionals, but the response was not as expected. The manager was discussing with the owner about how to improve the effectiveness of the quality assurance programme. A business plan was drawn up at the company level covering both this and another company’s home. It contained the budget and financial information. The home recorded who was responsible for service users’ financial matters, but did not hold their money. Staff supervision and appraisals were set and up Lady Spencer House I51 s14923 LADY SPENCER HOUSE v215767 260405 stage 4.doc Version 1.30 Page 19 and running. The records, apart from those individually addressed, such as staff references, were up to date and appropriate. The home ensured the practices and procedures were safe and ensured service users’ safety and well being. Lady Spencer House I51 s14923 LADY SPENCER HOUSE v215767 260405 stage 4.doc Version 1.30 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score 2 3 4 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 x 14 3 15 3 COMPLAINTS AND PROTECTION 3 3 3 3 3 3 3 3 STAFFING Standard No Score 27 3 28 x 29 1 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 3 3 2 3 3 3 3 3 3 3 Lady Spencer House I51 s14923 LADY SPENCER HOUSE v215767 260405 stage 4.doc Version 1.30 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. Standard 31 Regulation 8 Timescale for action This was required on the new previous inspection. The timescale manager must be registered with by 30/11/05 the CSCI. In current circumstances, the new trainee manager must apply for registration at the end of her induction. The statement of purpose and 30/11/05 the service users guide must be up dated and contain detailed staff information, or point out where these would be available. The name of the regulatory authority must be up dated from NCSCto the CSCI The registered person must 30/11/05 ensure that two written references are obtained for staff and that the POVA disclosures are obtained prior to the start date for staff that work supervised while awaiting for the CRB disclosures Requirement 2. 1 5 3. 29 19 Lady Spencer House I51 s14923 LADY SPENCER HOUSE v215767 260405 stage 4.doc Version 1.30 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. Refer to Standard 7 Good Practice Recommendations The care plans should be signed by service users or their representatives to demonstrate their involvement when it happens. This signature would also indicate that care plans are available to service users. Lady Spencer House I51 s14923 LADY SPENCER HOUSE v215767 260405 stage 4.doc Version 1.30 Page 23 Commission for Social Care Inspection Clifton House 4a Goldington Road Bedford MK40 3NF 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 Lady Spencer House I51 s14923 LADY SPENCER HOUSE v215767 260405 stage 4.doc Version 1.30 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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