Inspection on 13/12/05 for Spencefield Grange

This inspection was carried out on 13th December 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector 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

Spencefield Grange 04/03/10

Spencefield Grange 23/11/09

Spencefield Grange 16/02/09

Spencefield Grange 06/03/07

Spencefield Grange 26/05/05

Similar services:

Byars Care Home

St Marys Nursing Home

Bramble Lodge

Parkmanor Residential Home

Thornham Grove

Hunter`s Lodge

London Road Neurological and Specialist Care Unit

Carlton Care Home

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

CARE HOMES FOR OLDER PEOPLE Spencefield Grange Davenport Road Leicester Leicestershire LE5 6SD Lead Inspector Martin Hefferman Unannounced Inspection 13th December 2005 09:30 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 Spencefield Grange DS0000064398.V271021.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. Spencefield Grange DS0000064398.V271021.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Spencefield Grange Address Davenport Road Leicester Leicestershire LE5 6SD 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) 0116 2418118 HiCare Limited Mrs Deborah Crawford Care Home 56 Category(ies) of Dementia - over 65 years of age (34), Mental registration, with number Disorder, excluding learning disability or of places dementia - over 65 years of age (31), Old age, not falling within any other category (56), Physical disability (37), Physical disability over 65 years of age (56) Spencefield Grange DS0000064398.V271021.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 4. No person under 55 years of age who falls within category PD may be admitted into the home. No person who falls in category MD(E) may be admitted to the home when 31 persons in total of this category are already accommodated in the home. No person who falls in category DE(E) may be admitted into the home when 34 persons who fall within this category are already accommodated in the home No person who falls within category PD may be admitted to the home when 37 persons who fall within this category are already accommodated in the home. 26/05/05 Date of last inspection Brief Description of the Service: Spencefield Grange is registered to provide care for up to 56 older people. The home is located in a quiet suburb on the outskirts of Leicester and has access to a regular bus service. Residents’ rooms are situated on both the ground and first floors. Residents have access to a dining room and a choice of lounges. All areas of the home are accessible. There is a patio to the rear of the building with seating and ornate water fountain. The home was in the process of building a conservatory at the time of the inspection. Spencefield Grange DS0000064398.V271021.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The focus of inspections undertaken by the Commission for Social Care Inspection (CSCI) is upon outcomes for service users and their views of the service provided. This process considers the establishment’s capacity to meet regulatory requirements & minimum standards of practice and focuses on aspects of service provision that need further development. This inspection took place over the course of approximately five and a half hours. The primary method of inspection used was ‘case tracking’ which involved selecting three residents and tracking the care they receive through review of their records, discussion with them (where appropriate), staff and observation of care practices. Eight residents and a visitor were interviewed during the course of this visit. The registered manager, area manager and owner facilitated the inspection. What the service does well: What has improved since the last inspection? There is an ongoing process of redecoration and refurbishment at the home. Work on the garden has been completed since the date of the last inspection. The home was in the process of building a conservatory and fitting radiator covers at the time of this visit. The registered manager stated that the remaining covers would be fitted by the end of the following day. Staff members have received instruction with regard to the control of infection. They are due to start a distance learning training course in the New Year. Spencefield Grange DS0000064398.V271021.R01.S.doc Version 5.0 Page 6 What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Spencefield Grange DS0000064398.V271021.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 Spencefield Grange DS0000064398.V271021.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): 6 The requirements of Standard 6 are not applicable. EVIDENCE: The home does not provide intermediate care. Spencefield Grange DS0000064398.V271021.R01.S.doc Version 5.0 Page 9 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&9 Care plans are clear and comprehensive. Residents are generally well protected by the home’s medication arrangements. EVIDENCE: Individual plans were available for the residents who were chosen for the purposes of case tracking. The plans that were inspected were clear and comprehensive. Records indicate that they have been kept under review. Medication administration records for the residents who were chosen for the purposes of case tracking met relevant requirements. They accurately reflected the amount of medication taken by each resident. A discussion took place with regard to the medication arrangements for a resident identified at the time of the inspection. The existing arrangement involved staff members and the resident removing a week’s medication from a blister pack and placing it in a dosset box for the resident to administer himself. It is strongly recommended that the home seek further advice from a pharmacist with regard to these arrangements. The registered manager agreed to obtain a larger locked tin to enable the resident to store his medication securely. Spencefield Grange DS0000064398.V271021.R01.S.doc Version 5.0 Page 10 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): 12, 13 & 14 Arrangements for daily life & social activities appear to meet residents’ expectations. EVIDENCE: The home employs a part-time activity organiser. A number of residents participated in a game of bingo on the day of the inspection. They stated that they enjoy the social activities that are provided. Individual plans set out residents’ cultural needs. One of the residents who were chosen for the purposes of case tracking confirmed that arrangements had been made to enable him to practice his faith. Religious services are held within the home. A relative of a resident stated that he is made to feel welcome whenever he visits. Residents confirmed that family and friends are able to visit at any time. Residents stated that they are able to determine their own daily routine, deciding, for example, when to get up & to go to bed and whether or not to participate in activities. Whilst the requirements of standard 15 (Meals & Mealtimes) were not inspected on this occasion, a resident stated that the dietary requirements associated with his faith were catered for. Spencefield Grange DS0000064398.V271021.R01.S.doc Version 5.0 Page 11 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): Not applicable EVIDENCE: None of the standards in this section were inspected on this occasion. Spencefield Grange DS0000064398.V271021.R01.S.doc Version 5.0 Page 12 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, 25 & 26 Residents are provided with comfortable surroundings in which to live. EVIDENCE: The parts of the home that were inspected were decorated and furnished to a satisfactory standard. They were clean and free from offensive odours. There is an ongoing process of redecoration and refurbishment. Work on the garden has been completed since the date of the last inspection. The home was in the process of building a conservatory and fitting radiator covers at the time of this visit. The registered manager stated that the remaining covers would be fitted by the end of the following day. The registered manager stated that staff members have received instruction with regard to the control of infection since the date of the last inspection and that they are due to start a distance learning training course in the New Year. Spencefield Grange DS0000064398.V271021.R01.S.doc Version 5.0 Page 13 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): 28, 29 & 30 Arrangements for recruiting and training staff are generally well managed. EVIDENCE: The registered manager stated that two of the twenty-one members of care staff have completed National Vocational Qualification level 2 and that three were in the process of completing NVQ level 3. The owner stated that difficulties accessing funding for the training had prevented more staff from obtaining the qualification. Eleven staff members were due to start NVQ level 2 in the New Year. The registered manager was in the process of completing a NVQ level 4 in management & care. The staff records that were inspected indicated that appropriate preemployment checks have taken place. Staff members have received copies of the General Social Care Council’s Codes of Conduct. New members of staff complete induction training based upon the standards set by Skills for Care (the Training Organisation for Personal Social Services). Records indicate that staff members have received training on a range of issues relevant to their work. Spencefield Grange DS0000064398.V271021.R01.S.doc Version 5.0 Page 14 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): 33, 35 & 38 Arrangements for ensuring that the services provided by the home meet the needs of residents and for handling their finances appear to be well managed. EVIDENCE: The owner stated that residents and their representatives are encouraged to complete survey forms. The overall results of the most recent survey are published as part of a regular newsletter produced by the company. The owner and the area manager visit the home on an almost daily basis. The registered manager keeps a record of any discussions that take place during the course of those visits. The inspector agreed to seek guidance regarding whether those records meet the requirements of Regulation 26. The home maintains records of any money it handles on behalf of residents. The records that were inspected had been signed by two members of staff and Spencefield Grange DS0000064398.V271021.R01.S.doc Version 5.0 Page 15 receipts had been kept. Staff members rectified a slight discrepancy identified at the time of the inspection. Records indicate that fire tests & drills have taken place at the required frequency. The home has completed risk assessments on a range of safe working practices. Spencefield Grange DS0000064398.V271021.R01.S.doc Version 5.0 Page 16 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 X X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 X 9 3 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 X COMPLAINTS AND PROTECTION Standard No Score 16 X 17 X 18 X 3 X X X X X 3 3 STAFFING Standard No Score 27 X 28 2 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X X 3 X 3 X X 3 Spencefield Grange DS0000064398.V271021.R01.S.doc Version 5.0 Page 17 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. Standard Regulation Requirement Timescale for action 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 OP9 Good Practice Recommendations It is strongly recommended that the home seek further advice from a pharmacist with regard to the medication arrangements for a resident identified at the time of the inspection. Spencefield Grange DS0000064398.V271021.R01.S.doc Version 5.0 Page 18 Commission for Social Care Inspection Leicester Office The Pavilions, 5 Smith Way Grove Park Enderby Leicester LE19 1SX 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 Spencefield Grange DS0000064398.V271021.R01.S.doc Version 5.0 Page 19 - 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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