Inspection on 26/05/05 for Spencefield Grange

This inspection was carried out on 26th May 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 13/12/05

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 Paula Dutton Unannounced Inspection 26th May 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.V291909.R02.S.doc Version 5.1 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.V291909.R02.S.doc Version 5.1 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 0116 2418118 Debbie@hicare.co.uk 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.V291909.R02.S.doc Version 5.1 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. 16/11/2004 Date of last inspection Brief Description of the Service: The home provides accommodation for 56 people and is owned by Hicare Limited. It is located in a quiet suburb on the outskirts of the city of Leicester and has access to a regular bus service. The building is a modern purpose built accommodation offered with ground and first floor level bedrooms with ample car parking facilities to the front and side of the home. At the rear of the home there is an extended patio terrace with garden furniture and ornate water fountain. The garden has level access for people with mobility impairments. Spencefield Grange DS0000064398.V291909.R02.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This announced inspection took place over one day. The owner, area manager, manager and assistant manager were present during the inspection. Three residents’ records were examined in detail including care plans, risk assessments, daily notes, accident records, medication record, discussion with staff, discussion with management, observation of residents’ bedrooms, observing/speaking with residents. This process is known as ‘case tracking’. A tour of the premises took place and all communal areas were viewed. Some residents spoke to the inspector about the services they receive at the home. What the service does well: What has improved since the last inspection? What they could do better: The management of medication must be monitored more closely so that the administration of medication is accurately delivered. It is noted that immediately following this Inspection the Registered Provider confirmed that all shortfalls had been fully addressed. Spencefield Grange DS0000064398.V291909.R02.S.doc Version 5.1 Page 6 Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Spencefield Grange DS0000064398.V291909.R02.S.doc Version 5.1 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.V291909.R02.S.doc Version 5.1 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): 1, 3, 4 There is comprehensive and informative information provided so that residents and their representatives are able to make informed decisions. EVIDENCE: There is a comprehensive Statement of Purpose and Service Users’ Guide containing details about the services provided by the home. The information provided is clear and informative. Information includes the complaints policy and procedure which refers to the contact details for The Commission for Social Care Inspection. A resident’s personal record file showed the manager gains professional assessments prior to admission including those assessments from social workers. Spencefield Grange DS0000064398.V291909.R02.S.doc Version 5.1 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, 8, 9, 10 The management of medication was partially inadequate at the time of inspection . General medication process and management is supportive of care EVIDENCE: A resident was identified as having dementia care needs. The home does have access to a dementia care information package. The area manager explained training is provided for staff in how to cope with the needs of residents with dementia care needs and challenging behaviours. Medication was securely stored in a lockable trolley in a locked room. A resident’s medication record chart was viewed. This showed all tablets had been signed for as given. On examining the blister packs it was found that a tablet prescribed for heart conditions (Isosorbide Mononitrate 20mg) had not been given twice in the previous three days despite staff signatures. Communication with the Registered Provider immediately following the Inspection has fully addressed short fall issues. Spencefield Grange DS0000064398.V291909.R02.S.doc Version 5.1 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): 15 There is a choice of nutritional meals offered to residents. EVIDENCE: The planned menus were available within the kitchen. These showed a varied and nutritional diet is offered to residents. A resident stated a choice of food is offered each day. Residents were observed entering the dining room before lunchtime. Residents were unhurried and relaxed. They were able to choose where to sit. Spencefield Grange DS0000064398.V291909.R02.S.doc Version 5.1 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): 16, 18 There is a clear and accessible complaints procedure so that residents and their representatives can express their concerns and expect a prompt response. Staff are aware of the measures for the prevention of abuse so that residents are delivered a safe environment to live in. EVIDENCE: Information contained within the Statement of Purpose and Service Users’ Guide lists the complaints policy and procedure. The complaints policy and procedure is clear and easy to follow. This is available on notice board in the main communal hallway. A copy of the Department of Health’s guidance entitled NO SECRETS: Mistreatment of Vulnerable Adults was available for all staff to read. There is an ongoing programme of National Vocational Qualification training in Care (level two) which includes training in the prevention of abuse when working with older people. A staff member was spoken with who had a good understanding of the rights of residents, this staff member was aware of the NO SECRETS document and the Whistleblowing policy Spencefield Grange DS0000064398.V291909.R02.S.doc Version 5.1 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, 20, 21, 22, 23, 24, 25, 26 Generally the environment is well maintained . EVIDENCE: A tour of the premises found all areas of the home to be clean, well decorated and tidy. There is a programme of renewal and refurbishment taking place. Evidence was seen of new building works including a large conservatory overlooking an ornate fountain and patio area. Outside seating and tables were available. The rear garden was secured with a fence. All areas of the premises were accessible for people with mobility impairments. The inspector established, using a digital thermometer, that the hot water supply to a bath upstairs was 58.2 degrees centigrade. This temperature was later challenged by the registered owner who stated the temperature was 41 degrees centigrade. Due to the high risk nature of this subject the Registered Provider was reminded to continue to maintain all suitable checks on water temperature. Since the inspection the registered owner has formally confirmed Spencefield Grange DS0000064398.V291909.R02.S.doc Version 5.1 Page 13 that readings from this point of supply now consistently read as 41 degrees centigrade. The maintenance worker stated monthly checks had been completed for hot water supplies and a record kept of findings. Some minor issues regarding the use of disposable plastic gloves were identified, however since the Inspection the Registered Provider has confirmed that additional in house training has taken place. Spencefield Grange DS0000064398.V291909.R02.S.doc Version 5.1 Page 14 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 There are sufficient numbers of staff provided with a skills mix and length of experience suitable to ensure the safety and care needs of residents are met. EVIDENCE: A staff rota showed sufficient staff are provided for each duty. There are higher levels of staffing for times of peak activity such as each morning shift. Each shift is led and coordinated by a senior carer. Senior carers are completing a National Vocational Qualification in Care (level three). The manager stated there are always at least two staff members awake on duty throughout the night. A member of the management team is on call during night shifts. All staff on call are within 15 minutes of the premises. The manager stated that when there are 40 residents there are two staff awake on shift with a sleep in member of staff or there are three staff awake all night on shift. Spencefield Grange DS0000064398.V291909.R02.S.doc Version 5.1 Page 15 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): 31, 36, 37, 38 The home is managed in the best interests of the residents’ health and welfare. EVIDENCE: The manager has over seven years of service with the company and has been in the position of manager for one year. The manager is currently completing a National Vocational Qualification in Care Management (level four). There is a formal supervision policy and procedure to be offered to all staff. This system encompasses appraisal. Residents’ individual records are securely stored. Evidence of records viewed demonstrated record entries were non judgemental, signed and dated. Spencefield Grange DS0000064398.V291909.R02.S.doc Version 5.1 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 3 N/A 3 3 N/A N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 10 3 11 N/A DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 N/A 13 N/A 14 N/A 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 N/A 18 3 3 3 3 3 3 3 3 3 STAFFING Standard No Score 27 3 28 N/A 29 N/A 30 N/A MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 N/A N/A N/A N/A 3 3 N/A Spencefield Grange DS0000064398.V291909.R02.S.doc Version 5.1 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. 1 Standard OP9 Regulation 13 Requirement The administration of medication must be effective and ensure residents do receive their medication. Timescale for action 23/07/05 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 Spencefield Grange DS0000064398.V291909.R02.S.doc Version 5.1 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.V291909.R02.S.doc Version 5.1 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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