Inspection on 28/09/06 for Spencer Court

This inspection was carried out on 28th September 2006.

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

Similar services:

St Vincents

The Cotswold Home

Newbeech House

Winton House

Rush Court

Hillyfield Rest Home

The Maypole Nursing Centre

The Briars

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

CARE HOMES FOR OLDER PEOPLE Spencer Court Union Street Woodstock Oxford OX20 1JG Lead Inspector Jane Handscombe Unannounced Inspection 28th September 2006 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 Spencer Court DS0000067335.V313995.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. Spencer Court DS0000067335.V313995.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Spencer Court Address Union Street Woodstock Oxford OX20 1JG 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) 01993 812725 manager.spencercourt@osjctoxon.co.uk The Orders Of St John Care Trust Patricia Clague Care Home 46 Category(ies) of Dementia - over 65 years of age (19), Old age, registration, with number not falling within any other category (46), of places Physical disability over 65 years of age (4) Spencer Court DS0000067335.V313995.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The total number of residents to be accommodated at any one time must not exceed 46 This is the services first inspection Date of last inspection Brief Description of the Service: Spencer Court is a care home providing personal care and accommodation for 46 older people. It is situated in Woodstock which is a small picturesque market town approximately six miles north of Oxford and close to many amenities The home provides 24-hour support for all the service users accommodated at the home, and meets the assessed needs of the service users. The home does not provide nursing care. The care home is owned and managed by the Orders of St John Care Trust, which is a charitable organisation that also owns homes in Wiltshire and Lincolnshire. Fees for this service range from £600 - £700 per week Spencer Court DS0000067335.V313995.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The Commission has, since the 1st April 2006, developed the way it undertakes its inspection of care services. This inspection of the service was an unannounced ‘Baseline Inspection’ ie: the first inspection since registration. The inspection involved one inspector, which took place over one day. The inspector arrived at the service on 28th September 2006 and was in the service for 8 hours. It was a thorough look at how well the service is doing. It took into account detailed information provided by the service’s manager, and any information that CSCI has received about the service since the last inspection. The inspector asked the views of the people who use the services and other people seen during the inspection or who responded to questionnaires that the Commission had sent out. The inspector looked at how well the service was meeting the standards set by the government and has in this report made judgements about the standard of the service. Comments received from residents during the inspection included: ‘It’s a palace really compared to what it used to be’ ‘If you need anything, you’ve only got to go and ask’ You can bring anything to the residents meeting and it gets seen to, may take time, but gets seen to’ ‘the staff are very friendly, all of them’ ‘the manager is brilliant’ ‘I would recommend spencer court, Favourable comments were received from the District Nursing team and other health and social care professionals in contact with the home. The inspector would like to thank the residents, their families, staff members and other health professionals for their assistance during this inspection Spencer Court DS0000067335.V313995.R01.S.doc Version 5.2 Page 6 What the service does well: What has improved since the last inspection? This is the first inspection of the home. Earlier this year in March residents moved from Spencer Court at Witan into the newly built home in Woodstock. Moving to a new environment has been a challenge to both the residents and staff team. The manager and her staff must be commended; they have worked very hard together as a team, to settle the residents into their new surroundings, whilst providing a consistent provision of care and consolidating what the inspector viewed as a warm, friendly, welcoming home during a difficult transitional period for all concerned. Residents spoken to were complimentary of their new home and the provision of care they receive. Spencer Court DS0000067335.V313995.R01.S.doc Version 5.2 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. Spencer Court DS0000067335.V313995.R01.S.doc Version 5.2 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 Outcomes Statutory Requirements Identified During the Inspection Spencer Court DS0000067335.V313995.R01.S.doc Version 5.2 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 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 the service. All prospective service users are provided with information about the home and undergo an assessment of needs prior to being offered a permanent place at Spencer Court. The home does not provide for intermediate care. EVIDENCE: Prospective service users are provided with information about the home and the services they are able to offer. Information contained in the Service User Guide and the home’s Statement of Purpose is very comprehensive allowing prospective residents and their families to get a ‘feel’ of the home. Information within these include detailed information on the aims, objectives of the home, the ethos of care, details about the qualifications and experience of the manager and staff and the facilities and services that are provided at Spencer Court. Spencer Court DS0000067335.V313995.R01.S.doc Version 5.2 Page 10 The Registered Manager or a senior carer, trained to undertake such a task, undertakes an assessment of any prospective service user in order to satisfy themselves and the service user that the home will be able to meet the assessed needs in full, before being offered a permanent place or respite care. Additional information is sought from GPs, district nurses, hospital staff, social workers, relatives and any other relevant person who could contribute to such an assessment. From the evidence seen by the inspector and comments received, the inspector considers that this service is able to provide a service to meet the needs of individuals of various religious, racial or cultural needs. Spencer Court DS0000067335.V313995.R01.S.doc Version 5.2 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 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 the service. All service users have an individualised personal plan of care detailing their needs and how these are to be addressed in order to meet these needs fully. Within a risk management process, service users are enabled to maintain responsibility for their own medication should the need be required. Service users are treated with dignity and respect at all times EVIDENCE: The inspector examined a sample of service users care plans, and found them to be comprehensive and clearly state their individual care needs. Monthly reviews and risk assessments are undertaken and clearly documented within the care plans. Spencer Court DS0000067335.V313995.R01.S.doc Version 5.2 Page 12 Residents who wish to maintain responsibility for their medication, are enabled to do so within a risk management process. The inspector examined the medication systems in place and observed the medication round. It was noted that some eardrops were held in the medication trolley for one particular resident, however upon enquiry it was established that these were no longer required. There was evidence in this case that details of treatment given by district nurses, had not been passed on appropriately and a recommendation has been made that systems are put in place to address this. The ethos of the care provision at Spencer Court is client centred and staff were observed to treat the service users with respect and dignity at all times. Appropriate terms of address are used, and attention is given to maintaining social contacts with relatives and friends. Spencer Court DS0000067335.V313995.R01.S.doc Version 5.2 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 the following standard(s): 12, 13, 14 and 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. Contact with family, friends and the local community is encouraged and support is given where required. A varied programme of activities satisfies the recreational interests of the residents. The meals offered to residents are very good, offering choice and variety, whilst catering for special dietary needs when required. EVIDENCE: There are few routines at Spencer Court and these are centred around meals and mealtimes. Wherever possible the service users are enabled to follow their social, cultural, religious and recreational interest and needs. The activities co-ordinator has developed an excellent programme of activities and social events for the residents’. Spencer Court DS0000067335.V313995.R01.S.doc Version 5.2 Page 14 Her working hours are flexible so that she can provide events in the evenings and weekends to suit the residents’ needs. The inspector chatted with residents in the evening, who were enjoying a drink from the bar and a game of cards. Activities offered are undertaken both in a group environment as well as one to one for those who prefer. This is commendable and reflects the focus of all the activities being planned around and for the residents’. There is a hairdressing salon within the home, where residents are able to book appointments as required. Weekly church services are offered and residents are able to take communion if they so wish. Residents are encouraged to maintain contact with family, friends and the local community as they wish, and the home welcomes visitors at any reasonable time. Feedback around meals offered at Spencer Court was very positive The inspector was informed that there is always a choice of menu for residents to choose from and specialist diets are catered for. Meals can be taken in either the communal dining rooms or can be served in the resident’s room if required. The inspector took lunch with the residents, and noticed the relaxed atmosphere in which lunch was taken. Residents were not rushed and staff were on hand to give assistance to those who required in an unhurried, discreet and supportive manner. Spencer Court DS0000067335.V313995.R01.S.doc Version 5.2 Page 15 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, 17, 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. The home has a satisfactory complaints procedure with evidence that residents feel their views are listened to and acted upon. EVIDENCE: The home facilitates access to an independent advocate if the need should arise details of which are accessible within the home to residents and their families. All residents are registered on the electoral role to ensure that residents are enabled to take part in the local and national elections, either by postal votes or visiting the local polling station, as they require. The home has in place robust procedures in circumstances where there are any suspicions concerning possible abuse. There are policies and procedures in place to guide the manager and staff on how to respond to any suspicion of abuse. Training is provided to all members of staff to assist them in becoming aware of their own care practices, to recognise signs and symptoms of abuse and to emphasise each staff member’s responsibility to ‘whistle blow’ on any poor practice or concerns that come to their attention. Spencer Court DS0000067335.V313995.R01.S.doc Version 5.2 Page 16 The home has an appropriate complaints procedure, which is referred to in the Service Users’ Guide. Residents said they felt able to speak to the manager about anything of concern; ‘if I wasn’t happy about something, I would tell them’ The home has not received any complaints since the last inspection, nor has the Commission received any information about a complaint. Spencer Court DS0000067335.V313995.R01.S.doc Version 5.2 Page 17 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, 21, 22, 23, 24, 25, and 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. The home was purpose built and offers all the essential facilities required of a care home. The décor and furnishings are of a high standard and afford a comfortable pleasant home for the residents. EVIDENCE: At the time of this inspection the resident’s were busy going about their daily activities and were observed using the attractive communal lounges that afford a choice of environments for them to enjoy. Spencer Court DS0000067335.V313995.R01.S.doc Version 5.2 Page 18 The standard of environment within this home is good, providing residents with an attractive and comfortable place to live and offers all the essential facilities required of a care home. All parts of the home are accessible to the service users, with the use of grab rails and a lift to facilitate mobility around the home. The inspector noted the cleanliness was generally very good, which residents confirmed was always the case, however whilst touring the home food was found uncovered and inappropriately stored, this were immediately removed and discarded by carers. The manager assured the inspector, that these were not for resident’s consumption and dealt with the matter appropriately. In each dining area, there are kitchenettes which are accessed by staff to provide for drinks and snacks for residents when required. It was noted that the recording of the refrigerator temperatures were not always being undertaken on a regular basis. A requirement has been made to ensure that appropriate monitoring and recording is undertaken so as to ensure unnecessary risks to the health and safety of service users. There are sufficient suitable washing and lavatories throughout the home, to meet the service users and visitors needs although a tablet of soap was found in one communal bathroom which could pose as a threat to the possibility of cross infection; a good practice recommendation has been made within this report to address this. The home encourages residents to bring small items of furniture and memorabilia to personalise their rooms to their own liking, which was evident on touring the home. Residents bedrooms viewed on the day of inspection were all wheelchair accessible and contained en suite facilities which included a washbasin, shower and WC. Grab rails were seen to be fitted in both the bedroom and en suite to aid residents where needed. All residents’ rooms are provided with a telephone point, satellite TV point and a call system with an accessible alarm facility to call staff in the case of an emergency. Residents spoken to were very happy with their rooms and found them to be spacious, furnished to a good standard and meeting their needs appropriately. Spencer Court DS0000067335.V313995.R01.S.doc Version 5.2 Page 19 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, 28, 29 and 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. The home provides adequate staffing to meet the needs of the residents and ensure their safety. Robust recruitment procedures are in place to support and protect the residents. EVIDENCE: The staff members at Spencer Court are an enthusiastic team who have worked positively with the residents during their first six months at their new home. They have offered a consistency of care to those using the service and worked very well as a team, ensuring that the needs of the residents are met. Recruitment procedures at the home were generally robust with clear monitoring systems in place to promote the protection of service users including application form; interview notes, references and Criminal Records Bureau (CRB) check being sought. Whilst viewing staff files, it was noted that whilst two volunteers disclosure checks had been obtained, the records failed to note at which level. The manager undertook to deal with this immediately and followed good practice. Spencer Court DS0000067335.V313995.R01.S.doc Version 5.2 Page 20 She informed the inspector, prior to writing this report that new disclosures have been applied for. There was one instance in which a staff member’s file failed to contain a recent photograph. Whilst the file contained a very clear copy of the staff members passport which contained a photograph, the manager assured the inspector this would be dealt with when the member was staff next on duty. The inspector has received confirmation from the registered manager that this was dealt with the following day. All new members of staff undergo induction training, upon appointment to their posts, and are offered ongoing training and encouraged to undertake the National Vocational Qualification (NVQ) in care, which equips them to meet the assessed needs of the residents within the home and allow for personal development. Presently there are 20 of staff who hold NVQ level 2 in care or above and a further nine care staff are registered on the course. Recent staff training has included; health and safety, bereavement, fire safety, first aid, adult protection and abuse, fire marshal training and NVQ workshops. Future planned training to be provided for staff includes; infection control, pressure care, customer care and dementia care. Regular staff meetings are held in the home, which are minuted and placed in the staff room for all staff to access. Copies of the minutes were seen by the inspector. Spencer Court DS0000067335.V313995.R01.S.doc Version 5.2 Page 21 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, 33, 35 and 38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. Spencer Court is a well managed home, run in the best interests of the residents, using the service, with safeguards in place to protect their health, safety and welfare. There are clear robust systems in place to protect the residents’ financial interest. Spencer Court DS0000067335.V313995.R01.S.doc Version 5.2 Page 22 EVIDENCE: The inspector met with the administrator, who has recently taken post, and discussed the management of the residents’ finances. The home has systems and records in place to provide a clear audit trail to safeguard the residents’ financial interest. Both residents and staff informed the inspector that the manager is very approachable and supportive and values their opinions and suggestions. It was felt that she runs the home in an open, transparent manner and always in the best interests of those using the service. Regular residents meetings are held, which keep residents informed and allow for any concerns to be discussed. Likewise, Relative and Friends meetings are also held. These meetings are minuted and distributed around the home. Safeguards are in place to protect the both the residents and staffs health, safety and welfare. However there were two instances (See section headed Environment) which can be seen to compromise the resident’s health and safety. A requirement and recommendation have been made to address these issues. The CSCI is notified under Regulation 37 of The Care Homes Regulations 2001 of any occurrence affecting the welfare of service users, and the manager and staff showed an awareness of what events need reporting. All accidents and incidents are recorded, monitored and appropriate action taken, including sharing the information with line management. Spencer Court DS0000067335.V313995.R01.S.doc Version 5.2 Page 23 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 X 3 X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 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 3 18 3 2 X 2 3 3 3 3 3 STAFFING Standard No Score 27 3 28 3 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 2 Spencer Court DS0000067335.V313995.R01.S.doc Version 5.2 Page 24 Are there any outstanding requirements from the last inspection? N/A 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 OP38 Regulation 13(4)(C) Requirement The registered manager must ensure that appropriate monitoring and recording of refrigerator temperatures is undertaken so as to ensure unnecessary risks to the health and safety of service users. Timescale for action 30/11/06 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 OP21 Good Practice Recommendations It is a good practice recommendation to ensure tablet soap is not made available in communal bathing and toileting facilities, and the provision of liquid soap remains available. It is recommended that a discussion between the manager and other health professionals take place to ensure that there are systems in place whereby they always pass on details of treatment given to the care staff or manager. It is recommended that staff files be monitored to ensure they contain a recent photograph at all times. DS0000067335.V313995.R01.S.doc Version 5.2 Page 25 2 OP9 3 OP29 Spencer Court Spencer Court DS0000067335.V313995.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection South East Regional Office 4th Floor Caledonia House 223 Pentonville Road London N1 9NG 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. 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