Inspection on 14/05/09 for Spencer Grove Care Home

This inspection was carried out on 14th May 2009.

CQC found this care home to be providing an Good service.

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

Other inspections for this house

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 15/11/2009.

Key inspection report CARE HOMES FOR OLDER PEOPLE Spencer Grove Care Home Spencer Grove Care Home Springwood Gardens Belper Derbyshire DE56 1JR Lead Inspector Susan Richards Key Unannounced Inspection 14th May 2009 09:30 DS0000072427.V375366.R01.S.do c Version 5.2 Page 1 This report is a review of the quality of outcomes that people experience in this care home. We believe high quality care should: • • • • • Be safe Have the right outcomes, including clinical outcomes Be a good experience for the people that use it Help prevent illness, and promote healthy, independent living Be available to those who need it when they need it. We review the quality of the service against outcomes from the National Minimum Standards (NMS). Those standards are written by the Department of Health for each type of care service. Copies of the National Minimum Standards – Care homes for older people can be found at www.dh.gov.uk or bought from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop. The mission of the Care Quality Commission is to make care better for people by: • Regulating health and adult social care services to ensure quality and safety standards, drive improvement and stamp out bad practice • Protecting the rights of people who use services, particularly the most vulnerable and those detained under the Mental Health Act 1983 • Providing accessible, trustworthy information on the quality of care and services so people can make better decisions about their care and so that commissioners and providers of services can improve services. • Providing independent public accountability on how commissioners and providers of services are improving the quality of care and providing value for money. Spencer Grove Care Home DS0000072427.V375366.R01.S.doc Version 5.2 Page 2 Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report Care Quality Commission General Public 0870 240 7535 (telephone order line) Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CQC copyright, with the title and date of publication of the document specified. www.cqc.org.uk Internet address Spencer Grove Care Home DS0000072427.V375366.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Spencer Grove Care Home Address Spencer Grove Care Home Springwood Gardens Belper Derbyshire DE56 1JR 01773 599349 01773 599344 spencergrove@milfordcare.co.uk Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Milford Care Limited Donna Annable Care Home 57 Category(ies) of Old age, not falling within any other category registration, with number (57), Physical disability (57) of places Spencer Grove Care Home DS0000072427.V375366.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following categories of service only: Care Home with nursing - code N to service users of the following gender: Either whose primary care needs on admission to the home are within the following categories: Old age, not falling within any other category - Code OP Physical Disability - Code PD The maximum number of service users who can be accommodated is 57 2. Date of last inspection Brief Description of the Service: Spencer Grove provides twenty four hour nursing and personal care and support for older people and also people with a physical disability up to a maximum of fifty seven. The home is located close to the town centre of Belper, within a residential setting having good access to all local shops and amenities. The home is a newly converted building registered within the last six months. It is set into a hillside with extensive south facing views. It is decorated, furnished and equipped to a high specification. Main facilities are set over two floors, providing all single room accommodation, each having a large ensuite facility, including a walk in shower. There is a choice of lounge and dining areas to each floor, including quiet space and with access to a well presented safe and accessible roof top garden, with seating. There is a large atrium bringing light to the central ground floor internal court yard area, which has bedrooms off. And there is a choice of assisted communal bathing and toilet facilities that are suitably located and a range of environmental aids and adaptations to assist those with mobility problems, including a nurse call system throughout, a shaft lift, corridor and hand rails and a variety of hoist equipment. A loop system is also provided for assist those with hearing difficulties. And there are central kitchen and laundry facilities, with additional separate facilities to enable people to make drinks and snacks. People are provided with care and support from a team of nursing, care and hotel services staff led by a registered general manager and with a named lead nurse clinician. There is also strong external company management support. Fees charged per week range from a minimum of £450 to £550. Fees are Spencer Grove Care Home DS0000072427.V375366.R01.S.doc Version 5.2 Page 5 determined in accordance with individuals assessed needs, and may include for those eligible, funding assistance via the local Primary Care Trust for nursing care provision and/or local authority funding assistance for accommodation and personal care and support. There are additional charges for hair dressing, personal toiletries, private chiropody and newspapers. Charges for these are as per vendor. Spencer Grove Care Home DS0000072427.V375366.R01.S.doc Version 5.2 Page 6 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 2 stars. This means the people who use this service experience good quality outcomes. (This is the first inspection of Spencer Grove since registration in November 2008). For the purposes of this inspection we have taken account of all the information we hold about this service. This includes our annual quality assurance assessment questionnaire (AQAA), which we ask the home to complete on an annual basis in order to provide us with key information about the service. Along with any information we receive by way of survey returns from people who use the service, or who have an interest there. At this inspection there were thirty three people accommodated, including fourteen receiving nursing care. We used case tracking in our methodology, where we looked more closely at the care and services that three people receive. We did this by speaking with them and with their advocates as available. We observed staff interactions with them and we looked at their written care plans and associated health and personal care records, including for their medicines. And, we also looked at their private and communal accommodation. We spoke with staff about the arrangements for their recruitment, induction, training, deployment and supervision and we examined related records. We also spoke with the registered manager and area operations manager about the arrangements for the management and administration of the home and we examined associated records. All of the above was undertaken with consideration to any diversity in need for people who live at the home. At the time of our visit all people accommodated are of British white background, Christian religion, with two people falling under the category of physically disabled and the remainder under the category of older persons. What the service does well: People may be assured that they will be well supported and informed throughout the admission process and that their needs will be effectively accounted for. People’s health care needs are well met within a person centred approach to their care. And their rights to privacy, dignity and respect are strongly promoted. Spencer Grove Care Home DS0000072427.V375366.R01.S.doc Version 5.2 Page 7 People are being well supported to experience a flexible lifestyle in the home, which seeks to match their individual expectations, preferences, capacities and needs. People are being well supported to experience a flexible lifestyle in the home, which seeks to match their expectations, preferences, capacities and needs. And they are provided with a nutritious and varied diet. Comments received include, Staff is marvellous, they always have time for me. I am satisfied with the care I get. Staff is approachable and kind. The meals are very good and there are always fresh baked cakes and plenty of fresh fruit readily available. My room is perfect. I have my own things and a lovely en suite shower. The roof garden is beautiful. Concerns or complaints raised are taken seriously, listened to and acted on and people are protected from harm and abuse. People benefit from a safe, clean and comfortable home, that is decorated, furnished and equipped to a high standard and which suits their needs. Peoples’ needs are met from staff. That is effectively inducted, trained and deployed and for the most part, recruited. The home is well managed and run, in peoples’ best interests and their health, safety and welfare is effectively promoted and protected. What has improved since the last inspection? What they could do better: Ensure that two written references are always obtained in respect of each staff member to be employed to work at the home. In order to fully assess they are fit to do so. Use a minimum and maximum thermometer to determine the daily temperature of the medicines refrigerator and to ensure that people medicines stored there are stored within the correct temperature range. Ensure hand written medicines instructions are always signed and dated by the person writing them and countersigned by a witnessing staff member. To reduce the potential risk to any service user, that may arise from any error in recording. Spencer Grove Care Home DS0000072427.V375366.R01.S.doc Version 5.2 Page 8 Monitor the temperatures of the medicines storage room to ensure it does not become too warm for the safe storage of medicines. Monitor washing machine capacity in the laundry as resident numbers increase to ensure sufficiency and timely turnaround of personal laundry. If you want to know what action the person responsible for this care home is taking following this report, you can contact them using the details on page 4. The report of this inspection is available from our website www.cqc.org.uk. You can get printed copies from enquiries@cqc.org.uk or by telephoning our order line – 0870 240 7535. Spencer Grove Care Home DS0000072427.V375366.R01.S.doc Version 5.2 Page 9 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 Grove Care Home DS0000072427.V375366.R01.S.doc Version 5.2 Page 10 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): People using the service experience excellent quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People may be assured that they will be well supported and informed throughout the admission process and that their needs will be effectively accounted for. EVIDENCE: In our annual quality assurance questionnaire completed by the home told us that they strive to ensure a comprehensive admission and needs assessment process. Information they gave is tells us that the process is person centred and inclusive and ensures appropriate consultation with each persons family or representative, together with outside health and social care professionals. To ensure that people are not admitted to the home unless their needs can be met, including their equality and diversity needs. Spencer Grove Care Home DS0000072427.V375366.R01.S.doc Version 5.2 Page 11 They told us how they provide evidence of the above. And we looked at some of this looked at our inspection visit, including key service information and related records. They also told us how they have developed their pre-admission assessment process and their aims for improvement in the coming months, which included the provision of a welcome book. At our visit people told us they were provided with the information they needed to assist them in choosing to live at the home and that they were provided with a written contract as agreed with them. We saw that people were provided with welcome packs in their own rooms, which contained all key service information necessary to assist and inform people, including a copy of the most recent newsletter. We saw that key service information can be provided in alternative formats, including language and large print. People told us that there needs were being met and recorded admission and needs assessment information that we looked were comprehensive, person centred and with a standardised approach determining peoples risk assessed needs. Spencer Grove Care Home DS0000072427.V375366.R01.S.doc Version 5.2 Page 12 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People’s health care needs are well met within a person centred approach to their care. And their rights to privacy, dignity and respect are strongly promoted. EVIDENCE: In our annual quality assurance questionnaire completed by the home they told us they have a strong ethos in promoting peoples rights in respect of their involvement in their care planning and reviews, their privacy and dignity and in their access to outside health professionals. They also told us that they work in partnership with peoples’ families and advocates to ensure peoples best interests are promoted, in accordance with the residents’ wishes and individual mental capacity. Spencer Grove Care Home DS0000072427.V375366.R01.S.doc Version 5.2 Page 13 They told us about ways in which they have developed the service to benefit people who live there. These include the establishment of good working links and relationships with a range of outside health and social care professionals. And by creating access to these for people as necessary. They told us they have purchased new profiling beds and a range of pressure relieving mattresses. And that each person has person centred written care plans in place. They also told us about some of the improvements they aim to make over the coming months. These relate peoples’ inclusion in their care planning and reviews and in promoting physical exercise programmes for people in accordance with their capabilities. Along with the development of a specified approach to individual’s nutritional risk assessment and improving access to local dental services for people. At our visit people told us that they usually received the care and support they need, and always receive the medical support they need. And that staff treat them respect and that their rights to privacy and dignity are upheld. Comments that people made included, Staff is marvellous, they always have time for me. I am satisfied with the care I get. Staff here is approachable and kind. Another person told us about her recent mobility difficulties and that following her fairly recent admission to the home. That with staffs’ encouragement and support she was now able to walk a few steps each day and was delighted about this. Peoples written care plans that we looked at were mostly in accordance with their assessed needs and reflective recognised guidance concerned with the care of older people. And they had regularly recorded reviews. Although for one person with identified communication problems, there was no communication plan in place. However, staff spoken with was conversant with that persons communication needs and described a consistent approach towards this aspect of their care. Their relative also told us that staff knew how to communicate effectively with them. We found from speaking to key senior staff, that there was an action plan in place to ensure the full completion of peoples care plans and for the ongoing monitoring of these. We also found the arrangements for the management and administration of peoples’ medicines to be satisfactory and generally in accordance with recognised guidance concerned with the arrangements for people medicines in care homes. Although, we observed some minor areas for improvement and discussed these with the manager and senior care responsible for medicines. These, included the method used for the recording of the temperatures of the Spencer Grove Care Home DS0000072427.V375366.R01.S.doc Version 5.2 Page 14 medicines refrigerator, hand written medicines instructions and for the monitoring of the temperature of the medicines room, which is an internal room and was fairly warm. Temperature records for the latter sometimes indicate above 25 degrees centigrade. Spencer Grove Care Home DS0000072427.V375366.R01.S.doc Version 5.2 Page 15 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): People using the service experience excellent quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People are being well supported to experience a flexible lifestyle in the home, which seeks to match their expectations, preferences, capacities and needs. And they are provided with a nutritious and varied diet. EVIDENCE: In our annual quality assurance questionnaire completed by the home, they told us that they have a strong commitment to promoting peoples’ participation and rights to make decisions about their care and daily living routines. And they gave us some examples of ways in which they do this. These included, for participation in menu and social events planning, involvement in staff recruitment interviews, supporting people to maintain contacts with family and friends and the local community, including by way of internet access. Support for people to celebrate any key events in their lives, Spencer Grove Care Home DS0000072427.V375366.R01.S.doc Version 5.2 Page 16 including with their families and friends. Inviting people to bring in their personal possessions into their own rooms and consulting with about the layout of their rooms. And by providing people with key information about local and community social events and activities, including those organised within the home and also about local advocacy services and how to access these. Their aims for improvement over the coming months include obtaining and displaying information for people about relevant national support groups, facilitating links and access to local churches for people in accordance with their chosen denomination, creating a system of resident be-frienders to assist new residents. And in formalising the role of the Friends of Spencer Grove group. At this inspection people told us that the arrangements for activities were developing in consultation with them and we saw that people were provided with written information about these, including by way of a residents notice board and also within the home’s Welcome Pack. Information about a range of advocacy services is also included. Residents social meetings are held at quarterly intervals, again the details of these, including access arrangements and minutes of meetings were posted on the residents’ notice board. A range of activities and seasonal celebrations are regularly organised. Examples include painting, crafts, board games, cooking, music, visiting library, slide shows, outside visiting entertainers, excursions out, including a river cruise, a mothers day lunch with families invited, St Patrick’s Day celebrations with a Folk Dance and Easter and Summer fair where residents are involved in stalls. Local radio DJs are attending the summer fair planned and a Fathers Day event was also being planned. One service user had recently spoken with his family overseas via webcam facility provided in the home. Residents also have access to telephones, either their own or as provided by the home. An activities co-ordinator keeps records of activities organised and individuals’ choice, participation and enjoyment in these. And photographs of people engaged in activities are displayed in the home. For one of the people we case tracked who had severe communication and mobility difficulties, we saw that time was taken for ensure their social stimulation, including sensory activities which they enjoyed. Another person was being assisted to obtain talking books via the library service due to their sight difficulties. Arrangements were also made to support a service user to attend a Stroke Club at the local hospital. Spencer Grove Care Home DS0000072427.V375366.R01.S.doc Version 5.2 Page 17 We saw that key information was recorded about peoples’ financial arrangements and decisions. Staff told us about training being rolled out in respect of the Mental Capacity Act 2005 and we saw that a recorded needs assessment format was being introduced into each persons care file to assist in determining best interests here. People told us they enjoy the food provided and said that there is always a choice that they are offered at each meal. And we saw that there is a menu meeting held each week where people participate in menu planning One person told us, The meals are very good and there are always freshly baked cakes and plenty of fresh fruit readily available between meals. We saw that cakes and fruit are put out between meals in communal areas of the home for people to help themselves and there are kitchenette areas, where people and their visitors can make drinks and snacks. And we observed that lunches were served to people either in the dining rooms, or in their own rooms as they choose. Tables were attractively set and lunch was well presented. The daily menu was displayed and staff took time to consult with people about their choices of food and drink and to assist them as necessary. Spencer Grove Care Home DS0000072427.V375366.R01.S.doc Version 5.2 Page 18 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Concerns or complaints raised are taken seriously, listened to and acted on and that they will be protected from harm and abuse. EVIDENCE: In our annual quality assurance questionnaire completed by the home, they told us that they seek to actively encourage peoples’ suggestions, to raise any concerns they may have and to use the home’s complaints procedure. Also that they aim to investigate and manage complaints effectively and sensitively and to reflect on and identify learning outcomes from any complaints they receive. They also say they have a robust approach to safeguarding people from abuse. They tell us that since their registration they have ensured that all staff is trained in safeguarding people from abuse. And that over the coming months they aim to ensure they continue to provide this training for any new staff, ensure all staff receive training in dealing with aggression and in the Mental Capacity Act 2005 and Deprivation of Liberty safeguards. And that they Spencer Grove Care Home DS0000072427.V375366.R01.S.doc Version 5.2 Page 19 ensure a regular agenda item at resident and staff meetings in respect of How to Complain. They also gave us some statistical information that we asked for, which tells us that the home had received four complaints that they have investigated and responded to within twenty eight days. All were upheld and relatively minor in nature. At this inspection we saw that the home keeps satisfactory records in respect of complaints received, including investigation, outcome and any action taken as a result. People told us that they know who to speak with if unhappy and how to complain. And we saw that information is provided, both on open display and within the home’s Welcome Pack provided in each room about How to Complain. This information is also available in alternative formats, including language and large print. Staff that we spoke with was conversant with their role and responsibilities concerned with dealing with complaints and safeguarding people from harm and abuse. They confirmed that they are provided with suitable policy and procedural guidance and that they had received instruction and training for these. Spencer Grove Care Home DS0000072427.V375366.R01.S.doc Version 5.2 Page 20 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): People using the service experience excellent quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People benefit from a safe, clean and comfortable home, that is decorated, furnished and equipped to a high standard and which suits their needs. EVIDENCE: In our annual quality assurance questionnaire completed by the home, they told us that the home is safe, clean, well maintained and decorated to a very high standard and suitably equipped. Having a lively atmosphere and with access to pleasant roof top gardens. Spencer Grove Care Home DS0000072427.V375366.R01.S.doc Version 5.2 Page 21 They tell us that they encourage people to see this as their own home and continuously seek peoples’ views as to their environment and always encourage people to personalise their own rooms. They also tell us that where there are any proposed changes to the environment, that this will always be undertaken in consultation with people. And that most of the feedback they have received to date from people has been very positive. Although they tell us that they could improve their laundry service, and have recruited more staff to assist in this, including a faster turn around time for personal laundry returns. Over the coming months they aim for further development of the roof top garden in consultation with people. Also carry out regular infection control audits and to continue to ensure that new staff is also trained in this area. At this inspection people told us that the home is always fresh and clean and that they are very satisfied with their environment. Comments received included, ‘My room is perfect. I have my own things and a lovely en suite shower. ‘The roof garden is beautiful and some of the views are spectacular.’ The private and communal accommodation that we looked at accessed by people case tracked was safe, clean, furnished, decorated and equipped to a high specification. Peoples own rooms were personalised. Bedrooms located on the ground floor have a front door opening onto an indoor courtyard area with planting and a large glass atrium above, bringing light from the roof top garden. The doors are decorated as front doors with brass letter boxes and door knockers and each of those rooms has a rear door accessing the internal ground floor corridor of the home. All bedrooms have en suite facilities, some with large walk in showers and there is a choice of disabled access bathrooms and toilets located to each floor. People told us there is always plenty of hot water. There is a range of communal lounge and dining space with TVs and music systems provided to the former and with smaller seating areas for quieter reflection. And the roof top garden provides two themed garden areas, being Spring and Summer. There is also a separate hair dressing room and nurse call system throughout, together with a range of environmental aids and adaptations to assist people who may have mobility problems and also a loop system to assist those with hearing problems. The laundry was clean and tidy and there are suitable sluicing and hand washing facilities for staff. Some people told us that they felt improvements could be made in the laundry service and in respect of turn around. We saw that there is one very large industrial washing machine provided and two Spencer Grove Care Home DS0000072427.V375366.R01.S.doc Version 5.2 Page 22 industrial dryers and we discussed the possible need to monitor capacity as resident numbers increase, given the washing machine provision. Spencer Grove Care Home DS0000072427.V375366.R01.S.doc Version 5.2 Page 23 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Peoples’ needs are met from staff. That is effectively inducted, trained and deployed and for the most part, recruited. EVIDENCE: In our annual quality assurance questionnaire completed by the home, they told us that they consider their recruitment process to be integral to their service delivery and that they involve residents in the recruitment process, including staff interviews. They also describe a comprehensive approach to staff induction and training and team building. They identified improvements they are making and also aimed for over the coming months. These include by way for formal staff supervisions and personal individual development plans, continuing to adjust staffing levels and skill mix in response to further resident admissions and their assessed needs. And continue to promote staffs’ access to NVQ training. At this inspection people told us that staff is usually available when they need them and that they usually listen and act on what they say. Spencer Grove Care Home DS0000072427.V375366.R01.S.doc Version 5.2 Page 24 Staff described effective arrangements for their recruitment, induction, training and deployment and associated records that we examined were reflective of this, with the exception that for two out of four staff recruitment records that we looked at. For those two the home had only obtained one reference for each of them as opposed to two required. For one person this meant that there was no reference obtained to date from their most recent employer, although this had been requested in writing twice. We spoke at length with a named senior care staff. Who has the delegated management responsibility for co-ordinating staff training arrangements. This was well co-ordinated and with a training matrix and training plan in place and individual training record for each staff member. Monthly training statistics were being collated and reported to the lead company trainer. Spencer Grove is part of the Milford Care Group who has their own accredited training academy. Seventy five percent of staff had achieved at least NVQ level 2 or above. Training records that we looked showed that staff has access to a comprehensive range of training from nationally recognised key skills induction training, national vocational qualifications, core health and safety training, adult protection, mental capacity, specialist medical conditions of people who may be accommodated and preventative and palliative care pathways. The group has also been invited to sit on the Macmillan Life enhancing Care Programme Steering Group, funder by Macmillan Cancer Support and hosted by Derby City Primary Care Trust (NHS). To share best practise standard aimed at improving peoples quality of life when requiring palliative or end of life care. They tell us they aim to promote Dignity Champions in each of their homes, including Spencer Grove in the coming months, to support the ten point Dignity Challenge Agenda set by the government. Staff also confirmed that they receive well in excess of the minimum standard for three paid training days per year. Spencer Grove Care Home DS0000072427.V375366.R01.S.doc Version 5.2 Page 25 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): People using the service experience excellent quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home is well managed and run, in people’s best interests and their health, safety and welfare is effectively promoted and protected. EVIDENCE: The information provided by the home in our annual quality assurance questionnaire (AQAA) tells us that the service aims to ensure that the home is run in peoples’ best interests, in consultation with them and to promote peoples health, safety and welfare within a climate of openness and respect. Spencer Grove Care Home DS0000072427.V375366.R01.S.doc Version 5.2 Page 26 They also provided us with detailed information relating to their operational management and administration systems which underpin the above. The AQAA contained excellent information throughout that was fully supported by appropriate evidence and demonstrated throughout a high level of understanding about the importance of equality and diversity. They told us about some improvements they are making, relating to health and safety policy and practise developments, including specified areas of staff training. And their strategy for formal consultation with people who use the service, their families, advocates, staff and outside health and social care professionals. The Registered Manager told us about some of the training and development she has achieved, including NVQ level 4 and Registered Managers Award. She and the acting clinical nurse lead for the home have undertaken a range of training over the last 12 months, including necessary core health and safety training alongside staff. And records that we looked at confirmed this. Robust external management support is also provided. Staff told us about effective arrangements to assist and support them in their role, including for their training and supervision and for ensuring they obtain they information they need in respect of residents individual care needs. We looked at quality assurance and monitoring systems. These are comprehensive and include regular formal auditing and monitoring of all aspects of the service including accident and falls monitoring. We saw that satisfaction surveys are sent out to each service user and their representative eight weeks from their admission. As this is a new service, the manager advised that satisfaction surveys are also to be circulated to service users and their representatives, relevant outside health and social care professionals and to staff at quarterly intervals. We saw results collated from surveys returns to date, which are displayed openly in a graphical form for people to see. These show overall positive feedback is obtained to date, with some matters arising including relating to the laundry service and access into the home. And we saw what action the home is taking to address these. People spoke with regard for the manager, who meets with them regularly, both by way of formal meetings and informal individual discussions in order to seek their opinion as to the care and services they receive. The home does not manage monies on behalf of any resident. There are suitable arrangements in place for safekeeping and support and the home invoices people separately for any personal bills paid for on their behalf, such as private chiropody, hair dressing. Spencer Grove Care Home DS0000072427.V375366.R01.S.doc Version 5.2 Page 27 Staff described satisfactory arrangements in respect of promoting safe working practises, including for their training, access to comprehensive policy and procedural guidance and the provision of equipment. And during our visit we observed the environment to be free from observable hazards to peoples’ health and safety. Spencer Grove Care Home DS0000072427.V375366.R01.S.doc Version 5.2 Page 28 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 4 X 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 3 13 4 14 3 15 4 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 4 X X X X X X 3 STAFFING Standard No Score 27 3 28 4 29 2 30 4 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 4 4 X 3 3 3 3 Spencer Grove Care Home DS0000072427.V375366.R01.S.doc Version 5.2 Page 29 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 OP29 Regulation 19 Requirement A person must not be allowed to work at the home unless the employer has obtained in respect of that person all of the information and documents specified in paragraphs 1 to 7 of Schedule 2. In this instance, we are referring to two written references that must be obtained in respect of each person. So as to ensure their fitness to do so. Timescale for action 14/07/09 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 A minimum and maximum thermometer should be used to determine the temperature of the medicines refrigerator (to be checked and recorded daily). So as to ensure peoples medicines are stored within the correct temperatures range. Hand written instructions for peoples medicines should DS0000072427.V375366.R01.S.doc Version 5.2 Page 30 2. OP9 Spencer Grove Care Home 3. 4. OP9 OP26 always be signed and dated by the person completing them and countersigned and dated by a witnessing staff member. So as to reduce the potential risk to any service user, that may arise from any error in recording. The temperatures of the medicines storage room should be monitored to ensure it does not become too warm for the safe storage of medicines. Washing machine capacity in the laundry should be monitored as resident numbers increase to ensure sufficiency and timely turnaround of personal laundry. Spencer Grove Care Home DS0000072427.V375366.R01.S.doc Version 5.2 Page 31 Care Quality Commission East Midlands Region Citygate Gallowgate Newcastle upon Tyne NE1 4PA National Enquiry Line: Telephone: 03000 616161 Email: enquiries@cqc.org.uk Web: www.cqc.org.uk We want people to be able to access this information. If you would like a summary in a different format or language please contact our helpline or go to our website. Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CQC copyright, with the title and date of publication of the document specified. 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