Inspection on 22/08/07 for Spennymoor Care Home Ltd

This inspection was carried out on 22nd August 2007.

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

Spennymoor Care Home Ltd 06/06/06

Similar services:

Chirnside House

Keer Sands Residential Home

Ruskin Lodge

Bushell House

Langrigg House

Parkside

Dystlegh Grange

Thornton Lodge

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

CARE HOMES FOR OLDER PEOPLE Spennymoor Care Home Ltd Ivy Road/Church Road Bolton Lancashire BL1 6EE Lead Inspector Mike Murphy Unannounced Inspection 09:30 22 August 2007 nd 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 Spennymoor Care Home Ltd DS0000066964.V337584.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. Spennymoor Care Home Ltd DS0000066964.V337584.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Spennymoor Care Home Ltd Address Ivy Road/Church Road Bolton Lancashire BL1 6EE 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) 01204 846008 Spennymoor Care Home Limited Teresa Maria Jackson Care Home 19 Category(ies) of Old age, not falling within any other category registration, with number (19) of places Spennymoor Care Home Ltd DS0000066964.V337584.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 6th June 2006 Brief Description of the Service: Spennymoor is a care home providing residential care for older people. It is a large, converted detached house with an added extension. The home has two floors and a passenger lift. There is a garden area with borders and a patio to the front of the building. The weekly fees range from £339.64 to £385.54 per week. Please contact the home for further details. Spennymoor Care Home Ltd DS0000066964.V337584.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection which the home did not know was going to happen took place on the 22nd of August 2007. The inspection took place over five hours. The inspection included discussion with residents, their relatives, a tour of the premises, inspection of care and other records maintained at the home and discussion with the registered manager and care staff. What the service does well: What has improved since the last inspection? What they could do better: Some areas that need to be improved are detailed within this report that when implemented can only enhance a good level of care, support and protection currently provided to residents. These include some changes to residents care records, menus, staff training, how the home checks it is providing a good service and how staff records are maintained. Spennymoor Care Home Ltd DS0000066964.V337584.R01.S.doc Version 5.2 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. The summary of this inspection report can be made available in other formats on request. Spennymoor Care Home Ltd DS0000066964.V337584.R01.S.doc Version 5.2 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 Spennymoor Care Home Ltd DS0000066964.V337584.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 3. Standard 6 does not apply to this service. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. No prospective residents are admitted to the home without their care and support needs being assessed appropriately. EVIDENCE: Prior to residents being admitted to the home the registered manager carries out an assessment of the prospective resident’s needs in consultation with the resident, their relatives and relevant health (for example doctors) and social care professionals (for example social workers). The purpose of such an assessment is to assist the prospective resident (and their relatives) in their considerations of how appropriate a placement at the home would be and enable the person conducting the assessment to judge if the home will be able to meet the prospective resident’s needs appropriately. Spennymoor Care Home Ltd DS0000066964.V337584.R01.S.doc Version 5.2 Page 9 3 (recently admitted) residents pre-admission assessments were inspected at this inspection. The records identified that pre-admission assessments had been carried out by the home and were supplemented by assessments conducted by Social Services. However it is recommended that the document used by the home to record the pre-admission assessment be clearly identified as such and not recorded in other documentation used – to avoid confusion. Spennymoor Care Home Ltd DS0000066964.V337584.R01.S.doc Version 5.2 Page 10 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. 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 this service. The health and personal care provided for residents appears to be suitable, well organised, and meets the expectations of residents and their relatives. EVIDENCE: The care records of three residents were inspected. These contained care plans that were initially based on the pre-admission assessment that is referred to earlier in this report. Care plans addressed the health and personal care needs of residents in a clear, organised way and were evaluated at least monthly. Risk assessments, that seek to protect resident’s health and welfare are recorded individually or incorporated into the care plans in respect of residents skin integrity (assessing the risk of pressure sores), mobility/moving and handling, nutrition, (including regular weight monitoring) and other areas of potential risk for individual residents were also assessed at least monthly. Daily statements regarding resident’s progress are also recorded. However it is recommended that these be recorded in individuals care records rather than collectively as they are at present. These should be dated, timed and signed by Spennymoor Care Home Ltd DS0000066964.V337584.R01.S.doc Version 5.2 Page 11 staff completing them. Care records have been reviewed by the manager since the last inspection and have significantly improved. The manager stated to the inspector that she intends to continue that review to further improve them. All residents are registered with a local GP and it was evident that they were enabled to access dieticians, opticians, chiropodists, dentists, district nurses and other specialist services as individual residents needed. Pre-inspection comment cards completed by relatives and discussion with relatives on the day of inspection indicated that they are kept informed of all changes in their relation’s health. The practices for the receipt, recording, storage, handling, administration and disposal of resident’s medicines were appropriate and safe. Staff responsible for the management of resident’s medicines have all received appropriate training. Medicine records had been completed properly. It is however recommended that all handwritten entries on medication administration records are checked and signed by 2 staff to ensure maximum protection of residents. Discussion with residents and staff (and responses in Pre-inspection comment cards completed by residents and relatives) revealed that residents were treated with respect and that their right to privacy was upheld. Comments made included; ‘all the staff are very respectful and caring’, ‘I like to spend a lot of time in my room and this is respected by the staff who are very supportive, kind and caring’, ‘My mother is looked after excellently and they always make sure she sees the doctor or attends appointments as needed’. On the day of inspection staff were observed to interact positively with residents and show them respect, protect their dignity and assist them properly throughout the day. Residents and relatives all spoke very positively in respect of the care and attention provided by the manager and her staff. Spennymoor Care Home Ltd DS0000066964.V337584.R01.S.doc Version 5.2 Page 12 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. 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 this service. Residents are being supported by staff to participate in social activities and are able to retain the ability to make personal choices. There was a high level of satisfaction with meals provision at the home. EVIDENCE: Discussion with residents and relatives (and observations made on the day of inspection) indicate that the routines of daily life in the home are as flexible as possible in such a setting. Residents said they are able to choose the times they get up and go to bed, which social activities they join in and were of the view that they are consulted and able to influence the care and support they need. Clearly this is very important in enabling residents to retain as much control over their life as possible. The arrangements for providing social and leisure activities are satisfactory. Activities at the home are co-ordinated by staff. A varied programme of activities/pastimes (including some reminiscence sessions, entertainers and outings) are provided. A programme of activities was prominently displayed Spennymoor Care Home Ltd DS0000066964.V337584.R01.S.doc Version 5.2 Page 13 on the notice board at the entrance to the home. Residents spoken to say the programme was suitable for them and they felt able to suggest changes/alternatives and that their suggestions were listened to and acted upon. Residents wishing to maintain their religious links are enabled to do so. The home has an open visiting policy. There are no restrictions on the time people visit. The only time restrictions would be imposed is when requested by residents. Relatives spoken to during the inspection said they were always made welcome at the home and were able to see their relatives in the privacy of their own room or in a quieter lounge area. A hairdresser comes to the home once a week. Residents spoken to expressed satisfaction with care provided and organisation of life at the home. Observation of care practice and information in care plans indicated residents are encouraged to make choices. For example what time they like to get up/go to bed. While some residents chose to sit in the lounge a number were observed to spend their time in their own rooms. Meals are cooked on site in the home’s kitchen – which has been completely refurbished to a high standard since the last inspection. Meals are served in a designated dining room. This is an appropriately furnished room that provides a comfortable area for residents to have their meals. Residents’ meal times are as reasonable and as flexible as they can be in a communal setting. Lunch was observed on the day of inspection. This was a hot and substantial meal and staff assisted and served residents their meals appropriately. Discussion with residents revealed a very high level of satisfaction with meals provided. Residents said they like the way the food is all ‘home cooked’ and said they were always provided with an alternative if they personally disliked particular meals. A record of all meals provided to residents is maintained. It is recommended that a menu – including the options provided be prominently displayed Spennymoor Care Home Ltd DS0000066964.V337584.R01.S.doc Version 5.2 Page 14 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents and relatives knew how to make a complaint if they felt it necessary. Written guidance and training arrangements ensure that staff members have knowledge of abuse and protection arrangements and safeguards were in place to protect the welfare of residents. EVIDENCE: The complaints procedure was prominently displayed (and has been reviewed since the last inspection) in the home and included details of how to contact the CSCI. Residents and relatives spoken to on the day of inspection (and in completed pre-inspection surveys) said any issues brought to the manager’s attention are responded to quickly and don’t become formal complaints. Policies and practices (currently being reviewed by the manager) aimed at protecting residents from abuse are in place. Also Bolton’s inter agency protection procedure is held on site. Training records indicated that approximately half the staff had received recent adult protection training at the time of this inspection. The registered manager stated that plans had been be made for the remaining staff to receive such training in September 2007. Spennymoor Care Home Ltd DS0000066964.V337584.R01.S.doc Version 5.2 Page 15 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 24 and 26. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home provides a comfortable and appropriate environment to accommodate, care for and support residents. EVIDENCE: A tour of the premises revealed that the home was very clean and free of malodour. Discussion with residents and their relatives revealed that the home is regularly cleaned to a high standard. The lounges and dining room provide appropriate and very comfortable communal areas for residents. Most bedrooms were inspected on this occasion – these were clean, warm, suitably ventilated, personalised and comfortable and suitably decorated and furnished. An extensive programme of bedroom (and other areas of the home) re-decoration and refurbishment has commenced since the last inspection and is nearing completion. Residents and Spennymoor Care Home Ltd DS0000066964.V337584.R01.S.doc Version 5.2 Page 16 relatives spoke highly of the accommodation they are provided and all said how comfortable and ‘homely’ it was. Residents are encouraged to bring personal items into the home and this creates a more personalised atmosphere in resident’s own rooms. Appropriate measures to prevent the spread of infection were in place – including adequate hand washing/cleaning facilities, laundry and sluicing arrangements, provision of disposable gloves and aprons for staff, adequate provision of house keeping staff and appropriate arrangements for the disposal of waste. The manager informed the inspector that she was in the process of arranging staff training in preventing the spread of infection. Spennymoor Care Home Ltd DS0000066964.V337584.R01.S.doc Version 5.2 Page 17 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. 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 this service. The recruitment, provision and training of staff employed at the home are being managed appropriately. This is important to ensure resident’ are being cared for adequately and appropriately by staff who are able to deliver this support safely and competently. EVIDENCE: Inspection of staffing rotas indicated that staffing provision at the home complied with the current minimum requirements that apply to care homes for older people. Discussion with manager and staff at the home indicated that they were of the view that staffing levels were appropriate to meet the dependency levels and needs of resident’s. There is also adequate provision of housekeeping, catering and ancillary staff at the home. Inspection of 2 staff personnel files (the number employed since the last inspection) revealed that these contained an application form (including health declaration), 2 written references, a Criminal Records Bureau check (including a ‘POVA first’ check), proof of identity (however 1 file did not contain a recent photograph of the employee) and evidence of induction training. It is recommended that the application form be amended to ensure applicants know Spennymoor Care Home Ltd DS0000066964.V337584.R01.S.doc Version 5.2 Page 18 they have to provide a detailed work history and explain any gaps in their work history. This is important as it helps ensure residents are being cared for and supported by suitable people. There is a commitment to NVQ with over 50 of all care staff having at least an NVQ 2 in care. Training in moving and handling, fire safety, first aid, protection of vulnerable adults (and other training) is provided by the home. However the manager needs re-organise staff training to comply with the common induction standards framework developed by ‘Skills for Care’. Spennymoor Care Home Ltd DS0000066964.V337584.R01.S.doc Version 5.2 Page 19 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. 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 this service. The home was being appropriately managed in a way that enables residents, their relatives and staff to feel that they are being supported properly. EVIDENCE: The registered manager is experienced and has commenced the NVQ Level 4 in care and management training since the last inspection. Discussion with residents, their relatives and staff indicate that the manager operates a management style that is open and accessible. The home was well organised with a clear management structure. Senior carers and a team of care staff support the manager. Spennymoor Care Home Ltd DS0000066964.V337584.R01.S.doc Version 5.2 Page 20 The manager has developed a quality assurance system to measure residents and their relative’s satisfaction, with the level of care and accommodation provided. This is essential as such information will enable a quality improvement plan to be fully developed and implemented to further improve the quality of life for residents. The manager informed the inspector that she intends to further develop the quality assurance system to incorporate the views of visiting doctors, nurses, social workers and others who regularly come to the home. And to develop a system of checks (for example of care records, medicines, social activities, catering, complaints/protection, the home environment, staff training and management processes generally) to ensure practices in the home are of as a high a standard as possible. Measures were in place to ensure that residents’ financial interests are safeguarded. Residents are encouraged to control their own money. However where they are unable (or choose not to) personal allowances are managed by the home. The arrangements for this were secure and appropriately documented. However it is recommended that receipts be obtained for hairdressing and chiropody services provided to residents and kept with individual resident’s financial transaction records. The health, safety and welfare of residents and others is promoted and protected. For example staff are provided with regular training and appropriate equipment to ensure resident’s moving and handling needs are met. An example of this would be for a resident who needs to be safely moved with the aid of a hoist. Fire safety training is regularly provided. Information provided by the home indicates that electrical/gas/other equipment safety inspections/servicing have been carried out. Spennymoor Care Home Ltd DS0000066964.V337584.R01.S.doc Version 5.2 Page 21 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 3 X X X 3 X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 2 X 3 X X 3 Spennymoor Care Home Ltd DS0000066964.V337584.R01.S.doc Version 5.2 Page 22 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 OP18 Regulation 13(1)(6) Requirement That it is confirmed in writing to the CSCI that all staff have completed protection of vulnerable adults training That it is confirmed in writing to the CSCI that a recent photograph is kept of all staff working at the home That the CSCI is informed in writing what progress has been made with providing NVQ training to newly recruited staff, induction training that conforms to the common induction standards and how the details (including dates) of training provided to individual staff is recorded. That the CSCI is informed in writing what actions have been taken to develop the home’s systems of quality assurance Timescale for action 30/10/07 2 OP29 3 OP30 19 (Schedule 2) 18 30/10/07 30/10/07 4 OP33 24 30/10/07 Spennymoor Care Home Ltd DS0000066964.V337584.R01.S.doc Version 5.2 Page 23 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 OP3 Good Practice Recommendations That the document used by the home to record the preadmission assessment is clearly identified as such and not recorded in other documentation used – to avoid confusion. That all handwritten entries on medication administration records are checked and signed by 2 staff to ensure maximum protection of residents. That the meals menu – including the options provided be prominently displayed. 2 OP9 3 OP15 4 OP29 5 OP35 That the application form be amended to ensure applicants know they have to provide a detailed work history and explain any gaps in their work history. This is important as it helps ensure residents are being cared for and supported by suitable people. That receipts for hairdressing and chiropody services provided to residents be obtained and kept with individual resident’s financial transaction records. Spennymoor Care Home Ltd DS0000066964.V337584.R01.S.doc Version 5.2 Page 24 Commission for Social Care Inspection Manchester Local office 11th Floor West Point 501 Chester Road Manchester M16 9HU National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 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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