Inspection on 06/06/06 for Spennymoor Care Home Ltd

This inspection was carried out on 6th June 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. 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 22/08/07

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 Rukhsana Yates Key Unannounced Inspection 6th June 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 Spennymoor Care Home Ltd DS0000066964.V296097.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.V296097.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.V296097.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1 The home is registered for a maximum of 19 service users, to include: Up to 19 service users in the category of OP (Older People). Not applicable. Registered as a new service on 16.05.06 Date of last inspection 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 lawned area with borders and a patio to the front of the building. The weekly fees range from £315.18 to £367 per week. Spennymoor Care Home Ltd DS0000066964.V296097.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was unannounced and carried out over two days. During the inspection, discussions took place with five residents, two staff members and the manager. A meal was taken with the residents, and half of the inspection time was spent watching the way in which staff supported residents, and in talking with them individually as a group. Paperwork was looked at that related to the care and safety of everyone living or working at the home. The inspection assessed the home against all of the key standards. These standards cover moving in, the care provided, routines and social activities, complaints and protection, comfort, safety and cleanliness, how staff are employed and trained, and how the home is managed. What the service does well: What has improved since the last inspection? Not applicable as this is a new service due to a change in ownership. Spennymoor Care Home Ltd DS0000066964.V296097.R01.S.doc Version 5.2 Page 6 What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Spennymoor Care Home Ltd DS0000066964.V296097.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.V296097.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 3 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Each person considering moving to Spennymoor is assessed prior to admission, and is given information about the home so that they know what to expect from the service. EVIDENCE: There has been one admission since the change in the home’s ownership. This resident moved to the home following a stay in an intermediate care service. The records showed that a basic care plan had been devised, and the manager stated that she visited the resident before the move to carry out an assessment to ensure that the home would be suitable, although this assessment was not recorded. The resident’s daughter looked around the home before any decision was made, and other residents confirmed that they or their relatives had visited this and other homes before making a choice. The manager was advised to devise and use a pre-admission assessment form. Spennymoor Care Home Ltd DS0000066964.V296097.R01.S.doc Version 5.2 Page 9 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents feel that the staff understand their care needs, but the full range of needs to be addressed are not clearly reflected and updated in the care plans. The home promotes service users’ health. Arrangements for managing medication are safe. Residents feel that they are rights to privacy and respect are upheld. EVIDENCE: The care plans for each resident cover a range of relevant areas relating to personal and healthcare needs. However, there was insufficient information relating to individuals’ preferred daily routines, specific instructions to staff in respect of how to meet particular needs, and the format does not allow for changes in needs to be properly reflected. Some changes to care plans had not been dated, and some daily reports were vague, for example using phrases such as the resident was “fine” or “good diet taken”. Monthly reviews were evidenced by a date and signature, but no indication of areas that had been reviewed and changes made to care delivery as a result. Risk assessment Spennymoor Care Home Ltd DS0000066964.V296097.R01.S.doc Version 5.2 Page 10 information was brief, although staff had a good knowledge of risks and measures to deal with them. For example, it was apparent from the equipment provided and from observations that residents were receiving good pressure area care. Care plans need to be devised that fully reflect the range of needs and risks for each resident and these should be reviewed monthly. The arrangements for residents medicines were secure, and administration records accurately maintained. Only senior staff administer medication, and have received appropriate training in the safe handling of medicines. Discussions with residents and visitors, along with observations made during the course of the inspection indicated that staff care about the residents’ welfare, treat them with respect and seek to maintain their privacy and dignity when providing personal care. Residents are enabled to see their GP, health staff and visitors in private. Patient and sensitive attitudes were observed during mealtimes and when assisting residents to the toilet. There are no residents with specific religious or cultural needs that cannot be met at the current time. Spennymoor Care Home Ltd DS0000066964.V296097.R01.S.doc Version 5.2 Page 11 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 adequate. This judgement has been made using available evidence including a visit to this service. Residents’ preferences need to be better met in terms of activities and outings. The manager is making progress in promoting residents right to exercise choice and control in their daily routines. Good attention to dietary needs and preferences ensures that residents enjoy their meals. EVIDENCE: Some of the activities that take place at the home include armchair aerobics, reminiscence, dominoes, and arts and crafts. However, residents said that activities are very infrequent and their motivation had diminished. As one resident said “I suppose we’ve got used to doing nothing and so we don’t want to anymore”. In discussions, residents listed activities and suggestions they would be interested in. These included quizzes, more arts and crafts and video nights. Some wanted to go shopping to town centre shops and the market, or small scale trips out to, for example, Rivington Barn or a garden centre. The home needs to address this, and ensure that staffing levels are increased on occasion to facilitate outings. In terms of routines, comments made by residents indicated set times for rising and having breakfast so that they were Spennymoor Care Home Ltd DS0000066964.V296097.R01.S.doc Version 5.2 Page 12 ready for the “day shift”. This was discussed with the manager who, by the second day of the inspection, had initiated discussions with staff to ensure that changes in practices were put in place so that residents have a choice about the time they get up and go to bed. The home has open visiting arrangements, with visitors using the conservatory or resident’s bedroom for privacy. A hairdresser comes to the home once a week. The home’s cook has worked there for 5 years and clearly had a good knowledge of residents’ dietary needs and preferences. Alternatives to the main meal are always available, and records of alternatives taken are recorded. The kitchen was well organised and ample stocks of good quality food supplies were seen. Residents consulted liked the meals, saying they are “really good”. Special dietary needs are catered for and elements of pureed meals are prepared separately which is good practice. Menus are varied and nutritious. Spennymoor Care Home Ltd DS0000066964.V296097.R01.S.doc Version 5.2 Page 13 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 and 18 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents feel they can talk to the manager and staff if they have concerns, and that they are listened to, but an accessible complaints procedure is needed that all residents and their relatives are aware of. Although there is some awareness of responsibilities in respect of reporting suspicions of abuse, the manager and staff need training in local procedures so that they know how to respond should an incident arise. EVIDENCE: At present, residents and their relatives do not have access to a user-friendly complaints procedure that details the actions that will be taken and timescales. Residents and relatives did, however, say that they find the manager approachable and that “the staff are very nice and you can talk to them if you’re not happy with something”. With regard to adult protection, staff consulted were able to describe a range of examples of what constitutes abuse and said they would report any concerns to the manager. Records showed that there has been very little training in this area in the last two years, and there is a need for the manager and staff to be aware of the local systems and procedures in place for safeguarding adults so that they take appropriate action. Spennymoor Care Home Ltd DS0000066964.V296097.R01.S.doc Version 5.2 Page 14 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 and 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Spennymoor provides a clean, comfortable and safe environment for residents. EVIDENCE: Residents were happy with the environment, describing it as “comfortable” and one resident said “I like it because it’s not too big”. The home was seen to be clean and hygienic. Bedrooms seen were comfortably furnished and personalised. Communal lounges and dining areas were also clean and appropriately furnished. Individual aids and adaptations had been provided to residents, including hoisting and pressure care equipment. The manager recognised the need to have an ongoing programme of refurbishment and redecoration, and a discussion took place regarding prioritising the kitchen within this programme due to the age and poor layout of the units. Spennymoor Care Home Ltd DS0000066964.V296097.R01.S.doc Version 5.2 Page 15 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 this service. Residents care needs are effectively met by the numbers of staff. The staff group has the skills and management support it needs to ensure that residents receive good care. Although some staff have NVQ qualifications, several need to receive updated training in key areas to ensure safe and good practice. Safe recruitment processes ensure that care staff employed are suitable. EVIDENCE: The staffing rotas indicated that the manager is on duty with three care staff during the day and evening. Two staff members provide cover in the evening. The manager stated that she was reviewing the deployment of staff and the hours for kitchen cover to ensure that staff are not under pressure to rush residents at peak times of activity. All staff consulted were positive about the management support they receive, and residents know the staff and therefore benefit from good continuity of staff support. Recent staff training undertaken includes medication, first aid and fire training, and over half of the staff group have NVQ qualifications in care. There is a need for all staff to be updated in mandatory training topics. The manager has put together clear training records so she can identify the training that each staff member requires, and intends to introduce regular supervision and appraisals for all staff. Spennymoor Care Home Ltd DS0000066964.V296097.R01.S.doc Version 5.2 Page 16 It was clear from discussions with the manager that she is fully aware of the procedures to be followed to ensure that recruitment practices are safe and meet regulatory requirements when a new staff member is employed. The manager is working towards organising existing staff files so that information can be easily accessed. . Spennymoor Care Home Ltd DS0000066964.V296097.R01.S.doc Version 5.2 Page 17 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 this service. The new manager has the commitment and motivation to run the home in a way that promotes a good quality of care for residents and positive motivation for staff. Quality assurance systems need to be in place to show how the views of residents and others affect plans for improvements at the home. Residents’ financial interests are safeguarded. A wide range of regular health and safety checks ensure that the environment is safe and suitable for those who live and work at the home. EVIDENCE: Discussions with the manager indicated that she is enthusiastic and committed to making positive changes at the home, both in terms of the physical Spennymoor Care Home Ltd DS0000066964.V296097.R01.S.doc Version 5.2 Page 18 environment and in addressing any requirements identified. The staff and residents find her approachable and competent in her role. The home does not currently have a quality assurance system and a discussion took place as to how this should be developed. Residents’ personal finances were checked. Only the manager and deputy have access to residents’ monies. A clear and simple record of credits, debits and balances is maintained. Health and safety matters are properly addressed. Records and test certificates were seen to be satisfactory for fire precautions, gas and electrical safety, legionella testing and portable appliances. Hoisting equipment is regularly serviced. Spennymoor Care Home Ltd DS0000066964.V296097.R01.S.doc Version 5.2 Page 19 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 X HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 2 3 X X X X X 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 1 X 3 X X 3 Spennymoor Care Home Ltd DS0000066964.V296097.R01.S.doc Version 5.2 Page 20 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 OP7 Regulation 14,15 Requirement Care plans must fully reflect the range of needs and risks for each resident and these should be reviewed monthly. Residents’ preferences must be better met in terms of activities and outings. An accessible complaints procedure is needed that all residents and their relatives are aware of. The manager and staff must arrange to receive training in adult protection procedures. All staff must receive training in mandatory training topics. Quality assurance systems need to be in place to show how the views of residents and others affect plans for improvements at the home. Timescale for action 02/10/06 2 3 OP12 OP16 16 22 02/10/06 02/10/06 4 OP18 13 02/10/06 5 6 OP30 OP33 13 24 02/10/06 04/12/06 Spennymoor Care Home Ltd DS0000066964.V296097.R01.S.doc Version 5.2 Page 21 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 The manager is advised to devise and use a pre-admission assessment form for new admissions. Spennymoor Care Home Ltd DS0000066964.V296097.R01.S.doc Version 5.2 Page 22 Commission for Social Care Inspection Bolton, Bury, Rochdale and Wigan Office Turton Suite Paragon Business Park Chorley New Road Horwich, Bolton BL6 6HG 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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