Inspection on 15/12/06 for Spetisbury Manor

This inspection was carried out on 15th December 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

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

Other inspections for this house

Spetisbury Manor 06/09/07

Spetisbury Manor 22/05/06

Spetisbury Manor 17/03/06

Spetisbury Manor 13/06/05

Spetisbury Manor 26/11/04

Spetisbury Manor 13/04/04

Similar services:

Fairfields Country Rest Home

Poldhu

Queensmount

Trevaylor Manor

Didsbury Court Rest Home

Belma

Hunters Care Centre

Manor Lodge

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

CARE HOMES FOR OLDER PEOPLE Spetisbury Manor Spetisbury Blandford Dorset DT11 9EB Lead Inspector Catherine Churches Key Unannounced Inspection 10:30 15 December 2006 and 9th January 2007 th 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 DS0000026768.V324383.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. DS0000026768.V324383.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Spetisbury Manor Address Spetisbury Blandford Dorset DT11 9EB 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) 01258 857378 01258 858384 Country House Care Limited Mrs Sally Scott Care Home 25 Category(ies) of Old age, not falling within any other category registration, with number (25) of places DS0000026768.V324383.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. A maximum of four bedrooms from those listed may be used for shared occupancy at any one time: Rooms 2, 3, 6, and 16, Kingfisher, Mallard and Heron Suites. One named person (as known to CSCI) in the category of PD may be accommodated to receive care. 22nd May 2006 Date of last inspection Brief Description of the Service: Spetisbury Manor is registered to provide personal care for a maximum of 25 older people in 21 rooms, 4 of which may be used as shared rooms by residents who have made a positive choice to share with each other. Mr Kevin Ellis is the Responsible Individual; he also owns another registered care home, Glenhurst Manor in Bournemouth. The Registered Manager is Mrs Sally Scott. The home is situated on the outskirts of the small village of Spetisbury. Some residents frequently travel in the homes courtesy car to go shopping in Blandford, Wimborne and Poole. Spetisbury Manor stands in four acres of grounds laid to attractive gardens leading down to the river Stour. The accommodation is on three floors with a passenger lift serving the first and second floors. Eighteen bedrooms have en-suite hygiene facilities, and there are assisted bathrooms and toilets on each floor. At the time of the inspection the current scale of charges per week ranged from £495 to £980 (for a double room double occupancy). DS0000026768.V324383.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection, which started on 15th December 2006 and was completed on 9th January 2007. In total seven hours were spent in the home undertaking the inspection. Mrs Scott, the registered Manager, was present throughout the second day of inspection. The inspection took place as part of the regular, programmed inspection schedule for the home. The last inspection was May 2006. The purpose of this visit was to monitor the homes compliance with National Minimum Standards and with requirements and recommendations made during the previous inspection. Also, to check that the home is run in a satisfactory manner and that the people who are living in the home are properly cared for. The premises were inspected and a number of records examined. Time was also spent time observing routines within the home and talking with residents, visitors and staff. This report refers throughout to “residents” meaning to include persons accommodated in the residential units of the home, patients in the nursing units and the overall term “service users”, which is the preferred term of the Commission. What the service does well: Spetisbury Manor provides a homely, relaxed and comfortable environment with a welcoming and friendly atmosphere. The home is well presented and has nicely maintained gardens. The home has maintained good standards of care, activity, food and accommodation over the last two inspections. Most areas inspected on this occasion were found to be satisfactory. The home is positively managed and well staffed. The staff group is stable and were observed to be respectful, helpful and caring. All residents spoken with were positive about the care and attention that they receive. DS0000026768.V324383.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? 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. The summary of this inspection report can be made available in other formats on request. DS0000026768.V324383.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 DS0000026768.V324383.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 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Assessments of prospective residents needs are satisfactory. This means that residents can be certain that the home is aware of most of their requirements prior to their admission to the home and that the staff will therefore be able and prepared to meet these needs. EVIDENCE: Documentation for three residents was examined as part of the case tracking procedure used during this inspection. Two of these residents had been newly admitted to the home since the last inspection. Both pre-admission assessments were viewed. They had been undertaken by Mrs Scott and included a visit to the prospective resident. Documents included the information specified in the National Minimum Standards. A letter confirming, that following assessment, the home can meet their needs and DS0000026768.V324383.R01.S.doc Version 5.2 Page 9 evidence that the Statement of Purpose, Service Users Guide etc had been given to the resident, was available. During the course of the inspection it was noted that two people who had returned to the home for subsequent periods of respite care had not had their needs reassessed nor had a resident who had spent time in hospital. DS0000026768.V324383.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 adequate. This judgement has been made using available evidence including a visit to this service. Care plans for residents who live at Spetisbury Manor are detailed and informative. This means that staff have sufficient information to provide a good level of care and the home can also demonstrate the care that has been provided. Some further work is required regarding documentation of care for residents returning to the home for respite care or following hospital admissions. The home ensures that resident’s healthcare needs are met through seeking appropriate input from GP’s and other healthcare professionals. Residents’ medication at this home is well managed, therefore promoting good health. The ethos in the home is one of respect for the residents living there. This means that the residents feel settled at the home and their privacy is respected. DS0000026768.V324383.R01.S.doc Version 5.2 Page 11 EVIDENCE: Documentation for three residents was examined as part of the case tracking procedure used during this inspection. All three residents were spoken with/observed either in the privacy of their rooms or in the lounge. The detail and content of care plans was good with informative notes regarding each person’s daily needs and how assistance is provided. Weights for most residents were checked monthly and daily records were up to date and detailed. Care plans were being reviewed monthly and there was evidence of resident involvement and consultation. It was noted that, despite daily records noting deterioration, care plans for people returning to the home for further respite or following hospital admission, had not been reviewed and updated. It was noted that in some cases the scales owned by the home did not suit residents needs and weights had therefore not been recorded for some time for those people meaning that proper nutritional assessment could not be demonstrated. Evidence was available on file and through discussion that GP’s, district nurses, specialist nurses and other health professionals are called upon whenever the need arises. Medicines in the medication cupboard were examined together with administration records and policies. These were found to be satisfactory. Those staff responsible for medication administration have received appropriate training. Policies for the promotion of privacy and dignity were reviewed and satisfactory. Residents also confirmed during discussions that they felt their privacy was respected and their dignity promoted. Staff confirmed that they promote and maintain resident’s privacy when receiving personal visits from professionals such as GP’s and solicitors, family and friends. It was observed that staff knock on doors before entering and that residents preferred form of address is recorded and used. DS0000026768.V324383.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): All Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Spetisbury Manor provides a caring, homely and relaxed environment. The range of recreational activities available in the home as well as trips out is good. Open visiting arrangements are in place enabling residents to retain contact with families and friends. Residents have the opportunity to choose their own lifestyle within the home and this means that their individual preferences and routines are respected. Dietary needs of the residents are well catered for with a balanced and varied selection of food available that meets resident’s tastes and needs. EVIDENCE: Mrs Scott and the staff understand the importance of activity and fulfilment for residents. To this end there are frequent trips out in small groups or on a one to one basis, various organised activities such as quizzes and exercises and DS0000026768.V324383.R01.S.doc Version 5.2 Page 13 visiting entertainers. Residents are also encouraged to continue any interests that they followed prior to moving to the home. The visitor’s book showed that there is a constant stream of visitors to the home and discussions with staff confirmed this as well as the fact that many residents are taken out by visitors. During the course of the inspection visitors were observed in the home. They were made welcome by staff and clearly had a good relationship with the staff. Discussion with residents and staff as well as examination of records and observation during the inspection evidenced that residents are assisted appropriately to exercise choice and control over their lives. Residents and staff confirmed that, in their opinion, a suitable and varied diet is provided in the home. Foods records were examined and confirmed this to be the case. Residents said they enjoyed their food. One person commented “the food is first class”, the staff had comprehensive lists of likes and dislikes and a wide range of meals are prepared to suit all tastes and appetites. DS0000026768.V324383.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): 17 and 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Spetisbury Manor has a satisfactory policy and procedure for the making of complaints. This means that residents and others involved in the home that may wish to make a complaint should feel confident that they would be listened to and matters of concern will be acted upon. Arrangements for protecting service users from abuse were satisfactory. This means that Spetisbury Manor is a safe environment that will protect residents from abuse. EVIDENCE: Spetisbury Manor has a satisfactory complaints procedure that is displayed in the home as well as included in the Service Users Guide. Those spoken to confirmed that they knew how to make complaints and would feel able to do so should the need arise. One complaint had been made to the home since the last inspection and this had been investigated and appropriately documented. No complaints have been made to CSCI. Policies and procedures for adult protection and whistle blowing were checked and found to be satisfactory. Staff have also received training in the signs and symptoms of abuse and action they should take should they suspect abuse is taking place. DS0000026768.V324383.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 and 26 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home is very well presented: it is nicely decorated and furnished and has a homely atmosphere. The grounds are also very well maintained, providing lots of colour and interest as well as a variety of places to sit and relax. The home maintains a good standard of hygiene and all areas seen were clean and free from offensive odours. EVIDENCE: Residents at the service enjoy the delightful surroundings of the Manor and its well-maintained gardens. All rooms have a unique character, and are furnished to a high standard. Matching soft furnishings complement each room, which are refurbished as they become vacant. The home’s maintenance person was on duty on the day of the visit, and clearly takes great pride in his DS0000026768.V324383.R01.S.doc Version 5.2 Page 16 role, which also includes driving the home’s vehicle. The manager outlined plans to refurbish the home’s dining room and create an Orangery. Some radiators in the home remain uncovered. The manager confirmed that highest risk radiators have already been covered and that a programme is in place to cover those still outstanding. All hot water outlets in resident areas are limited to prevent scalding and a new radiator has been fitted in one suite which was previously identified has having inadequate heating. All areas of the home visited were clean, hygienic and free from offensive odours. The home has a very small laundry, with little space to manoeuvre. There is one domestic washing machine and tumble dryer. Given that the home is registered for twenty-five residents, one domestic washing machine and the limited space available is inadequate to meet the needs of people living in the home. This could potentially compromise infection control procedures. A recommendation has been made in the last six inspection reports and this was then made a requirement in the last report. Mr Ellis and Mrs Scott confirmed that work is currently being scheduled to create a purpose built laundry, with commercial equipment, on the ground floor of the home. DS0000026768.V324383.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): All Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The number of staff working in the home meets residents’ needs although the number of residents is increasing which means that staffing levels will need to be reviewed. The home has made progress in identifying training needs, and implementing a plan of statutory training. The home has a good ratio of care staff who have achieved National Vocational Qualifications and has introduced the Skills for Care Induction training; thus working to ensure that residents are in safe hands at all times. People living at Spetisbury Manor are satisfactorily supported and protected by the home’s recruitment policy and practices. EVIDENCE: Examination of the staff rota and observation throughout the inspection demonstrated there was a sufficient number and skill mix of staff to meet the needs of residents. However, it was noted that both numbers and needs of residents are increasing. Given the layout of the building and the needs of some people, there are some periods, especially in the afternoon when additional staffing will be required to ensure safety and continuity of care. DS0000026768.V324383.R01.S.doc Version 5.2 Page 18 At the time of the visit six staff members held a National Vocational Qualification of the ten care staff working in the home. A further member of staff has started an NVQ programme at level 2. Three staff files were seen. The files contained items as required by legislation. The manager has completed an analysis of staff training needs and has implemented a training plan, which includes mandatory subjects, to address these. The new Skills for Care induction programme has been implemented in the home. DS0000026768.V324383.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. Mrs Scott holds appropriate management qualifications as well as having many years experience in nursing. She is a competent, approachable and committed manager. This results in a home where residents, staff and visitors feel supported and consulted and visible improvements are being made to the service. Resident’s finances are safeguarded with clear policies and procedures and management guidance. The management arrangements for the home support good care practice for the residents. Quality monitoring systems need to be better defined and coordinated in order to further demonstrate that the home is run in the best interests of the residents. DS0000026768.V324383.R01.S.doc Version 5.2 Page 20 Resident’s finances are safeguarded with clear policies and procedures and management guidance. The health, safety and welfare of residents and staff is protected by the systems that the home has in place for staff training, maintenance and risk assessment. EVIDENCE: The management arrangements for the home support good care practices for the residents. Mrs Scott has demonstrated that she is a competent manager both through training and experience as well as the improvements that have been made since the last inspection. Systems for quality assurance and resident consultation are being developed with the aim of ensuring that the home is run in the best interests of the residents and that performance issues are identified and addressed. Mrs Scott confirmed that residents are encouraged to retain control of their own finances for as long as possible. Where they state that they no longer wish to or they lack the capacity to do so then the home ensures that either family or other representatives such as solicitors take on this role. No cash or valuables are held in the home for residents. Fire records, staff training records and accident books were examined and found to be up to date and detailed. DS0000026768.V324383.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 2 X X X HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 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 X X X X X 2 2 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 2 X 3 X X 3 DS0000026768.V324383.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. Standard Regulation Requirement Timescale for action 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 Reviews should be undertaken prior to each admission to the home for any resident receiving respite care or returning from hospital to assess to what degree, if any, care needs have changed. Nutritional screening must be undertaken on admission and on a periodic basis, a record maintained of nutrition & appropriate action taken. Residents must be weighed regularly. Risk assessments must be completed for radiators, portable heaters and water outlets, which present a risk of scalding and appropriate action taken according to the outcome. 15/12/06 Progress has been made in this area: all radiators must be covered. DS0000026768.V324383.R01.S.doc Version 5.2 Page 23 2 OP8 3 OP25 4 OP26 5 OP33 The Registered Person must ensure that foul laundry is appropriately sluiced prior to washing. The laundry room must be enlarged and improved to ensure that the home has sufficient facilities for laundering and control of infection. 15/12/06 Progress has been made in this area: improved procedures have been implemented for infection control and work is scheduled to create a new laundry area. Further work must be undertaken with regard to quality assurance systems in the home, by means of surveys, analysis and annual development plans, in order to demonstrate that the home is meeting its aims and objectives and statement of purpose. DS0000026768.V324383.R01.S.doc Version 5.2 Page 24 Commission for Social Care Inspection Poole Office Unit 4 New Fields Business Park Stinsford Road Poole BH17 0NF 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. Extracts may not be used or reproduced without the express permission of CSCI DS0000026768.V324383.R01.S.doc Version 5.2 Page 25 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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