Inspection on 17/03/06 for Spetisbury Manor

This inspection was carried out on 17th March 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 found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Spetisbury Manor 06/09/07

Spetisbury Manor 15/12/06

Spetisbury Manor 22/05/06

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 Unannounced Inspection 10:30 17 March 2006 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.V288115.R01.S.doc Version 5.1 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.V288115.R01.S.doc Version 5.1 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 Care Home 25 Category(ies) of Old age, not falling within any other category registration, with number (25) of places DS0000026768.V288115.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. A maximum of four bedrooms from those listed may be used for shared occupancy at any one time: 1, 11, 15, 16, 19, 20, or 21. 13th June 2005 Date of last inspection Brief Description of the Service: Spetisbury Manor is registered to accommodate 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 one another. Mr K Ellis is the Responsible Individual. The home has been without a registered manager since September 2004. The home is situated on the outskirts of Spetisbury, a small village close to Blandford Forum. The home is set in four acres of grounds, which are attractively landscaped, and has access to the river Stour. The accommodation is on three floors with a passenger lift providing level access to all areas of the home. Eighteen bedrooms have ensuite facilities and there is an assisted bathroom and communal toilets on each floor. DS0000026768.V288115.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was unannounced and took place during the late morning and early afternoon of 17th March 2006. The inspection took place as part of the regular, programmed inspection schedule for the home. This report should be read in conjunction with that from the inspection in June/July 2005 as all key inspection standards are reported on in these two reports. The purpose of this visit was to monitor the homes compliance with requirements and recommendations issued at the last inspection, 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 and staff. The home has been without a registered manager since September 2004. Anew manager, Mrs Scott has been appointed by the owner but is not yet registered with CSCI. 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 beautifully maintained gardens. The majority of residents have low needs and are therefore able to remain actively involved in decisions regarding their lives and activities as well as retaining as much independence as possible. There is a range of activities and outings provided and the new manager is intending to review these to ensure that a wide range and level of activities is available to ensure that as many residents as possible take part. The staff group is stable and were observed to be respectful, helpful and caring. Over half of the staff group have the minimum qualification of NVQ level 2 in care. All residents spoken with were very positive about the care and attention that they receive. They were also particularly positive and confident in the new manager and confirmed that they felt able to approach her with problems. The home provides an excellent range of meals using fresh produce and prepared on the premises. DS0000026768.V288115.R01.S.doc Version 5.1 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. DS0000026768.V288115.R01.S.doc Version 5.1 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.V288115.R01.S.doc Version 5.1 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 Prior to admission, the needs of each prospective resident are assessed to ensure that the home will be able to properly meet them. The assessment is comprehensive but the documentation and methodology used to support this process is unwieldy. Improved systems would make processes simpler and therefore provide better evidence that the standard is complied with. EVIDENCE: Pre-admission assessment for 1 resident, accommodated in the home, was examined. Only one was examined as the new manager has only admitted one person since her appointment. After careful analysis and discussion, it was found that the required information was available although the methodology and documentation used by the home was at times hard to follow. A letter was also sent to the resident prior to their admission, confirming that the home could meet their needs. DS0000026768.V288115.R01.S.doc Version 5.1 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 and 10 Systems for care planning and resident consultation are in place but could be reviewed and improved to provide more effective information and therefore further enhance evidence that the home meets the needs of residents. The home ensures that resident’s healthcare needs are met through seeking appropriate input from GP’s and other healthcare professionals. Internal procedures for monitoring health need to be improved to further promote good health. Residents are respected and their right to privacy is supported. EVIDENCE: Care Plans and related documentation regarding care for 3 residents were examined. After careful analysis and discussion, it was found that the required information was available although the methodology and documentation used by the home was at times hard to follow. Mrs Scott confirmed that she had undertaken her own analysis of the care planning system and was aware of its shortfalls. She stated that the improvement of care planning was a priority that will be addressed as soon as possible. DS0000026768.V288115.R01.S.doc Version 5.1 Page 10 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. There was no nutritional assessment of residents and monthly recording of weights was not being carried out. Mrs Scott confirmed that resident’s privacy is promoted when receiving personal care, 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.V288115.R01.S.doc Version 5.1 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 The social and recreational activities provided by the home meet the expectations of residents. Residents have the opportunity to choose their own lifestyle within the home and this means that their individual preferences and routines are respected. Open visiting arrangements are in place enabling residents to retain contact with families and friends. Great emphasis is placed on the provision of food in the home. Menus are well planned and provide an interesting, balanced and nutritious diet. EVIDENCE: Notices were displayed within the home giving information on the range of activities on offer. There are regular in house activities such as gentle exercise classes, reminiscence activities, quizzes and music. The home also has a people-carrier that is used to take people on shopping trips. A number of residents mentioned the activities when speaking with the Inspector and all said they enjoyed them. 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. DS0000026768.V288115.R01.S.doc Version 5.1 Page 12 Discussion with residents and staff as well as examination of records also evidenced that residents are assisted appropriately to exercise choice and control over their lives. The home employs a full time chef. A wide range of freshly prepared meals are provided and the chef confirmed that he will provide various alternatives to the main menu should residents request this. Many residents have expressed particular likes and dislikes and this is all recorded on a board in the kitchen. All residents spoken with were very positive about the quality of meals provided in the home. DS0000026768.V288115.R01.S.doc Version 5.1 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 The home has a satisfactory system for making complaints. This means that residents and others involved in the home that may wish to make a complaint can feel confident that they would be listened to and matters of concern will be acted upon. The manager and staff demonstrated a satisfactory knowledge and understanding of Adult Protection issues. Some policies and procedures should be updated to ensure that current information is always available to staff to enable them to take appropriate action should the need arise. EVIDENCE: The home has a satisfactory complaints procedure that is displayed in the home. Those residents spoken with confirmed that they would feel able to approach the new manager with any concerns or complaints that they may have. Staff have all received training in Adult protection although for some this is now more than 3 years ago. Mrs Scott confirmed that up date training for staff is being planned. It was noted that the local adult protection procedure document “No Secrets” was out of date. The Whistle blowing procedure did not provide information regarding the Public Information Disclosure Act 1998 nor did it contain the address and contact details of the local CSCI office. DS0000026768.V288115.R01.S.doc Version 5.1 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): 26 The home was found to be clean and comfortable. However the poorly equipped laundry could prove hazardous should there be any infectious illness in the home. The current machine would not disinfect the laundry and the room is too small to allow separation of fouled laundry and therefore prevent cross contamination. EVIDENCE: A tour of the premises was undertaken and the home was found to be clean, hygienic and free from offensive odours. Residents confirmed that the home is always clean and comfortable. The home has a very small laundry room on the first floor. There is insufficient space to allow adequate separation of foul laundry. The washing machine is of a domestic standard and does not have the facility to maintain 65°C for at least ten minutes or to comply with other disinfection standards. It is of concern that such inappropriate equipment could compromise infection control procedures. DS0000026768.V288115.R01.S.doc Version 5.1 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): 28,29 and 30 There is an ongoing staff training programme and 50 of staff have now achieved an NVQ level 2 qualification or higher. Such training has lead to an increased level of competency and motivation amongst the staff. Recruitment and employment practices have improved since the last inspection therefore providing greater protection for residents. Improvements to the way staff receive induction training are being made which will lead to an increased competency amongst the staff. EVIDENCE: Three of the six care staff have now achieved NVQ level 2 in care and one further person is currently undertaking this NVQ2. The home is committed to providing training for staff and currently three people, having completed level 2, have gone on to study level 3. Files for one recently employed member of staff was examined. This person had completed application forms, been interviewed and given a job description and contract of employment. All of the required checks and references had been obtained. Mrs Scott had obtained the new guidance for staff induction and this was being implemented for the member of staff that had recently been employed. DS0000026768.V288115.R01.S.doc Version 5.1 Page 16 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): 33,35 and 38 The manager indicated that it is her intention to run the home in the best interests of the residents but the quality assurance system does not reflect this. Organisation of management tasks and administration of records could be better defined to ensure that residents therefore benefit from efficient management of staff and the home and up to date care information. Sound practices and procedures are in place regarding residents’ finances. 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: Discussion with Mrs Scott confirmed that she has a good understanding of the National Minimum Standards and is aware of the need to introduce a quality assurance system to the home. DS0000026768.V288115.R01.S.doc Version 5.1 Page 17 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. Fire records, staff training records and accident books were examined and found to be up to date and detailed. An audit of accidents had been undertaken and a training plan had been developed to ensure that staff remain up to date with core training such as moving and handling, 1st aid, infection control, health and safety and basic food hygiene. DS0000026768.V288115.R01.S.doc Version 5.1 Page 18 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 1 8 2 9 X 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 1 X X X X X X X 1 STAFFING Standard No Score 27 X 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X X 1 X 3 X X 3 DS0000026768.V288115.R01.S.doc Version 5.1 Page 19 Are there any outstanding requirements from the last inspection? Yes 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 The Registered Provider must make available a Service Users Guide providing all of the required information necessary for compliance with this standard. Two previous timescales for this requirement have not been met. The manager confirmed that she was aware of this and will be addressing it. Failure to comply may result in enforcement action. The Registered person must ensure that residents have a comprehensive plan of care (that is generated from a preadmission assessment for new admissions) that is drawn up with them. This plan must set out in detail actions that need to be taken by care staff to ensure that all aspects of health, personal and social care needs are fully met. The care plan must be reviewed by staff at least once a month and must be updated to reflect changing needs. Timescale for action 1 OP1 4 30/09/06 2 OP7 13 and 15 30/06/06 DS0000026768.V288115.R01.S.doc Version 5.1 Page 20 3 OP18 12 4 OP26 13 and 16 5 OP31 9 6 OP33 24 7 OP37 26 The Registered person must ensure that there are robust and up to date procedures in place for responding to the suspicion or evidence of abuse. Information must be available regarding No Secrets, Public Information Disclosure Act 1998 and contact details for CSCI. Two previous timescales for this requirement have not been met. The manager confirmed that she was aware of this and will be addressing it. Failure to comply may result in enforcement action. The Registered Person must ensure that foul laundry is washed at appropriate temperatures (minimum 65°C for not less than 10 minutes) to thoroughly clean linen and control the risk of infection. The Registered Person must submit an application for registration of the manager. The Registered person must ensure that effective quality assurance and quality monitoring systems, based on seeking the views of service users, are in place to measure success in meeting aims, objectives and Statement of Purpose of the home. The Responsible Individual must arrange for the home to be visited at least once each month to inspect the premises, interview, with their consent, residents and staff and must provide to the Commission a written report on the conduct of the home. This requirement is carried over, as it was not assessed during this inspection. 30/06/06 30/09/06 30/04/06 30/06/06 30/06/06 DS0000026768.V288115.R01.S.doc Version 5.1 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 OP8 Good Practice Recommendations Nutritional screening must be undertaken on admission and on a periodic basis, a record maintained of nutrition, including weight gain and loss, & appropriate action taken. The medicine administration records for each resident should clearly state any allergy to medicines, or none known. This recommendation is carried over, as it was not assessed during this inspection. Handwritten amendments and additions to medicine admnistration records should be signed and dated by the writer, and countersigned by somewhat who has checked the entry for accuracy. This recommendation is carried over, as it was not assessed during this inspection. All staff involved in handling medicines should receive accredited training in this work. This recommendation is carried over, as it was not assessed during this inspection. Facilities for the correct recording of Controlled Drugs should be provided. This recommendation is carried over, as it was not assessed during this inspection. There should be a written summary of all medicines prescribed for each resident, describing purpose and possible side-effects. This recommendation is carried over, as it was not assessed during this inspection. It is recommended that the laundry room be enlarged and improved to ensure that the home has sufficient facilities for laundering and control of infection. (This recommendation has been included in 6 previous inspections). Staffing levels should be reviewed in accordance with the Residential Forum calculator for the number of care hours provided. This recommendation is carried over, as it was not assessed during this inspection. 2 OP9 3 OP9 4 OP9 5 OP9 6 OP9 7 OP26 8 OP27 DS0000026768.V288115.R01.S.doc Version 5.1 Page 22 Commission for Social Care Inspection Poole Office Unit 4 New Fields Business Park Stinsford Road Poole BH17 0NF 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. Extracts may not be used or reproduced without the express permission of CSCI DS0000026768.V288115.R01.S.doc Version 5.1 Page 23 - 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. 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