CARE HOMES FOR OLDER PEOPLE
Spindrift Care Home 36/39 Cleveland Road Lytham St Annes Lancashire FY8 5JH Lead Inspector
Mrs Lillian McMullen Unannounced Inspection 7th November 2005 9:00 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 Spindrift Care Home DS0000064223.V260267.R01.S.doc Version 5.0 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. Spindrift Care Home DS0000064223.V260267.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION
Name of service Spindrift Care Home Address 36/39 Cleveland Road Lytham St Annes Lancashire FY8 5JH 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) 01253 737014 01253 794742 Spindrift Care Home Limited Mrs Alison Elizabeth Murgatroyd Care Home 33 Category(ies) of Learning disability (2), Old age, not falling registration, with number within any other category (30), Physical of places disability (1) Spindrift Care Home DS0000064223.V260267.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION
Conditions of registration: 1. 2. The service should employ a suitably qualified and experienced manager who is registered with the Commission for Social Care Inspection The home is registered for a maximum of 33 service users to include Up to 30 service users in the category of OP (older people over the age of 65 years) One named person in the category of PD (adults with physical disabililty) Two named people in the category of LD (adults with learning disabilities) 6th May 2005. Date of last inspection Brief Description of the Service: Spindrift is a Christian rest home and is run very much within the Christian ethos, however the home accepts residents of all religious denominations. The home offers personal care to residents of both sexes who are aged 65 years and above. Additional support services are brought into the home as required these include G.P. visits, district nurses, continence advisor, C.P.N., chiropodist, opticians, etc. Regular visits are made by the hairdresser and occupational therapist. There are 28 single bedrooms and 2 double bedrooms. Whilst the home is quite large it encompasses 4 houses within a terrace and therefore is able to offer spacious communal space in a variety of settings. This promotes small group interaction and allows residents to associate with other service users on a personal and social level. Spindrift Care Home DS0000064223.V260267.R01.S.doc Version 5.0 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This inspection was unannounced and started at 9am and took place over 5 and half hours. The Pharmacy inspector accompanied the lead inspector to examine the medication procedures. At the time of the inspection all three directors were present. The Inspector spoke to 7 residents, 3 staff members the registered manager, the responsible individual and the financial director. Comment cards were left for relatives and residents, the ones returned contained, in the main, positive views of the home. What the service does well: What has improved since the last inspection?
Since the previous inspection the home has gained stability with the new management team assuming full responsibility for the day to day running of the home. Spindrift Care Home DS0000064223.V260267.R01.S.doc Version 5.0 Page 6 A new staffing structure has been introduced which provides all staff with delegated areas of responsibility whilst ensuring a shift leader is on duty at all times. Some areas of the home have been redecorated and new carpets have been fitted to a number of rooms. 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. Spindrift Care Home DS0000064223.V260267.R01.S.doc Version 5.0 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 Spindrift Care Home DS0000064223.V260267.R01.S.doc Version 5.0 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): EVIDENCE: The above core standards were assessed at the previous inspection. However during this inspection the inspector noted that the pre admission procedure was being followed. It was pleasing to note that two senior staff members were travelling to Southport to conduct a pre admission assessment and from discussion it was clearly evident that no resident is admitted to Spindrift Care Home unless a pre admission assessment has been conducted and that the registered manager is confident that the needs of the prospective resident can be met. Intermediate care is not provided at Spindrift Care Home. Spindrift Care Home DS0000064223.V260267.R01.S.doc Version 5.0 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): 9 The medication procedures ensure all residents receive their medication as prescribed. However some improvements are required to the recording systems. EVIDENCE: The medication procedures were examined by the Pharmacy Inspector, he noted that a number of improvements are required to the recording systems. All areas that require attention will be addressed to the registered manager by a separate letter. Whilst the other core standards were assessed at the previous inspection the inspector was pleased to note that the standard of care provided is good. This is particularly evident in the care of one resident who has been cared for in bed for the last two years. This resident looked extremely comfortable and has no bedsores. Records of fluid and food intake and turn charts were in place and fully completed. Spindrift Care Home DS0000064223.V260267.R01.S.doc Version 5.0 Page 10 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): EVIDENCE: All the above core standards were assessed at the previous inspection. However residents spoken to were able to confirm that regular social activities are arranged. Residents spoke of their enjoyment of a firework display and a recent outing to Rochdale Town Hall to have tea with the Mayor who is the nephew of one of the residents. Spindrift Care Home DS0000064223.V260267.R01.S.doc Version 5.0 Page 11 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 Policies are in place that ensures residents are protected from abuse. The home has a satisfactory complaints procedure, which is contained in the Service User Guide and also displayed, around the home. EVIDENCE: The procedure for the Protection of Vulnerable Adults is robust and would be implemented should there be an allegation or suspicion of abuse or bad practice. All policies and procedure meet with the Department of Health guidance ‘No Secrets’ and incorporate local protocols for the reporting and recording of any allegation or suspicion of abuse and bad practice. Also contained in the policy document is a whistle blowing procedure that directs and informs staff of their responsibility to report any incident of bad practice. All staff receives training in the Protection of Vulnerable Adults and recently staff have attended a training course in the management of challenging behaviour. Spindrift Care Home has a comprehensive complaint policy and procedure that would be implemented if a complaint was raised. The procedures are compliant with all requirements and recommendations of the Care Standard Act 2000. The management team are pro active in gaining comments from residents, relatives and staff. Questionnaires devised by the home have been sent to
Spindrift Care Home DS0000064223.V260267.R01.S.doc Version 5.0 Page 12 residents and staff requesting comments regarding the quality of the service provided. The returned questionnaires provided evidence that in the main both relatives and residents were satisfied with the standard of care provided and were aware of the complaint procedure. In addition comment cards issued by the Commission for Social Care Inspection were sent to relatives, from the eight that were returned only one stated that they were not aware of the complaint procedure. The inspector is confident that the management do all they can to inform people of the complaints procedure. Residents are provided with a copy at the time of their admission and a copy is displayed on the notice board in the dining room. Spindrift Care Home DS0000064223.V260267.R01.S.doc Version 5.0 Page 13 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 There is a planned maintenance and renewal programme for the redecoration and refurbishment of the home that ensures residents live in a comfortable, homely and safe environment. EVIDENCE: The home is well maintained and a programme of maintenance is on going. A number of areas have been redecorated and re carpeted since the previous inspection. Plans are in place to continue to upgrade the physical environment of the home, which will include making improvements to a number of bedrooms and bathrooms. A maintenance man is employed and a record of all routine maintenance is maintained. From discussion with him the inspector was pleased to note his enthusiasm and commitment to maintaining the home to a safe standard. Spindrift Care Home DS0000064223.V260267.R01.S.doc Version 5.0 Page 14 It was noted that a number of toilets do not have appropriate locks fitted and these should be fitted as a matter of priority. A programme of fitting locks to bedroom doors should also be implemented. From touring the home the inspector also noted that some bedrooms doors have fire glass inserted and to protect privacy these doors should have curtains or blinds in place. It was also noted that some bathrooms had bubble bath and shampoo left on display, to avoid accidental ingestion these should be stored safely. The home is clean and free from offensive odours. Systems are in place to reduce the risk of infection. An efficient laundry system is in place and all washing is washed at the specified temperatures. All staff receives training in infection control. Spindrift Care Home DS0000064223.V260267.R01.S.doc Version 5.0 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): EVIDENCE: All the above core standards were assessed at the previous inspection. Spindrift Care Home DS0000064223.V260267.R01.S.doc Version 5.0 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): 38 The policies, procedures and working practices in the home ensure that the health, safety and welfare of the residents and staff are promoted. To fully protect residents and staff a more pro-active approach to conducting risk assessments must be adopted. EVIDENCE: A health and safety policy is in place together with additional policies in relation to Fire Safety and Control of Substances Hazardous to Health. Regular fire drills take place and the registered manager was asked to ensure full details of persons present at the drill be recorded together with details of the instruction given. Training in all mandatory subjects is provided as soon as practical following employment. Training records are maintained on individual files. The inspector
Spindrift Care Home DS0000064223.V260267.R01.S.doc Version 5.0 Page 17 advised the recording of all training should be in greater detail, which should clearly show what training has been undertaken and the dates that refresher courses are due and suggested that a training matrix be developed. At present the home’s risk assessments are not in sufficient detail to fully protect residents and staff. The registered manager and the other directors for the home were strongly advised that risk assessments in relation to all working practices must be in place. All risk assessments must include the identified hazard together with the details of the action to be taken in order to minimise the hazard. Once in place all risk assessments must be under constant review and signed by staff once they have read and understood the content. Information supplied on the pre inspection questionnaire provided evidence that all equipment is regularly maintained. At the time of the inspection evidence was seen to confirm that all electrical appliances are tested on an annual basis. However the electrical installation certificate could not be located. The registered manager is confident that the present electrical certificate is valid until 2006 but in the event that it is not located arrangements will be made to have the electrics tested again this year. Spindrift Care Home DS0000064223.V260267.R01.S.doc Version 5.0 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 X X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 X 8 X 9 2 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 X 14 X 15 X COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X X X 3 STAFFING Standard No Score 27 X 28 X 29 X 30 X MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X X X X X X X 2 Spindrift Care Home DS0000064223.V260267.R01.S.doc Version 5.0 Page 19 Are there any outstanding requirements from the last inspection? 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 2 3 Standard OP19 OP38 OP38 Regulation 23 16 23 Requirement All toilets must have an appropriate locks fitted. A valid electrical installation certificate must be produced. Risk assessments for all safe working practices must be in place. Timescale for action 30/11/05 30/11/05 31/12/05 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 2 3 4 Refer to Standard OP19 OP19 OP19 OP38 Good Practice Recommendations Glass in bedroom doors should have curtains or blinds fitted. Bubble bath and shampoo should be safely stored. A programme of fitting locks to bedroom doors should be implemented. A training matrix should be developed. Spindrift Care Home DS0000064223.V260267.R01.S.doc Version 5.0 Page 20 Commission for Social Care Inspection North Lancashire Area Office 2nd Floor, Unit 1, Tustin Court Port Way Preston PR2 2YQ National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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