Inspection on 04/09/06 for Spinney (The)

This inspection was carried out on 4th September 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

Spinney (The) 15/05/07

Spinney (The) 08/03/06

Spinney (The) 28/07/05

Similar services:

Henry Nihill House

Birchwood

The Infirmary

Orchard House Nursing Home

St Josephs Rest Home

Red Court Nursing Home

Queen Elizabeth House

Spring Lane Care Home

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

CARE HOMES FOR OLDER PEOPLE Spinney (The) 21 Forest View Chingford London E4 7AU Lead Inspector Harun Rashid Unannounced Inspection 4th September 2006 10:00 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 Spinney (The) DS0000061978.V309612.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. Spinney (The) DS0000061978.V309612.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Spinney (The) Address 21 Forest View Chingford London E4 7AU 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) 020 8524 2200 020 8529 1346 Care Base (Chingford) Ltd Ms Carol Anne Bryan Care Home 46 Category(ies) of Dementia (0), Dementia - over 65 years of age registration, with number (0), Old age, not falling within any other of places category (0) Spinney (The) DS0000061978.V309612.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. Total number of beds 46 to be used flexibly between the following categories: DE 55 both genders DE(E) both genders OP (not falling within any other category) both genders 8th March 2006 Date of last inspection Brief Description of the Service: The Spinney is a purpose built care home on three levels run by Care Base (Chingford) Ltd. The home is situated in the north Chingford area of the London Borough of Waltham Forest. The home has access to all community amenities including Chingford rail and bus stations. At present it caters for 46 elderly peoples of both sexes. The home is awarded a major variation for dementia category for 11 beds on the top floor of the Spinney known as Maple unit. 35 service users are accommodated in single bedrooms with en-suites, one single room without en-suite facility and five double rooms have en-suites. Spinney (The) DS0000061978.V309612.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The unannounced inspection was conducted on a weekday morning on 04/09/06. The Inspector interviewed eight care workers in addition to the manager, a senior carer, the activity co-ordinator and the administrator. The Inspector also interviewed six service users and four service users’ relatives. What the service does well: What has improved since the last inspection? What they could do better: The registered person must review current staffing level in accordance with service users assessed needs. The manager must apply for her registration to the CSCI. The manager to complete her Registered Manager’s Award. The manager must ensure that Regulation 37 notification is sent to the Commission without delay. The manager must ensure that service users satisfaction questionnaires are completed on a periodic basis and the results of the satisfaction questionnaires are published at least on an annual basis. The registered provider must ensure that Regulation 26 visit’s report is sent to the CSCI on a monthly basis. Spinney (The) DS0000061978.V309612.R01.S.doc Version 5.2 Page 6 The manager must ensure that all staff receive at least six one to one supervision in a year as required by Regulation and National Minimum Standards (NMS). 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. Spinney (The) DS0000061978.V309612.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 Spinney (The) DS0000061978.V309612.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): 2 and 3 The quality in this outcome area is good. This judgement had been made using available evidence including a visit to this service. Service users were issued satisfactory contracts. Prospective service users’ assessments of needs were carried out prior to admissions. EVIDENCE: It was evident from the examination of service users files that they were issued with contracts. The contracts included a statement of terms and condition with the home. The contracts were signed by the service users or their family members and with the management of the home. The manager ensures that service users needs assessments are carried out prior to admissions. The needs assessments determine the dependency level of an individual service user. The assessment of needs is detailed with information. Standard 6 is not applicable to this service as the home does not provide intermediate care. Spinney (The) DS0000061978.V309612.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 The quality in this outcome area is good. This judgement had been made using available evidence including a visit to this service. All service users have individual care plans and staff reviews those on a monthly basis. Staff support service users to attend medication appointments. EVIDENCE: A large number of service users accommodated in the home are self-funded. Their care plans were developed from comprehensive assessments carried out by the manager/ senior carer. The home also obtained assessments of needs from the local authorities social workers or health professionals who were placed by them. Service users files examined confirmed that care plans were reviewed at least on a monthly basis. From the examination of care files it was clear that service users attended medical appointments accompanied by staff. Some cases when service users were unable to visit medical professionals, G.P. district nurses and chiropodist visited service users at home. A designated senior carer administers medication in each floor. Medication administration was observed. Staff recorded all medication administered in Spinney (The) DS0000061978.V309612.R01.S.doc Version 5.2 Page 10 Medication Administration Record sheets. These were examined and found to be satisfactory. Senior carers who administer medication were provided medication administration training. It was observed during the inspection that bedroom doors, toilets and bathroom doors were shut when personal care was provided. Staff maintain service users privacy and dignity at all times. Service users interviews confirmed this statement. Spinney (The) DS0000061978.V309612.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 The quality in this outcome area is good. This judgement had been made using available evidence including a visit to this service. The home provides individual and group activities for service users and their family members and friends are encouraged to visits them. The home meet service users dietary needs. EVIDENCE: An activity co-ordinator visits the home from Monday to Fridays. She organises activities in each floors. On the day of inspection she conducted Domino games on the first floor and a ‘sing alone’ group on the second floor. She informed that she had arranged three one to one outings to London Eye this summer. Staff encourage service users to visits at any time. On the day of the inspection the inspector observed that a number of service users family members and friends visited them. Service users were able to receive their visitors in their bedrooms in private. Some of the service users manage their personal allowances by themselves and each bedroom has a lockable drawer to keep valuables. The home provides information to service users and their relatives how to get accesses to advocacy services. Service users have opportunities to bring their personal Spinney (The) DS0000061978.V309612.R01.S.doc Version 5.2 Page 12 belongings with them. Service users have access to read their records in accordance with the home’s policy. The home employs cook and kitchen assistants. The weekly menus were examined which confirmed that service users receive a varied, wholesome and nutritious diet. The menu offers of at least two main meals at each time. The home ensures that service users dietary needs are met. Kitchen staff keep records of the fridge and freezer temperature on a daily basis. At the time of the inspection the kitchen was found clean and tidy. All kitchen staff attended food hygiene training. Spinney (The) DS0000061978.V309612.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 The quality in this outcome area is adequate. This judgement had been made using available evidence including a visit to this service. The home has a complaint procedure which staff adhere to and staff have awareness to adult protection issues. However, the management must ensure that Regulation 37 notification is sent to the Commission without delay. EVIDENCE: A record of complaints was kept by writing in a complaint book including details of investigation and action taken by staff. The complaints received were minor in nature and those were investigated and resolved accordingly. The CSCI has not received any complaint against the service since the last inspection. The manager advised that the issue with regard to a service user had been resoled. Following the completion of social worker’s assessment the service user was transfer to a nursing home. All staff have attended dementia awareness training. The manager has ‘Diploma in Dementia Care Matters’ also provides staff training and advice to staff. All staff have attended adult protection training. Staff who completed NVQ training confirmed that their training also covered this topic. It was evident from staff interview that they have awareness on adult protection issues. Spinney (The) DS0000061978.V309612.R01.S.doc Version 5.2 Page 14 The inspector informed the manager that on two occasions Regulation 37 notifications were not sent to the CSCI on time. The manager acknowledged this and assured to rectify this matter in the future. The inspector advised the manager that she should delegate this to a senior carer who can complete those and send to the CSCI in her absence. Therefore, the management must ensure that Regulation 37 notification is sent to the Commission without delay. Spinney (The) DS0000061978.V309612.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19,20, 24 and 26 The quality in this outcome area is good. This judgement had been made using available evidence including a visit to this service. The home is suitable for its stated purpose, which is safe and well maintained. The home is free from offensive odour. EVIDENCE: The home is located in a desirable residential area of North Chingford, which is popular. There are 35 single rooms and five double rooms with en-suite facilities. The grounds are kept clean and tidy and safe. An attractive garden is provided to the rear of the building with access to wheelchair users. The manager informed that they have applied for a variation to increase two additional beds. Lighting in communal areas are domestic in character, sufficiently bright and positioned to facilitate reading and other activities. Furnishings of communal rooms are domestic in character and of good quality and suitable for the range of interests and activities preferred by service users. Spinney (The) DS0000061978.V309612.R01.S.doc Version 5.2 Page 16 All bedrooms were inspected. There were adequate furniture available in each room. Service users personalised their bedrooms with family pictures/posters. Service users have opportunities to bring their personal belongings with them. The premises were kept clean, hygienic and free from offensive odour throughout. Hand wash facilities are prominently sited in areas where infected material is handled. The home employs laundry persons. The kitchen was inspected and found clean and tidy. All kitchen staff attend food hygiene course. Spinney (The) DS0000061978.V309612.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29 and 30 The quality in this outcome area is adequate. This judgement had been made using available evidence including a visit to this service. The home provides training for its staff development. However, the registered provider to review staffing level in accordance with the needs of current service users. EVIDENCE: The home employs 29 full and part-time care staff and 16 ancillary staff e.g. cooks, domestic workers, laundry persons and a handyman. The home also employs one full time activity co-ordinator. At the last inspection report it was stated that the registered provider must review their staffing level in accordance with service users assessed needs. The manager informed the inspector that she has requested a meeting with the directors of Care Base (Chingford) Ltd. to review staffing level of the home. The manager advised that they have advertised for a newly created deputy manager’s position and wish to recruit a deputy manager within two months. In addition to this they are looking to recruit an extra member of staff at night. The manger to confirm this in writing to the CSCI within new timescale. 15 members of staff have completed their NVQ level 2/3 training in care. However, it was evident during the staff interview that some of the staff are waiting to commence their NVQ level 2 training in care from six months to over a year. The manager informed that due to the lack of funding the process is delaying. However, she is anticipating the training will commence soon. Spinney (The) DS0000061978.V309612.R01.S.doc Version 5.2 Page 18 From the examination of staff files it was evident that the management have completed ‘ the Spinney residential home foundation work book’ for the newly appointed staff. A newly member of staff confirmed that her induction programmes was going well. The home operates a thorough recruitment policy based on equal opportunity policy which reflects on staff recruitment of the home. The management carry out all relevant checks on staff before appointment. Staff files examined confirmed that the registered provider carried out all relevant checks including CBR disclosures. Following the requirement of the last inspection report all staff have completed dementia awareness training. The manager has’ Diploma in Dementia Care Matters’ also provides staff training and advice to staff. In addition to this staff have attended other training recently, for example, health and safety, moving and handling, first aid, writing care plans and learn to care. The manager also informed that their kitchen staff also attended various training. Spinney (The) DS0000061978.V309612.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31,33,35,36 and 38 The quality in this outcome area is poor. This judgement had been made using available evidence including a visit to this service. The home appointed a manager for over six months; however, the manager has not submitted her registration application to the CSCI yet. Service users satisfaction questionnaires were not completed. The registered provider is not sending Regulation 26 visit’s report on a monthly basis. Staff are not receiving adequate level of supervision as required by Regulation and NMS. EVIDENCE: The manager has completed her NVQ level 4 qualification in care and she informed the inspector that she is commencing Registered Managers’ Award in September 2006. She is experienced in running a care home for nine years. The manager is required to apply for her registration to the CSCI. This matter was discussed in the previous inspection and the inspector spoke to the manager again that she must apply for her registration without delay. The manager showed her completed registration application form to the inspector Spinney (The) DS0000061978.V309612.R01.S.doc Version 5.2 Page 20 and said that she is now waiting for her CRB disclosure and the doctor’s certificate. Her failure to apply for registration within the new timescale, the CSCI will consider for further action. It was evident that service users satisfaction questionnaires were not completed recently. Therefore, the manager must ensure that service users satisfaction questionnaires are completed on a periodic basis and the results of the satisfaction questionnaires are published at least on an annual basis. In addition to this, recent three month’s Regulation 26 visits reports were sent to the CSCI on the same day of the month. The manager acknowledged this and assured to rectify this matter in the future. It is required that, the registered provider must ensure that Regulation 26 visit’s report is sent to the CSCI on a monthly basis. The manager advised that the home no longer manage any service users finances. Service users finances are managed by their family members or by the Court of Protection. Some of the service users manage their personal allowances by themselves and each bedroom has a lockable drawer to keep valuables. The manager informed that the home pays service users personal expenditures from the home’s patty cash, for example, chiropodists fees and news paper bill and later the home invoice those costs to the appropriate persons for payments. Staff files examined confirmed that all staff are not receiving adequate number of supervision as required by Regulation and NMS. A night staff has received her last supervision in January this year. Eight care workers interviewed confirmed that they have not received regular supervision this year. Therefore, the manager must ensure that all staff receive at least six one to one supervision in a year. The home ensures that regular fire equipment, gas and electric appliances are checked by the professionals involved. Copies of certificates were available during the inspection. Staff carry out fire alarm testing on regular basis. The home has a valid insurance against loss or damage to the property which was displayed in the office. The home provides staff training on health and safety, first aid, infection control and manual handling. Spinney (The) DS0000061978.V309612.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 3 3 x x N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 x 18 2 3 3 x x x 3 x 3 STAFFING Standard No Score 27 2 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 x 1 x 3 1 x 3 Spinney (The) DS0000061978.V309612.R01.S.doc Version 5.2 Page 22 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. 1. Standard OP31 Regulation 9 Requirement The manager must apply for her registration to the CSCI. (This is an outstanding requirement must be met within new timescale). The manager must complete her Registered Manager’s Award (RMA). The registered provider must review staffing level in accordance with service users assessed needs. (This is an outstanding requirement must be met within new timescale). The manager must ensure that Regulation 37 notifications are sent to the CSCI without delay. The registered provider must ensure that Regulation 26 visit’s report is sent to the CSCI on a monthly basis. The manager must ensure that service users satisfaction questionnaires are completed on a periodic basis and the results of the satisfaction questionnaires are published at least on an annual basis. The manager must ensure that DS0000061978.V309612.R01.S.doc Timescale for action 30/11/06 2. 3. OP31 OP27 9 18 31/03/07 30/11/06 4. 5. OP18 OP33 37 26 30/09/06 30/09/06 6. OP33 24 31/12/06 7. OP36 18 31/12/06 Page 23 Spinney (The) Version 5.2 all staff receive at least six one to one supervision in a year as required by Regulation and NMS. RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Spinney (The) DS0000061978.V309612.R01.S.doc Version 5.2 Page 24 Commission for Social Care Inspection Ilford Area Office Ferguson House 113 Cranbrook Road Ilford IG1 4PU 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 Spinney (The) DS0000061978.V309612.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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