CARE HOMES FOR OLDER PEOPLE
The Spinney 21 Armley Grange Drive Leeds LS12 3QH Lead Inspector
Sue Dunn Announced Inspection 12th December 2005 12:30 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information
Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address The Spinney DS0000001504.V259257.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. The Spinney DS0000001504.V259257.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION
Name of service The Spinney Address 21 Armley Grange Drive Leeds LS12 3QH 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) 0113 279 2571 0113 279 2571 Mr Richard Martin Duffy Mrs Pauline Patricia Duffy Mrs Diane Russell Care Home 30 Category(ies) of Old age, not falling within any other category registration, with number (30) of places The Spinney DS0000001504.V259257.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION
Conditions of registration: Date of last inspection 19 July 2005 Brief Description of the Service: The Spinney is a large detached house which has been extended twice to provide accommodation for 30 older people. The home is comfortably furnished to retain a ‘domestic’ feel. The rooms in the most recent extension have been built to a high standard to meet current requirements. Only one room, in the older part of the house, is shared and most rooms have en suite facilities. The home, situated in a residential area of Armley has a small area for off road parking and is within walking distance of public transport. There is a small outdoor sitting area but no shops or other community facilities within easy reach for residents. The home has a non smoking policy and is not suitable for people who need a secure environment. The proprietors take an active part in the day to day operation of the home. Staff who have the certificate in Basic food Hygiene take turns to do the cooking. The Spinney DS0000001504.V259257.R01.S.doc Version 5.0 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This announced inspection was carried out by one inspector. Comment cards were sent to the home before the inspection. Three visitors to the home returned completed cards before the inspection. A pre inspection questionnaire was completed by the manager before the last inspection which was also announced. The purpose of the inspection was to ensure the home was operating and being managed in the best interests of the residents. The residents in the home are comfortable and satisfied with the standard of physical care which is good. The quality of the records could be improved to provide more evidence of how care is given. There are some requirements outstanding from the last inspection which are highlighted in bold font at the end of the report. This work must be completed in the new timescales given. What the service does well: What has improved since the last inspection?
The Spinney DS0000001504.V259257.R01.S.doc Version 5.0 Page 6 The pre admission assessment information, which the manager requires from other agencies was much improved including reports from other professionals to show what needs the home would be required to meet. The recruitment and selection procedures have been tightened up since the last inspection and all staff have thorough checks before starting to work in the home. What they could do better:
The home’s pre admission process did not provide a judgement about the resources needed to provide the care therefore it was not clear how a decision was reached when the home did not feel they could meet some care needs. Every care file must include a photograph of the resident, including those people on short stay visits. It is recommended that the proprietors make suitable arrangements to ensure this is not overlooked. The home must make the most of relevant information from other professionals when developing the care plans. Some recommendations regarding social and recreational care programmes had been overlooked in the home’s care plan. Care plans must show what plan of care has been agreed with each resident to meet their range of needs and provide guidance for staff on how the care is to be given. It is recommended that the care booklets currently in use be used just for factual information as the format restricts the amount of information which needs to be included if a care plan is to be effective. There must be evidence to show the action taken in response to any physical symptoms which staff might observe. There has been little apparent progress made to provide more social and recreational stimulation in the home as identified in previous inspections. Residents should not have to rely solely on friends and relatives for this aspect of their care. There should be evidence to show how complaints have been handled. There must be evidence to show that all staff have had training in the Protection of Vulnerable Adults. The manager must ensure that she discharges her registration responsibilities and notifies the CSCI appropriately about anything which affects the welfare of residents. The proprietor and manager must ensure that the outstanding fire safety work is done and the CSCI notified on its completion. In the interests of Health and safety fire doors must not be wedged open. If people wish their doors to remain open, suitable hold open devices linked to the fire alarm system must be installed. The Spinney DS0000001504.V259257.R01.S.doc Version 5.0 Page 7 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 Spinney DS0000001504.V259257.R01.S.doc Version 5.0 Page 8 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 The Spinney DS0000001504.V259257.R01.S.doc Version 5.0 Page 9 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): 3,4 There has been an improvement in the background information which the home asks for to identify needs over and above personal and physical care needs. However the pre admission assessments carried out by the home are not detailed enough to show what resources the home can provide to assure service users and their relatives that their needs will be met EVIDENCE: The home manager had made sure that information about the assessment of needs had been received before admission. In the case of an emergency respite admission the information was faxed to the home. Another file included a good ‘easy care ‘ assessment which included an occupational therapists report and occupational plan for the person. The homes own pre admission assessments must show more clearly what resources the home can provide (or not) in order to ensure needs can be met. This will allow the manager to provide clear justification for not accepting people whose needs cannot be met. The Spinney DS0000001504.V259257.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8 Written care plans were poor, and although health care needs were met due to the good system of verbal communication, the lack of appropriate records provides the possibility of needs to be overlooked. Those care files which lacked a photograph did not meet the requirements. EVIDENCE: The home does not have a system for ensuring care files contain a photograph but relies on families to supply a picture. Consequently not all files had a photograph. It is recommended that the home takes a more proactive approach to this part of the admission process. In one file seen the pre admission assessment information from other agencies showed the resident had been involved in the process. It provided good guidance for social and occupational activities for a person with a mental health condition. Unfortunately none of this guidance had been transferred to the home’s care plans therefore none of the activities had taken place. There was no information in the care plan to explain to staff the meaning of the diagnosed condition and how they should provide care.
The Spinney DS0000001504.V259257.R01.S.doc Version 5.0 Page 11 The manager and proprietor have, over time, looked at different formats for care plans to improve the systems. The present system uses a pre printed booklet which is useful for factual information and summarising progress but does not allow scope for the details which guide staff towards providing care in a person centred way. The care plans were superficial, lacked focus and did not direct staff on how care was to be given. Some daily records were better than others in describing what staff had done in response to events. It was concerning to note two entries in one persons file which could have indicated a serious underlying health problem. There was nothing to show if this had been brought to the manager’s attention or if any medical advice had been sought. Despite the shortfalls in the written care plans staff were caring and knowledgeable about each persons preferences. Residents were comfortable and valued for their individuality. The Spinney DS0000001504.V259257.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12,14 EVIDENCE: A few people in the home, with the help of families, continue to go to clubs they attended before moving into the home. An activity file gave some ideas for activities such as board games, dominoes, quizzes and chair exercises. There were no activities seen on the day of the inspection and there seems to have been little progress made in this area since previous inspections. The double room has the potential to create a conflict of interests between people having to share the space in the room. The Spinney DS0000001504.V259257.R01.S.doc Version 5.0 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): 16,18 Residents are aware of the complaints procedure and how to use it. There should be a more detailed record to show how complaints have been handled. The lack of staff training to raise awareness of adult protection issues raises concerns that residents are not fully protected from abuse. EVIDENCE: The home keeps a log of any complaints however there is no record or means of cross reference to show how complaints have been handled. Staff have not yet had adult protection training. This must be given high priority before the end of the inspection year. The Spinney DS0000001504.V259257.R01.S.doc Version 5.0 Page 14 Environment
The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19,22,23,24,25,26 Overall the home offers a comfortable, well-maintained environment for the residents and provides appropriate bathing and toilet facilities. The practice of wedging doors open must cease in the interests of fire safety. There was no evidence to show that every resident had been offered the opportunity to have a key to their bedroom door for the protection of privacy and security of possessions. EVIDENCE: The home offers a comfortable ‘homely’ environment. However, bedroom doors have not been fitted with hold open devices linked to the fire alarm system and a tour of the building found several bedroom doors wedged open. The fire safety officer is clear that this practice must cease. If any doors need to be kept open they must be fitted with an approved hold open device. Engineers were working to repair an intermittent problem with parts of the resident call system at the time of the inspection. The CSCI had not been
The Spinney DS0000001504.V259257.R01.S.doc Version 5.0 Page 15 notified as required when anything occurs which may affect the well being of residents. Some bedroom doors were locked. One person said they had not been offered a bedroom door key though the manager was concerned about the security of his personal property. The personal possessions and arrangements in the bedrooms varied according to the tastes of each person. The shared room had been well personalised but this was likely to create difficulties for anyone else sharing the room. The home was clean, well decorated and free from any unpleasant odours. The standard of care of personal clothing was high. An extractor fan had been fitted in the staff lavatory. The Spinney DS0000001504.V259257.R01.S.doc Version 5.0 Page 16 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): 29,30 The numbers and skill mix of staff were sufficient to meet the needs of the service users. There are good recruitment procedures in place to protect service users. EVIDENCE: The documentation for the most recently appointed member of staff was checked. An interview checklist had been completed and included comments. The manager was reminded that the comments should be a balanced overview of the interviewee’s performance. CRB ,POVA and two written references had been obtained before the person had started work. The induction training for new staff includes a period of working with an experienced member of staff during the first week. The home is keeping pace with a rolling programme of NVQ training. Six staff had completed the NVQ award with four more due to complete it by May. The Spinney DS0000001504.V259257.R01.S.doc Version 5.0 Page 17 Management and Administration
The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31,32,35,37,38 The management systems of the home allow staff to be kept informed and contribute to the decision making process. The interests of the residents are seen as very important to the manager and staff. There was some outstanding work and practices leading to shortfalls in health and safety procedures. EVIDENCE: The home has a good system of handover between shifts which gives staff the opportunity to update themselves on information about the care of residents. Advocacy support from Age Concern has been used when people have needed assistance with their personal finances. The manager has been advised carry out a risk assessment and management plan regarding the finances of one person about whom she had concerns.
The Spinney DS0000001504.V259257.R01.S.doc Version 5.0 Page 18 The quality of recorded information in the care plans does not give assurance that residents care needs will not be overlooked. There should be evidence to show that complaints from residents, their relatives, or staff, have been handled appropriately. The fire safety work identified in the last fire officer’s report must be completed by the end of March. The manager said that several smoke detectors were not working but engineers were booked to repair these on the Thursday following the inspection. This work has since been completed. Several bedroom doors had been wedged open as they did not have a hold open device linked to the fire alarm system. This is not acceptable to the fire safety officer as it places residents at risk. Engineers were working to repair an intermittent fault on the residents call system at the time of the inspection. The manager was informed that the home must have sufficient staff to respond to residents needs if the problem was not rectified. This was a notifiable event which the Registered manager had failed to report to the CSCI. The Spinney DS0000001504.V259257.R01.S.doc Version 5.0 Page 19 SCORING OF OUTCOMES
This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from:
4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable
CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 x x 3 2 x x HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 x 10 x 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 x 15 x COMPLAINTS AND PROTECTION Standard No Score 16 3 17 x 18 2 2 x x 3 3 3 2 3 STAFFING Standard No Score 27 x 28 x 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 3 x x 3 x 2 2 The Spinney DS0000001504.V259257.R01.S.doc Version 5.0 Page 20 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 OP4 Regulation 14(1)d Requirement The home must be able to demonstrate before people are admitted to the home how it will meet the assessed needs Care plans must show what has been agreed with each resident and give detailed guidance to staff on how the care needs are to be met. The must be a photograph of every resident. The home must provide a varied and flexible programme of activities suited to each persons preferences and expectations Staff must be provided with training which ensures residents can be protected from all types of abuse The registered persons must ensure that the home meets the requirements of the fire safety officers report and the health and safety of residents and staff is protected The registered manager must ensure the CSCI is notified
DS0000001504.V259257.R01.S.doc Timescale for action 31/03/06 2 OP37OP7 15,17 31/03/06 3 OP12 12 31/03/06 4 OP28OP18 18 31/05/06 5 OP38OP19 13,23 31/03/06 6 OP31 37 31/01/06 The Spinney Version 5.0 Page 21 7 OP16OP7O P37 17,22 without delay about any event in the home which may affect the well being of residents Service users best interests must 31/03/06 be protected by the homes records 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 Refer to Standard OP8OP7 OP7 Good Practice Recommendations The home should introduce a suitable format for care plans which allows for more detailed guidance and recording The home should make satisfactory arrangements for ensuring there is a photograph of every resident The Spinney DS0000001504.V259257.R01.S.doc Version 5.0 Page 22 Commission for Social Care Inspection Aire House Town Street Rodley Leeds LS13 1HP National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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