Inspection on 19/07/05 for The Spinney

This inspection was carried out on 19th July 2005.

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

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

The Spinney 28/10/08

The Spinney 30/10/07

The Spinney 08/11/06

The Spinney 12/12/05

The Spinney 28/02/05

The Spinney 28/07/04

Similar services:

Abbey The

Snydale Care Home

Hawkhills

Larchfield Manor

Beeches The - North Yorkshire County Council

The Grove Waltham

Carentan House

Ravensworth Lodge

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

CARE HOMES FOR OLDER PEOPLE The Spinney 21 Armley Grange Drive Leeds LS12 3QH Lead Inspector Sue Dunn Announced 19 July 2005 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 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 20050719 The Spinney AN Stage 4 S1504 V230192 J52.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service The Spinney Address 21 Armley Grange Drive, Leeds, LS12 3QH Telephone number Fax number Email 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 20050719 The Spinney AN Stage 4 S1504 V230192 J52.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: None. Date of last inspection 28 February 2005 Brief Description of the Service: The home is situated in a quiet residential area of Armley between two main bus routes into the city centre. The shopping centres of Armley and Bramley are within a mile of the home but few service users would be able to reach the shops without the assistance of transport. The Spinney was initially a large detached house which had an extension, built several years ago to meet the Residential Care Homes Regulations 1984. Work has recently been completed on a further extension, affecting 10 rooms but providing an additional 8 rooms. This has been built to a high standard, improved the facilities and made all the rooms single occupancy. The home has some ground floor accommodation and most rooms offer en-suite facilities. There is passenger lift access to the first floor. A small lawned garden at the back of the building and a paved patio area overlooking the street provide a sitting out area for service users. The new extension includes a conservatory which has increased the communal sitting area. The home has male and female occupants and is non smoking. The home is neither equipped nor staffed to provide care for people with high physical dependency needs or for people who require a secure environment. The home is owned by Mr Richard and Mrs Pauline Duffy, who are actively involved in the day to day activities and the general upkeep and maintenance of the house, and managed on their behalf by Mrs Diane Russell. The proprietors have been successful in retaining a ‘domestic’ feel to the internal areas of the home. The Spinney 20050719 The Spinney AN Stage 4 S1504 V230192 J52.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. One inspector undertook the inspection, which was announced. The inspection started at 10.50am and finished at 5.15pm. The purpose of the inspection was to make sure the home was operating and being managed for the benefit and well being of the residents. The registered manager has been successful in gaining a management award and the knowledge and skills obtained through this were evident in her increased confidence and management of the home. The inspector spoke to the proprietor, who takes an active part in the management of the home, residents, visitors, and care staff. Records were looked at, including resident’s care plans and daily occurrence sheets and a selection of records. What the service does well: What has improved since the last inspection? There has been some improvement in the quality of the information gathered and recorded during the pre admission assessments. Care files include more background history which staff can use to treat each person as an individual. The home has made good progress towards meeting the target of 50 care staff with an NVQ (National Vocational Qualification) award and there is evidence that staff try to put into practice what they have learnt. The Spinney 20050719 The Spinney AN Stage 4 S1504 V230192 J52.doc Version 1.30 Page 6 What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The Spinney 20050719 The Spinney AN Stage 4 S1504 V230192 J52.doc Version 1.30 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 Standards Statutory Requirements Identified During the Inspection The Spinney 20050719 The Spinney AN Stage 4 S1504 V230192 J52.doc Version 1.30 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 standard(s) 2,3,4,5 The home must provide every resident in the home with a copy of the terms and conditions of their occupancy which has been signed and informs them what is expected of both parties. There has been some progress made towards improving the quality of information recorded when assessing if the home can meet needs. However, the home should show more evidence of how judgments were made before admission to show that people can be assured their needs, including social and recreational needs can be met. EVIDENCE: There was no evidence to show that all residents have been made aware of the number and type of room they will occupy and the terms and conditions of their occupancy. At the time of the inspection only privately funded and new residents had received this information. The Spinney 20050719 The Spinney AN Stage 4 S1504 V230192 J52.doc Version 1.30 Page 9 A pre admission assessment for one person admitted from hospital was satisfactory but gave no background information prior to the person going into hospital. This information was better in another referral which indicated that the views of the person concerned had been included in the assessment. The home’s pre admission assessment has improved slightly. The manager had recorded some of the personal items prior to admission which the person would need in order to settle in and had discussed this with the family. Discussion with some of the residents indicated that either they or their family had been for an introductory visit. This should be recorded in the pre admission assessment information. The Spinney 20050719 The Spinney AN Stage 4 S1504 V230192 J52.doc Version 1.30 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 standard(s) 7,8,10,11 Care plans must show what has been agreed with each resident or their representative to provide a satisfactory quality of life and show how staff are to support them to achieve this aim. The daily log should show sufficient information to say what the staff have done with, and for, people on a day-today basis. The written care plan must be amended as needs are met or change. The home provides a high standard of health and personal care. The manager and staff take an interest in people as individuals and are well informed about each persons care needs despite the shortfall in the records due to the absence of clear care plans. Residents and their families are very satisfied and secure in the knowledge they will be looked after with care and compassion. EVIDENCE: Pre printed care books are used to record background information. This was well done and gave a good picture of each person. However, the books have their limitations as they did not include information to give guidance in the form of a care plan, which anyone coming into the home to work a shift could follow. The Spinney 20050719 The Spinney AN Stage 4 S1504 V230192 J52.doc Version 1.30 Page 11 The daily log of events is recorded on separate sheets which are then transferred to each persons file. The staff were not recording information on the basis of their own actions but simply what the residents had done, therefore judgements about the quality of care could only be made from observation and anecdotal evidence. A section of the books is used to review the care but as there were no goals to work towards in the form of a care plan and little relevant information in the daily logs there was only very basic written information on which to base the monthly evaluation therefore the review notes were repetitive and not very informative. There was background information but no care plan for a person, who was hoping to move into supported housing, in order to enable the person to retain independence. For example there was nothing to say why the home was managing the medication, though there is a policy for people to manage their own medication if appropriate. It was agreed that anyone receiving respite care must have a care plan with an evaluation at the end of the period of the stay. This has not been done up to now. The way in which information was recorded did not indicate any forward planning though it was clear from speaking to the proprietor, manager and staff that everyone was aware of what was happening in the home and the level of health and personal care each person required. All the people spoken with spoke highly of the care. Positive comments from a range of people were as follows:- staff sitting with ill residents when officially off duty is ‘beyond the call of duty, from a relative, ‘more secure and better cared for than for years’, from a resident ‘the home provides the best care in the area’ from a doctor. The Spinney 20050719 The Spinney AN Stage 4 S1504 V230192 J52.doc Version 1.30 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 standard(s) 12,13,14,15 Residents said they would like more things to pass the time. A more imaginative programme of events and activities on a daily basis must be arranged for those who wish to participate. Staff should place more emphasis on what they do to provide care and support when writing in the daily logs. Resident’s choice and independence should be promoted at mealtimes for those who can help themselves. EVIDENCE: The manager said that people enjoy bingo, which is organised by staff. The proprietor intended organising some card making later in the year and there was evidence of books, a daily newspaper and magazines around in the lounges. One person’s favourite TV programmes had been recorded in the care file but daily records did not show if this was part of the daily activity for this person. Several residents said that there is nothing about the home for them to complain about. They felt well cared for, the staff were kind and the food was good. However they said they would like more to do to pass the time. Embroidery was suggested but one person said they needed someone to ‘lead’ such activities. One resident continues, with support from family, to attend a centre he went to before moving into the home. The Spinney 20050719 The Spinney AN Stage 4 S1504 V230192 J52.doc Version 1.30 Page 13 Family contact is encouraged, people were seen to be taken out by their families and relationships between staff and visitors were seen to be good. There seems to be little done by the home to take residents out other than to ‘walk up the street’ occasionally. Daily logs did not record what the staff had done to enhance peoples quality of life. One person described ‘a lovely party’ which the home had arranged for her birthday but the log simply stated ‘……birthday today’. People were satisfied with the food, which was served in the dining room from a hot trolley. One person felt the meal had been spoiled by too much gravy. The manager and staff should look at ways in which they can improve the level of choice and independence at mealtimes by allowing people to serve themselves. The Spinney 20050719 The Spinney AN Stage 4 S1504 V230192 J52.doc Version 1.30 Page 14 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) None. EVIDENCE: The Spinney 20050719 The Spinney AN Stage 4 S1504 V230192 J52.doc Version 1.30 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 standard(s) 19,20,23,24,25,26 Residents live in a safe, well maintained home that is clean and comfortable with a pleasant ‘homely’ feel. The work required to clean the water tanks must be given high priority and areas of work outstanding from the building of the extension completed. EVIDENCE: The home is clean and well maintained with a rolling programme of upgrading and redecoration. A visitor commented on the welcoming smell of home cooking encountered on visits to the home. Examination of the report from a recent check on the water supply and storage tanks in the home revealed that work is needed to reduce any risks of Legionella. The proprietor is waiting for quotes to have this work done. It was agreed that this work must be given high priority and the timescale to complete the fitting of suitable locks to the remaining bedroom doors will be extended to allow for this. The Spinney 20050719 The Spinney AN Stage 4 S1504 V230192 J52.doc Version 1.30 Page 16 Radiator covers have been fitted in one room with a further 10 on order for the older part of the building. People are encouraged to bring personal possessions into the home in order to make their own rooms comfortable and familiar. Any specialist equipment is supplied on loan through the district nursing service. The recently completed extension of the building has provided a variety of pleasant communal lounges. The staff toilet window was blocked up during the building work and the work to fit an extractor fan appears to have been overlooked. This work must be completed. The rear garden area needs tidying up and landscaping. The Spinney 20050719 The Spinney AN Stage 4 S1504 V230192 J52.doc Version 1.30 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27,28,29,30 There has been a marked improvement in the quality of induction and training in the home since the present manager came into post. This is reflected in the increased confidence and professionalism of the staff which indicates residents are in safe and caring hands. The rotas provides a well balanced competent staff team on each shift. The manager is reminded that CRB checks cannot be carried from one employer to another. EVIDENCE: The home employs a total of 19 care staff. Seven have completed NVQ and more places have been applied for so the home is well on the way to achieving the target of a minimum of 50 with the award. A relatively new care worker said she had been interviewed by two people and asked questions about why she thought she would be right for the job. She shadowed a senior care worker on the first two days and spent the first week going through the requirements for the job with the manager. A member of staff who is doing NVQ with Age Concern had to first complete a six week induction period with Age Concern. The staff spoken with got job satisfaction from there work. One person said ‘I go home feeling I have not just been at work for the pay’. One person employed in February had provided a copy of a CRB check done by the Community Mental Health Trust a month earlier. The manager is reminded that CRB checks cannot be carried from one employer to another. The Spinney 20050719 The Spinney AN Stage 4 S1504 V230192 J52.doc Version 1.30 Page 18 The staff handover systems make sure staff are kept up to date with information each time they start a shift. A care worker said that people who are in their rooms are regularly checked and staff spend time with restless residents rather than giving reassurances whilst telling people to sit down. She felt the home could give those residents with no family contact more chance to go out. The Spinney 20050719 The Spinney AN Stage 4 S1504 V230192 J52.doc Version 1.30 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31,32,36,37,38 The home is well managed and staff are well informed about residents. Staff appear happy and well motivated and this affects the quality of care residents receive. There is room for improvement in the written records to back up the verbal communication systems to make sure care needs are not overlooked. Records were orderly and readily available for inspection which made it easy to find information. Water storage checks revealed a medium to low risk of contamination of the water storage tanks. These must be cleaned as a matter of high priority for the safety of everyone in the home. EVIDENCE: The manager and proprietor work well as a team. The manager has completed a Management Award at Leeds Metropolitan University and gained knowledge and confidence which she has been putting into practice. She is taking a The Spinney 20050719 The Spinney AN Stage 4 S1504 V230192 J52.doc Version 1.30 Page 20 proactive approach to manage absenteeism in the interests of everyone in the home. A member of staff confirmed what the manager said about supervision and said she found it helpful. The last staff meeting was poorly attended. The manager should persevere and increase the frequency of meetings in order to draw on the knowledge and ideas of the whole team for the benefit of the residents. A quality audit questionnaire in February identified training issues and is used to monitor progress. This should be developed further to look at other aspects of life in the home such as choice, rights, independence, privacy, fulfilment and dignity. The proprietor has done a costing for the coming year to cover laundry, radiators, re decoration and replacement of the stair carpet and staff training. The business plan should also show overall income and outgoings as evidence of the home’s continuing viability. Records of equipment safety checks were up to date and staff training records showed the health and safety of staff and residents is promoted and protected. The Spinney 20050719 The Spinney AN Stage 4 S1504 V230192 J52.doc Version 1.30 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score x 2 3 2 3 x HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 x 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION 2 3 x x 3 3 2 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score x x x 3 3 x x x 3 3 2 The Spinney 20050719 The Spinney AN Stage 4 S1504 V230192 J52.doc Version 1.30 Page 22 yes 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. Standard OP2 Regulation 5 Requirement There must be evidence that every service user or their representative has received and understood the terms and conditions of their occupancy. Pre admission assessments must show how the home proposes to meet each persons needs and include details of any pre admission visit to the home. Care plans must provide staff with a guide of how each person wishes to have their care needs met. The daily log must show how care has been carried out on a day to day basis. The home must introduce a more imaginative programme of daily activities. Work must be done to make sure the water storage arrangements meet with the requirements of the recent report. All radiators must have covers. The appearance of the rear garden must be improved and the staff toilet fitted with some form of ventilation. 20050719 The Spinney AN Stage 4 S1504 V230192 J52.doc Timescale for action By 31.10.05 2. OP4 14 By 31.10.05 3. OP7 15 By31.10.05 4. 5. OP12 OP25,OP38 16 23 By 31.10.05 By 31.08.05 6. 7. OP25 OP19 23 23 By 31.03.06 By 31.03.06 The Spinney Version 1.30 Page 23 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 14,15 Good Practice Recommendations The home should look at ways service users can exercise more control and choice at mealtimes to accommodate their personal preferences. The Spinney 20050719 The Spinney AN Stage 4 S1504 V230192 J52.doc Version 1.30 Page 24 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 © 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 The Spinney 20050719 The Spinney AN Stage 4 S1504 V230192 J52.doc Version 1.30 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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