Inspection on 21/05/08 for The Spinney

This inspection was carried out on 21st May 2008.

CSCI found this care home to be providing an Adequate service.

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

The Spinney 06/06/07

The Spinney 30/06/06

The Spinney 24/11/05

The Spinney 04/05/05

The Spinney 13/12/04

The Spinney 18/05/04

The Spinney 12/02/04

Similar services:

Chirnside House

Keer Sands Residential Home

Ruskin Lodge

Bushell House

Langrigg House

Parkside

Dystlegh Grange

Thornton Lodge

Extracts from inspection reports are licensed from CQC, this page was updated on 28/09/2008.

CARE HOMES FOR OLDER PEOPLE The Spinney 16 College Road Upholland Wigan Lancashire WN8 0PY Lead Inspector Mr Graham Oldham Unannounced Inspection 21st May 2008 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 The Spinney DS0000039828.V360311.R02.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. The Spinney DS0000039828.V360311.R02.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service The Spinney Address 16 College Road Upholland Wigan Lancashire WN8 0PY 01695 632771 01695 625599 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) Bondcare (Spinney) Ltd vacant post Care Home 35 Category(ies) of Old age, not falling within any other category registration, with number (35), Physical disability (3) of places The Spinney DS0000039828.V360311.R02.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. The home is registered for a maximum of 35 service users to include: Up to 35 service users in the category of OP (Old Age not falling within any other category). Up to 3 service users in the category of PD (Physical Disability). Date of last inspection 6th June 2007 Brief Description of the Service: The Spinney is a thirty-five bedded care home providing nursing and personal care. Accommodation is over three floors, which can be accessed by a lift. Thirty-one rooms are single, six of which have en-suite facilities. Two shared rooms are also available. Twenty-three residents were accommodated on the day of the inspection. Lounges are provided on the ground and first floor. The ground floor lounge is large and spacious. The first floor lounge is smaller, but comfortable and furnished nicely. There is a dining room on the ground floor. The home is furnished to a satisfactory standard, and has a friendly ambiance. The most recent inspection report is available in the reception area of the home. A statement of purpose and service users guide are available for residents or their families to be informed of the facilities and services the home provides. The fees for The Spinney range from £394 to £450 per week. This does not include hairdressing, newspapers or magazines and toiletries. Outings are subsidised and residents may have to contribute. The Spinney DS0000039828.V360311.R02.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place on the 21st May 2008 and included a visit to the service. Much of the information gained was obtained from talking to residents and staff members. The views of residents were obtained on a variety of topics. Three residents were case tracked. Two staff members were interviewed to provide information towards case tracking. Case tracking gave the inspector an overall view of the specific care for the individual resident by checking the plans of care, other documentation and talking to residents and staff. Some of the views have been reported collectively with specific comments contained within the body of the report. The inspector took detailed notes during the inspection, which have been retained as evidence. Staff were directly and indirectly observed carrying out their tasks and interacting with residents. Paperwork examined included plans of care, assessment documentation, policies and procedures or documents relevant to each standard and the AQAA. This is a self-assessment document, which informs the Commission for Social Care Inspection of the status of the home in relation to the standards. The document tells us what has improved, the current situation and how further improvements can be made. A tour of the building was conducted on the day of the inspection. The quality rating for this service is one star. This means the people who use this service experience adequate quality outcomes. Eleven residents returned survey forms to the CSCI. One had been issued with a contract and ten could not remember Two received enough information to make an informed choice to enter the home and nine did not. Comments from 8 of the 9 indicated it was a family member. Six always received the care and support they needed, four usually and one sometimes. Two commented, I think the care staff are excellent and the staff help to make things easier for me. Nine thought staff listened and acted upon their views and two did not. Residents said, Staff are willing to help at all times, I feel the staff chat too The Spinney DS0000039828.V360311.R02.S.doc Version 5.2 Page 6 much over me, the staff cannot do enough for me and I am new here and the staff have really helped me. Three thought staff were always available, five usually and three and sometimes. All eleven thought they always received the medical support they needed. Four thought there were always suitable activities on offer, five sometimes and two did not answer but said, I am very happy watching television and listening to music. I am too old for other activities and I do my knitting and rug making by myself as I do not want to be in a group. Seven thought food was always good, two usually and two sometimes. • Residents said, I would like more variety. • I enjoy all my meals which are very well cooked. • The meals are of a very high standard. Fresh vegetables every day and plenty of variety. We all look forward to mealtimes. It is always a treat. • The food is always very good. Nine always knew who to talk to if unhappy or make a complaint and two sometimes. Eight knew how to make a complaint and three did not. Ten said the home was fresh and clean and one usually. Five residents commented further: • I feel I wait a long time for appointments. Although I have bad eyesight and poor use of my fingers I would like more entertainment. • I am made to feel as comfortable as possible. • Too many people giving orders. • Extremely satisfied. I joke that I sleep like a log and eat like a horse. • The lounge gets too noisy. In general the response from residents was positive although there are areas for improvement. Four staff members returned survey forms to the CSCI Three always they were always kept informed about the needs of residents and one usually. All thought the inspection process was robust. Two thought the induction process covered all topics very well and two mostly. One said, I would have liked more. All four thought training was relevant to the role, helped understand the diversity of residents and kept them up to date. “ Two thought support was regular and two often. The Spinney DS0000039828.V360311.R02.S.doc Version 5.2 Page 7 All knew how to complain. Three usually thought there was enough staff and one sometimes. This person said more staff needed. One thought support was always enough to meet the diverse needs of residents and three usually. Three commented on what the service does well. • Always trying to improve care for residents. • Look after the clients. • Provides service users with a warm, friendly, caring, safe environment where their needs and wishes can be met. Cared for to the highest standard to retain their individuality and independence as much as possible. One commented on what the service could do better – Provide more choice in menus. Provide more activities and entertainment. Provide better linen. Provide an outside area for residents and improve staff shortages. I feel that improvement has been made over the last twelve months. Staff were generally contented and well supported but there are areas for improvement. Ten relatives returned survey forms to the CSCI. Seven thought information was always sufficient to make informed decisions about their relatives and three usually. One said communication with staff is spot on. Six thought the needs of their relative was always met and four usually. One person said, Extremely well looked after by all the staff. Nine thought they were always kept on touch with their relatives, one usually and one sometimes. One said excellent and another said, they are happy to help her dial a telephone number and welcome visitors. Eight thought they were always kept up to date with important issues and two usually. Seven thought the care and support given to residents was always enough and three usually. Seven thought staff always had the skills and experience to meet the needs of residents and three usually. One said, very experienced staff – an eye opener for me to see what is involved. The Spinney DS0000039828.V360311.R02.S.doc Version 5.2 Page 8 Eight thought the diverse needs of residents were always met and two usually. One said, as far as I can say I have observed support for different religions. Eight knew how to make a complaint and two did not. All thought the response to a concern would always be appropriate. Three thought the care service always supported people to live the life they chose, six usually and one sometimes. One person said, My husband is completely dependent upon the staff as he is unable to communicate. I and my family are quite satisfied with the support he is given. Comments on what the home did well included: • My husband is always kept clean and well cared for. The staff are always responsive to any requests we make concerning his care. The Spinney is clean and has a homely atmosphere. The staff are hospitable to me, my family and friends. We are always included and made welcome to any special events for the residents. • Caring and responsible staff throughout. They make my mother feel comfortable and assure her when she needs support at all times. • Caring and understanding individual needs of a resident. • They listen and work very hard to ensure everyone is happy. • Food, cleanliness and entertainment. • They are friendly, caring and supportive. Always greeted with a smile. The staff are very patient and understanding when dealing with the residents. • They give all the love and help we need. • They look after the everyday needs of my mother. • They treat people as individuals are wherever possible always acknowledge requests for help straight away. • Take care of day to day needs. Comments on how the service could improve included: • More activities for residents because they complain of inactivity and boredom. • The patients need more stimulation. • There is a need for mental stimulation and I mean activities that are geared to the capabilities of the service users, not to the abilities of the staff (a common problem in this area). Activities need to be correctly structured and tailored to the individuals not the blanket ‘look good’ for the outsiders display. Fine tuning to ensure individuals clothing are not lost in the laundry process. There is nothing worse for a relative than to see that the person they love is wearing clothing they would not have been seen dead in when they were in control of their own life. • Any care home can only improve if the staff are given more money and equipment to make changes and enough staff to run the place efficiently. • Entertainment. Thank you for improving my mothers health and providing her with a healthier lifestyle. • Creation of some outdoor space and better laundry control. The Spinney DS0000039828.V360311.R02.S.doc Version 5.2 Page 9 • • Redecoration of bedrooms and outdoors to give it the look it truly deserves. My mum has only been in The Spinney for a short period but first impressions are excellent. In general relatives were satisfied with care but thought more activities would improve the lifestyle for residents. What the service does well: The assessment process enabled staff to develop a plan of care to meet the needs of residents. The Statement of Purpose, Service User Guide and contract document informed prospective residents of the services and facilities the care home had to offer. Residents case tracked said, “I came from London. My daughter is up here - that’s why I moved here and she chose it” and “a family member choose here for me. I was ill and my husband was not able to look after me. They talked to my daughter and we all had a little talk about my care.”. Sufficient information was available for prospective residents or family members to make an informed choice to enter the care home. Residents were indirectly observed receiving personal care in a private manner. Residents case tracked said, “they treat me privately” and “staff treat me privately and with dignity. Personal care was delivered in a professional manner for the benefit of residents. One resident case tracked said, “They get the doctor if I feel ill”. Plans of care showed residents had access to specialists to help meet their health care needs. The majority of residents said food was good on the day of the inspection. Residents case tracked said, “the food is all right – passable” and “I am not very happy with the food. It’s me – I don’t feel like eating”. In general food met resident’s expectations. Resident’s case tracked said, “my daughter comes in every day. She can come when she wants” and “my husband comes to see me and my daughter. They can visit when they want”. Residents were able to socialise freely with their relatives and friends. Resident’s case tracked said, “Staff treat me all right. They look after me” and “The staff are nice to me. They are looking after me very well”. Residents case tracked were satisfied with their care and the attitude of staff. One resident case tracked said, “I like my room I have put some of my own things in my room”. During the tour of the home the décor was found to be to a reasonable standard and homely. The Spinney DS0000039828.V360311.R02.S.doc Version 5.2 Page 10 Staff questioned were aware of the adult abuse procedures, complaints procedure and whistle blowing policy. One resident case tracked said, “I feel very safe here. I would complain to the manager if I had a complaint”. Residents were able to voice their concerns and were protected from abuse. Staff survey forms showed staff felt supported. Staff questioned during the inspection said, “Some days there is a good team and at times at not so good. We get supervision” and “I like working here. There is a good team. We get supervision from the manager.” In general staff felt supported. Robust recruitment procedures protected residents from possible abuse. Over 90 of staff had obtained NVQ2 or higher to provide a well trained staff team to residents. Health and safety policies, procedures, the maintenance of equipment and staff training protected the health and welfare of residents and staff. What has improved since the last inspection? What they could do better: Plans of care must clearly show the action staff have to take to meet residents needs. Plans of care must show evidence that following monthly review any changes are recorded for staff to follow. Plans of care must show that where a risk has been identified action is taken and recorded to ensure all staff are aware of each residents needs. The doors to resident’s bedrooms must be lockable to protect the privacy and dignity of residents. Hot water outlets supplied to residents must not pose a threat to the health and welfare of residents. A suitable device should be fitted or maintained to protect residents. The Spinney DS0000039828.V360311.R02.S.doc Version 5.2 Page 11 Activities should be provided which are suitable for residents to live a stimulating and fulfilled life. Outdoor lighting should be provided in areas staff and visitors use to prevent accidents. Sufficient and suitable outdoor space should be provided for resident’s enjoyment. Each resident should have a lockable space to protect their money and valuables. The quality assurance surveys sent by the care service should include families and stakeholders to ensure their views can be acted upon. 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 summary of this inspection report can be made available in other formats on request. The Spinney DS0000039828.V360311.R02.S.doc Version 5.2 Page 12 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 DS0000039828.V360311.R02.S.doc Version 5.2 Page 13 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. JUDGEMENT – we looked at outcomes for the following standard(s): OP1, OP2 and OP3 The quality outcome for this standard group was good. This judgement has been made using available evidence including a visit to this service. Residents were assessed to ensure their needs could be met at the home. EVIDENCE: The Statement of Purpose and service user guide had been updated. Each resident retained a copy. Residents or their family members had been issued with a contract. Residents and their families were supplied with sufficient information to make an informed choice to enter the care home. Three residents were assessed during the case tracking process. A qualified person from the home had undertaken an assessment of each person. Social services or the local Primary Care had also undertaken assessments to determine if social or nursing care was required. The assessment of residents gave staff the knowledge to develop a plan of care and meet the needs of each individual. The Spinney DS0000039828.V360311.R02.S.doc Version 5.2 Page 14 The Spinney DS0000039828.V360311.R02.S.doc Version 5.2 Page 15 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. JUDGEMENT – we looked at outcomes for the following standard(s): OP7, OP8, OP9 and OP10 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Plans of care did not fully address all the needs of residents. The health care needs of residents were not always met. Residents were treated with respect and dignity to ensure they were comfortable with the personal care they received. Policies, procedures and staff training ensured medication was administered safely. EVIDENCE: Three residents were involved in the case tracking process. This involved looking at the plans of care and talking to staff and residents about the care each person required. Staff were accurate in describing residents care. Residents were satisfied the care delivered was what they required and had agreed to. This was recorded and reviewed in the plans of care. One plan of care contained some good information for staff to follow for the most part although areas around pressure area care should be more specific and on assessment a possibility of choking had been identified. A robust plan must be developed for staff to follow. One plan of care did not have any reference to a resident’s pressure area care although a sore had developed and advice had The Spinney DS0000039828.V360311.R02.S.doc Version 5.2 Page 16 not been sought. Whilst the care and equipment provided met the resident’s needs this must be recorded in the plan of care. The final plan had not been updated for mobility needs. Plans of care had been reviewed on a monthly basis and new problems identified but not updated in the plans of care. Plans of care showed evidence residents or their families had been involved in care planning. In general plans of care contained a lot of detail but some specific areas (as demonstrated in the requirements made) would ensure a residents needs are fully met. Plans of care examined during the case tracking process demonstrated residents had access to health care specialists such as a GP, District Nurses, Dieticians, Chirpodists and Opticians and hospitals to see various consultants. Health care assessments for falls, tissue viability and nutrition had been undertaken and reviewed although any problems had not always been recorded in the plans of care. Survey forms showed evidence residents received medical assistance. The health care needs of residents were met although better paperwork would demonstrate sound practice. Staff were observed to deliver personal care in private. Residents case tracked said staff were careful to maintain their dignity. Survey forms contained evidence residents thought personal care and staff were given in a professional manner. Personal care was given in a satisfactory way to residents. There were policies and procedures for staff to follow for the administration of medication. There was a controlled drug cupboard and register. Drugs were securely stored. The medication administration chart was examined and contained no errors. There was a policy for the disposal of medication. Records were maintained of medication entering and leaving the home. There was a British National Formulary and a copy of the Royal Pharmaceutical Societies guidelines. Trained staff administered medication. Medication policies, procedures and staff training helped protect residents from possible errors. The Spinney DS0000039828.V360311.R02.S.doc Version 5.2 Page 17 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. JUDGEMENT – we looked at outcomes for the following standard(s): OP12, OP13, OP14 and OP15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Leisure activities did not always meet the expectations of residents or their families. Visiting was promoted and unrestricted to enable residents to meet their families and friends. The food served at the home met residents nutritional needs. EVIDENCE: Leisure activities were provided at the care home in a planned manner. Evidence taken from survey forms indicated that residents and relatives in particular did not think the activities were suitable or sufficiently stimulating for residents to lead a fulfilling life. The registered manager said two staff were now designated as activities co-ordinators. On the day of the inspection some residents were joining in a singing session. There were planned special events such as outings. Activities co-ordinators should gain the views of residents and their families to determine what would best provide suitable activities. Three resident’s plans of care were examined during the case tracking process and personal choice was well recorded for food and drink, personal care and daily routine. Residents case tracked were satisfied with the choices they were offered. Residents were offered choices to help retain some independence. The Spinney DS0000039828.V360311.R02.S.doc Version 5.2 Page 18 Residents case tracked received visitors on a regular basis. Survey forms showed evidence staff were communicative with families and residents. Visiting was encouraged to enable residents to socialise. There was a choice of meals. Residents were observed to be fed in an individual and discreet manner. The cook carried out necessary environmental health checks such as a record of food taken and fridge temperatures. Mealtimes are relaxed and unhurried. Each resident had a nutritional assessment and action taken to assist residents with reducing or gaining weight. Resident’s case tracked said food was satisfactory and met their tastes. Other residents spoken to held mixed views with three residents saying food was good and two said there was not enough choice. Survey forms showed evidence food was good. Evidence showed in general the food served was satisfactory to the majority or residents. The Spinney DS0000039828.V360311.R02.S.doc Version 5.2 Page 19 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. JUDGEMENT – we looked at outcomes for the following standard(s): OP16 and OP18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents were aware of their right to complain and confident to approach management with any concerns. Residents were protected from possible abuse. EVIDENCE: There had been no complaints to the Commission for Social Care Inspection since the last key inspection of 06/06/07. The registered manager said she had dealt with several minor complaints made to the care service. All complaints had been finalised within 28 days. There were polices and procedures for complaints which met current standards. A copy of the complaints procedure was retained in resident’s rooms. Both staff interviewed and residents case tracked were aware of the complaints procedure. The open management system encouraged residents to come forward with any concerns. The home had a copy of the ‘No Secrets’ document. There were policies and procedures for the protection of adults. The home followed the Lancashire Social services procedures to follow a local initiative. Policies were available to protect residents from financial abuse. Two staff members questioned were aware of the safeguarding procedures. Resident’s case tracked said they felt safe. The registered manager followed the procedures to protect the health and welfare of residents. The Spinney DS0000039828.V360311.R02.S.doc Version 5.2 Page 20 The Spinney DS0000039828.V360311.R02.S.doc Version 5.2 Page 21 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. JUDGEMENT – we looked at outcomes for the following standard(s): OP19 – OP26 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home was well decorated, equipped and furnished to meet residents needs. Infection control policies and procedures protected the health and safety of residents and staff. Not all areas of the home met current privacy and health and safety guidelines. EVIDENCE: The grounds residents can access are currently being upgraded and the registered manager said suitable furniture would be purchased when the work had been completed. More patio area is to be provided and raised flowerbeds for residents to use. Local residents wished to be involved with the project and provide some help. Several survey forms mentioned the garden as an area for improvement. When the work has been completed the garden should provide leisure activities and enjoyment for residents. On the day of the inspection a tour of the building was conducted. All communal areas and seven bedrooms were visited. The home was warm, The Spinney DS0000039828.V360311.R02.S.doc Version 5.2 Page 22 clean, did not have any offensive odours and the areas visited were well decorated. Toilets were accessible and contained aids for residents with disabilities. Suitable equipment for assisted bathing was provided. Toilets were provided close to communal and private space. There were grab rails and a passenger lift for residents to access all areas of the home. There were no wheelchairs observed to be stored in a manner to cause accidents. The call bell system was observed to be working. Bedrooms contained good levels of equipment and some exceeded spatial requirements. All rooms visited were carpeted. Rooms were heated and lighting was sufficient to meet resident’s needs. Windows on the upper floor had restrictors fitted. No bedroom doors were could be locked and the majority of rooms did not have a lockable storage space. The double rooms contained only one resident. The water temperature taken in bedrooms was found to be over 65 degrees Centigrade in some rooms. All bathrooms were within normal limits. Emergency lighting was provided and being maintained on the day of the inspection. Rooms were centrally heated and the radiators did not pose a threat to the health and welfare of residents. The laundry was well away from any food preparation areas and had sufficient equipment to meet the needs of residents. Walls and floors were easily cleanable. There were no locks on sluices to stop residents from entering. Staff had been trained in infection control issues and had access to policies and procedures to follow. The Spinney DS0000039828.V360311.R02.S.doc Version 5.2 Page 23 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. JUDGEMENT – we looked at outcomes for the following standard(s): OP27, OP28, OP29 and OP30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Resident’s needs were met by the numbers and skill mix of a well-trained staff group. The recruitment procedures were robust and safeguarded residents from possible abuse EVIDENCE: Two staff files examined during the inspection contained documents to prove the home had recruited staff in a responsible manner. References had been obtained. There was a copy of the POVA and CRB check. Other documentation such as an application form, interview form, terms and conditions of employment, job description and record of induction was contained within the files. Copies had been retained of training undertaken. Staff had received a copy of the codes of conduct. Supervision was ongoing Two members of staff confirmed the training had been undertaken. Currently there are 90 of staff who have attained NVQ qualifications. There was a well-trained staff team to care for the residents needs. The Spinney DS0000039828.V360311.R02.S.doc Version 5.2 Page 24 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. JUDGEMENT – we looked at outcomes for the following standard(s): OP31, OP33, OP35 and OP38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Quality assurance systems need to be further developed to take into account the views of family members and stakeholders. Resident’s financial interests were safeguarded. The health, safety and welfare of residents and staff was promoted and protected. EVIDENCE: The Registered Manager had was suitably qualified and experienced to manage the care home and was registered with the Commission for Social Care Inspection. She had updated her knowledge by attending safeguarding, food hygiene and fire marshal training. The financial administrator said, “We do not look after anybodies finances”. The Spinney DS0000039828.V360311.R02.S.doc Version 5.2 Page 25 Pocket money is recorded on an individual record. Dates and the reason for monies taken out recorded. We write to family members if money is needed. We get receipts for everything we buy. Residents ask a member of care staff for the money and we sign it out”. The system was observed and was safe for residents. There were health and safety policies and procedures for staff to follow. Staff had attended mandatory training in health and safety issues such as moving and handling, food hygiene, first aid, fire awareness and safeguarding. The registered manager was aware of health and safety legislation and procedures. Accidents were recorded appropriately. Gas and electrical installations and equipment had been serviced and the certification was provided. Health and safety policies, procedures and staff training helped protect the welfare of residents and staff. The Spinney DS0000039828.V360311.R02.S.doc Version 5.2 Page 26 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 3 3 3 X X X HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 3 3 3 3 2 2 3 STAFFING Standard No Score 27 3 28 4 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 2 X 3 X X 3 The Spinney DS0000039828.V360311.R02.S.doc Version 5.2 Page 27 Are there any outstanding requirements from the last inspection? Not specifically although similar. 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 OP7 Regulation 15 (1) Requirement The registered manager must ensure a written plan of care is developed, which details how a residents needs are to be met. This includes specific action staff should take for an assessed need. The registered manager must ensure resident’s plans of care are kept under review. As problems develop any new needs must be assessed and the action taken added to the plan of care. The registered manager must ensure the health care needs of a resident are met. Where tissue viability or choking is identified as a risk a full assessment must be undertaken and advice taken from relevant professionals. The registered person must ensure the home is conducted in a manner, which protects the privacy and dignity of residents. A suitable lock must be fitted on bedroom doors. The registered person must promote and make proper provision for the health and DS0000039828.V360311.R02.S.doc Timescale for action 31/07/08 2. OP7 15 (2)(b) 31/07/08 3. OP8 13(2)(b) 30/06/08 4. OP24 12(4)(a) 30/12/08 5. OP25 12(1)(a) 30/09/08 The Spinney Version 5.2 Page 28 welfare of residents. The hot water outlets must not be delivered at scalding temperatures and sluices should have suitable locking devices fitted. 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 OP12 Good Practice Recommendations The registered manager and activities co-ordinators should gain the views of residents and their families of activities they feel would provide a more fulfilling and stimulating lifestyle. The registered person should ensure outside lighting is provided to protect the welfare of staff and visitors. The registered person should ensure the grounds are accessible, safe, tidy and attractive for residents. The registered person should provide a suitable lockable space in each persons bedroom The registered person must ensure a system is established for reviewing the quality of care and services provided at the home. This should include gaining the views of family members and stakeholders. When completed the results should be summarised and provided to interested parties. 2. 3. 4. 5. OP19 OP19 OP24 OP33 The Spinney DS0000039828.V360311.R02.S.doc Version 5.2 Page 29 Commission for Social Care Inspection Lancashire Area Office Unit 1 Tustin Court Portway Preston PR2 2YQ National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 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 DS0000039828.V360311.R02.S.doc Version 5.2 Page 30 - 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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