Inspection on 24/11/05 for The Spinney

This inspection was carried out on 24th November 2005.

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

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

Other inspections for this house

The Spinney 21/05/08

The Spinney 06/06/07

The Spinney 30/06/06

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 09/07/2008.

CARE HOMES FOR OLDER PEOPLE The Spinney 16 College Road Upholland Wigan Lancashire WN8 0PY Lead Inspector Anne Taylor Unannounced Inspection 24th November 2005 09:30 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 DS0000039828.V257906.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 DS0000039828.V257906.R01.S.doc Version 5.0 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 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.V257906.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 4. 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). The service should, at all times, employ a suitably qualified and experienced manager who is registered with the Commission for Social Care Inspection. Staffing must be provided to meet the dependency needs of the service users at all times and will comply with any guidelines which may be issued through the Commission for Social Care Inspection regarding staffing levels in care homes. 4th May 2005 5. Date of last inspection Brief Description of the Service: The Spinney is a thirty-five bedded care home providing nursing and personal care. A trained nurse is on duty at all times. At the time of inspection there were twenty-nine residents living at the home. Twenty were receiving nursing care and nine receiving personal care. Bond Care (Spinney) Ltd, a private company own The Spinney nursing home. 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. Lounges are provided on the ground and first floor. The ground floor lounge is large and spacious. The smaller lounge is used less often but provides a quiet area for service users. The small dining room is on the ground floor. A number of aids and equipment are available to assist staff in meeting the needs of service users. Garden space has been reduced due to the development of land to the front of the house. The Spinney DS0000039828.V257906.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection that took place over one day in November 2005. A regulation manager accompanied the inspector. Following a change of ownership and changes of manager the Spinney experienced a period of instability and there was a decline in standards. Improvements have been made since the recent appointment of a manager; however, a lot of work is still needed before a number of the National Minimum Standards can be considered met. The inspection involved discussion with the people who lived and worked at the home, examination of records, policies and procedures and a tour of the premises. As part of the inspection process the inspector used “case tracking” as a means of assessing some of the National Minimum Standards. This process allows the inspector to focus on a small group of people living at the home. All records relating to these people are inspected along with the rooms they occupy in the home. They are invited to discuss their experience of the home with the inspector, however this is not to the exclusion of other people living at the home. What the service does well: The service user guide was well presented and gave prospective residents enough information about the facilities and services available to enable them to make an informed decision about coming to live at the home. The Spinney provided a homely environment for the people that live there and visitors made to feel welcome. Care was provided in surroundings and by staff that made service users feel safe and cared for. Leadership and direction was provided by a new manager so staff were clear about what was expected of them and encouraged to carry out their duties professionally. The Spinney DS0000039828.V257906.R01.S.doc Version 5.0 Page 6 What has improved since the last inspection? What they could do better: The standard of record keeping needs to be better to help the care process and promote the welfare of residents. Prospective and current residents need to be involved in the care planning and assessment processes so that they can be sure their needs and wants have been made clear. More importance should be given to health and safety matters so that people living and working in the home can do so safely. Immediate requirement notices were issued in respect of intermittent problems with the lift and the unsatisfactory electrical installation certificate. The home should continue reviewing and developing the service provided to ensure that the improvements made are maintained and the service continues to develop and improve. There had been no improvements to the environmental standards and some bedrooms are still in need of redecoration and refurbishment. The Spinney DS0000039828.V257906.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 DS0000039828.V257906.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 DS0000039828.V257906.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): 1, 3 The statement of purpose was complex and difficult to read, however the home provided sufficient information about the service provided to enable potential residents to make an informed decision about coming to live at the home. The pre admission procedure was not thorough enough to ensure that prospective residents were involved in the process and their individual wants and needs properly assessed. EVIDENCE: The statement of purpose was complex, lengthy and not in a format suitable for prospective residents. It was difficult to determine the facilities and services offered and there was a great deal of cross-referencing to the home’s polices and procedures. The service user guide was much easier to read and provided enough information for prospective residents about the home and what service they provided. The Spinney DS0000039828.V257906.R01.S.doc Version 5.0 Page 10 A visitor present at the time of inspection said, “ I got a leaflet with information about the home so we knew what they provided”. Care records seen showed that pre admission assessments carried out by the home did not involve prospective residents and or their relatives. This meant that residents could not be sure what sort of care they should expect to receive when they came to live at the home or that all their individual needs could be met by the home. Pre admission assessments generally lacked detail and varied in content so that needs were not always clearly identified. There had been no new admissions to the home since the new manager started. However, the manager said that she would carry out pre admission assessments or delegate the task to another trained nurse to make sure someone with the right skills and experience did them. The Spinney DS0000039828.V257906.R01.S.doc Version 5.0 Page 11 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, The care planning process was not thorough enough to ensure the needs of residents were properly identified and appropriately documented. The provision of basic nursing and personal care had improved and health needs given more attention so that the overall standard of care was better. EVIDENCE: Records showed that there was no consistency in the standard of care planning and the files were generally disorganised with some unnecessary duplication of assessments. Care plans and risk assessments had not always been reviewed and evaluated so it was difficult to monitor any progress that might have been made. Care records seen showed that each resident had a plan of care but the plan had not always been agreed with him or her or a relative. This meant that residents or their relatives could not be sure what care they should expect to receive whilst living at the home. It also meant that they might not have been The Spinney DS0000039828.V257906.R01.S.doc Version 5.0 Page 12 given the opportunity to discuss any concerns and identify any specific needs or preferences. Although staff were able to discuss individual needs and how the home met those needs this was not reflected in the care records. Care plans were sometimes too brief, did not cover all assessed needs, particularly health needs and a plan for residents at risk of falling. Written instructions for staff were sometimes not specific enough to help the care process and promote the welfare of residents. Records showed that people living at the home generally had access to health care services according to individual need so that specialist advice and treatment could be provided. Residents were settled, appropriately dressed and seemed well cared for. Staff were able to discuss the individual needs of the people they cared for and how they organised their workload to ensure those needs were met. They made reference to way they used the care plans and attended regular handovers when there was a change of shift, so that they knew about any changes to the care residents needed. A visitor said that she was generally satisfied with the care and felt that the home was able to meet her mother’s needs. At the last inspection a requirement was made about establishing a system for reviewing and improving the quality of care provided. The new manager had developed a system to do this but had not been in post long enough to implement it. The system should be implemented as soon as possible to make sure the progress made continues. Standard 9 was not fully assessed, however a pharmacy inspection was carried out on the 29th September 2005 and some requirements and recommendations were made. Some progress had been made in trying to address them but a number remain outstanding. They have, therefore been included in the requirements and recommendations made in this report and some of the timescales for action extended. Standard 10 was not fully assessed, however the bad practice and a lack of consideration for the needs of the residents observed at the last inspection was no longer an issue and staff were seen to be upholding residents’ rights to privacy dignity and respect. The Spinney DS0000039828.V257906.R01.S.doc Version 5.0 Page 13 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, 15 The range of social activities available met the expectations of people living at the home. Daily routines were flexible so that residents were able to make choices and exercise some control over their daily lives. The importance of providing a well balanced diet was recognised by the home so that clients were able to eat healthily and given some choice about what they ate. EVIDENCE: Records showed that attention was paid to helping residents to take part in activities that were already established or developed in the home so that the lifestyle experienced by residents met their expectations and preferences as much as possible. Since the last inspection the home had improved the range of activities and the proposed appointment of a designated activities organiser should help to make sure that the improvement is maintained and developed according to the wishes of residents. Residents spoken to were generally satisfied with the activities available. The Spinney DS0000039828.V257906.R01.S.doc Version 5.0 Page 14 Discussion with the manager showed that the home was trying to improve the way in which information is given to residents about planned activities and forthcoming events. Some further work is needed to make sure residents are fully consulted about what they want and information is available to them in a format suitable to their abilities. Residents spoken to said that they were able to exercise choice about what time they got up and went to bed and what clothes they wore, giving them some control over their lifestyle. For residents unable to make such choices, personal preferences had been identified by their relatives and recorded in care plans. When asked how they helped residents to exercise choice staff said, “we ask if they want to get up and what they want to wear every day”. During conversations with residents and staff it was evident that residents were able to make choices about the way they lived within the home and in particular within the privacy of their own room. Rooms had been personalised by residents bringing in some of their own possessions so that they had familiar and treasured items around them. A record of all items brought into the home by residents should be kept so that staff know which items belong to each resident. Residents not able to exercise full control over their financial affairs were mainly helped by a family member. The registered manager knew how and when to access an advocate to act on behalf of a resident without a representative to ensure that any decisions made were in the best interests of that resident. There had been a great improvement in the way in which dietary needs were managed and instructions for staff about specialist diets and individual preferences were kept in the dining room so staff could refer to it at each mealtime. The manager updated the information frequently so that staff could be made aware of any changes. The lunchtime meal was relaxed and unhurried with staff available to assist if needed. Some residents had chosen to eat in the dining room, others in their bedroom. One resident said, “I have breakfast and tea in my room and lunch in the dining room”. Residents spoken to were generally satisfied with the range and quantity of food available to them. When asked one resident said, “we do get a choice, at tea time every day, they come round and ask what you want, I suppose if you didn’t like it they would get you something else”.” Records showed that there wasn’t a choice of menu at lunchtime and the home should consider offering one so that residents are able to choose something they like without first having to refuse the meal offered and then have to wait for an alternative to be prepared. The Spinney DS0000039828.V257906.R01.S.doc Version 5.0 Page 15 At lunchtime a member of staff was taking food in the lift to residents who had either chosen to stay in their room or were unable to come to the dining room. The plates were not covered so the food was not protected and also might go cold before the residents could eat it. The home should make arrangements to ensure food is transported safely and is still hot when it reaches residents. The Spinney DS0000039828.V257906.R01.S.doc Version 5.0 Page 16 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 The home had an accessible complaints procedure that informed people of how and who to complain to. Management processes in relation to abuse were thorough enough to ensure the protection of any vulnerable residents. EVIDENCE: A complaints procedure was in place. The procedure was included in the service user guide and on display in reception so residents and visitors had access to information about how and who to complain to. Residents and visitors spoken to knew who to contact if they had cause for concern. Staff were able to discuss how they would respond if a resident complained to them and realised how important it was to make sure residents felt able to raise concerns and be sure they were listened to. The home had received two complaints, both of which were upheld. The manager must make sure complaints are fully documented and a record kept of the nature of the complaint, any investigation, the outcome and any action taken. An adult abuse policy was in place and included a whistle bowing policy. A copy of the “no secrets in Lancashire” document was in the policy manual. The The Spinney DS0000039828.V257906.R01.S.doc Version 5.0 Page 17 procedure should include contact details for relevant authorities such as social services, CSCI and the Police. The manager was aware of her responsibilities in relation to protecting people living at the home and making sure staff were appropriately trained to recognise and act upon any signs of possible abuse. Since the last inspection staff had received training about the subject of abuse and the protection of vulnerable adults. Staff confirmed that they had received recent training about abuse so that they were aware of the need to protect the people they care for. The Spinney DS0000039828.V257906.R01.S.doc Version 5.0 Page 18 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): 26 The home was clean, tidy and free from offensive odours and residents lived in pleasant and hygienic surroundings. EVIDENCE: The amount of available outdoor space has reduced since the development of flats on what used to be the lawn at the front of the home. Some work is still needed to ensure the outdoor areas are safe and accessible to residents. The paved pathway around the house that forms part of a fire escape route, ends at the foot of a dirt slope, which would be very difficult for wheelchair users or the less mobile to negotiate. It presents significant health and safety risk and action must be taken to rectify this so that external areas are safe for residents to use. Policies and procedures were in place that identified infection control measures in place at the home. Staff were able to discuss infection control procedures and how implementing them correctly helped to minimise the risk of cross The Spinney DS0000039828.V257906.R01.S.doc Version 5.0 Page 19 infection. The home was clean and free from offensive odours. One resident said, “ My room is always clean and tidy”. The home still needs to make sure that all the facilities and services provided comply with the Water Supply (Water Fittings) Regulations 1999 and that all pipe work in bathrooms and toilets is appropriately covered so that residents continue to live in a safe environment. The Spinney DS0000039828.V257906.R01.S.doc Version 5.0 Page 20 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29,30 The skill mix of and the number of staff on duty was sufficient to ensure the needs of residents were met. Training for new and existing staff had improved and this helped make sure that staff were competent do their jobs and able to practice safely. The recruitment process was not thorough enough to ensure the continued protection of residents. EVIDENCE: Staff rotas showed the number and skill mix of staff on duty at any given time and the capacity in which they were employed. Staff rotas indicated that minimum staffing levels were being maintained. Relatives spoken to at the time of the inspection indicated that the home had enough staff on duty to ensure the needs of residents could be met. Since the last inspection more attention had been paid to training and developing staff. The approach to training was more structured and the record keeping more organised. Discussion with the manager and staff showed that each member of staff had an individual training and development record. Each had been asked to complete a form that identified training already done and any deficits so that any training needs were clear and a training programme could be developed. The manager should ensure that the information obtained The Spinney DS0000039828.V257906.R01.S.doc Version 5.0 Page 21 is collated and properly analysed so that a detailed training plan can be developed. Some mandatory training had been completed since the last inspection so that staff were able to work safely and had some underpinning knowledge about the work they did. National vocational training (NVQ) was available to care staff and a small number of care staff had completed level two or three. The home should make sure that the minimum of fifty per cent of care staff need to achieve NVQ at level two or above in order to meet the national minimum standard. The new manager had not recruited any new staff since she had been in post. A recruitment checklist had been developed to assist the recruitment process and records showed that in general the recruitment procedure had improved since the last inspection. However, in order to protect residents all necessary checks need to be carried out before an employee starts work. Also staff members should each have a job description and a statement of terms and conditions of employment. Discussion with the manager showed that she was aware of the need to appoint suitable staff that would be able to provide good care and protect people living at the home. Staff recently employed at the home were able to discuss their interview and confirmed that they had been asked about previous experience and what training they had done that was relevant to the job of care assistant. The Spinney DS0000039828.V257906.R01.S.doc Version 5.0 Page 22 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): 35,38 The arrangements for handling money on behalf of residents were thorough enough to ensure their financial interests were safeguarded. Some improvements in relation to health and safety matters had been made however, the home was not able to show that the health, safety and welfare of residents and staff was consistently protected. EVIDENCE: Standard 31 could not be assessed, as the new manager has not yet been registered with CSCI. She intends to submit an application in the very near future. Standard 33 was not fully assessed at this inspection. However, the requirement made at the last inspection was discussed with the manager and the requirement remains outstanding. It has therefore been included in the requirements made in this report. The Spinney DS0000039828.V257906.R01.S.doc Version 5.0 Page 23 The home handled few personal allowances for residents. Any personal allowances and money brought in by relatives for residents was stored in a safe that only two members of staff had access to. This meant that residents’ money was appropriately safe guarded. Records were kept of any money handed in for safekeeping and receipts kept for any purchases made on behalf of residents so a clear audit trail of income and expenditure was available if needed. When asked about access to their money residents said, “my family look after my money” and “I have a bit of money, I think in the safe here at the home, my family look after everything else”. The new manager had developed a more structured approach to managing health and safety matters and record keeping had improved. However, not all certificates to confirm that equipment and systems used by the home were up to date. Immediate requirement notices were issued regarding intermittent problems with the lift and the unsatisfactory electrical installation certificate. The registered provider must take immediate action to address the issues raised. In addition a risk assessment to show how the home manages the risk of legionella should be in place and the manager should ensure that all recommendations made by the environmental health department are acted upon. Mandatory training for staff had also improved and a number of staff had completed training in moving and handling, infection control and fire safety. Some further training courses had been arranged to make sure all staff received the training needed to help them carry out their duties safely. The Spinney DS0000039828.V257906.R01.S.doc Version 5.0 Page 24 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 2 X 2 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 x 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 2 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 2 X X X X X X X 2 STAFFING Standard No Score 27 3 28 2 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X X 1 X 3 X X 2 The Spinney DS0000039828.V257906.R01.S.doc Version 5.0 Page 25 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 OP1 Regulation 4 Schedule 1 Requirement An up to date statement of purpose must be produced and made available to current and prospective residents. The format must be suitable to the needs and capactities of residents. (Timescale of 31st July 2005) not met. A full preadmission assessment must be undertaken prior to any resident coming to live at the home. Residents or a representative must be involved in the assessement. Residents must receive written confirmation that the home is able to meet their assessed needs. (Timescale of 31st July 2005 not met). A written plan of care that 31/01/06 clearly identifies needs and how the home will meet those needs must be in place for all residents. Care plans must be reviewed regularly. (Timescale of 30th June not met). DS0000039828.V257906.R01.S.doc Version 5.0 Page 26 Timescale for action 28/02/06 2 OP3 14(1) (c)(d) 31/01/06 3 OP7 15(1) The Spinney 4 OP8 24(1) (a) (b) 5 OP9 13(2) The system for reviewing and improving the quality of care provided must be implemented quickly to ensure good practice is maintained and progress continued. The provider must ensure that the medication policies and procedures are reviewed and implemented. The provider must ensure that homely remedies are only administered in accordance with the homes policies and procedures, from a dedicated supply. (Timescale extended form pharmacy inspection). The provider must ensure that all medication records including those for the administration and assessment of selfadministration of medication are complete, clear, accurate and up-to-date. (Timescale extended from previous inspection and more recent pharmacy inspection) Arrangements must be made to ensure food is transported safely and is hot when it reaches residents. External grounds that are suitable for and safe for use by residents must be provided and maintained. The pathway around the home must be made safe and advice taken about how to cover the dirt slope. Pipe work and radiators throughout the home must be guarded or have guaranteed low surface temperatures. (Timescale of 31st August 2005 not met). The registered person must DS0000039828.V257906.R01.S.doc 31/01/06 05/12/05 6 OP9 13(2) 31/12/05 7 OP9 13(2) 31/12/05 8 OP15 13(c) 31/12/05 9 OP19 23(2)(0) 31/01/06 10 OP25 13(3)(4) 28/02/06 11 OP29 19 28/02/06 Page 27 The Spinney Version 5.0 Schedule 2 12 OP33 24(1)(3) 13 OP38 23 13(4) 14 OP38 13(4)(5) 23 15 OP38 13(3) ensure that all necessary checks are obtained for staff prior to the start of employment. A system to reviw the quality of service provided that includes consultation with residents and their representatives must be established.(Timescale of 31/08/05 not met). The registered person must submit written confirmation that the elecrical installation system is of a satisctory standard and the work highlighted on the last certificate has been completed. (Immediate requirement notice issued). The registered person is required to provide to the Commission a report of an inspection of the lift by an engineer, which clearly identifies if the lift is safe to be used for the transporattion of passengers between floors. (Immediate requirement notice issued). A risk assessment must be carried out that shows how the home is managing the control of legionella. 31/03/06 06/12/05 28/11/05 31/12/05 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 3 Refer to Standard OP9 OP9 Good Practice Recommendations Nurse delegation to competent staff is evidenced, and their responsibilities are recorded. The procedures for the ordering and stock control of medication should be reviewed. The Spinney DS0000039828.V257906.R01.S.doc Version 5.0 Page 28 4 5 6 7 8 9 10 11 12 13 OP12 OP14 OP15 OP16 OP18 OP26 OP28 OP30 OP38 OP38 The home should continue developing the range of activities provided and make sure residents are fully consulted about what they want. A written record should be kept of all items brought into the home by residents. The home should consider having a choice of menu at lunchtime. Complaint records should include, details of the complaint, the investigation, outcome and any action taken. The homes adult abuse procedure should include contact details for relevant authorities. The home should make sure that facilities and services provided comply with the Water Supply (Water Fittings) Regulations 1999. Fifty per cent of care staff should be trained to NVQ level 2 or above. Information obtained in relation to training needs should be collated, analysed and used to produce a detailed training plan. The manager should ensure that planned training in relation to safe working practices is completed. The home should ensure that all recommendations made by the environmental health officer are addressed. The Spinney DS0000039828.V257906.R01.S.doc Version 5.0 Page 29 Commission for Social Care Inspection Chorley Local Office Levens House Ackhurst Business Park Foxhole Road Chorley PR7 1NW 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. 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