Inspection on 29/05/07 for The Spinney

This inspection was carried out on 29th May 2007.

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. These are things the inspector asked to be changed, but found they had not done. The inspector also made 8 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

The Spinney 05/10/05

The Spinney 17/05/05

The Spinney 09/11/04

The Spinney 15/06/04

The Spinney 25/02/04

Similar services:

2 Perhaver Park

The Vicarage

7 Hyde Road

St George`s

5 Seafield Road

Credence House

Radfords

Trevaylor Manor

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

CARE HOME ADULTS 18-65 The Spinney The Spinney Tavistock Road Roborough Plymouth Devon PL6 7BD Lead Inspector Helen Tworkowski Unannounced Inspection 29th May 2007 8:30 The Spinney DS0000047871.V335011.R01.S.doc Version 5.2 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 DS0000047871.V335011.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. 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 DS0000047871.V335011.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service The Spinney Address 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) The Spinney Tavistock Road Roborough Plymouth Devon PL6 7BD 01752 707190 Quality Lifestyle Limited Mr Trevor Kendall Mr Shaun Drury Care Home 4 Category(ies) of Learning disability (4), Physical disability (4) registration, with number of places The Spinney DS0000047871.V335011.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 5th October 2005 Brief Description of the Service: The Spinney was registered as a care home in February 2004. The home offers care to four service users who have learning disabilities who may also have physical disabilities, and behaviour that challenges services. The home has two downstairs bedrooms that are adapted to meet the needs of physically disabled service users, and two upstairs bedrooms. The property is a detached modern house that has been refurbished to a high standard, and is set in a semi-rural situation near the village of Bickleigh that has shops, a post office and a bus route to Plymouth. The home has its own transport, and has a pleasant garden. There is 24 hour staffing including waking night staff. There is a Statement of Purpose and Service Users Guide, these are available in the office. The home charges between £2,300 and £2,600 per week, the fee does not include the cost of toiletries or clothes. The Spinney DS0000047871.V335011.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection included an unannounced site visit that took place 29th May 07 (8.35 am to 4.30pm) and on 30th May 07 (9.25 am to 1.40pm). During this site visit the Inspector individually with seven staff and one of the service users. The Inspector also spent time with the other three service users. The site visit included an inspection of various records including those relating to the service users, staff (recruitment and training), medication, and safety. The Inspector observed staff working with service users, and giving out medication. As part of this inspection the Inspector looked at the care of three of the Service Users in some detail. In addition to the site surveys were also sent to all care staff, eleven were returned. Four surveys were also sent to health care professionals, one was returned. Surveys were also sent to the four service users, none were returned. The Inspector spoke by telephone to three relatives of Service Users and with one Care Managers. The Registered Manager Shaun Drury completed a pre-inspection questionnaire, and provided additional information used in this inspection. Mr Drury, the Registered Manager, was on leave during the site visits to the Spinney, but when he returned to work the Inspector spoke with him by telephone. What the service does well: One Care Professional said that he held the spinney in high regard, and that they knew what they are doing. One relative commented that she was very happy with the Spinney and felt that her relation did have enough to do. She also said that there was lots of consultation. The Spinney provides a good standard of accommodation that is well suited to the people who live there. The accommodation is stylish, spacious and airy. Furniture and fittings are of a good robust standard. People moving to the Spinney are assessed and their needs are known to staff, before a move take place. Staff treat Service Users with respect and make the effort to communicate with them. Service Users are offered a good range of appropriate activities both in the home and in the community. Service Users are able to make choices, as far as they are able to about how they spend their time. Staff feel that there is an open culture and that where they have concerns that they are able to approach the manager. One member of staff said “The manager of the care home treats us all very well and I thing that you need when you work in care, its nice to kno3w you have all the support you need”. The Spinney DS0000047871.V335011.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? 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 summary of this inspection report can be made available in other formats on request. The Spinney DS0000047871.V335011.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection The Spinney DS0000047871.V335011.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1 and 2. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service Users can be confident that staff at the Spinney will know about their needs before they move. EVIDENCE: It was recommended at the last inspection made at the last inspection in October 2005 that the Service User Guide is produced in a format that accessible to individuals who live at the Spinney. The Service User Guide should provide information about what an individual can expect from living at the Spinney. No revised document was available. The only copy of the Service Users Guide/ Statement of Purpose that was available was out of date. It is important that such documents are up to date as they provide information not only to Service Users but also to people who purchase the service and to the Commission about what the Spinney will provide. One person has moved to the Spinney since the last inspection. Staff spoken with explained that they had been involved in getting to know the individual before the move. The Inspector was told that people who knew the individual had come to talk to staff team at the Spinney, about the individual and how they communicated. There was also information on file about the individual in reports prepared by care professionals. However the assessment work carried out by staff from the Spinney was not available for during the site visits to the The Spinney DS0000047871.V335011.R01.S.doc Version 5.2 Page 9 Spinney. Mr Drury confirmed that a record had been made of the assessment carried out by staff from the Spinney. The Spinney DS0000047871.V335011.R01.S.doc Version 5.2 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7,and 9 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Service Users generally receive the support they need and are able to make decisions, as far as they are able, regarding their daily lives. The systems for recording and therefore monitoring challenging behaviour are not robust which means that dealing with and changing these behaviours is more difficult. EVIDENCE: The Service User Plans for all of Service Users were looked at during this inspection. These documents are important, they should specify in detail what a person’s needs are and how they should be met. Each of the four files looked at included information on what the person’s needs were, there was guidance to staff on how to meet needs. The files also contained risk assessments, these identified how risks would be managed and minimized. Staff told the Inspector that the key worker reviewed these every 6 months, although this did not necessarily involve a meeting. One staff explained that The Spinney DS0000047871.V335011.R01.S.doc Version 5.2 Page 11 they had frequent meeting with the psychiatrist and family where the individual and their well being was discussed. The people who live at the Spinney can at times exhibit behaviour that challenges. It is important that staff should have specific guidance to deal with particular behaviours, and that these are monitored so that the effectiveness of particular approaches can be understood. The Service User Plans appeared to contain such relevant guidance. However when the Inspector asked staff if there were aware of any guidance on dealing with a particular behaviour that a Service User was displaying, the Inspector was told that there was no guidance. Staff said that they were advised to avoid situations where difficult behaviour was likely to occur. Staff related to the inspector two serious incidents, but there was no record of these incidents. The Inspector understood that the manager was not aware of these incidents. Where incidents had been recorded the information recorded was limited, lacking detail. One member of staff told the inspector of an incident where he/she had been pinned to the floor by a service user for 10 minutes, and was unable to breakaway. He/she had shouted for help but as the only other staff was in the garden he/she could not be heard. The Inspector discussed this situation with Mr Drury on his return from leave. He confirmed that he was unaware of these incidents. He said that he had already arranged for all staff in the unit to attend training in breakaway techniques, and this should be taking place in the near future. The Inspector looked through the incident reports that had been completed over the previous months. The inspector was told that the home manager Mr Drury did check through these reports, and some forms had been countersigned. However there appeared to be no evidence of any analysis of behaviours. Staff confirmed to the Inspector that there were regular meetings with medical professionals to monitor changes in behaviour. Feedback from one care professional was that he thought that the home dealt well with difficult behaviours and had made significant changes to the lives of Service Users, so that they were able to get their needs met with out having to exhibit difficult behaviours. The Inspector discussed with Mr Shaun Drury the Mental Capacity Act, and then need to implement the Act in relation to the people who live at the Spinney. The Inspector spoke with staff about each person’s daily routines and each individual had their own routines, some people like to get up early and to start the day, others prefer a later start. Staff explained to the Inspector how they had worked so that they respected the individual but set standards and reasonable expectations. For example- giving an individual drinks when requested, but also trying to space them out and to involve the person in making the drinks. The Spinney DS0000047871.V335011.R01.S.doc Version 5.2 Page 12 The Inspector spoke with one Service Users about times to get up and go to bed, and he/she explained that these were things that he/she chose. The Inspector also observed staff working with Service Users over the two days, and staff gave service users options as part of their daily life. The information in the pre-inspection questionnaire states that the home manager assists one person with their benefits. A requirement was made at the last inspection that money belonging to the individual should not be paid into bank accounts that are used for the running of the home. Staff were not able to explain what was currently happening. However Mr Drury has since confirmed that an account previously but no longer used by the company is now used for the sole purposes of managing this individual’s money. Mr Drury said that he would arrange for a record of transactions to be provided. This account is not ideal as the account is not in the name of the individual, and is a business account. Mr Drury said that they had discussed this matter with the bank however they were still awaiting a response. The Spinney DS0000047871.V335011.R01.S.doc Version 5.2 Page 13 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15, 16, 17. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People who use the service are able to make choices abut their life style, and are supported to engage in meaningful activities. EVIDENCE: All of the Service Users at the Spinney have a daily plan of activities. Each person is offered the opportunity to go out each day. The Inspector discussed with staff the sorts of activities that service users were offered. Staff explained that these were chosen on the basis of knowing what people liked to do, and what had been known to succeed in the past. There is a plan for the day and activities are clear identified with vehicles and staff allocated to ensure that they happen. On each of the days of the inspection Service Users went out and the plans for the day were generally followed, some activities did not happen. The daily notes however did not always contain information about what activities were planned and whether they happened and if they didn’t what was the reason. Very limited information was recorded about what Service Users did each day; the main focus of the recording was what the individual had eaten. The Spinney DS0000047871.V335011.R01.S.doc Version 5.2 Page 14 Staff had a good awareness of the needs. Staff said that for one person long walks were an important part of their daily lives, and the inclusion of these walks had helped the individual to sleep better at night. The Inspector noted throughout the inspection that staff always addressed Service Users with respect. Where an individual had difficulty with communication staff had developed the skills to be able to communicate and had learnt signs. Staff talked to Service Users, and for example when talking to some one in a wheelchair, they got down to their level, so they could speak eye to eye. The Inspector spoke with relatives about their views of the service. One relative commented that he/she was very satisfied with the service, they had lots of contact and there was good communication. The relative commented that he/she had really appreciated that support had been provided for the Service User to attend an important family anniversary. One individual explained to the Inspector that he/she had a bedroom door key, however this was a “star key” as there is no proper bedroom door lock. Consideration should be given to fitting appropriate door locks that can be used by Service Users if they so wish. The daily notes show that Service Users have a varied diet; there is plenty of fresh fruit available. Service Users appeared to enjoy the food that they were offered. Specific diets are well catered for at the Spinney. There were records of individual weights and where there had been significant changes, then there was also a plan of what was to happen- e.g. cutting out snacks between meals. The Spinney DS0000047871.V335011.R01.S.doc Version 5.2 Page 15 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19, 20. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The health and personal care that people receive is based on their individual needs. The principles of respect, dignity and privacy are put into practice. The systems for auditing medication are not being properly implemented. EVIDENCE: The Inspector spoke with staff about the care provided to individual service users. They were able to explain the help that individual’s required, for example in relation to getting up. They talked about the need to be flexible and the need to respond to individual preferences and differences. For example it was noted that one person was a “morning person” and another service user was not, and they were both treated accordingly. Staff were also aware of differences in mood, and that there were times when it was better to back off and leave individuals alone for a little while. All of the Service Users were well dressed in clothes that they looked comfortable and at ease in. One person had a jewellery rack at a low level so that the person could make his or her own selection of what to where, and did. The Spinney DS0000047871.V335011.R01.S.doc Version 5.2 Page 16 There were very good records of contact with GP and other health care professionals on file. One health care professional who responded to a survey confirmed that health care needs are always met by the service. Another professional commented that they were very satisfied with the standard of care. The medication system was looked at during this inspection. A monitored dose system is used. This is pre-packed by the pharmacist in a bubble pack. The Inspector observed staff administering medication and they did so with great care, each item of medication administered being checked by two people. There were systems for checking that no medication had gone missing. However in looking at these records errors had been made, and the monitoring was not effective. There were also systems in place for staff to record what was happening with prescriptions and receipt of medication. Again there were some errors in this system. The home keeps some “homely remedies”, and there was record of agreements about what should be used for each Service User. However on checking the medication cupboard there were additional some medication that was not on the list. The Inspector spoke to staff about training in relation to medication and was advised that the dispensing pharmacist had provided training, but also staff were “shadowed” until they were deemed competent. One Service User requires a medication that staff must receive specific training to be able to administer, and where there must be agreement from the medical person responsible that each staff member is competent. The Inspector was told that because of staff changes that only one or two of the staff were now able to give this medication, and this had been the case for some time. Staff also told the Inspector that training had now taken place, but the authorisation paperwork had not been received. The Spinney DS0000047871.V335011.R01.S.doc Version 5.2 Page 17 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People who use or who have contact with this service area bale to express their concerns, and have access to a complaints procedure. Service Users are protected from abuse and have their rights protected. EVIDENCE: The Commission has received no complaints regarding the Spinney since the last inspection. The Pre-Inspection questionnaire completed by the Registered Manager showed that the Spinney had received no complaints. The Inspector discussed with the staff in charge how they would deal with complaints whilst the manager was away, and they explained that they would follow the appropriate procedures that were documented. The Inspector spoke with two relatives about whether they would be able to raise concerns, and they felt that they would be able to speak to Mr Drury, although one person noted that this was always difficult to do when a relative lived in a home. Of the eleven staff responding to the staff survey nine said that they were aware of adult protection procedures. When the Inspector asked staff what they would do all said that they would talk to the home manager. When asked if there was anyone outside the service that they might contact if they were for some reason unable to talk to the manager, no one was able to name any outside agency where the matter could be referred. The Pre-Inspection Questionnaire shows that “Protection from Abuse” training is planned in the future. The Spinney DS0000047871.V335011.R01.S.doc Version 5.2 Page 18 All of the staff spoken with said that they felt confident in being able to approach the manager if they had any concerns, and had done so in the past. The Spinney DS0000047871.V335011.R01.S.doc Version 5.2 Page 19 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24 and 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. A high standard of spacious and comfortable accommodation is provided. EVIDENCE: The Spinney is a large detached house that is registered to provide accommodation for four people. All of the bedrooms have their own private bathrooms, and three are en-suite. All of the bedrooms are of a good size and proved plenty of space for individuals to use their rooms as bed sitting rooms. The communal areas are spacious and provide room for Service users to move about the home without coming into close contact with each other. This inspection included a tour of the whole building, apart from one bedroom. The standard of furnishing throughout the home is high. And it was clear that care and thought had gone into making sure that the house is well suited to those who live in it. Bedrooms very much reflected individual tastes and preferences. There were some signs of wear and tear in the house, some of the carpets were stained and paintwork had been damaged in some places. The Spinney DS0000047871.V335011.R01.S.doc Version 5.2 Page 20 However, the Inspector was told by staff that someone had recently taken over responsibility for minor repairs and these issues were being dealt with. On the days of the inspection the house was clean and tidy, though not institutional. The Inspector discussed with staff the degree of incontinence that they have to manage. It is recommended that alternative methods for the management of soiled linen be considered. This will help ensure that service users and staff are protected from the spread of infection. The Spinney DS0000047871.V335011.R01.S.doc Version 5.2 Page 21 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34, 35 and 36 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. Staff recruitment systems are poor; the induction and training subsequently received by staff is limited in some areas, this results in staff who may not have the skills to deal with the situations they experience. EVIDENCE: The recruitment records of five staff recently recruited to the home were inspected during this visit. Four had incomplete employment histories. It is important that there is a complete history and where there are gaps in employment then these should be accounted for. References had not always been taken, and where they had been taken they had not been taken from the most appropriate referee. At least two written references must be obtained, and verified. Where a person has worked with vulnerable people then the references then a reference must be sought from this referee. At least two of the individuals had recently worked in care homes, and references had not been sought from these employers. In addition one “reference” was a testimonial i.e. written to whom it may concern, also it was three years out of date. The Spinney DS0000047871.V335011.R01.S.doc Version 5.2 Page 22 None of the individuals had any record of “Protection of Vulnerable Adults” Check being made, whilst waiting for a Criminal Records Bureau check to be complete. This additional check permits cares staff to work in a care home, under supervision, whilst waiting for the CRB check. One person had a Criminal Records Bureau check on file that was from a previous employer. CRB checks are not transferable, and therefore this check was not valid. There were records of induction on file for three people; this related to the first day. The other two people appeared to have no induction. The induction form indicated that the induction should have continued on other days, however the form had not been completed. Staff spoken to about the induction said that they had spent time shadowing other staff so that they could learn about their role. There was no record of training that was available during this inspection, however the Inspector spoke with seven staff during the visit about training. Where staff had received training this was in relation to areas such as First Aid and Food Hygiene, there had been very little training in relation to working with people with challenging behaviour or autism. The people who live at the Spinney have significant and complex needs, and the training of the staff should reflect this. Staff expressed a need for additional training. The PreInspection Questionnaire shows that training is planned for the future, and the Inspector was told that a training officer had been appointed. Two people said that were about to start National Vocational Qualifications, and Mr Drury confirmed that 90 of staff were either working towards or had completed “NVQ 2”. Nine of the eleven staff responding to the survey said that they got enough support to do their job well; seven out of eleven said they got regular supervision. The inspector asked staff about whether they had recent formal supervision; some staff said that they had not received any for a year. It was also noted that whilst there had been a staff meeting in the last couple of weeks, prior to that there had not been one for a year. The rota and staff discussions confirmed that there were generally six staff on duty during the daytime; this decreases to two waking staff during the night. This level of staffing is to ensure that two service users are able to go out each accompanied by two care staff, during the day. The other two service users, at home are supported by two staff. The inspector was told that when staff were sick, or there was no cover, then these ratios could not be met. Some staff felt that on these occasions it was difficult to maintain the standard of service. The Spinney DS0000047871.V335011.R01.S.doc Version 5.2 Page 23 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. 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 are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37,39, 42 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The management and administration of this home is based on openness, however the systems that should be in place to monitor the quality and safety of the service are not being fully implemented. EVIDENCE: Mr Shaun Drury, who has been managing the home for a number of years, and who has a record of sound management, manages the Spinney. Mr Drury was on annual leave during the site visit to this home. There were however clear guidelines for management in the home, staff had been assigned responsibilities and staff were fulfilling these. Staff spoken with and who responded to the surveys commented that Mr Drury had an open door policy and they were able to go and speak with him at any time. The Spinney DS0000047871.V335011.R01.S.doc Version 5.2 Page 24 There was information about a quality assurance system; however there appeared to have been no survey of quality since March 05. A requirement was also made that at the last inspection that a representative of the company should conduct monthly-unannounced visits to the home and produce a report of these visits. The Commission has received no such reports and the records in the home that there has been no report of visits by the Registered Provider since January 2006. It was of concern that such checks of quality were not taking place as they are one of the ways that some of the issues identified in this report might have been dealt with earlier. The inspector looked at the risk assessments; these are documents that identify how risks will be managed. Most of the risk assessments available were those relating to individual service users. One area of risk assessment needs to be reviewed is in relation to the use of the trampoline. Service Users and staff on occasions do stand and bounce on the trampoline. The risk assessment lacked any reference in relation to nets that could prevent a fall to the ground, although this was a risk. The fire risk assessment did not mention any fire training, although staff are regularly trained. There were records of fire checks being regularly made, and of fire drills being conducted. The Inspector asked to see the fire procedure that would state what to do in the event of a fire, no fire procedure could be found. Staff on duty were able to explain what they would do, having been told what to do by the manager. There were checks made and recorded of cleaning of showerheads, however there was no Legionella risk assessment. Checks were also being made of fridge and freezer temperatures, to ensure that food was stored at the correct temperature. These checks were being carried out twice a day, and those for refrigerator showed that the fridge was operating at temperature of around minus ten degrees centigrade for much of the previous weeks. The Inspector discussed this with one of the care and checked the fridge. As the salad and other items were not frozen then it was clear that the fridge could not be operating at this temperature. It was of concern that no staff had stopped and considered what they were writing down and whether something was amiss. The Spinney DS0000047871.V335011.R01.S.doc Version 5.2 Page 25 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 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 2 3 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 4 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 1 35 2 36 2 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 X 2 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 X 3 X 1 X X 2 X The Spinney DS0000047871.V335011.R01.S.doc Version 5.2 Page 26 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 YA39 Regulation 26 Requirement Timescale for action 01/08/07 2. YA1 4&5 3. YA6 ; YA9 12 (1) (b) The Registered Provider must ensure that monthlyunannounced visits are made to the home, and reports produced of the conduct of the home, as specified in Regulation 26. Copies of these reports should be forwarded to the Commission. (This requirement was made at the inspection on 5th October 2005 to be met by 1st December 05). The Statement of Purpose and 01/09/07 Service User Guide must be brought up to date so that they contain information that is specified in the regulations and standards, so that Service Users can make an informed choice before a move. Copies of these documents must be supplied to the Commission. Service Users challenging 01/08/07 behaviour must be appropriately managed. This should include appropriate systems for recording, monitoring and analysing particular behaviours. Plans must be drawn up to guide staff on what to do under DS0000047871.V335011.R01.S.doc Version 5.2 The Spinney Page 27 4. YA34 19 5. 6. YA35 YA39 18 1(c)i 24 7. YA42 13 (4) (c) particular circumstances, and where necessary additional training must be provided. Staff must not be employed at the home unless a thorough recruitment process has been completed. This must include obtaining: a full employment history (with all gaps accounted for), two relevant, verified, written references including where appropriate from previous employment with vulnerable people, a “POVA” or POVA First Check, and that a CRB check has been initiated. All staff must receive structured induction and on going training that is appropriate to the work. Quality Assurance Systems that involve consulting with Service Users and where appropriate their representative must be set up, so that Service Users benefit from a service that is learning from what it is doing. Risk assessment must be reviewed so that where risk have been identified appropriate measures are taken to reduce them. For example in relation to Legionella or fire. Where checks are made, for example in relation to fridge temperature, then appropriate actions need to be taken as a result of these checks. 01/08/07 01/09/07 01/10/07 01/09/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations The Spinney DS0000047871.V335011.R01.S.doc Version 5.2 Page 28 1. 2. 3. 4. YA12 YA16 YA20 YA36 Daily recording should be in sufficient detail so that it can be used to help make appropriate plans for future activities. Service Users bedrooms should have suitable door locks fitted that they can use. Systems for auditing medication should be properly implemented. Staff should be provided with regular supervision and opportunities to discuss their work, so that issues relating to difficult or challenging behaviour can be discussed and better managed. The Spinney DS0000047871.V335011.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection Ashburton Office Unit D1 Linhay Business Park Ashburton TQ13 7UP 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. 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