Inspection on 30/10/07 for The Spinney

This inspection was carried out on 30th October 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Excellent. 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 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 28/10/08

The Spinney 08/11/06

The Spinney 12/12/05

The Spinney 19/07/05

The Spinney 28/02/05

The Spinney 28/07/04

Similar services:

Abbey The

Snydale Care Home

Hawkhills

Larchfield Manor

Beeches The - North Yorkshire County Council

The Grove Waltham

Carentan House

Ravensworth Lodge

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

CARE HOMES FOR OLDER PEOPLE The Spinney 21 Armley Grange Drive Leeds LS12 3QH Lead Inspector Paul Newman Key Unannounced Inspection 30th October 2007 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 DS0000001504.V353785.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 Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. The Spinney DS0000001504.V353785.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service The Spinney Address 21 Armley Grange Drive Leeds LS12 3QH Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 0113 2792571 0113 2792571 Mr Richard Martin Duffy Mrs Pauline Patricia Duffy Mrs Diane Russell Care Home 30 Category(ies) of Old age, not falling within any other category registration, with number (30) of places The Spinney DS0000001504.V353785.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: NONE Date of last inspection 08/11/06 Brief Description of the Service: The home is situated in a quiet residential area of Armley between two main bus routes into the city centre. The shopping centres of Armley and Bramley are within a mile of the home but few service users would be able to reach the shops without the assistance of transport. The Spinney was initially a large detached house which had an extension, built several years ago to meet the Residential Care Homes Regulations 1984. A further extension has provided an additional 8 rooms built to current standards. This has improved the facilities and made all but one room single occupancy, some on the ground floor. Most rooms have en-suite facilities. There is passenger lift access to the first floor. A small garden at the back of the building and a paved patio area overlooking the street provide a sitting out area for service users. The proprietors have been successful in retaining a domestic feel to the internal areas of the home. The home has male and female occupants and is non-smoking. The building is not suitable for people who require a secure environment. The proprietors are actively involved in the day-to-day operation of the home and work well with the registered manager. Details provided during the inspection visit on 30 October 2007 outline the weekly fees as between £392 to £429, the highest rate being for single ensuite rooms in the most recent extension. Fees do not include hairdressing, private chiropody services. The Spinney DS0000001504.V353785.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced visit carried out by one inspector that started at 9:30 and finished at 15:30 on 30 October 2007. The purpose of the inspection was to make sure the home was operating and being managed for the benefit and well being of the people who live there and that the outcomes for the people meet National Minimum Standards. Before the inspection, information collected about the home over the last year was reviewed. This included looking at any reported incidents, accidents and complaints. Survey forms were sent to the home before the inspection for the manager to give out to people living at the home, visitors, healthcare professionals involved in peoples’ care and the staff working at the home. This gives people the opportunity to comment if they want to. Information provided in this way may be shared with the provider but the source will not be identified. A good proportion of surveys were returned and some of the written comments that were made are included in the report to show what people think of the way the home is run. The manager had completed an Annual Quality Assurance Assessment (AQAA) before the visit to provide additional information. This is a self-assessment of the service provided and this gives a lot of information about how the manager thinks the home is meeting standards, how it has improved during the last year and what it intends to do in the coming year. All of this information was used to plan the inspection visit. A number of documents that the home must keep up to date were looked at during the visit. All areas of the home used by the people who live there were checked. Time was spent talking with the people and visitors, watching what was going, as well as talking with the manager and most staff on duty. The owners, who had just returned from their annual holiday, were also seen and explained further improvements they want to make to the building. They were involved in the verbal feedback about the outcome of the inspection visit. There was a warm welcome given and lots of assistance and cooperation from the owners, manager, staff, visitors and people living at the home. What the service does well: The home is well managed and the staff team are trained in safe working practices, experienced and equipped for the job. They are happy in their work and committed to providing high standards of person centred care. The needs of people are the focus of the staffs’ attention and people looked happy and well cared for. The owners are fully involved in the home, in touch with what is going on and keen to make sure that standards are maintained and The Spinney DS0000001504.V353785.R01.S.doc Version 5.2 Page 6 improving. Staff make sure that people are treated with dignity. Staff are also good at supporting family members who visit the home. Information about the home is readily available. People are properly assessed before they come to live at the home. This helps to make sure a good care plan can be drawn up that identifies peoples’ needs. The home works closely with other healthcare professionals, makes referrals at an early stage and takes the advice that is given. The food provided is wholesome and always freshly cooked with fresh ingredients and it meets with the approval of people living there. The building is homely, safe and comfortable. These are some of the written comments made by healthcare professionals who visit the home on a regular basis: • • • • • ‘Excellent communication skills, always respect residents wishes and maintain dignity and treat each resident as an individual’. ‘Spinney staff always make sure that any foot problems on clients are pointed out to me and acted upon’. ‘Any advice I give is acted upon and district nurses or doctors informed if needed’. ‘All clients are well dressed and clean and well presented. Clean well maintained rooms and buildings and furnishings’. ‘Caring staff who have time for the clients, an efficiently run service’. Some written comments made by peoples’ relatives included: • • • • • • • • • ‘Staff bend over backwards to try to help in any way they can’. ‘If they have any concerns they always report this to me or my sister. ‘The information I got was excellent’. ‘They have been very supportive to me, especially in the early days when Mum first went into care which was a very emotional time’. ‘Staff are all very caring – staff give 100 in all they do’. ‘The care home is good at – putting people at their ease, always having a chat and a laugh with people in care and visitors alike, we are totally at ease and so is my mum which is most important’. ‘We would recommend anybody who needs a care home to look at The Spinney. I am sure they would be impressed’. ‘As I don’t see my Mum regularly, I ring her weekly. A member of staff always assists my Mum to the phone so we can chat. They are helpful and it is appreciated’. ‘Living 180 miles away from Mum could have been a worry. However I appreciate my Mum is always well cared for, spotless, with kind caring staff. Her warm smile and conversation of her happiness as a resident leaves me nothing much to add’. The Spinney DS0000001504.V353785.R01.S.doc Version 5.2 Page 7 Several visitors were spoken with during the visit and their comments about the staff, the care and the support to them and their relatives was extremely complimentary. What has improved since the last inspection? What they could do better: The home continues to provide good standards of care and some aspects are excellent. The one requirement and recommendations made below by no means affect the positive outcomes for people living at the home. Although it is acknowledged that there is a good induction programme for new staff and that they are never left unsupervised during this period, the owners must make sure all the required information is obtained before a carer starts work at the home. Recommendations made are: • • To expand the section in the statement of purpose that refers to the criteria for admission to the home to more fully reflect and explain the range of needs that the home can provide for. To improve its knowledge and awareness of end of life care, the home should seek to enrol for a new initiative in Leeds called CHESS - Care Homes End of Life Supportive Services Programme. DS0000001504.V353785.R01.S.doc Version 5.2 Page 8 The Spinney • • A summary report of the findings of the last satisfaction survey should be completed as soon as possible so that people who took the time to be involved can see the results and any actions that are planned. To consider employing an administrative assistant to make some areas of general record keeping are more effective. 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 DS0000001504.V353785.R01.S.doc Version 5.2 Page 9 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection The Spinney DS0000001504.V353785.R01.S.doc Version 5.2 Page 10 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): 1 and 3. Standard 6 is not applicable to this home. People who use the service experience good quality outcomes in this area. We have made this judgement using available evidence including a visit to this service. People have clear and accurate written information about the services provided at the home to help them choose about where to live. Peoples’ needs are properly assessed before admission. EVIDENCE: The statement of purpose and service user guide are reviewed regularly. These are readily available for visitors in the reception area of the home and the admission check list seen on the files that were checked indicated that The Spinney DS0000001504.V353785.R01.S.doc Version 5.2 Page 11 people are given a copy of the service user guide on admission. The documentation in the reception area was checked and found to accurately reflect the care and services provided at the home but it was recommended that the section on criteria for admission to the home be expanded to more fully reflect the range of needs that the home can provide for. The information provided before the inspection visit that was summarised in the Annual Quality Assurance Assessment (AQAA), showed that all people considering coming to live at the home and their relatives are seen personally and a visit to the home is arranged when at least the relatives and, if possible, the prospective service user can see the room available, general facilities and meet other people living there. People spoken to during the inspection visit confirmed this. The files of four people were checked to make sure that good quality information is gathered before someone comes to live at the home, so that everyone is sure that the person’s care needs can be met. One of the files was for the most recent admission. Apart from the home’s own assessment documentation, other information is gathered from any social worker or healthcare professionals that have been involved. Easy care documentation was on file. Risk assessments are also made before a person is admitted and were on file. From this information, if the home believes it can meet the person’s needs, a plan of the care needed is written. Once living in the home, individuals’ progress is monitored to make sure that care needs are met. The Spinney DS0000001504.V353785.R01.S.doc Version 5.2 Page 12 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): 7, 8, 9, 10. People who use the service experience good quality outcomes in this area. We have made this judgement using available evidence including a visit to this service. Peoples’ healthcare needs are met and care plans provide clear instruction for staff to follow. Staff are aware of peoples’ needs and there is good communication amongst the staff group and with healthcare professionals. Medication policies, procedures and practices are safe. People are treated with respect and in a dignified way. EVIDENCE: The files that were checked showed that care plans are drawn up and reviewed regularly. The plans are based on a pre admission assessment carried out by the manager. Other information like easy care documentation on the four files checked showed that the care plans that had been written accurately and all The involvement of the family and the persons needs had been identified. The Spinney DS0000001504.V353785.R01.S.doc Version 5.2 Page 13 person about their life history, likes and dislikes, preferred ways of living and routines, is a way to make the care plans more person centred and helps staff deliver care in an individual way. Since the last inspection the home has introduced care plan diaries. This is the ‘working record’ and details in sufficient information the sort of things that staff must know to deliver the right care in a safe and personalised way. Key workers are responsible for making sure things are up to date and reviewed each month and the documentation shows clearly that the care plans are audited and reviewed by the manager. Specific health care needs were well documented and audit trails of staff observations and concerns that they document about an individual’s health problem could be followed with any subsequent referral to the GP or other health care professional. The advice and treatment that was given by healthcare professionals was noted on the file. Short-term care plans are used when a person is in need of additional monitoring. The trainee assistant manager was responsible for the administration of the lunchtime medication and took time to explain the systems in place, the way prescribed drugs are ordered and checked in, disposed of and administered. Her practices were observed and these were careful, thorough and safe. The drug administration charts were checked and found to be error free over a period of time. To improve its knowledge and awareness of end of life care, the home should seek to enrol for a new initiative in Leeds called CHESS - Care Homes End of Life Supportive Services Programme. This initiative aims to improve end of life care for people by introducing multidisciplinary documents which are designed to help all people irrespective of diagnosis, to be cared for and die in the place of their choice whilst receiving first class quality care. The initiative provides expert facilitators, workshops providing education and training, designed to support care delivery, monthly support meetings and information packs for staff to increase their knowledge and awareness of end of life issues. Staff spoken with had a good knowledge of the individual needs of people. Some time was spent around the home watching staff practices. This showed that they know the care needs and personal preferences of individuals and are good at identifying non-verbal behaviour that indicates when a person is happy or unhappy. They were good at making sure nobody was isolated and got as much positive attention as possible. The relationships between staff and the people they care for are warm and friendly with some obviously enjoying some physical reassurance. Clothing was clean and all of the residents looked well cared for with their hair attended to, ladies ‘made up’ and nails polished. Staff were careful to make sure doors were closed at times when personal care was delivered and were seen knocking on doors before entering rooms. They were The Spinney DS0000001504.V353785.R01.S.doc Version 5.2 Page 14 attentive to people and some overheard conversations showed staff to have a nice manner that people appreciated. The surveys that were returned further reinforced the good practices seen during the inspection visit. Some written comments made by healthcare professionals included: • • • • • ‘Excellent communication skills, always respect residents wishes and maintain dignity and treat each resident as an individual’. ‘Spinney staff always make sure that any foot problems on clients are pointed out to me and acted upon’. ‘Any advice I give is acted upon and district nurses or doctors informed if needed’. ‘All clients are well dressed and clean and well presented. Clean well maintained rooms and buildings and furnishings’. ‘Caring staff who have time for the clients, an efficiently run service’. A community nurse visiting the home at the time of the inspection visit to administer a flu injection said that her mother had lived at the home up to point where she needed nursing care and that she had been very happy indeed with the care provided at the home. Some written comments made by peoples relatives included: • • • • • • • • • ‘Staff bend over backwards to try to help in any way they can’. ‘If they have any concerns they always report this to me or my sister’. ‘The information I got was excellent’. ‘They have been very supportive to me, especially in the early days when Mum first went into care which was a very emotional time’. ‘Staff are all very caring – staff give 100 in all they do’. ‘The care home is good at – putting people at their ease, always having a chat and a laugh with people in care and visitors alike, we are totally at ease and so is my mum which is most important’. ‘We would recommend anybody who needs a care home to look at The Spinney. I am sure they would be impressed’. ‘As I don’t see my Mum regularly, I ring her weekly. A member of staff always assists my Mum to the phone so we can chat. They are helpful and it is appreciated’. ‘Living 180 miles away from Mum could have been a worry. However I appreciate my Mum is always well cared for, spotless, with kind caring staff. Her warm smile and conversation of her happiness as a resident leaves me nothing much to add’. Several visitors were spoken with during the visit and their comments about the staff, the care and the support to them and their relatives was extremely complimentary. The Spinney DS0000001504.V353785.R01.S.doc Version 5.2 Page 15 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): 12, 13, 14 and 15. People who use the service experience good quality outcomes in this area. We have made this judgement using available evidence including a visit to this service. Peoples’ social expectations and personal preferences are met and they are able to exercise choice in their daily routines. People living at the home are provided with a varied and nutritious diet. EVIDENCE: The information in the AQAA that was provided stated: ‘We encourage clients to maintain their daily and social activities. We have an activities book. Staff take it turns to organise activities each day. One client who goes to a day centre sometimes brings a friend back for tea and scrabble. Small groups go out for fish and chips and staff take them shopping. We celebrate birthdays and have a Christmas party with friends and relatives. We are trying new ideas and interests. We have improved by having more The Spinney DS0000001504.V353785.R01.S.doc Version 5.2 Page 16 entertainers, more games available and listened to clients and respect their choice to join in or not. Visitors are welcome at all times and are offered refreshments. We provide fresh home cooked meals and cakes and people are offered choice on menu’. The activities diary confirmed the range of activities provided and during the visit some people were enjoying dominoes and scrabble. Some were reading, watching TV and listening to music and some enjoying conversation with each other and/or visitors. The atmosphere was social, pleasant and at times humorous and lively. Two people were out at day centres. There is a monthly communion service and it was noted on the most recent person to be admitted notes, how much she had appreciated being involved in the last service. Local clergy also visit in a pastoral role when people are unwell. It was clear from the visitors spoken with that they are made to feel welcome, can visit at any time and are offered refreshments or a meal. The care plans identify peoples’ preferred routines. Overheard conversations showed that staff encourage people to say what they would like to wear ( with assurances about how they looked when dressed), where they would like to be and what they would like to do. People spoken with said that they get up and go to bed when they want, can eat in their rooms if they wish and choose what activities they want to join in. The bedrooms seen showed that people are able and encouraged to bring things from home to personalise it and make it more individual and homely. On the tour of the building (to check things), it was noted how attractive the dining tables had been set. This had been done by two people who like to be involved in some of the domestic side of home life and had achieved ‘expert’ results. The home does not employ a cook or chef. This is done on a rota basis by the care staff providing they have a food hygiene qualification. This appears to work well and comments made by visitors and people living at the home said that the food was consistently good and there was plenty of it. The home prides itself on good wholesome cooking with fresh good quality produce. Staff said that because they are involved in both care and cooking, this helps make sure that people get their preferred choices. The lunchtime meal looked appetising and was enjoyed by all of those spoken with. There is a diary of the food provided at each meal. The Spinney DS0000001504.V353785.R01.S.doc Version 5.2 Page 17 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): 16 and 18. People who use the service experience good quality outcomes in this area. We have made this judgment using available evidence including a visit to this service. There is a clear complaints procedure made available to the people at the home. The people who live at the home and their relatives feel confident that they will be listened to and that appropriate action will be taken when necessary. There are adult protection procedures that staff have awareness of and understand. People can be assured that they can feel safe at the home. EVIDENCE: The AQAA said that the home encourages people to air views and concerns so that staff can act upon this and resolve things quickly. There has been one complaint made since the last inspection. This was properly recorded, investigated and resolved to everyone’s satisfaction. Everyone spoken to said that staff were approachable, listened and wanted to make sure people were happy. One visitor said with great conviction that you can see any member of staff, the manager or the owners who ‘always seem to be around’. The complaints procedure is in the service user guide that all new admissions The Spinney DS0000001504.V353785.R01.S.doc Version 5.2 Page 18 receive. It is also clearly positioned at the reception desk where all visitors sign the visitors’ book. The home sends out satisfaction surveys every six months and the manager felt this also helped keep on top of how people are feeling. Policies are in place aimed to set out how the home protects service users and prevents harm or abuse and this includes a whistle blowing policy. The manager was aware of the need to report any suspected or alleged abuse to the local authority and other relevant authorities. Staff spoken with confirmed that they had received training in the protection of vulnerable adults. The Spinney DS0000001504.V353785.R01.S.doc Version 5.2 Page 19 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): 19 and 26. People who use the service experience good quality outcomes in this area. We have made this judgement using available evidence including a visit to this service. People live in a safe, comfortable and well maintained environment. EVIDENCE: The tour of the building found things to be clean, comfortable, well maintained and free from unpleasant odours. There is a definite ‘homely feel’ when entering the building and most of the visitors said this was one of the positive things that attracted them and their relative to make the decision about living there. The Spinney DS0000001504.V353785.R01.S.doc Version 5.2 Page 20 The report written by the owners each quarter that is sent to the Commission has kept us informed of improvements made to the building. The issues raised in the last inspection report about a fire door, privacy locks to bedrooms and radiator guards have been resolved. There is a maintenance book where staff record things that need attention. With the owners in six days out of seven each week, things get sorted out quickly. There is a programme of ongoing redecoration and refurbishment and several rooms have been upgraded with new furniture. The exterior of the building has been repainted and new patio furniture provided. Bedding and towels have been replaced. The kitchen has been upgraded to include new cooker and a cooker extractor fan is to be fitted. The home has been successful in getting a local authority improvement grant and is converting a bathroom to a walk in shower. This will improve peoples’ choice. The owners also want, as part of this improvement to make an adjacent bedroom en-suite. There are other plans to improve office and storage facilities. Throughout the visit staff were seen to take great care in making sure that they wore protective clothing and wash hands to prevent cross infection. Laundry facilities were clean and organised with systems in place to minimise the risk of things being misplaced. The Spinney DS0000001504.V353785.R01.S.doc Version 5.2 Page 21 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): 27, 28, 29 and 30. People who use the service experience good quality outcomes in this area. We have made this judgement using available evidence including a visit to this service. People living in the home are cared for by experienced staff who are trained and qualified for the job. Recruitment procedures need to be more thorough to protect the people living at the home. EVIDENCE: Since the last inspection there have been changes in the way the staff are organised on each shift. They are designated to a colour code that determines in what part of the building they will be working, and the people they will care for. It also determines the tasks they will be responsible for. The manager and owner felt this had provided clarity of task and purpose and the staff also felt this to be the case. With this approach it is much easier to hold staff to account for their work, but also encourages them to take responsibility. The combination of evidence from rotas seen, watching staff at work, comments made in the surveys that were returned and conversations during the visit suggest that there are enough staff on duty and that they are able to give The Spinney DS0000001504.V353785.R01.S.doc Version 5.2 Page 22 people the care and attention they need. Communication systems like shift handovers are well established. When watching staff at their work they are very personable but professional, the large majority having worked for a long time at the home and show great loyalty to the owners, manager, each other, but above all, the people they care for. Training records and conversations with staff on duty show that they are up to date with safe working practice training and have developed their knowledge further in care planning, mental health, safe handling and administration of medication and nutrition and health. The home exceeds targets set in National Minimum Standards for the numbers who should achieve a National Vocational Qualification. Although recruitment records were checked at the last inspection and found to meet standards, the files of the two most recent staff appointments were checked and found to have shortfalls in the documentation that must be kept on file to evidence that staff have been properly checked with the Protection of Vulnerable Adults list (First POVA), Criminal Records Bureau and one file had only one written reference rather than the required two. It is acknowledged that there is a good induction programme for new staff and that they are never left unsupervised during this period. The lack of documentation was discussed with the owner who takes responsibility for this administrative role and because of the explained delays experienced with the agency currently used for these checks, an alternative agency to take on the task of POVA and CRB checks was given. The heavy burden of this and other administrative tasks was discussed and a suggestion made that the owners consider employing an administrative assistant to take make sure that this part of the management of the home is effective. The Spinney DS0000001504.V353785.R01.S.doc Version 5.2 Page 23 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): 31, 32, 33, 35 and 38. People who use the service experience good quality outcomes in this area. We have made this judgement using available evidence including a visit to this service. The home is well managed. The interests of the people who live there are seen as very important to the owners, manager and staff. There is a clear approach to resident care that is person centred and puts the best interests of individual residents central to staff practice. Regular auditing and checking of facilities, equipment and services make sure the home is a safe place to live. The Spinney DS0000001504.V353785.R01.S.doc Version 5.2 Page 24 EVIDENCE: The conversations with staff, people living at the home, visitors and CSCI surveys show a high regard and appreciation for the manager. She was described several times as ‘very approachable’ and ‘great to work for’. The manager has achieved the Registered Manager’s Award and carries a lot of experience in the care setting. Another theme that ran through the inspection was the dedication and commitment of the owners. They had been away in America for a month, but had kept in regular contact with the manager. They returned the night before the inspection visit and came to the home, as is usually the case each day, whilst the inspection visit was underway. Undeterred and not concerned about the inspection they were quickly engaged with the manager checking on things, getting around the home seeing the people, especially new admissions so that they could introduce themselves and reassure them (‘if there is anything you need, just ask’), and checking with staff that they were ‘OK’. This was good to see and reinforced their positive involvement in the running of the home and their care and concern for the people who live there together with the people they employ. Staff meetings are held on a regular basis and minutes were made available. In the conversations with staff they said that they felt that communication was good. The shift handover during the afternoon was observed and good quality information was passed on so that the oncoming staff were aware of people who may need some additional oversight for one reason or another. To make sure it is achieving its aim, the home conducts its own satisfaction surveys every six months. The last of these was two months ago but the summary report of the findings has not been completed but should be, so that people who took the time to be involved can see the results and any actions that are planned. The system for holding any money held for safekeeping for individuals was discussed and the way the records were kept was seen. The records were fine, individually recorded and transactions were clearly identified. The money kept is however held collectively in a cash tin, not individually. Although people have ready access to their cash, there is no quick and easy way to check that the money held is correct. Each individual’s total from their running record would have to be added and the sum total of cash held be checked. This was discussed and a recommendation made that each individual’s personal money is kept separately and regular checks made. This could be another role for the administrative assistant role that was also recommended. The information provided in the AQAA showed that regular checks are made of equipment and services to make sure that everything is safe and in good The Spinney DS0000001504.V353785.R01.S.doc Version 5.2 Page 25 working order. Staff have access to all essential policies and procedures and are trained in safe working practices. Checks were made of the fire safety records these were up to date. The Spinney DS0000001504.V353785.R01.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 X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 4 9 3 10 4 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 4 14 3 15 4 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X X X 3 STAFFING Standard No Score 27 4 28 3 29 1 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 4 3 X 3 X X 3 The Spinney DS0000001504.V353785.R01.S.doc Version 5.2 Page 27 Are there any outstanding requirements from the last inspection? NO 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 OP29 Regulation 19 Timescale for action The registered person must 31/12/07 ensure all the required information is obtained before a carer can commence work at the home and must do this retrospectively for the staff appointed. This will make sure that people are not placed at risk. Requirement 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 OP1 Good Practice Recommendations The registered persons should expand the section in the statement of purpose that refers to the criteria for admission to the home to more fully reflect the range of needs that the home can provide for. To improve its knowledge and awareness of end of life care, the home should seek to enrol for a new initiative in Leeds called CHESS - Care Homes End of Life Supportive Services Programme. DS0000001504.V353785.R01.S.doc Version 5.2 Page 28 2 OP7 The Spinney 3 OP33 4 OP37 A summary report of the findings of the last satisfaction survey should be completed as soon as possible so that people who took the time to be involved can see the results and any actions that are planned. The registered persons should consider employing an administrative assistant to make some areas of general record keeping are more effective. The Spinney DS0000001504.V353785.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection Aire House Town Street Rodley Leeds LS13 1HP 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 DS0000001504.V353785.R01.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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