Inspection on 06/06/07 for The Spinney

This inspection was carried out on 6th June 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 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 21/05/08

The Spinney 30/06/06

The Spinney 24/11/05

The Spinney 04/05/05

The Spinney 13/12/04

The Spinney 18/05/04

The Spinney 12/02/04

Similar services:

Chirnside House

Keer Sands Residential Home

Ruskin Lodge

Bushell House

Langrigg House

Parkside

Dystlegh Grange

Thornton Lodge

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

CARE HOMES FOR OLDER PEOPLE The Spinney 16 College Road Upholland Wigan Lancashire WN8 0PY Lead Inspector Mr Graham Oldham Unannounced Inspection 6th June 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 DS0000039828.V336702.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 DS0000039828.V336702.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service The Spinney Address 16 College Road Upholland Wigan Lancashire WN8 0PY 01695 632771 01695 625599 Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Bondcare (Spinney) Ltd Ms Wendy Jo Martin 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.V336702.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. The home is registered for a maximum of 35 service users to include: Up to 35 service users in the category of OP (Old Age not falling within any other category). Up to 3 service users in the category of PD (Physical Disability). Date of last inspection 30th June 2006 Brief Description of the Service: The Spinney is a thirty-five bedded care home providing nursing and personal care. Accommodation is over three floors, which can be accessed by a lift. Thirty-one rooms are single, six of which have en-suite facilities. Two shared rooms are also available. Twenty-three residents were accommodated on the day of the inspection. Lounges are provided on the ground and first floor. The ground floor lounge is large and spacious. The first floor lounge is smaller, but comfortable and furnished nicely. There is a dining room on the ground floor. The home is furnished to a satisfactory standard, and has a friendly ambiance. The most recent inspection report is available in the reception area of the home. A statement of purpose and service users guide are available for residents or their families to be informed of the facilities and services the home provides. The fees for The Spinney range from £300.11 to £492.50 per week. This does not include hairdressing, newspapers or magazines and toiletries. The Spinney DS0000039828.V336702.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced key inspection, which included a visit to the home, took place on the 6th June 2007. Much of the information gained was obtained from talking to residents and staff members. The views of residents were obtained on a variety of topics. People living within the home allowed the inspector to call them residents. Three residents were case tracked. Case tracking gave the inspector an overall view of the specific care for the individual resident by checking their plans of care, other documentation and talking to staff about the care they gave each resident case tracked. All three residents case tracked were unable to give the inspector their views. Three further residents provided information about the home. Two staff members were questioned about the care of the residents case tracked. Some of the views have been reported collectively with specific comments contained within the body of the report. The inspector took detailed notes during the inspection, which have been retained as evidence. Staff were directly and indirectly observed carrying out their tasks and interacting with residents. Paperwork examined included plans of care, assessment documentation, policies and procedures or documents relevant to each standard. A tour of the building was conducted. The manager and regional manager were present for the inspection and feedback. What the service does well: One professional returned a survey form to the Commission for Social Care Inspection (CSCI). All answers provided were positive about the service. Six survey forms were returned from relatives to the CSCI and said, • Three family members always received enough information to make an informed choice to enter the home and three usually. One commented they try to give as much information as possible to relatives and friends. • Five thought the home always met their needs and one usually. • One always thought the home helped them keep in touch with their relative and one usually. The four who declined to answer all commented the visited on a daily basis. The Spinney DS0000039828.V336702.R01.S.doc Version 5.2 Page 6 Three thought they were always kept up to date with important issues and three usually. Relatives commented, There have been no major problems with my mothers health so far so this has not been an issue and I have been informed when my father became unwell. I am unaware of any other occurrence I felt I should have been contacted. • Five thought care given was as agreed and one usually. • Three thought staff always had the right skills and three usually. • Four thought the service always met the diverse needs of residents and one usually. One commented, As far as I am aware they do and my father is C of E and I have always found he has been treated with respect and dignity. • All six knew how to make a complaint and the said the service was responsive to concerns. • Two said the care service always supported residents to live the life they choose, two usually and two commented they don’t choose to grow old and this is not applicable in our case because my mother cannot communicate and I cannnot answer for others. • When asked what the home does well the following comments were made. They cater for the needs of my mother – everything. Nursing care is very good – always welcoming and friendly – the home is clean and generally well run – they hold fairly regular patient and relative meetings, always the residents seem clean, tidy and well looked after. My step father has been in The Spinney for five months and I have no complaints – he is quite happy and settled in well, therefore I cannot comment long term and he is quite a fit man. • One further comment – I am very satisfied with the care my mother receives. No visitors wished to talk to the inspector. In general the good responses from relatives demonstrated the home was open and transparent. There was a contract document agreed by residents or family members, which informed residents of their rights of occupancy at The Spinney. The good assessment of residents enabled staff to determine that the needs of residents could be met. Residents said, “Rooms are all right. They are clean and well looked after” and “I have a nice room – have some of my own things in my room”. Residents were satisfied with their private space and had personalised their rooms to make it homely. Staff were observed treating residents with dignity. Staff spoken to were aware of privacy issues. Residents said, “Staff treat me privately and good”, “We are treated pretty well” and “The staff are great”. The good attitude of staff allowed residents to feel comfortable with the personal care they received. One visitor said, “I am very satisfied with the care my mother receives. There are no problems with visiting, I come when I want and the staff here make me The Spinney DS0000039828.V336702.R01.S.doc Version 5.2 Page 7 • welcome”. Residents said, “We can go outside or out with our family. Families can visit anytime and we see them regularly. There are no restrictions on going out” and “Visitors are made welcome”. Visiting at the home was encouraged for the benefit of residents. Residents said, “The food is grand”, “The food is good”, “Food is very good”, “I mostly like the food but you could have a choice” and “I enjoyed my lunch immensely”. The food served was liked by residents and matched their tastes. There was a satisfactory complaints procedure for residents or their families to access. Residents said, “I would complain to my key worker”, “If I have a complaint I would tell the staff. We have a key worker – we have a few we can talk to and “No problems and very well run - no complaints at all”. Family members survey forms demonstrated visitor were aware of the complaints procedure. Residents and their families were able to voice their concerns. Staff training, policies and procedures protected residents from possible abuse. The décor and furnishing of the home provided a homely environment for residents. Residents said, “Its gorgeous living here”, “The girls look after me they are great” and “The staff are very nice. We can talk to them and they will help us. We have no complaints about the staff. We have no problems and the home is very well run - no complaints at all”. The good attitude of staff and managers provided residents with a relaxed and happy atmosphere. What has improved since the last inspection? What they could do better: Written confirmation the service can meet the needs of residents must be issued to each individual to provide a guarantee to residents their needs can be met. Plans of care were reviewed but information was not transferred from assessment documentation to the plans. Information must be up to date and reliable in plans of care for staff to be up to date with current care issues. The Spinney DS0000039828.V336702.R01.S.doc Version 5.2 Page 8 The registered person must devise a strategy for the prevention and treatment of pressure area care that includes staff training, pain relief and equipment that needs to be provided to fully meet the health and welfare needs of residents. A written record of the food provided for residents must be retained by the home for inspection. Hot water outlets must be risk assessed and where a risk is identified suitable temperature control devices fitted. In nursing homes a sluicing disinfector must be provided to improve cross infection dangers to staff and residents. The kitchen floor must be replaced to reduce the possibility of an accident or cross infection. The manager must be registered with the CSCI to meet current requirements. Quality assurance systems must be developed to gain and react to the views of residents and their families. The administration of medication must be improved to protect the health and welfare of residents. Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. The Spinney DS0000039828.V336702.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 DS0000039828.V336702.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): OP2, OP3 and OP4 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The statement of purpose, contract and service user guide enabled residents to make an informed choice to enter the home. The assessment process ensured staff had sufficient information to be able to meet the needs of residents. assessed. EVIDENCE: Three residents took part in the case tracking process. Residents files contained a terms of accommodation/contract document which had been signed by residents or a relative. The files of residents contained assessment documentation to enable staff to develop plans of care for each individual and ensure their needs could be met at the home. Residents did not receive written confirmation, following assessment, that their needs could be met with regard to their health and welfare. The Spinney DS0000039828.V336702.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): OP7, OP8, OP9 and OP10 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Plans of care did not contain all the information to enable staff to meet the healthcare needs of residents. Residents were treated with respect and dignity to ensure they were comfortable with the personal care they received. Administration of medication did not filly protect the health and welfare of residents. EVIDENCE: Three plans of care were examined during the case tracking process. Plans of care had been completed for the two residents accommodated for some time and was in the process of being completed for the resident newly admitted. Plans of care had been developed with residents or familyies involvement. Staff were able to accurately describe the care they gave to that written in the plans. Plans of care had been well reviewed but were not up to date due to assessment information not being transferred into the plans. Plans of care must be kept up to date to ensure staff are able to access up to date information to meet the care needs of residents. The Spinney DS0000039828.V336702.R01.S.doc Version 5.2 Page 12 Three plans of care examined during the case tracking process demonstrated residents had access to health care professionals. The manager said they could not get some health care professionals to attend because they were on the borders of two Primary Care Trusts. This included the tissue viability nurse. Two residents case tracked had pressure sores. It was required trained staff (as a minimum) attended a tissue viability course. The new manager had reacted to the needs of residents and was currently attending a course. The care service needed to devise a strategy using their assessment tool to inform staff what care or equipment residents needed when at risk of developing sores. This is unclear at present. The manager was advised to contact the head nurse at the primary care trust to inform them of their difficulty in specialists providing on site advice. While residents were able to attend specialists some training and development work is needed to further protect the health and welfare of residents. Residents were observed being helped in a dignified and good-natured way by staff. Residents who were involved in the inspection process were satisfied they were treated with privacy and dignity and comfortable with the care they received. Policies and procedures for the handling and administration of medication were available, however these did not fully reflect current practice. Staff must follow these documents at all times in order to protect the health and wellbeing of residents. Staff did not always have enough information to administer medication safely. All medicines that are only to be used when required should have clear instructions that are personalised to needs, signs and symptoms of the individual resident. This is particularly important for residents who have communication problems and who find it difficult to express their needs. Where variable doses are prescribed, the actual dose administered should be clearly recorded. The health and wellbeing of residents is at risk of harm if medication is not administered correctly and recorded accurately. Accurate written records of medication entering and leaving the home had not been maintained. This meant that it was impossible to see how much medication should be present and therefore it was not possible to fully audit all medication in order to find out whether it had been administered correctly. The manager must make regular checks on how well medication is managed within the service. An audit was in place, however this had failed to highlight the shortfalls noted on this visit. An effective audit should include checking Medication Administration Record charts (MARs), Controlled Drugs and making sure that all stock can be accounted for. It was suggested that the number of tablets and other medications brought forward from the previous month be recorded in order to make auditing easier. The results of the audits should be recorded, together with action taken where necessary. The Spinney DS0000039828.V336702.R01.S.doc Version 5.2 Page 13 A sample of records and current stocks showed that some residents were not given their medication as directed by the prescriber. Records showed that some medication had been signed for, but not given. Not all residents had supplies of their current medication available. Some residents had medication, creams and dressings in stock that were not recorded on the MARs. The health and wellbeing of residents is at risk of harm if medication is not administered as prescribed and if adequate supplies are not available. Staff did not always sign MARs as medication was administered and there were some gaps on the MARs where medication had been given but not signed for. The recording of administration of creams and external products was poor. The health and wellbeing of residents is at risk of harm if records do not show accurately exactly what has been administered. Some residents were given their medication via a feeding tube (PEG tube). It is important that written consent is obtained from the prescriber before administering medication via this route. Instructions recorded on the MARs for flushing the tube following medication differed to those on the care plan. There should be a clear personalised protocol for each resident given medication via PEG in order to ensure they receive their medication safely. A number of handwritten entries had been made on MARs following verbal dose changes, new admissions or the prescribing of new medicines. Not all the MARs entries were accurate. Verbal dose changes and new medications should be clearly recorded on the MARs and signed by two members of staff, so that residents receive the correct dose of medication. Written confirmation of dose changes should be obtained from the prescriber where possible. Full and accurate records are essential in order to ensure that all residents are given the correct treatment at the right time. It was recommended that all eye drops, insulin and other short dated products should have the date of opening recorded on them. This reduces the risk of residents being given medication that is out of date. One resident prescribed eye drops had two bottles available, but both were out of date, furthermore one was kept on the trolley rather than in the fridge as recommended by the manufacturers. Insulin in current use was stored in the fridge. This is also against current guidance. Medication must be stored at the correct temperature in order to ensure it is safe and effective. The Spinney DS0000039828.V336702.R01.S.doc Version 5.2 Page 14 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): OP12, OP13, OP14 and OP15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Leisure activities provided were suitable to residents tastes and helped provide a fulfilling life. Visiting was open and unrestrictive to encourage socialising with family and friends. Residents were able to exercise choice to retain some independent living. The food served at the home met residents nutritional needs. EVIDENCE: One family member said in a survey form they did not think there were enough activities for residents in wheelchairs. The manager had appointed a new member of staff to organise leisure activities and the progress made would be investigated at the next inspection. Three residents (two were wheelchair bound) all confirmed there were enough activities to meet their needs. Residents were able to receive visitors in private. Residents said there were no restrictions to their families visiting rights. One visitor confirmed he could visit when he wanted and was made welcome into the home. Visiting was encouraged to enable residents to have good social interaction. Staff and residents were able to describe the choices they made to ensure retained some autonomy over their lives. The Spinney DS0000039828.V336702.R01.S.doc Version 5.2 Page 15 Meals provided were hot, nutritious and tasteful. Residents who required assistance were helped in a discreet and individual manner. There was a choice of meal. The cook carried out necessary environmental health checks. There were sufficient dining facilities for all residents to enjoy a meal as a social occasion. Special diets were catered for. Residents said food was good. The Spinney DS0000039828.V336702.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): OP16 and OP18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents were aware of their right to complain and confidant to approach management with any concerns. Robust policies, procedures and staff training protected residents from possible abuse. EVIDENCE: There was a complaints procedure, which met current guidelines. There had been two substantiated complaints made to the service, which had been dealt with in appropriate timescales and appropriate action taken. Two substantiated complaints had been received by CSCI. Both complaints had been addressed and appropriate action taken. The manager took complaints seriously and acted in a responsive manner to achieve a satisfactory outcome. There was a whistle blowing policy and adult abuse procedures. Policies and procedures for financial transactions such as witnessing wills, resident’s monies etc were observed. The manager had actioned the Lancashire Adult abuse procedures which proved to be unsubstantiated. Two staff members were aware of abuse issues and had received POVA training. Residents were protected from possible abuse. The Spinney DS0000039828.V336702.R01.S.doc Version 5.2 Page 17 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): OP19 – OP26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents lived in a clean, tidy and safe environment. The home was well decorated while fixtures; fittings and furnishings were domestic in character, which made for a homely and comfortable environment. There were sufficient aids and adaptations to meet the needs of residents with mobility problems. EVIDENCE: A tour of the building was conducted during the inspection. All communal areas and seven bedrooms were inspected. Communal rooms were well decorated and contained a good amount of suitable furniture. Furniture was domestic in character and in good order. Lighting was sufficient to meet residents needs. Rooms had been personalised to residents tastes and contained good levels of equipment. All residents spoken to were satisfied their rooms met their needs and they were happy with their private space. There was a lift. Grab rails and mobility devices aided residents with mobility problems. The kitchen flooring needed to be replaced. The Spinney DS0000039828.V336702.R01.S.doc Version 5.2 Page 18 The hot water system is not controlled – including hot water outlets to the baths. The manager said, “Risk assessments are in place for the hot water”. Some residents mental faculty are impaired which may put them at risk of scalding. Hot water outlets to baths must be temperature controlled. Radiators were guarded and windows had restrictors fitted. There was a sluice, for the management of soiled linen and to reduce the risk of cross-infection. Wheelchair storage did not pose a threat to the health and safety of residents. Emergency lighting was provided and maintained. Residents said the home was clean. Three cleaners were employed on all three floors on the day of the inspection. Gardens were accessible and there is seating for residents and visitors. Grounds were safe and tidy. There was a program of routine maintenance and handyman to carry out the work. The environment meets the needs of residents but due regard must be given to the hot water system to fully protect the health and welfare of residents. The laundry had new equipment following two substantiated complaints from residents. The equipment was suitable for washing laundry to a high standard. There was a contract for the removal of clinical waste, medication and sharps. The laundry would benefit from a good cleaning and the walls needed painting. Infection control policies, procedures and staff training helped protect the health and welfare of residents and staff. The Spinney DS0000039828.V336702.R01.S.doc Version 5.2 Page 19 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): OP27, OP28, OP29 and OP30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents needs were met by the numbers and skill mix of a well-trained staff group. Induction and foundation training was undertaken in a professional manner to ensure staff are competent to meet the needs of residents. EVIDENCE: The staffing rota demonstrated sufficient numbers of well-trained staff were on duty throughout the day. Staff received training in many aspects of caring for the resident group accommodated at the home. Only 20 of staff had attained NVQ qualifications although more staff were enrolled on a course. Residents case tracked said their care was good. Induction training had been completed or was ongoing for new employees. Each staff member had an individual training record and there was a staff training matrix for the home. Two staff members spoken to had completed mandatory training such as moving and handling and one was completing NVQ2 in care. Residents needs were met by staff employed at the home. All necessary documentation and checks had been obtained for the employment of staff to help protect the health and welfare of residents. The Spinney DS0000039828.V336702.R01.S.doc Version 5.2 Page 20 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): OP31, OP33, OP35 and OP38 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. There is no quality assurance system to seek the views of all concerned about the running of the home. The financial system protected residents from possible abuse. Health and safety policies, procedures, staff training and the maintenance of equipment helped protect the health and welfare of residents. EVIDENCE: The new manager had only been in post since 16th March as acting manager and from the 9th May as manager designate and is not, as yet, registered with the Commission. The manager was undertaking training in tissue viability to help her better meet the needs of residents and is sufficiently qualified and experienced to run the home. The Spinney DS0000039828.V336702.R01.S.doc Version 5.2 Page 21 Residents case tracked (or their families) managed their own financial affairs. The administrator held the personal allowance of some residents. The system for managing this was examined and seen to be secure. No one at the home managed the finances of residents and therefore the risk of financial abuse was minimal. Meetings were held with staff and residents and these were recorded. Resident and family meetings were also held to gain their views. The new manager could not locate the questionnaires she believed had been completed by the previous manager. Effective quality assurance systems must be developed to react to the changing needs and views of residents. All electrical appliances and equipment has been serviced and certificated. Health and safety policy and procedures were available for staff to use. Health and safety legislation information was retained within the office. Staff had undertaken training in health and safety issues. Health and safety systems were good and protected staff and residents from possible harm. The Spinney DS0000039828.V336702.R01.S.doc Version 5.2 Page 22 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 X 3 3 1 X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 3 3 3 3 3 2 2 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 2 X 4 X X 3 The Spinney DS0000039828.V336702.R01.S.doc Version 5.2 Page 23 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 OP8 Regulation 12(1)(a) Requirement The registered person must ensure proper provision is undertaken for the health and welfare of residents. This includes exploring pain relief for residents with pressure sores. The registered person must ensure staff receive training appropriate to the work they are to perform. This must include tissue viability training for all staff who are involved in pressure wound treatment. The registered person must ensure full and accurate records of all medicines received, administered and leaving the care of the home must be maintained to ensure people are given the correct medication. There must be a full record of all medication and doses currently prescribed for each resident. Timescale for action 30/06/07 2. OP8 18(1)(c) 30/09/07 3. OP9 13(2) 06/07/07 4. OP9 17(1) Sch3 The registered person must 06/07/07 ensure there is a safe system for the administration of medication. Staff must administer medication in accordance with the DS0000039828.V336702.R01.S.doc Version 5.2 Page 24 The Spinney prescribers instructions. There must be adequate supplies of all medication available for each resident. 5. OP9 24 There must be an effective system in place to audit medicines management within the service in order to ensure that people who use this service are receiving the correct medication. The registered person must ensure the premises are kept in a good state of repair externally and internally. The kitchen floor needs to be replaced. The registered person must ensure all unnecessary risks to the health and safety of residents are identified and so far as possible eliminated. The hot water supply to the baths must be suitably controlled. 06/07/07 6. OP19 23(2)(b) 30/08/07 7. OP25 13(4)(c) 30/06/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard OP4 Good Practice Recommendations The registered person must confirm in writing to each resident that having regard to the assessment the care home is suitable for the purpose of meeting their needs in respect of their health and welfare. The registered person must ensure residents needs are revised at any time when it is necessary, having regard to any changes of circumstances. Any changes noted must be documented in the plan of care. The registered person should ensure care staff receive training in pressure area care and this is documented. The registered person should ensure a system is devised to tie pressure area risk assessment to the treatment and DS0000039828.V336702.R01.S.doc Version 5.2 Page 25 2. OP7 3. 4. OP8 OP8 The Spinney equipment needed to meet each residents needs. 5. OP9 The registered manager should ensure good practices are followed for the safe administration of medication. Staff should be familiar with and follow the medication policies and procedures at all times. Dose changes should be clearly recorded and signed by two members of staff, so that residents receive the correct dose of medication. Where possible, changes should be confirmed in writing by the prescriber. There should be clear, personalised directions for the use and administration of when required and variable dose medication for all service users prescribed such items. When required, and variable dose medicines should also be included in the residents care plan. There should be clear, personalised protocols in place for the administration of medication via PEG tubes. Written consent should be obtained from the prescriber prior to administering medication via this route. The opening date should be recorded on eye drops and other items with a short expiry date. Medication requiring refrigerated storage should be stored in a dedicated medication fridge. The fridge temperature should be maintained between 2-8°C. Insulin in current use should not be stored in the fridge. 6. 7. OP15 The registered person should ensure a record is maintained of the food served to residents and special diets prepared for individual residents. The registered person should ensure all hot water outlets are risk assessed and where a risk is identified a suitable device is fitted to control the water temperature. The registered person should ensure the laundry is hygienically clean and the walls painted. The registered person must ensure a system is established for reviewing the quality of care and services provided at the home. OP25 8. 9. OP26 OP33 The Spinney DS0000039828.V336702.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Lancashire Area Office Unit 1 Tustin Court Portway Preston PR2 2YQ National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI The Spinney DS0000039828.V336702.R01.S.doc Version 5.2 Page 27 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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