CARE HOMES FOR OLDER PEOPLE
The Spinney 21 Armley Grange Drive Leeds LS12 3QH Lead Inspector
Sue Dunn Key Unannounced Inspection 8th November 2006 10:40 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 DS0000001504.V313905.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. DS0000001504.V313905.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 279 2571 0113 279 2571 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 DS0000001504.V313905.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION
Conditions of registration: Date of last inspection 12th December 2005 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. DS0000001504.V313905.R01.S.doc Version 5.2 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. The purpose of the inspection visit was to ensure the home was operating and being managed for the benefit and well being of the service users. One inspector undertook the inspection, which was unannounced. The inspection started at 10.40am and finished at 5.15 pm. A pre inspection questionnaire had been completed and returned by the manager and was used to support judgements made during the inspection visit. The report is based on information received from the home since the last inspection in December 2005, observation and conversation with service users, staff and relatives, examination of documentation including 3 care files (two of which were tracked), sampling the midday meal and an inspection of the premises. The weekly fees range from £373 to £417 per week. The services not included in the fee are hairdressing, private chiropody, personal clothing and toiletries, newspapers and magazines. All the requirements and recommendations made in the last report had been completed or showed signs of improvement. DS0000001504.V313905.R01.S.doc Version 5.2 Page 6 What the service does well: What has improved since the last inspection?
There had been some improvement in the assessments particularly in the quality of information received from other agencies. The care files had been improved with daily events well recorded and relevant to the care given. All care files included a photograph and showed evidence of the involvement of service users. An excellent personal profile section in each file gave staff an understanding of each person’s uniqueness and guided them towards the type of support needed. There was a more proactive approach to activities which gave social activities within the home and opportunities in the wider community. Formal adult protection training for staff was well underway. The manager had developed a file about abuse and the action to be taken for the benefit of new staff. The CSCI had been notified of any events in the home affecting the well being of service users. The fire training had been formalised with a visual presentation followed by a written test.
DS0000001504.V313905.R01.S.doc Version 5.2 Page 7 Some carpets and the dining room furniture had been replaced since the last inspection. Bedrooms were clean and well decorated. These were redecorated when they became vacant. Work had started to upgrade the laundry area. The garden had been improved to create an additional outdoor sitting area following the completion of building work. Recruitment and selection procedures had been improved. 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. DS0000001504.V313905.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS
Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection DS0000001504.V313905.R01.S.doc Version 5.2 Page 9 Choice of Home
The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 3, 4 and 5 Quality outcomes in this are good. This judgement is based on all the available evidence, which included, discussion with the manager, service users and relatives and examination of three care files. The manager expects detailed information from social workers and encourages prospective service users to visit to be able to make an informed choice about the home. The home’s own assessment did not give sufficient detail to show how staff had reached the decision that needs could be met. This could be improved by making more use of the comments section of the form. It is recommended that a copy of the Statement of Purpose and brochure be made accessible to people who live in the home as these documents are often held by relatives. EVIDENCE: Two care files were examined in order to check the quality of pre admission assessments of people being admitted to the home. There was a very informative ‘Easy Care’ assessment and hospital discharge sheet for a person admitted since the last inspection but no evidence of an assessment by the home. The manager and care worker thought this had been done but were unable to locate it.
DS0000001504.V313905.R01.S.doc Version 5.2 Page 10 Another file included notes of a pre visit and the person’s views on the home. The assessment was in a pre printed tick box format which gave an indication of basic care needs. This could have been improved by writing more in the comments section of the form. Both people, when spoken to, said they had not received any written information about the home and felt they should have done. This was discussed with the manager. One of the files contained an admission checklist sheet signed by the person to say he had received the Statement of Purpose and Brochure. The proprietor said she thought families might have kept the information. It is suggested that a copy of the information about the home be placed in each bedroom for people to read at their leisure. Two relatives spoken with said they and the prospective service users had the opportunity to visit the home to make an informed choice about moving in. DS0000001504.V313905.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9, 10 and 11 Quality outcomes in this are were good. This judgement was based on all the available evidence which included examination of three care files, discussion with service users , relatives and the manager and staff and observation. The health and overall care needs of service users were well met with good written and verbal systems of communication observed. Service users were able to manage their own medication subject to approval by the GP and were protected by the medication systems. EVIDENCE: Three care files were examined. The home had developed the care plan documentation with the introduction of a second book, used as a diary of events. A brief plan (the form did not allow for more than a summary) at the front of the book covered each area of care in a way which made it easy for staff to follow. Both books had their strengths and used in conjunction gave a full picture of the care given. The layout of the books however limited the way care planning information was recorded, only allowing scope for one overall care plan. Each need should be identified separately and have a clear action plan. In this way more could be done to show how the risk management plans supported independence.
DS0000001504.V313905.R01.S.doc Version 5.2 Page 12 The care plan books had very good personal profile information and included the documentation of monthly reviews of care. Staff were responsible for updating information each month from the daily diary notes therefore the care documentation reflected the care given. One of the files seen included a list of preferences and strengths, sleeping patterns and preferences a dependency profile, medical appointments and details of other health professional visits. It was clear that the service users had been involved in this process. District nursing notes were held together with the care files so could be used for cross-reference. Communication was good between the staff and the manager who was seen to take action in response to any concerns brought to her attention. A district nurse and a psychiatrist visited during the course of the inspection visit. A local vicar made one of his routine visits the home to provide group and individual practical and spiritual support. A member of staff explained the medication procedures whilst giving the lunchtime medication. This was done in a safe and competent way with a good understanding of safety measures and the medication being given. Staff who administered medication had received training which was seen to be put into practice. DS0000001504.V313905.R01.S.doc Version 5.2 Page 13 Daily Life and Social Activities
The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15 The quality outcome in this area is good. This judgement is based on all the available evidence, which included, information from the pre inspection questionnaire and activities file, observation, discussion with staff, service users, the vicar and relatives. Some people in the home wished to continue activities as before. The home appeared to strike a good balance between relaxation and a more proactive approach to social and recreational activities. The nutritious and varied food was freshly cooked by enthusiastic staff who took a pride in the standard of their cooking. EVIDENCE: Observation and conversation with service users, staff, a vicar, relatives and the manager revealed a more proactive approach to social and recreational activities. An activities file had been introduced which showed who participated in which activity when. Staff take turns to organise some kind of activity each afternoon. A member of staff said the personal profile in the care files was very helpful in prompting conversation. There were several people in the home who enjoyed Scrabble and an enthusiastic team had formed. Newspapers and magazines were seen around the home and people were able to make an active choice about watching the television.
DS0000001504.V313905.R01.S.doc Version 5.2 Page 14 Arrangements had been made for some people to attend local community facilities and a day centre as long as they were able to fund their own transport. At least one person was to attend the local remembrance service and the proprietor had taken small groups of people out for a fish and chip lunch. The manager was discrete in pointing out anything which might compromise dignity. This was clearly appreciated. The manager spoke of friendships, which had developed, to the mutual benefit and self esteem of the service users. Two people had the task of folding napkins decoratively for the dining tables. This was a daily task, which they clearly enjoyed. Care staff with the basic food hygiene certificate do the cooking on a rotational basis. Staff were said to be quite competitive in their ideas for fresh baking and dishes, which they thought service users would like. The meal sampled used freshly cooked ingredients and baking served from a heated trolley in the dining room. Service users had been consulted when the teatime menu was changed for the winter months to provide a hot option. Freshly baked Cornish pasties were on the teatime menu. Service users said that if they wished they could have breakfast and other meals in their rooms. Dining tables were nicely laid with clean cloths, mats, napkins and condiments. Weight is routinely monitored and food supplements were being used for some people. DS0000001504.V313905.R01.S.doc Version 5.2 Page 15 Complaints and Protection
The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 Quality in this outcome area is good. This judgement is based on all the available evidence, which included, discussion with the manager and proprietor, service users, relatives, staff and examination of documentation. There is a non-judgemental approach which encourages service users to express their views and feel they can grumble. The manager was said to listen and deal with matters within her control. There had been improvements in the area of adult protection. EVIDENCE: There had been no complaints since the last inspection. Some people openly grumbled about matters beyond the home’s control, such as having to pay for a regular chiropody service and about their wish to go out unaccompanied. There is an open attitude to such grumbles and a relative said the manager would deal with anything that was within her control. Some staff had had Adult Protection training since the last visit and others were booked to do the course. The manager had put an information file together about abusive behaviour for all new staff that told them what to do if it was observed. The home should have a system in place for periodic updating of Criminal Record Bureau checks. DS0000001504.V313905.R01.S.doc Version 5.2 Page 16 Environment
The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 21, 22, 23, 24, 25 and 26 Quality outcomes in this are good. This judgement is based on all the available evidence, which included, discussions with the proprietor and manager, observation and a tour of the building and conversations with service users and relatives. There is an ongoing programme of repair, maintenance and cleaning which keeps the home to a high standard of cleanliness and comfort. EVIDENCE: The home’s maintenance man employed for one day a week was gradually providing covers on the radiators throughout the home. Most bedroom doors had locks of an approved type with only a few in the older part of the building still needing to be replaced. It was pleasing to note that several people had locked their bedroom doors and several were using their room during the day. The ongoing improvement programme included the redecoration of bedrooms as they became empty and new hall and staircase carpets. Service users said they had been shown the samples of carpet and wallpapers before redecoration and replacement.
DS0000001504.V313905.R01.S.doc Version 5.2 Page 17 The dining room furniture had been replaced with a selection of chairs and tables to suit all requirements. This also allowed space between furniture for people to move about freely. Some settling of the doorframe of the fire exit door on the first floor was causing it to stick and not close fully once opened. This required attention. The home was clean and free from unpleasant odours with the exception of one room. The proprietor may wish to consider a non- slip washable floor covering if the problem persists. The laundry area was in the process of a refurbishment. It was noted that personal clothing and bedding was well laundered and cared for. Antibacterial hand washing gels are to be provided in all key areas when the laundry is completed. Some staff said they carried their own. Instructions on the heating system were posted on the office wall to ensure staff could adjust the heating according to service users needs. Radiators could be individually adjusted. The rear of the building had been landscaped with table and chairs for people to sit out. Service users said they had parasols and sunhats for shade during the hot summer period. DS0000001504.V313905.R01.S.doc Version 5.2 Page 18 Staffing
The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30 Quality outcome in this area is good. This judgement is based on all available evidence, which included info from the pre inspection questionnaire, examination of staff files and other documentation, discussion with two staff recently appointed into post, and observation. The home had a thorough recruitment and selection procedure followed by a good training programme. This resulted in a stable, well-balanced mix of competent staff and the consequent benefits for the service users. EVIDENCE: The home has a stable staff team. Staff were observed to be confident, open and friendly in their dealings with service users who spoke highly of the care they received. Good progress had been made on training and the home had exceeded the minimum target for staff with the NVQ award. For example all but three staff on nights had NVQ, four were working towards the award. Three more staff were doing a literacy test in preparation for NVQ on day of the visit. The NVQ assessor spoke highly of the home’s commitment to training. Recruitment and selection information was inspected. This showed a professional approach. One post advertised internally, had a job description, employee spec and a copy of interview questions. Notes from an interview could have been improved however with more detailed information to show how decisions had been reached. Induction training records met GSCC standards.
DS0000001504.V313905.R01.S.doc Version 5.2 Page 19 Specific staff training had included dementia, anxiety and depression, adult protection and annual updates on moving and handling. The trainee deputy manager of only a few weeks said she was familiar with the guidance on National Minimum Standards for Care Homes. Staff were observed to communicate well between each other and the manager regarding their whereabouts and care given to service users. Information given to the manager about changing care needs was acted upon quickly. Staff appeared confident in recording the care they had given as a matter of routine. DS0000001504.V313905.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 32, 33, 35, 36, 37 and 38 Quality outcomes in this area were good. This judgement is based on all the available evidence, which included, information from the pre inspection questionnaire, examination of documentation, discussion with the proprietor, manager and staff and observation. The home is well managed with a constant eye on how improvements can be made. There is a commitment to a training programme that gives staff the skills and knowledge to act in a way which protects the safety and interests of the people living in the home. EVIDENCE: The manager and proprietor form a good team. Both have day-to-day contact with service users and set clear standards for staff. Staff meetings are held three monthly. Examination of the minutes of the last meeting in October showed the content of the meeting covered care and health and safety matters. Staff are able to contribute to the agenda via a
DS0000001504.V313905.R01.S.doc Version 5.2 Page 21 suggestion box before each meeting and are encouraged to actively participate in discussions. All staff sign to say they have read the minutes of the meetings. Staff said they have formal supervision but the manager said she had struggled to provide this 6 times a year. This may improve when the trainee deputy manager can assist. Service users, visitors and staff received customer satisfaction questionnaires last year (05). The notes on this showed the proprietor had taken action in response to comments. Service users were able to access to their own money easily and were kept informed about their remaining balance. New staff said they receive instruction on the fire safety system, policies and procedures, and the layout of home. A full fire training using a CD and followed by a written test took place in October. Each member of staff had a record of their fire training in their staff file. A newly installed fire system shows any faults at each break glass point. These are checked on a rotational basis and the results recorded. The fire exit door on the first floor needed repairing to ensure it was fully closing. DS0000001504.V313905.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 3 3 3 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 4 9 3 10 4 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 4 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 x 18 3 3 3 3 3 3 2 2 4 STAFFING Standard No Score 27 4 28 3 29 3 30 4 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 4 4 3 x 3 3 3 2 DS0000001504.V313905.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 2 3 Standard OP38 OP24 OP25 Regulation Reg.23 Reg. 16 Reg.13 Requirement The door to the internal fire escape route must be made to close fully. All bedroom doors must be fitted with locks of an approved kind. The outstanding work to provide covers for all radiators must be completed. Timescale for action 31/12/06 31/03/07 31/03/07 DS0000001504.V313905.R01.S.doc Version 5.2 Page 24 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 2 3 4 5 Refer to Standard OP1 OP4 OP7 OP26 OP29 Good Practice Recommendations A copy of the Statement of Purpose and Brochure should be accessible for people to refer to when they are in the home. The homes pre admission assessment should be detailed enough to show how the overall range of needs are to be met The home should introduce a format for care plans that shows each area of need separately. A satisfactory solution should be found to improve odour control in the area discussed Interview notes should contain enough detail to show how decisions had been reached DS0000001504.V313905.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection Aire House Town Street Rodley Leeds LS13 1HP National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
© This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI DS0000001504.V313905.R01.S.doc Version 5.2 Page 26 - 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. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!
