Inspection on 14/06/05 for The Spinney Hop

This inspection was carried out on 14th June 2005.

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

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

Other inspections for this house

The Spinney Hop 30/11/06

The Spinney Hop 28/12/05

The Spinney Hop 19/10/04

The Spinney Hop 29/06/04

Similar services:

Byars Care Home

St Marys Nursing Home

Bramble Lodge

Parkmanor Residential Home

Thornham Grove

Hunter`s Lodge

London Road Neurological and Specialist Care Unit

Carlton Care Home

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

CARE HOMES FOR OLDER PEOPLE THE SPINNEY Woodlands off Lansdowne Road Brimington Chesterfield Derbyshire S43 1BE Lead Inspector Rose Veale Unannounced Inspection Tuesday 14th June 2005 at 9.45am 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 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 C52 CO2 S35801 The Spinney V232583 140605 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service The Spinney Address Woodlands off Lansdowne Road Brimington Chesterfield Derbyshire S43 1BE 01246 347530 01246 347530 Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Derbyshire County Council Margaret Pont Care Home 37 Category(ies) of OP registration, with number of places THE SPINNEY C52 CO2 S35801 The Spinney V232583 140605 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: None Date of last inspection 19/10/2004 Brief Description of the Service: The Spinney is a care home registered to provide personal care and accommodation for up to 37 older people. It is a purpose built care home located at the head of a residential cul-de-sac in its own private grounds. The home is near to the local shops and the village of Brimington. Residents at the home are all accommodated in single, ground floor rooms. The rooms are arranged in 3 wings of the home, each wing having its own kitchen, lounge and dining areas. The home provides 3 short-term care beds and 5 en-suite bedrooms for rehabilitation. There is a large lounge and reception area. The home has well-maintained gardens with accessible seating areas for residents. THE SPINNEY C52 CO2 S35801 The Spinney V232583 140605 Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection was unannounced and took place over a period of five and a half hours. There were 37 residents accommodated in the home on the day of the inspection, including 5 for rehabilitation and 6 for short-term care. 7 residents, 3 staff and 2 visitors were spoken with during the inspection. The care files of four residents were examined, plus other records relating to the home. A tour of the home was undertaken. The acting manager, Suzanne Dore, was available and helpful during the inspection. What the service does well: What has improved since the last inspection? An acting manager had been appointed to ensure satisfactory organisation and management of the home. The home had met some of the requirements made following the last inspection. This resulted in improved access to the garden and improvements in record keeping and staff supervision. The home had provided handrails to the garden and patio area to assist residents. THE SPINNEY C52 CO2 S35801 The Spinney V232583 140605 Stage 4.doc Version 1.30 Page 6 What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. THE SPINNEY C52 CO2 S35801 The Spinney V232583 140605 Stage 4.doc Version 1.30 Page 7 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 Standards Statutory Requirements Identified During the Inspection THE SPINNEY C52 CO2 S35801 The Spinney V232583 140605 Stage 4.doc Version 1.30 Page 8 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 standard(s) 3, 4 and 6 Although residents had their needs assessed, the assessments did not provide enough information to ensure that all individual needs were fully met. The rehabilitation service provided by the home focused on promoting independence and was well-used. EVIDENCE: Care files were seen for four residents. Two were long-term residents, one was a short stay resident, and one was receiving rehabilitation. All the files seen contained appropriate assessment information such as the Community Care Assessment, an assessment by hospital staff, or an assessment by the community rehabilitation team. The files of the long-term and short stay residents did not have properly completed nutritional assessments, and two files had no moving and handling assessments. None of the files seen contained risk assessments. Three of the files contained a Personal Service Plan detailing the care and assistance required by each resident for activities of daily living. The care file THE SPINNEY C52 CO2 S35801 The Spinney V232583 140605 Stage 4.doc Version 1.30 Page 9 for the resident receiving rehabilitation did not contain a Personal Service Plan. Although the care plans covered most of the required areas, there was a lack of detail in some areas about the action needed by staff to ensure residents’ needs were properly met. (See Standard 7). Residents spoken with during the inspection were pleased with the care provided by the home and felt their needs were met. Staff spoken with felt that appropriate and adequate training was provided to enable them to meet the needs of residents. Staff commented on the usefulness of recent dementia awareness training. The acting manager said that the home had recently started sending letters to new residents, (following assessment), to say that The Spinney was able to meet their individual needs. This was a requirement at the previous two inspections. The home provides a rehabilitation service for up to 5 people. Residents receiving the rehabilitation service are accommodated on a wing of the home dedicated for this purpose with single, en-suite rooms. Residents admitted for rehabilitation received specialist support from occupational therapists and physiotherapists. Dedicated space and equipment was provided specifically for rehabilitation. The acting manager said that, since the last inspection, a medical certificate from the GP was required for residents admitted for rehabilitation directly from hospital. This was to ensure that the residents’ needs could be properly met by the home as previously residents had been admitted whose needs were primarily medical. THE SPINNEY C52 CO2 S35801 The Spinney V232583 140605 Stage 4.doc Version 1.30 Page 10 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 standard(s) 7and 8 There was a lack of detail in care plans which may mean that not all residents’ needs could be fully met. EVIDENCE: The care files of four residents were seen. One resident admitted for rehabilitation had a multi-disciplinary care plan from the occupational therapist and physiotherapist, but no Personal Service Plan prepared by the home. The other three residents had Personal Service Plans which covered most of the areas required. However, these plans did not include oral care and were not always detailed enough in describing the action required by staff to meet residents’ needs. The three Personal Service Plans seen had been reviewed monthly by the linkworker. However, the plans had not been updated to include changing needs of residents. For example, one resident’s monthly reviews noted recent falls and increasing continence needs but the plan did not reflect these issues. The monthly reviews did not appear to include consultation with the resident or their representative. None of the Personal Service Plans seen were dated. The acting manager said that some training regarding care plans had been carried out with staff. Also, that one of the deputy managers had been allocated to oversee care plans and to assist staff with writing and reviewing care plans. THE SPINNEY C52 CO2 S35801 The Spinney V232583 140605 Stage 4.doc Version 1.30 Page 11 Records were seen of visits from GPs, District Nurses, chiropodist, dentist and optician. It was identified in one care plan seen that the resident had recently been fitted with a hearing aid. From the care files seen, some aspects of residents’ health needs were not adequately assessed by the home. For example, none of the files seen contained a fully completed nutritional assessment or an assessment of the risk of developing pressure sores. Although Standard 9 was not assessed at this inspection, the Medication Administration Records, (MARs), and the home’s Controlled Drug book were seen as part of checking care notes and related records. All the MARs seen were completed with initials or code letters in the administration record. Some MARs had handwritten entries which were not signed by the person writing them or countersigned to show they had been checked by another person. The Controlled Drugs book had not always been correctly completed – there were instances of drugs taken home with residents not recorded, and stock received into the home entered in the book but not signed by the staff checking it. The drugs fridge temperature had been checked weekly until the day of the inspection, then daily checking had commenced. However, the temperatures were not monitored with a maximum / minimum thermometer as advised in the Royal Pharmaceutical Society guidelines for care homes. THE SPINNEY C52 CO2 S35801 The Spinney V232583 140605 Stage 4.doc Version 1.30 Page 12 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 standard(s) 13 The home’s visiting policy ensured that residents were able to maintain contact with family and friends. EVIDENCE: Residents spoken with confirmed that they were able to have visitors at any reasonable time and were able to see visitors in private. The home had an open visiting policy and the Service User’s Guide referred to this. Two visitors spoken with during the inspection said they were always made to feel welcome by staff and that they enjoyed visiting the home. THE SPINNEY C52 CO2 S35801 The Spinney V232583 140605 Stage 4.doc Version 1.30 Page 13 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 standard(s) 16 The policies and procedures in the home, and staff awareness and attitudes, ensured that residents had confidence in the home’s ability to deal effectively with complaints. EVIDENCE: The home had a clear complaints procedure in place which contained all the required information. There was a notice on each wing of the home referring to the complaints procedure. A record was kept of minor complaints, (ie those complaints where the complainant did not wish to go through the formal procedure), and the action taken. This was put in place following a recommendation made at the last inspection. Staff spoken with were aware of the complaints procedure in the home. Residents spoken with said they had never had any cause to make a formal complaint, but they would feel comfortable bringing any complaint to the attention of staff, particularly those staff residents knew well. One resident said a minor issue had been dealt with quickly by staff as soon as it was brought to their attention. THE SPINNEY C52 CO2 S35801 The Spinney V232583 140605 Stage 4.doc Version 1.30 Page 14 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 standard(s) 19, 20, 24 and 26 The home was clean and comfortable, and the garden was well-maintained and accessible, providing a pleasant environment for residents. EVIDENCE: The home was generally well maintained and decorated. The work required to make the garden paths safe and accessible had been carried out, (as required following the last inspection). Hand-rails had been installed in the garden and patio areas to assist residents. The communal areas of the home were pleasant and comfortable. The furnishing and lighting in these areas was domestic in character. The gardens had patios with seating for residents. The acting manager said raised beds around a patio area were being planted by staff with the assistance of a visitor to the home. Residents spoken with were discussing the progress of this work. Residents said they enjoyed using the garden in good weather and said they were able to have meals outside during the summer. THE SPINNEY C52 CO2 S35801 The Spinney V232583 140605 Stage 4.doc Version 1.30 Page 15 During a tour of the home, several residents’ bedrooms were seen. All were clean, pleasant, comfortably furnished and personalised with residents’ own possessions. All rooms had a lockable drawer and all the doors were lockable. The care files seen contained a record of the wishes of the resident regarding having a key to their bedroom door. The home appeared clean, hygienic and free from offensive odours on the day of the inspection. The laundry was clean and tidy and met with all requirements. THE SPINNEY C52 CO2 S35801 The Spinney V232583 140605 Stage 4.doc Version 1.30 Page 16 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27 The staffing levels in the home were adequate, but needed to be kept under review to ensure the changing needs of residents could always be met. EVIDENCE: The staff rotas were seen which indicated appropriate staffing levels for the needs of residents. The acting manager said that staff vacancies in the home had recently been advertised with a good response for one post, but a disappointing response to two other posts. Staff spoken with felt that staffing levels were adequate, but that additional staff would help to provide a better service for residents. Staff particularly felt that they would be able to provide more social activities and one-to-one time for residents if staffing levels were increased. Residents spoken with were generally happy with staffing levels in the home, though one short-term care resident felt that staff were more stretched than they had been on previous admissions. The staffing rotas did not specify the designation of staff and did not include details of the hours worked by the acting manager or deputy managers. THE SPINNEY C52 CO2 S35801 The Spinney V232583 140605 Stage 4.doc Version 1.30 Page 17 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31, 36 and 37 Acceptable management arrangements were in place to ensure the satisfactory organization of the home and to safeguard residents and improve the service offered. EVIDENCE: The manager of the home was on long-term sick leave and the acting manager had been recently appointed. The Commission for Social Care Inspection had been notified of this situation, as required following the last inspection. The acting manager had previously worked as a deputy manager at the home. She had several years experience in care and was working towards the Registered Manager’s Award. Staff spoken with were pleased that the acting manager had been appointed and felt confident in her ability to manage the home. Staff felt that all the management team were approachable and ‘hands on’. Staff supervision records were seen and indicated that staff were receiving supervision at least every other month. Staff spoken with confirmed that THE SPINNEY C52 CO2 S35801 The Spinney V232583 140605 Stage 4.doc Version 1.30 Page 18 supervision was taking place and said they found it useful. The acting manager said that she and the deputy managers received supervision from their line manager. Records were stored securely in the home. Requirements had been made following the last inspection with regard to record keeping and some of these had been met, such as notification to CSCI of events covered by Regulation 37. However, some gaps in record keeping remained, as indicated in Standards 3 and 7. The policies and procedures manual in use in the home had not been reviewed or updated as required following the last inspection. The gas safety certificate was not available at this inspection and it appeared that the work required for completion of this had not been carried out. This was a requirement following the last inspection. THE SPINNEY C52 CO2 S35801 The Spinney V232583 140605 Stage 4.doc Version 1.30 Page 19 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score x x 2 3 x 3 HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 x 10 x 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 x 13 3 14 x 15 x COMPLAINTS AND PROTECTION 3 3 x x x 3 x 3 STAFFING Standard No Score 27 3 28 x 29 x 30 x MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x x 3 x x x x 3 2 x THE SPINNEY C52 CO2 S35801 The Spinney V232583 140605 Stage 4.doc Version 1.30 Page 20 YES Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard 3 Regulation 14 Schedule 3 15 Schedule 3 Requirement Full assessment information must be obtained for all service users admitted to the home that covers standard 3.3. Original timescale 01/12/04 The registered person must prepare a written plan as to how the service users needs in respect of their health and welfare are to be met including those service users accommodated on the rehabilitation unit. Original timescale 01/12/04 The registered person must ensure that service users plans set out in detail the actions that need to be taken by care staff to meet the needs of the service user. Original timescale 01/10/04 A risk assessment with particular attention to falls must be included in the personal service plan. Original timescale 01/10/04 The personal service plan must be reviewed in consultation with the service user or their representative All medication received into the Timescale for action 31/07/05 2. 3 31/07/05 3. 7 15 31/07/05 4. 7 15 31/07/05 5. 7 15 31/07/05 6. 9 13 31/07/05 Page 21 THE SPINNEY C52 CO2 S35801 The Spinney V232583 140605 Stage 4.doc Version 1.30 7. 8. 9 33 13 17 Schedule 3 9. 37 17 10. 38 13 home and and all medication leaving the home must be correctly recorded All entries in the Controlled Drugs book must be signed by two members of staff Policies and procedures must be regularly reviewed in light of changing legislation and of good practice advice from the Department of Health, local / health authorities and specialist / professional organisations. Original timescale 01/02/05 The registered person must ensure that records are maintained in accordance with the regulations. Original timescale 01/01/05 The registered person must ensure that the works identified for completion on the gas safety certificate of July 2004 are completed. Original timescale 01/12/04 31/07/05 30/09/05 30/09/05 31/07/05 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. 3. 4. Refer to Standard 1 1 1 27 Good Practice Recommendations Service user views of the home should be included in the service user guide Information as to how to contact the local health care authorities should be included in the service user guide The Statement of Purpose should include details of the rehabilitation beds, the admission criteria and the range of needs The staffing rota should clearly identify the designation of staff and should include the acting manager and deputy managers THE SPINNEY C52 CO2 S35801 The Spinney V232583 140605 Stage 4.doc Version 1.30 Page 22 Commission for Social Care Inspection Cardinal Square Nottingham Road Derby DE1 3QT 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 THE SPINNEY C52 CO2 S35801 The Spinney V232583 140605 Stage 4.doc Version 1.30 Page 23 - 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!