Inspection on 28/12/05 for The Spinney Hop

This inspection was carried out on 28th December 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. 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 Hop 30/11/06

The Spinney Hop 14/06/05

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 Denise Bate Unannounced Inspection 28th December 2005 10:15 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 DS0000035801.V275563.R01.S.doc Version 5.1 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 DS0000035801.V275563.R01.S.doc Version 5.1 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 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) Derbyshire County Council Margaret Pont Care Home 37 Category(ies) of Old age, not falling within any other category registration, with number (37) of places The Spinney DS0000035801.V275563.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. One place in the category of MD for one named person (PB) dob 12/01/42 for as long as they are accommodated at the home. 14th June 2005 Date of last inspection 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 DS0000035801.V275563.R01.S.doc Version 5.1 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 four hours. There were 35 residents accommodated in the home on the day of the inspection. Six residents were spoken with during the inspection. The care files of four residents were examined, plus other records relating to the home. The acting manager, Suzanne Dore, was available and helpful during the inspection. What the service does well: What has improved since the last inspection? The home had met requirements made following the last inspection. This resulted in improved care planning documentation. The Spinney DS0000035801.V275563.R01.S.doc Version 5.1 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 DS0000035801.V275563.R01.S.doc Version 5.1 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 Outcomes Statutory Requirements Identified During the Inspection The Spinney DS0000035801.V275563.R01.S.doc Version 5.1 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 the following standard(s): 3 Residents had their needs assessed prior to admission to the home. 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 and two were 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 contained background information, referral sheet, medical history, risk assessments, care plans, reviews, residents’ signatures and daily logs (see standard 7). Staff at the home worked closely with other professionals, particularly in relation to residents on the rehabilitation unit. The Spinney DS0000035801.V275563.R01.S.doc Version 5.1 Page 9 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 The arrangements for planning care in this home were generally good ensuring that health, personal and social care needs of people living in the home were fully met. EVIDENCE: The home had worked on care planning since the last inspection. As outlined previously, documents seen on care planning files included appropriate risk assessments, evidence that residents had been consulted about their care plans, evidence of a review system, and care plans that included residents’ preferred routines. Examples of risk assessments included personal handling and assessments of pressure sore risk. Several individual resident’s health needs were discussed, and had been dealt with appropriately. Care plans had been typed and were clear and easy to follow, and included daily routines. It was noted that some care plans for a few residents still had to be updated and were being prepared on the day of inspection. The Spinney DS0000035801.V275563.R01.S.doc Version 5.1 Page 10 Residents spoken to were pleased with the standard of care provided by the home. All were complimentary about the staff, and felt they were hard working and helpful. Staff were observed treating residents with dignity and respect and they met residents’ needs with tact. The controlled drug book was seen and the requirement from the last inspection regarding signing of the drug control book had been complied with for entries after the last inspection. It was noted that one resident is self medicating but had not signed a self medication form because the medication was stored in the medication trolly. The Spinney DS0000035801.V275563.R01.S.doc Version 5.1 Page 11 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, 14, 15 Residents have a lifestyle that matches their expectations and preferences and are able to exercise choice and control over their lives. Dietary needs of service users are well catered for with a balanced and varied selection of food available that meets residents’ tastes and choices. EVIDENCE: Residents confirmed that they are able to follow their own routines, and that activities are available. Activities take place on a daily basis, and a programme was made available. Residents’ interests and preferences are recorded on care planning documentation. Some residents follow their own hobbies and enjoy spending time in their rooms. Most residents enjoy the social life and had established friendships within the home. There had been a Christmas fair and other seasonal activities had taken place. It was clear from residents’ descriptions that they had really appreciated all the hard work undertaken by staff to ensure a good Christmas was enjoyed by everyone. The Spinney DS0000035801.V275563.R01.S.doc Version 5.1 Page 12 Residents indicated that they feel the staff are approachable and any problems can be discussed with them or with one of the managers. All indicated that they are able to exercise choice about aspects of their daily lives. All residents were complimentary about the standard of catering, and the choice of menus that are available. Menus were seen and found to be varied and to offer choice. Residents said that the food is always well presented, and that Christmas dinner had been excellent. The home has adequate stocks of food, and keeps appropriate health and safety records in the kitchen. Some areas of the kitchen are poorly decorated with flaking paint; some cupboards have no doors, and some work surfaces are uneven. It is understood that a meeting is to be held with the estates department early in 2006 to discuss an action plan for improvement. The Spinney DS0000035801.V275563.R01.S.doc Version 5.1 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 the following standard(s): 18 There are systems in place which promote the protection of service users from abuse and neglect. The Acting Manager is aware of adult protection procedures and staff have had received training. EVIDENCE: A discussion took place with the Acting Manager, who is aware of adult protection issues and feels she would receive good advice and support from her line manager if ever an adult protection situation arose within the home. Most staff have had training in adult protection within the last two years and this is recorded on their individual training records. The Spinney DS0000035801.V275563.R01.S.doc Version 5.1 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 the following standard(s): None No standards were inspected on this occasion. EVIDENCE: The Spinney DS0000035801.V275563.R01.S.doc Version 5.1 Page 15 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): 29, 30 Residents are supported and protected by the home’s recruitment policy and practices. Staff are generally trained and competent to do their job, although it was noted that fire safety training was outstanding for some staff. EVIDENCE: Some new members of staff had been recruited and are awaiting CRB checks before starting work. Recruitment policies are laid down by Derbyshire County Council, and, by agreement, some personnel records are held centrally. Training records for some staff were seen. It was noted that the home have over 50 of care staff trained to NVQ level 2. Staff spoken to indicated that training opportunities were good and that training offered was of a high standard. However, some records are not complete, and several members of staff have not had fire safety training within the last year. The Acting Manager stated that she has been involved in the induction of new staff. Staffing rotas were made available and they specified the designation of staff and details of the hours worked by the acting or deputy managers, as required at the last inspection. The Spinney DS0000035801.V275563.R01.S.doc Version 5.1 Page 16 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): 33, 35,38 The home is run in the best interests of the residents. Residents’ financial interests are safeguarded. Not all documentation could demonstrate that residents’ health, safety and welfare is generally promoted and protected. EVIDENCE: All residents spoken to expressed satisfaction with standards within the home and were complimentary about the staff. The home had worked on the requirements made at the last inspection and so demonstrated a willingness to carry out on going improvements. The Spinney DS0000035801.V275563.R01.S.doc Version 5.1 Page 17 The home has a system for safeguarding residents’ money and valuables and this was explained and demonstrated. The records were checked against some monies and found to be correct. Health and Safety documentation and records were examined. Some records were up to date, e.g. fire safety records, PAT testing, risk assessments, and COSHH assessments. Other records had been filed in the wrong place, e.g. gas safety records, some servicing records. Some records could not be found, e.g. hoist servicing records, 5 year hard wiring certificate. It was accepted by the home that the records need to be organised and updated to provide ease of access to information, and ensure that all appropriate health and safety records were in place. Further gas safety work has been identified as needing to be done (report dated November 2005). Although management arrangements were not formally inspected on this occasion, a discussion took place with the acting manager and two deputies. Each deputy takes responsibility for an aspect of the day to day running of the home, and it is felt that this clear responsibility and commitment to team work is helpful. The acting manager will inform CSCI if any changes are made to management arrangements in the near future. Regular Regulation 26 visits take place and copies of reports were made available. The Spinney DS0000035801.V275563.R01.S.doc Version 5.1 Page 18 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 X 3 X X X HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 X 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 X 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 X 17 X 18 3 X X X X X X X X STAFFING Standard No Score 27 X 28 X 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X X 3 X 3 X X 2 The Spinney DS0000035801.V275563.R01.S.doc Version 5.1 Page 19 no 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. 2. 3. 4. 5. Standard OP7 OP15 OP15 OP30 OP38 Regulation 15 23 2 (b) 23 2 (b) 23 4 (d) 23 2 (b) Requirement The programme of updating care plans must be completed and maintained. The kitchen must be redecorated. Consideration must be given to replacing and/or upgrading work surfaces and cupboards. All staff must receive appropriate fire safety training within the specified timescales. Health and safety records need to be organised and updated to provide ease of access to information, and ensure that all appropriate health and safety records up to date, including gas safety work (report dated November 2005). Timescale for action 28/02/06 30/06/06 30/06/06 28/06/06 28/06/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. The Spinney Refer to Good Practice Recommendations DS0000035801.V275563.R01.S.doc Version 5.1 Page 20 1. Standard OP9 If residents are self medicating they should sign the appropriate self medication forms. The Spinney DS0000035801.V275563.R01.S.doc Version 5.1 Page 21 Commission for Social Care Inspection Derbyshire Area Office 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 DS0000035801.V275563.R01.S.doc Version 5.1 Page 22 - 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!