Inspection on 27/11/07 for Cold Springs Park

This inspection was carried out on 27th November 2007.

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

Cold Springs Park 08/10/08

Cold Springs Park 28/09/06

Cold Springs Park 20/10/05

Cold Springs Park 29/04/05

Cold Springs Park 25/10/04

Cold Springs Park 07/04/04

Cold Springs Park 27/02/04

Extracts from inspection reports are licensed from CQC, this page was updated on 08/07/2008.

CARE HOMES FOR OLDER PEOPLE Cold Springs Park Scaws Road Penrith Cumbria CA11 8EY Lead Inspector Jenny Donnelly Unannounced Inspection 27th November 2007 09:10 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 Cold Springs Park DS0000022545.V351802.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. Cold Springs Park DS0000022545.V351802.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Cold Springs Park Address Scaws Road Penrith Cumbria CA11 8EY 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) 01768 890360 lannigab@bupa.com www.bupa.co.uk BUPA Care Homes (CFC Homes) Ltd Mrs Lynne Diane Stanley Care Home 40 Category(ies) of Dementia - over 65 years of age (5), Old age, registration, with number not falling within any other category (40) of places Cold Springs Park DS0000022545.V351802.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The home is registered for a maximum of 40 service users to include: up to 40 sevice users in the category of OP (Older people) up to 5 service users in the category of DE(E) ( Dementia over 65 years of age) The service should at all times employ a suitably qualified and experienced manager who is registered with the Commission for Social Care Inspection. 28th September 2006 2. Date of last inspection Brief Description of the Service: BUPA Cold Springs Park provides accommodation and care for up to 40 older people, five of who may have dementia. The home is owned and run by Care Homes First Limited, a subsidiary of BUPA Care Services. The home is in a residential area approximately one mile from the centre of the market town of Penrith and local amenities. Single occupancy accommodation for residents is on ground floor level with en-suite toilet and hand wash facilities. There are three lounges, which can be used for activities. The building and garden areas are very well maintained and there are sheltered patio areas. Car parking facilities are available for staff and visitors. People who use wheelchairs can access all parts of the home and grounds. At the time of this inspection the weekly fees ranged from £373.00 to £576.00. Information about Cold Springs Park, including a brochure, statement of purpose and copies of inspection reports could be obtained directly from the home. Cold Springs Park DS0000022545.V351802.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was the main or “key” inspection of the service. Jenny Donnelly inspector, made an unannounced visit to the service on 27th November between the hours of 09.10 and 15.15 hours. During the visit we toured the building, spoke with residents, visitors, staff and the manager. We looked at care, medication, staffing and maintenance records, and observed how people were spending their day. Prior to this visit the manager had completed and returned an Annual Quality Assessment Audit (AQAA) that we had requested. The AQAA is a selfassessment that focuses on how well outcomes are being met for people using the service. It also gave us some numerical information about the service. We sent surveys out to half of the people who live in the home, their relatives and staff. The findings of the surveys are included in this report. What the service does well: What has improved since the last inspection? What they could do better: The management of medicines in the home was not good enough. Improvements need to be made in the recording, storage and administration of medicines, and requirements are made on this. Good practice recommendations are that people should be invited to read and sign agreement to their care plan. The bathrooms should be upgraded. Records of complaints should be better managed. The manager should take Cold Springs Park DS0000022545.V351802.R01.S.doc Version 5.2 Page 6 advice from the environmental health officer about the arrangements for people to smoke in the home. 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. Cold Springs Park DS0000022545.V351802.R01.S.doc Version 5.2 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 Cold Springs Park DS0000022545.V351802.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 3 and 5 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. There is good information available about the service for anyone interested, and the admission process helped people to know if this care home would suit their needs. EVIDENCE: The home had produced a statement of purpose and an informative information pack for prospective residents and their families. People were issued with a contract of residency either directly with themselves or through their funding agent. The manager had carried out pre-admission assessments of prospective residents, to assess their health, personal and social care needs. This helped the manager judge whether Cold Springs Park would be suitable for each person’s individual needs. The process also allows prospective residents and their families to ask more about the service. Some people we spoke to have particularly chosen to live at Cold Springs Park, whilst others said it was the only place available at the time. People were welcome to visit Cold Springs Park DS0000022545.V351802.R01.S.doc Version 5.2 Page 9 and look around the home. The home does not provide an intermediate care facility. Cold Springs Park DS0000022545.V351802.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. People were receiving a good standard of daily personal care, but the management of medicines could be improved. EVIDENCE: Since the last inspection a new care planning system had been set up in the home, and this was mostly working very well. We looked at the care records of four people and found them to be well organised and up to date, with most risk assessments having being regularly reviewed. There were some instances where new information recorded in the daily notes, should have been included in the persons care plan. There was no evidence that people or their representatives had signed to agree to their plan of care, although there appeared to be a page set up for this purpose. Care plans did include information about people’s personal preference and choice, such as who liked a bath or shower and what time people liked to get up and go to bed. There was evidence showing that people had good access to their doctor and to the community nurse, as well as other health professionals including the Cold Springs Park DS0000022545.V351802.R01.S.doc Version 5.2 Page 11 chiropodist and optician. We spoke with a visiting community nurse who told us the care staff communicated well with them and listened to their advice. We saw that people were smartly dressed in clean clothing and wearing appropriate footwear. We saw staff treating people with respect and dignity. People told us they were well looked after and got attention when they needed it, some said they occasionally had to wait, and attention to detail (with clothing) could be better. The management of medicines in the home was inspected, and there were some shortfalls that need to be addressed. The majority of medicines were supplied in weekly pre-packed cassettes, and there were monthly medicine records. The management of variable dose medicines, and once weekly medicines was good. However, some alternate day medicines and short courses such as antibiotics were not so well managed and errors were found in the recording and stock balance. In one instance antibiotics had been given three times a day, not four times as prescribed, so the course would not be completed on time. There were a number of omissions on the medicine charts where items had not been signed as administered and no code for nonadministration entered. There were procedures in place for people to manage their own medicines if they wished within a risk assessment framework, and this was working well. Some medicines with a short shelf life that should be discarded 28 days after being opened did not have the date of opening recorded on them. The photographs of people used for identification purposes need to be re-organised, so they do not fall out of the medicines records. Staff had undertaken medicines training recently, but it this needs to be re-visited. Cold Springs Park DS0000022545.V351802.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. People are offered freedom of choice in how to spend their time, there is good variety of activities and entertainment, and the meals are very good. EVIDENCE: The home employs an activities organiser for 15 hours a week over three days. She organises visiting entertainers, outings, and in house activities including crafts, flower arranging and aerobics. People praised the different musical entertainers she booked, saying they were most enjoyable. A group of people had been on a recent trip to see the Blackpool lights and have a fish and chip supper. The home funds these outings, but asks for voluntary contributions, and extra money for activities is raised though raffles and sponsored events. There is a weekly church service on a Wednesday. Recently some Duke of Edinburgh Award students have visited the home to work with individuals making life history books, both the students and the residents enjoyed this project. People were seen to be able to choose where and how to spend their day, and visitors were made welcome at any time suitable to the resident. People told us: Cold Springs Park DS0000022545.V351802.R01.S.doc Version 5.2 Page 13 “(My relative) has settled in well and is encouraged to join in with other residents and has been on a couple of outings which he enjoyed” • “They organise good day trips and visiting entertainment” • “Activities are brilliant” • “We have a brilliant activity lady” One person thought more money should be spent on activities and another person was disappointed not to be able to access the homes’ transport to go on the trips out. • We observed lunch being served in the two dining rooms and saw people enjoying their meals. There was a menu on display showing the two options available for lunch and evening meal, and people confirmed they had been asked in advance to choose. People said: • “We have a brilliant cook” • “The food is very good” • “They ask what we want” • “No-one could ever complain about the food here”. Since the last inspection BUPA have introduced a new “Menu Master” and a “Night Bite” menu so that people know what is available to eat and drink outside of normal kitchen operating hours. People said if they didn’t fancy anything on the menu they could have an alterative and that the kitchen was very accommodating of this. Cold Springs Park DS0000022545.V351802.R01.S.doc Version 5.2 Page 14 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People felt safe and protected in the care home and thought any serious complaint would be addressed satisfactorily, but minor complaints could be managed more positively. EVIDENCE: The home has a complaints procedure that is on display and there are complaint forms available on the reception desk for anyone who wishes to make a formal complaint to BUPA. People told us they knew how to complain and would speak to the manager if needed. All complaints made to the manager or staff, were reported to head office with some of the responses managed centrally. This means that the home does not have a copy of some complaints and the subsequent investigations and outcome. Earlier in the year a relative had sent us a copy of their letter of complaint to the home, along with the response they received, but these were not on file in the home. The manager needs to have a copy of these, so that she can move forward with making any necessary improvements in the service as a result of a complaint being made. The manager told us that minor complaints are recorded separately from the main complaint records in people care notes. One person told us she felt her recent concerns about lack of maintenance and cleaning in her bedroom were not given adequate attention. It is recommended that the recording of complaints, any investigation or action taken and the outcome, be more carefully logged. Cold Springs Park DS0000022545.V351802.R01.S.doc Version 5.2 Page 15 The majority of staff had received training on safeguarding vulnerable adults and abuse in the past. Two staff were currently undertaking a three day course in this subject and a new BUPA training package on safeguarding was to be rolled out to all staff shortly. There were policies and procedures available to guide staff in what to do in the event of an allegation of abuse being made. The manager was aware of the need to involve outside agencies in such circumstances. People told us they felt safe living in the home. Cold Springs Park DS0000022545.V351802.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. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 21, 23, 24 and 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People live in a well designed, spacious and clean home. Bedrooms and communal rooms are lovely, but the bathrooms could be improved. EVIDENCE: Cold Springs Park is a purpose built care home with all accommodation situated on one level. There is currently an extension being built to add a further 20 bedrooms, the building site was well screened off from resident access. There are currently forty single bedrooms with ensuite toilets and hand basins. Bedrooms were nicely decorated and made personal to the people living in them. Communal areas consist of a reception area, one large lounge and a smaller ‘smoking’ lounge. There were two dining rooms. At the time of this inspection there were no smokers accommodated in the home, and it is recommended the management consult with environmental health, as Cold Springs Park DS0000022545.V351802.R01.S.doc Version 5.2 Page 17 this ‘smoking’ room does not appear to meet with current legislation. The home was generally clean, tidy and well maintained throughout. The home has plenty of bathrooms, but these are in need of some refurbishment, as they appear quite dated. The majority of the baths are ordinary baths with no adaptations. Only two of the baths have an adjustable bath seat and are suitable for people with mobility difficulties. There is one shower, but this has uneven floor access, is quite small and the shower curtain does not close properly. The manager said there were plans to completely refurbish this bathroom and install a new shower facility shortly. The laundry is situated in the basement and is shared by another BUPA care home, with Cold Springs Park laundry being managed during the mornings only, for purposes of separation. People said they were happy with the way their clothes were laundered. Seventeen staff had received infection control training recently. The home was warm and comfortable and had good quality furnishings provided throughout. Cold Springs Park DS0000022545.V351802.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. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People are cared for by a well trained, competent and caring staff team. EVIDENCE: Staffing arrangements in the home were good and appeared to satisfactorily meet peoples care needs. There is one senior and four care staff on duty in the mornings until 2pm, and then one senior and 3 care staff until 8pm, with two staff over night. The rota showed some shifts where an additional person had been on duty, as part of their induction. In addition to these, were catering, domestic, administrative and managerial staff. People spoke well of the staff team, saying: • “Staff seem to perform professionally” • “Staff are always happy” • “Staff smile and are willing to sit and talk to residents” Some people felt there were not enough staff and said they sometimes had to wait for attention although we did not see any evidence of this during the inspection. Staff had received regular training updates on health and safety, fire, moving and handling, food hygiene and infection control. BUPA have developed a new distance learning training pack for dementia care, which the manager said all staff would be completing, but it was not known how many staff had commenced this so far. With the new extension intended to provide dementia Cold Springs Park DS0000022545.V351802.R01.S.doc Version 5.2 Page 19 care, it is important that this training is undertaken. The home has 78 of care staff qualified at National Vocational Qualification (NVQ) level 2 in care, which is very good. Staff files showed that recruitment procedures were satisfactory with written references being taken up, the POVA list checked (a list of people deemed by the department of health to be unsuitable to work with vulnerable adults), and criminal records bureau checks (CRB) were applied for. Staff sometimes started their period of supervised induction prior to the CRB results being returned. This is only acceptable providing all other recruitment checks are satisfactory, which they were. Cold Springs Park DS0000022545.V351802.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): 31, 33, 34, 35, 36 and 38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People benefit from the home having stable internal management as well as good external support from the company. EVIDENCE: Cold Springs Park has a care manager, Lynne Stanley, who is registered with the commission. She is closely supported by a local senior manager, and by the company’s operations manager, who visits the care home monthly, and provides a written report to us about this. The company have a quality assurance process that includes annual surveys of residents, they hold residents and relatives meetings, and carry out quality checks of care and medication records. All staff receive regular documented Cold Springs Park DS0000022545.V351802.R01.S.doc Version 5.2 Page 21 supervision and an annual appraisal, through which care practice and training needs are discussed. The home assists a number of people to manage their spending money, and manages their hairdressing and newspaper bills. The administrator manages this with all transactions being authorised through the finance department at head office. Money is held in a bank account with individual interest being added monthly. The service has an annual financial and business plan in place. Staff had received regular training updates in matters relating to health and safety, and the fire log, maintenance and service records were complete and up to date. Cold Springs Park DS0000022545.V351802.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 X 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 3 14 3 15 4 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 3 4 3 2 X 3 3 X 3 STAFFING Standard No Score 27 3 28 4 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 3 3 3 X 3 Cold Springs Park DS0000022545.V351802.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 OP9 Regulation 13 (2) Requirement Timescale for action 31/01/08 2. OP9 13 (2) Medicines must be administered as prescribed, in accordance with the prescribing doctor’s instructions. Medicine administration records 31/01/08 must be accurate, and show a record each medicine administered, or explain why a medicine was not administered. Medicine records must reflect an accurate stock balance of medicines. 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. Refer to Standard OP7 OP9 OP9 Good Practice Recommendations Residents or their representatives should be invited to read and sign in agreement to their care plan. The opening date should be recorded on medicines with a short shelf life, so they can be discarded when out of date. Photographs used with medicine records for identification purposes should be named and organised so they do not DS0000022545.V351802.R01.S.doc Version 5.2 Page 24 Cold Springs Park 4. 5. 6. OP16 OP21 OP38 fall of the records. Records of complaints, the details of any subsequent investigation and the outcome, should be clearly recorded and held on file in the care home. The bathrooms, including the shower facility should be upgraded. The manager should liaise with the environmental health officer over the homes’ smoking lounge to ensure it complies with new legislation. Cold Springs Park DS0000022545.V351802.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection Eamont House Penrith 40 Business Park Gillan Way Penrith Cumbria CA11 9BP 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 Cold Springs Park DS0000022545.V351802.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. 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