Inspection on 14/12/05 for Spring Gardens

This inspection was carried out on 14th December 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 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

Spring Gardens 01/03/07

Spring Gardens 28/06/05

Spring Gardens 21/12/04

Spring Gardens 24/06/04

Spring Gardens 25/02/04

Similar services:

Snydale Care Home

Abbey The

Hawkhills

Larchfield Manor

Beeches The - North Yorkshire County Council

The Grove Waltham

Carentan House

Ravensworth Lodge

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

CARE HOMES FOR OLDER PEOPLE Spring Gardens Westbourne Grove Otley Leeds LS21 3LJ Lead Inspector Valerie Francis Unannounced Inspection 14th December 2005 09:30 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Spring Gardens DS0000033235.V271155.R01.S.doc Version 5.0 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. Spring Gardens DS0000033235.V271155.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Spring Gardens Address Westbourne Grove Otley Leeds LS21 3LJ 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) 01943 464497 Leeds City Council Department of Social Services Mrs Angela Mosby Care Home 30 Category(ies) of Old age, not falling within any other category registration, with number (30) of places Spring Gardens DS0000033235.V271155.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 28th June 2005 Brief Description of the Service: Spring Gardens is a purpose built local authority care home situated in the small market town of Otley in West Yorkshire. It provides personal care and support for up to 30 older people who are not in need of nursing care. There are 28 permanent places and two places for residents who come for respite care. The home is run by Leeds Social Services Department and managed on its behalf by Angela Mosby. The two-story building enables residents to have bedrooms and utilise communal seating areas on either floor. The majority of rooms, which vary in size, are now single occupancy but there are two double rooms for couples.There are no en-suite toilet facilities. The home is situated in a quiet residential area which has easily accessible bus services or a short walk into Otley town centre which has a wide selection of shops and riverside walks. There are connecting services into Leeds, Bradford and Harrogate. The majority of residents are from the Otley area and have the benefit of being able to retain contacts with friends, family and former neighbours quite easily. Spring Gardens DS0000033235.V271155.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. Over an inspection year from April until March, regulated care homes have a minimum of two inspections a year. These may be announced or unannounced visits. This is the second inspection carried out within the inspection year both inspections has been carried out on an unannounced basis. There have been no further visits until this unannounced inspection. The last inspection took place on the 28 June 2005. This inspection started at 9.40am and finished at 5.00pm. The people who live in the home use the term residents; therefore this is the term that will be used throughout this report. During the inspection records were examined, all areas of the premises were seen, such as communal sitting room/dining room, residents bedrooms, bathrooms, toilets and laundry area Staff were observed carrying out their work and interacting with residents. Approximately 20 residents were spoken to, either in a group or individually. Three sets of relatives visiting at the time were also spoken to about the care and attention given to their relative living in the home. One resident had visitors who had spent most of the day with their relative who was ill at this time. The care officer facilitated in the inspection process until Mrs Mosby, the manager came on duty. What the service does well: Residents and their visitors said that the staff provide good care and support. Staff are flexible to make sure that the needs of residents are met. The visiting District nurse said that staff are helpful and report any incidents that need a nursing intervention, they always follow advise and get the appropriate equipments or any dressing that is required for residents. Residents are provided with good standard of food and are consulted about their likes and dislikes individually. Spring Gardens DS0000033235.V271155.R01.S.doc Version 5.0 Page 6 The staff members offer resident’s care and support in a homely and friendly environment. During discussion with residents and visitors they described staff members as “helpful” and “kind”. What has improved since the last inspection? What they could do better: The manager must ensure that all care needs identified have a plan of care in place of the action to be taken by staff to meet the individual needs. All identified risks must have a plan of action to be taken to minimise the risk. A Nutritional risk assessment must be carried out for all residents with a plan of care for any resident who is identified as being at risk. Those residents who have a history of fall must have risk assessment with a plan of care. Staff must have training to meet the needs of residents who are terminally ill. Spring Gardens DS0000033235.V271155.R01.S.doc Version 5.0 Page 7 The registered provider must make sure that there is enough staff available to residents over 24hours, taking into consideration the size and lay out of the building and the time. 50 of the care staff team must have a NVQ qualification. Care plan on the last wishes of residents should be in place. Copies of staff recruitment and selection information should be in place in their individual files 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. Spring Gardens DS0000033235.V271155.R01.S.doc Version 5.0 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 Spring Gardens DS0000033235.V271155.R01.S.doc Version 5.0 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): 2 & 4. The admission procedure includes pre-assessment and introduction visits and trial period if it is appropriate. The home’s information, which is given at the visit to the home provide prospective residents and their relatives with information about the service, provided. EVIDENCE: The records inspected found that residents are given terms and condition (licences) of residency, which is signed by the resident, or relative or someone advocating on their behalf. The records reviewed showed that pre-assessments take place and copies of assessment carried out by care professionals before resident’s admission to the home were present, to make sure that the home can meet their needs. Spring Gardens DS0000033235.V271155.R01.S.doc Version 5.0 Page 10 The manager said that residents, relatives and health care professionals and others involved in the residents care are involved in the care assessment process. Unplanned admissions are avoided if it is possible, however, there are times when the home has to admitted residents in an emergency. When an emergency occurs much information is got within a short period of time. Prospective residents and their relatives/carers are invited to home and the person is invited to spend the day and have lunch. At the time of the inspection a prospective resident was spending the day as part of the assessment period. It was noted that the person was given the opportunity to meet the other people living at the home and take part in the social activities happing at the time. A member of staff was assigned to this person and an assessment was made of the visit from observation from discussions. From discussion with residents and their visitors they said that staff had been very helpful at their visit to the home before they moved in to the home. The home Statement of Purpose, which is available to prospective residents and their carers during their visit to the home, gives them information on the experience and the qualification of the staff working at the home. The staff team appears to have the experience and skills to meet the needs of the resident group. Most of the staff team have been working at the home for some time or have worked in a care home caring for older people with specialist needs. Planned training is given to staff to enable them to have the knowledge to meet the needs of the people living at the home. Spring Gardens DS0000033235.V271155.R01.S.doc Version 5.0 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& 11. Care plans needs further work so that individual needs are recorded and staff know how to meet them. There are no real plans of care for residents who are in the last days of their life. EVIDENCE: Three sets of care records were checked. Although information in one set of documentation identified the care needs, and how needs were being met, there were little or no plans of care in place for the other two reviewed. The manager said one of the resident needs had changed and a review of her care needs had taken place, however, there was no written information to evidence that her needs had changed so that staff can put a new plan of care in place. So that staff can have an action plan to meet her care needs. One resident had recently moved into the home but only three areas of needs had been identified despite the up to date and good information in the easy care assessment document and information from the previous home. Although risk assessments had been carried out for some identified risks, there was no plan of action to be followed to minimise risks. Spring Gardens DS0000033235.V271155.R01.S.doc Version 5.0 Page 12 No nutritional risk assessment had been carried out for any residents. The manager said assessments are carried out only if a problem is identified. The manager said that there was new system to be put in place to make sure that all residents have a Nutritional risk assessment carried out. In all care files seen there was a “Falls Management” form which is completed with details of the time and date of the fall, however there were no risk assessments for people who had a history of falls or a care plan how the risk of fall would be minimised. There was some information of the person’s last wishes in the Life Style Plan in the section “Personal Choices”, and there was indication that the resident’s family would take care of the funeral arrangements or that the resident would like to be buried or cremated, the name of the undertaker was available. The manager said plans were in place for a one day training course for all staff on Dying and Death. The manager said residents who were dying were mostly hospitalised, however, if it was there wish, support would arranged form outside agencies i.e. (District Nurses) would be involved. At the time of the inspection one resident had made the choice of staying in the home for the last days of her life, her family also expressed their wishes for this and staff was been supported by the health professionals to meet her wishes. Staff have access the Policy procedure on dying and death. Spring Gardens DS0000033235.V271155.R01.S.doc Version 5.0 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): 12,14 & 15. The home offers a range of social and leisure activities and residents are encouraged to make informed decisions if the wanted to take part. Meals appeared nourishing and take into account resident’s likes and dislikes. The daily routine of the home appeared flexible and based around the needs of the residents. EVIDENCE: Although there is not an activities organiser on staff, the manager said all staff take part in the social activities for residents, by using the skill of each members of staff for the social simulation. Some residents pursue their own interest by engaging others in board games, and discussions on current affairs. Some choose to be on their own in their bedrooms and others make a decision not to take part in any recreational activities. Information on resident’s hobbies and interest before moving into the home are recorded in their Life Style Plan. A record is kept of all activities arranged in the home. Residents meet with their visitors in the privacy of their bedrooms, however some also use the large sitting room. Spring Gardens DS0000033235.V271155.R01.S.doc Version 5.0 Page 14 Visitors said they were regular visitors and they always feel welcome and felt their relatives are cared for in happy caring environment, staff was said to be friendly. During the inspector’s discussion with residents they confirmed that they were happy with the care and were able to spend their time doing what they chose. Residents made positive comments about the food and they were confident that if they did not like what was being served they could have an alternative. The cook works closely with residents to make sure their likes and dislikes are taken into consideration when meals are planned. Anyone needing a special diet would be catered for making sure that they have well balance and nutritious meals, which take into account of any specialist care needs, despite the lack of nutritional risk assessments. Residents who require assistance with their meals receive discreet support and assistance from staff to make sure they eat a well balance meal. Monthly weight checks are carried out for all residents. Spring Gardens DS0000033235.V271155.R01.S.doc Version 5.0 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): 17. There are systems in place to support residents to maintain their rights and independence. EVIDENCE: Families, friends or solicitors mainly handle residents’ affairs. The home has contact with Age Concern advocacy to advocate and support residents. The manager has good contact with Age concern advocacy; residents who have the capacity and wishes at the time of voting either attend polling stations or have postal votes. Residents and their relatives are aware of their rights to see any information held in relation to them. There are policies in place to support this. The manager takes legal advice and support from other professionals to assist residents. Spring Gardens DS0000033235.V271155.R01.S.doc Version 5.0 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 & 26. No breaches of health and safety were noted during the inspection of the premises. The building was found to be welcoming and comfortable and aspects of infection control taken into consideration. EVIDENCE: The home has a large sitting area and dining room on the ground floor and three other communal sitting areas. Residents choose where to spend their time during the day. No residents’ rooms have en-suite toilets however there are WC and bathing facilities situated strategically around the home on each floor, to allow residents easy access. Some residents have a commode, which is used mainly during the night. There is loop system in place in the main lounge on the ground floor, to help those people wearing a hearing aide with clearer surround sound. Spring Gardens DS0000033235.V271155.R01.S.doc Version 5.0 Page 17 Bedrooms appeared to be comfortable. The occupants had taken the opportunity to furnished their room with relics of their past and photographs of their families. The laundry has recently been equipped with a sluice cycle washing machine, which would enhance infection control for soiled washing to be carried out on a 65’c and above wash. All other laundry equipment was in full working order and free from health and safety risks. Some staff have had training on infection control and all have undertaken health and safety as part of their induction training. Fire safety equipment is in place and up to date. Staff receives regular training in fire safety in the building. It was noted through out the building in bathrooms, toilet and the laundry area that staff have access to hand washing, drying and in addition hand gel sanitizer (for which risk assessment and COSHH assessments has been carried out) to make sure infection control is not compromised. No malodour was noted at this inspection, the building was seen to be clean and tidy. Spring Gardens DS0000033235.V271155.R01.S.doc Version 5.0 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): The registered providers, Leeds City Council Social Service Department have a robust interview process when recruiting staff. Staffing levels have improved since the last inspection. New staff are provided with a comprehensive induction training programme to ensure they are competent to do their jobs. EVIDENCE: Since the last inspection three new members of staff have been employed. Staff at the home have experience and skills to meet the needs of the resident group, however, on going review of staffing should be carried to make sure that staffing level are enough to meet the needs and specialist care needs of people living in the home. Some consideration should also be given to increase the staffing levels during the night to make sure both residents and staff health and safety are not compromised, with the lay out and size of the building. The rota indicated at the time of the inspection that there was enough staff to cover shifts for that day, which were 4 in the morning and 3 in the evening. Staff time is spent carrying out care to residents and the 4 day care service users from the community. Two staff files were inspected the information in place in the files were There was a copy of the front of the application form, copies of two references, Spring Gardens DS0000033235.V271155.R01.S.doc Version 5.0 Page 19 disclosure and information that CRB (Criminal Record Bureau) and certificate of courses attended and qualification were available for inspection. The manager said all new staff are given a copy of the General Social Care Council code of conduct. The manager said all other required information is held at the head office. Leeds City Council Social Service recruitment and selection policy procedure is available in the home. All new staff undertake the induction training and on going training. Seven staff have a National Vocational Qualification level 2 and four others are undertaking an NVQ qualification. Six members of staff to start a twelve week course on Dementia, some staff have already completed this course, three staff have undertaken an infection control course. Spring Gardens DS0000033235.V271155.R01.S.doc Version 5.0 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): 34,35,36,37 & 38. The health and safety of residents and staff is promoted. The home has no formal systems in place to monitor quality of services. Staff receive regular supervision which they value, as it provides opportunities to discuss their professional development. EVIDENCE: Insurance cover and suitable accounting procedures are in place for the home as part of the Leeds City Council Social Services. Records are kept of all financial transaction carried out in the home. Records are kept of any monies held and any transaction carried our on their behalf. The manager said when possible residents are encouraged to handle their affairs, or family to do so. Spring Gardens DS0000033235.V271155.R01.S.doc Version 5.0 Page 21 The home’s management team carries out one to one supervision sessions, which provides staff with opportunities to discuss care practices and personal development. The manager carries out annual staff appraisals Risk assessments have been carried out of the building and for staff jobs when caring for residents. Health and safety checks for the building are carried out as required a record was in place for all checks carried out all of which met the required timescales. Spring Gardens DS0000033235.V271155.R01.S.doc Version 5.0 Page 22 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X 3 3 3 X X HEALTH AND PERSONAL CARE Standard No Score 7 2 8 X 9 X 10 X 11 2 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 X 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 X 17 3 18 X 3 3 3 3 3 3 3 3 STAFFING Standard No Score 27 2 28 2 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X X X 3 3 3 3 3 Spring Gardens DS0000033235.V271155.R01.S.doc Version 5.0 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 OP7 Regulation 15 Requirement The manager must ensure that all care needs identified have a plan of care in place of the action to be taken by staff to meet the individual needs. All identified risks must have a plan of action to be taken to minimise the risk. A Nutritional risk assessment must be carried out for all residents with a plan of care for any resident who is identified as being at risk. Those residents who have a history of fall must have risk assessment with a plan of care. Staff must have training to meet the needs of residents who are terminally ill. The registered provider must make sure that there is enough staff available to residents over 24hours, taking into consideration the size and lay out of the building and time. 50 of the care staff team must have a NVQ qualification. Timescale for action 27/02/06 2 3 OP7 OP15 13 &15 12 & 14 27/02/06 27/02/06 4 5 6 OP7 OP11 OP27 13 & 15 18 18 27/02/06 10/03/06 30/03/06 7 OP28 18 31/03/06 Spring Gardens DS0000033235.V271155.R01.S.doc Version 5.0 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 Refer to Standard OP7 OP29 Good Practice Recommendations Care plan on the last wishes of residents should be in place. Copies of staff recruitment and selection information should be in place in their individual files in the home. Spring Gardens DS0000033235.V271155.R01.S.doc Version 5.0 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 Spring Gardens DS0000033235.V271155.R01.S.doc Version 5.0 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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