Inspection on 28/06/05 for Spring Gardens

This inspection was carried out on 28th June 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 found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Spring Gardens 01/03/07

Spring Gardens 14/12/05

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 28 June 2005 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. Spring Gardens J52 S33235 Spring Gardens V231052 060605 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Spring Gardens Address Westbourne Grove Otley Leeds LS21 3LJ 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) 01943 46497 Leeds City Council Mrs a Mosby Care home 30 Category(ies) of Old Age (30) registration, with number of places Spring Gardens J52 S33235 Spring Gardens V231052 060605 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 21 December 2004 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 home provides both permanent residential and respite care. 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 J52 S33235 Spring Gardens V231052 060605 Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. One inspector carried out this inspection, which was unannounced over a day. Which started at 10am and completed at 5.30pm. On arrival of the home the inspector met the person in charge. The manager was not at the home, she however joined the inspector and facilitated in the inspection process later on. A Comment card, was given to the manager for her feedback on the way in which the inspection was carried out. Comment cards for both residents and visitors and the new CSCI service users information leaflets were also left. During this inspection residents’ records and care plans were assessed, and observation was made of staff interaction with residents and their relatives. A mealtime was observed although this standard was not audited. Residents, their visitors and staff were spoken with. What the service does well: What has improved since the last inspection? Some redecoration and replacement of furnishings has been carried out since the last inspection. Spring Gardens J52 S33235 Spring Gardens V231052 060605 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. Spring Gardens J52 S33235 Spring Gardens V231052 060605 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 Spring Gardens J52 S33235 Spring Gardens V231052 060605 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) 1,3 and 5 Prospective residents and their carers/relatives can only access the homes’ information during their visits to the home, they are not able to take away the full document which would enable them to have an informed choice about living at the home. The home assessment document is not always completed. Therefore it was not possible to identify how the needs of the prospective residents could be met. EVIDENCE: The homes’ statement of purpose document is available to prospective residents and others when they visit the home. The Service User Guide is available to residents, providing them with some of the information from the statement of purpose, copy of the terms and conditions of residency, information on other agencies and a copy of the last inspection report. Although there is a leaflet available to prospective residents and their carers this does not give full information on services that is specific to the home for people to make an informed choice. Spring Gardens J52 S33235 Spring Gardens V231052 060605 Stage 4.doc Version 1.30 Page 9 It was evident from discussion with visitors; that it would be useful if they could have more information about home other than the leaflet given. One person only got a copy after their relative had moved into the home. Although on the three files seen that each person living at the home has been assessed, the Visit Assessment document had either not been fully completed or not at all, the manager said copies of the “easy care” assessment was given to them. This is sometimes out of date, which results in people not being properly assessed by the home, and them not having a care plan with an action plan, which outlines how their care needs would be met. This was evident for some residents. The opportunity is given to all prospective residents and their carers to visit the home, so that an assessment can be carried out. Prospective residents can have an over night stay if there is accommodation available. Spring Gardens J52 S33235 Spring Gardens V231052 060605 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) 7,8,9 and10. Although there was a good system for care needs assessment, there were little or no written plans of care for some residents in place. The home provides good healthcare and works effectively with healthcare services. EVIDENCE: Three residents files were inspected, only one of the files had any information describing how individual people would be looked after. The lack of information that was due to little or no information on the visit assessment form that should have been completed on the assessment visit to the home. Thus leading to people not receiving the care that meets their needs and also being inappropriately placed at a home that cannot meet their needs. Although it is acknowledged that home has a staffing level problem, a full assessment of care needs must be carried out before an invitation is made to people to live at the home. Medication is ordered in accordance with the policy procedure and administered by staff. Residents have the opportunity to administer their medication subject to risk assessment and there is an agreement, which is signed by resident to indicate that they agree with terms to self medicate. Spring Gardens J52 S33235 Spring Gardens V231052 060605 Stage 4.doc Version 1.30 Page 11 Each person has access to a lockable cupboard or drawer in his or her bedroom where medicine could be stored. From discussion with residents it was obvious that staff offered care that was friendly, caring and encouraging, thus providing a service that up- holds privacy, independence, rights and choice. Spring Gardens J52 S33235 Spring Gardens V231052 060605 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) 12 and 13 Social activities for residents are limited which has created the opportunity for boredom. There are systems in place for Residents to keep in touch with their relatives and friends. EVIDENCE: Although there was some information about people’s social life style before coming into the home there was no evidence in files to indicate how the home would meet the social care of residents. During the inspection residents were observed making their own entertainment. As it was a sunny day some people were sitting out talking to each other or their visitors, or sitting in sitting areas talking to each other. During discussion with residents some people said they were sometimes bored and needed some entertainment. Although the programme of entertainment in the home is displayed informing people of the activities to come, the manager and staff said some residents do not wish to take part in any of the group activities. One to one activities are arranged for some residents. The manager acknowledged that sometimes it is virtually impossible for staff to spend time with resident with social activity because of the staffing level. Spring Gardens J52 S33235 Spring Gardens V231052 060605 Stage 4.doc Version 1.30 Page 13 However, the inspector found that on the day of the inspection a substantial amount of residents appeared to be bored and needed some stimulation. This was also reiterated in feedback cards from some residents and their visitors. It was evident that family and friends are encouraged to visit the home to see their loved ones. Visitors spoken to said staff were friendly and caring and felt that despite the staff shortage nothing is to hard for them to do for the people living at the home. Prospective residents are provided with information regarding visiting at the home. It was apparent that there are no real restrictions on visiting. Spring Gardens J52 S33235 Spring Gardens V231052 060605 Stage 4.doc Version 1.30 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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 16 and 18. The are good systems in place for people to complain and to protect residents from abuse. EVIDENCE: During discussion with residents and their visitors it was apparent that they knew how and to whom to complain. They were aware of the home’s complaints procedure, which is displayed on the notice board, and they had been given a copy of the procedure. It was evident that all were clear about their right to complain, felt that the manager and staff were approachable, and they felt their complaint would be dealt with. Systems had been put in place for all staff to attend an awareness-training course on adult protection. Staff have access to the adult protection procedure and from discussion it was evident that they knew what to do if an abuse situation occurred. Senior staff were also clear of the procedure to follow and who to contact if it was alleged that abuse had occurred in the home. The home has the multi-agency adult protection procedure, which is available to all staff. Spring Gardens J52 S33235 Spring Gardens V231052 060605 Stage 4.doc Version 1.30 Page 15 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. The building is well maintained with on going replacement and redecoration. Residents are placed at risk if procedures and protocols are not followed. EVIDENCE: Although the inspector found in general that the home was maintained to a good standard some of the areas needed redecorating, however in discussion with the manager it would appear that there was systems in place for replacement and redecoration. Bathrooms had been refurbished and new baths installed; at the time of the inspection one of the bathrooms was awaiting the arrival of a new bath. Whilst walking around the building the inspector found that the window on the top floor central area needed a window restrictor to prevent it opening fully, which could result in an accident. The inspector found that in the laundry the COSSH cupboard door was open there was also no COSSH information to alert staff of the dangers of the cleaning materials and equipment used in the home. One bedroom door was not closing fully shut, which could be a potential hazard to the person living in the room in the event of a fire. Spring Gardens J52 S33235 Spring Gardens V231052 060605 Stage 4.doc Version 1.30 Page 16 Although there was a system in place to check hot water temperatures through out the home, this had not done since 18th April 2005. There is one washing machine and a dryer, both of which are of a domestic style. In light of infection control the inspector advised that the organisation should give some consideration to supply the home with a washing machine that has a sluice cycle and dryer that can meet the needs of the amount of people living at the home. The inspector found throughout that through out, the building was clean to a good standard. Spring Gardens J52 S33235 Spring Gardens V231052 060605 Stage 4.doc Version 1.30 Page 17 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 and 28. Staffing levels and the lack of recruitment of permanent care staff could place residents at risk. Staff are not always provided with the time to undertake training that would assist them with the delivery of care to residents. EVIDENCE: 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 three in the evening and 2 waking during the night. However this number of staff appeared to be insufficient to meet the needs of the residents considering the lay out of the home. This also allows staff no time to carry out social activities with residents. The home also offers day care to 4 people from the community. There were several staff vacancies and long term sickness, which resulted in the use of overtime and the use of agency staff to cover those missing hours. The inspector was told that a staff recruitment drive has been arranged to try to employ permanent staff, thus ensuring residents have staff they know providing their care. Although most of the staff have had some training, and they had had moving and handling and fire safety training, some were out of date and needed updating. The manager said she was putting together a fire safety training pack for all staff to use in house. Spring Gardens J52 S33235 Spring Gardens V231052 060605 Stage 4.doc Version 1.30 Page 18 Discussion with staff confirmed that sometimes due to low staffing levels they were unable to attend courses that had been arranged. Spring Gardens J52 S33235 Spring Gardens V231052 060605 Stage 4.doc Version 1.30 Page 19 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 and32. There is continuity in the home’s management team, who are committed to the care of residents. EVIDENCE: The manager has the required qualification and when possible attend update training. During discussion with residents, visitors and staff they confirmed that the management of the home was friendly, approachable, positive and open. Spring Gardens J52 S33235 Spring Gardens V231052 060605 Stage 4.doc Version 1.30 Page 20 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 3 x 3 x 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 1 8 3 9 3 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 x 15 x COMPLAINTS AND PROTECTION 2 x x x x x x x STAFFING Standard No Score 27 1 28 2 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 3 3 3 x x x x x 2 Spring Gardens J52 S33235 Spring Gardens V231052 060605 Stage 4.doc Version 1.30 Page 21 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 (1) Requirement residents must have an assessment carried out by the home before they move into home. Residents must have a plan of care for staff to to meet their individual needs. Attention needs to be given to provide all residents with social activities that meet their needs. A window restrictor identifed must be fitted to the window identified to the manager. Staff must be aware of the dangers of leaving the COSSH cupboard door unlock and opened The bedroom door that was identfied to the manager must be repaired to shut fully. Hot water temperatures must be monitored and recorded. Staffing levels at the home must increase so that there are sufficient staff available to residents at all time. and have had training to meet their needs. Timescale for action Immediate as advised. Immediate as advised. 2. 7 15 (1) 3. 12 16 (2 ) (M). 30th September 2005. 30th July 2005 Immediate as advised. 30th July 2005 30th July 2005 30th september 2005 4. 5. 19 38 23 (2) 13 (4) 6. 7. 8. 38 38 27 13 (4) 13 (4) 18 (1) (a) Spring Gardens J52 S33235 Spring Gardens V231052 060605 Stage 4.doc Version 1.30 Page 22 and any specialist needs residents may have, 9. 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 27 19 Good Practice Recommendations Permanent staff to be available to residents to ensure they have continuity from the people providing their care. some considertion should be givin to provide the home with a sluice cycle washing machine. Spring Gardens J52 S33235 Spring Gardens V231052 060605 Stage 4.doc Version 1.30 Page 23 Commission for Social Care Inspection Aire House Town Street Rodley 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 J52 S33235 Spring Gardens V231052 060605 Stage 4.doc Version 1.30 Page 24 - 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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