Inspection on 18/10/05 for Spring House

This inspection was carried out on 18th October 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

Spring House 27/01/08

Spring House 05/12/06

Spring House 11/05/05

Spring House 05/10/04

Spring House 27/04/04

Similar services:

Fairfields Country Rest Home

Queensmount

Poldhu

Trevaylor Manor

Didsbury Court Rest Home

Belma

Hunters Care Centre

Manor Lodge

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

CARE HOMES FOR OLDER PEOPLE Spring House Peter Tavy Tavistock Devon PL19 9NP Lead Inspector Helen Tworkowski Announced 18 & 19 October 2005 th th 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 House D54 D07 S3807 Spring House V244396 181005 Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Spring House Address Peter Tavy Tavistock Devon PL19 9NS 01822 810465 01822 810465 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) Mrs B Luckham Care Home 19 Category(ies) of OP - 19 MD(E) - 19 DE(E) - 19 registration, with number of places Spring House D54 D07 S3807 Spring House V244396 181005 Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: None Date of last inspection 11/5/05 Brief Description of the Service: Spring House provides care for up to 19 older people in the small village of Peter Tavy, three miles from the market town of Tavistock. The home offers care and support to older people including people with dementia and mental health needs. All of the bedrooms expect one are single, and all have en-suite toilets and hand basins, two also have en-suite showers. The home has a stair lift to the first floor. There is a through lounge/diner, which the only communal space in the home. The home has a small garden and patio area to the rear of the home.The home is registered to care for people with a range of needs including dementia and mental disorder. The home is staffed 24 hours per day; at night there is a waking night staff and a sleep in staff. The home employs cooks who prepare all the meals in the home. There is a small laundry on the premises. A major extension to the home is being built. Spring House D54 D07 S3807 Spring House V244396 181005 Stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection took place over 2 days, on the 18th and 19th October 05. The first phase of a new extension is almost complete. The completed works should provide additional communal space, improved bathing, staff and laundry facilities. The works should also improve access to the first floor and provide a safe garden area as well as additional parking. Five additional bedrooms, with en-suite shower facilities have also been built. The Registered Provider plans to increase the number of people who can occupy the home from 19 to 25, however this increase had not been approved at the time of this inspection. The inspection included discussions with staff, service users, relatives and the Registered Provider, Mrs Luckham. A full tour of the building was made, including the new extension. Two meals were eaten with Service Users, and time was spent sitting, observing and talking with service users. A number of records were looked at: assessments, service user plans, risk assessments, and staff records. What the service does well: What has improved since the last inspection? At the time of this inspection there have been no improvements, the building of a new extension has caused disruption. It appears that maintaining the service whilst coping with the disruption and building works has focus of the staff team and Mrs Luckham’s energy over the last year. Spring House D54 D07 S3807 Spring House V244396 181005 Stage 4.doc Version 1.40 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 House D54 D07 S3807 Spring House V244396 181005 Stage 4.doc Version 1.40 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 House D54 D07 S3807 Spring House V244396 181005 Stage 4.doc Version 1.40 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 and 3 The system for assessing prospective uses needs to be improved, so that each and every service user’s needs are known prior to moving. EVIDENCE: A Statement of Purpose and Service User’s Guide has been developed however these documents are not complete. These documents provide prospective service users with information about the home. Discussions with relatives about whether the home had met their expectations confirmed that what they had been told about the home had proved to be accurate. The majority to people who come to live at Spring House are from the local area, and Mrs Luckham confirmed that prospective Service Users were visited and assessed prior to a move. Records confirmed this, and that there was evidence that the assessment was then updated following admission. However one person had recently moved from further a field, and whilst Mrs Luckham said she had repeatedly requested an assessment, none had been received before the move. It is essential that assessments are received before a move, this ensues that a prospective users needs are known and that they can be confident that their needs can and will be met. This is particularly important when an individual has dementia. Knowledge of the individual’s history and Spring House D54 D07 S3807 Spring House V244396 181005 Stage 4.doc Version 1.40 Page 9 preferences can then be taken into account in planning care. This is the responsibility of the Registered Provider. Spring House D54 D07 S3807 Spring House V244396 181005 Stage 4.doc Version 1.40 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 and 10 Not every service user had a comprehensive Service User Plan, these documents are important in ensuring that service users needs will be consistently met. The way staff help service users to move, where they need assistance, need to be reviewed so that both staff and service users are safe. Service Users are treated with respect and dignity. EVIDENCE: Three Service User Plans were looked at during this inspection. These documents are important as they give detailed information for staff about how needs will be met. Two of the Service User Plans had been regularly updated as needs had changed. However as there was no assessment for one person who had recently moved to the home- no proper Service User Plan, containing detailed information about how needs are to met, had been completed Some of the people who live at Spring House have dementia and it is important that these documents are able to reflect the individuals preferences and choices about their lives. Information about an individual’s life and history is useful to help understand what it important for that person. Files contained information about risk assessments and moving and handling assessment; risk assessments identify how risks will be managed and mitigated. However observation of staff during the inspection showed that the Spring House D54 D07 S3807 Spring House V244396 181005 Stage 4.doc Version 1.40 Page 11 manner in which they helped move service users was not appropriate, and must be reviewed. Discussions with Service Users and with visitors indicated that people felt that their needs were met, and that staff did so in a respectful and caring manner. Service users spoke to staff confidently and with great assurance, indicating very positive relationships. What is particularly impressive is the way that Service Users feel confident enough to organise activities themselves. It is clear that Service Users feel they have a say in what happens in the home. A “monitored dose system” is used for medication; the local pharmacist prepares this. Medication was observed being appropriately administered. Spring House D54 D07 S3807 Spring House V244396 181005 Stage 4.doc Version 1.40 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) 12,13,14, and 15 Service Users enjoy participating in a range of activities in the home, and visitors are welcomed. There is a very good standard of food. EVIDENCE: There is a weekly plan of formal activities in the home, which includes bingo, singsongs, and trips out. Service Users confirmed they enjoy these activities, and are that they are well attended. Trips out often involve visitors to the home, and from the description offered are thoroughly enjoyed. One service user told the inspector that she runs a “music afternoon”, and this again is well attended. Service Users also took part in activities in the village and in Tavistock. Some Service Users have photo albums, which contain photos of friends and families. It is recommended that support is offered to help record who is in the photos, so that they can help prompt memories and for individuals to maintain a sense of who they are. Visitors spoken with during this inspection said that they felt they were made very welcome and that they were offered tea. They felt happy to visit at any time. Spring House D54 D07 S3807 Spring House V244396 181005 Stage 4.doc Version 1.40 Page 13 Service Users are able to make choices about how they live their lives at Spring House. Service Users said that they are able to get up and go to bed when they choose, some service users choose to lock their rooms and all service users are able to decorate and furnish their rooms in a way that reflects their personality. There is a set menu, which provides choices at each meal. The cook asks each person what they would like to eat. The cook uses fresh ingredients and there is fresh fruit available in the dining room. Service Users are offered wine and sherry with their lunch. Service Users said that they enjoyed the food and that is well cooked. The current dining room and lounge are inadequate; these facilities will be much improved on the completion of the extension. The current arrangements mean that not everyone has the opportunity to be seated at a table. Staff were observed assisting people to eat, and they did so with care and consideration, allowing individuals to maintain as much independence as possible. Spring House D54 D07 S3807 Spring House V244396 181005 Stage 4.doc Version 1.40 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 There are systems in place to ensure that if concerns are raised they are promptly addressed. EVIDENCE: No complaints have been received by the Registered Provider or by CSCI. There is a complaints procedure and a system for recording complaints. Discussions with visiting relatives confirmed what Mrs Luckham said, concerns are picked up at an early stage and dealt with before they become complaints. Relatives said that they felt confident that if they had an issue they could approach staff, and when they had concerns these were resolved. The home has a policy in relation to the protection from abuse, and a copy of the local “Alerter’s Guide” was available. There is a system for ensuring that staff read and sign policies and procedures. Spring House D54 D07 S3807 Spring House V244396 181005 Stage 4.doc Version 1.40 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, 20, 23, 25 and 26 When the extension is complete the accommodation will be much improved and meet the National Minimum Standards. In spite of being a little crowded the house is clean and comfortable and Service User make themselves at home. EVIDENCE: A major extension is being built at Spring House. This will provide additional lounge and dining space, as well as improving facilities for existing Service Users, so that the home meets the National Minimum Standards. The first phase of these works are nearing completion however they have necessitated some disruption and will continue to do so in the immediate future. Service User’s bedrooms seen were clean and all were decorated and furnished to reflect the individual’s choice and preferences. Some Service Users had chosen to bring in items of their own furniture, and Service Users are able to decorate their rooms or make minor alterations. Service Users are offered keys to their rooms: some individuals always lock their doors, others never do. Spring House D54 D07 S3807 Spring House V244396 181005 Stage 4.doc Version 1.40 Page 16 The first phase of the building works are almost complete, though there are still some major works to be completed, which inevitable will cause disruption. In spite of the dust caused by the work, the home was clean and tidy, and there were no odours. The laundry is to be replaced by a more appropriate area where there will be improved facilities for washing clothes etc. Spring House D54 D07 S3807 Spring House V244396 181005 Stage 4.doc Version 1.40 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, 29 and 30 There are robust recruitment and induction procedures however these are not always used. Sound recruitment and induction procedures help ensure that Service Users are protected. EVIDENCE: The staffing level is four care staff in the morning and three in the afternoon and evening, with two care staff on duty at night. There is a cook and cleaner, administrative support in addition to Mrs Luckham as the manager. These staffing levels are to be reviewed to accommodate the planned increase in numbers. Staff and service users both felt that there were sufficient staff. One new member of staff has been recruited since the last inspection, two references had been taken and a Criminal Records Bureau check completed, as part of the recruitment process. However no equivalent checks has been made for a volunteer working in the home. No formal induction had been completed for either the volunteer or for the new employee. A formal induction helps ensure that a new worker knows what is expected of them. The majority of care staff now have an NVQ 2 in Care or above, and Mrs Luckham said that this was one of the home’s priority. Staff said that over the period of the building of the extension, training had been put on hold. However training is now being planned- including training in relation to medication, and nutrition and people with dementia. Spring House D54 D07 S3807 Spring House V244396 181005 Stage 4.doc Version 1.40 Page 18 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) 33, 35 and 38 There are good systems in place to safeguard Service Users money. Safety checks have not be carried out as required, and this could place service users at risk. EVIDENCE: There is a quality assurance system, which involves consulting Service Users and their representatives; Mrs Luckham said that this consultation process has not been completed yet this year. However discussions with staff, service users and visitors confirmed that Spring House is run in the interests of the people who live there. Mrs Luckham has a system for keeping Service User’s money on their behalf, receipts are kept and any transactions can be tracked. Where Service Users wish to hold keep their own money, a lockable cash box is provided. Spring House D54 D07 S3807 Spring House V244396 181005 Stage 4.doc Version 1.40 Page 19 There are risk assessments which help ensure that Spring House is a safe environment. However not all of the necessary checks identified in the risk assessments have been carried out, for example in relation to legionella and scalds from hot water. Mrs Luckham said that the building works had disrupted some of the usual routines. Spring House D54 D07 S3807 Spring House V244396 181005 Stage 4.doc Version 1.40 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 2 x 2 x x N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 3 10 4 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION 2 2 x x 3 x 2 3 STAFFING Standard No Score 27 3 28 x 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x 3 x x 3 x 3 x x 2 Spring House D54 D07 S3807 Spring House V244396 181005 Stage 4.doc Version 1.40 Page 21 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. Standard OP1 Regulation 4 Requirement The Registered Person must compile a Statement of Purpose, supply a copy to the Commission, and made available to Service Users and their representatives, (This requirement was made at previous inspections) The Registered Person must ensure that a comprehensive assessment has been completed for eah person admitted to the home, prior to a move. The Registered Person must continue to work towards implementing the plan to extend the building so that it provides sufficeint space in the home including:- communal space (lounge and dining)- space for service users to meet visitors in private, separate staff accommodation for staff sleeping in, storage space and adequate laundry and sluicing facilities. The Registered Provider must ensure that each person has a comprehensive Service User Plan, based on an assesment of need. The Registered Provider must Timescale for action 1/12/05 2. OP3 14 15/11/05 3. OP19, OP20, OP25 16,23 1/1/06 4. OP7, OP8 15 1/12/05 5. OP7 13 1/12/05 Page 22 Spring House D54 D07 S3807 Spring House V244396 181005 Stage 4.doc Version 1.40 6. 7. OP29, OP30 OP38 19,18 13 ensure that appropriate moving and handling assements are in place and they are properly implemented. The recruitement and induction system must be implemented for all staff and volunteers. The Registered Provider must ensure that all necessary checks are completed to ensure that all people in the home are safe. 1/12/05 1/12/05 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard OP12 Good Practice Recommendations Support is offered to Service Users to help them maintain photo ablums and memory books. Spring House D54 D07 S3807 Spring House V244396 181005 Stage 4.doc Version 1.40 Page 23 Commission for Social Care Inspection Unit D1 Linhay Business Park Ashburton Devon, TQ13 7UP 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. 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