Inspection on 15/02/06 for Spring Lake

This inspection was carried out on 15th February 2006.

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 found no outstanding requirements from the previous inspection report, but made 3 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Spring Lake 20/10/07

Spring Lake 23/11/06

Spring Lake 28/07/05

Spring Lake 17/02/05

Spring Lake 22/06/04

Similar services:

Ashlong House

Norbury Crescent (30)

Edenvale

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Chatsworth Care - Dawson House

Cowden Road, 52 - 54

Chatsworth Care - Tudor Lodge

Foxley Lane (121a)

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

CARE HOME ADULTS 18-65 Spring Lake Spring Lake 17 Forty Lane Wembley Park Middlesex HA9 9EU Lead Inspector Dia Balraj Unannounced Inspection 15th February 2006 09:00 Spring Lake DS0000017450.V282984.R01.S.doc Version 5.1 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 Lake DS0000017450.V282984.R01.S.doc Version 5.1 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. 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 Lake DS0000017450.V282984.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Spring Lake Address Spring Lake 17 Forty Lane Wembley Park Middlesex HA9 9EU 020 8908 5233 020 8908 5233 sprilake@aol.com 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) Mr Ian Jones Perpetua Mary Caesar Care Home 11 Category(ies) of Learning disability (11) registration, with number of places Spring Lake DS0000017450.V282984.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 28th July 2005 Brief Description of the Service: Spring Lake is part of a group comprising two residential care homes and five supported living units. It was first registered in 1997 and transferred its registration to the former NCSC in 2002 and to the CSCI in 2004 under the Care Standards Act 2000.The home is registered to provide accommodation and care service to 11 male and female young adults with learning disability, autistic spectrum disorder and behaviour challenges. At the time of this inspection, the home had 3 vacancies. All admissions are planned and the home does not accept emergency admissions. The home is located in Wembley close to a variety of shopping, transport, leisure, recreational and social facilities and services. The property is a large detached house with two detached outer buildings used as learning centres for residents and staff. The bedrooms are all single occupancy and one with en suite facilities. The home has a registered manager and deputy manager plus a full complement of care staff. Spring Lake DS0000017450.V282984.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The unannounced inspection took place in one day. The registered care manager was on annual leave. The inspection process was assisted with contributions from the deputy manager and staff. The Inspector was able to observe the standard of care, the rapport between staff and residents and examined a sample of residents’ case files, residents’ individual care plans and their medication reviews. The home had a good standard of cleanliness and residents appeared well cared for with an adequate mix of staff with relevant experiences, training and competencies. On the day of inspection the Deputy manager informed the inspector that the central heating had been turned off by British Gas on the 14th February 2006 as it was unsafe for use. An engineer came to the home during the inspection process and advised that a new boiler would be fitted on Friday 17th February 2006. The home was using electric heaters in the communal rooms. The Inspector advised the deputy manager that a new boiler should be installed as a matter of urgency to ensure residents health and safety. The Deputy Manager informed the CSCI on the 17th February that a new boiler had been fitted. What the service does well: What has improved since the last inspection? Spring Lake DS0000017450.V282984.R01.S.doc Version 5.1 Page 6 The service continues to develop links with advocacy services and one resident is on the waiting list for an advocate. There has been progress to update residents’ care plans and three staff are being trained on centred care planning. Leisure and social activities have been further developed to meet the needs of residents and offer them more stimulation and fulfilling activities. The first floor bathroom has been upgraded. 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 Lake DS0000017450.V282984.R01.S.doc Version 5.1 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Spring Lake DS0000017450.V282984.R01.S.doc Version 5.1 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): EVIDENCE: This standard was not inspected. Spring Lake DS0000017450.V282984.R01.S.doc Version 5.1 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 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&9 Service users are able to exercise a degree of choice in activities based on Staff’s knowledge of their individual preferences. Service users are enabled to participate in activities to promote their independence. EVIDENCE: A thorough and comprehensive multi-disciplinary assessment is carried out for each resident before they move to the home. Each resident’s care plan identifies the individuality and personal preferences of each resident. The key workers were observed to work closely with each resident for example in the development of their independence and living skills. The programme of activities is tailored to meet each resident’s individual needs and is reviewed according to residents’ changing needs and choices. Records and observation on the inspection confirm that staff make efforts to communicate with the residents, recognise changes in their moods and feelings and coordinate daily activities. During the course of this inspection a member of staff was observed as ensuring a resident’s wishes before enabling the resident to participate in the scheduled activity. Spring Lake DS0000017450.V282984.R01.S.doc Version 5.1 Page 10 The inspector observed the serving of Lunch and noted that residents were offered choices. Spring Lake DS0000017450.V282984.R01.S.doc Version 5.1 Page 11 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 11, 12, 13, 16 &17 The lifestyle at Spring Lake gives residents opportunities for personal development and to be part of the community. The activities offered are appropriate to residents’ needs and their rights are respected. Residents have a healthy diet. EVIDENCE: The inspector observed a good rapport between staff and residents. Staff had a good understanding of residents’ needs. The inspector observed a one to one ratio of staff support. There is an intensive activity programme which residents seemed to enjoy. Each resident has a different set of indoor and outdoor activities every day. These included: Drive to Wembley park station, bowling Park royal, Sensory room, Day services (Day centre and House), Heathrow airport. The outdoor activities enabled residents to feel part of the community and drives, walks and visits fostered links with the local community. Residents were observed to be treated with respect, with due consideration being given to ascertaining their wishes prior to engaging in an activity. The inspector observed the serving of Lunch and was satisfied that the menu was varied and that residents were given choices. The menu was nutritious Spring Lake DS0000017450.V282984.R01.S.doc Version 5.1 Page 12 and the atmosphere was relaxed. Residents were observed to enjoy their meal. Spring Lake DS0000017450.V282984.R01.S.doc Version 5.1 Page 13 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): This standard was not inspected. EVIDENCE: The requirement from the last inspection relating to the review of the medication profile of each resident had been carried out. The monitoring and review to help prevent overstocking of medication through the repeat prescription process had also been implemented. Spring Lake DS0000017450.V282984.R01.S.doc Version 5.1 Page 14 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): This standard was not inspected. EVIDENCE: Spring Lake DS0000017450.V282984.R01.S.doc Version 5.1 Page 15 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 30 The home is clean. The heating in the home was not adequate. Areas of the building required redecoration. EVIDENCE: The heating on the day of inspection was not adequate. British gas had been contacted to remedy the central heating. After carrying out a check British Gas switched off the heating system for safety reasons on the 14th February. Electric heaters had been provided in the communal areas. The Deputy Manager stated that an engineer had been contacted to replace the boiler. The CSCI was informed on 17th that a new boiler had been fitted. The registered person had implemented a maintenance programme for the year 2005/2006 : The painting of the exterior of the building identified during the last inspection on the 28th July 2005 was outstanding. A section of the wall in the corridor leading to the staff room was peeling off and requires repair. Spring Lake DS0000017450.V282984.R01.S.doc Version 5.1 Page 16 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): This standard was not inspected. EVIDENCE: Spring Lake DS0000017450.V282984.R01.S.doc Version 5.1 Page 17 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. 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 are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 42 The health, safety and welfare of service users were protected with the exception of the central heating system, which was out of action. EVIDENCE: There was evidence that staff worked towards promoting the welfare of residents. The provider had taken steps to remedy the situation and had contacted an engineer to replace the boiler. However the delay in the replacement of the boiler meant that residents were without central heating. for a couple of days. Spring Lake DS0000017450.V282984.R01.S.doc Version 5.1 Page 18 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 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 X 2 X 3 X 4 X 5 X X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 X 23 x ENVIRONMENT Standard No Score 24 2 25 x 26 x 27 x 28 x 29 x 30 3 STAFFING Standard No Score 31 X 32 X 33 X 34 X 35 X 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score X 3 X 3 X LIFESTYLES Standard No Score 11 3 12 3 13 3 14 X 15 x 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score X X X x X X X X X 2 X Spring Lake DS0000017450.V282984.R01.S.doc Version 5.1 Page 19 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 YA42YA27 Regulation 16,23 Requirement The provider must ensure that there is adequate heating in the home at all times. Repairs or renewal to the heating system must be carried out without delay to ensure that residents live in a comfortable environment.. The registered provider must ensure there is a programme of regular maintenance for the home, including external painting and upkeep. The registered provider must inform the CSCI of any event in the care home which adversely affects the welfare of service users. Timescale for action 17/02/06 2. YA40 37 24/02/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Spring Lake Refer to Good Practice Recommendations DS0000017450.V282984.R01.S.doc Version 5.1 Page 20 1. Standard YA40 The registered provider must ensure that a copy of the Care Homes Regulations 2001 is kept on the premises for reference. Staff must also familiarise themselves with the requirements of the Regulations. Spring Lake DS0000017450.V282984.R01.S.doc Version 5.1 Page 21 Commission for Social Care Inspection Harrow Area office Fourth Floor Aspect Gate 166 College Road Harrow HA1 1BH 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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