Inspection on 20/07/05 for Spring Lane Care Home

This inspection was carried out on 20th July 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 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 Lane Care Home 27/11/08

Spring Lane Care Home 09/01/07

Spring Lane Care Home 31/10/05

Spring Lane Care Home 02/11/04

Spring Lane Care Home 06/05/04

Similar services:

Byars Care Home

St Marys Nursing Home

Bramble Lodge

Parkmanor Residential Home

Thornham Grove

Hunter`s Lodge

London Road Neurological and Specialist Care Unit

Carlton Care Home

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

CARE HOMES FOR OLDER PEOPLE Spring Lane 168 Spring Lane Lambley Nottingham NG4 4PE Lead Inspector Rob Cooper Unannounced 20 July 2005 10:00 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 Lane C53 C03 S8765 Spring Lane V239284 200705 Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Spring Lane Address 168 Spring Lane Lambley Nottingham NG4 4PE 0115 967 0341 0115 967 4928 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) Spring Lane Nursing Homes Limited Ms Nicola Harrison Care Home 60 Category(ies) of OP Old Age 60 registration, with number of places Spring Lane C53 C03 S8765 Spring Lane V239284 200705 Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: The service is registered for sixty places for older people aged 60 years and over, not falling into any other registration catagory. Date of last inspection 2nd November 2004 Brief Description of the Service: Spring Lane Care Home is purpose built and is registered to cater for the needs of service users within the older people catagory. Accommodation is on the ground and first floor. The first floor is accessed either by stairs or a passanger lift for those with a physical disability or infirmity. The proprietor is Mrs S Poole. The registered company; Spring Lane Care Home Ltd. Spring Lane C53 C03 S8765 Spring Lane V239284 200705 Stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection took place over one day and was carried out by two inspectors, Rob Cooper and Elaine Cray. As Rob is new inspector, Elaine was present to lend her experience. The methodology used was to talk with a number of service users and some of their relatives, and to interview staff. Case tracking of four service users files. There are currently 47 residents living at Spring Lane, although the home said it has a lengthy waiting list for rooms. The home was clean and well equipped, and there were enough staff on duty to meet the needs of the people living at the home. There were some concerns around health and safety practice and how choice is offered to service users, and staff training records need to be developed further. What the service does well: What has improved since the last inspection? Most of the requirements from the last inspection have been met. Every service user now has a risk assessment within their file around their desire and /or ability to self-medicate. Spring Lane C53 C03 S8765 Spring Lane V239284 200705 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 Lane C53 C03 S8765 Spring Lane V239284 200705 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 Lane C53 C03 S8765 Spring Lane V239284 200705 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 2 & 3 Prospective service users are given adequate information to make an informed choice about coming to live at Spring Lane prior to doing so. This information is also available to relatives, where service users are unable to make a decision unaided. Social Services Community Care Assessments have been carried out for newer residents, but are missing from those who have been in residence for more than twelve months. Service users receive a copy of the homes terms and conditions. EVIDENCE: A number of service users were spoken with and they confirmed that they had been given information before they moved into Spring Lane so that they could make an informed decision regarding going to live there. Two relatives were spoken with, and they confirmed that they were also given adequate information before their father/ father-in-law moved into the home. The Statement of Purpose and the Service User Guide for the home were seen, and these met the requirements of the minimum standards. Some of the residents have had a social services community care assessment carried out, but these Spring Lane C53 C03 S8765 Spring Lane V239284 200705 Stage 4.doc Version 1.40 Page 9 tended to be for people who have moved in more recently. All of the files seen contained a statement of terms and conditions of residence. Spring Lane C53 C03 S8765 Spring Lane V239284 200705 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 & 10 Every service user has an individual plan of care. The quality of that plan varies, with some service users having more in depth information than others. The medication procedures do not sufficiently protect service users from risk. The home has met the requirement from the last inspection with regard to each service user having a risk assessment for self-medication. Service users said they thought they were treated with dignity and respect, although one did not. EVIDENCE: Case tracking of four files showed that generally there was adequate information regarding the health needs of the service users, although in some files the assessment information was not as comprehensive, and consequently care plans were not as detailed. Health care records that were seen were complete. The lunchtime medication round was partially observed. The home uses the Boots monitored dosage system. Staff were seen to handle medication, rather than using medicine pots for transporting tablets from the trolley to the service users. Medication was also left on the dining room table – beside a resident’s plate where it was fully accessible to any other resident in the home. The medication administration records sheets were seen to be signed by staff before the service user had actually swallowed their medication. Spring Lane C53 C03 S8765 Spring Lane V239284 200705 Stage 4.doc Version 1.40 Page 11 Every service user has a risk assessment concerning medication within their file, and it is clear from this assessment, which service users want to selfmedicate. A number of residents were asked about their perception of whether the staff treated them with respect and dignity. With the exception of one service user they thought they did, and gave a number of examples. Spring Lane C53 C03 S8765 Spring Lane V239284 200705 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 & 15 Social activities are organised within the home, but record keeping within the home of such activities means a judgement about their frequency and their ability to meet the needs of the individuals is difficult to make. There are positive links between residents and their families and friends, and visitors are made to feel welcome. The home needs to consider how it offers choice to it’s residents, particularly those who have difficulty communicating, and how the issues around choice can be improved. The home’s record keeping around food is not adequate, and does not meet the regulations. EVIDENCE: During the inspection there was some musical entertainment in one of the lounges with a singer and an organist – singing mainly 40’s 50’s and 60’s songs. Those residents who attended said that they had enjoyed the ‘singalong’. There was a programme of activities displayed within the home, but some residents commented that those activities didn’t always take place. The home employs an activities co-ordinator. Records of social activities in service user files were incomplete and superficial. There were a number of relatives and friends visiting during the inspection, those relatives spoken with said that they were able to visit their relatives’ bedrooms, or find one of the smaller lounges for a quieter visit. The lunchtime meal was observed, and for those service users who are confused there were issues around choice. Several Spring Lane C53 C03 S8765 Spring Lane V239284 200705 Stage 4.doc Version 1.40 Page 13 people declined the choice of dessert on offer, either verbally or by not eating the food provided, but were not readily offered an alternative. There is no record kept of alternative food options given to individuals. Spring Lane C53 C03 S8765 Spring Lane V239284 200705 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 17 & 18 The home has a complaints procedure which protects service users, and which service users and relatives are able to access and use. The home is aware of service user’s legal rights. EVIDENCE: A sample of service users and their relatives were asked about the home’s complaints procedures. Everyone said that they either had a copy, or had seen a copy. They were also confident they knew who to complain to and where to take any complaint if they were unsatisfied with the response they had received. Prior to the inspection one service user had telephoned the Commission’s offices in Nottingham, and had found the telephone number in the service user guide supplied by the home. There was information in the service users files relating to their desire to vote. The home has abuse policies and procedures in place, and staff who were asked, were able to describe the abuse policy and procedure, and were aware of adult protection issues. Spring Lane C53 C03 S8765 Spring Lane V239284 200705 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) 26 The home was clean and tidy and there were cleaning schedules, and an infection control policy in place. EVIDENCE: A visual inspection of the building, showed it to be clean, tidy and orderly. There were domestic staff on duty on the day of the inspection, and those staff members were observed to be carrying out a range of cleaning duties. The home’s infection control policies were also seen. Spring Lane C53 C03 S8765 Spring Lane V239284 200705 Stage 4.doc Version 1.40 Page 16 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) 30 Staff training records are superficial and incomplete which leaves service users at risk. EVIDENCE: The home’s staff training file was seen; this listed the titles of courses undertaken with a date. The records did not provide any detail regarding the duration of the course, the provider, or the course content, merely that an individual attended a course on a given date. The records also appeared to be out of date, as one person’s record showed he had last undertaken training in 2003. There were no records of annual updates for statutory training, and there were no individual training plans for any member of staff outlining forth coming training. Spring Lane C53 C03 S8765 Spring Lane V239284 200705 Stage 4.doc Version 1.40 Page 17 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 & 38 The home needs to consider it’s procedure for staff hand overs, and consider how the needs of service users will continue to be met at this time. Service users’ health and safety is potentially at risk from inadequate storage of Control of Substances Hazardous to Health (COSHH) materials. The Employers Liability Insurance certificate expired on the 29th June 2005. The records relating to fire tests within the home are incomplete. EVIDENCE: One relative commented that often it was difficult to get a member of staff during hand over periods. These hand overs can last up to 30 minutes, and it was particularly a problem if a non-mobile, or semi-mobile resident needed the toilet. Another relative who was visiting a different resident confirmed this to be the case. There are no locks on any of the sluice room doors. A number of Control of Substances Hazardous to Health (COSHH) materials were stored within the sluice rooms. These were stored on open shelves, and included ant Spring Lane C53 C03 S8765 Spring Lane V239284 200705 Stage 4.doc Version 1.40 Page 18 killer. The Employers Liability Insurance Certificate displayed in the front foyer was found to be almost one month out of date, having expired on the 29th June 2005. Examination of fire test records, showed some gaps, and some records not completed within the necessary time frame – i.e. weekly/monthly records. Spring Lane C53 C03 S8765 Spring Lane V239284 200705 Stage 4.doc Version 1.40 Page 19 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 4 4 2 x x x HEALTH AND PERSONAL CARE Standard No Score 7 3 8 2 9 2 10 2 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 4 14 2 15 2 COMPLAINTS AND PROTECTION x x x x x x x 4 STAFFING Standard No Score 27 x 28 x 29 x 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 4 3 3 x x 2 x x x x 2 Spring Lane C53 C03 S8765 Spring Lane V239284 200705 Stage 4.doc Version 1.40 Page 20 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 38.3 Regulation OP13 (4a) Timescale for action The registered person shall make 27/07/05 suitable arrangements to prevent infection, toxic conditions and the spread of infection at the care home, and therefore sluice room doors must be fitted with a lock, and must be kept locked when not in use. The registered person shall make 20/07/05 suitable arrangements to prevent infection, toxic conditions and the spread of infection at the care home, and therefore Control of substances hazardous to health (COSHH) materials must be stored in a locked cupboard designated for the purpose The registered person shall 20/07/05 ensure that unecessary risks to the Health & Safety of service users are identified and as far as possible eliminated. Staff must follow the homes medication procedures with regard to administration of medicines and recording of that administration. The Registered person must 30/09/05 ensure that there is a staff training and development programme which meets National Training Organisation Version 1.40 Page 21 Requirement 2. 38.3 OP13 & OP16 3. 9.3 & 9.4 OP13 4. 30.1 OP18 Spring Lane C53 C03 S8765 Spring Lane V239284 200705 Stage 4.doc 5. 38.2 OP13 & OP16 6. 27.1 OP18.1a 7. 14 OP12 8. 12 OP16 9. 15 OP16 10. 15 OP17 workforce training targets and ensures staff fulfil the aims of the home and meet the changing needs of service users, and that staff receive training appropriate to the work they perform.. The Registered manager must ensure safe working practices in respect of fire safety, by implementation of the appropriate fire procedures. The registered person need to review staffing arrangements during handover periods to ensure that at all times suitably qualified, competent and experienced persons are working in the care home in such numbers as are appropriate for the health and welfare of service users. The Registered person must ensure that service users are consulted on the choice of activities; their personal preferences and expectations should be recorded in the social care plans. The registered person needs to ensure that social activities for service users are adequately recorded within the service users file. The registered person must ensure that choice at meal times is encouraged and supported with all service users, not just those who are able to express a view. The registered person is required to keep records of all food and alternatives offered to, and given to service users. 25/07/05 30/09/05 30/09/05 30/09/05 30/09/05 30/09/05 Spring Lane C53 C03 S8765 Spring Lane V239284 200705 Stage 4.doc Version 1.40 Page 22 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 3 Good Practice Recommendations Service users who have been in residence longer than twelve months should be re-assessed to ensure that their current needs are identified and are able to be met. Spring Lane C53 C03 S8765 Spring Lane V239284 200705 Stage 4.doc Version 1.40 Page 23 Commission for Social Care Inspection Edgeley House Riverside Business Park Tottel Road Nottingham NG2 1RT 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 Lane C53 C03 S8765 Spring Lane V239284 200705 Stage 4.doc Version 1.40 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. 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