Inspection on 12/09/05 for Spring Lodge

This inspection was carried out on 12th September 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 Lodge 13/02/07

Spring Lodge 04/02/06

Spring Lodge 01/02/05

Spring Lodge 18/08/04

Similar services:

Claremont House

Oak Ridge

Sun Court Nursing Home

Ashville House

Bilney Hall

Hill Barn

Mabbs Hall Nursing Home

Henrietta House

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

CARE HOMES FOR OLDER PEOPLE Spring Lodge 23 Vicarage Gardens Clacton On Sea Essex CO15 1BU Lead Inspector Pauline Dean Unannounced 12th September Final 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 Lodge I56 I05 S61194 Spring Lodge V224549 UI120905 Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Spring Lodge Address 23 Vicarage Gardens Clacton On Sea Essex CO15 1BU 01255 420045 01255 420045 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) Black Swan International Ltd Mrs Maria Teresa Cardwell Ms Margaret McKeen Care Home 18 Category(ies) of Old age, not falling within any other category registration, with number (18) of places Spring Lodge I56 I05 S61194 Spring Lodge V224549 UI120905 Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: 1. Persons of either sex, aged 65 years and and over, who require care by reason of old age only (not to exceed 18 persons). Date of last inspection 2nd February 2005 Brief Description of the Service: Spring Lodge is an established care home for older people offering accommodation for eighteen service users on the ground and first floor. Accommodation is in sixteen single rooms, eight with en suite facilities of wash hand basin and toilet and one double room with en suite facilities of wash hand basin and toilet. Access to the first floor is by a staircase or passenger lift. Toilets and assisted bathrooms are found on each floor. The property is detached, located in a tree-lined road in a residential area of Clacton on Sea. Spring Lodge is close to the town centre, which has the usual amenities of shops, post office, library and leisure facilities. The sea front and promenade are within walking distance. Communal areas consist of a main lounge and dining room on the ground floor, with a further small lounge on the first floor. Catering and laundry services are in house and are found to the rear of the property. Spring Lodge I56 I05 S61194 Spring Lodge V224549 UI120905 Stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection, which took place over one day in September 2005. This was the first inspection of the inspection year 2005 to 2006. Throughout the day there was discussion with the registered manager, Ms McKeen. Four care staff, three residents and one visitor, who was present during the inspection, were also interviewed as part of the inspection. There were eighteen residents at home on the day of inspection. A tour of the premises was conducted and both resident and staff records were sampled and inspected. Policies and procedures were also sampled and inspected. Twenty-one of the thirty-eight standards were inspected; of these fourteen were met, with six standards almost met. One standard was not applicable. At the last inspection, there were seven requirements and one recommendation. Whilst it is noted that there has been a slight improvement some of the previous requirements still require attention. These are namely staffing level calculations, the adult protection policy and premises and gas safety certification shortfalls. It is anticipated, that these remaining shortfalls will receive early attention to ensure compliance. What the service does well: When asked what they felt the service did well, Ms McKeen said that Spring Lodge is able to offer consistent, good care practice. She also said that Spring Lodge has an established, committed staff group who interact well with the residents. During this inspection this was observed by the inspector, with examples of kindness, joking and chatting witnessed, as staff went about their work. Ms McKeen spoke of residents being able to approach staff as they wished and an example of action taken at the request of a resident was noted. Residents spoken with appreciated the established staff group, acknowledging that they had an understanding of their needs and wishes. One resident said that both the manager and staff were “very kind”. Other residents spoke of being able to choose whether they stayed in their room or use the communal areas during the day. Spring Lodge I56 I05 S61194 Spring Lodge V224549 UI120905 Stage 4.doc Version 1.40 Page 6 What has improved since the last inspection? 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 Lodge I56 I05 S61194 Spring Lodge V224549 UI120905 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 Lodge I56 I05 S61194 Spring Lodge V224549 UI120905 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) 3 and 6. This service operates a thorough and responsible pre-admission assessment process, with care and attention given to ensure that the home can meet the individual’s needs, resulting in appropriate admissions. Intermediate care is not offered at Spring Lodge. EVIDENCE: The files of two new residents were inspected and clear evidence of a completed pre-admission assessment was seen. Spring Lodge does not offer intermediate care. Spring Lodge I56 I05 S61194 Spring Lodge V224549 UI120905 Stage 4.doc Version 1.40 Page 9 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. Residents’ health care needs and medication requirements are consistently met within the home. Spring Lodge has an established staff team with a good understanding of resident’s individual needs. Staff treated residents with respect, and actively supported them to maintain control of their care and health needs as appropriate. EVIDENCE: Three care planning files, for three residents were sampled and inspected. On two of the files there were detailed plans of care, which covered all aspects of health, personal and social care needs of the resident. These were found to be reviewed monthly with an evaluation of the planned care completed. On the third file inspected, an assessment review and care planning notes had been developed for a recent admission. Record keeping is managed through a key worker system, with staff involved in the care planning, record keeping and reviews. Health care visits are held within appropriate record sheets, with entries seen of input from GPs, a chiropodist, an audiologist and the district nursing service. Spring Lodge I56 I05 S61194 Spring Lodge V224549 UI120905 Stage 4.doc Version 1.40 Page 10 Medication administration, receipt, storage and record keeping was sampled for two residents. This was found to be in good order, as was the storage and administration of Controlled Drugs for three residents. All three residents spoken with were very positive about the way personal and health care needs were being met and felt that staff treated them in an appropriate way, respecting their privacy and dignity. A member of staff interviewed gave examples of ways in which they could ensure that residents’ privacy and dignity was respected. Spring Lodge I56 I05 S61194 Spring Lodge V224549 UI120905 Stage 4.doc Version 1.40 Page 11 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. The daily routine and activities in the home were flexible, with residents being encouraged to make choices and be independent. Family contact and visiting arrangements were open and relaxed, with family links encouraged and promoted. The home offered a varied, planned menu, with thought given to dietary requirements. EVIDENCE: From discussion with residents and staff, routines in the home were found to be flexible with residents’ individual choices accommodated. Three residents interviewed confirmed that they were able to exercise their choice with regard to leisure and social activities in the home. All three spoke of sitting out in the garden in the summer months and one resident confirmed that trips to a local pub for lunch and to the theatre were enjoyed by some of the residents. All three residents said that family and friends were made very welcome when they visited the home and that refreshments were offered. This was confirmed by a visitor who spoke of the friendliness of the management and staff when visiting the home. Three care staff also spoke of recent trips to the theatre and for a pub lunch. Five residents had chosen to attend. Regular in-house entertainment such as Spring Lodge I56 I05 S61194 Spring Lodge V224549 UI120905 Stage 4.doc Version 1.40 Page 12 singers and the Salvation Army were said to be enjoyed by the majority of the residents. Two residents who had recently been admitted to Spring Lodge, confirmed that they had been able to bring some of their personal possession into the home, the extent of which had been agreed to on admission. Spring Lodge uses a two-week rotation menu plan, with at least two choices available at lunch and teatime. Seasonal variations are included in the menu planning and produce from the garden such as fruit and vegetables are incorporated into the menu. Nutrition records seen denoted liquidised and diabetic meals served, with a light supper and drink offered to residents as they wish before adjourning to bed. The dining room area was well decorated, with the presentation of the food well managed. Record keeping and the management of the taking and recording fridge and freezer temperature checks were considered. These now denote clearly the fridges and freezers checked. Spring Lodge I56 I05 S61194 Spring Lodge V224549 UI120905 Stage 4.doc Version 1.40 Page 13 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 home’s complaints procedure is made available to residents and their families to enable them to progress complaints as they wish. An adult protection procedure is in place to help ensure that residents are protected from abuse. This requires further development to ensure local authority guidance and the Protection of Vulnerable Adults (POVA) register is considered. EVIDENCE: Copies of the home’s complaints procedure was readily available in the home with copies found on resident’s files which are held in their room. All three residents spoken with were aware of the home’s complaints procedure and said that if they had any concerns they would take these matters to the home’s manager. One visitor to the home said that they would raise any concern they had with the home’s manager. Complaint logs are available for that purpose. As at the last inspection, there is a need to review and revise the policies on Adult Abuse and Protection of Service Users. The last review was dated February 2003. There is a need to urgently review this document to ensure that it clearly details local authority guidance and the implementation of the Protection of Vulnerable Adults (POVA) register. One member of staff interviewed was able to detail the action they would take should they become aware of a resident being abused. Details of local training on offer regarding the Protection of Vulnerable Adults for care staff was given to Ms McKeen. Spring Lodge I56 I05 S61194 Spring Lodge V224549 UI120905 Stage 4.doc Version 1.40 Page 14 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, 25 and 26. The home provides a safe, well-maintained environment that is accessible to residents, homely and meets individual needs. EVIDENCE: Records relating to premises issues were not inspected in full at this inspection. Hot water temperature records were seen and records detailed hot water temperatures at approximately 43 degrees centigrade. A tour of the premises was conducted and the home was found to be warm, clean and homely. The property inside and outside was very well maintained, with ongoing decoration and repair. One resident and their visitor spoke of the home’s premises being well decorated and bright, with the garden getting a special recommendation. Ongoing maintenance and decoration were seen to have been completed, with just three remaining radiator covers to be fitted in the lounge, dining room and entrance hall. Ms McKeen said that the home had experienced a problem Spring Lodge I56 I05 S61194 Spring Lodge V224549 UI120905 Stage 4.doc Version 1.40 Page 15 finding a plumber, but they would ensure that radiator covers are fitted before the heating is turned on again for winter. Spring Lodge has an in-house laundry, situated at the rear of the property. There are two washers and two dryers on site. Ms McKeen said that the laundry is completed during the day and at night the ironing is completed. One resident said that Spring Lodge has a good laundry service, with items returning promptly ironed and laundered. Ms McKeen said that the services and facilities comply with the Water Supply (Water Fittings) Regulations 1999. Spring Lodge I56 I05 S61194 Spring Lodge V224549 UI120905 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) 27, 29 and 30. No consideration has been given to the Department of Health Residential Forum Guidance when calculating staffing levels and therefore it was not possible to confirm if resident’s needs are met. Spring Lodge operates a thorough staff recruitment procedure to ensure the protection of residents. The level of training helps ensure that residents are well cared for. EVIDENCE: Staff rotas detailed staff on duty. Spring Lodge continues to have an established staff group, with only one change since the last inspection. Ms McKeen said that the home is currently advertising to fill this vacancy, with current care staff covering these hours. All staff were said to be over 18 years of age and staff left in charge of a shift are over 21 years of age. The ratio of care staff to residents had not been determined according to the assessed needs of residents and a system for calculating staff numbers had not been used. Ms McKeen was advised to review staffing levels taking consideration of the Department of Health Residential Forum Guidance. Staff recruitment records and checks for two care staff were sampled and inspected, they were found to be in good order. Within the home there is ongoing training. Evidence was seen of staff attending First Aid, Medication Administration and Protection from Abuse training since the last inspection. Further training in Protection from Abuse is planned for other care staff. All Spring Lodge I56 I05 S61194 Spring Lodge V224549 UI120905 Stage 4.doc Version 1.40 Page 17 staff are encouraged and enabled to undertake National Vocational Qualification (NVQ) Level 2 in care. There are currently nine care staff who have achieved this qualification and the home is just short of meeting the minimum ratio of having 50 of care staff trained to NVQ Level 2 in care by 2005. Spring Lodge I56 I05 S61194 Spring Lodge V224549 UI120905 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 is a need to introduce an effective quality assurance and quality monitoring system to help ensure that the home is run in the best interests of the residents. Residents’ financial interests are safeguarded through written records of all transactions, although there was an error in the monies and records inspected. The health and safety of residents and staff is protected through the renewal and updating of health and safety certifications, although not all certifications were complete. EVIDENCE: The need to develop an effective quality assurance and quality monitoring system was discussed with Ms McKeen. A questionnaire analysis had been completed February 2004 and the need to develop this with future questionnaires was considered. Records relating to personal allowances held by the home were sampled. Of the two sampled one was found to be short by 50 pence, an error in record Spring Lodge I56 I05 S61194 Spring Lodge V224549 UI120905 Stage 4.doc Version 1.40 Page 19 keeping would appear to account for this. Other records and monies held were in good order. Secure facilities are made available for residents, to hold money and valuables, in their rooms should they wish. The registered manager ensures safe working practices through ongoing basic training courses. See ‘Staffing’ section of this report for more details. Further training courses are being progressed, with Basic Food Hygiene and First Aid training booked. Gas safety certification was sampled and inspected. A Landlord’s Gas Safety certificate was seen, dated 7th July 2005. As stated at the last inspection the requirement is for both gas safety and the detailing of servicing and maintenance checks for gas equipment. Spring Lodge I56 I05 S61194 Spring Lodge V224549 UI120905 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 x x 3 x x N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION 3 x x x x x 2 3 STAFFING Standard No Score 27 2 28 x 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x 2 x x 2 x 2 x x 2 Spring Lodge I56 I05 S61194 Spring Lodge V224549 UI120905 Stage 4.doc Version 1.40 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 18 Regulation 12, 13, 17, 18, 19, 22 Requirement Timescale for action 23/10/05 2. 25 16 3. 27 18 The registered person must ensure that residents are safeguarded from abuse, making reference to the Protection of Vulnerable Adults (POVA) register and it’s implications. (This is a repeat requirement from the last inspection. Previous timescale of 18/03/05 not met.) 23/10/05 The registered person must ensure that the heating and water supply meet relevant environmental health and safety requirements and the needs of the individual residents. This is with regard to hot water pipe work and radiators in communal areas. (This is a repeat requirement from the last inspection. Previous timescale of 18/03/05 not met.) The registered manager must 23/10/05 ensure that staffing levels are appropriate to the assessed needs of the service users, the size, layout and purpose of the home, as calculated using the Department of Health Residential Forum Guidance. Version 1.40 Spring Lodge I56 I05 S61194 Spring Lodge V224549 UI120905 Stage 4.doc Page 22 4. 33 21 5. 35 17 6. 38 16, 17, 26, 37 The registered person must 23/10/05 develop effective quality assurance and quality monitoring systems, based on seeking the views of residents, to measure the homes success in meeting aims, objectives and it’s statement of purpose. The registered manager must 23/10/05 ensure that safeguards are in place to protect the interests of residents money when held by the home. (This is a repeat requirement from the last inspection. Previous timescale of 18/03/05 not met.) The registered manager must 23/10/05 ensure so far as is reasonably practicable the health, safety and welfare of residentss and staff, as detailed within the National Minimum Standards for Care Homes for Older People – Standard 38. This is with regard to gas safety and maintenance certification. (This is a repeat requirement from the last inspection. Previous timescale of 18/03/05 not met.) 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 Good Practice Recommendations Spring Lodge I56 I05 S61194 Spring Lodge V224549 UI120905 Stage 4.doc Version 1.40 Page 23 Commission for Social Care Inspection 1st Floor Fairfax House Causton Road Colchester CO1 1RJ 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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