Inspection on 04/02/06 for Spring Lodge

This inspection was carried out on 4th 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 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 12/09/05

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 Inspection 4th February 2006 09:15 X10015.doc Version 1.40 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 Lodge DS0000061194.V280433.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 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 DS0000061194.V280433.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Spring Lodge Address 23 Vicarage Gardens Clacton On Sea Essex CO15 1BU 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) 01255 420045 Black Swan International Limited 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 DS0000061194.V280433.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. Persons of either sex, aged 65 years and over, who require care by reason of old age only (not to exceed 18 persons) 12th September 2005 Date of last inspection 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 DS0000061194.V280433.R01.S.doc Version 5.1 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 February 2006. This was the second inspection of the inspection year – 2005 – 2006. The inspector was assisted throughout the inspection by the Senior Care. One care staff member was interviewed and all staff on duty were spoken with as they went about their duties. On the day of the inspection there were seventeen residents in the home and during this inspection four residents were spoken with. In addition four relatives were spoken with as they visited their relatives in the home. Following this inspection and prior to writing this report, a Relatives/Visitors Comment Card was completed and returned. The relative spoke very highly of the care offered to their relative, praising the standard of care, choice and meals in the home. 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. The majority of the key standards were inspected at the last inspection. Eleven of the thirty-eight standards were inspected at this inspection; of these seven were met, with four standards nearly met. This is a slight improvement since the last inspection. The requirements, which continue to be outstanding, are the Adult Protection policies and procedures, staffing level calculations using the Residential Forum Guidance, the National Vocational Qualification training for management and the Gas Service Maintenance Check certification. What the service does well: As at previous inspections, Spring Lodge presents as a pleasant, welcoming care home. All four residents spoke with the home praised the care received and the warm atmosphere in the home. Two of these residents were new to Spring Lodge and they spoke positively of moving and settling in the home. Two of the four relatives spoke with also complimented the home on its warm atmosphere, complimenting both management and staff on their kindness and good nature. Ongoing maintenance and decoration of Spring Lodge continues to ensure that the garden and the home are light, bright and attractive. Decoration and furnishings are of a high standard with residents able to personalise their rooms with their belongings. Spring Lodge DS0000061194.V280433.R01.S.doc Version 5.1 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 DS0000061194.V280433.R01.S.doc Version 5.1 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 Outcomes Statutory Requirements Identified During the Inspection Spring Lodge DS0000061194.V280433.R01.S.doc Version 5.1 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 the following standard(s): None of these Standards were inspected in full at this inspection. EVIDENCE: The Key Standards relating to the ‘Choice of Home’ were not considered in full at this inspection. They were inspected at the last inspection. However, during this inspection, the inspector spoke with two new residents and both said that they has settled into the home very well. One resident said that they were very pleased with their room and they had been able to bring in items from their home. The inspector was informed that both residents had come into the home on a trail basis, with time given to allow them to settle into the home. Spring Lodge DS0000061194.V280433.R01.S.doc Version 5.1 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 the following standard(s): None of these Standards were inspected in full at this inspection. EVIDENCE: The Key Standards relating to the ‘Health and Personal Care’ of the residents were not considered in full at this inspection. They were inspected at the last inspection. However, during this inspection three residents confirmed that their health needs were considered and met. Two residents gave examples of when the district nursing service and GPs had been called in to visit them and the care and attention they had received from the care staff. Three relatives spoken with during the inspection also confirmed that their relative received appropriate medical attention and help as needed. They also said that they are kept fully informed, as they would wish, of any health need intervention required. Issues around privacy and dignity were considered with three residents and a member of the care staff. All three residents confirmed that staff give consideration of their privacy and dignity when attending to their personal care Spring Lodge DS0000061194.V280433.R01.S.doc Version 5.1 Page 10 needs. The one care staff member spoken with also gave examples of occasions when they ensure that residents’ privacy and dignity is respected and managed in their work. Spring Lodge DS0000061194.V280433.R01.S.doc Version 5.1 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 the following standard(s): None of these Standards were inspected in full at this inspection. EVIDENCE: The Key Standards relating to the ‘Daily Life and Social Activities’ of the residents were not considered in full at this inspection. They were inspected at the last inspection. From speaking to residents, the inspector noted several examples of residents being able to make choices with regard to the social activities and pursuits they wished to follow. Two residents spoke of trips to the theatre and parties over the Christmas period. Two relatives confirmed that residents had enjoyed the Christmas activities in the home and they had been included in the festivities. One resident spoke of enjoying sport on the television and they had a daily paper as they requested. During this inspection, residents were seen to go about the home as they wished and if they wished to spend time in their rooms they were able to. Spring Lodge DS0000061194.V280433.R01.S.doc Version 5.1 Page 12 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 the following standard(s): 18. 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: As at previous inspections, the home needs to review and revise the policies on Adult Abuse and Protection of Service Users. The last review was dated February 2003 and signed by a joint registered provider. Care staff in post in March 2003 were seen to have signed as having read the policy. This list had not been updated and did not fully reflect the current staff group. As stated at the last inspection 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. Both the Senior Care staff member and a second member of staff spoken with confirmed that they would ensure that the registered manager was made aware of any concern brought to their attention. The inspector was informed that all twelve care staff had attended in-house Protection of Vulnerable Adults (POVA) training. In addition, the registered manager confirmed in a telephone conversation that they were to attend an Essex County Council Protection of Vulnerable Adults (POVA) workshop. Spring Lodge DS0000061194.V280433.R01.S.doc Version 5.1 Page 13 Spring Lodge DS0000061194.V280433.R01.S.doc Version 5.1 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 the following standard(s): 20, 21, 24 & 25. The home provides a safe, well-maintained environment that is accessible to residents, homely and meets individual needs. EVIDENCE: 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. New chairs in the entrance hall created a cosy welcoming area at the entrance of the home. Communal areas in the home comprise of the main lounge, dining room, entrance hall and the first floor small lounge. All of these areas were well decorated with good quality furniture and furnishings. Radiator covers have been fitted on the remaining unguarded radiators in the lounge, dining room and entrance hall. Lighting in these communal areas was of good quality and domestic in character. Bathroom and toilet facilities were as at the last inspection. There have been no changes to these facilities. Spring Lodge DS0000061194.V280433.R01.S.doc Version 5.1 Page 15 Bedroom accommodation comprises of sixteen single rooms, eight with ensuite facilities of a wash hand basin and toilet and one double room with ensuite facilities of a wash hand basin and toilet. The remaining single rooms have a wash hand basin only. A resident confirmed that they were held a key and they were able to lock their room as they wished and they had been able to bring in personal items such as photographs, books and pictures to decorate their room. Spring Lodge DS0000061194.V280433.R01.S.doc Version 5.1 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 consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27 & 28. 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. Staff are trained and competent to do their work, through a training programme which includes National Vocational Qualifications (NVQ) training. EVIDENCE: Staff rotas detailed staff on duty. Spring Lodge continues to have an established staff group. From discussion with the Senior Care and the registered manager on the telephone it was understood that 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. As at the last inspection, the care is advised to review staffing levels taking consideration of the Department of Health Residential Forum Guidance. From discussion with the Senior Care, care staff and the registered manager it is understood that six care staff out of twelve care staff have obtained a National Vocational Qualification (NVQ) level 2 in care. Furthermore two more care staff are to start an NVQ level 2 in the near future. Spring Lodge has therefore met the minimum ratio of 50 trained members of care staff with NVQ level 2 or equivalent by 2005. Spring Lodge DS0000061194.V280433.R01.S.doc Version 5.1 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 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 & 38. The management approach of Spring Lodge is open, positive and inclusive to ensure residents are able to access the manager. Spring Lodge has effective quality assurance and quality monitoring systems 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. 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: Three care staff spoken to said that they found the management approach of Ms McKeen as open, positive and approachable. Spring Lodge DS0000061194.V280433.R01.S.doc Version 5.1 Page 18 It was not possible at this inspection to discuss personally with the registered manager the requirement that the registered manager must have a level 4 NVQ in management and care by 2005. It is understood that Ms McKeen has not obtained this qualification. The care home is therefore reminded of the need for the registered to obtain a NVQ level 4 qualification in management and care and confirmation of the action to be taken to enrol and obtain this qualification is required with this report’s Action Plan. A Quality Assurance, Development Plan and Annual Audit File was sampled and inspected. A questionnaire devised for completion by the residents was found on file. Twelve residents had completed this questionnaire in October 2005 and a summary and analysis had been completed in November 2005. This summary and analysis had been shared with residents, with copies found on their individual files found in their bedrooms. Whilst it was not possible to sample and inspect in full residents’ monies, records and receipts were found to be in order. This will be inspected in full at future inspections. As at the last inspection ongoing training courses ensure that staff follow safe working practices. A staff file sampled evidenced Basic Food Hygiene and Moving and Handling training in 2005. Safety certification was sampled and inspected. The Fire Alarm System certificate of testing, the Nurse Call and Emergency Lighting certificate, the passenger lift and the Parker Bath hoist (chair) and the Patient hoist all had current service certificates. Still outstanding from the last inspection is the Gas Service Maintenance Check. The inspector was informed that this had been pursued by the home following the last inspection. A copy of a letter to obtain this certification was found on file. However, this certification was not available. Spring Lodge DS0000061194.V280433.R01.S.doc Version 5.1 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 Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X X X X X HEALTH AND PERSONAL CARE Standard No Score 7 X 8 X 9 X 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 X 14 X 15 X COMPLAINTS AND PROTECTION Standard No Score 16 X 17 X 18 2 X 3 3 X X 3 3 X STAFFING Standard No Score 27 2 28 3 29 X 30 X MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 3 X 3 X X 2 Spring Lodge DS0000061194.V280433.R01.S.doc Version 5.1 Page 20 Are there any outstanding requirements from the last inspection? Yes 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 OP18 Regulation 12,13,17, 18,19,22 Requirement Timescale for action 14/04/06 2. OP27 18 The registered person must ensure that residents are safeguarded from abuse, making reference to the Protection of Vulnerable Adults (POVA) register and its implications. (This is a repeat requirement from the last two inspections. Previous timescales of 18/03/05 and 23/10/05 were not met.) 14/04/06 The registered manager must 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. (This is a repeat requirement from the last inspection. Previous timescale of 23/10/06 was not met.) The registered person must ensure that the registered manager has the required qualification, i.e. NVQ Level 4 in care and management, within 2006. The registered manager must DS0000061194.V280433.R01.S.doc 3. OP31 18, 19 14/04/06 4. OP38 16,17,26, 14/04/06 Page 21 Spring Lodge Version 5.1 37 ensure so far as is reasonably practicable the health, safety and welfare of residents 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 two inspections. Previous timescales of 18/03/05 & 23/10/05 were 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. Refer to Standard Good Practice Recommendations Spring Lodge DS0000061194.V280433.R01.S.doc Version 5.1 Page 22 Commission for Social Care Inspection Colchester Local Office 1st Floor, Fairfax House Causton Road Colchester Essex 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. Extracts may not be used or reproduced without the express permission of CSCI Spring Lodge DS0000061194.V280433.R01.S.doc Version 5.1 Page 23 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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