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Inspection on 18/05/05 for Spring Lodge Care Home

Also see our care home review for Spring Lodge Care Home for more information

This inspection was carried out on 18th May 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

What follows are excerpts from this inspection report. For more information read the full report on the next tab.

What the care home does well

The home has a homely atmosphere, with professional caring staff. The staff are well trained and their competence is regularly checked by a senior member of staff. The owner is committed to the ethos of the home and takes a close interest in its management. The home has recently been approved by the Commission as competent to care for up to 7 people, within the total of 27, with mild dementia.

What has improved since the last inspection?

The radiators are being replaced to prevent the risk of injury from hot surfaces, and this will be followed by a re-decoration programme. Medication procedures have been tightened up to ensure that the person who dispenses the drugs into the pots also gives them to the resident.

CARE HOMES FOR OLDER PEOPLE Spring Lodge Care Home Main Road Woolverstone Ipswich IP9 1AX Lead Inspector John Goodship Announced 18 May 2005 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 Care Home I54 - I04 S24492 Spring Lodge V218887 050518 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Spring Lodge Care House Address Main Road Woolverstone Ipswich Suffolk IP9 1AX 01473 780791 01473 780969 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 Lodge (Care Home) Limited Miss Suzanna Boar Care Home 27 Category(ies) of OP Old Age (27) registration, with number DE (E) Dementia-over 65 (7) of places Spring Lodge Care Home I54 - I04 S24492 Spring Lodge V218887 050518 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: NONE Date of last inspection Brief Description of the Service: Spring lodge is situated in the small village of Woolverstone about five miles from Ipswich. The home is a registered care home for 27 people.The accommodation is situated on two floors. The majority of the bedrooms are on the ground floor and provide single accommodation. Each bedroom has a wash hand basin and two rooms (one double and one single) have a WC en-suite. Bathrooms are situated on both floors. Communal areas are all on the ground floor and include a main lounge and three other areas. There is also a central dining room.The home is situated within its own grounds with parking for visitors. There is a large, attractive and enclosed garden at the rear of the property, which is well maintained and provides a variety of seating areas for service users. Spring Lodge Care Home I54 - I04 S24492 Spring Lodge V218887 050518 Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an announced inspection. The previous inspection which was unannounced took place on 15 December 2004. At this inspection, the owner, manager,and deputy manager were present for all or part of the inspection. The inspector also spoke to a number of staff either separately or in the course of their duties. Residents were also spoken to, and were very happy to talk about the home and themselves. All their comments were favourable to the home and its staff. What the service does well: What has improved since the last inspection? What they could do better: Spring Lodge Care Home I54 - I04 S24492 Spring Lodge V218887 050518 Stage 4.doc Version 1.30 Page 6 No staff must start work until they have been fully checked with the Criminal Records Bureau. 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 Care Home I54 - I04 S24492 Spring Lodge V218887 050518 Stage 4.doc Version 1.30 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 Care Home I54 - I04 S24492 Spring Lodge V218887 050518 Stage 4.doc Version 1.30 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) 1,3,4,5. 6 is not relevant to this home. Prospective residents can be assured that there is sufficient information about the home together with visiting opportunities to enable them and their family to make an informed choice. No one is admitted without an assessment of their care needs to ensure that the home can provide for them. EVIDENCE: The home had updated its statement of purpose and service users guide to reflect that its registration category had been amended to allow it to care for up to 7 persons with a diagnosis of dementia. 2 recent admissions were tracked. All pre-admission procedures had been followed. Spring Lodge Care Home I54 - I04 S24492 Spring Lodge V218887 050518 Stage 4.doc Version 1.30 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) 7,8,9,10,11 Residents’ health is assessed, reviewed regularly, and monitored to make sure that emerging as well as continuing needs are being met, both by the home and by health professionals. EVIDENCE: Care plans inspected were up-to-date and informative. A resident had recently been admitted to hospital with suspected scabies. However this had still not been confirmed. The home had consulted the appropriate specialists and was taking the advised precautions. One resident had developed a pressure area after a stay in hospital. This was being treated successfully by the district nurse. Drug administration procedures had been improved following the last inspection, to ensure that there was always a carer trained to undertake drug rounds on duty. These arrangements included the manager and deputy manager when necessary. A new drug room was being created from the previous staff room. This would improve security and bring a number of documents together. A medication review for all residents was carried out every 2 months with the GP. Spring Lodge Care Home I54 - I04 S24492 Spring Lodge V218887 050518 Stage 4.doc Version 1.30 Page 10 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) 12,13,15 A variety of communal areas give residents choice of where to go when they leave their rooms according to their preference for access to company. This also allows for activities to take place without disturbing those who do not wish to take part. Residents are able to choose where to take the meals of the day. The catering service is responsive to residents’ wishes, and provides a balanced diet. EVIDENCE: Care plans listed the preferences of residents for daily routines, including the time of getting up and going to bed, type of food, and activities. One of the senior carers had responsibility for the development of activities. There was currently a good variety but more were planned to cater for residents’ preferences, but also to stimulate them to try new things. The chef was trained and had a well-equipped kitchen. Although he was knowledgeable about residents’ likes and dislikes, he stated that he occasionally tried to tempt them with new dishes which they might not normally choose. Spring Lodge Care Home I54 - I04 S24492 Spring Lodge V218887 050518 Stage 4.doc Version 1.30 Page 11 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 Residents and relatives have any concerns dealt with at the time they are raised, which prevents complaints arising. EVIDENCE: There had only been one complaint received by the Commission in the last 12 months. Some aspects had been partly upheld and action had been taken to remedy the deficiencies. Spring Lodge Care Home I54 - I04 S24492 Spring Lodge V218887 050518 Stage 4.doc Version 1.30 Page 12 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 19,20,21,23,24,25,26 The home provides a safe and comfortable individual and communal environment for residents. EVIDENCE: The replacement of the radiators required from the last inspection was in hand. The work had been delayed until the weather was warmer as the home would be without heating for part of the contract. The corridors would then be redecorated. Where necessary, devices had been fitted to the doors of residents’ rooms to ensure that they closed if the fire alarm sounded. The temperature of the hot water outlets was tested weekly. All outlets met the standard. Spring Lodge Care Home I54 - I04 S24492 Spring Lodge V218887 050518 Stage 4.doc Version 1.30 Page 13 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) 27,28,29,30 Although residents were protected by the home’s commendable training and supervision programmes, there had been two occasions when recruitment practices had not been followed. This could have residents at risk. EVIDENCE: Two new staff had begun employment before the home had received the POVA check. In one case this was 6 days later, but in the other case it was 6 weeks later. It has been made a requirement that this must not happen again. Staffing numbers were assessed to be adequate for the needs of the residents. Those with dementia were only exhibiting mild signs of the condition at the moment. The regular reviews of care needs will pick up changing staffing requirements. No agency staff were used. A member of staff commented that “all the staff are dedicated, and all will help out to cover shifts”. The home had a commendable programme of training and supervision under the deputy manager. It was recommended that an annual forward programme of training should be prepared for budgeting and monitoring purposes. Spring Lodge Care Home I54 - I04 S24492 Spring Lodge V218887 050518 Stage 4.doc Version 1.30 Page 14 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) 31,32,33,34,37,38 The home has a owner who visits the home weekly, and a strong management structure with regular reporting, to ensure that standards are maintained for the protection and confidence of the residents. EVIDENCE: The Home had an excellent training programme. Individual members of staff expressed their satisfaction with the availability of internal and external training opportunities. Evidence from the staff files confirmed this. The system of supervision was very comprehensive, covering care practice audits and training needs analysis with regular reviews of competence. The home had been complimented by the Fire Officer on the quality of their Fire Risk Assessment. The owner received weekly reports from the manager , the deputy manager and the senior carer on all aspects of the home. Spring Lodge Care Home I54 - I04 S24492 Spring Lodge V218887 050518 Stage 4.doc Version 1.30 Page 15 It was recommended that the owner check with the lift maintenance company regarding safety devices on the lift doors to prevent them closing if they were not clear. The supervision system has been commended under Staffing. The ethos of the home was clear from the support of staff for their colleagues and the residents. Spring Lodge Care Home I54 - I04 S24492 Spring Lodge V218887 050518 Stage 4.doc Version 1.30 Page 16 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 3 x 3 3 3 x HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 x 15 3 COMPLAINTS AND PROTECTION 3 3 3 x 3 3 3 3 STAFFING Standard No Score 27 3 28 3 29 2 30 4 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x x 3 3 3 3 x x 3 3 Spring Lodge Care Home I54 - I04 S24492 Spring Lodge V218887 050518 Stage 4.doc Version 1.30 Page 17 no Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard 29 Regulation 19 Requirement The registered provider must ensure that no employee starts work until a full CRB certificate has been received, or, in special circumstances, a POVA check has been received Timescale for action Immediate and ongoing. 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 38 Good Practice Recommendations The registered provider should seek advice on the provision of a safety device on the doors of the shaft lift to prevent injury to users. Spring Lodge Care Home I54 - I04 S24492 Spring Lodge V218887 050518 Stage 4.doc Version 1.30 Page 18 Commission for Social Care Inspection St Vincent House Cutler Street Ipswich IP1 1UQ 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 Care Home I54 - I04 S24492 Spring Lodge V218887 050518 Stage 4.doc Version 1.30 Page 19 - 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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