CARE HOMES FOR OLDER PEOPLE
Springcroft 58 Springfield Road St Leonards On Sea East Sussex TN38 OTZ Lead Inspector
Caroline Johnson Unannounced Inspection 28th September 2005 09:30 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 Springcroft DS0000014057.V250484.R01.S.doc Version 5.0 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. Springcroft DS0000014057.V250484.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION
Name of service Springcroft Address 58 Springfield Road St Leonards On Sea East Sussex TN38 OTZ 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) 01424-431856 Mr T Samy Mrs Rosemonde Marie-Josee Samy Care Home 12 Category(ies) of Old age, not falling within any other category registration, with number (12) of places Springcroft DS0000014057.V250484.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION
Conditions of registration: 1. 2. 3. The maximum number of service users to be accommodated at any one time is twelve (12) Service users should be aged sixty-five (65) and over on admission. Only older people who have been assessed as requiring nursing/residential care are to be acommodated. 3rd February 2005 Date of last inspection Brief Description of the Service: Springcroft Nursing Home is a detached property in a residential road in St Leonard’s-on- Sea. It is registered to provide nursing care for 12 service users. The home is on three floors. There is a shaft lift and in addition to this there are two stair lifts provided. Fire escape staircases evacuate to the rear garden. Service users have use of a lounge and conservatory for communal activities. There is level access to the home through the front garden. A gate at the side of the property gives security to a rear, neatly tended, walled garden providing a pleasant area for service users. The home offers nursing care in a relaxed, but professional environment. Springcroft DS0000014057.V250484.R01.S.doc Version 5.0 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This was an unannounced inspection, the first in the year running from April 1 2005 to March 31 2006. The inspection lasted from 09.40am until 2.45pm. During the inspection there was an opportunity to meet with four residents. Two members of staff were interviewed individually. A number of records were examined and plans for the care to be provided for two residents were seen on this occasion. There was an opportunity to meet with a relative of a resident who was visiting at the time of inspection. A full tour of the building was not undertaken. However, most of the bedrooms and the laundry and kitchen facilities were seen on this occasion. What the service does well: What has improved since the last inspection?
There have been a number of improvements to the physical environment. These include, new carpets in four bedrooms. One bedroom has been completely redecorated and a new ensuite facility installed. Door guards have been fitted to all bedroom doors. In addition a new chair lift has been installed on one of the stairs. The one requirement and two good practice recommendations made at the last inspection of the home have been met. As stated above staff continue to receive regular training on a variety of topics and the home is now on target to meeting the requirement to have 50 of the staff trained to NVQ level two. Springcroft DS0000014057.V250484.R01.S.doc Version 5.0 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. Springcroft DS0000014057.V250484.R01.S.doc Version 5.0 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 Springcroft DS0000014057.V250484.R01.S.doc Version 5.0 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): Prospective residents and there relatives are given detailed information about the home to assist them in deciding if they would like to live at Springcroft. EVIDENCE: There is a statement of purpose in place providing prospective residents with advice and information on the care and support provided in the home. There have been no new admissions since the last inspection of the home. At the time of inspection there were nine residents one of whom was in hospital. Springcroft DS0000014057.V250484.R01.S.doc Version 5.0 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): The quality of care planning is very good, and this can be enhanced further by encouraging staff to record in more detail the action they have taken to meet the social and emotional needs of the residents. They arrangements in place in respect of the storage and handling of medication are good. EVIDENCE: Two care plans were examined in detail during this inspection. Detailed advice is included to assist staff in meeting the assessed needs of the residents. Daily records demonstrate clearly the action taken by staff to meet the physical needs of the residents. Whilst there is some evidence that staff also record information about each resident’s social and emotional needs staff should be encouraged to write more frequently about how this is achieved. In respect of one of the care plans seen the dependency profile needs to be updated. Records seen in respect of medication administered to residents were in order. Storage and handling arrangements were also satisfactory. The home has set up a contract for dealing with the safe disposal of unused or unwanted medications. They were awaiting delivery of a container for this purpose. All staff with responsibility for medication receive regular training on the subject.
Springcroft DS0000014057.V250484.R01.S.doc Version 5.0 Page 10 When needed the home seeks advice from the Tissue Viability Nurse. She also provides advice on equipment available. Springcroft DS0000014057.V250484.R01.S.doc Version 5.0 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): The home communicates well with the relatives of residents keeping them informed of any changes in the welfare of their relative. Staff spend time with individual residents regularly doing activities that they enjoy. The quality of the food served is good and the menus are balanced and varied. EVIDENCE: There was an opportunity to meet with the relative of one of the residents who described the home as a `four star home’. She stated that it was very comfortable, the food served always looks very good and she is made to feel very welcome in the home’. She visits the home regularly and as soon as she arrives a tea tray is brought to the room. There is a programme of activities in place. A number of residents are very frail so group activities are not always possible. However, time is set aside regularly for staff to spend on a one-to–one with each resident doing activities that they enjoy. One of the residents had a special birthday recently and the home organised a party to which the resident’s relatives and other residents were invited. The week prior to the inspection a new cook was appointed. There is a four-week menu in place. Any alternatives to the main menu are recorded. The cook advised that all food is freshly prepared on site. She will be introducing homemade soup to the evening menu and will be providing freshly baked
Springcroft DS0000014057.V250484.R01.S.doc Version 5.0 Page 12 cakes on a daily basis. She has been advised of residents’ likes and dislikes and stated that when new residents are admitted to the home she will personally meet with them to discuss their individual dietary requirements. Springcroft DS0000014057.V250484.R01.S.doc Version 5.0 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 the following standard(s): The home listens to the views of relatives and on the rare occasions when concerns are raised they ensure that action is taken to resolve the issues raised with them. The procedures in place on adult protection and prevention of abuse are very good and staff are clear about the procedure and the action to be taken should abuse be suspected. EVIDENCE: Records showed that there had been one complaint recorded since the last inspection of the home. The manager dealt with the complaint appropriately and the complainant was satisfied with the action taken as a result. There is a very detailed procedure in place in respect of adult protection and prevention of abuse. All staff receive training on the subject. Staff spoken with during the inspection were clear about the steps that would be taken by the home should abuse be suspected. Springcroft DS0000014057.V250484.R01.S.doc Version 5.0 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): The home is well decorated and is comfortable and homely in design. There is a programme of redecoration in place and the owners are continually working on improving the quality of the environment. Fire procedures are generally clear and fire drills are held regularly to ensure that staff know what to do when the alarms sound. The home needs to consider the action to be taken by staff should the alarms sound at peak times such as when bathing residents. EVIDENCE: Since the last inspection one of bedrooms has been completely redecorated. Door guards have been fitted to all bedroom doors. Carpets have been replaced in four bedrooms. A new ensuite facility has been installed in one of the bedrooms. In addition a new chair lift has been installed to a section of the building where there were three steps. As required at the last inspection a portable television has been removed from one of the rooms, as it was no longer needed. At the time of inspection arrangements were being made to have a television ariel point fitted in one of the ground floor rooms. All areas of the home seen were clean and there were no unpleasant odours. Records
Springcroft DS0000014057.V250484.R01.S.doc Version 5.0 Page 15 seen in respect of fire safety were detailed and the home is now recording how long it takes to carry out each fire drill, as this was required at the last inspection. Staff spoken with during the inspection, were clear about the steps to be taken should the alarms sound. However, the home should consider the action to be taken by staff should the alarms sound at peak times such as when bathing residents. Springcroft DS0000014057.V250484.R01.S.doc Version 5.0 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): The home is well on its way to meeting the requirement to have 50 of the care staff trained to NVQ level two. The strong emphasis on staff training ensures that the needs of the residents can be more easily met. EVIDENCE: Staffing levels were examined and although reduced slightly since the last inspection due to the reduction in numbers of residents, they were still assessed as satisfactory. The home is also going to appoint to adaptation nurses in the near future. There are CRB checks in place for all staff employed to work in the home. Two care staff have completed NVQ level two. Another member of staff has almost completed level two and two staff have recently started the course. Emphasis is placed on staff training. Each month the owner, who is a qualified trainer, provides staff training on a particular topic. Future courses include: POVA, Care skills, Management of Continence, Pressure area care/tissue viability, care planning, and administration of medication. Springcroft DS0000014057.V250484.R01.S.doc Version 5.0 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): The owners are well qualified and competent to run the home. Staff are well supported and are given regular opportunities to share their views on the home. There are very good procedures in place to ensure the health, safety and welfare of the residents. EVIDENCE: Both Mr and Mrs Samy have completed NVQ level four in management. Mrs Samy has also completed the Assessor’s Award. Between them they have a wealth of experience and qualifications that equip them to run the home. Staff spoken with stated that the `home is well run’. They are well supported in their individual roles and receive formal supervision every two months. They also stated that they do not need to wait for their supervision, as both Mr and Mrs Samy are very approachable’. They are encouraged to share their views during staff meetings and advised that their `contributions are valued’. The home has very limited involvement in the management of residents’ finances.
Springcroft DS0000014057.V250484.R01.S.doc Version 5.0 Page 18 Records seen in respect of this were in order. Hot water temperatures tested on the day of inspection were within agreed safety limits. The water system was tested in relation to Legionella in May 2005. Records seen in respect of accidents were sufficiently detailed. Both the lift and the gas were serviced on the day of inspection. A questionnaire was sent to residents and relatives in 2004 to seek views in relation to the quality of the care provided in the home. The manager advised that she questionnaires would be sent again this year. Springcroft DS0000014057.V250484.R01.S.doc Version 5.0 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 3 x x x x x HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 x 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 x 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 x 18 4 2 x 3 x 3 3 x 3 STAFFING Standard No Score 27 3 28 3 29 x 30 4 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 4 3 x 3 3 x 3 Springcroft DS0000014057.V250484.R01.S.doc Version 5.0 Page 20 Are there any outstanding requirements from the last inspection? NO 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. Standard Regulation Requirement Timescale for action 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 OP7 OP19 Good Practice Recommendations Daily records should be used to record the action taken by staff to meet the social and emotional needs of residents. In relation to fire safety the home should consider the action to be taken by staff should the alarms sound at peak times such as when bathing residents. Springcroft DS0000014057.V250484.R01.S.doc Version 5.0 Page 21 Commission for Social Care Inspection East Sussex Area Office Ivy House 3 Ivy Terrace Eastbourne East Sussex BN21 4QT National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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