Inspection on 01/02/06 for Springdale

This inspection was carried out on 1st February 2006.

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.

Other inspections for this house

Springdale 26/01/09

Springdale 12/12/06

Springdale 05/07/05

Springdale 26/01/05

Springdale 19/08/04

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 Springdale Cucumber Lane Brundall Norwich Norfolk NR13 5QY Lead Inspector Mr Roger Andrews Unannounced Inspection 1st February 2006 16:00 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 Springdale DS0000036310.V281534.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. Springdale DS0000036310.V281534.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Springdale Address Cucumber Lane Brundall Norwich Norfolk NR13 5QY 01603 712194 01603 717483 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) Norfolk County Council-Community Care Mr Paul Mann Care Home 35 Category(ies) of Dementia - over 65 years of age (1), Old age, registration, with number not falling within any other category (35) of places Springdale DS0000036310.V281534.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. Springdale can accommodate service users who require wheelchairs to assist with independent mobility at the point of admission into those rooms which are over 12 sq metres. This means that only rooms numbered 1, 2, 12, 13, 14, 18, 19, 20, 21, 22, 23 and 33 are suitable for wheelchair users. One (1) Service User, who is named in the Commission’s records and who has dementia, maybe accommodated within the overall number of 35 Service Users Springdale is registered to offer personal care for up to 35 service users who are aged 65 and over. 5th July 2005 2. 3. Date of last inspection Brief Description of the Service: Springdale is a Local Authority home catering for up to 35 elderly people. It is situated in the village of Brundall, a few miles east of the city of Norwich. The home is set in sizeable grounds with garden areas to the side and rear and parking space to the front. The home is operated by Norfolk County Council Social Services Department. Springdale DS0000036310.V281534.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was unannounced. A number of records were looked at and informal discussion took place with some residents and the manager. A relative who calls in on a regular basis was also spoken with informally. A tour of the premises was also made. Springdale does not have a history of complaints being made and, to date, the Commission considers it to be a well managed home with caring staff. What the service does well: What has improved since the last inspection? What they could do better: Support plans which set out information about each resident and the support they need must be properly completed in all sections so residents receive the help they need. Staff should have regular supervision sessions with their manager to give them opportunities to discuss good care practices and their personal development, which helps equip them to give residents a better service. The lift is old fashioned and ideally should be replaced so that residents can use this facility more easily. Springdale DS0000036310.V281534.R01.S.doc Version 5.1 Page 6 Ideally at least two double electric sockets should be provided in each bedroom. Residents should be able to adjust the heating in their room with individual thermostatic controls. 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. Springdale DS0000036310.V281534.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 Springdale DS0000036310.V281534.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): 1&3 Residents and visitors have relevant information and assessments are carried out on prospective residents. EVIDENCE: The Statement of Purpose is displayed in the main reception area for residents and guests to read. This contains a copy of the previous inspection report. A resident who moved to the home recently confirmed that she had been able to visit Springdale prior to moving in. Admission records are in place on new residents and a sample were viewed. New residents are assessed and reports taken up from other professionals where appropriate. Springdale DS0000036310.V281534.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): 7, 8, 9 & 10 Support plans need completing thoroughly, though there are examples of independence, such as managing own medication, and privacy and dignity are respected. EVIDENCE: Three support plans were viewed during the inspection. These contained various sections on personal, social and health care needs, though there was some variation in the extent to which sections had been completed. One support plan, for example, did not have the social acre section filled in. In some cases sections that show whether risk assessments have been carried out are not filled in. Two of the support plans had been signed by the residents. One was not. See requirement. Support plans covered areas of care such as mobility, sight, continence, personal routine including preferences such as getting up and going to bed times. They indicate where a resident is self-medicating. One plan reflected the resident’s wish for the staff to take over this task for them. Medication and drug allergies are recorded. Medication is only managed by the care coordinators. Springdale DS0000036310.V281534.R01.S.doc Version 5.1 Page 10 Healthcare needs are recorded including visits from the G.P. Specialist involvement is organised where appropriate. These include, for example, the Occupational Therapists and district nurses. The Optician, Chiropodist and the dentist visit the home or appointments can be made privately if desired. The District Nurse and the Continence Advisor also visit regularly. From observations of staff assisting residents and from discussion with residents privacy and dignity are respected, for example, when helping a resident to the toilet and staff were observed chatting with residents whilst assisting them. Springdale DS0000036310.V281534.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): 13 & 14 Visitors are free to come and go. Residents have a variety of information provided for them. EVIDENCE: Residents are able to receive visitors and to go out as they wish. One resident reported who has lived at Springdale for just a few months said that she was able to go out with family when she pleased and they could visit her at times convenient to them. A relative was seen visiting her mother and was spoken with briefly. She reported that she visited practically every day and was always made welcome by the staff. Residents are given quite a wide range of information about services and rights in the form of written literature and leaflets. There are also residents’ meetings from time to time. Residents are provided with leaflets and newsletters about what is going on in the local community. Residents now have copies of their support plans in their bedrooms. Springdale DS0000036310.V281534.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): 16 & 18 Residents are protected by well trained staff who take their concerns seriously. EVIDENCE: Springdale has a publicised complaints procedure and any complaints are recorded in the complaints book. There have been no complaints made to the home since the previous inspection took place and no complaints have been received by the Commission about this service. Residents have the opportunity to put forward issues at residents’ meetings. The staff have received training on adult protection issues. The manager is proactive in informing the Commission of any issues that arise that may affect the welfare of the residents at Springdale either by fax or by telephone. Residents spoken to described the staff as “very kind” and “caring”. From observations on this and at previous inspections there is always a very relaxed atmosphere in the home and the staff and manager seem to have very much an open door policy. Springdale DS0000036310.V281534.R01.S.doc Version 5.1 Page 13 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): 19, 20, 21, 22 & 26 Residents have a choice of clean and comfortable communal areas. There are sufficient clean toilet and bathroom facilities. The lift is old fashioned and should be replaced with a more modern one. EVIDENCE: A tour of the premises was made. All areas looked clean and free from any obvious hazards. Over the last year some areas such as lounges have undergone redecoration and refurbishment. Residents have a choice of lounges, (Four on the ground floor and one on the first floor), on both ground and first floors. One of the ground floor lounges is set aside for residents who wish to smoke. Bathrooms and toilets were clean and tidy and there are adequate numbers of toilets distributed around the building. Facilities are available for residents who have disabilities. Springdale DS0000036310.V281534.R01.S.doc Version 5.1 Page 14 The manager reported that bedrooms will be having new door locks fitted in March 2006. Some rooms have had addition electric sockets fitted. As has been highlighted in previous inspection reports the lift is old fashioned and has a concertina type inner metal gate. The lift also comes to quite an abrupt stop. Ideally the lift should be replaced with a new model. If this is not possible in the foreseeable future consideration should be given to investigating whether the inner lift door could be replaced by a solid door that would offer less likelihood of fingers being trapped. See recommendation. Two long standing recommendations about sufficient electric sockets in rooms and residents having individual thermostats in their room so they can alter the temperature are repeated. Springdale DS0000036310.V281534.R01.S.doc Version 5.1 Page 15 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, 29 & 30 The staff undertake regular training and NVQ training is underway. There are sufficient staff. A recent photograph is required on all staff files to meet the requirements of the Care Homes Regulations 2001. EVIDENCE: At the time of the inspection there were 27 residents living at Springdale. The manager was on duty along with a care co-ordinator and three members of care staff. Additional catering and domestic staff are employed. Staffing was deemed to be sufficient. A relative, (who visits on almost a daily basis), reported that the staff were very helpful and caring and she had a very positive impression of the care the residents received. Two staff files were viewed at random. One file required a recent photograph of the member of staff. Evidence of Criminal Records Bureau checks is now provided to the manager by the personnel department and kept on file. Seven staff have now completed their NVQ training and two staff are currently undertaking this award. Foundation training is undertaken by new staff within the first six months of their employment. Examples of other training completed by the staff include ‘diversity and rights’, effective communication, ‘the aging process and ageism’ and ‘an introduction to dementia’. Staff also have training and refresher courses in training such as food hygiene, moving and handling and emergency aid. The names of staff trained in Springdale DS0000036310.V281534.R01.S.doc Version 5.1 Page 16 emergency aid and first aid appointed persons are displayed throughout the home. Springdale DS0000036310.V281534.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): 33, 34, 36 & 38 The frequency of supervision needs to be monitored to make sure that sessions take place on a reasonably regular basis in line with guidance in the National Minimum Standards. EVIDENCE: A sample of supervision records was viewed. These contained some good examples of discussion about, for example, the proper use of wheelchairs, maintaining a good rapport with residents and training needs. In some instances there is a considerable time lapse between supervision sessions. See requirement. The staff have regular staff meetings and the timetable for the coming year is displayed in the office. Senior staff meetings and night staff meetings are also timetabled. Springdale DS0000036310.V281534.R01.S.doc Version 5.1 Page 18 Financial records have been fully audited following a small discrepancy. These records are also checked on a quarterly basis by Springdale’s administrator. Some records were viewed at random and were in order. The fire equipment was serviced in October 2005. Fire doors are held open by magnetic catches connected to the fire alarm system. Mechanical hoist and bath equipment is services in line with requirements. The hoists were serviced on 30th January 2006. The baths were serviced in October 2005. An asbestos register is maintained for all contractors who may undertake work in the building. A certificate of insurance liability is displayed in the main reception area. Springdale DS0000036310.V281534.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 3 X 3 X X X HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 3 14 3 15 X COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 3 3 2 X X X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X X 3 3 X 2 X 3 Springdale DS0000036310.V281534.R01.S.doc Version 5.1 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. 1 2 Standard OP7 OP36 Regulation 17 18 Requirement Support plans should be completed as thoroughly as possible. Staff must be regularly supervised on a frequency in line with guidance in the National Minimum Standards. Timescale for action 01/03/06 01/03/06 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 OP22 Good Practice Recommendations Ideally the lift should be replaced. In the interim consideration should be given to providing an alternative inner door other than the metal concertina type currently in place. It is recommended that each bedroom has two double electric sockets for use by service users. It is recommended that radiators in bedrooms have individual thermostatic controls. 2 3 OP24 OP25 Springdale DS0000036310.V281534.R01.S.doc Version 5.1 Page 21 Commission for Social Care Inspection Norfolk Area Office 3rd Floor Cavell House St. Crispins Road Norwich NR3 1YF 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 Springdale DS0000036310.V281534.R01.S.doc Version 5.1 Page 22 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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