Inspection on 21/12/05 for Springdale, 29

This inspection was carried out on 21st December 2005.

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

The inspector found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 4 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Springdale, 29 26/08/08

Springdale, 29 13/07/06

Springdale, 29 06/07/05

Springdale, 29 09/03/05

Springdale, 29 08/09/04

Similar services:

22 Sandown Road

The Highlands

Dilston College Of Further Education

West View House

Prince Bishop Court

Park View (15)

Craigmore House

1 Lanark Close

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

CARE HOME ADULTS 18-65 Springdale, 29 29 Springdale Tweedmouth Berwick Upon Tweed Northumberland TD15 2DD Lead Inspector Dennis Bradley Unannounced Inspection 21st December 2005 14:30 Springdale, 29 DS0000000571.V258010.R01.S.doc Version 5.0 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, 29 DS0000000571.V258010.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 Adults 18-65. 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, 29 DS0000000571.V258010.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Springdale, 29 Address 29 Springdale Tweedmouth Berwick Upon Tweed Northumberland TD15 2DD 01289 - 302169 01289 302169 communityhome@springdalenhs.fsworld.co.uk 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) Northgate & Prudhoe NHS Trust Mrs Claire Selby Care Home 3 Category(ies) of Learning disability (3) registration, with number of places Springdale, 29 DS0000000571.V258010.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 6th July 2005 Brief Description of the Service: The service at Springdale is provided by Northgate and Prudhoe NHS Trust and offers care and support to three adults who have a learning disability. Springdale is a three bedroom, semi-detached property situated in a residential area in Tweedmouth, on the outskirts of Berwick upon Tweed. The property is rented from Berwick District Council. The accommodation is arranged on two floors and there is a small garden to the front of the property and a larger area to the rear. The Home is within walking distance of Berwick town centre and a range of local amenities. Springdale, 29 DS0000000571.V258010.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 that started at 14.00pm. The inspection lasted 4.00 hours. One resident was spoken to as well as three members of staff. The inspector was shown around the house. A sample of records was also examined. What the service does well: 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. Springdale, 29 DS0000000571.V258010.R01.S.doc Version 5.0 Page 6 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Springdale, 29 DS0000000571.V258010.R01.S.doc Version 5.0 Page 7 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard 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. Standard 2 was met at the time of the last inspection. EVIDENCE: Springdale, 29 DS0000000571.V258010.R01.S.doc Version 5.0 Page 8 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 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. The key standards were all met at the time of the last inspection. EVIDENCE: Springdale, 29 DS0000000571.V258010.R01.S.doc Version 5.0 Page 9 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 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 & 17. Standards 12, 13 & 15 were met at the time of the last inspection. The relationships between staff and residents were good and personal support was provided in such a way as to promote and protect residents’ privacy, dignity and independence. The meals in the Home were generally satisfactory and provided residents with a varied diet. Staff consulted residents about their preferences for meals. EVIDENCE: There was clear written guidance for staff regarding how they should respect and safeguard the residents’ right to privacy. Residents had unrestricted access to all areas of the Home other than the office and each other’s bedrooms. Residents could help with household tasks. Throughout the inspection staff were observed talking to, and engaging with the residents. The Home had a 4-week menu but this was not always kept to. Records were kept of any changes to the meals specified on the menus. The records indicated that the meals were generally varied and well balanced. One of the residents said they liked the meals and confirmed that they could help staff do the food shopping and prepare the meals. Staff were observed involving the residents in choosing what they wanted for their evening meal. All of the staff Springdale, 29 DS0000000571.V258010.R01.S.doc Version 5.0 Page 10 had been trained in basic food hygiene however their accredited training was out of date. Springdale, 29 DS0000000571.V258010.R01.S.doc Version 5.0 Page 11 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 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. Standards were 18 & 20 were met at the time of the last inspection. promoted the health and well being of the residents. EVIDENCE: Records indicated that staff monitored the health care needs of each resident and took action to address any needs identified. Records were kept of health care appointments. Staff supported residents to attend regular chiropody appointments and have regular eye checks and dental checks. The monthly summaries in each person’s plans of care included details of any health care issues. The female residents attended regular ‘Well Woman Clinics’ and the male resident attended a regular ‘Well Man Clinic’. Staff Springdale, 29 DS0000000571.V258010.R01.S.doc Version 5.0 Page 12 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 23. Standard 22 was met at the time of the last inspection. Suitable arrangements were in place to protect residents from abuse. EVIDENCE: A copy of the local multi agency policy and guidelines on the protection of vulnerable adults was available in the Home. There was also a copy of the Trust’s ‘Vulnerable Adults Briefing’ that contained brief guidance for staff on matters such as reporting arrangements. All but one of the staff had had training in the protection of vulnerable adults. Training had been arranged for this person in February 2006. A member of staff was able to describe the action they would take to support a resident if they informed them of an alleged incident of abuse. One resident who was spoken to confirmed that they felt safe living at the Home and that they felt they could tell staff if they had any worries or concerns. The inspector was not able to communicate with the other two residents. Springdale, 29 DS0000000571.V258010.R01.S.doc Version 5.0 Page 13 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 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. Standards 24 & 30 were both met at the time of the last inspection. EVIDENCE: Springdale, 29 DS0000000571.V258010.R01.S.doc Version 5.0 Page 14 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34, 35 & 36. The staff team was competent and provided consistency of care within the Home. However, a suitable training and development plan was not in place and, although the majority of staff were well qualified, the training offered to staff regarding the specific conditions and care needs of the residents was not fully adequate. The arrangements for making staff personnel files available for inspection were still not satisfactory and it was not possible to confirm that there were suitable vetting and recruitment practices that safeguarded residents. There was some improvement in the arrangements for supporting and supervising staff but they were still not fully satisfactory. EVIDENCE: Springdale, 29 DS0000000571.V258010.R01.S.doc Version 5.0 Page 15 The majority of staff had significant experience of working with people who have learning disabilities. 5 staff had completed the NVQ 2 award in ‘Care’. 3 staff had applied to do the NVQ 3 award. As stated in previous inspection reports, some staff wanted additional training regarding the specific conditions and care needs of the residents and, in particular, training on Autism. However, despite requesting this training none to date had been provided. 2 of the residents were autistic. Apart from records kept by one person, there were no individual training records available for inspection and there was no training and development plan for the staff team for the year 2005 – 2006. All of the staff’s food hygiene training was out of date. Staff personnel records were kept at Northgate Hospital Personnel Department and were not available for inspection as required. This matter was also being followed up in separate correspondence. No new staff had been appointed during the previous 12 months. Arrangements had been put in place for staff to receive individual supervision from their line manager. However, this was not taking place at least 6 times a year as required. Records indicated that one member of staff had only had 2 supervision sessions in 2005. Records of staff appraisals were not available for inspection. Springdale, 29 DS0000000571.V258010.R01.S.doc Version 5.0 Page 16 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. 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 are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39, 41 & 42. The Registered Manager was suitably qualified and experienced. There had been an improvement in the action taken to monitor the Home but the arrangements for reviewing the service were not satisfactory and it was not adequately demonstrated that residents’ views underpinned any review and development. Although there had been some improvement the arrangements for protecting the health and safety of residents were still not fully adequate. The arrangements for storing some of the Home’s records securely were not adequate. EVIDENCE: The Registered Manager had relevant qualifications in management and care. Her training record was not available for inspection. On her return to work from a period of leave the Manager was being transferred to another home. A quality assurance and quality monitoring system was in place. However, the records available indicated that the system had not been fully implemented Springdale, 29 DS0000000571.V258010.R01.S.doc Version 5.0 Page 17 during the previous 12 months. Monitoring visits to the Home had been carried out more regularly since the last inspection. Staff received regular core training that covered moving and handling, fire safety, first aid and basic food hygiene. A range of risk assessments was in place covering safe working practices. For some the review dates had not been kept to. For example, the moving and handling risk assessment was last reviewed in September 1998. Regular checks of the Home’s fire equipment were being done. Staff had regular fire instruction and all of the staff had recently taken part in a fire drill. The fire risk assessment did not specify how often staff should take part in fire drills. The Home’s electrical equipment had been checked in January 2005 but a check of the electrical installations was out of date. Some of the Home’s records were being stored in an outhouse because there was limited storage available within the Home. Springdale, 29 DS0000000571.V258010.R01.S.doc Version 5.0 Page 18 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score X X X X X X Standard No 22 23 Score X 3 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score X X X X X Standard No 24 25 26 27 28 29 30 STAFFING Score X X X X X X X LIFESTYLES Standard No Score 11 X 12 X 13 X 14 X 15 X 16 3 17 Standard No 31 32 33 34 35 36 Score X 2 X 2 2 2 CONDUCT AND MANAGEMENT OF THE HOME 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Springdale, 29 Score X 3 X X Standard No 37 38 39 40 41 42 43 Score 3 X 2 X 2 2 X DS0000000571.V258010.R01.S.doc Version 5.0 Page 19 YES Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard YA34 Regulation 17 Timescale for action The Registered Person must 28/02/06 ensure that staff personnel files, or copies of documents obtained in the recruitment process, are kept at the home and made available for inspection. (Previous timescale of 1.11.04 not met) The Registered Person must 28/02/06 ensure that all staff have regular, recorded supervision meetings at least six times a year with their senior/manager (Previous timescale of 1.5.05 not met) The Registered Person must 28/02/05 arrange for the Trust’s quality assurance and quality monitoring system to be fully implemented in relation to 29 Springdale Road. (Previous timescale of 1.5.05 not met.) The Registered Person must 28/02/05 arrange for an inspection of the Homes electrical system to be carried out at least every five years. Requirement 2 YA36 18 3 YA39 24 4 YA42 23 Springdale, 29 DS0000000571.V258010.R01.S.doc Version 5.0 Page 20 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 YA35 Good Practice Recommendations The Registered Person should ensure that: 1. A training needs assessment is carried out for the staff team as a whole; 2. The Home has a training and development plan; 3. Staff receive training in the specific disabilities and conditions of the residents living at 29 Springdale. The accredited training for staff in basic food hygiene should be updated. The Home’s risk assessments should be reviewed on a regular basis. Suitable, secure storage should be provided for all the Home’s records including those that are not in current use. If these cannot be appropriately stored within the Home consideration should be given to storing them centrally. 2 3 4 YA42 YA42 YA41 Springdale, 29 DS0000000571.V258010.R01.S.doc Version 5.0 Page 21 Commission for Social Care Inspection Cramlington Area Office Northumbria House Manor Walks Cramlington Northumberland NE23 6UR 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, 29 DS0000000571.V258010.R01.S.doc Version 5.0 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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