Inspection on 26/08/08 for Springdale, 29

This inspection was carried out on 26th August 2008.

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 found no outstanding requirements from the previous inspection report, but made 1 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Springdale, 29 13/07/06

Springdale, 29 21/12/05

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 27/11/2008.

CARE HOME ADULTS 18-65 Springdale, 29 29 Springdale Tweedmouth Berwick Upon Tweed Northumberland TD15 2DD Lead Inspector Anne Urwin Brown Key Unannounced Inspection 26th August 2008 10:00 Springdale, 29 DS0000000571.V371675.R01.S.doc Version 5.2 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.V371675.R01.S.doc Version 5.2 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.V371675.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Springdale, 29 Address 29 Springdale Tweedmouth Berwick Upon Tweed Northumberland TD15 2DD 01289 - 302169 F/P 01289 302169 GM.E.NTAWNT.springdale@nhs.net 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) Northumberland, Tyne & Wear NHS Trust Ms Louise Donaldson Care Home 3 Category(ies) of Learning disability (3) registration, with number of places Springdale, 29 DS0000000571.V371675.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 13th July 2006 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.V371675.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating of this service is 2 star. This means that people using this service experience good quality outcomes. How the inspection was carried out Before the visit: We looked at: • Information we have received since the last visit on (date). • How the service dealt with any complaints & concerns since the last visit. • Any changes to how the home is run. • The provider’s view of how well they care for people. • The views of people who use the service & staff & other professionals. The Visit: An unannounced visit was made on 26th August and a further visit on 5th September was carried out. The inspection lasted seven hours. During the visit we: • • • • • • Talked with people who use the service, staff and the manager. Looked at information about the people who use the service & how well their needs are met, Looked at other records which must be kept, Checked that staff had the knowledge, skills & training to meet the needs of the people they care for, Looked around the building/parts of the building to make sure it was clean, safe & comfortable, Checked what improvements had been made since the last visit . We told the manager/provider what we found. What the service does well: Good information is available to help people make an informed choice about living at Springdale. Pre-admission assessments are used to prepare individual plans so that staff are well informed about peoples’ care needs. The care plans provide good information for staff about peoples’ needs and how these will be met. Changes are updated as they occur and there are good monitoring systems in place. Springdale, 29 DS0000000571.V371675.R01.S.doc Version 5.2 Page 6 People have regular holidays and social activities and are encouraged to follow up interests and hobbies. Daily tasks are allocated efficiently which helps staff to make sure everything has been done and that all residents needs have been met. People are protected by the service’s policies and procedures for dealing with complaints and allegations. Good systems for record keeping are in place that safeguard people living in the home and staff. Information is securely stored to ensure that confidentiality is maintained. Bedrooms are personalised to suit individual taste and interests. furnishings mean that rooms are comfortable and homely. Good Staff have good training opportunities provided to ensure that they are equipped with appropriate skills to meet peoples’ needs. 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. The summary of this inspection report can be made available in other formats on request. Springdale, 29 DS0000000571.V371675.R01.S.doc Version 5.2 Page 7 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.V371675.R01.S.doc Version 5.2 Page 8 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 1 and 2 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Good information is available about the service provided at Springdale and comprehensive assessments are undertaken to make sure that prospective service users’ needs can be met. EVIDENCE: The home recognises the importance of having sufficient information when choosing a care home. It has developed clear information about the specialist service provided at Springdale. This information includes pictures to help people understand what the service offers. There is emphasis placed on responding to individual needs for information and is available in different formats that are accessible to service users. These include communication dictionaries, DVD, photographs, clip art pictures and leaflets. Records showed that a comprehensive needs assessment is undertaken before someone is admitted to the service. The manager described how the home obtains a care management assessment and care plan before admission. Staff carry out their own assessment and information is used to determine whether or not the person’s needs can be met and to draw up a care plan. Individuals Springdale, 29 DS0000000571.V371675.R01.S.doc Version 5.2 Page 9 are supported and encouraged to take part in the admission process. has been admitted to the service since the last inspection. No one Springdale, 29 DS0000000571.V371675.R01.S.doc Version 5.2 Page 10 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 6, 7 and 9 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Individuals are involved in decisions about their lives and are encouraged to take an active role in planning the care and support they receive. EVIDENCE: Care plans show that people using the service are well known to staff and that decisions about their care are reached after careful consideration that takes account of people’s preferences. Each person has a care plan that is based on their assessment. This is added to during their placement and the plan is developed with the person concerned. Plans include reference to equality and diversity issues relevant to each person. There is clear information to show the development of plans and peoples’ changing needs. Information about peoples’ health care needs is clearly recorded. Some information from individual records could be archived as it is no longer in use. Springdale, 29 DS0000000571.V371675.R01.S.doc Version 5.2 Page 11 People using the service have limited ability to be able to be fully involved in planning their care, however there was evidence from staff and records that their wishes are respected and taken into account. Care plans are up to date and monthly reviews provide up to date information about any changes. Copies of care management reviews were also on file for each of the service users. Staff were well informed about people’s needs and a key worker system is in place. Copies of reviews were available and these showed that people are assisted to be involved in the process as far as possible and in planning for the future. Each plan included comprehensive risk assessments that were up to date and clear. The service has a positive view towards risk assessments that focuses on supporting people to live the life they want to lead. Records show that assessments are regularly updated. Any limitations on freedom, choice or facilities are in people’s best interests and these are well documented and agreed with the person and/or their representatives. Springdale, 29 DS0000000571.V371675.R01.S.doc Version 5.2 Page 12 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 12, 13, 15, 16 and 17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People who use the service are able to make choices about their lifestyle, and are supported to develop their life skills. Social, educational, cultural and recreational activities meet individual’s expectations. EVIDENCE: There are a good opportunities in leisure and education for each person that are generally well supported by staff and the only limitations are due to staff shortages. At the time of this inspection staffing levels had been affected by staff holidays and sickness. Staff recognise the importance of enabling people to follow their own interests and to take an active part in life in the local community. People living at the home are generally able to enjoy full and stimulating lives that suit their preferences and routines. Springdale, 29 DS0000000571.V371675.R01.S.doc Version 5.2 Page 13 Staff said people take regular holidays. They are regularly involved in domestic routines in the house. Visitors are always welcome at any time and links with family and friends are supported and encouraged. Each person is able to visit people that are important to him or her. People living in the home are encouraged to take a role in household tasks. One person regularly enjoys baking sessions and made some excellent rock cakes on the day of the inspection. Each person has responsibilities within the home and maintains independent skills inline with their needs and abilities. Menus are varied and nutritious. Each person is able to make choices based on personal preferences and in line with the domestic nature of the home. Good work has been carried out to balance healthy eating with preferred food choices. The food budget, which includes the cost of cleaning materials is £108 per week and has not been reviewed for more than five years. Staff report that they struggle to manage sometimes with the money available. Springdale, 29 DS0000000571.V371675.R01.S.doc Version 5.2 Page 14 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 18, 19 and 20 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Good arrangements are in place to ensure that the health and personal care that people receive is based on their individual needs. The principles of respect, dignity and privacy are put into practice. EVIDENCE: People receive personal and healthcare support that is person centred and based on principles of dignity, respect, equality and fairness. Personal healthcare needs are clearly recorded and include reference to specialist health, nursing and dietary needs where appropriate within person centred plans. Changes in healthcare needs are recorded and records provide a comprehensive overview of each person’s current health care. Individual plans provide good information about the support provided to each person living at Springdale. Staff demonstrated a good knowledge of people’s preferences and personal needs. All personal support is provided in private. There are no restrictions regarding times for going to bed and getting up other Springdale, 29 DS0000000571.V371675.R01.S.doc Version 5.2 Page 15 than for scheduled activities and routines. There was evidence that people are encouraged to choose their own clothes and to take care of their appearance. Specific staff training has been provided to ensure that staff are able to effectively meet individual needs and have a good understanding of person centred planning. There are good procedures and policies in place to protect service users receiving medication. Arrangements for the administration of medicines protect people living in the home and are agreed in the service user plan. Records are well maintained and arrangements for the storage of medicines are satisfactory. Training in administration of medicines has been provided for all staff. Springdale, 29 DS0000000571.V371675.R01.S.doc Version 5.2 Page 16 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 22 and 23 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People who use the service are able to express their concerns and access an effective complaints procedure, and are protected from abuse. EVIDENCE: Clear information is available about dealing with complaints and this is easy to understand. There is a picture form of the complaints procedure as well as a DVD to help the people living at Springdale understand the process and express any concerns or complaints. People living in the home are encouraged to put forward their views. Staff know people well and are alert to changes in behaviour or mood that may indicate dissatisfaction with something. There have been no complaints since the last inspection. There is a good system in place to ensure a complaint, the investigation and outcome are well recorded. There have been no safeguarding referrals have been made since the last inspection. Policies and procedures are in place for safeguarding adults. Staff at the home demonstrated that they are aware of what the procedure is and how to respond. They have received appropriate training and staff records confirm this. Individual risk assessments protect residents from potential selfharm. Springdale, 29 DS0000000571.V371675.R01.S.doc Version 5.2 Page 17 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 24, 25, 27 and 30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The service users live in a very homely and comfortable environment that is generally well maintained to a good standard. EVIDENCE: This semi-detached house provides comfortable and homely accommodation for the people living there, although some upgrading work is needed. Work is planned to fit a new gas central heating system instead of the existing solid fuel system. Since the last inspection a leak from the bathroom has caused damage to the kitchen and dining room ceilings. This is being repaired after some negotiations with the landlord have delayed work. Clear agreements are needed about responsibilities for maintenance work to ensure that people’s lives are not disrupted or put at risk. Springdale, 29 DS0000000571.V371675.R01.S.doc Version 5.2 Page 18 The wall tiles in the kitchen have also been affected by the leaking water and are coming away from the wall. There is a small garden to the front of the property and a lawned area to the rear. The path to the side of the house from the front gate is uneven and there are weeds growing up through broken paving. The rear garden has a shed and people are able to sit out here. Some rubbish lying near the rear fence in a neighbouring garden could attract vermin and does spoil the area. The sitting and dining room are comfortably furnished and the décor is homely, although there are plans to replace the worn three-piece suite. New carpet is to be fitted in the sitting room and hallway when the central heating work is complete. The bedrooms are well decorated and furnished and show evidence of people’s individual taste and interests. The bathroom is to have a new bath fitted with an overflow plug to try to prevent it overflowing again. The bathroom needs updating to provide a good environment for people living in the house. A new shower has been fitted. Everywhere that was inspected was clean. The washer and dryer are in the kitchen. Springdale, 29 DS0000000571.V371675.R01.S.doc Version 5.2 Page 19 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 32, 34 and 35 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. There is appropriately trained staff team in place to support people using the service. Staffing numbers are not always sufficient to meet the needs of the people living at Springdale. EVIDENCE: Staffing levels at Springdale are at a minimum level and are compromised at times of holidays and sickness. Staff members work additional hours to cover for sickness and holidays as there is not sufficient flexibility within the staff numbers to cover this. This was highlighted in the last inspection report and the manager says that there are discussions going on with the placing authority about funding issues. However, staffing constraints are affecting the quality of care provided, as well as rights, choices and inclusion of people. Members of staff are both working overtime to meet people’s needs and coming in to carry out duties during their holidays. Those staff on duty demonstrated good will and excellent values and attitudes and are to be commended for providing a good service. Springdale, 29 DS0000000571.V371675.R01.S.doc Version 5.2 Page 20 The Northumberland and Tyne and Wear Trust hold all staffing records relating to recruitment centrally. The manager does not have access to staff records and is not always involved in the appointment of staff. She said that she is aware that reference and Criminal Records Bureau checks are made, but she does not see them. Staff provided verbal evidence of their training and said that the training was good, and that it supported in doing their job. Records are kept in the home and these showed that staff have access to appropriate training opportunities. Springdale, 29 DS0000000571.V371675.R01.S.doc Version 5.2 Page 21 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 37, 39 and 42 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. A good system is in place for self-monitoring, review and development. The health and safety of the service users is promoted and safeguarded. EVIDENCE: The Manager is experienced in working with people who have learning disabilities and displays excellent values and attitudes. She is undertaking the Registered Manager’s award and has opportunities to develop her skills as a manager. She has a good knowledge of the organisation’s key principles and organisational values. The manager communicates a clear sense of direction and promotes equal opportunities. She understands the importance of person centred care. Springdale, 29 DS0000000571.V371675.R01.S.doc Version 5.2 Page 22 Quality assurance systems have been developed and are used to gain people’s views of the service they receive. The home receives an unannounced monthly visit from a Locality Manager where quality matters are inspected. There are effective systems in place to ensure that there are good records of any money held on behalf of people living in the home. People living in the home are supported to manage their own money where possible. Those who don’t have the skills are encouraged to take as much responsibility as it is safe to do. All working practices are regularly reviewed. Mandatory training is provided for all staff and is regularly updated. Good systems are in place for checking on health and safety in Springdale. Records are kept in good order for these checks. Appropriate training is provided for staff and regularly updated. Risk assessments for the premises and for fire are in place. Fire alarm tests are carried out weekly and records were available to confirm this. Accident records are kept in good order. Springdale, 29 DS0000000571.V371675.R01.S.doc Version 5.2 Page 23 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 Standard No Score 1 3 2 3 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 2 25 4 26 X 27 2 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 1 34 2 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 3 X 3 X X 3 X Springdale, 29 DS0000000571.V371675.R01.S.doc Version 5.2 Page 24 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. Standard YA33 Regulation 18 Requirement Staffing levels must be sufficient to cover the rota taking account of peoples’ needs at all times. Arrangements to provide staff cover for sickness and annual leave must be reviewed. Timescale for action 30/11/08 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. 3. Refer to Standard YA17 YA24 YA34 Good Practice Recommendations There should be a review of the food budgets in line with increasing costs. Consider replacing the bathroom suite and redecoration to improve the environment. The manager and service users should be involved in the recruitment of staff to ensure that people with appropriate skills are appointed. Springdale, 29 DS0000000571.V371675.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection North Eastern Region St Nicholas Building St Nicholas Street Newcastle Upon Tyne NE1 1NB National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 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.V371675.R01.S.doc Version 5.2 Page 26 - 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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