Inspection on 06/07/05 for Springdale, 29

This inspection was carried out on 6th July 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 but made no statutory requirements on the home.

Other inspections for this house

Springdale, 29 26/08/08

Springdale, 29 13/07/06

Springdale, 29 21/12/05

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 29 Springdale Tweedmouth Berwick upon Tweed Northumberland TD15 2DD Lead Inspector Dennis Bradley Unannounced 6 July 2005 15:00 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationary 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. 29 Springdale v232173 b53-b03 s571 springdale v232173 060705 stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service 29 Springdale Address Tweedmouth Berwick upon Tweed Northumberland TD15 2DD 01289 302169 01289 302169 communityhome@springdalenhs.fsworld.co.uk Northgate & Prudhoe NHS Trsut Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Mrs Claire Selby CRH 3 Category(ies) of LD Learning Disability (3) registration, with number of places 29 Springdale v232173 b53-b03 s571 springdale v232173 060705 stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: Not applicable. Date of last inspection 09 March 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. 29 Springdale v232173 b53-b03 s571 springdale v232173 060705 stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection that started at 15.00pm. The inspection lasted 4.75 hours. One resident was spoken to as well as two members of staff. The inspector was shown around the house and two of the residents showed him their bedrooms. Records were also examined. What the service does well: What has improved since the last inspection? What they could do better: Staff should be provided with additional training regarding the specific disabilities and conditions of the residents who live at the home. Each member of staff needs to have formal supervision at least six times a year as well as an annual appraisal. The Home’s quality assurance and quality monitoring system needs to be fully implemented and monthly unannounced monitoring visits need to be carried out. Each member of staff needs to take part in fire drills at suitable intervals. 29 Springdale v232173 b53-b03 s571 springdale v232173 060705 stage 4.doc Version 1.30 Page 6 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. 29 Springdale v232173 b53-b03 s571 springdale v232173 060705 stage 4.doc Version 1.30 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 Standards Statutory Requirements Identified During the Inspection 29 Springdale v232173 b53-b03 s571 springdale v232173 060705 stage 4.doc Version 1.30 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 2. Suitable arrangements were in place to assess the needs and wishes of prospective residents to ensure that these could be met at the Home. EVIDENCE: All of the residents had lived at the Home for over 20years. Prior to moving into 17 Springdale each resident had undergone an assessment. Their ‘care manager’ visits every six months to monitor their care. Individual care plans had been done for each resident. 29 Springdale v232173 b53-b03 s571 springdale v232173 060705 stage 4.doc Version 1.30 Page 9 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 standard(s) 6, 7 & 9. Suitable plans of care and risk assessments were in place for each resident that provided staff with appropriate information about each person’s support needs and how to minimise identified risks. The arrangements for supporting residents to make decisions about their daily lives and preferences were satisfactory. EVIDENCE: Each service user had an individual plan of care that described how their needs would be met at the Home. The plans included a range of risk assessments and there was evidence that these were regularly reviewed and updated. The risk assessments clearly detailed the steps to be taken by staff to reduce/eliminate risks. Records indicated the involvement of relevant professionals and agencies such as GPs, opticians and dentists. Each service user had a key member of staff who oversaw their plans of care. Staff supported and encouraged residents to make decisions about their daily lives and routines, such as what time they went to bed and what they wanted to eat or drink. They were also involved in choosing outings and activities as well as the décor of their bedrooms. Those residents who had difficulty with communicating verbally were supported to use other methods of communication such as gesture or using pictures. None of the residents were 29 Springdale v232173 b53-b03 s571 springdale v232173 060705 stage 4.doc Version 1.30 Page 10 able to leave the Home without the support and supervision of staff and this was recorded in their care plan. 29 Springdale v232173 b53-b03 s571 springdale v232173 060705 stage 4.doc Version 1.30 Page 11 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 standard(s) 12, 13, 15, Suitable arrangements were in place for residents to take part in appropriate activities in line with their needs and preferences. The residents and staff had good links within the local community and the arrangements for supporting residents to maintain contact with their friends and family were satisfactory. 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. EVIDENCE: Each resident had a weekly activity programme. Two residents attended the local adult training centre, one for two and a half days and the other four days a week. One of these residents also went horse riding and to a weekly dance workshop. One of the residents could not attend the training centre but went to the local sports centre. Each resident had one day a week where they received individual staff support to go on activities or outings such as to the zoo or shopping at, for example, the Metro Centre. The residents used local amenities such as the shops, pub and cafés as well as the local healthcare services. Staff said the residents knew the neighbours and got on well with most of them. 29 Springdale v232173 b53-b03 s571 springdale v232173 060705 stage 4.doc Version 1.30 Page 12 Relatives of the residents could visit the Home and staff supported the residents to visit their friends and relatives. 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. However, the records of meals provided indicated that they were generally varied and well balanced, apart from lunches where there had, until recently, been too many meals involving eggs. One of the residents said they liked the meals and confirmed that they could help staff do the food shopping and prepare the meals. The staff had all received training in food hygiene. 29 Springdale v232173 b53-b03 s571 springdale v232173 060705 stage 4.doc Version 1.30 Page 13 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 standard(s) 18 & 20. Suitable plans of support were in place and staff had a good understanding of each resident’s support needs. The arrangements for the administration and recording of medication were satisfactory and safeguarded residents. EVIDENCE: Support plans were in place for each resident regarding their personal and general care needs and preferences. They described how staff should provide this care. Staff supported and assisted the residents to choose their own clothes, hairstyles and toiletries. None of the service users were assessed as being able to self-medicate. No problems were noted in the sample of medication records examined. A lockable storage facility was available for the safe storage of medication. Written consent had been obtained from each resident’s doctor for the administration of non-prescription medication. All but one of the staff had had training in the safe handing of medicines 29 Springdale v232173 b53-b03 s571 springdale v232173 060705 stage 4.doc Version 1.30 Page 14 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 standard(s) 22. Suitable arrangements were in place for handling complaints with some evidence that residents’ views were listened to. EVIDENCE: One resident said that the best thing about living at the Home was the staff. She said “you can talk to anyone if you’re worried”. A Complaints Policy and related procedures were in place. The Service Users Guide contained guidance on how to make a complaint. The guidance is produced in a format for those service users who are not literate. The Home’s Complaints Record indicated that no complaints had been received by the Home since February 2004. 29 Springdale v232173 b53-b03 s571 springdale v232173 060705 stage 4.doc Version 1.30 Page 15 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 standard(s) 24 & 30. The arrangements for keeping the Home clean and tidy were satisfactory. The standard of the décor was generally satisfactory and provided residents with a comfortable and homely place to live. EVIDENCE: The Home was clean, tidy and homely in appearance. There was nothing to distinguish the premises from the other houses in the area and the premises were accessible to all service users. An annual maintenance programme was in place. Parts of the Home had been redecorated and fitted with new carpets. Arrangements had been made to redecorate and fit new carpets in two of the residents’ bedrooms. The residents concerned will pay the costs of this. New covers were also to be fitted to the seating in the lounge. A resident confirmed that they had been consulted regarding the choice of carpet and decor in their bedroom. The washing machine and dryer were situated in the kitchen area. This was accepted at the time the Home was registered. Cleaning materials and other potentially hazardous substances were safely stored. Policies and procedures were in place relating to the Control of Hazardous Substances and Infection Control. 29 Springdale v232173 b53-b03 s571 springdale v232173 060705 stage 4.doc Version 1.30 Page 16 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 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 32, 33, 34, & 36. The staff team was competent and provided consistency of care within the Home. However, 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. Staffing levels were adequate and arrangements were in place to improve them. The arrangements for making staff personnel files available for inspection were 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 inadequate. EVIDENCE: 29 Springdale v232173 b53-b03 s571 springdale v232173 060705 stage 4.doc Version 1.30 Page 17 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’ and all of the staff had attended training in the protection of vulnerable adults. However, 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. A review of staffing levels had been carried out. From October 2005 the staff team will have an additional full-time member of staff. This should enable more flexible staff cover particularly in the evenings when there is usually only one member of staff on duty. Staff personnel records were kept at Northgate Hospital Personnel Department and were not available for inspection as required. Arrangements had been put in place for staff to receive regular, individual supervision from their line manager. However, this was quarterly rather than at least 6 times a year as required. Staff had not had an annual appraisal. Staff said that because of the location of the Home they felt somewhat isolated and it was sometimes difficult to attend training. 29 Springdale v232173 b53-b03 s571 springdale v232173 060705 stage 4.doc Version 1.30 Page 18 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 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 39 & 42. The arrangements for monitoring and reviewing the service provided by the Home were not satisfactory and it was adequately demonstrated that residents’ views underpinned any review and development. The arrangements for protecting the health and safety of residents were not fully adequate. EVIDENCE: A quality assurance and quality monitoring system was in place. However, the records available indicated that the system had not been fully implemented during the previous 12 months. Monthly monitoring visits to the Home were not being carried out. There had only been 7 such visits during the previous 12 months. 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. Regular checks of the Home’s fire equipment were being done. Staff had regular fire instruction but one member of staff had not taken part in 29 Springdale v232173 b53-b03 s571 springdale v232173 060705 stage 4.doc Version 1.30 Page 19 a fire drill and another had not done so for over a year. 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. 29 Springdale v232173 b53-b03 s571 springdale v232173 060705 stage 4.doc Version 1.30 Page 20 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 3 x x x Standard No 22 23 ENVIRONMENT Score 3 x INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 3 3 x 3 x Score Standard No 24 25 26 27 28 29 30 STAFFING Score 3 x x x x x 3 Standard No 11 12 13 14 15 16 17 x 3 3 x 3 3 3 Standard No 31 32 33 34 35 36 Score x 2 3 3 x 2 CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 29 Springdale Score 3 x 3 x Standard No 37 38 39 40 41 42 43 Score x x 1 x x 2 x v232173 b53-b03 s571 springdale v232173 060705 stage 4.doc Version 1.30 Page 21 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 34 Regulation 17 Requirement Timescale for action 30.9.05 2. 36 18 3. 39 24 4. 39 26 The Registered Person must 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 30.9.05 ensure that: 1. 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); 2. All staff have an annual appraisal with their line manager to review performanc and agree career development plans. The Registered Person must 30.9.05 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 30.9.05 ensure that unannounced mintoring visits, as specified under Regulation 26 of The Care Homes Regulations 2001, are carried out at least once a month v232173 b53-b03 s571 springdale v232173 060705 stage 4.doc Version 1.30 29 Springdale Page 22 5. 42 23 The Registered Person must ensure that: 1. All staff take part in fire drills at suitable intervals; 2. Arrange for an inspection of the Homes electrical system to be carried out at least every five years. 30.9.05 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 32 42 Good Practice Recommendations Arrange for staff to receive training in the specific disabilities and conditions of the residents living at 29 Springdale. Develop the Homes fire risk assessment to specify how often staff should take part in fire drills. 29 Springdale v232173 b53-b03 s571 springdale v232173 060705 stage 4.doc Version 1.30 Page 23 Commission for Social Care Inspection 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 29 Springdale v232173 b53-b03 s571 springdale v232173 060705 stage 4.doc Version 1.30 Page 24 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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