Inspection on 16/02/06 for Springfield

This inspection was carried out on 16th 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 found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Springfield 18/01/07

Springfield 06/10/05

Springfield 25/02/05

Springfield 23/06/04

Springfield 03/03/04

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Larchfield Manor

Hawkhills

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The Grove Waltham

Carentan House

Ravensworth Lodge

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

CARE HOMES FOR OLDER PEOPLE Springfield 1-3 Lowther Avenue Garforth Leeds West Yorkshire LS25 1EP Lead Inspector Steve Marsh Unannounced Inspection 09:30 16 February 2006 th 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 Springfield DS0000001505.V278274.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. Springfield DS0000001505.V278274.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Springfield Address 1-3 Lowther Avenue Garforth Leeds West Yorkshire LS25 1EP 0113 286 3415 0113 287 8600 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) Springfield Care Services Mrs Glenys Lawson Care Home 55 Category(ies) of Dementia - over 65 years of age (20), Mental registration, with number disorder, excluding learning disability or of places dementia (3), Mental Disorder, excluding learning disability or dementia - over 65 years of age (3), Old age, not falling within any other category (30) Springfield DS0000001505.V278274.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. The places for MD are for specific, named service users. Date of last inspection 6th October 2005 Brief Description of the Service: Springfield Care Home is situated in a residential area of Garforth, which is located on the outskirts of Leeds. The home is presently registered to care for fifty-five service users in two separate buildings. Springfield accommodates forty residents and Springfield Grange accommodates fifteen residents and is primarily a dementia care unit. Bedroom accommodation is provided in both single and double rooms, many of which have en-suite facilities. There is ramped access to both properties and passenger or stair lifts available to assist residents with mobility problems reach the bedrooms on the upper floors. Both properties have pleasant communal areas for the residents to relax and/or dine and communal toilet facilities are conveniently situated in both properties. The home is well served by public transport and there is a car park to the rear of the property. Springfield DS0000001505.V278274.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was the second unannounced inspection visit for the year ending 31st March 2006, and was carried out by one Inspector over approximately seven hours. No additional visits have been made to the home. The methods used during this inspection included the examination of records, observation of care practices, discussion (both group and individual) with residents, staff and management and a partial tour of the premises. Comment cards were left for the residents and/or relatives to enable them to share their views of the service with the Commission. Feedback was given to Mrs Glenys Lawson (registered manager) at the end of the inspection. Requirements and recommendations made during this visit can be found at the end of the report. What the service does well: The home continues to provide a warm, comfortable and safe environment for the residents and there is an ongoing programme of refurbishment and renewal. The admission procedure is thorough and the manager will not admit a resident unless she feels the staff team can provide the level of care they require. Residents confirmed that they were always treated with respect and found the manager and staff to be friendly and approachable. Residents are encouraged to make as many decisions as possible in relation to their daily lives and their freedom of choice is not restricted. There continues to be a genuine commitment to staff training and this is reflected in the level of National Vocational Qualification (NVQ) training made available to the staff team. The staff recruitment and selection procedure continues to be thorough and helps to protect the residents from abuse. The manager takes all complaints seriously and ensures immediate action is taken to resolve matters. Springfield DS0000001505.V278274.R01.S.doc Version 5.1 Page 6 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. Springfield DS0000001505.V278274.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 Springfield DS0000001505.V278274.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): 1,2,3,5 Residents and/or relatives are provided with sufficient information to enable them to make an informed decision about the home. The admission is thorough and the manager will not admit a resident unless she feels the staff team can meet their assessed needs. EVIDENCE: The manager confirmed that there had been no changes to the homes statement of purpose or service user guide, which are available to both current and existing residents. The records of the two most recent admissions to the home (Springfield Grange) were reviewed and they showed that pre-admission assessment visits are carried out to see all prospective residents. The manager confirmed that the residents, relatives and other healthcare professional contribute to the assessment process although this is not always clearly evidenced in the assessment report. Springfield DS0000001505.V278274.R01.S.doc Version 5.1 Page 9 Unplanned admissions are avoided if at all possible although the home does respond to crisis situations and will take emergency admissions providing the manager is sure that the staff team can meet their needs. In addition to the assessment visit residents and/or relatives are invited to visit the home prior to admission to view the accommodation, meet the other residents and staff and stay for a meal if they wish to do so. Residents are also able to move into the home for a trial period although for some residents diagnosed with dementia this is not practical or advisable as they may become more confused or disorientated. The manager confirmed that all residents are provided with a contract (terms and conditions of occupancy) on admission in line with the National Minimum Standards. Springfield DS0000001505.V278274.R01.S.doc Version 5.1 Page 10 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): 7,8,9,11 Care plans are completed to a good standard and give clear guideline to the staff on how to meet the individual residents’ needs. Records and reports indicate that the resident’s healthcare needs are met in line with their care plan and any problems are identified and dealt with at an early stage. To safeguard the residents the manager must however ensure that a stock control system is implemented for medication administered on a PRN (as and when required) basis. EVIDENCE: Care plans have been completed for all residents and cover all aspects of their health and general welfare. The care plans are reviewed at least monthly or sooner if the residents’ needs change significantly. The four care plans reviewed were completed to a good standard and there was evidence to show that the residents and/or relatives are involved in the care planning process. It was however recommended that whenever possible residents and/or relatives are asked to sign and date the care plan to acknowledge their agreement with its contents. Springfield DS0000001505.V278274.R01.S.doc Version 5.1 Page 11 All residents are registered with a general practitioner and have access to the full range of NHS services. The input of other healthcare professionals is clearly recorded in the residents’ care plan and specialist equipment is provided if required. Residents said that they were very pleased with the medical attention they received and confirmed that medical examinations are always carried out in the privacy of their own room. The manager confirmed that nutritional screening is carried for all residents on admission and residents are weighed on a regular basis throughout the duration of their stay. As recommended in the last inspection report the home has recently purchased sit-on scales to enable the frailer residents to be weighed. On reviewing the medication system in place (Springfield Grange) no discrepancies were noted on the Medication Administration Record sheets. However, a stock control system still requires implementing for medication administered to the residents on a PRN (as and when required) basis. The manager confirmed that at present no residents administer their own medication although new admissions to the home would be encouraged to do so if they had the capability. The home has policies and procedures in place in relation to the dying and death of a resident and the manager confirmed that comfort and support is offered to all parties during this very difficult period. Springfield DS0000001505.V278274.R01.S.doc Version 5.1 Page 12 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): 14 Residents are encouraged and supported by the staff team to make informed decisions and choices about their daily lives for as long as it is practical for them to do so. EVIDENCE: The daily routines of the home appear flexible and the manager confirmed that the residents are encouraged to make as many decisions and choices as possible in relation to their daily lives. Two residents in particular confirmed that they had chosen the home because it had been made clear to them by the manager that their freedom of movement and choice of lifestyle would not be restricted in anyway. Residents are encouraged to handle their own financial affairs if they have the capability and are made aware of external agency’s that will act in their best interest if necessary. The manager confirmed that the residents are made aware that they can have access to their personal records held by the home in line with the Data Protection Act1998. Springfield DS0000001505.V278274.R01.S.doc Version 5.1 Page 13 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16,18 Robust complaint and adult protection procedures continue to ensure that the residents are listened to and protected from abuse. EVIDENCE: The home has a complaints procedure and the resident/relatives confirmed that if they had any concerns they would feel able to raise them with the manager or the senior staff team. They were also confident that their concerns would be taken seriously and resolved without them having to make a formal complaint. The manager confirmed that no complaints had been received since the last inspection visit. Policies and procedures are in place in relation to adult protection and all members of staff receive appropriate training. Staff spoken to appeared aware of the home’s policy on “whistle blowing” and were able to detail what they would do if they felt any practices were not in the residents best interest. Springfield DS0000001505.V278274.R01.S.doc Version 5.1 Page 14 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19,26 Springfield Care Services have acknowledged the need to improve the environment for the residents living in Springfield Grange and are presently working with the Commission to achieve this. EVIDENCE: Springfield – both internally and externally the property appears well maintained although some areas of the original building would benefit from refurbishment. Springfield Grange – Internally the property is now in need of extensive refurbishment if it is to successfully meet the needs of the residents. However, within the physical limitations of the building the staff team continue to provide a comfortable and safe environment for the residents. At the present time Springfield Care Services are in discussions with the Commission about the refurbishment of Springfield Grange and it is anticipated that work will commence later in 2006. Springfield DS0000001505.V278274.R01.S.doc Version 5.1 Page 15 On the day of the visit the standard of hygiene and cleanliness in both buildings was found to be good although it was noted that a lid was missing from a clinical waste bin on Springfield Grange. Springfield DS0000001505.V278274.R01.S.doc Version 5.1 Page 16 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29,30 Residents continue to be protected by a robust staff recruitment and selection procedure, which includes Criminal Record Bureau (CRB) checks. The level of training made available to the staff is commendable and the skill mix within the staff team ensures that the resident’s needs are met. EVIDENCE: A staff rota for the week of inspection was taken, which showed that sufficient care staff are employed on both day and night duty to meet the needs of the residents. The home also employs sufficient catering and cleaning staff to ensure that the premises are kept clean and free from offensive odours and the residents dietary needs are met. All staff providing personal care are over eighteen years of age and all senior staff are over twenty-one years of age in line with the National Minimum Standards. Three staff files were reviewed and they contained all the relevant information including Criminal Record Bureau (CRB) checks to evidence that a safe recruitment and selection procedure is in place. The manager confirmed that all new members of staff receive induction and foundation training, and additional training both to meet the needs of the residents and for personal development is encouraged. Springfield DS0000001505.V278274.R01.S.doc Version 5.1 Page 17 There is also an expectation that all members of care staff will achieve a National Vocational Qualification (NVQ) at level two or above depending on the post they hold. At the present time over 70 of the care staff team have achieved a NVQ, which is commendable. Springfield DS0000001505.V278274.R01.S.doc Version 5.1 Page 18 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): 33,35,38 The quality assurance monitoring systems in place ensure that the views and opinions are sought and action is taken to resolve matters. To safeguard the residents the manager must ensure that a balance figure is always recorded on the resident’s financial transaction sheets. All policies and procedures in use at the home are reviewed on a regular basis to ensure the health and safety of the residents, relatives and staff. EVIDENCE: The home has quality assurance monitoring systems in place and have achieved the Investors in People Award. The home continues to seek the views and opinion of the residents, relatives and other healthcare professional as part of this process and an annual survey questionnaire is sent out. In addition, a representative of Springfield Care Services now prepares a written monthly report on the conduct of the home and supplies a copy to the Commission. Springfield DS0000001505.V278274.R01.S.doc Version 5.1 Page 19 Residents and/or relatives confirmed that they were kept informed of any changes in policies and procedures, which affect the running of the home and felt that their views and opinions were listened to and valued. Staff meetings are also held on a regular basis and formal one-to-one supervision continues to be held at least every two months in line with the National Minimum Standards. The manager confirmed that residents and/or relatives are encouraged to manage their own financial affairs if at all possible although the Finance Manager for Springfield Care Services will assist/advise in financial matters if requested to do so. Only senior staff deal with the resident’s finances held at the home and transaction sheets are available indicating income, expenditure and a balance. On reviewing the transaction sheets it was however noted that in one instance the staff were not entering a figure in the balance column, therefore it was difficult to establish how much money the resident actually had in safekeeping. The manager confirmed that this was an oversight and would address the matter. Policies and procedures are in place to ensure the health and safety of the residents, visitors and staff and are reviewed on a regular basis to ensure that they meet with present legislation. However, health and safety concerns were raised regarding the methods of transferring residents in wheelchairs in Springfield Grange as two of the three wheelchairs in use did not have footrests fitted. Springfield DS0000001505.V278274.R01.S.doc Version 5.1 Page 20 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 3 3 X 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 4 9 2 10 X 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 X 14 3 15 X COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X X X 2 STAFFING Standard No Score 27 3 28 4 29 3 30 4 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X X 3 X 2 3 X 2 Springfield DS0000001505.V278274.R01.S.doc Version 5.1 Page 21 Are there any outstanding requirements from the last inspection? yes 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 OP9 Regulation 13(2) Requirement Springfield Grange -- The registered manager must ensure that a stock control system is implemented for medication administered on a PRN (as and when required) basis. (Outstanding from last inspection report – timescale 30/11/05 not met). Springfield Grange – The lid to the clinical waste bin must be replaced. The registered manager must ensure that all financial transactions completed on behalf of the residents are recorded appropriately. Springfield Grange -- footrests must be fitted to all wheelchairs. Timescale for action 31/03/06 2. 3. OP26 OP35 16(2)(k) 17 31/03/06 31/03/06 4. OP38 13 31/03/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Springfield Refer to Good Practice Recommendations DS0000001505.V278274.R01.S.doc Version 5.1 Page 22 1. 2. Standard OP3 OP7 It is recommended that the pre-admission assessment forms more clearly identify who participated in the assessment process. It is recommended that wherever possible the residents and/or relatives sign and date the care plan to acknowledge their agreement with its content. Springfield DS0000001505.V278274.R01.S.doc Version 5.1 Page 23 Commission for Social Care Inspection Aire House Town Street Rodley Leeds LS13 1HP 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 Springfield DS0000001505.V278274.R01.S.doc Version 5.1 Page 24 - 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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