Inspection on 06/10/05 for Springfield

This inspection was carried out on 6th October 2005.

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 16/02/06

Springfield 25/02/05

Springfield 23/06/04

Springfield 03/03/04

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Snydale Care Home

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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 LS25 1EP Lead Inspector Steve Marsh Unannounced 6 October 2005 th 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 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 20051006 Springfield UN Stage 4 S1505 V256013 J52.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Springfield Address 1-3 Lowther Avenue Garforth Leeds LS25 1EP 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) 0113 2863415 0113 2878600 Springfield Care Services Mrs Glenys Lawson Care Home Only 55 Category(ies) of Old Age (30) Dementia Over 65 (20) Mental registration, with number Disorder Over 65 (3) Mental Disorder (3) of places Springfield 20051006 Springfield UN Stage 4 S1505 V256013 J52.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: The places for MD are for specific named service users Date of last inspection 25/02/05 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, which accommodates forty service users and Springfield Grange, which accommodates fifteen service users and which 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 service users with mobility problems reach the bedrooms on the upper floors. Both properties have pleasant communal areas for the service users 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 20051006 Springfield UN Stage 4 S1505 V256013 J52.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was the first inspection visit (unannounced) for the year 2005/06 and was carried out by one Inspector over a period of approximately eight hours. The last inspection of this service was in February 2005 and the main purpose of this visit was to assess the homes progress in meeting the requirements and recommendations made at that time. The methodology used in this inspection included the examinations of records, observation of care practices, discussion with service users, visitors and staff and a tour of the premises. Comment cards were also left at the home to enable the service users and/or their relatives share their views of the service with the Commission. Comments received in this way will be fed back to the registered manager of the home without revealing the identity of the respondent. Requirements and recommendations from this inspection are detailed at the end of the report. What the service does well: The home continues to provide a safe and comfortable environment for the service users. The manager and staff team are approachable and appear to have a genuine understanding of their needs. The service users are treated with respect at all times, and their views and opinions on the standard of care/services they receive are actively sought and valued. Members of staff encourage the service users to make as many decisions as possible in relation to their daily lives, and activities/outings are organised in line with their wishes. Mealtimes are unhurried and the food prepared is appetising and well presented. The staff recruitment and selection procedures are robust, and the level of training made available to the care staff team is commendable. Springfield 20051006 Springfield UN Stage 4 S1505 V256013 J52.doc Version 1.40 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 20051006 Springfield UN Stage 4 S1505 V256013 J52.doc Version 1.40 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 Standards Statutory Requirements Identified During the Inspection Springfield 20051006 Springfield UN Stage 4 S1505 V256013 J52.doc Version 1.40 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 standard(s) 1,3,5, Service users and/or their relatives are provided with sufficient information to enable them to make an informed decision about the home. The admission procedure in general appears good, however the manager must avoid unplanned admissions to the home if at all possible. 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 prospective service users. The records of the three most recent admissions to the home (Springfield) were reviewed and showed that two of the service users had been admitted on an emergency basis from an assessment centre. A pre-admission assessment visit to see them had therefore not been carried out by the manager however, assessment information had been provided by the centre, which indicated that the home would be able to meet their needs. Springfield 20051006 Springfield UN Stage 4 S1505 V256013 J52.doc Version 1.40 Page 9 The manager confirmed that the third admission to the home had been planned. Although no pre-admission assessment visit had been carried out, the service user had visited the home for a day prior to admission, and an initial assessment of her needs was undertaken at that time. In addition further assessment information had been provided by the agency making the referral, prior to admission. The manager confirmed that service users are able to move into the home for a trial period if they wish, to enable them and/or their relatives to make an informed decision about the standard of care/facilities provided. It is however acknowledged that for some service users admitted to Springfield Grange with a diagnosis of dementia, it may not always be appropriate for them to visit the home or move in for a trial period, as they may become more confused and/or disorientated. Service users and relatives spoken to, said that the manager and staff had been very helpful when they had initially visited the home, had shown them around, answered any questions and provided general information about the care/services provided. Springfield 20051006 Springfield UN Stage 4 S1505 V256013 J52.doc Version 1.40 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 standard(s) 7,8,9,10 Service users’ healthcare needs are met and any problems are identified at an early stage. Medication systems are safe but records must be kept for medication used on an “as and when required “ basis. EVIDENCE: Care plans have been completed for all service users and there is sufficient evidence to show that they and/or their relatives are involved in the care planning process. The manager confirmed that the care plans are reviewed on at least a monthly basis, or sooner if needs change significantly. In addition to the care plans, risk assessments are completed for individual service users highlighting specific areas of concern, and moving and handling assessments are completed if required. Springfield 20051006 Springfield UN Stage 4 S1505 V256013 J52.doc Version 1.40 Page 11 All service users are registered with a general practitioner and have access to the full range of NHS services. The manager confirmed that the home has established good working relationships with other healthcare professionals such as district nurses, and advice is always sought if staff have concerns about the health or wellbeing of a service user. Service users spoken to said that prompt medical attention was provided if they felt unwell, which they found reassuring and medical examinations were always carried out in the privacy of their own room. Relatives spoken to on the day of the visit confirmed that they were kept informed of any changes in the service user’s general health, and were given the opportunity to meet other healthcare professionals involved in their care if they wish to do so. The manager confirmed that nutritional screening is completed for all service users on admission and any significant weight loss or gain is monitored and recorded. It is recommended that the home purchase sit-on weighing scales to assist the more frail service users, and/or service users with mobility problems. On reviewing the medication system no discrepancies were noted. However a stock control system must be implemented for prescribed medication administered to the service users on a prn (as and when required) basis. At the present time no service users administer their own medication although the manager confirmed that new admissions would be encouraged to do so if they had the capability. Staff continue to monitor the health of service users taking long-term medication, and professional advice would be sought if they had any concerns. Springfield 20051006 Springfield UN Stage 4 S1505 V256013 J52.doc Version 1.40 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 standard(s) 12,13,15 The home offers a range of social and leisure activities, and the service users are encouraged to make informed decisions about their daily lives. Meals appear nourishing and take into account the likes and dislikes of individual service users. EVIDENCE: The manager confirmed that the daily routines of the home are flexible and based around the needs of the service users. The interests and hobbies of individual service users are recorded in their care file, and the manager confirmed that wherever possible they are encouraged to pursue them for as long as they are able. The home does not employ an activities organiser, however a senior member of staff is responsible for organising outings/social events, and the care staff arrange daily activities for the service users in line with their wishes. The home continue to struggle to find appropriate social/leisure activities for one service user who is under sixty five years of age, but are making every effort to address this matter. Springfield 20051006 Springfield UN Stage 4 S1505 V256013 J52.doc Version 1.40 Page 13 The manager confirmed that service users are encouraged to follow their own religious beliefs and local church leaders hold services at the home on a regular basis. Arrangements can also be made for individuals to attend places of worship if they wish to do so. Service users spoken to said that they were happy with the level of activities organised for them. On the afternoon of the visit a number of them enjoyed a game of bingo in one of the lounge areas. Service users confirmed that they were able to see visitors in the privacy of their own rooms, and that their relatives and friends were made to feel welcome when they visited the home, and were offered light refreshments. The meals provided were described by the service users as very good, and they confirmed that the menus always offered them a varied and balanced diet and a choice at all mealtimes. On the day of the visit the meals provided at both lunch and teatime looked appetising, and certainly the buffet served at teatime was thoroughly enjoyed by all the service users. The main kitchen is situated in Springfield House and cooked food is transported to Springfield Grange in a hot trolley. On Springfield Grange there is a designated dining room. Although there are three separate dining areas on Springfield not all the service users are able to sit to a dining table at meal times, and some eat their meals from small occasional tables placed in front of their easy chairs. The manager is aware of the benefits a designated dining room would have for the service users but the layout of the building makes this difficult to achieve at the present time. Springfield 20051006 Springfield UN Stage 4 S1505 V256013 J52.doc Version 1.40 Page 14 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 standard(s) 16,18 Robust complaint and adult protection policies and procedures ensure that the service users are listened to and protected from any form of abuse. EVIDENCE: The home has a complaints procedure and the manager confirmed that there had been no formal complaints received since the last inspection visit in February 2005. The service users and relatives spoken to said that they knew what to do and who to approach if they were unhappy with the standard of care/service provided. However, they felt that if they did have any concerns they would be dealt with immediately by the manager or members of the staff team without having to make a formal complaint. Policies and procedures are in place at the home in relation to the protection of vulnerable adults, and the manager ensures that all members of the staff team receive appropriate training. The manager is also aware of the Protection Of Vulnerable Adults register and the implications this has had on the staff recruitment, selection and disciplinary procedures in place at the home. Members of staff spoken to confirmed that that they were aware of the home’s policy on “whistle blowing” and their responsibility to safeguard the service users from any form of abuse. Springfield 20051006 Springfield UN Stage 4 S1505 V256013 J52.doc Version 1.40 Page 15 Springfield 20051006 Springfield UN Stage 4 S1505 V256013 J52.doc Version 1.40 Page 16 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 standard(s) 19,20,21,24,26 The home provides a pleasant, comfortable and safe environment for the service users. However, some refurbishment work is required in both buildings to improve the standard of accommodation/facilities. EVIDENCE: Springfield – Both internally and externally the property appears generally well maintained although the older part of the building would benefit from refurbishing. The communal areas used by the service users including lounges and dining rooms are mainly situated on the ground floor of the building, although there is also a lounge area on the first floor, which is primarily used by visitors. Since the last inspection visit patio doors have been fitted in the designated smokers lounge/dining room, through which the service users are able to access a recently decked outside area. Springfield 20051006 Springfield UN Stage 4 S1505 V256013 J52.doc Version 1.40 Page 17 The general standard of décor and furnishings in all lounges and dining rooms was good and they continue to be pleasant areas for the service users to relax and/or dine. Communal bathroom and toilet facilities are conveniently located throughout the building, and it was noted that since the last inspection visit appropriate hand washing facilities had been provided in all areas. The laundry facility located on the ground floor of Springfield serves both Springfield and Springfield Grange, and has recently been refurbished and equipped. Springfield Grange – Internally the building now requires some refurbishment and the manager confirmed that Springfield Care Service is presently planning a programme of refurbishment work to improve the overall standard of accommodation. The communal areas used by the service users are situated on the ground floor of the building and consist of a lounge, dining room and conservatory, through which they can access a secure patio/garden area. Bathroom and toilet facilities are conveniently located on both floors of the building, and it noted that an emergency call lead had been installed in one ground floor toilet as required in the last inspection report. It was also noted that hand washing facilities had been provided in the sluice room on the first floor of the building since the last inspection visit. On the day of the visit the standard of hygiene and cleanliness in both buildings was found to be good although an odour problem was noted in one bedroom (identified to the manager). Both service users and relatives said that they were happy with the accommodation provided, and felt that the manager and staff tried hard to create a warm, welcoming and homely environment for them. Springfield 20051006 Springfield UN Stage 4 S1505 V256013 J52.doc Version 1.40 Page 18 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27,28,29,30 Service users are protected by a robust staff recruitment and selection procedure, which includes Criminal Record Bureau (CRB) checks. Training opportunities for the staff team are good, and the skill mix within the staff team ensures that the needs of the service users are met in line with their care plan. EVIDENCE: A rota for the week of inspection was taken, which showed that sufficient numbers of staff are employed on both day and night duty to meet the needs of the service users. There appears to be a good skill mix within the care staff team and all members of staff providing personal care are over eighteen years of age in line with the National Minimum Standards. At the present time the home continues to employ contract cleaners to ensure the premises are clean and free from offensive odours. This situation will change in the near future as the management have recently recruited three overseas workers to work as domestic/laundry assistants. The staff recruitment and selection procedures are thorough and the manager confirmed that all new members of staff receive induction and foundation training. Springfield 20051006 Springfield UN Stage 4 S1505 V256013 J52.doc Version 1.40 Page 19 There is also an expectation that all members of the care staff team will then go on to achieve a National Vocational Qualification (NVQ) at level two or above. The manager confirmed that to facilitate this Springfield Care Services has established its own training unit and is now recognised as a NVQ assessment centre, with designated assessors and an internal verifier. At the present time over 60 of the care staff team have already achieved a NVQ at level two (or above) and a further five members of staff will have achieved the qualification by December 2005. In addition all senior members of staff have achieved or are studying for a NVQ at level three or four. The level of training made available to the care staff team in general is commendable, and there appears to be a genuine commitment to training both to meet the needs of the service users and for personal development. Springfield 20051006 Springfield UN Stage 4 S1505 V256013 J52.doc Version 1.40 Page 20 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31,32,33,36,38 The manager is competent, provides good leadership to the staff team and ensures that the service users are protected and cared for appropriately. The views and opinions of the service users and/or their relatives are actively sought and valued. EVIDENCE: The registered manager has many years experience in the caring profession and achieved the Registered Managers Award in 2003. The manager appears to communicate a clear sense of direction and leadership to the staff team, and staff spoken to, confirmed that she has an open and approachable management style. Springfield 20051006 Springfield UN Stage 4 S1505 V256013 J52.doc Version 1.40 Page 21 The manager is supported in her role by an external management team who visit the home on a regular basis and are involved in the overall management and development of the service. The manager ensures clear channels of communications within both Springfield and Springfield Grange by holding regular staff meetings. All members of staff also receive one-to-one supervision with their line manager at least every two months in line with the National Minimum Standards. There are recognised quality assurance monitoring systems in place at the home, and the manager confirmed that the home continue to hold the Investor in People Award. However, as highlighted in the last inspection report, to comply with regulation 26 of the Care Home Regulations 2001, a representative of Springfield Care Services must prepare a monthly written report on the conduct of the home and supply a copy of the report to the Commission. Policies and procedures are in place to ensure the health and safety of the service users, visitors and staff, and the manager confirmed that they are reviewed on a regular basis in line with changes in legislation. Springfield 20051006 Springfield UN Stage 4 S1505 V256013 J52.doc Version 1.40 Page 22 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score 3 x 3 x 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 x 15 3 COMPLAINTS AND PROTECTION 3 3 3 x x 3 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 Standard No 16 17 18 Score 3 x 3 4 4 2 x x 3 x 3 Springfield 20051006 Springfield UN Stage 4 S1505 V256013 J52.doc Version 1.40 Page 23 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 OP9 Regulation 13(2) Requirement The registered manager must ensure that a stock control system is implemented for medication administered on a prn (as and when required) basis. The registered manager must ensure that the odour control problem in the bedroom identified on the day of the visit is eliminated. Regulation 26 visits -- The responsible individual for Springfield Care Service must forward a copy of the monthly report to the Commission. (outstanding from the last inspection report -- timescale 30/04/05 not met). Timescale for action 30/11/05 2. OP26 23 30/11/05 3. OP33 26 30/11/05 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. Refer to Standard OP8 Good Practice Recommendations It is recommended that the home purchase sit-on weighing scales to assist the more frail service users. 20051006 Springfield UN Stage 4 S1505 V256013 J52.doc Version 1.40 Page 24 Springfield Springfield 20051006 Springfield UN Stage 4 S1505 V256013 J52.doc Version 1.40 Page 25 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. 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