Inspection on 26/11/08 for Springfield Care Home

This inspection was carried out on 26th November 2008.

CSCI found this care home to be providing an Adequate service.

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 Care Home 14/08/07

Springfield Care Home 13/02/07

Springfield Care Home 26/04/06

Springfield Care Home 27/02/06

Springfield Care Home 24/05/05

Springfield Care Home 11/03/05

Springfield Care Home 16/07/04

Similar services:

Byars Care Home

St Marys Nursing Home

Bramble Lodge

Parkmanor Residential Home

Thornham Grove

Hunter`s Lodge

London Road Neurological and Specialist Care Unit

Carlton Care Home

Extracts from inspection reports are licensed from CQC, this page was updated on 30/01/2009.

CARE HOMES FOR OLDER PEOPLE Springfield Care Home Lawton Drive Bulwell Nottingham NG6 8BL Lead Inspector Janis Robinson Unannounced Inspection 26th November 2008 09:00 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 Care Home DS0000002305.V373244.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 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 Care Home DS0000002305.V373244.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Springfield Care Home Address Lawton Drive Bulwell Nottingham NG6 8BL 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) 0115 927 9111 0115 979 4759 ckpatel1@tiscali.co.uk Annesley (Oldercare) Limited Natasha Burbidge (not yet registered) Care Home 40 Category(ies) of Dementia (40), Old age, not falling within any registration, with number other category (40) of places Springfield Care Home DS0000002305.V373244.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category of service only: Care Home with Nursing - Code N To service users of the following gender: Either Whose primary care needs on admission to the home are: Old age, not falling within any other category - Code OP Dementia - Code DE The maximum number of service users who can be accommodated is: 40. 14th August 2007 2. Date of last inspection Brief Description of the Service: Springfield is registered to provide personal care and accommodation for 40 older people, including those with a diagnosis of dementia. The home is owned by Annesley (Oldercare) Limited. The home is located on the outskirts of Bulwell town centre which is approximately 4 miles to the north of Nottingham city centre. The home was purpose built and was opened in November 1989. It consists of a three-storey building with the lower ground floor being used to accommodate the dining room and conservatory, kitchen and laundry. All but four of the homes bedrooms are single. All bedrooms have en-suite facilities that consist of a toilet and wash hand basin. There is a passenger lift. The gardens are mainly laid to one side and the rear. They are easily accessible from the conservatory and consist of lawned areas. There is a car park to the front of the building. The fees for this service are currently £329-£550 per week. Written information about the home, in the form of a service user guide, and a copy of the Commission for Social Care Inspection (CSCI) latest inspection report are available from the home. Springfield Care Home DS0000002305.V373244.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 1 star. This means that the people who use this service experience adequate quality outcomes. This was an unannounced key inspection carried out by Janis Robinson regulation inspector. A site visit took place between the hours of 9.15 am and 4:15 pm on the 26th of November 2008. A new manager, Natasha Burbidge, had been in post since the 8th of October 2008. The manager was present for the site visit. Prior to the visit the previous manager had submitted an Annual Quality Assurance Assessment (AQAA) which detailed what the home was doing well, what had improved since the last inspection and any plans for improving the service in the next twelve months. Information from the AQAA is included in the main body of the report. On the day of the site visit staff were observed interacting with people that live in the home. Opportunity was taken to make a partial tour of the premises, inspect a sample of care records and records relating to the running of the home. Six people living at the home, and two relatives were spoken with about their experiences of living at and visiting Springfield. The majority of staff on duty were spoken with about their jobs, and two staff were formally interviewed about their skills and experience of working at the home. The inspector checked all key standards and the standards relating to the requirements outstanding from the homes last inspection in August 2007. The progress made has been reported on under the relevant standards in this report. What the service does well: Communication difficulties meant that some people living in the home were unable to answer questions fully. However, staff interactions with people living at the home were caring, positive and respectful. People spoken with said; “Staff are smashing” Springfield Care Home DS0000002305.V373244.R01.S.doc Version 5.2 Page 6 “They are lovely” “I’m well looked after” Relatives spoken with were happy with the care provided to their loved one and said that they had no concerns. Care plans were in place for all people living at the home. They set out personal, social and health care needs and recorded some of the staff action required to make sure all identified needs were met. People’s health care was monitored and access to health specialists was available. People said that they had a choice of food and that the food served was “good”. There was a complaints procedure and adult protection procedure in place, to promote peoples safety. People said that they felt safe living at the home. The majority of the home was well maintained to provide a pleasant place for people to live. Some training took place, to equip staff with the essential skills needed to carry out their duties. Systems were checked and serviced to maintain a safe environment. What has improved since the last inspection? Risk assessments were up to date so that essential information was available to keep people safe. The volume of the call alarm system had been reduced so that it did not invade daily living. Further equipment to assist in moving and handling people had been provided to better meet peoples needs. Menus had been reviewed and reorganised to provide more variety. Plate covers had been provided so that people’s meals remained hot whilst they were being brought from the kitchen. Some work routines had been reorganised so that people had more choice. The manager had reviewed all care plans and had commenced updating them so that fuller information was available. Springfield Care Home DS0000002305.V373244.R01.S.doc Version 5.2 Page 7 Training needs had been identified and a training matrix developed so that ‘at a glance’ information was available. Staff training events had been organised so that staff would become up to date with essential training. Some new furniture in bedrooms had been provided so that people had good quality furnishings provided to them. New washers had been purchased to improve the laundry. What they could do better: Care plans must detail the actions required of staff to ensure individual needs and preferences are identified and met. Daily records should include more information so that staff are aware of peoples current state of health and wellbeing. Medication systems must be improved to reduce risk. Written instructions on the drugs held and Medication Administration Records (MAR) must correspond so that safe systems were in place. Medication Administration Records must be fully completed each time medication is given. Further activities should be available to people to improve choice. Damaged windows and furniture must be replaced to maintain a pleasant living space. Full employment history must be obtained, and any gaps identified and explored so that thorough and safe procedures are adhered to. Further domestic staff must be employed to support the housekeeper in maintaining standards of cleanliness. Staff supervisions should take place at least six times each year so that appropriate levels of support are in place. The manager must register with the CSCI so that full procedures are adhered to. The results of surveys should be published so that they are available to people. Staff must be provided with all aspects of mandatory training so that they have the essential skills needed to keep people safe. A system to monitor staff attending fire drills should be introduced to make sure all staff participate at appropriate frequencies. Checks on the fire systems must take place at a consistent frequency to make sure they are in working order. Springfield Care Home DS0000002305.V373244.R01.S.doc Version 5.2 Page 8 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. Springfield Care Home DS0000002305.V373244.R01.S.doc Version 5.2 Page 9 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 Care Home DS0000002305.V373244.R01.S.doc Version 5.2 Page 10 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. JUDGEMENT – we looked at outcomes for the following standard(s): 1,5 and 3 People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Information about the home was available to people so that they could make an informed choice about the service. Pre admission assessments made sure peoples needs could be met before they decided to move in. People could visit the home prior to admission to help them make a decision. EVIDENCE: The inspector obtained copies of the statement of purpose and service user guide. Copies were seen on display in the entrance area of the home and in each vacant bedroom ready for new occupants. The statement of purpose had Springfield Care Home DS0000002305.V373244.R01.S.doc Version 5.2 Page 11 recently been updated to include information on the new manager. A copy of this had been forwarded to the Commission for Social Care Inspection (CSCI). The manager confirmed that people’s needs were assessed before they moved into the home; to make sure these could be met. She said that she visited people in their own homes to gather relevant information. Relatives were always involved in the assessment as often people that may be moving into the home had communication difficulties. Pre admission assessments were seen in the three care plans checked. These had been fully completed and contained enough information to write a plan of care. Copies of social workers SNAP (Shared Nottingham and Nottinghamshire Assessment process) assessments were obtained where available so that all relevant information was provided. Copies of these were seen in the three care plans checked. People were able to visit the home before choosing to move in, meeting staff and other people living there, having a meal and seeing the accommodation. The manager spent some time during the site visit showing one family around the home. The relatives spoken with said that they had visited the home to look around before their loved one moved in. Springfield Care Home DS0000002305.V373244.R01.S.doc Version 5.2 Page 12 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. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9and 10 People who use the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Individual care plans ensured that people’s health needs were well met. Deficits in medication practices did not fully protect people. Peoples right to privacy was upheld so that they were respected. EVIDENCE: Three care plans were checked. These contained information on personal, social and health care needs. The staff spoken with were aware of the contents of care plans and were knowledgeable about peoples individual needs. However, the plans seen contained general statements such as ‘assist to wash and dress’ and did not describe the staff actions required to make sure individual needs and preferences were identified and met. Risk assessments Springfield Care Home DS0000002305.V373244.R01.S.doc Version 5.2 Page 13 had been undertaken and were included in the plans. Those seen were up to date and had been reviewed. The care plans seen had been reviewed on a monthly basis. Care staff wrote daily records in care plans. These recorded very brief information, which did not fully reflect peoples well being or events of the day so that staff were fully informed. People living at the home and their relatives spoken with felt that people were well looked after. Comments included; “Staff do a good job, we are not worried” “They are lovely, I’m taken care of” “They talk to me and keep us all happy” The care plans identified that a range of health professionals visited the home to assist in maintaining peoples health. Records showed that GP’s, dentists, opticians and chiropodists visited the home as requested. Medicines were securely stored in a locked trolley within a locked storeroom. The deputy manager confirmed that a pharmacist audited medication systems alongside internal monitoring to keep people safe. Senior staff administered medications. The manager confirmed that all staff that administered medication had been provided with training. Part of the morning and lunchtime medication round was observed; staff administered safely and observed people whilst they took their medication. Controlled drugs (CD) were kept at the home, appropriate CD storage and recordings were in place. Some procedures within the home did not fully protect people. Information on hand written MAR did not always correspond with the drugs held. Of the sample MAR checked, one medicine was recorded ‘one to be sucked slowly’. The medicine box stated’ ‘swallow whole, do not suck or chew’. A further MAR detailed that medication had been given in the mornings, whilst the medicine box stated administer at night. Two medicine boxes checked stated that tablets should be taken before or with a meal. This information had not been transferred to the MAR sheet. One MAR checked had not been fully completed, and had two gaps in the record where staff should have signed to say the medication had been administered, or refused. Staff spoken to were aware of the need to treat people with dignity and respect and were observed interacting in a friendly and pleasant way, and knocking on peoples doors before entering. Staff took time to chat and interact with people. Springfield Care Home DS0000002305.V373244.R01.S.doc Version 5.2 Page 14 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14 and 15 People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Peoples preferred lifestyles were respected so that they had choice. The provision of further social opportunities would improve this choice. A wholesome and appealing diet, in pleasant surroundings, was provided so that people could enjoy meals. EVIDENCE: The staff spoken with said that they organised all the activities. These included shopping, arts and crafts, theatre trips, and board games. The provision of activities depended on staff availability. However, it is acknowledged that an activity worker had recently been recruited to improve choice and free care staff for other duties. The activities worker would commence employment once all checks had been undertaken. Care staff had organised trips to the theatre over the next month and some people said that they were looking forward to this. During the afternoon of this visit, several Springfield Care Home DS0000002305.V373244.R01.S.doc Version 5.2 Page 15 activities took place, such as various board games. Staff encouraged people to participate but respected those that indicated they would prefer not to join in. The people spoken with confirmed that they could go to bed and get up when they chose to do so. People were seen spending time in their room as they wished. Staff confirmed that there was an open visiting policy; relatives and friends could visit the home at any time. Two relatives spoken with said that they were always made to feel welcome, and confirmed that they could visit at any time. People said the food was “Good”. The cook on duty explained that choices were always offered and snacks and drinks were always available. The kitchen was clean and well ordered. There were plentiful supplies of fresh fruit and vegetables for people to enjoy. Part of the mid day meal was observed. Staff were sitting with people and offering assistance in a quiet and dignified manner. The meal was not rushed so that people could enjoy this social opportunity. Whilst some people ate in the dining room on the lower ground floor, some people had their meals on table trays in the lounge. Staff stated that this was a matter of choice and individual preference. The manager stated that the menus had been reviewed so that more variety was available. Relatives spoken with said that the food preferred by their loved one was provided by the home. Springfield Care Home DS0000002305.V373244.R01.S.doc Version 5.2 Page 16 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. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People’s complaints were acted upon so they felt listened to. Some staff had not been provided with adult protection training so that people were fully protected. EVIDENCE: The home had a complaints procedure, which was provided in the service user guide and was seen on display throughout the home. This contained details of who to speak to at the home and who to contact outside of the home to make a complaint should people wish to do so. No complaints had been received since the last inspection. Staff spoken to were clear how to respond to and record any complaints received. An adult protection procedure was in place; the manager confirmed that these included local multi-agency and whistle blowing procedures so that full information was available. Some staff had undertaken formal training on adult protection, to equip them with the skills needed to respond appropriately to any allegations. However, the training matrix seen evidenced that only 33 percent of the staff team had been provided with this. It is acknowledged that Springfield Care Home DS0000002305.V373244.R01.S.doc Version 5.2 Page 17 the manager had booked further training events so that all staff had up to date knowledge to keep people safe. The staff interviewed could describe the different types of abuse and were clear about the action to take if an allegation was made or they suspected abuse. People spoken to said that they felt safe living at the home. Springfield Care Home DS0000002305.V373244.R01.S.doc Version 5.2 Page 18 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. JUDGEMENT – we looked at outcomes for the following standard(s): 19,20,21,22,23,24,25 and 26 People who use the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. On the whole, the home was well-maintained so that a comfortable place for people to live was provided. EVIDENCE: A partial tour of the environment was made. Accommodation was provided on three floors. The first floor comprised of bedrooms. The ground floor comprised of bedrooms, and two lounges. The lower ground floor comprised of the dining room, laundry and kitchen. A garden was provided for people to enjoy, which had seating and ornaments. Springfield Care Home DS0000002305.V373244.R01.S.doc Version 5.2 Page 19 Whilst the majority of the home appeared well maintained and well decorated, some chairs in communal lounges were old and worn. The paintwork on corridor areas was worn and chipped. The external window frames had old and chipped paintwork, which did not create a positive first impression. A longer timescale has been given to the requirement to replace window frames to acknowledge that this should be undertaken in milder weather for the comfort and consideration of people. All of the bedrooms seen were well personalised with peoples own belongings so that they had some control over their personal space. Whilst some bedrooms had new furniture that added to the appearance of the room, other bedrooms had old and worn furniture. Some bedrooms did not have a lockable facility to keep personal belongings safe. The bedrooms and stocks of bedding seen showed that all bedding was miss matched tired in appearance. Individual space would be further improved with the provision of new bedding. Sufficient toilets and bathrooms were provided, and aids were in place to met peoples needs. A full time housekeeper was employed. On the day of the inspection the home was clean and free from offensive odours. However, the housekeeper was the only domestic employed. Therefore levels of cleanliness would be difficult to maintain during her holidays or periods of sickness. Whilst redecoration and refurbishment clearly took place, this was done in a reactive manner, things were replaced and redecorated when worn. No refurbishment and redecoration plan was in place to ensure improvements to the environment were undertaken in a planned way. Springfield Care Home DS0000002305.V373244.R01.S.doc Version 5.2 Page 20 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. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29 and 30 People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Sufficient care staff were provided to meet peoples needs. Insufficient domestic staff were provided to ensure there was always domestic support. Staff training and recruitment procedures, on the whole, protected people. EVIDENCE: Staff rotas showed that there was sufficient staff employed to meet the needs of people. Staff said that there were usually enough staff on duty to meet peoples needs. However, only one domestic staff, a housekeeper, was employed. She worked full time and was at the home each weekday. The manager stated that a further domestic had been recruited to work part time at weekends. Recruitment checks were being undertaken prior to them commencing. Whilst the housekeeper is commended for maintaining cleanliness, further staff would ensure that domestic support is always available, for example in times of sickness and holidays. The manager stated that some care vacancies had recently been recruited to, and was waiting for completion of checks prior to staff commencing work. Staff said they worked well together as a team and enjoyed working at the home. Springfield Care Home DS0000002305.V373244.R01.S.doc Version 5.2 Page 21 The training records seen showed that new staff were provided with induction training to equip them with necessary skills to do their job. Training records seen showed that a planned programme of training in Dementia Awareness and Challenging Behaviour was in place for staff so that they had relevant skills. A programme of National Vocational Qualifications (NVQ) was available to staff. The AQAA stated that of the 15 care staff, 9 had achieved NVQ level 2 in care, and a further staff member was working towards this qualification. The deputy manager had achieved NVQ level 3 in Health and social care. Three records of employment were checked. These included some of the required information, verification of identity, references, certificates of training, and evidence of Criminal Records Bureau (CRB) checks. Whilst application forms recorded employment history, details of only the three previous jobs were requested, which did not provide a full history. One file checked had a gap in employment that had not been explained. Two records seen only gave the years of previous employment and did not supply full dates. Springfield Care Home DS0000002305.V373244.R01.S.doc Version 5.2 Page 22 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. JUDGEMENT – we looked at outcomes for the following standard(s): 31,33,35,36, and 38 People who use the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home was well managed so that people received consistent quality care. People were safeguarded by the financial procedures in operation. The health and safety systems, in the main, ensured people were kept safe. Gaps in staff training did not promote peoples welfare. EVIDENCE: Springfield Care Home DS0000002305.V373244.R01.S.doc Version 5.2 Page 23 Since the last inspection a new manager had been recruited. She had been in post since the 8th of October 2008. She had not yet applied to register as manager with the CSCI. The manager evidenced that she had identified issues and areas for improvement and was acting on these in priority. All of the staff spoken with said that the manager was approachable and listened. A quality assurance system was in operation. Surveys were given to people living at the home annually, to obtain their views. However, the results of these surveys needed to be published and made available to interested parties so that appropriate information was provided to them. The home handled money on behalf of some people. Three peoples financial records were checked. Spending money was available to people should they need it. The amounts kept tallied with the records and receipts were kept of each transaction to protect people. Formal staff supervision, to develop, inform and support staff had commenced. Whilst this improvement is acknowledged, staff were not receiving supervision at the recommended frequency to ensure they were fully supported. Staff meetings took place for staff development. Fire records seen and a tour of the environment evidenced that equipment at the home was serviced and maintained. Fire alarm checks took place each week to make sure they were in working order. However, some checks on the emergency lighting system had not taken place at the weekly frequency. Fire records showed that staff participated in fire drills so that they knew how to respond in an emergency. However, the records did not specify staff names so there was no system in place to make sure all members of staff participated in drills. The training records showed that 43 percent of staff had been provided with fire safety training. Training records seen showed that whilst some mandatory training was provided, not all staff had undertaken all aspects of mandatory training. Some staff required training in moving and handling, food hygiene, infection control and health and safety. A training matrix to monitor this had been developed by the manager so that training updates could be provided at relevant frequencies. It is acknowledged that the manager had organised some mandatory training events to address this issue. Springfield Care Home DS0000002305.V373244.R01.S.doc Version 5.2 Page 24 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 X 3 X 3 X HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 2 3 3 3 3 2 3 3 STAFFING Standard No Score 27 2 28 3 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 2 X 3 2 X 2 Springfield Care Home DS0000002305.V373244.R01.S.doc Version 5.2 Page 25 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 OP7 Regulation 15.Sch 3 Requirement Ensure remaining care plans are developed to have sufficient detail of care and support required and abilities of residents. Timescale extended (Previous timescale of 30/09/07 not met) 2 OP7 15 Care plans must contain specific information on the staff actions required to meet individual needs so that these can be met in a way that reflects people’s ability and preferences. Safe procedures for recording and administration of medication must be in operation to protect people. Drug labels and MAR must have corresponding information. Full instruction on administration must be recorded on MAR sheets. MAR sheets must be fully completed each time a Springfield Care Home DS0000002305.V373244.R01.S.doc Version 5.2 Page 26 Timescale for action 28/02/09 28/02/09 3 OP9 13 31/01/09 4 OP18 13 5 OP19 23 medication is administered. All staff must be provided with 28/02/09 adult protection training so that they have relevant knowledge to keep people safe. The home must be well 30/06/09 decorated and well maintained to provide a pleasant living space. All damaged and worn window frames must be replaced. The home must be well 31/03/09 decorated and well maintained to provide a pleasant living space. All worn chairs must be replaced. All worn bedroom furniture must be replaced. Worn paintwork on corridor areas must be redecorated. People must be provided with lockable storage in their rooms so that privacy is respected. Where this is not required, this must be recorded. Sufficient domestic staff must be employed to ensure cleaning staff are always available. A full employment history must be obtained and any identified gaps in employment must be explored so that full and safe procedures are adhered to. The manger must apply to register with the CSCI. The results of all surveys must be published and made available to people, so that they have access to this information. All staff must be provided with all aspects of mandatory training so that they have the skills to meet people’s needs. Staff must be up to date with; 6 OP19 23 7 OP24 23 28/02/09 8 9 OP27 OP29 18 18 28/02/09 31/01/09 10 11 OP31 OP33 8 24 31/01/09 28/02/09 12 OP38 18 28/02/09 Springfield Care Home DS0000002305.V373244.R01.S.doc Version 5.2 Page 27 Moving and handling Food hygiene Fire safety 13 OP38 13 Infection control training Procedures to check emergency systems must be adhered to so that risk is minimised and people are safe. 31/01/09 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 4 5 6 7 Refer to Standard OP7 OP12 OP36 OP19 OP24 OP29 OP38 Good Practice Recommendations Daily records should contain more detail so that a full picture of a person day and well being is available. Opportunities for further social activities should be made available to people to improve choice. Staff should be provided with individual supervisions a minimum of six times each year so that they are appropriately supported. A maintenance and redecoration plan should be developed so that a rolling programme is in place. All old and tired bedding should be replaced with matching sets to improve individual accommodation. Full dates of previous employment should be obtained so that any gaps can be identified. A system should be put in place to monitor fire drills so that all staff participate at regular intervals. Records of fire drills should detail the names of all participating staff to help monitor. A system to ensure mandatory training is provided at relevant frequencies should be developed to maintain staff skills. 8 OP38 Springfield Care Home DS0000002305.V373244.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Eastern Region Commission for Social Care Inspection Eastern Regional Contact Team CPC1, Capital Park Fulbourn Cambridge, CB21 5XE 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 Springfield Care Home DS0000002305.V373244.R01.S.doc Version 5.2 Page 29 - 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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