Inspection on 14/09/05 for Springfield House

This inspection was carried out on 14th September 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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Springfield House 30/01/07

Springfield House 21/03/06

Springfield House 23/02/05

Springfield House 22/09/04

Springfield House 04/03/04

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Larchfield Manor

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

CARE HOMES FOR OLDER PEOPLE Springfield House Springfield Avenue Morley Leeds LS27 9PW Lead Inspector Stevie Allerton Announced 14 September 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 House 20050914 Springfield House AN Stage 4 S1507 V200586 J52.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Springfield House Address Springfield Avenue Morley Leeds LS27 9PW 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 2521969 0113 2521969 Mrs Susan Elizabeth Hart Care Home Only 22 Category(ies) of Old Age (22) Mental Disorder Over 65 (6) registration, with number of places Springfield House 20050914 Springfield House AN Stage 4 S1507 V200586 J52.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: None Date of last inspection 23.2.05 Brief Description of the Service: Springfield House provides accommodation for up to 22 older people who are in need of personal care rather than nursing care. It was first established in 1985 by the owner and her late husband and has always been managed by the owner. The home is a large, stone-built detached property which stands in its own grounds, situated in a quiet residential area of Morley, on the outskirts of Leeds. It is fairly close to shops and public transport links into Morley town centre and to Leeds. The original house had a large ground floor extension added in the late 1990’s, constructed in stone to blend in with the original building. The home now provides 18 single bedrooms in total (9 with en-suite facilities) and 2 doubles (1 with en-suite). Communal living space is in four large rooms on the ground floor of the original house, providing flexible dining and sitting arrangements. Many of the service users are from the local area, which enables them to maintain contacts within the community. Springfield House 20050914 Springfield House AN Stage 4 S1507 V200586 J52.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was announced in advance and was carried out by one inspector over one whole day. Pre-inspection material, including posters announcing the inspection and comment cards, had been sent to the home in advance, so that preparations could be made and service users, relatives and staff could be informed of the date. A selection of the National Minimum Standards were examined, in relation to measuring the outcomes for service users, how well their needs are being met. Three service users were selected to be case-tracked, their care plans examined in depth and discussions held with them about their care. Other service users were also spoken to in the communal lounges during the course of the day. Staff of various job roles were also spoken to, as were some visitors. Some records, policies and procedures were looked at, but a full tour of the building did not take place during this visit. What the service does well: What has improved since the last inspection? There has been an improvement in staff accountability and the development of the seniors, particularly the arrangements for the management of the home at weekends when the registered provider is not around. Springfield House 20050914 Springfield House AN Stage 4 S1507 V200586 J52.doc Version 1.40 Page 6 Staff supervision is now underway, with formal one-to-one meetings taking place every three months at present. The results of the quality survey have led to some improvements in day-to-day practice and increased personal choice, for example, the timing of staff assistance with personal care. Work has continued to upgrade the existing fire safety precautions to current day standards. Record keeping has continued to improve. An example of this was seen in the accident records, which now contain much more detail about follow-up attention or treatment. These are also now analysed regarding the times and types of accident that occur, to highlight risk areas. 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 House 20050914 Springfield House AN Stage 4 S1507 V200586 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 House 20050914 Springfield House AN Stage 4 S1507 V200586 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 & 4 The home makes every effort to ensure that service users have the information they need before coming into the home. The standard of written information is good and the home is very flexible about pre-admission visits, to fit in with the needs and preferences of the individual. The home is careful to obtain sufficient assessment information about prospective service users, so as to inform them of likely care needs. EVIDENCE: The home has a comprehensive Statement of Purpose and Service user Guide, which is kept in a folder in the hallway for ease of reference. This outlines what the home can provide and how it intends to achieve that. It is written in plain English and can be readily understood. One of the most recently admitted service users described how her family had been for visits and obtained information on her behalf, before she came for a trial visit herself. She felt reassured through the whole admission process, particularly as she felt the home had a good reputation locally. She felt her care and support needs, as assessed in hospital, were being met very well. Springfield House 20050914 Springfield House AN Stage 4 S1507 V200586 J52.doc Version 1.40 Page 9 A service user currently in hospital was discussed with the Manager and other staff, regarding specific care needs and the difficulty staff had in meeting them. It was clear that a careful re-assessment would be taking place when discussing a possible return to the care home, to ensure that staff had the equipment and skills to meet those care needs. Springfield House 20050914 Springfield House AN Stage 4 S1507 V200586 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 Care plans are clear and concise and enable staff to understand what service users need assistance with, although they are not reviewed as often as they ideally should be, to pick up and respond to changes in care need. There is good attention to meeting health care needs and service users are treated with respect. There are safe systems in place for the storage, administration and recording of medicines within the home, also for those who look after their own medication. EVIDENCE: Care plans for three service users were looked at in depth, the findings confirmed by discussion with those individuals about their care, or with staff delivering the care. Where a need had been identified for specific equipment to promote independence, for example, this could be seen in place in the service user’s room. Service users also confirmed that what was written in care plans, was what was being provided. For example, preferring to eat meals in private, or the frequency of night checks by staff. Some of the care plans were not being Springfield House 20050914 Springfield House AN Stage 4 S1507 V200586 J52.doc Version 1.40 Page 11 reviewed as often as is ideal to meet the standards, i.e. once every 4 – 6 months, instead of monthly. Throughout the day, it could be seen that care and other support staff were respectful of privacy, always knocking before entering bedrooms or asking if it was alright with the service user to do housekeeping tasks, for example. Service users were satisfied with the arrangements for GP visits, dentists, opticians and chiropody (the chiropodist was visiting on the day of inspection). One service user said that she had been feeling unwell during the night, but was reassured by the night staff checking regularly on her. She was confident that if she requested, her GP would be called. The medication system was examined, the Assistant Manager outlining the procedure in place. The home uses a pre-dispensed blister pack system provided by the local pharmacist each month. Storage facilities are secure and the accompanying record sheets appeared to have been accurately completed. There is a list of staff that have been trained to administer the prescribed medication, either through a formal training course or by in-house training and supervision. Springfield House 20050914 Springfield House AN Stage 4 S1507 V200586 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, 14 & 15 There is a varied programme of organised activities that provide service users with opportunities to mix socially, or enjoy some one-to-one time with staff. The home encourages visitors, which also enhance service users’ social opportunities. The atmosphere in the home encourages service users to make their own choices about daily life, where to spend the day, whether to join in with activities, where to eat, etc. The quality of the meals at the home is very good and service users enjoy the food. EVIDENCE: Service users spoke to the inspector about daily life in the home. It was apparent that there was something “organised” nearly every day, that they could take part in if they wished. Those who prefer a more private social life said they did not feel under pressure to “join in” if they did not want to. There was praise for the activities co-ordinator, who seemed to be very popular. Her activity diary was seen and found to be very informative, being not only a record of what was done, but also who took part and how they responded to it. It was clear that individual chats and one-to-one time took Springfield House 20050914 Springfield House AN Stage 4 S1507 V200586 J52.doc Version 1.40 Page 13 place, as well as group activities such as cards, dominoes, flower arranging, bingo and trips out. A registered PAT dog pays visits, very much appreciated by those who had owned pets in the past. A holiday took place earlier this year, in a selfcatering facility near Skipton, for 8 service users and as many staff/volunteers. The photographs of this holiday (and other trips) were displayed in the hall and are still a source of conversation amongst those who went. The three service users who were case-tracked were spoken to in their own rooms, all of which were arranged differently, according to the individual’s taste and care needs. They spoke about their own space and how they had decided what personal possessions they needed to bring. When asked about daily life, they all expressed satisfaction with the home, particularly the “home from home” atmosphere. It was evident that they all enjoyed passing the time in different ways and were still able to do this. There were very good comments once again about the food and it was clear that the home cooking was appreciated. A food committee has been set up, comprising the cook and other members of the staff team. They have developed some questionnaires, established service users’ likes and dislikes, gained some suggestions for favourite recipes and give out feedback sheets to any visitors that have a meal. The cook also said that service users will tell her if they haven’t enjoyed a meal. Springfield House 20050914 Springfield House AN Stage 4 S1507 V200586 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 Service users are protected from possible abuse and concerns and complaints are handled appropriately. EVIDENCE: Two of the senior staff have recently attended an Adult Abuse training course run by Leeds Social Services Adult Protection Unit. This has provided them with some material to use within the home, both to raise awareness in the staff team and to link in with their existing Adult Protection policy. An inhouse course has been planned for October and the care staff seem keen to attend. Service users said they felt confident to raise any concerns directly with the staff and it was evident that visitors also knew about the complaints procedure and how that worked. Springfield House 20050914 Springfield House AN Stage 4 S1507 V200586 J52.doc Version 1.40 Page 15 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, 23, 24 & 26 The registered provider continually looks at ways of improving facilities for service users. The home is well maintained, decorated and furnished and provides a comfortable environment, inside and outside. There is good attention to hygiene and cleanliness throughout. EVIDENCE: On a brief tour of the ground floor, the registered provider described the outstanding fire safety work that had been completed and what was still left to do (an extra fire door to be fitted in the extension corridor). Plans to create some more en-suite facilities upstairs are still in the discussion stage. Future work to be done next includes the refurbishment of the dining room and resurfacing the car park. The grounds provide an interesting and level tour round the garden, service users making use of the handrail and level pathway to enjoy a trip round to sit on the seat under the big tree. Even those who cannot get outside so easily Springfield House 20050914 Springfield House AN Stage 4 S1507 V200586 J52.doc Version 1.40 Page 16 can enjoy the garden from their room windows; one lady’s family had bought her a bird table that was sited so that she could view it from her chair. The ground floor bedrooms have en-suite facilities and the rooms are sufficiently large to allow the use of the hoist for moving immobile service users. The service users appear to have as good a relationship with the domestic staff as they do the care staff; the person doing the cleaning that day was heard to knock on doors and ask permission to vacuum, etc., and the service users were heard to call her by name. There was a good level of cleanliness seen throughout the home, with appropriate protective equipment (gloves, aprons, etc.) available for the staff. Springfield House 20050914 Springfield House AN Stage 4 S1507 V200586 J52.doc Version 1.40 Page 17 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, 29 & 30 The staffing rotas reflect the needs of the service users at the current time. Staff have appropriate training and supervision to do their jobs and have a good attitude towards the service users. Recruitment procedures follow good practice guidelines. EVIDENCE: The inspector had a joint discussion with the registered provider (also Manager), the Care Manager, the Assistant Manager and two senior carers that take responsibility as shift leaders, one of whom covers the weekends. There are clear lines of accountability at all times now. The development of the weekend manager post was said to have been beneficial to visitors, knowing who to ask about their relative’s condition, etc., and there has been good feedback from visitors about this. There are effective mechanisms in place for the handover of information between shifts, so that each team leader in charge is apprised of recent events as they take over each shift. A senior staff meeting also takes place once a month. Handover sheets were seen, which outlined tasks and areas of responsibility for each shift, who they had been delegated to, etc., as well as noting changes in service users’ condition to pass on to the next shift. The Assistant Manager has responsibility for the staff rota, which is planned a week ahead. Some staff have their own set hours, but others work flexibly Springfield House 20050914 Springfield House AN Stage 4 S1507 V200586 J52.doc Version 1.40 Page 18 around them. The home has their own bank of casual staff that they use to fill in for absences, rather than use agency staff. The recruitment records were seen for the newest member of staff. These contained a completed application form, two written references (which had also been verified by telephone) and evidence that Criminal Bureau Checks had been carried out. Some advice was given to the Care Manager regarding the checking of a person’s identification and how to record this better. The member of staff had had a 3 day induction to the routines of the home and it was intended to put her through the TOPSS induction and foundation standards, even though she was very experienced in care work. Some staff training records were seen, which showed that 10 staff had recently done a First Aid course, one of the seniors had been on an accredited Medication course and two had attended training on Adult Protection. NVQs (National Vocational Qualifications) were discussed; staff expressed frustration at the lack of external assessors, which has meant their work has had to be put on hold. Some of the staff are keen to complete level 2 so they can go on to level 3, and the Care Manager and Assistant Manager are looking for a provider that can take them through level 4. Once the existing staff have had their work verified and completed level 2, the home will have achieved 50 of the staff qualified. A programme of staff supervision has commenced, which offers 3 monthly one-to-one time with either the Care Manager or Assistant Manager, discussing such things as the home’s policies, working in a team, training needs and Health and Safety. Springfield House 20050914 Springfield House AN Stage 4 S1507 V200586 J52.doc Version 1.40 Page 19 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) 32, 33, 36 & 37 The home is managed with an open and inclusive approach, in which service users and their relatives are encouraged to be involved. Record keeping continues to improve, providing better evidence that service users are being safeguarded. EVIDENCE: On entrance to the home, the impression is one of active involvement. There is information posted in the hall, photographs of events and the day’s menu and activities on display. A new addition is an information board with photographs and names of all of the staff team, with information about who is on duty that day. There is also an “employee of the month” scheme, where service users vote for the member of staff that has had the most impact on them. Springfield House 20050914 Springfield House AN Stage 4 S1507 V200586 J52.doc Version 1.40 Page 20 The Assistant Manager has continued to distribute her Quality Assurance questionnaires, to service users, staff, relatives and visiting professionals, such as GPs and Social Workers. She felt the return rate had been disappointing, but had collated the responses and found some interesting parallels; an action plan was developed to address the issues raised, which is ongoing. A selection of statutory and operational records were inspected, which included: service users’ care plans; accident records; medication records; staff personnel and training records; activities records and the results of the quality survey. Records were generally quite well maintained, information was easy to access and most of the records seen appeared to be up to date. There was a query about the hard-wiring certificate, which at 5 years old may be out of date, and also some of the care plan reviews, which were not being updated as frequently as necessary. There was also a minor omission in the records being kept about staff working in the home. Springfield House 20050914 Springfield House AN Stage 4 S1507 V200586 J52.doc Version 1.40 Page 21 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 3 x N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 3 14 3 15 3 COMPLAINTS AND PROTECTION 2 3 x x 3 3 x 3 STAFFING Standard No Score 27 3 28 x 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x 3 x 4 3 x x 2 2 x Springfield House 20050914 Springfield House AN Stage 4 S1507 V200586 J52.doc Version 1.40 Page 22 NO 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. 2. 3. Standard 19 36 37 Regulation 23(4) 18(2) 19(4)(b) Requirement The building must comply with the recommendations of the Fire Officer. Care staff must receive formal supervision at least 6 times a year. The employer must obtain proof of identity when recruiting staff, and keep records demonstrating that this has been done. Service users care plans must be reviewed at least once a month. The registered person must be able to demonstrate that the electrical hard wiring is in a safe condition. Timescale for action By 1.4.06 By 1.4.06 By 1.4.06 4. 5. 7 & 37 38 15(2) 23(2)(b) By 1.1.06 By 1.4.06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard Good Practice Recommendations Springfield House 20050914 Springfield House AN Stage 4 S1507 V200586 J52.doc Version 1.40 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 House 20050914 Springfield House AN Stage 4 S1507 V200586 J52.doc Version 1.40 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. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!