Inspection on 22/02/06 for Springfield Park Nursing Home

This inspection was carried out on 22nd February 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector 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 Park Nursing Home 25/02/09

Springfield Park Nursing Home 28/06/07

Springfield Park Nursing Home 14/09/05

Springfield Park Nursing Home 14/09/05

Springfield Park Nursing Home 08/03/05

Springfield Park Nursing Home 18/11/04

Springfield Park Nursing Home 29/07/03

Springfield Park Nursing Home 21/05/02

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

CARE HOME MIXED CATEGORY MAJORITY OLDER PEOPLE Springfield Park Nursing Home Springfield Park Bolton Road Rochdale Lancashire OL11 4RE Lead Inspector Diane Gaunt Unannounced Inspection 22nd February 2006 09:00 X10029.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 Park Nursing Home DS0000017329.V269835.R01.S.doc Version 5.1 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People and Care Homes for Adults 18 – 65*. 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 Park Nursing Home DS0000017329.V269835.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Springfield Park Nursing Home Address Springfield Park Bolton Road Rochdale Lancashire OL11 4RE 01706 646333 01706 523898 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) Mr Paul Mellor Mrs Jane Mellor Mrs Marylyn Beaumont Care Home 66 Category(ies) of Old age, not falling within any other category registration, with number (66), Physical disability (56), Terminally ill (4) of places Springfield Park Nursing Home DS0000017329.V269835.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. The home is registered for a maximum of 66 service users to include:up to 66 service users in the category of OP (Older People) up to 56 service users in the category of PD (Adults with Physical Disabilities under 65 years of age) up to 4 service users in the category of TI (Adults with Terminal Illness under 65 years of age) The bedrooms on the first floor are not to be used for category PD or for those requiring nursing care. The service should employ a suitably qualified and experienced Manager who is registered with the Commission for Social Care Inspection. 8th March 2005 2. 3. Date of last inspection Brief Description of the Service: Springfield Park is a large detached building that has been extensively extended and refurbished to a high standard. It is situated in parkland with easy access to public transport and the motorway network. The home is equipped to cater for male and female residents in sixty-six single en suite bedrooms. It is registered to care for people who require personal care and for people who have nursing needs. It is also registered to provide palliative care. The home does not admit people with an overt mental illness. The majority of the accommodation is on the ground floor. The home is suitably adapted for disabled access. Suitably qualified and experienced nurses, supported by trained care assistants, provide nursing care. Physiotherapy is provided, as is access to chiropody, dentists and opticians. There is a full time activities organiser who ensures that the social needs of the residents are met. Springfield Park Nursing Home DS0000017329.V269835.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection took place over a period of 7½ hours. Two inspectors and a pharmacy inspector spent time at the home looking at the building, paperwork about the running of the home and the care given. The home had not been told beforehand that the inspectors would visit. In order to find out more about the home inspectors spoke with thirteen residents, five relatives, one unit manager, 3 nurses, 5 care assistants, 2 domestics, the activities organiser, an administrator and the general manager. What the service does well: 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 Springfield Park Nursing Home DS0000017329.V269835.R01.S.doc Version 5.1 Page 6 contacting your local CSCI office. Springfield Park Nursing Home DS0000017329.V269835.R01.S.doc Version 5.1 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home Health and Personal Care Daily Life and Social Activities Complaints and Protection Environment Staffing Management and Administration Scoring of Outcomes Statutory Requirements Identified During the Inspection Older People (Standards 1–6) (Standards 7-11) (Standards 12-15) (Standards 16-18) (Standards 19-26) (Standards 27-30) (Standards 31-38) Adults 18 – 65 (Standards 1–5) (Standards 6, 9, 16 and 18–21) (Standards 7, 15 and 17) (Standards 22–23) (Standards 24–30) (Standards 31–35) (Standards 8, 10 and 37–43) Springfield Park Nursing Home DS0000017329.V269835.R01.S.doc Version 5.1 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 (Older People) and Standards 1 – 5 (Adults 18 – 65) are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. (YA NMS 1) Each service user has a written contract/ statement of terms and conditions with the home. Each Service User has an individual contract or statement of terms and conditions with the home. (YA NMS 5) No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Prospective Service Users’ individual aspirations and needs are assessed. (YA NMS 2) Service users and their representatives know that the home they enter will meet their needs. Prospective Service Users know that the home they choose will meet their needs and aspirations. (YA NMS 3) Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Prospective service users have an opportunity to “test drive” the home. (YA NMS 4) Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. 6. The Commission considers Standards 3 and 6 (Older People) and Standard 2 (Adults 18-65) the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): None of these standards were assessed on this occasion. EVIDENCE: Springfield Park Nursing Home DS0000017329.V269835.R01.S.doc Version 5.1 Page 9 Health and Personal Care The intended outcomes for Standards 7 – 11 (Older People) and Standards 6, 9, 16, 18 –21 (Adults 18-65) are: 7. The service user’s health, personal and social care needs are set out in an individual plan of care. Service Users know their assessed and changing needs and personal goals are reflected in their individual plan. (YA NMS 6) Also Service Users are supported to take risks as part of an independent lifestyle. (YA NMS 9) Service users’ health care needs are fully met. Service Users physical and emotional health needs are met. (YA NMS 19) 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, retain, administer and control their own medication where appropriate and are protected by the home’s policies and procedures for dealing with medicine. (YA NMS 20) Service users feel they are treated with respect and their right to privacy is upheld. Service Users rights are respected and responsibilities recognised in their daily lives. (YA NMS 16) Also Service Users receive personal support in the way they prefer and require. (YA NMS 18) Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The ageing, illness and death of a Service User are handled with respect and as the individual would wish. (YA NMS 21) 8. 9. 10. 11. The Commission considers standards 7, 8, 9 and 10 (Older People) and Standards 6, 9, 16, 18, 19 and 20 (Adults 18-65) are the key standards to be inspected at least once during a 12 month period JUDGEMENT – we looked at outcomes for the following standard(s): 7, 9 and 11(Older People) and 6, 20 and 21 (Adults 18-65) Residents and their relatives were consulted about required care, and improvement was noted with regard to their involvement in reviews to discuss changing care needs. Procedures were in place to facilitate the safe handling of medicines, but written assessment had not been completed for all selfadministration. With regard to terminal care, residents were confident their wishes were recorded and they would be carried out when they died. EVIDENCE: Seven care plans were inspected. Those relating to residents receiving nursing care were seen to be comprehensive, with excellent organisation of documentation. A comprehensive checklist completed on admission ensured Springfield Park Nursing Home DS0000017329.V269835.R01.S.doc Version 5.1 Page 10 all elements of care were addressed. The plans included full assessments and detailed care actions in relation to residents’ health, personal and social care. Individual preferences were recorded. The care plans were reviewed as and when necessary but at least on a monthly basis. There was clear evidence of resident and relative involvement in reviews. Improvement was noted with regard to care plans for those receiving personal care in the Beaumont Suite (1st floor of the home). The plans were more organised and detailed, and evidence that residents and some relatives had been involved in reviews was available. However, a relative who was actively involved in the care of a resident and visited the home almost daily had not been consulted or involved in reviews. In addition, feedback shared with the inspector by another resident had not been identified during recent review. This meant that these care plans did not contain all the up to date information in relation to these residents. Day to day management of the unit had been transferred to a nurse two weeks prior to the inspection and the above feedback was acknowledged and understood by her. Immediate action was taken to address the issue. Since working on the unit she had provided some training for carers regarding care plans and review, and intended to do so on an ongoing weekly basis. Whilst standard care plan formats were still in use on the unit, monthly internal reviews reflected individual approaches and were seen to describe the care that residents spoken with were currently receiving. Further improvement was seen with regard to risk assessments which had also been regularly reviewed and clearly described the up to date intervention needed. With regard to personal care on the 1st floor unit, one resident informed the inspector that weekly baths had not been provided. Records verified this and the inspector was informed this had occurred as a result of a misunderstanding of District Nurse advice. The unit manager was in the process of introducing twice weekly bathing for those who wanted it, and planned to monitor frequency of bathing on a weekly basis. Another instance of inconsistent care was with regard to the provision of supper, which two residents said was dependent upon which staff were on duty. Residents and relatives spoken with commented on the changes in staffing on this unit since the last inspection and expressed concern about the lack of consistency. However, they felt that recent changes were for the better and expressed satisfaction with current provision of care, hoping a stable staff team would now be maintained. Comprehensive policies and procedures describing the handling of medication within the home were available. These include a policy for self-administration. Following written assessment of safe self-administration one resident took complete responsibility for managing her own medication. But, where residents self-administer only an external preparation (e.g. cream) written assessment had not been competed. On the nursing floor qualified nurses administered all other medication; trained carers or qualified nurses Springfield Park Nursing Home DS0000017329.V269835.R01.S.doc Version 5.1 Page 11 administered medicines on the residential floor (Beaumont Suite). All staff handling medication were familiar with the homes medication policies and procedures and medication was securely stored. The pre-printed MARs were generally up-to-date throughout the home. However, the medication audit trail was incomplete, as comprehensive records of medication received into the home were not maintained. There was a policy in place to ensure that terminally ill residents were given care and comfort, and at death handled with due dignity and propriety. Residents’ wishes regarding terminal care and arrangements after death were discussed, usually with the representative, and carried out in accordance with their stated wishes. One resident said he had ‘talked to my family and the staff about dying and have been able to set my affairs in order, they all know what I want to happen if I pass away.’ Nursing staff ensured that appropriate attention and pain relief was administered and residents were able to spend their final days in their own rooms, unless there were strong medical reasons to prevent this. The general manager ensured that staff and residents who wished to offer comfort were enabled to do so. Relatives and friends of a resident who was dying were supported and able to stay with the resident as long as they wished. Information about individual resident choices and wishes regarding death and dying was recorded within their own care plan. A compliments file containing letters from relatives of residents who had died was looked at. Positive comments were made about the care given during this time and referred to ‘the excellent loving care’; ‘how extra caring all the staff were during the last weeks of mum’s life’; and the ‘support and understanding shown’ by the matron. Springfield Park Nursing Home DS0000017329.V269835.R01.S.doc Version 5.1 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 (Older People) and Standards 7, 11– 15 and 17 (Adults 18-65) are: 12. 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 have opportunities for personal development. (YA NMS 11) Also Service Users are able to take part in age, peer and culturally appropriate activities. (YA NMS 12). Also Service users engage in appropriate leisure activities. (YA NMS 14) Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service Users are part of the local community. (YA NMS 13) Also Service Users have appropriate personal, family and sexual relationships. (YA NMS 15) Service users are helped to exercise choice and control over their lives. Service Users make decisions about their lives with assistance as needed. (YA NMS 7) Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. Service Users are offered a healthy diet and enjoy their meals and mealtimes. (YA NMS 17) 13. 14. 15. The Commission considers standards 12, 13, 14 and 15 (Older People) and Standards 12, 13, 15 and 17 (Adults 18-65) the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13 and 14 (Older People) and 12, 13 and 15 (Adults 18-65) The range of leisure activities available in the home was varied, reflecting the diversity of residents and their social, intellectual and physical capacities. Links with the community were good and the home valued the role which relatives and friends continued to play in the lives of residents. Residents benefited from being able to exercise choice and control over their lives. EVIDENCE: Residents’ involvement in social activities varied greatly according to their interests, abilities and needs. The home employed an activities person who was described by one resident as ‘an absolute pearler’. He organised events and activities within the home as well as trips out to various places of interest. The programme of activities was displayed in the reception area and in other Springfield Park Nursing Home DS0000017329.V269835.R01.S.doc Version 5.1 Page 13 strategic places throughout the home, so that residents were aware of what was ‘going on’. They were also detailed in the monthly newsletter, a copy of which was given to each resident. Apart from details about games, quizzes and activities it also gave information about how often religious services would be held and when the mobile library would be calling at the home. Minutes of the last residents meeting were also included. Residents and relatives on the ground floor unit all praised the efforts of the activities person and some highlighted the weekly yoga sessions and art classes as particularly enjoyable. One resident commented on the confidence the artist gave ‘through his calm and encouraging manner’ and considered the classes also gave the opportunity “to talk about things that bother you in a safe and relaxed manner’. The day before the inspection thirteen residents had been taken to Rivington Barn, in Bolton, for a meal and concert. Three residents who had been said how much they enjoyed the day. Some residents spoken with preferred to stay in their own bedrooms and enjoyed reading, listening to music and watching the television. They were encouraged to join in activities but did not always choose to do so. This was particularly so on the 1st floor unit where inspection of care plans showed that past and present interests and hobbies had not always been identified or discussion held as to how best social needs could be met. Residents did however enjoy one to one contact with staff and the unit manager may wish to consider more involvement of the activities organizer on the 1st floor or extension of the keyworker role to include one to one time. Visitors said they were made very welcome and inspectors observed a large number of visitors coming and going freely. They related to the management and staff in a friendly way, one relative who visited daily spoke very highly of the staff and the care they provided. The choices residents made each day varied, dependent upon their mental frailty but residents generally chose what time to get up, go to bed, what clothes to wear, where to spend their day, what food to eat, whether to participate in activities. The home was only directly involved in management of approximately 15 residents’ finances, the majority having chosen to manage their own affairs of have them managed by relatives or solicitors. Residents said they were given the choice of whether they wished to have the key to their room and lockable space. Overall, residents considered they were encouraged to do what they could for themselves and make appropriate choices through the day. Information about advocacy services was available at the home. The general manager was also aware of new initiatives to be introduced locally, and was planning to inform residents of these services as soon as they became operational. Residents were registered for postal votes which some chose to use. Springfield Park Nursing Home DS0000017329.V269835.R01.S.doc Version 5.1 Page 14 Complaints and Protection The intended outcomes for Standards 16 – 18 (Older People) and Standards 22 – 23 (Adults 18-65) 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 feel their views are listened to and acted on. (YA NMS 22) Service users’ legal rights are protected. Service Users are protected from abuse, neglect and self-harm. (YA NMS 23) Service users are protected from abuse. Service Users are protected from abuse, neglect and self-harm. (YA NMS 23) The Commission considers standards 16 and 18 (Older People) and Standards 22 and 23 (Adults 18-65) the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 (Older People) and 22 and 23 (Adults 18-65) Residents and relatives were aware of who to contact if they had a complaint and expected they would be listened to, taken seriously and acted upon. Appropriate systems were in place to protect residents from abuse, including staff training. EVIDENCE: The home had a complaints procedure. It was on the notice board in the entrance area and included in the Statement of Purpose and Service User Guide, copies of which were provided in each bedroom. Complaints investigated by the manager were recorded in a complaints file, along with detail of the investigation. Inspection of the complaints file showed that four had been investigated since the last inspection and, when substantiated, satisfactory action had been taken. The CSCI had investigated one complaint since the last inspection, it was not upheld. Residents and relatives spoken with had not made any complaints about the service but said they would speak to a senior staff member or the general manager if they had any to make. A procedure for responding to allegations of abuse was available, as was the Rochdale Inter-Agency Protection of Vulnerable Adults (POVA) procedure. Policies and procedures in relation to management of physical and verbal aggression, and residents’ money and valuables supported these procedures. Springfield Park Nursing Home DS0000017329.V269835.R01.S.doc Version 5.1 Page 15 Further comment regarding management of residents’ money is made in the Management and Administration section below (Standard 35). All staff members had received POVA training and those spoken with understood the importance of reporting malpractice. Residents interviewed said they felt safe living at Springfield Park. Springfield Park Nursing Home DS0000017329.V269835.R01.S.doc Version 5.1 Page 16 Environment The intended outcomes for Standards 19 – 26 (Older People) and Standards 24 – 30 (Adults 18-65) are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service Users live in a homely, comfortable and safe environment. (YA NMS 24) Service users have access to safe and comfortable indoor and outdoor communal facilities. Shared spaces complement and supplement service users’ individual rooms. (YA NMS 28) Service users have sufficient and suitable lavatories and washing facilities. Service Users toilets and bathrooms provide sufficient privacy and meet their individual needs. (YA NMS 27) Service users have the specialist equipment they require to maximise their independence. (YA NMS 29) Service users’ own rooms suit their needs. Service Users’ own rooms suit their needs and lifestyles. (YA NMS 25) Service users live in safe, comfortable bedrooms with their own possessions around them. Service users’ bedrooms promote their independence. (YA NMS 26) Service users live in safe, comfortable surroundings. Service Users live in a homely, comfortable and safe environment. (YA NMS 24) The home is clean, pleasant and hygienic. The home is clean and hygienic. (YA NMS 30) The Commission considers standards 19 and 26 (Older People) and Standards 24 and 30 (Adults 18-65) the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19 and 26 (Older People) and 24 and 30 (Adults 18-65) A safe, clean, pleasant, hygienic and well- maintained building was provided for residents. EVIDENCE: A tour of the home confirmed that the home was well maintained, clean and free from any offensive odours. Ramped access was provided to the front door and level access throughout each of the two floors. A passenger lift was provided and handrails fitted to corridors throughout. Everyone spoken with thought the home was a safe place to live and work in. Springfield Park Nursing Home DS0000017329.V269835.R01.S.doc Version 5.1 Page 17 The home had a planned maintenance and renewal programme for the redecoration and refurbishment of the home. A maintenance worker and decorator were employed and staff and residents said they addressed matters as they were raised with them. Cyclical maintenance ensured the home was comfortable, clean and safe. Grounds were seen to be safe, tidy and accessible. Residents said they looked forward to sitting outside in the good weather. The Environmental Health Department had undertaken a food inspection in May 2005. Requirements and recommendations had been met in June 2005. Twelve residents spoken to were very pleased with their individual rooms and said that they had ‘brought in a number of personal possessions to make them feel more homely’. All bedrooms were fitted with door locks and lockable storage space to ensure resident’s valuables were kept safe. Staff have a master key, which could be used to gain access in an emergency. Residents said staff kept the building clean and odour free, inspection of the premises supported this view. Discussion with two domestics verified that sufficient staff and equipment were provided to ensure the home was maintained in a clean and hygienic condition. An infection control policy was in place and training was provided in this area. Staff spoken with described safe infection control practice. Disposable gloves and colour-coded aprons were provided for staff use and liquid soap was available throughout. Satisfactory practice was in place with regard to disposal of clinical waste. The laundry was sited away from the food preparation area and was seen to be clean and orderly. Sufficient and suitable equipment was provided and laundry was attended to efficiently. Five residents said that they were satisfied with the laundry system at the home and that there was a quick turn around on the clothes sent for cleaning. One relative said that she took some of her relatives clothes home to wash, but this was a personal decision and not due to any concerns over the service provided by Springfield Park. Springfield Park Nursing Home DS0000017329.V269835.R01.S.doc Version 5.1 Page 18 Staffing The intended outcomes for Standards 27 – 30 (Older People) and Standards 31 – 35 (Adults 18-65) are: 27. 28. 29. Service users needs are met by the numbers and skill mix of staff. Service users are supported by an effective staff team. (YA NMS 33) Service users are in safe hands at all times. Service Users are supported by an effective staff team. (YA NMS 32) Service users are supported and protected by the home’s recruitment policy and practices. Service Users benefit from clarity of staff roles and responsibilities. (YA NMS 31) Also Service Users are supported and protected by the home’s recruitment policy and practices. (YA NMS 34) Staff are trained and competent to do their jobs. Service Users individual and joint needs are met by appropriately trained staff. (YA NMS 35) 30. The Commission considers standards 27, 28, 29 and 30 (Older People) and Standards 32, 34 and 35 (Adults 18-65) the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 28 and 29 (Older People) and 31, 32 and 34 (Adults 18-65) Recruitment and selection procedures were satisfactory, safeguarding residents living at the home. Provision of ongoing training both external and in-house provided a trained and competent workforce who were both motivated and knowledgeable. EVIDENCE: A trained workforce of care staff supported the registered nurses working at the home. Seven staff had an NVQ level 3, and nineteen had an NVQ level 2. Ten carers were undertaking the NVQ level 2 at the time of the inspection, leaving only 3 without an NVQ qualification. Of these 3, one had another relevant qualification, one was due to start NVQ level 2 in September 2006 and the other was undergoing foundation training. An induction and foundation course, which met National Training Organisation (NTO) specification, was provided for new members of staff. All new members of staff were supervised throughout the induction period. The home had a comprehensive recruitment policy and procedure. Inspection of three staff files showed that the registered manager followed the procedure, Springfield Park Nursing Home DS0000017329.V269835.R01.S.doc Version 5.1 Page 19 and ensured the interview process, POVA/Criminal Record Bureau (CRB) checks, written references, health checks and past work history were all obtained and satisfactory before the person started work. One staff member whose file was looked at is from another country and had undergone all checks necessary for foreign workers including work permits, passport and immunisation records. Nurses at the home maintained periodic registration with the Nursing and Midwifery Council to ensure they are able to practice. Springfield Park Nursing Home DS0000017329.V269835.R01.S.doc Version 5.1 Page 20 Management and Administration The intended outcomes for Standards 31 – 38 (Older People) and Standards 8, 10, 23, 37 – 43 (Adults 18-65) are: 31. 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 a well run home. (YA NMS 37) Service users benefit from the ethos, leadership and management approach of the home. (YA NMS 38) The home is run in the best interests of service users. Service Users are consulted on and participate in, all aspects of life in the home. (YA NMS 8) Also Service Users are confident their views underpin all selfmonitoring, review and development by the home. (YA NMS 39) Service users are safeguarded by the accounting and financial procedures of the home. Service Users benefit from competent and accountable management of the service. (YA NMS 43) Service users’ financial interests are safeguarded. Service Users are protected from abuse, neglect and self-harm. (YA NMS 23) Staff are appropriately supervised. Service Users benefit from well supported and supervised staff. (YA NMS 36) Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. Service Users know that information about them is handled appropriately, and that their confidences are kept. (YA NMS 10) Also Service Users rights and best interests are safeguarded by the home’s policies and procedures. (YA NMS 40) and (YA NMS 41) The health, safety and welfare of service users and staff are promoted and protected. The health, safety and welfare of service users and staff are promoted and protected. (YA NMS 42) 32. 33. 34. 35. 36. 37. 38. The Commission considers standards 31, 33, 35 and 38 (Older People) and Standards 37, 39 and 42 (Adults 18-65) the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33 and 35 (Older People) and 37 and 39 (Adults 18-65) The registered manager discharged her responsibilities fully, ensuring residents’ needs were met and their financial interests safeguarded. The home regularly reviewed aspects of its performance through self-review and consultation, which included seeking the views of residents, staff and relatives. EVIDENCE: Springfield Park Nursing Home DS0000017329.V269835.R01.S.doc Version 5.1 Page 21 The manager holds the Registered Manager’s Award (RMA) and is registered with the CSCI. She is a registered nurse with vast experience in private and NHS services. She had experience in community, hospital, residential and educational services and had many years of management experience. She had obtained teaching and NVQ assessing qualifications and was actively involved in teaching and assessing at Springfield Park. In addition she ensured her own training was regularly updated and had recently completed a coaching and mentoring course. From talking to staff and inspecting records, it was evident that the manager actively promoted staff training and development opportunities. The home did not act as appointee for any residents. However, they did manage the personal allowances of a number of residents. Records in relation two residents were inspected. It was noted that receipts were not kept for all transactions e.g. internet shopping, purchases from the home; and in one instance an inaccurate amount had been entered on the record and not noticed on verification. Banked monies were held in a pooled residents account. Whilst in-house records showed the total amount held for each resident, bank statements did not provide this detail. With the exception of one resident who wished to have more detail of his personal finances, residents and relatives interviewed were happy with the arrangements regarding personal monies. The administrator said she would respond to this residents’ wish. The home had an accredited quality assurance system. Resident and relative meetings were held on a regular basis and minutes circulated to people living in the home. Staff had meetings with the matron and manager and everyone was encouraged to join in with discussions and voice their opinions. Residents and staff agreed that they were able to express ideas, criticisms and concerns without prejudice. The management team were said to take action where necessary to bring about positive change. In addition to meetings, feedback was sought from the residents and relatives through satisfaction questionnaires, which were issued regularly on a random basis. Policies and procedures were up dated and reviewed as an ongoing practice and action is being taken to ensure the requirements of the inspection reports were met within timescales. The general manager also completed in-house audits of the home and its service on a monthly basis. The matron had a system to review how the home met National Minimum Standards, addressing an average of three standards each month. The CSCI was regularly informed of notifiable incidents at the home within 24 hours of their occurrence. However, it was noted one such incident had not been notified. This matter was addressed when raised with the general manager. Springfield Park Nursing Home DS0000017329.V269835.R01.S.doc Version 5.1 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 Standard No Score 1 X 2 X 3 X 4 X 5 X 6 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 X 9 2 10 X 11 4 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 X COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 ENVIRONMENT Standard No Score 19 4 20 X 21 X 22 X 23 X 24 X 25 X 26 3 STAFFING Standard No Score 27 X 28 4 29 3 30 X MANAGEMENT AND ADMINISTRATION Standard No Score 31 3 32 X 33 3 34 X 35 3 36 X 37 X 38 X Springfield Park Nursing Home DS0000017329.V269835.R01.S.doc Version 5.1 Page 23 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 Standard OP9 Regulation 13 Requirement The registered person must ensure that all medication records including those for: receipt and for the assessment of self-administration are complete, clear, accurate and up-to-date. Timescale for action 03/04/06 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. 2. 3. 4. Refer to Standard OP7 OP9 OP9 OP9 Good Practice Recommendations Relative/resident involvement in care planning and reviews should be further developed. Consideration should be given to the implementation of the homely remedies policy Consideration should be given to the inclusion of dividers and photographs within the MARs file. Advice should be sought regarding the denaturing of controlled drugs for disposal. 5 OP12 Care plans on the 1st floor residential unit should record residents’ past and present interests in order to ensure provision of suitable activities. Springfield Park Nursing Home DS0000017329.V269835.R01.S.doc Version 5.1 Page 24 6 OP35 Whenever possible, receipts should be held for all financial transactions undertaken on behalf of residents. Springfield Park Nursing Home DS0000017329.V269835.R01.S.doc Version 5.1 Page 25 Commission for Social Care Inspection Bolton, Bury, Rochdale and Wigan Office Turton Suite Paragon Business Park Chorley New Road Horwich, Bolton BL6 6HG 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 Park Nursing Home DS0000017329.V269835.R01.S.doc Version 5.1 Page 26 - 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. 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