Inspection on 19/08/05 for Springfield Residential Care Home

This inspection was carried out on 19th August 2005.

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

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Springfield Residential Care Home 24/09/08

Springfield Residential Care Home 27/11/06

Springfield Residential Care Home 20/02/06

Springfield Residential Care Home 19/10/04

Springfield Residential Care Home 17/06/04

Similar services:

Claremont House

Oak Ridge

Sun Court Nursing Home

Ashville House

Bilney Hall

Hill Barn

Mabbs Hall Nursing Home

Henrietta House

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

CARE HOMES FOR OLDER PEOPLE Springfield Residential Care Home 63 The Causeway March Cambridgeshire PE15 9NY Lead Inspector Matthew Bentley Unannounced 19 August 2005 @ 13:00 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 Residential Care Home I03 I53 s37329 SPRINGFIELD v241558 020805 STAGE 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Springfield Address 63 The Causeway March Cambridgeshire PE15 9NY 01354 652451 01354 652451 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) Orchid Care Homes Ltd Mrs Carole Wood Care Home 29 Category(ies) of Dementia - over 65 years of age (29), Mental registration, with number Disorder, excluding learning disability or of places dementia - over 65 years of age (29), Old age, not falling within any other category (29) Springfield Residential Care Home I03 I53 s37329 SPRINGFIELD v241558 020805 STAGE 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: None Date of last inspection 19th October 2004 Brief Description of the Service: Springfield provides accommodation, care, and support for up to 29 older people including those with dementia or a mental disorder. The home is a large detached property near to the centre of March. The building has been extended and equipped to meet the needs of older people, some of whom may have difficulty with mobility. Accommodation is on two floors, the upper floor being accessed via a stair lift. The home has 25 single and 2 double rooms; four bedrooms have en suite facilities. Service users have access to 8 toilets and there are 4 bathrooms, though a number are unsuitable for their purpose and the proprietor plans to remove one bath and provide a walk-in shower. Shared accommodation comprises 4 sitting rooms and 3 dining areas. There is a large well-maintained garden, which is enclosed and suitable for the needs of older people. Care staff are employed to support service users by day, and two waking staff are on duty overnight in case help is needed. Springfield Residential Care Home I03 I53 s37329 SPRINGFIELD v241558 020805 STAGE 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took 4 hours and took place on 19th August 2005 between 13.30 and 17.30. The inspection was carried out by one inspector who spoke to a number of service users, staff members, and visitors. The inspection also included reading documents, speaking to the manager, and a tour of the building. Comments from residents were generally very positive; especially with regard to the staff, who were described as ”wonderful” and “lovely”. What the service does well: What has improved since the last inspection? What they could do better: The kitchen facilities need to be improved, and there is only one serviceable bath. The system for checking whether new staff members are suitable to work with vulnerable people needs to be improved. Please contact the provider for advice of actions taken in response to this Springfield Residential Care Home I03 I53 s37329 SPRINGFIELD v241558 020805 STAGE 4.doc Version 1.40 Page 6 inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Springfield Residential Care Home I03 I53 s37329 SPRINGFIELD v241558 020805 STAGE 4.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 Residential Care Home I03 I53 s37329 SPRINGFIELD v241558 020805 STAGE 4.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, 5 Suitable measures are taken to ensure that potential service users’ needs are fully assessed prior to their moving into the home, and the service is able to meet the needs of older people including those with dementia. EVIDENCE: The home has a brochure which outlines the services offered. If a person is interested in moving into the home, the manager visits the person concerned and meets with family members and any professionals who may be involved, so that as much information about the person’s needs as possible is obtained. Residents’ files have within them the information that had been gathered on each person’s needs, including pre-admission assessments and details of the person’s social histories, hobbies and interests. Staff are experienced and competent and have a good level of knowledge about the general needs of older people and the people living at the home specifically. Aids and adaptations are available to help staff to meet service users’ needs, and discussions with staff and residents indicated that the home is capable of meeting the needs of older people. The home is not registered to provide nursing and no nursing tasks are carried out by care staff, however, Springfield Residential Care Home I03 I53 s37329 SPRINGFIELD v241558 020805 STAGE 4.doc Version 1.40 Page 9 the manager said that district nurses are very supportive and carry out nursing tasks when they are needed. New residents are admitted for a trial period of up to four weeks, after which the arrangements are reviewed to see how the person feels about the placement and ensure that the home is meeting their needs. Individuals and their families are encouraged to visit the home before making a decision about the home, and to stay for a meal if they wish. Springfield Residential Care Home I03 I53 s37329 SPRINGFIELD v241558 020805 STAGE 4.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 The system of care planning gives a good description of what help each person’s needs and how that assistance should be given so that staff can be clear about what they need to do. Arrangements are in place to ensure each service user receives input from relevant professionals to ensure each person’s health needs are met. Personal care is given sensitively so that individuals’ dignity and privacy are maintained. Procedures for managing service users’ medication are satisfactory and were being properly followed, so that medication is safely administered. EVIDENCE: Care plans relating to 3 residents were seen and showed the action required to meet their assessed health, personal, and social care needs. The plans have been reviewed every month and updated to show any changing needs or goals. The manager said that working relationships with the GPs, district nurses, and other people working in the health service are good and action has been taken to ensure that people have the equipment needed to promote their health and safety. At the time of the inspection none of the residents had a pressure sore. Springfield Residential Care Home I03 I53 s37329 SPRINGFIELD v241558 020805 STAGE 4.doc Version 1.40 Page 11 The home uses a pre-dispensed monitored dosage system for administering medication; records relating to the management of medication were examined and were found to be in order and the person responsible for medication at the time of inspection said that she had received sufficient training to give out medication safely. Care staff were seen talking with service users whilst helping them walk from one place to another and with other tasks; the way they spoke was respectful and polite. One member of staff was seen helping a resident to use the stair lift; the person concerned was told what was going to happen and was allowed to do as much for herself as possible rather than the staff member taking over. Springfield Residential Care Home I03 I53 s37329 SPRINGFIELD v241558 020805 STAGE 4.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 The range and frequency of organised activities is good, and staff provide appropriate support to facilitate contact with family and friends. Residents are encouraged to make choices about their lives and are encouraged to maintain their independence. Dietary needs are well catered for, with a balanced and varied selection of food available to meet residents’ individual tastes and choices, however, work needs to be done to improve the kitchen facilities. EVIDENCE: Since the last inspection an activities co-ordinator has been employed. Individuals are encouraged to take part in a range of activities in the home, and trips out to places of interest, and residents spoken to said that there was always plenty going on in the home. Forthcoming trips and outings are posted on the notice board; recent activities include an outing to the coast, exercise sessions and games. Relatives and friends are welcome to visit at any time, and during the inspection a number of relatives were coming and going and said that they felt able to visit without notice and were always made to feel welcome. Residents confirmed that they were able to exercise choice about what they did in the home and could come and go as they pleased. Residents can bring personal possessions into the home, and many had done so, however, items of furniture and electrical equipment must meet the relevant safety standards. Springfield Residential Care Home I03 I53 s37329 SPRINGFIELD v241558 020805 STAGE 4.doc Version 1.40 Page 13 The kitchen area is well organised, and generally clean, however a number of cupboard doors are worn as is the work surface. An inspection carried out by the environmental health officer on 11th January 2005 made requirements about this; a further requirement is made in this report. Records relating to food show that each resident is getting a balanced, healthy diet, and individual likes and dislikes are recorded by the kitchen staff. Meals are served in the two dining areas, which provide a pleasant, homely and relaxed atmosphere, though some people choose to eat some meals in their rooms. Residents said that the food was generally very good and that they were happy with the quality and quantity of the food provided, however, some said that they would like more variety at tea time especially more savoury food; this was discussed with the manager. One person said that she was pleased that the manager had arranged for her to have a snack before she went to sleep, and other requests had also been met. Springfield Residential Care Home I03 I53 s37329 SPRINGFIELD v241558 020805 STAGE 4.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) 18 The arrangements for ensuring the protection of service users from neglect or harm are satisfactory, and residents are protected from abuse or mistreatment, however, more rigorous procedures are needed prior to employing new staff. EVIDENCE: The home has an adult protection policy to guide staff in dealing with allegations of abuse or mistreatment, and there is also a whistle blowing policy aimed at encouraging staff to voice any concerns. Staff are required to sign that they have read and understood the adult protection policy. The need to check whether potential new staff are included on the Protection of Vulnerable Adults (POVA) list (a national register of people deemed unfit to work with vulnerable people) before their employment was discussed with the manager, and a requirement has been made to that effect. Springfield Residential Care Home I03 I53 s37329 SPRINGFIELD v241558 020805 STAGE 4.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, 21, 22, 24, 25, 26 The home is suitable for the needs of those living there, and sufficient equipment is provided so that service users’ independence is maximised. The home is clean and hygienic and there are no unpleasant odours. EVIDENCE: The home is close to the main shopping area of the market town of March. Access to the home is via stairs and a newly installed ramp. The building is on 2 floors, access to the upper floor is via 2 stair lifts, and the building is equipped with aids and adaptations to meet the needs of older people. The home is generally well-maintained and has a homely and pleasant atmosphere, however, as noted elsewhere, the kitchen facilities need updating and improving. Areas that during the last inspection were identified as needing attention have been re-decorated or cleaned as appropriate. Springfield Residential Care Home I03 I53 s37329 SPRINGFIELD v241558 020805 STAGE 4.doc Version 1.40 Page 16 The home has four bathrooms and eight toilets, however, not all of the bathrooms provided are accessible to older people with mobility problems and in fact only two are currently being used. The manager said that work was due to be carried out to convert one of the baths into a walk-in shower, however, a requirement has been made about the matter. En-suite facilities are provided in three single rooms and one double room, and each resident has a toilet near to their bedroom. Bedrooms are well maintained, tidy and clean. Furniture provided appears to be comfortable and appropriate to the needs of individuals, and residents are able to bring with them items of furniture as long as they meet fire safety standards. One resident said that she would like to have a lockable space to store her personal items; the manager said that this would be arranged. Pre-set valves are fitted to the baths used by residents to ensure that the hot water provided does not exceed 43°c, all rooms are centrally heated and residents were able to control the heating in their bedrooms with support if needed. Since the last inspection covers have been bought for the radiators to guard residents from hot surfaces, and the manager said that these will be fitted before the cold weather returns. The premises were clean and appeared hygienic, and there were no unpleasant odours. Springfield Residential Care Home I03 I53 s37329 SPRINGFIELD v241558 020805 STAGE 4.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, 28, 29, 30 Sufficient staff were on duty to ensure that service users’ needs were properly met. Staff were clear about their roles and were competent and properly trained and experienced, so that they could meet residents’ needs. The home’s recruitment procedures needed to be revised so that full checks were carried out on potential staff to ensure that unsuitable people were not employed. EVIDENCE: There were 3 care staff in the home, which was adequate for the number of people who they were supporting. Staff were well presented and were courteous, welcoming and helpful. Domestic and catering staff were also on duty, and two waking staff are on duty overnight with an on-call system in place in case management support is needed. All new members of staff receive an induction to the home which is supervised by a suitably qualified and experienced person. Since the last inspection the National Training Organisation TOPSS has been re-organised and is now called Skills for Care; the manager said that she would discuss with the induction supervisor, what needs to be done to ensure that any induction for new staff meets the requirements of the new organisation. The home has a training programme, which includes essential core training such as moving and handling, fire safety and first aid, which is needed to ensure service users’ safety and that of the staff and staff spoken to said that they received ongoing training to allow them to carry our their duties effectively and safely. Springfield Residential Care Home I03 I53 s37329 SPRINGFIELD v241558 020805 STAGE 4.doc Version 1.40 Page 18 Staff files include two written references, and Criminal Record Bureau (CRB) checks had been carried out, as had verification of staff members’ identity, and the majority of the other required checks, however, as noted elsewhere, potential new staff are being appointed without first checking whether they are included on the Protection of Vulnerable Adults (POVA) list, and a requirement has been made about this. Springfield Residential Care Home I03 I53 s37329 SPRINGFIELD v241558 020805 STAGE 4.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) 31, 33, 36, 38 The home is being managed properly and there is leadership, guidance, and direction for staff to ensure residents receive consistent quality care. Measures are in place to ensure that the health, safety and welfare of the people using the service were being protected EVIDENCE: The registered manager is Carole Wood. Carole has worked in the home for more than 10 years, beginning as a member of care staff and working up to senior carer before being appointed manager in January 2001. Carole has suitable management experience within the home, and has undertaken courses relevant to her work, including staff supervision, elder abuse, infection control and report book writing; she has also gained the NVQ level 4 in management and care. Since the last inspection, the management arrangements have continued to be developed to provide additional support to the manager and to offer the opportunity for delegation of specific tasks to other members of staff. Springfield Residential Care Home I03 I53 s37329 SPRINGFIELD v241558 020805 STAGE 4.doc Version 1.40 Page 20 Staff and residents said that they thought the home was well-run and said that if the need arose, they would not hesitate to approach the manager with any concerns. Accounts and business plans were not inspected, however, given the high demand for places at the home there is no reason to question the financial viability of the business. The manager has put in place systems to ensure that all staff receive formal supervision every 2 months and an annual appraisal of staff members’ competence, strengths and any training needs is also carried out. A full check of records required to be kept in a home as detailed in Schedule 4 was not undertaken, however, records of the tests of fire alarms were seen and were found to be satisfactory, and records indicated that the emergency lighting system had been tested at least every month and the home’s electrical equipment has been tested for safety. Under Regulation 26 the provider is required to visit the home at least once a month and provide a report of their findings to the manager and the Commission. At present this is not happening and a requirement has been made about the matter. Notifications of incidents affecting the welfare of service users are being sent as required under Regulation 37. Springfield Residential Care Home I03 I53 s37329 SPRINGFIELD v241558 020805 STAGE 4.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 3 x HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION 2 3 2 x x 3 3 3 STAFFING Standard No Score 27 3 28 3 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score x x 2 3 x 3 x x 3 x 2 Springfield Residential Care Home I03 I53 s37329 SPRINGFIELD v241558 020805 STAGE 4.doc Version 1.40 Page 22 YES Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard 18 & 29 Regulation 19(1)(b) Requirement The manager must ensure that Protection of Vulnerable Adults (POVA) First checks are carried out before staff are appoointed Timescale for action From the date of this inspection (i.e. 19 September 2005) and ongoing By 31 December 2005 By 30 November 2005 2. 19 & 38 16(2)(g) 3. 21 23(2)(j) 4. 38 26 The kitchen facilities must be renewed and the requirements made be the environmental health officer must be met The number of accessible baths or showers must be increased so that the home has the same ratio of bathing facilities as it did prior to 31 March 2002. This was a requirement from the last inspection; failure to comply with this requirement may result in legal action being taken against the service The registered provider must visit the home on an unannounced basis at least once a month and a report of the visit must be provided to the registered manager and to the Commission From the date of this inspection (i.e. 19 September 2005) and ongoing Springfield Residential Care Home I03 I53 s37329 SPRINGFIELD v241558 020805 STAGE 4.doc Version 1.40 Page 23 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 15 Good Practice Recommendations The manager should arrange for service users to be consulted about their preferences regarding the early evening meal Springfield Residential Care Home I03 I53 s37329 SPRINGFIELD v241558 020805 STAGE 4.doc Version 1.40 Page 24 Commission for Social Care Inspection CPC1, Capital Park Fulbourn Cambridge CB1 5XE 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 Residential Care Home I03 I53 s37329 SPRINGFIELD v241558 020805 STAGE 4.doc Version 1.40 Page 25 - 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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