Inspection on 19/09/06 for Springfields

This inspection was carried out on 19th September 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

Springfields 25/01/06

Springfields 27/07/05

Springfields 16/11/04

Springfields 06/04/04

Springfields 29/08/02

Similar services:

The Shelley

Springfield House

Sutton Lodge Nursing Home

St Helier`s Residential Hotel

St Joseph`s

Ridgemount

Wingham Court

Old Hastings House

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

CARE HOMES FOR OLDER PEOPLE Springfields 11 Langdale Road Hove East Sussex BN3 4HQ Lead Inspector Elizabeth Dudley Key Unannounced Inspection 19th September 2006 10:00 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Springfields DS0000014059.V308053.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Springfields DS0000014059.V308053.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Springfields Address 11 Langdale Road Hove East Sussex BN3 4HQ 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) 01273-735784 01273-738260 Mr Joginder Singh Vig Mrs Beant Kaur Vig Mrs Colleen Hutton Care Home 32 Category(ies) of Old age, not falling within any other category registration, with number (32) of places Springfields DS0000014059.V308053.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 4. The maximum number of service users to be accommodated at any one time is thirty two (32). Service users should be aged sixty five (65) and over on admission. That the home is registered to admit three service users aged over sixty-five years on admission, with a dementia-type illness. Only older people who have been assessed as requiring nursing/residential care are to be accommodated. 25th January 2006 Date of last inspection Brief Description of the Service: Springfields is a care home providing nursing and personal care for up to thirty-two older people. It is owned by Mr & Mrs Vig, who also own four other care homes in East Sussex. The home is situated in the centre of Hove, within close walking distance of the sea front. There are local shops and transport links nearby. Accommodation is provided over two floors in a large property that has been converted from three houses. A passenger lift enables residents to access all parts of the home. There is a pleasant garden at the rear of the building that is accessible to residents. Springfields provides eighteen single and seven shared rooms, eight of which are en-suite. There is a lounge/dining area on the ground floor, and a small sitting area in the foyer of the home. Current fees charged are between £454-£550, with extra charges for hairdressing, chiropody and outings. Springfields DS0000014059.V308053.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced key inspection took place on the 19th September 2006 and was facilitated by Mrs C Hutton, home manager. Prior to visiting the home, questionnaires were sent to residents and relatives of residents, staff members and general practitioners. Responses received back consisted of eight responses from relatives or visitors to the home, six responses from staff members and two responses from general practitioners. Seven residents also responded. A further 15 residents and nine members of staff were spoken with during the visit. Telephone calls were made to five visitors to the home who had given permission for the CSCI to contact them. During the visit to the home, a tour of the home took place and documentation including personnel files, care plans, health and safety and catering documents were examined. Comments received from residents included ‘Lovely home’, ‘we are very lucky here’ and ‘staff make a home and the staff are very nice here’. Relatives and visitors to the home stated ‘she is much better since she came to live here’, ‘I am very satisfied, the staff always inform us of any concerns or when the doctor has been’ and ‘He has improved since he came to the home and the staff always make us welcome, he is happy’. What the service does well: Staff are encouraged to attend training which together with the well documented and detailed care plans enables a high standard of care delivery. All residents appeared well cared for and said that they were well looked after. The home provides good range of activities and outings for residents and they spoke of their enjoyment in going out for tea and for ‘fish and chips on the seafront’. Residents who do not leave their rooms have the benefit of one – to one conversation with the activities organiser. All residents are supplied with bowls of fresh fruit, which is cut up into fingersized pieces for easy eating in the middle of the morning. Cakes and puddings are homemade and most residents stated that they enjoyed the food ‘We get a choice of food and can have a cooked breakfast in the morning, and we can have our breakfast in the garden’. Visitors stated that they are made very welcome and always given a cup of tea when they arrive. Relatives said that they are consulted about any concerns or changes in the resident’s condition. Springfields DS0000014059.V308053.R01.S.doc Version 5.2 Page 6 A group of residents spoken with said that ‘Staff make a home and our staff are very nice’. Policies and procedures and documentation show that they have been reviewed on a regular basis. The general management systems within the home are good and the home is kept very clean. The relationships between residents, staff and manager are good and the home provides a pleasant home for older people, which takes into account their individual personalities. What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Springfields DS0000014059.V308053.R01.S.doc Version 5.2 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 Outcomes Statutory Requirements Identified During the Inspection Springfields DS0000014059.V308053.R01.S.doc Version 5.2 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 the following standard(s): 1,2,3,4 and 5 Quality in this outcome area is good; this is based on the available evidence including a visit to this service. Prospective residents receive sufficient information to enable them to make an informed decision over whether Springfield’s Nursing Home can meet their needs and whether they wish to make it their home. EVIDENCE: The home produces a Service User Guide and Statement of Purpose that meets the regulations and the National Minimum Standards. A brochure containing accurate information about the home is also provided. The manager confirmed that she takes a copy of the service user guide and the brochure with her when assessing a prospective resident and all residents have a copy of the service user guide. Residents spoken with confirmed that they had these in their possession. Springfields DS0000014059.V308053.R01.S.doc Version 5.2 Page 9 All prospective residents are assessed by the manager prior to being admitted to the home. This process ensures that the home will be able to meet the resident’s needs. Residents or their representatives can visit the home prior to their admission in order to make and informed choice over whether they wish to live at Springfields Nursing home. The assessment is detailed and contains details of the resident including physical, psychological and social needs, and any special details such as wound care required. It also contains the preferred name of the resident and any special dietary needs. This forms the basis of the care plan. Staff said that the manager informs them in detail about the prospective resident, and that the care plan is commenced prior to the resident entering the home, this enables them to ensure that they have any specialist equipment or can access any specialised health care professionals that may be necessary on the resident’s admission. Staff have undertaken various study days relating to the conditions affecting the older person. A Registered Nurse is on duty twenty-four hours a day and some care assistants have attained their National Vocational Qualification level 2 in care. All residents receive a statement of terms and conditions following their admission to the home and evidence was seen of these. These meet the National Minimum Standard and the Regulations. The statement of purpose and service user guide are displayed in the foyer within the entrance hall to the home, together with letters and cards complimenting the home and a copy of the home’s menu and activities programme. There is information, which states that the CSCI Inspection report is available on request from the manager. Springfields DS0000014059.V308053.R01.S.doc Version 5.2 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 the following standard(s): 7,8,9,10 and 11 Quality in this outcome area is good; this is based on the available evidence including a visit to this service. The standard of care planning and medication administration ensures a high standard of care and protection for residents in the home. Resident’s dignity and choice is impaired through lack of systems to enable them to have their room doors open if they wish. EVIDENCE: During the visit to the home a sample of fifteen care plans were examined, care of six residents being followed in detail (case tracked). All care plans were seen to be clear, detailed and concise. They had been reviewed on a monthly basis and, wherever possible, signed by either the resident or their representative. Care required by the resident was clearly documented and there was evidence of nutritional and monthly blood pressure monitoring, risk assessments and consent forms for the use of bedrails. Springfields DS0000014059.V308053.R01.S.doc Version 5.2 Page 11 Evidence was seen of visits by the wound care nurse, dentist and optician, and a chiropodist. Involvement of the continence nurse specialist is sought as required. The home has replaced all mattresses with new ones, which will afford protection from pressure damage, including one mattress to be specifically used for those residents who are at a high risk from this. The manager sought advice from the wound care nurse prior to buying these. Several new beds have been purchased and all rooms now have either a standard hospital type bed or an electric variable position bed. All residents appeared well cared for and comfortable. The presence of fluid and turning charts was apparent for those residents requiring a high level of nursing care. Comments from questionnaires sent to General Practitioners were received by the CSCI and one General Practitioner was spoken with during the visit to the home. All said that they were pleased with the care given to residents and one doctor stated that he was always called appropriately. The inappropriate use of paper continence protectors on beds was discussed with the manager who has addressed the issue during the visit. The Nursing Home Support Team used the home in 2005 to conduct a study of residents in nursing homes with non-cancerous terminal conditions, and stated that ‘The home proved they were aware of all aspects of the care required, and provided a good standard of care’. A relative of a resident stated that ‘It has been lovely to see how well and happy he has become since moving to the home’. Residents also commented on the improvement in one of their colleagues in the time spent at the home, and stated how hard the staff had worked to achieve this. Residents spoken with said that they were well looked after, their call bells were answered within a reasonable time and that the doctor was called when they needed to see one. One resident said that she had gone to the General Practitioner surgery that morning accompanied by a care assistant. Care assistants always accompany residents on hospital appointments if their relatives are unable to do so. However resident’s dignity and rights are compromised by the failure of the home in ensuring that individual room doors can be kept open if the residents so wish. A requirement made around this has only partly been complied with and therefore residents have to keep their doors shut to ensure their safety in the event of fire. Springfields DS0000014059.V308053.R01.S.doc Version 5.2 Page 12 Care staff identified that they were aware of the importance of using the preferred form of address with residents and residents confirmed that staff did this. It is recommended that notices informing staff of dietary needs be removed from the walls of individual bedrooms as this infringes on residents dignity and confidentiality. It was seen that all medical and nursing interventions took place in private and that there was good and courteous interaction between residents and staff. Screening is provided in shared rooms. Although there were no residents that were seriously ill on this visit, letters from relatives of deceased residents were seen and these thanked staff for their care of the relatives as well as of those residents who were ill. They commended the staff on their thoughtfulness and kindness to the relatives during this time. The manager and the senior staff are enrolled on the Gold Standards Framework which is a course of study relating to the care of the dying resident, and all registered nurses have attended study days at the local hospice and have knowledge of the use of syringe drivers and other forms of analgesia administration. All medications were seen to be correctly stored with evidence of stock rotation, all were signed for following administration, and all controlled drugs were accurately recorded. The clinic room was clean and there was evidence that drug fridge temperatures were being monitored and recorded, and that other equipment used was checked on a regular basis. All drugs and dressings are stock rotated and the providing pharmacist has undertaken an audit of medication recently. All medications are disposed of correctly when no longer required and there is a range of medicine policies and procedures that have been recently updated. Notices warning of medical gases being used were in place. Springfields DS0000014059.V308053.R01.S.doc Version 5.2 Page 13 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 the following standard(s): 12,13,14 and 15 Quality in this outcome area is good; this is based on the available evidence including a visit to this service. A good range of activities, staff attitudes and commitment towards the residents enhances resident’s quality of life. The quality of catering is good thus ensuring residents enjoy a varied diet. The home is to be commended for its practice of offering fresh fruit prepared to enable residents to eat easily, on a daily basis. EVIDENCE: Residents spoken with said that they could choose what time they went to bed and got up in the morning and could go to their rooms at any time. They stated that staff respected their choices over what they wished to do, what clothes they wished to wear and in which part of the home they wanted to spend their day. They said that they could choose to have their meals either in their rooms or in the lounge and one resident said that they could have breakfast in the garden during the summer ‘It’s lovely having it out there’. The home employs an activities co-ordinator for fifteen hours a week, he organises activities such as entertainers, ‘Pat-a-Dog’, outings which include visits to Paradise Park, Devil’s Dyke, and the Sea Front. Residents said that they would like more outings and loved to go out for ‘fish and chips’. Springfields DS0000014059.V308053.R01.S.doc Version 5.2 Page 14 A minibus is arranged with staff accompanying residents when they go out. The entertainers provided by the home have included jazz groups, Music for Health, and a theatre group. Other activities include reminiscence, the provision and changing of library books and accompanying to the shops. The activities co-ordinator was aware of the need of one-to -one conversation and activities for those residents who do not wish to leave their rooms, and residents confirmed that this took place. All residents were in possession of an activities programme and this was also displayed in the home. All residents spoken with made very positive comments about the home ‘It’s a lovely place, you can please yourself what you do’, ‘Terrific here, staff wonderful, lovely matron’, ‘It’s a lovely home, the staff are lovely, they really take an interest in you as individuals, and yet they have so many of us to remember here’. One resident said that a member of staff had brought a retired film actress that she admired, in to visit her. She was thrilled that this had happened and also that the staff would think of her when they were off duty and take the trouble to do this. There is an open visiting policy in the home with visitors welcome at any time. Residents said that their visitors are offered tea when they come in and also that they are made very welcome. Questionnaires received back by the CSCI from relatives of residents confirmed this. Ministers of religion visit the home and there was evidence that the religious preferences of ethnic minority residents within the home were adhered to. There was evidence that the manager is aware of how to contact advocates for residents and has done so in the past and also that solicitors and financial advisors can be accessed as required. There is a monthly menu and this showed that a good choice of varied meals was offered to residents. This includes the availability of a cooked breakfast on all days of the week, homemade cakes and puddings, fresh fruit offered during the morning to all residents, a choice of meals and evidence of choices at each meal. Beverages are offered throughout the day. The menu was also displayed in the lounge. The standard of catering appeared good with the majority of residents saying that they enjoyed the food and that care staff ask them what they would like to eat each day. There is the opportunity to choose other items such as baked potatoes or omelettes not shown on the menu, and staff were aware of the likes and dislikes of each resident. Springfields DS0000014059.V308053.R01.S.doc Version 5.2 Page 15 One member of catering staff said that on occasion she had cooked three different meals for one resident in an effort to please them. Some residents were offered sherry and wine and the manager said that alcoholic drinks were always available for residents that wished for them. Catering staff have obtained their ‘Food Hygiene Certificate’ and the cook showed that he records resident’s alternative choices to the menu, fridge, freezer and hot food temperatures. There was a good amount of fresh fruit, vegetables, dry and frozen food in the home. The kitchen was reasonably clean and there is a cleaning schedule, but some improvements are needed and this will be facilitated if the refurbishment to the kitchen is undertaken. The Environmental Health Authority report highlighted work to be done and this is in progress. Dried goods were left in the storeroom with their packets open and this must be addressed. Springfields DS0000014059.V308053.R01.S.doc Version 5.2 Page 16 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16,17 and 18 Quality in this outcome area is good; this is based on the available evidence including a visit to this service. Residents are protected by the open and transparent manner in which the home addresses complaints and the knowledge of the staff regarding the protection of the people in their care. EVIDENCE: The home has a complaints policy, which is displayed in the home and is included in the service user guide. There have been two complaints made to the home since the last inspection, one concerning the time taken to call a General Practitioner, and one concerning the food offered to residents and the times of residents going to bed. Both of these were investigated, and evidence showed that both were unfounded. All complaints have been dealt with in an open and transparent manner and the homes’ documentation relating to dealing with complaints is good and complaints are dealt with within a short period of time. Staff have attended training on the protection of the vulnerable adult and showed knowledge of their responsibilities towards those in their care. They were aware of the rights of the residents and the methods of reporting any concerns they may have. Residents were aware of to whom to make a complaint. Springfields DS0000014059.V308053.R01.S.doc Version 5.2 Page 17 It is recommended that the manager and senior staff update their knowledge of the new reporting protocols in adult protection and cascade this to the rest of the staff. Springfields DS0000014059.V308053.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19,20,21,22,23,24,25 and 26 Quality in this outcome area is adequate, this is based on the available evidence including a visit to this service. Residents would benefit from a redecoration of the home. Residents live in comfortable accommodation and all residents can access the garden. EVIDENCE: Springfields Nursing Home provides accommodation for residents over two floors, the third floor being used as staff accommodation. Residents’ accommodation consists of eighteen single bedrooms and seven double rooms, six of the single bedrooms and three of the double rooms having ensuite facilities, which consist of a washbasin and WC. All rooms have a washbasin in place. All rooms conform to the sizes in the amended National Minimum Standards; this includes the two lounge areas. Springfields DS0000014059.V308053.R01.S.doc Version 5.2 Page 19 The entrance to the home is very pleasant with an attractive small lounge area being available for residents and relatives. Communal facilities consist of two lounges and a large garden, which is well maintained with patio and grass areas and accessible to all residents from the lounge. The main lounge appears crowded at times, although many residents stay in their rooms. The home is reasonably well maintained but some redecoration is required and although some parts of the corridor have been repainted recently, the home would benefit greatly from attention to redecoration throughout. Some of the carpets in resident’s rooms will require renewing and the manager states that she has noted this. Three relatives or representatives spoken with commented that the home could do with some redecoration. There is maintenance work to be done in the kitchen and this was made a requirement at the last inspection. The Environmental Health report also showed work to be undertaken. Since the last inspection one of the sluice rooms has been converted to a storage cupboard and one of the bathrooms to an assisted shower room. Two assisted showers are now available. There are five remaining assisted bathrooms and some of these are in need of maintenance. The tiles on the bath one first floor bathroom need attention and this was discussed with the manager. The home has been assessed by an occupational therapist and it was evidenced that the manager has reviewed this assessment and added further adaptations to aid residents. There was evidence of hoists; grab rails pressure relieving equipment and moving and handling equipment in the home. Resident’s rooms would benefit from redecoration, but were clean and comfortable with all curtains on their runners. All residents have a lockable drawer and there is the option for residents to have a lockable door. The manager can show that she has asked residents if they wish for this and this has been refused. All beds are adjustable and carpets are provided in most rooms. One room has linoleum flooring, but this meets the needs of the present resident. Risk assessments have been undertaken in all rooms, and temperatures of resident’s water outlets have been tested and recorded on a regular basis. All rooms have restricted windows. Springfields DS0000014059.V308053.R01.S.doc Version 5.2 Page 20 Some areas of the kitchen require attention to cleanliness, particularly the tiling and the corners of the floor. The rest of the home was very clean, notwithstanding that it is an old building in need of some redecoration and domestic staff are to be commended on this. The home was free from any odours. There is a range of infection control policies and evidence that staff have received training in this, there were gloves and disposable aprons available throughout the home and all staff were seen wearing these when entering the kitchen. Springfields DS0000014059.V308053.R01.S.doc Version 5.2 Page 21 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29 and 30 Quality in this outcome area is adequate, this is based on the available evidence including a visit to this service. Staff are employed in sufficient numbers and receive the appropriate training to meet the needs of the residents in the home. In order to protect resident’s adherence to the regulations is required relating to recruitment practices around people providing a service to residents. EVIDENCE: The off duty rota showed that sufficient staff to meet the assessed needs of the residents are employed during a twenty-four hour period. Staff stated that agency staff are rarely used and that they tend to cover for each other if one cannot work, staff turnover is low and the present staff complement have been working together for a number of year, with the home rarely being short staffed. Four members of staff have completed their National Vocational Qualification level 2 in Care, which is 23.5 of the staff. A further three members of staff are completing this, with one member of staff having handed her finished course to the assessor on the day of the visit. The manager anticipates that by December 2006 44 of staff will have National Vocational Qualification level 2 in care. Springfields DS0000014059.V308053.R01.S.doc Version 5.2 Page 22 Staff have undertaken other training, including all mandatory training including first aid, nutrition, diabetes, infection control, catheter care, continence management and stroke and heart failure. Registered nurses have undertaken training in The Gold Standards Framework (care of the terminally ill resident), updates in the use of syringe drivers, care of the dying and have attended courses held at the local hospitals and university, undertaken distance learning courses and attended courses advertised in the Nursing Press. A training programme is in place. The maintenance man has completed a distance-learning course on health and safety and COSHH (Control of Substances Hazardous to Health). All staff undertake a basic induction course on commencing employment, which includes care issues, and can be used towards their National Vocational Qualification level 2 in care. Ten personnel files were examined and the majority of these had all documentation required by the National Minimum Standards and the Regulations. There was evidence that a member of staff had been employed in 2005 prior to either the Protection of Vulnerable Adults and Criminal Records Bureau check being received and that the hairdresser recently attending the home has not had Protection of Vulnerable Adults clearance, although the manager stated that the majority of the time she was supervised by a staff member. An immediate requirement was made and the manager asked to provide an action plan to address this issue. Springfields DS0000014059.V308053.R01.S.doc Version 5.2 Page 23 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31,32,33,34,35,36,37 and 38 Quality in this outcome area is good; this is based on the available evidence including a visit to this service. Resident’s wellbeing and safety are protected by the safe systems of day-today management within the home. The provider must ensure residents well being by participating in the quality monitoring of the home. EVIDENCE: The manager, Mrs Hutton has been working at the home for ten years and has been the registered manager for the past four years. She is a registered nurse (level1) and has attained her Registered Managers Award. Staff and residents described the home as having a ‘lovely atmosphere’, ‘a lovely caring place to work’ and ‘you can go to the manager no matter what Springfields DS0000014059.V308053.R01.S.doc Version 5.2 Page 24 problems you have’, ‘It’s a really nice place to live’, ‘We are very lucky here we all like it, the staff are nice and staff make the place’ and ‘The manager is proactive in the care of the residents’. The home has a quality-monitoring programme, which is reviewed by the manager on an annual basis, with some questionnaires sent out to residents and their representatives. A requirement made at the last inspection involved initiating a programme of feedback from stake holders involved in the home and in part this has been complied with, however there was no evidence of results having been collated and a subsequent action plan, neither are there any written goals for the home to achieve. All policies and procedures are reviewed regularly with amendments as required. Financial records for the home were not seen on this occasion as the company has recently undergone registration for another area and these were examined as part of this process. The home keeps small amounts of personal allowances for residents and records were seen, these were accurate and up to date with receipts kept. Supervision for staff is ongoing and records were available. There was no evidence of Regulation 26 visits having taken place this year. No personal or clinical supervision is being provided for the manager. All records relating to staff and residents are kept in a secure environment and are up to date and in good order. All certificates relating to the maintenance of utilities and equipment were in place and in date, apart from the Landlords Gas Certificate, which is not in the home, although there was evidence that this system has been examined and is free from faults. Staff have had all mandatory training. The manager must continue to ensure that all staff receive manual handling training on a yearly basis. The maintenance person and some care staff have received health and safety training. There was no evidence of a recent fire risk assessment, but the manager stated that this was due and would be addressed. Springfields DS0000014059.V308053.R01.S.doc Version 5.2 Page 25 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 3 3 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 4 8 3 9 4 10 2 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 3 18 3 2 3 3 3 3 2 3 2 STAFFING Standard No Score 27 3 28 2 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 2 3 3 3 3 3 Springfields DS0000014059.V308053.R01.S.doc Version 5.2 Page 26 Are there any outstanding requirements from the last inspection? No 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 OP19 Regulation Reg 23 (2) (c)(d) Requirement That general maintenance issues including the repair of the kitchen cupboard are undertaken and a programme of decoration maintained within all areas of the home. (This was a previous requirement 01/04/06) That compliance with the environmental health requirements takes place. That cleanliness in the kitchen is improved and monitored and that dried goods are sealed following use. That an alternative method of keeping those residents who wish their doors kept open, safe in case of fire is examined. (This was a previous requirement 25.01.06) That the provider undertakes monthly visits to the care home and provides a report as detailed in the regulations. That strategies are developed for enabling staff and other stakeholders to inform the way in which the service in the home is delivered. (This was a DS0000014059.V308053.R01.S.doc Timescale for action 01/12/06 OP26 2 OP38 OP10 Reg 13(4) Reg 12(3) Reg 26 01/12/06 3 OP33 01/11/06 4 OP33 Reg 21(1&2), 24(1) 01/12/06 Springfields Version 5.2 Page 27 previous requirement 01.12.05 and 01.04.06) 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 OP18 OP28 OP31 OP38 Good Practice Recommendations That the manager and senior staff attend an update on latest Protection of Vulnerable Adults reporting protocols. That there is a 50 ratio of staff who have attained National Vocational Qualification level 2 in care That personal and clinical supervision are provided for the manager. That the fire risk assessment is reviewed. Springfields DS0000014059.V308053.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection East Sussex Area Office Ivy House 3 Ivy Terrace Eastbourne East Sussex BN21 4QT 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 Springfields DS0000014059.V308053.R01.S.doc Version 5.2 Page 29 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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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