Inspection on 20/01/06 for Springfields

This inspection was carried out on 20th January 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 31/05/07

Springfields 24/08/06

Springfields 25/05/05

Springfields 17/11/04

Springfields 15/07/04

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 Springfields Easthorpe Road Copford Green Colchester Essex CO6 1DH Lead Inspector Diana Green Unannounced Inspection 20th January 2006 01:10 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 DS0000017935.V280053.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. 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 DS0000017935.V280053.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Springfields Address Easthorpe Road Copford Green Colchester Essex CO6 1DH 01206 212261 01206 213238 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) Springfields Residential Homes Limited Mrs Patricia Ann Green Care Home 16 Category(ies) of Old age, not falling within any other category registration, with number (16) of places Springfields DS0000017935.V280053.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. Persons of either sex, aged 65 years and over, who require care by reason of old age only (not to exceed 16 persons) 25th May 2005 Date of last inspection Brief Description of the Service: Springfields is a residential home providing care for up to 16 older people. The home is located in the village of Copford, close to Marks Tey where there are shops, a train station and access to the A12.Springfields is a three storey building previously a house. It has 16 single en-suite rooms. On the ground floor are communal rooms two lounges and a dining area. There is a passenger lift to reach the upper floors. The home has extensive, landscaped gardens to the rear of the property and ample visitor parking at the front of the house. This unit does not accommodate wheelchair users. Adjacent to the home is a nursing home managed and owned by the same company. Laundry and catering facilities are shared between the two establishments. Springfields DS0000017935.V280053.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection that took place on the 20/01/06, lasting 4 hours. The inspection process included: discussions with the proprietor, the registered manager, administrator, three staff, four residents and two relatives; a partial tour of the premises including a number of residents’ rooms, bathrooms and communal areas; and inspection of a sample of policies and records (including any records of notifications or complaints sent to the CSCI since the last inspection). Sixteen standards were inspected, one was commended and four requirements and two recommendations made. Action had been taken promptly to address all other previous requirements and recommendations. It was evident that Springfield Residential continues to provide a high standard of care for residents. The manager and staff were welcoming and helpful throughout the inspection. What the service does well: What has improved since the last inspection? Care planning continues to improve. General risk assessments are now recorded and residents who choose to self-medicate have a recorded risk assessment. There are now more that 50 of care staff who have achieved NVQ level 2 training. The range of social activities has extended and residents are closely consulted to determine their preferred choice of activities. Recently flower arranging and craft sessions have been organised. Springfields DS0000017935.V280053.R01.S.doc Version 5.1 Page 6 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 DS0000017935.V280053.R01.S.doc Version 5.1 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 DS0000017935.V280053.R01.S.doc Version 5.1 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): 3, 6 Assessment of residents is generally satisfactory to identify all residents’ needs that can be met. However the one resident had been admitted to the home for which the home is not registered and there is therefore no assurance their needs can be met. This home does not provide intermediate care. EVIDENCE: The assessments for four residents were inspected. Three included an assessment of need of all elements as detailed under this standard. Risk assessments were recorded for falls, moving and handling and a general risk assessment. A nutritional assessment was undertaken and weights recorded on admission. The fourth assessment identified the needs of a resident with mental health needs. The assessment was too brief to accurately detail their needs. Additionally the home is not registered to care for residents with a mental illness. This is an offence under the Care Standards Act 2000. Springfields DS0000017935.V280053.R01.S.doc Version 5.1 Page 9 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 Residents’ general health care needs are consistently well met within the home. However residents who have a mental illness cannot be appropriately cared for without being registered for this category of care that will ensure staff have the relevant skills and experience. Attention is required to ensure the safe storage, administration and recording of medicines at all times. EVIDENCE: Four care plans were inspected. Three care plans were comprehensive and included risk assessments. Regular reviews of care plans and risk assessments were evident. One residents’ care plan did not include a social/ therapeutic plan of care as appropriate to their mental health needs. The standard of personal care was observed to be good and several relatives confirmed that was their experience. Records showed appropriate and prompt referrals to GP’s and health and social care professionals. The home’s GP attended the home regularly to review residents’ needs and on request. The home had a medicines policy and procedures and up to date guidance available for information. Some omissions in the recording of medicines administration were evident with no reason identified. The providing pharmacist was available for advice and also provided staff training. Medication Springfields DS0000017935.V280053.R01.S.doc Version 5.1 Page 10 was stored in a trolley held in the office and a store cupboard on the first floor of the home. There was no temperature monitoring of storage facilities and advice was given with regard to this. Stock levels of medication appeared excessive and the manager was advised to review these in consultation with the pharmacist. One resident was self-medicating and advice was given to ensure staff monitored their compliance. Springfields DS0000017935.V280053.R01.S.doc Version 5.1 Page 11 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 Daily routines were flexible and there was a strong ethos in the home of promoting residents’ choice and independence. Visiting arrangements were open and relaxed and staff made efforts to ensure visitors were welcomed into the home. EVIDENCE: A range of individual and group social activities were provided that residents were enabled a choice of taking part. Activities were varied and efforts had been made recently to arrange further activities that suited residents’ cultural and lifestyle preferences. These included flower arranging and craft sessions. The home provided seasonal entertainment and there were links established with the library and local schools. Several residents went out regularly with their families to church, for walks and for meals. Visiting was open access. All rooms were single and residents could therefore see their visitors in private. Visitors spoken with said they were free to visit at anytime and were invited to various functions throughout the year and were always welcomed into the home. One resident regularly dined with a friend who was a resident in the adjoining nursing home. Springfields DS0000017935.V280053.R01.S.doc Version 5.1 Page 12 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): 18 Appropriate policies, procedures and practices were in place to promote the protection of residents from abuse. EVIDENCE: The home had and adult protection policy and procedures. There had been no incidents/allegations of abuse. However the manager was clear on the local procedures to follow in the event of an allegation of abuse and copies of the Essex Procedures for the Protection of Vulnerable Adults was available. Whistle blowing procedures were available for staff guidance. The manager and care staff had last received training during 2003 and was advised to investigate access to training organised by the Essex Protection of Vulnerable Adults Committee. Springfields DS0000017935.V280053.R01.S.doc Version 5.1 Page 13 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, 26 Springfields is safe, well maintained and provides residents with a homely place to live. The home was clean and hygienic with satisfactory standards of infection control evident. EVIDENCE: A partial inspection of the premises was made that included a number of residents’ rooms, communal rooms, the kitchen and bathrooms. The home was in a good state of maintenance and decoration. Communal rooms were well decorated and furnished to provide a homely environment for residents. The gardens are attractive with views over open countryside and exceptionally well maintained. The gardens were accessible to residents and wheelchair users. Records provided evidence that the building complied with the requirements of the local fire and environmental health department. Springfields DS0000017935.V280053.R01.S.doc Version 5.1 Page 14 The home was clean and hygienic throughout with no odorous smells. Infection control practices observed in the home were seen to be safe. Laundry and sluice facilities were located separately away from areas where food was prepared or eaten. Springfields DS0000017935.V280053.R01.S.doc Version 5.1 Page 15 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 The staffing levels were appropriate to the needs of residents. The required recruitment checks had not been obtained prior to employment. Processes therefore did not fully protect service users. EVIDENCE: There were sixteen residents at the home. Staffing levels comprised the manager and two care assistants and met the levels agreed with the CSCI; from inspection of the staff duty rota and discussion with staff and residents, there was evidence that staffing levels were well maintained, and met the needs of residents. The home had good retention of staff with some staff having been employed for some years, resulting in the provision of good continuity of care for residents. Domestic staff were employed in sufficient numbers to ensure the cleanliness of the home. Laundry, catering and maintenance staff were shared with the nursing home that was adjacent. There were more than 50 of care staff with NVQ level two. The recruitment records were sampled. One recently appointed care assistant had two satisfactory references but no evidence of identification. An application for Criminal Records Bureau disclosure had been requested but not yet obtained. Springfields DS0000017935.V280053.R01.S.doc Version 5.1 Page 16 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): 35, 38 The home is well managed and run in the best interest of residents. Robust arrangements are in place to ensure residents’ financial interests are protected. Health and safety standards are well monitored to ensure risks to service users and staff are minimised. EVIDENCE: The home did not manage any residents’ monies. Some residents managed their own finances and all others had a representative/advocate to manage them on their behalf. As there was no safe in the home, residents they were discouraged from holding large amounts of cash. All expenditure/sundries were invoiced directly to residents or their representatives. The home had a health and safety policy statement and there was evidence of statutory training in fire safety and moving and handling was provided for all Springfields DS0000017935.V280053.R01.S.doc Version 5.1 Page 17 staff as required. The premises were secure and systems were in place for maintenance of a safe environment. Checks to minimise the risks of Legionella and regular servicing of boilers and central heating systems were undertaken and evidenced from the records. Regular maintenance of hoist and other equipment was confirmed from the records. There was a need for weighing scales to be calibrated to ensure their accuracy. Springfields DS0000017935.V280053.R01.S.doc Version 5.1 Page 18 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 x x 2 x x N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 x 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 x 15 x COMPLAINTS AND PROTECTION Standard No Score 16 x 17 x 18 3 3 x x x x x x 3 STAFFING Standard No Score 27 3 28 4 29 2 30 x MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score x x x x 3 x x 3 Springfields DS0000017935.V280053.R01.S.doc Version 5.1 Page 19 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 OP3 Regulation 14 Requirement The registered person must ensure that residents are not admitted to the home for which the home is not registered to provide care. The registered person must ensure that care plans detail all identified needs including social/therapeutic needs. The registered person must ensure that all the required checks including identification and a satisfactory Criminal Records Bureau Disclosure are obtained and held on file. Timescale for action 17/02/06 2 OP7 15(1) 28/02/06 3 OP29 7, 9, 19 Schedule 2 28/02/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard 18 Good Practice Recommendations The registered person should ensure the manager and care staff attend protection of vulnerable adults training organised by the Essex Vulnerable Adults Protection DS0000017935.V280053.R01.S.doc Version 5.1 Page 20 Springfields 2. 38 Committee. The registered person should ensure the weighing scales are calibrated for accuracy. Springfields DS0000017935.V280053.R01.S.doc Version 5.1 Page 21 Commission for Social Care Inspection Colchester Local Office 1st Floor, Fairfax House Causton Road Colchester Essex CO1 1RJ 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. 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