Inspection on 07/02/07 for Springfields Care Centre

This inspection was carried out on 7th February 2007.

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 Care Centre 13/02/09

Springfields Care Centre 15/12/08

Springfields Care Centre 09/11/05

Springfields Care Centre 06/07/05

Springfields Care Centre 03/02/05

Springfields Care Centre 01/09/04

Springfields Care Centre 25/02/04

Similar services:

The Vicarage

Fairfields Country Rest Home

7 Hyde Road

5 Seafield Road

Poldhu

Queensmount

Trevaylor Manor

Didsbury Court Rest Home

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

CARE HOMES FOR OLDER PEOPLE Springfields Care Centre Springfields Care Centre 33 Springfield Road Elburton Plymouth Devon PL9 8EJ Lead Inspector Doug Endean Unannounced Inspection 7th February 2007 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 Care Centre DS0000003605.V323803.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 Care Centre DS0000003605.V323803.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Springfields Care Centre Address Springfields Care Centre 33 Springfield Road Elburton Plymouth Devon PL9 8EJ 01752 482662 01752 482210 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) www.fshc.co.uk Four Seasons (DFK) Limited (wholly owned subsidiary of Four Seasons Health Care Limited) Mrs Nicola Marie Kelly Care Home 85 Category(ies) of Dementia (20), Dementia - over 65 years of age registration, with number (20), Mental disorder, excluding learning of places disability or dementia (20), Mental Disorder, excluding learning disability or dementia - over 65 years of age (20), Old age, not falling within any other category (25), Physical disability (10), Physical disability over 65 years of age (65) Springfields Care Centre DS0000003605.V323803.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. There will be no more than the maximum of eighty-five (85) service users in the home at any time. 9th November 2005 Date of last inspection Brief Description of the Service: Springfield Care Centre is an 85 bedded purpose built home that provides nursing and personal care to adults who suffer from physical or mental health problems in separate units. There are presently 20 registered nursing beds on the dementia care unit that can be used for adults or the elderly. The remaining beds are to be found in two other distinct units, one providing general nursing care, and one that provides residential (personal) care. The residential care unit is undergoing refurbishment to provide separate facilities for older people and older people who suffer from early signs of dementia. The home has a Registered Manager who has overall responsibility for the running of the home. In addition to this each unit is separately staffed and has its own unit manager. Each of the two nursing units are managed by a registered nurse, and have a registered nurse on duty 24 hours a day. The residential care unit is managed by an experienced Senior Carer who may call on the District Nurses for any nursing needs the clients might have that do not warrant placement in a nursing home bed. The units are arranged over two floors with shaft lift’s between each floor. There is an enclosed garden at the rear of the home lying between the ground floor accommodation wings of the home. The homes fee structure begins at £350 rising to £500 plus the funded nursing care contribution. Springfields Care Centre DS0000003605.V323803.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This un-announced key inspection took place on the 7th February 2007 beginning at 10:20 and lasted 5 hours and 40 minutes. In that time the inspector carried out a full tour of the home, interviewed three visitors, three staff and the Registered Manager. He also reviewed the records of five service users and spoke with five service users as part of the case tracking process. The Registered Manager had prepared a pre-inspection form that held information about the home, staff, service users and training. A total of 16 comment cards were received from relatives. In addition the inspector received 20 service users surveys, 4 General Practitioner comment cards and 11 care worker survey forms. The Registered Manager and the Administrator assisted the inspector through out the course of the inspection. What the service does well: What has improved since the last inspection? What they could do better: Service users and their relatives were not happy with the variety or quality of the meals served each day. The Manager was aware of this and has plans in place to rectify the situation within the next 4 weeks. Springfields Care Centre DS0000003605.V323803.R01.S.doc Version 5.2 Page 6 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. The summary of this inspection report can be made available in other formats on request. Springfields Care Centre DS0000003605.V323803.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 Care Centre DS0000003605.V323803.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. JUDGEMENT – we looked at outcomes for the following standard(s): The homes performance was assessed against Standard 1, 3 and 4. Standard 6 does not apply. Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. The written information that is made available to prospective service users is of a high standard. The pre-admission assessments format is very well structured. It provides valuable information about the needs of prospective service users, and the resource implications if they are admitted. EVIDENCE: There is an informative Statement of Purpose and service users guide available to every service user and their advocate. It contains a copy of the complaints procedure and additional information that will inform the prospective service users and those already resident at the home of what service they can expect whilst living in the home. In addition to the Statement of Purpose the inspector Springfields Care Centre DS0000003605.V323803.R01.S.doc Version 5.2 Page 9 saw a number of leaflets that have been produced by the company on subjects that relate to the illnesses that commonly result in an admission to a care home or nursing home. Examples of the subjects covered are dementia, stroke, and incontinence. These are to be found at the entrance of the home in front of the signing in book. Each person who is admitted to the home has a pre-admission assessment carried out by an appropriately qualified person. The home admit only on the basis of beginning able to meet the needs of service users and not on the grounds of their race or religion. The home employs individuals from a variety of countries overseas who have differing religious beliefs. The inspector saw five examples of completed forms as part of the case tracking process that forms a part of the inspection process. These were held in service users records in the nursing and residential units. The forms are professionally prepared by the company and require valuable information to be gathered by the assessor. The result is that an informed decision can be made about whether the home is able to meet the needs of the referred client. Having read the assessments and service users files, the inspector interviewed the individual service users and felt the admissions were appropriate. The assessments obtained information about the service users past medical and psychiatric history, nutrition, medication, dexterity, continence, mobility etc. It established a dependency rating for each individual issue and an overall dependency rating. It then provided information on the needs to be met by the home and also by external health care providers. The resource implications are therefore clearly established by way of the assessment and dependency rating. The Registered Manager was able to show that she employs a group of staff that collectively have the skills to meet the assessed needs of the service users who are admitted to the home. (See staff training and staffing in standards 27 to 30) Springfields Care Centre DS0000003605.V323803.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. JUDGEMENT – we looked at outcomes for the following standard(s): The homes performance was assessed against Standard 7, 8, 9 and 10. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The whole process of care planning, including the review, was very good as a dependency level check is recorded at least monthly. The range of skilled staff, including the General Practitioner who attends the home, is beneficial to all of the service users. EVIDENCE: The home uses a care-planning format that has been developed by the company. It is well structured and provides a clear record of the results of assessments of service users needs and the action to be taken to resolve problems. It also includes space for the name and designation of the individual who has written the care plan. The company has recently updated the format. The inspector saw five examples of care plans during inspection, two from the residential unit and three from the nursing units. All the plans were clear, as the format is simple. Needs are identified using the dependency assessment Springfields Care Centre DS0000003605.V323803.R01.S.doc Version 5.2 Page 11 rating tool that is reviewed at least monthly. Evidence of the reviews were seen in the service users files. A separate plan of care was written for each issue that identified the expected results from care provided by staff following the care plan. Examples of issues covered were nutrition, communication, mobility and hygiene. The assessment plan identifies the resources that are needed to meet the service users needs. The resources include staff and their skills, equipment and the services of health care professionals from outside of the home such as Community Psychiatric Nurse, District Nurse, General Practitioner and Chiropodist. The home employs their own Doctor who attends twice a week to review service users. The care plans include such input as may be provided by these individuals who are named in the care plans. Medication was securely stored in each unit in locked trolleys that were securely tethered to the wall inside locked rooms. On the nursing units the registered nurses are responsible for the ordering, administrating and recording any medication that is in use. The company has its own policy and procedure for this management of medicines and also the guidance from the Nursing & Midwifery Council. The residential unit is not staffed by registered nurses. The care staff who are involved in medication management have all received training from a major pharmacy group. Staff training in medication administration was updated on the 18th January 2007. The records were look at and found to be satisfactory in each unit. The inspector observed that service users personal care was provided in their own room or another appropriate place (bathroom) so as to preserve their dignity. Every bedroom has an en-suite toilet of good size and shape for their personal use. The staff were heard to refer to the service users by name and this appeared to be acceptable to them. One relative comment card made the following statement, “Staff treat each resident with respect and develop a relationship with them according to the residents individual character traits/personality. In short the staff really do care”. Springfields Care Centre DS0000003605.V323803.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): The homes performance was assessed against Standard 12,13,14 and 15. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home provides an atmosphere that allows the service users to retain as much independence and control, as they are able to. The provision of room, personnel and equipment for activities is very good. The meals that are provided are adequate in that they meet the nutritional requirements of the service users but not the expectations of all in variety and taste. EVIDENCE: During the dependency assessment, and its reviews, a judgement is made about the service users ability to meet their own daily living needs. The service users likes and dislikes in food, clothing, etc is part of the information that is gathered and relatives and friends are included in this process. The staff then plan to deliver care and supervision that takes into account the service users abilities and wishes. The service users can exercise choice in the way their day progresses. Springfields Care Centre DS0000003605.V323803.R01.S.doc Version 5.2 Page 13 The service users may continue to maintain links with the community with the aid of relatives and friends and the home will assist in such ways as providing an early meal and preparing the service user so they are ready for collection at an appointed time. The home does provide activities for service users to attend and they have the choice of joining in or not. A full time Activities Coordinator is employed, and also a volunteer who has been vetted, including a Criminal Records Bureau check. The Activities Coordinator works with the Unit Heads to provide appropriate activities that meet the needs of those in the unit at any one time. A separate activities room is provided for crafts and other activities. The Registered Manager provided the inspector with a list in the pre-inspection questionnaire of the activities that the home does provide. A number of service users were enjoying a game of bingo in the activities room during the afternoon of this inspection. Activities of a therapeutic nature are facilitated by the home such as the “Stroke Club”. The home has several areas for the service users to watch TV. The front lounge is also used for the latest activity, karaoke, and several service users expressed delight at this activity. The home has invested in a new mini bus that has a hoist for wheel chair uses. The home allows visiting at any reasonable time and the service users have a choice of using one of the lounges or their own room if they wish. The only restrictions to visiting that may be exercised by the home would be on medical grounds or at the wishes of a service user. The inspector spoke to three visitors during the inspection, one of which was helping out with the main meal served to her husband. Apart from the quality and choice of the food provided on occasions they were complimentary about the holistic care, and the staff working at the home. During the inspectors tour of the home he saw that service users have personalised their rooms in various ways to suit themselves whilst allowing staff to deliver care safely. Some rooms that had originally been doubles were now providing a premium space to some individuals who were able to have a small lounge area within the now, single bedroom. It has been the choice of the home not to provide care in double rooms. The home does not manage the financial affairs of any of the service users. The inspector saw samples of the nutritional assessments that are undertaken on all service users and reviewed at least monthly. These assessments, alongside the likes and dislikes aid the staff in the preparation of meals. The home has its own hotel style kitchen that is staffed by cooks and kitchen assistants. Service users can eat in their own rooms or in one of the dining areas that are provided in each of the units. Where needed, staff will help service users to eat their meal in an unrushed way as was observed by the inspector. The service users, and also relatives, did comment in writing and also in person during the inspection that the standard of food now provided was adequate and not exciting. The Registered Manager supplied a copy of the homes current four-week rotating menus. She also told the inspector that Springfields Care Centre DS0000003605.V323803.R01.S.doc Version 5.2 Page 14 there are imminent changes to the menu and the kitchen staff. Three relatives comment cards made reported such things as “Too many chips, stews and casseroles”. A casserole was served at dinnertime on the day of the inspection. Some service users said that it had a bland taste. Another said that the variety and standard of meals sometimes can be questionable” and suggested that the money allocated to meals may be a reason for this. The inspector received 20 completed service users surveys. Eight said that the food was always good and one service user commented, “I enjoy them”. Seven service users ticked that they usually enjoy the meals with one commenting, “Some I enjoy more than others”. Five service users said that they sometimes like their meals or never like their meals commenting that the staff will find another alternative in most cases. Comments received were “Cooks find something else for me to eat”, and “Nothing seems home made”. Springfields Care Centre DS0000003605.V323803.R01.S.doc Version 5.2 Page 15 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. JUDGEMENT – we looked at outcomes for the following standard(s): The homes performance was assessed against Standard 16 and 18. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The complaints procedure is well written and circulated. Service users are safeguarded by good recruitment practice and by staff who have had vulnerable adults training. EVIDENCE: The home does have a complaints procedure that is displayed in the front lobby and in the Statement of Purpose/service users guide. The majority of the service users who responded to the service users survey knew how to make a complaint. A total of 14 out of 16 relatives responded in the comments card that they knew that the home had a complaints procedure. The home has records seen by the inspector as evidence of the procedure being followed. The staff who are employed by the home are fully vetted in line with the company procedure so as to avoid employing unsuitable individuals. A POVA First and a Criminal Records Bureau check is part of this procedure. The inspector saw evidence that this has occurred. The internal/company disciplinary procedure is robust enough to deal with acts of poor practice and abuse. During the course of this inspection, the inspector saw evidence that the Registered Manager has followed the disciplinary Springfields Care Centre DS0000003605.V323803.R01.S.doc Version 5.2 Page 16 procedure correctly. The whistle blowing policy is there as protection of staff who may report episodes of abuse. Staff files and the pre-inspection form showed that staff has undertaken “Protection of Vulnerable Adults training” and that this is an ongoing process as new staff joins the care team. The recruitment procedure is also used to prevent unsuitable people being employed in the home. The home does not manage the affairs of any of the service users. Springfields Care Centre DS0000003605.V323803.R01.S.doc Version 5.2 Page 17 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. JUDGEMENT – we looked at outcomes for the following standard(s): The homes performance was assessed against Standard 19, 20, 21, 23, 24, Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The improvements that have occurred in the building have improved its appearance inside and out, making it a more pleasing to the eye. The refurbishment that is underway is evidence of a large investment to the home as a whole. The home is well equipped to provide personal and nursing care. EVIDENCE: At each of the entrances of the home there is alcohol hand wash for everyone to use as they enter and leave the home. The inspector did observe the staff using this as they came on duty in the afternoon. Springfields Care Centre DS0000003605.V323803.R01.S.doc Version 5.2 Page 18 The entrances have a keypad system of entry for security. One relative who completed the inspection comment cards felt that they did have to wait a long time on occasions before the door was opened for her. At the time of this key inspection the home was in the process of a total refurbishment that included the replacement of what was historically described as sprung floors. This refurbishment will coincide with a re-division of space in the residential area of the home to produce a 16 bedded area for early suffers of dementia. This area had been closed in order for the builder to make the alterations that were necessary. Ten beds will remain on the ground floor for “older people”. The inspector took a full tour of the home and saw bedrooms that have been redecorated, re-carpeted and furnished to a good standard. Many of the beds have been replaced with more suitable height adjustable beds. A bathroom in the Dementia care unit has now been redecorated and has a new high-low bath that is accessed by a bath hoist. The décor in this bathroom was more domestic in nature through colour and pictures on display, unlike the previous occasion when this room was inspected. The initial view of a relative who had accompanied a new service user was that she liked the way her husband’s room was decorated and the en-suite toilet that was provided. All bedrooms through out the building are of good size and shape and have en-suite toilets. They were also furnished to the service users liking having aids where these were assessed as necessary such as pressure relief mattresses. One relative had commented in the comments card that the décor was suffering from the passage of time. The refurbishment is planned to continue until the entire home has been improved including more paving in the garden and raised flowerbeds. In general the home is well provided for with a nurse call system to all areas that the service users have access to. This produces a print out of when the call bell was pressed and then the time that the staff attended. The bell can only be cancelled at the point of call. There are two shaft lifts that provide access to service users and visitors between ground and the first floor. There was evidence of a satisfactory service history of the shaft lifts and also other equipment in the home such as hoists and the hi-low baths. Each bathroom was suitable for use by the disabled and there are toilets outside of the service users bedrooms and near communal areas that also provide disabled access. The whole building has double-glazing and all the radiators are now provided with secure and safe covers to prevent injury from hot surfaces. There are several boilers that provide hot water and heating throughout the home. These are regularly serviced and evidence of the last service was provided to the inspector. Water is stored above 60 degrees centigrade and the home has an annual check of its quality with records provided as evidence of this. Springfields Care Centre DS0000003605.V323803.R01.S.doc Version 5.2 Page 19 The home employs its own handy man who maintains a safe environment through good repair. The company also have their own Estates Manager. One is making a regular appearance at the home during the refurbishment. The home has its own risk assessment for the premise that will be reviewed along side of the changes made by the refurbishment. The pre-inspection form provided the inspector with details about the servicing of equipment and some of the dates were verified during the inspection such as hoists and baths that are height adjustable. The communal space that is provided can be used by the service users from any of the units, supervised in some cases. Each unit has its own lounge and dining room areas that have comfortable seating, which has a sensible height for mobile service users to get on and off. An additional lounge is being created in the dementia care unit. There is a lounge at the front of the building that is not inside any of the units and is used by service users for activities and staff for training. There is also a large laundry in the service area of the building that launders all the linen and also service users cloths. It has suitable equipment such as commercial dryers and washing machines with sluicing cycles. Springfields Care Centre DS0000003605.V323803.R01.S.doc Version 5.2 Page 20 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. JUDGEMENT – we looked at outcomes for the following standard(s): The homes performance was assessed against Standard 27, 28, 29 and 30. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The induction training process and subsequent training is very comprehensive. The home employs staff who are prepared well to complete the tasks expected of them. EVIDENCE: The home is staffed with individuals who have each received differing types of training appropriate to the task they are employed to carry out. All staff have completed the companies induction course that begins with at least three days supernumery practice shadowing other care workers. They then work with staff and also have their fire and moving and handling training. The training in the first weeks also includes food handling and effective communication. Overseas staff have an additional emphasis on their training of effective communication. The first stage’s of the induction is held over six weeks and the staff are required to complete a written questionnaire to verify that they have understood the training they have received. The points taught are recorded in a “Induction Programme” file with the mentor signing off each item as the staff member is competent or confident in the subject. Evidence of this was seen in the sample of files that the inspector read during this inspection. He also spoke to the newest member of staff, a trained nurse who said that she had had an Springfields Care Centre DS0000003605.V323803.R01.S.doc Version 5.2 Page 21 effective induction. Induction continues according to “Skills for Care” guidelines for six months and is recorded in staff training files as seen by the inspector. A care assistant was spoken to in the Dementia Care Unit who verified that the induction training had included fire and moving and handling. He also was able to verify how the staff are empowered to deal with problems, using their own knowledge and experience to make changes to benefit the needs of the service users. There is a formal document now used that records competencies as they are achieved over the first six months of employment. In addition to this the inspector saw the Registered Managers “Year Plan” that records all the up dating of training and when it should occur so that staff maintain their skills. National Vocational Qualification training is at almost 50 and will surpass this when the next 5 members of staff finish their level 2 training. The Registered Manager provided 4 weeks duty sheets covering each unit of the home. There were mixed views among staff and relatives about the numbers of staff on duty. One General Practitioner comment card said there was always a senior member of staff on duty to confer with whilst another disagreed. However there is always a registered nurse on duty 24 hours a day. Seven relative comment cards recorded that in their opinion there is sufficient staff on duty whilst nine relatives disagreed. One felt that the shortage was related to the domestic staff. Another felt that there was “Insufficient staff at meal times”. Another felt there was, “Always a staff shortage, especially weekends, holidays and nights”. However others reported that since Four Seasons took ownership delays in providing care, such as toileting, has now improved somewhat with only occasional delays. Another gave praise saying, ”Staff on Willow Unit (EMI) encourage residents to maximise their capabilities and provide them with excellent support and care at all levels”. The evidence from service users spoken to by the inspector and the homes ability to meet the assessed care of service users is that staffing levels are adequate. Eleven completed staff surveys were received and these represented care and ancillary staff. Three staff felt that the care would benefit from more staff on duty whilst three others felt that having staff employed who are interested in the work and care about what they do was more impotent. The comment, “Have cares whom really care about clients and have more time for one to one with them” was an answer to the question “If you could change one thing to improve the way the care home works, what would it be?” Two staff members said that support from management had improved by 100 and three staff felt that the improvements in training opportunities and the overall service had provided had improved since Four Seasons took control of the home. The inspector looked at four staff files matching information with the recruitment process and legislation. All the files held the evidence required of them including the results of a Criminal Records Bureau check, identification checks, contracts and evidence of training and qualifications. There were also supervision records held within the files. Springfields Care Centre DS0000003605.V323803.R01.S.doc Version 5.2 Page 22 Springfields Care Centre DS0000003605.V323803.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. JUDGEMENT – we looked at outcomes for the following standard(s): The homes performance was assessed against Standard 31, 33, 35 and 38. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The Registered Manager is very competent and she does have good leadership qualities. The home is well run and good care is provided. The present improvements to the premise have resulted in a better environment for the service users to live in. The refurbishment is ongoing. EVIDENCE: The home is managed by an experienced and competent Registered Manager. She is a registered nurse and also holds the appropriate qualifications in management. In the short time that she has worked at the home she has shown that she has the leadership skills to direct her team to achieve the aims and objectives of the home. She is clinically well prepared to meet the needs of Springfields Care Centre DS0000003605.V323803.R01.S.doc Version 5.2 Page 24 the service users and has commanded the respect of the staff that have said, “I feel the support we now have from management is now 100 ”, and “The manager now, has really made a difference to standards in most areas”. The inspector has seen evidence of her abilities in the changes to the premise, the moral and the effect that both has had on the service users and their advocates. Staff have been empowered to have a degree of say in how things are done and responsibility for doing them, if they wish too. One relative remarked that, “What is good here as well is that Matrons door is open and you can knock and go and see her anytime she is free to discuss anything”. Outside of the home the company registered “Four Seasons limited” has developed external management on a regional and national basis to provide support to the home on any level or subject. Quality assurance is handled through company policy. The views of individuals, service users and staff, are obtained for the Regulation 26 reports that are required by the Commission for Social Care Inspection. A new service users questionnaire is to be circulated for a more comprehensive collection of their views. Internal audit is carried that is verified by external company auditors. This included a Health & Safety audit, resident at risk audit, accident records and staff training audit, etc. The home does not accept responsibility for the control of any of the client’s financial affairs. There is information about advocacy and the clients are at liberty to meet with their solicitors or financial advisors. There are facilities for the safe keeping of money and valuables on a short-term basis. The home is maintained by an in house maintenance man and outside contractors and full records are kept of all work undertaken. A sample of these records was seen. There is also an Estates Manager who is visiting the home on a regular basis to monitor the refurbishment and also general maintenance of the home. The Registered Manager is able to provide evidence that she has used the resources available to her to maintain a safe environment for care to be provided in. She has also equipped her staff with training and equipment to deliver good care. Where incidents and accidents have occurred there are satisfactory records that cover the issues including any resulting action needed to change practices. Springfields Care Centre DS0000003605.V323803.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 4 X 4 3 X N/A HEALTH AND PERSONAL CARE Standard No Score 7 4 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 3 3 X 3 3 3 3 STAFFING Standard No Score 27 3 28 2 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 4 X 3 X 3 X X 3 Springfields Care Centre DS0000003605.V323803.R01.S.doc Version 5.2 Page 26 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 OP15 Regulation 16(2)(i) Timescale for action The registered person ensures 07/03/07 that service users receive a varied, appealing, wholesome and nutritious diet, which is suited to individual assessed and recorded requirements, and that meals are taken in a congenial setting and at flexible times. Requirement 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 OP28 Good Practice Recommendations Continue to offer National Vocational Qualification training to achieve 50 of care staff having level 2 or above. Springfields Care Centre DS0000003605.V323803.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Ashburton Office Unit D1 Linhay Business Park Ashburton TQ13 7UP National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 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 Care Centre DS0000003605.V323803.R01.S.doc Version 5.2 Page 28 - 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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