Inspection on 21/03/06 for Springhill Resource Centre

This inspection was carried out on 21st March 2006.

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

The inspector 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

Springhill Resource Centre 05/03/09

Springhill Resource Centre 07/12/06

Springhill Resource Centre 13/10/05

Similar services:

Chirnside House

Keer Sands Residential Home

Ruskin Lodge

Bushell House

Langrigg House

Parkside

Dystlegh Grange

Thornton Lodge

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

CARE HOMES FOR OLDER PEOPLE Springhill Resource Centre Springhill Resource Centre Broad Lane Rochdale Lancs OL16 4PP Lead Inspector Grace Tarney Unannounced Inspection 21st March 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 Springhill Resource Centre DS0000062995.V283240.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. Springhill Resource Centre DS0000062995.V283240.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Springhill Resource Centre Address Springhill Resource Centre Broad Lane Rochdale Lancs OL16 4PP 01706 659922 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) Rochdale MBC Miss Elizabeth Colley Care Home 21 Category(ies) of Dementia (5), Dementia - over 65 years of age registration, with number (21), Old age, not falling within any other of places category (21) Springhill Resource Centre DS0000062995.V283240.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. Within the maximum registered number (21), there can be up to :21 Older People (OP) 21 Adults with Dementia, over 65 years (DE(E)) 05 Adults with Dementia (DE) The service should, at all times, employ a suitably qualified and experienced Manager who is registered with the Commission for Social Care Inspection The registered Person must ensure that all staff working in the home have dementia awareness and dementia care training, which equips them to meet the needs of the service users accommodated, as defined in the individual plan of care. The service should at all times employ suitably qualified and experienced members of staff, in sufficient numbers, to meet the assessed needs of the service users with dementia. The Registered Person may accommodate up to 5 service users in the category of DE aged over 55 years of age. Work on the external grounds of the home, to make the area safe, attractive and accessible to service users must be completed by 31.5.05. 13th October 2005 2. 3. 4. 5. 6. Date of last inspection Brief Description of the Service: Springhill Resource Centre is registered to provide care for up to 21 older people, some or all of whom may have dementia. The service is working towards providing care ultimately for 21 people with dementia on a short term assessment type basis. At the moment the service is in a transitional stage, whilst it continues to offer permanent care to residents who resided at Springhill (before its refurbishment) and Birch View Older Persons homes (which has closed). The home is single storey and all bedrooms are single, with a small number having en-suite facilities. Springhill is spacious and provides 3 lounge/dining areas. Sufficient bathrooms and toilets are provided. An internal patio area is available to residents to access in good weather. The home is located close to the centre of Rochdale, and is easily accessible by bus route. Parking is available to the front of the home. A daycare unit is attached to the home however, this has not yet opened. Springhill Resource Centre DS0000062995.V283240.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The centre was not made aware that this inspection was to take place. This was an unannounced inspection. The inspector spent 6 hours at the centre. . During this time she looked at care and medicine records to check that the health and care needs of the residents were being met. To make sure that the home and the equipment in it was safe, the Inspector looked at the maintenance and service records. She also looked at how many staff were provided on each shift to make sure the residents needs were being met. She also looked at how the management recruit their staff and how they handle the residents’ spending money. The Inspector then looked around the building at the bedrooms, bathrooms toilets and sitting areas to check if they were clean and well decorated. She then visited residents in their own bedrooms to check out the care that was being provided for them. In order to obtain information about the resource centre the inspector also spent time speaking to 1 relative, 2 care assistants and the registered manager. . Not all the National Minimum Standards were looked at on this visit. The Inspector looked at the Standards that had not been looked at during the last inspection. The Standards that are looked at during inspections are those that are considered to be important for the residents’ safety and well-being. What the service does well: What has improved since the last inspection? What they could do better: Springhill Resource Centre DS0000062995.V283240.R01.S.doc Version 5.1 Page 6 More attention must be given to understanding the reasons for, and the importance of undertaking and reviewing risk assessments. This will reduce the risk of any possible harm to residents. 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. Springhill Resource Centre DS0000062995.V283240.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 Springhill Resource Centre DS0000062995.V283240.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): 1. The Statement of Purpose provides enough information for an informed decision to be made about whether the centre is suitable for residents who need admission for the purpose of assessment. EVIDENCE: A revised Statement of Purpose was given to the Inspector and this was detailed and very informative. It stated clearly that it referred to the residential facility and services for residents with dementia. It does make reference to the fact that the centre is accommodating 15 long stay service users and that it no longer accepts permanent residents. It states that as vacancies arise, they will be used to provide short term respite and assessment placements for older people with mental health needs. Springhill Resource Centre DS0000062995.V283240.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 Overall the care plans reflected the support needs of the residents. The failure of staff to regularly undertake or review risk assessments could result in risks going unnoticed, resulting in possible harm to residents. Although small improvements could be made, the medication system ensured that the residents received their medicines safely. EVIDENCE: The care plans of three residents were inspected. Two of the care plans were of the residents who were admitted for assessment and one was of a resident receiving long-term care. The care plans for the two residents admitted for assessment were detailed and gave a clear picture of the residents needs and also what they were able and less able to do. There was also a night care plan that gave clear guidance about the risk of falls, rising and retiring times, and whether the resident was to be “checked on” during the night. Risk assessments were in place and covered such areas as moving and handling, nutrition, pressure sores and falls. In addition each care plan had a risk assessment in relation to safety that was specific to the individual e.g. one Springhill Resource Centre DS0000062995.V283240.R01.S.doc Version 5.1 Page 10 resident being able to make hot drinks. This had been signed and agreed by the residents’ relative. The care plan for the long-term resident was detailed but did not give enough information in relation to the prevention of pressure sores. There was also no evidence of a pressure sore risk assessment. The Inspector visited this resident in her room. She was being cared for on an appropriate pressurerelieving mattress, she was sleeping and looked very comfortable. The Inspector was informed that staff have to take great care when positioning and repositioning this resident. This was not detailed in the care plan. It is essential that staff document in the care plan, the care that they are actually delivering. There was a nutritional risk assessment but this had not been evaluated since the 19/9/05. There was a moving and handling risk assessment but this had not been evaluated since the 1/6/05. The bedrail risk assessment had not been evaluated since the 31/5/05. All risk assessments in conjunction with the care plans must be evaluated as and when needs change, but at least on a monthly basis. The residents were weighed at least on a monthly basis and the weight recorded in their care plan. Equipment necessary for the prevention and treatment of pressure sores was available within the home or could be accessed via the community nurses. Entitlement to other NHS facilities was upheld. This was evidenced from the information available in the care plans and a discussion with a relative confirmed this Overall a safe system of medication management was in place. The medicine room was clean and tidy, kept locked and medications were securely stored. There were separate systems in place in relation to the storage of medicines for the long-term residents and those residents in for assessment. This is good practice. Only suitably trained and designated staff administered the medications. Some issues were identified in relation to the following: Transcriptions of medications were not signed, checked and countersigned. Signing and checking transcriptions reduces the risk of drug errors. Medications were not always kept in the container that they were dispensed in. This could result in mixing batches of medications or the medications that have been dispensed for one resident being given to another. Staff were not always documenting the amount of medications being received from pharmacy. This is necessary so that an audit trail can be undertaken if necessary. There was no controlled drug cupboard. The centre was using a portable locked box that was kept within a locked cupboard. In view of the fact that in the future there will possibly be a large turnover of residents, as well as up to Springhill Resource Centre DS0000062995.V283240.R01.S.doc Version 5.1 Page 11 20 day care clients, consideration should be given to providing a more secure cupboard. . Springhill Resource Centre DS0000062995.V283240.R01.S.doc Version 5.1 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): EVIDENCE: Not inspected on this visit. Springhill Resource Centre DS0000062995.V283240.R01.S.doc Version 5.1 Page 13 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 The complaint system in place enables residents and relatives to feel that their views are listened to and acted upon. EVIDENCE: The complaints procedure was displayed in the reception area. It gave clear guidance on how to complain and the time frames for response. It informs residents that they can contact the Commission for Social Care Inspection at any time. The Rochdale Council complaints procedure was also displayed and a copy left in each bedroom. A discussion with a relative indicated that there was a general awareness of how to make a complaint. This relative stated that if he had any concerns he would have no worries about speaking to the staff. He said that the staff were approachable and considerate. No complaints have been received since the last inspection. Springhill Resource Centre DS0000062995.V283240.R01.S.doc Version 5.1 Page 14 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 24 25 & 26 The residents live in very pleasant, clean, safe and comfortable surroundings. EVIDENCE: There is level access to the front of the resource centre with adequate on road parking at the front. As a security measure the front door is kept locked. Springhill is a purpose-built single storey resource centre providing 21 single bedrooms, some with an en-suite facility of toilet and washbasin. There are 3 lounge/dining areas that are themed in various colours of green, blue and yellow. This is to assist the residents with identification. The green lounge is large and is a thoroughfare to other areas of the home. The large well-equipped kitchen opens up onto this area. The lounges were bright, clean and well decorated Leading off from each lounge there is an enclosed garden area. Toilets are within close proximity of communal spaces. Each toilet and bathroom had a lock on the door to ensure privacy and the facilities were all clearly marked. Suitable aids and adaptations were in place in the bathrooms and toilets. Springhill Resource Centre DS0000062995.V283240.R01.S.doc Version 5.1 Page 15 The bedrooms were decorated to a good standard. They were clean and odour free. The majority were highly personalised. The bedroom doors had an overriding door lock and a lockable facility. The heating within the centre was adequate. All the rooms were centrally heated with radiators that were suitably protected. Thermostatic control valves were in place on immersion baths, washbasins and showers. The centre was clean and free from odours. Staff hand-washing facilities however, were not in place in the residents’ bedrooms. In view of the fact that most of the residents were receiving personal care, hand-washing facilities must be provided to help control/prevent cross infection. Clinical waste was handled appropriately and the centre had a contract for the removal of clinical waste. The laundry was well equipped and well organised. Protective clothing and staff hand washing facilities were in place. There was a sluicing facility on the washing machines but the staff told the Inspector that they did not have red alginate laundry bags and had to handle laundry that had to be sluiced before going into the machine. This is not an acceptable practice. Springhill Resource Centre DS0000062995.V283240.R01.S.doc Version 5.1 Page 16 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 & 30 The residents were cared for by sufficient numbers of staff that are suitably trained and recruited and therefore have the knowledge and skills to meet the residents’ needs. EVIDENCE: Examination of the duty rotas and a discussion with staff and a relative showed that there was enough care staff on duty to meet the care needs of the residents. It was identified that the centre does not have its own handyman. NVQ training continues. Of the 31 staff in post 26 have obtained a qualification in NVQ 2 or above. 19 staff members have attained NVQ 2 and 7 have attained NVQ level 3. The personnel files of three staff members were inspected. These contained all the requirements of Schedule 2. They had a completed application form, 2 professional references, an enhanced CRB disclosure check and health status declaration. A structured induction process was in place that was in accordance with TOPPS, and further training continues to be provided in moving and handling, medication, health and safety, infection control, fire safety, food hygiene, interpersonal skills and protection of vulnerable adults. In addition staff are undertaking training in dementia awareness, person centred care for people with dementia and loss and bereavement. The training details were kept in staff files. Springhill Resource Centre DS0000062995.V283240.R01.S.doc Version 5.1 Page 17 Springhill Resource Centre DS0000062995.V283240.R01.S.doc Version 5.1 Page 18 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): 31.33,35 & 38. The experience and qualifications of the manager ensures there is effective leadership and guidance to the staff thereby ensuring that the residents receive consistent quality care. Further arrangements need to be in place for the reviewing of the service provisions to ensure that the home delivers a quality service. A satisfactory accounting system was in place that ensured the residents’ interests were protected. Current practices within the centre in relation to the maintenance of a safe environment, promoted and safeguarded the health, safety and welfare of the people using the service. EVIDENCE: The registered manager has 17 years experience in residential care of older people including 14 years management experience. During this period the registered manager has gained considerable skills and experience in caring for older people with dementia and other mental health problems. Springhill Resource Centre DS0000062995.V283240.R01.S.doc Version 5.1 Page 19 The registered manager has achieved NVQ level 4 in care, the D32 and D33 assessors award and the Registered Manager NVQ level 4 certificate. At present there is no formal quality assurance system in place. Presently only service user satisfaction questionnaires are sent or given out to residents/ relatives. The manager told the Inspector that she is looking to expand on this to include the views of other stakeholders. The systems in place for the management of residents’ money were good. The centre had a satisfactory accounting system in place. Receipts were retained for all financial transactions. The Inspector was informed that any money accrued on behalf of the residents goes to the treasurers department in the residents’ name. The equipment and services within the centre were serviced on a regular basis in accordance with the individual requirements. There was a detailed Health & Safety Policy. Fire risk assessments and risk assessments for all safe working practices were performed and outcomes recorded. The fire logbook was up-to-date. All staff received Induction Training with regard to food hygiene, fire safety, moving and handling and infection control. Fire training was undertaken on an annual basis. Springhill Resource Centre DS0000062995.V283240.R01.S.doc Version 5.1 Page 20 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 x x x x N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 2 10 x 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 x 13 x 14 x 15 x COMPLAINTS AND PROTECTION Standard No Score 16 3 17 x 18 x 3 3 3 x x 3 3 2 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 x 2 x 3 x x 3 Springhill Resource Centre DS0000062995.V283240.R01.S.doc Version 5.1 Page 21 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 OP7 Regulation 15 Requirement When a resident is at risk of developing pressure sores a care plan for prevention must be in place. When a resident is at risk of developing pressure sores a pressure sore risk assessment must be in place. Risk assessments in conjunction with care plans, must be evaluated as and when needs change but at least on a monthly basis. Medications must retained in the container they were dispensed in. There must be an accurate record of any medications received into the centre. Staff hand washing facilities must be provided in the bedrooms where personal care is being given. A system for reviewing the quality of care provided must be established. Timescale for action 22/03/06 2. OP7 13 22/03/06 3. OP7 13 30/04/06 4. 5 6 OP9 OP9 OP26 13 13 13 21/03/06 30/04/06 30/06/06 7 OP33 24 30/06/06 Springhill Resource Centre DS0000062995.V283240.R01.S.doc Version 5.1 Page 22 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 OP9 OP9 OP26 OP27 Good Practice Recommendations Transcriptions of medications should be signed, checked and countersigned Serious consideration needs to be given to providing a more secure cupboard in which to store the controlled drugs. To reduce the risk of cross infection, consideration should be given to providing red alginate bags for foul linen A handyman should be employed within the centre. Springhill Resource Centre DS0000062995.V283240.R01.S.doc Version 5.1 Page 23 Commission for Social Care Inspection Bolton, Bury, Rochdale and Wigan Office Turton Suite Paragon Business Park Chorley New Road Horwich, Bolton BL6 6HG National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Springhill Resource Centre DS0000062995.V283240.R01.S.doc Version 5.1 Page 24 - 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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