CARE HOME ADULTS 18-65
Springpark Springpark Camden Road Lingfield Surrey RH7 6AF Lead Inspector
Lisa Johnson Unannounced Inspection 28th November 2005 2:00 Springpark DS0000013793.V257193.R01.S.doc Version 5.0 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 Springpark DS0000013793.V257193.R01.S.doc Version 5.0 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 Adults 18-65. 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. Springpark DS0000013793.V257193.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION
Name of service Springpark Address Springpark Camden Road Lingfield Surrey RH7 6AF 01342 832583 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) Ashcroft Care Services Ltd Mrs. Gillian Hickman Care Home 3 Category(ies) of Learning disability (3) registration, with number of places Springpark DS0000013793.V257193.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION
Conditions of registration: 1. The age/age range of the persons to be accommodated will be 37 - 65 years 22nd July 2005 Date of last inspection Brief Description of the Service: Springpark is a small residential home set up for three female service users with moderate to severe learning disabilities. The service is managed and owned by Ashcroft Care Services. The home is located in a quiet residential area and the home is in close proximity of shops and other community amenities near the small ton of Lingfield. The home is two storeys chalet style; the communal facilities of dining area, lounge, kitchen and utility area together with two service users bedrooms are all on the ground floor. A third single bedroom with en-suite shower and an office are situated on the first floor. There is an attractive and well-maintained garden to the rear of the home. Parking is available at the front of the house on the road. Springpark DS0000013793.V257193.R01.S.doc Version 5.0 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This was the homes second inspection for 2005/2006. One inspector carried out the unannounced inspection over four hours. A full tour of the home took place. Care plans, policies and procedures and other required documents were sampled. The inspector spoke to the registered manager and one member of staff Due to the communication difficulties of the service users living in the home their views about their care could not be obtained. However one service user was able to tell and show the inspector what she likes doing with some support. Other information gained was from observation of individuals within the home. This was a positive inspection. The inspector would like to thank the residents and staff for their hospitality and cooperation in carrying out this inspection. What the service does well:
There was a relaxed, homely and family like atmosphere in the home. The staff have a good knowledge of the needs of the service users in the home and are aware of their communication needs and were responsive. It was clear that service users were comfortable with staff in the home and were enjoying being in their company. During the inspection a music session as held and it was pleasing to see everybody being supported to take part. Service users were observed to be smiling and happy and were clearly enjoying the music. Staff were seen to be interacting with service users and involving them in activities. One individual asked the inspector if she would like a drink. Service users are provided with the opportunity to participate in some meal preparation and one individual said she liked making cakes. Service users have been on holidays and one service user showed the inspector photographs of her holiday, which she was happy to share especially when seeing pictures of activities that she had enjoyed. The house is decorated to a good standard and has a well-maintained garden, which contained a large trampoline. Bedrooms were of a good standard and personalised with individual’s interests. Springpark DS0000013793.V257193.R01.S.doc Version 5.0 Page 6 Each service user has a completed care plan, which are regularly reviewed. Plans were detailed and structured with clear goal plans in place What has improved since the last inspection? What they could do better:
A requirement was made at the previous inspection that where “own choice” is recorded on the menu, that staff record what each individual chooses. Progress has been made in recording this information but some gaps were still present. A further requirement was made that this information is recorded. This is to provide a clear record of anything eaten by service users in the home. A requirement was made in respect of one service user who requires a wheelchair for going out. The need for installing a ramp to the entrance of the
Springpark DS0000013793.V257193.R01.S.doc Version 5.0 Page 7 house is to be reviewed, which is to be based on an assessment from the occupational therapist. This is to ensure that service users are provided with the specialist equipment they require to maximise their independence. The slabs on the pathway to the entrance to the house are uneven. A requirement was made that this is reviewed. This is to ensure the health, safety and welfare of service users, staff and visitors to the home. A further recommendation was made that the external lighting is reviewed. Up-to-date records of police check numbers for staff were not available. A requirement was made that the company provides a record available to the home verifying that any police checks are satisfactory. This is to ensure that service users are protected by the homes recruitment policies and practices. A requirement was made that all opened packets of cereals are stored in sealed containers. Fire records were maintained adequately but a recommendation was made that the manager considers contacting the fire officer to review the present fire prevention equipment in the home. Further recommendations were made that the deputy manager attends the local authority protection of vulnerable adult training and that training in respect of ageing is perused. Records for the monthly quality visits from the responsible individual were sampled. These visits were being completed but there was a gap for one month. A recommendation was made that up-to-date records are maintained in the home. 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. Springpark DS0000013793.V257193.R01.S.doc Version 5.0 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS
Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Springpark DS0000013793.V257193.R01.S.doc Version 5.0 Page 9 Choice of Home
The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1,3, 4 &5 Adequate information was available that would assist prospective residents and relatives make an informed choice as to whether the home would be a suitable place to live. Pre admission assessments would be implemented and trial visits accommodated to “test drive” the home. Individual contracts were in place. EVIDENCE: There have not been any admissions to the home for a number of years. The Statement of Purpose was sampled which was detailed and comprehensive and clearly describes the homes aims and objectives and services it is able to offer. A service users guide is available. Pre admission assessments are completed and the home is available to offer introductory visits and trial stays Each individual is issued with a contract in the form of statement of terms and conditions. Springpark DS0000013793.V257193.R01.S.doc Version 5.0 Page 10 Individual Needs and Choices
The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 67&8 Each resident is provided with a completed care plan that is based on assessment. The home is able to demonstrate that personal goals are reviewed. Residents are supported to make decisions with assistance. Residents are given opportunities to participate in activities in the home. Confidential information is handled appropriately. EVIDENCE: Two care plans were sampled and each service user has a completed care plan, which has been regularly reviewed and based on assessment. Plans were detailed and structured with clear goal plans in place. Pen portraits, statement of choice, guidelines and risk assessments were completed and upto-date. At the previous inspection a recommendation was made that service users emotional needs and how these are being met should be identified in care in care plans. The manager has made progress in recording this information. A further recommendation was made that this information is completed Evidence was observed to support that service users are involved as far as possible in participating in aspects of life in the home. One service user was
Springpark DS0000013793.V257193.R01.S.doc Version 5.0 Page 11 seen assisting in the kitchen and told the inspector she likes to help make drinks and asked the inspector if she would like a drink, making cakes and laying the tables. Service users had been away on holidays and it was evident that holidays taken responded to individual’s preferences and interests. One service user showed her delight by showing the inspector her holiday photographs especially when she recognised herself, staff that she knew and animals that she had seen on her holiday. At the time of the inspection two service users were retuning from chiropody appointments. This was followed by a music session where service users were being supported and encouraged in the activity. Everybody was happy and smiling and responding to music which was clearly be enjoyed by everybody. Springpark DS0000013793.V257193.R01.S.doc Version 5.0 Page 12 Lifestyle
The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 & 17 Systems were in place that ensures service users rights are respected. Service users are offered varied and well-balanced meals. EVIDENCE: It was clear that service users had good relationships with staff and were enjoying being in their company. Staff were interacting with service users and this was seen during a music session and playing board games. Staff were seen talking to and involving service users in discussions and providing support where required. The staff have a good knowledge and understanding of the needs of service users from responding to verbal and non-verbal cues. A service users charter was in place. Menus were sampled and were varied and based on the individual preferences of service users. The teatime meal was seen which was nicely presented and nutritious. One individual requires support with regard to eating, as she is prone to choking. There are clear and detailed guidelines in place which has been implemented with the involvement of the speech therapist. A further requirement was made in respect of where “own choice” is indicated on the menu, that staff must record what individual chooses to eat. Progress has been made in completing this but there were still some gaps present.
Springpark DS0000013793.V257193.R01.S.doc Version 5.0 Page 13 Personal and Healthcare Support
The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 20 Service users are protected by the homes medication policies and procedures. EVIDENCE: Medication records were sampled and records were maintained adequately Medication was stored appropriately. Disposal of medication records were in place. As required medication protocols were completed. A photograph of each service users was present on the homes medication cupboard with a statement describing each individuals preferred way of receiving their medication. Staff receive training from the organisation. Springpark DS0000013793.V257193.R01.S.doc Version 5.0 Page 14 Concerns, Complaints and Protection
The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 23 Written policies and procedures were in place to ensure that residents are protected from abuse. EVIDENCE: There is a clearly written Protection of vulnerable Adult procedure, whistle blowing policy and an updated copy of the local authority protection of vulnerable adults policy in place. A further recommendation was made that the deputy manager attends the local authority protection of vulnerable adults training as this has not yet been completed. Springpark DS0000013793.V257193.R01.S.doc Version 5.0 Page 15 Environment
The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 25, 26,27,29 &30 Service users live in a comfortable, homely environment. The condition of the pathway needs to be reviewed. Bathrooms provide privacy. Service users bedrooms promote their independence. An assessment needs to take place in respect of access in to the house to ensure that service users have the specialist equipment they require. The home is clean and hygienic. EVIDENCE: The home is well maintained and has a homely atmosphere and is in keeping with the local community. The home is in close proximity to local shops and facilities. The home has been redecorated. There is a lounge/dining room and a separate kitchen, which is accessible. There is a large pleasant garden, which is well maintained. However the pathway requires attention, as the slabs are uneven. This is to ensure that the premises are safe. A recommendation was made that the external lighting is reviewed outside the front entrance of the house. Bedrooms were pleasant, comfortable and individualised with belongings. Service users bathrooms and toilets provide privacy and meet individual needs. Specialist equipment is available for one individual.
Springpark DS0000013793.V257193.R01.S.doc Version 5.0 Page 16 However it is required that access to the house is reviewed for one service user who requires a wheelchair to go out with the installation of a ramp. This is to ensure that service users have the specialist equipment they require in place. Records are maintained of routine maintenance including water, heating, electrical certificates. The home was cleaned to a good standard and hygienic Springpark DS0000013793.V257193.R01.S.doc Version 5.0 Page 17 Staffing
The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 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, 34 & 36 Staff are clear of their roles and responsibilities. The home should maintain up to date records of police checks undertaken. This is to ensure that service users are protected by the recruitment and policies and practices. All staff receive appropriate formal supervision. EVIDENCE: Three staff personal files were sampled job descriptions were available with annual appraisals being completed. Staff files were maintained to a good standard and comprehensive. However up-to-date information was not available in respect of police check. A requirement was made that a record of a satisfactory police check must be made available in the home. This is to ensure that service users are protected by the homes recruitment policies and practices. Staff supervision records were sampled and there was clear evidence that regular formal supervision was taking place every two months. A schedule is maintained in the office of the dates of all staff supervision. A further recommendation was made that the manager continues to pursue training given the age of one of the service users who lives in the home. Springpark DS0000013793.V257193.R01.S.doc Version 5.0 Page 18 Conduct and Management of the Home
The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. 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 are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37,40,41, 42 & 43 The home is run well and managed in an open and inclusive atmosphere. Service users interests are protected by the homes policies and procedures. Records were adequately maintained and kept secure. The health, safety and welfare of service users are protected. One issue in respect of food storage requires action. Service users are safeguarded by the financial procedures of the organisation. EVIDENCE: The home was seen to be run in an open and positive atmosphere and the manager portrayed a clear sense of direction and leadership. One member of staff spoken to said she was happy working in the home. Adequate record keeping was place and range of comprehensive policies and procedures were in place, which were sampled including complaints, resident’s finances, record keeping and confidentiality. Springpark DS0000013793.V257193.R01.S.doc Version 5.0 Page 19 The company’s responsible individual conducts monthly quality visits and copies are maintained in the home. There was a gap for one month and a recommendation was made those records of these visits should be up to date. Health and safety policies and procedures were in place including accident reporting, infection control, control of harmful substances. Accident records were maintained appropriately, regular water temperature checks take place, First aid boxes are checked weekly, fridge temperatures are recorded daily and fire drills are up to date. However a requirement was made that opened packets of cereals are stored in sealed containers. The home has smoke detectors in place and emergency lighting is not in place. A recommendation was made that the registered manager should consider arranging for the fire officer to visit the home to review the present equipment in place and that it is sufficient. The overall business plan is set by the organisation but the manager is able to contribute by submitting proposals for the home. The manager receives a budget for the home where copies of statements are maintained. An employer’s liability insurance certificate was in place. Springpark DS0000013793.V257193.R01.S.doc Version 5.0 Page 20 SCORING OF OUTCOMES
This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score 3 X 3 3 3 Standard No 22 23 Score X 3 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 3 X 3 3 X Standard No 24 25 26 27 28 29 30
STAFFING Score 2 3 3 3 X 2 3 LIFESTYLES Standard No Score 11 X 12 X 13 X 14 X 15 X 16 3 17 Standard No 31 32 33 34 35 36 Score 3 X X 2 X 3 CONDUCT AND MANAGEMENT OF THE HOME 2 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21
Springpark Score X X 3 X Standard No 37 38 39 40 41 42 43 Score 3 X X 3 3 2 3 DS0000013793.V257193.R01.S.doc Version 5.0 Page 21 Yes Are there any outstanding requirements from the last inspection? Springpark DS0000013793.V257193.R01.S.doc Version 5.0 Page 22 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 17 Regulation 17(2)( Requirement The registered manager must ensure that where “own choice is indicated on the menu, that staff record what each individual chooses what to eat. This is to provide a clear record of anything eaten by service users in the home. The registered manager must review installing a ramp dependent on the outcome of the assessment from an occupational therapist. This is to ensure that service users have the specialist equipment they require. The pathway to the front of the house must be attended to, as it is uneven. This is to ensure the heath, safety and welfare of service users, staff and visitors to the house. The registered manager must ensure that evidence of police checks carried out for staff are made available in the home. This is to ensure that service users are protected by the homes recruitment policies and practices. The registered manager must ensure that all opened packets of cereals are stored in sealed containers. Timescale for action 28/11/05 2 YA 29 23 (2) (n) 28/01/06 3 YA 24 23 (2) (b) 01/01/06 4 YA 34 19(5)(a) Schedule 2 05/12/05 5 YA 42 16 (2) (j) 05/12/05 Springpark DS0000013793.V257193.R01.S.doc Version 5.0 Page 23 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 2 3 4 5 5 Refer to Standard YA 6 YA 29 YA 35 YA 35 YA 33 YA 42 Good Practice Recommendations It is recommended that the registered complete the service users care plans to include service users emotional needs and how these are met. It is strongly recommended that the external lighting is reviewed at the front of the house. The manager should continue to pursue accessing training for staff in ageing. It is recommended that the deputy manager attend the local authority training for the protection of vulnerable adults. It is recommended that the reports of the monthly quality visit from the responsible individual are kept up-to-date The registered manager should consider arranging for the fire officer to review the fire equipment in the home. Springpark DS0000013793.V257193.R01.S.doc Version 5.0 Page 24 Commission for Social Care Inspection Surrey Area Office The Wharf Abbey Mill Business Park Eashing Surrey GU7 2QN National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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