Inspection on 02/11/06 for Springside

This inspection was carried out on 2nd November 2006.

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

The inspector found no outstanding requirements from the previous inspection report, but made 3 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Springside 05/01/10

Springside 25/09/07

Springside 16/03/06

Springside 05/10/05

Springside 18/02/05

Springside 27/08/04

Springside 18/03/04

Similar services:

2 Perhaver Park

The Vicarage

St George`s

5 Seafield Road

Credence House

Radfords

Honeybourne House

32 Beaumont Way

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

CARE HOME ADULTS 18-65 Springside 71 Halcombe Chard Somerset TA20 4DU Lead Inspector John Hurley Unannounced Inspection 2nd November 2006 09:30 Springside DS0000016241.V316639.R01.S.doc Version 5.2 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 Springside DS0000016241.V316639.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 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. Springside DS0000016241.V316639.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Springside Address 71 Halcombe Chard Somerset TA20 4DU 01460 66340 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) Mr David Edward Wright Mrs Sheila Grace Wright, Mrs Helen Anne Bond Ms Susan Anne Hill Care Home 7 Category(ies) of Learning disability (7) registration, with number of places Springside DS0000016241.V316639.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection Brief Description of the Service: Springside is a domestic scale residential home providing care and support for up to seven people who have learning disabilities. The home is located within easy walking distance of Chard town centre. The house is surrounded by a fenced garden area and is close to local shops and amenities. The manager Susan Hill and a small staff team support the seven people who currently live here. The providers Mr & Mrs Wright also have regular contact with the home and a family based ethos is promoted. Recreational and occupational activities are encouraged on both an individual and group basis. There is a strong focus on outdoor activities including horse riding, stable management and gardening. Maintaining links with friends and family are encouraged, both locally and outside the area. Springside DS0000016241.V316639.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was the first unannounced key inspection of Springside of 2006. The inspection process followed the Commission for Social Care Inspection Inspecting for Better Lives methodology. Prior to the inspection the homes proprietors completed a pre inspection questionnaire. The views of the service users and people important to them were also sought; where appropriate their comments are included in this report. The inspector toured the building, spoke with the management and staff on duty and spoke with service users. They inspected a sample of the service users documentation along with records relating to staff and other documents required by regulation. What the service does well: What has improved since the last inspection? What they could do better: It would further enhance the documentation if individual risk assessments were regularly reviewed, the findings recorded and action taken required to minimise identified risks recorded. Similarly the care plans need to reflect the individual’s health and social needs and aspirations. They must also be kept under review on a monthly basis and any significant events be formally recorded. Springside DS0000016241.V316639.R01.S.doc Version 5.2 Page 6 All staff files must contain all the information required by legislation, such as 2 written references, health declarations and full employment histories. The management must also ensure that all staff receive the statutory training required. It would also be helpful if the staff rotas clearly indicated the time staff start and finish their shifts. The statement of purpose requires updating to currently reflect what is happening at 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. The summary of this inspection report can be made available in other formats on request. Springside DS0000016241.V316639.R01.S.doc Version 5.2 Page 7 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 Springside DS0000016241.V316639.R01.S.doc Version 5.2 Page 8 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. JUDGEMENT – we looked at outcomes for the following standard(s): 1,2 Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. The statement of purpose and service user guide does not reflect the current practices at the home. If followed the stated policies and procedures relating to new admissions will meet the requirements of the National Minimum Standards. EVIDENCE: Through discussion with the manager it was established that the statement of purpose requires updating to reflect the current practices at the home. The manager informed the inspector that on occasions the home is un-staffed leaving one or two service user in the home. This is not mentioned in the statement of purpose or service user guide. The manager of the home informed the inspector that no new service users had taken up residency since the last inspection. They further informed the inspector that should a prospective service user wish to consider taking up residency they would provide information in the form of the service user guide and statement of purpose. This would also be complemented by visits to the home and meeting the existing service users. Springside DS0000016241.V316639.R01.S.doc Version 5.2 Page 9 They further informed the inspector that they would adopt a multi agency approach with regards to any new placements and use the local authorities single assessment process as a start point for establishing the individuals needs and whether the home could meet these needs or not. Through discussion with the service users and feedback from people important to them the inspector established that there were high levels of satisfaction with regard to the pre admission arrangements made by the home. The inspector considers that if the stated policies and procedures with regards to admission are followed then the service will met the National Minimum Standards required. Springside DS0000016241.V316639.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7,9 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. The care plans and risk assessments require further detail The support offered to the service is good EVIDENCE: The service users are considered to be quite independent at the home and are able to say how they wish to be supported. Evidence was seen of the service users involvement with their care plans they further confirmed this. The inspector felt that the information contained within the care plans required improving so that the home could evidence the work that they do with the individuals. Some risk assessments were seen in relation to service users activities, such as going out alone, daily routines and staying alone in the house. Evidence was Springside DS0000016241.V316639.R01.S.doc Version 5.2 Page 11 seen that the risk assessments are being reviewed. Although they highlight risks they do not necessarily identify what measures have been put into place to minimise the risk. Service users are encouraged to make as many decisions about their own lives as possible. The service users and people important to them confirmed this. Springside DS0000016241.V316639.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,15,16 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Service user live a lifestyle that reflects their needs and aspirations. EVIDENCE: Service users confirmed that they are involved in work experience placements and also attend a local day centre. If they wish they also attend evening classes in domestic science and arts and crafts. Service users make use of local facilities such as shops etc. They also enjoy close links with the proprietors other home and often participate in the activities on offer by that service. Service users are able to invite friends and families to the home and they are also able to go out and about with their own friends as long as this has been agreed. Service users told the inspector about inviting friends to the home and Springside DS0000016241.V316639.R01.S.doc Version 5.2 Page 13 about leisure activities. They talked about their Saturday outings and also their visits out with their families. Service users are able to let themselves in and out of the home as they wish. They also confirmed that they open their own post and that they are able to get up and go to bed when they wish although they do get called in the morning if they are going out. Meals are decided on a daily basis and currently the service user supported by the staff cook the meals. Springside DS0000016241.V316639.R01.S.doc Version 5.2 Page 14 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. JUDGEMENT – we looked at outcomes for the following standard(s): 18,19,20 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. The service users health and emotional needs are met by the service. EVIDENCE: The manager informed the inspector that at present none of the service users require assistance with their personal care. The health and social care needs are met through regular dental checks, doctor’s visits when required as well as any other interventions that are required on an as and when basis. The inspector noted that the records relating to medication coming into the home and also medication given to residents who self medicate continue to meet the National Minimum Standards. A regular check is maintained on the stock of medication within the home. The manager said that they have attended a course in relation to medication and found this very helpful. The service users and people import to them have commented that they consider the support offered by the staff with regards to their emotional needs to be good. The interactions between the service users and staff were also observed as professional and appropriate. Springside DS0000016241.V316639.R01.S.doc Version 5.2 Page 15 Springside DS0000016241.V316639.R01.S.doc Version 5.2 Page 16 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. JUDGEMENT – we looked at outcomes for the following standard(s): 22,23 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. The Service users and people important to them consider that their views are listened too and comments made are acted upon. The management need to update their knowledge of current vulnerable adult procedures in relation to multi agency working. EVIDENCE: The inspector was informed that no complaints have been made since the last inspection. The service users and people important to them confirmed to the inspector that they felt confident that they could raise issues with the staff or management and these would be dealt with sensitively and promptly. The home has a comprehensive complaints policy which if required will meet the National Minimum Standards required with some minor adjustments relating to the ability to contact the Commission for Social Care Inspection. The management have not had recent protection of vulnerable adults training; it would be helpful if some consideration were given to undertake training so that they can respond accordingly. Springside DS0000016241.V316639.R01.S.doc Version 5.2 Page 17 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. JUDGEMENT – we looked at outcomes for the following standard(s): 24,30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The standard of the environment and facilities within the home is good providing residents with a clean and homely place to live, which they have been able to personalise. EVIDENCE: On the day of the inspection the home was warm, well maintained and decorated. The furnishings were domestic in nature. The home was clean and there were no unpleasant odours. Service users expressed satisfaction with their environment. The service users informed the inspector that staff do the washing but they help with the vacuuming, food preparation and maintaining their own personal space, with assistance when required. The washing machine is sited so that it has to be accessed through the kitchen but the manager said that soiled linen is carried through in sealed bags. Springside DS0000016241.V316639.R01.S.doc Version 5.2 Page 18 At the time of the inspection it was noted that a large conservatory is under construction at the front of the house. The service users informed the inspector that they felt it would be a nice additional space when completed. Springside DS0000016241.V316639.R01.S.doc Version 5.2 Page 19 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. JUDGEMENT – we looked at outcomes for the following standard(s): 32,34,35 Quality in this outcome area is poor This judgement has been made using available evidence including a visit to this service. The staff files that were seen were found to be incomplete with little evidence that the National Minimum Standards had been applied robustly. There is sufficient evidence to say that staff are adequately supervised. EVIDENCE: These files were checked during a visit to the home. The inspector found that in general employees had not completed an application form, references were not generally taken up and there was no evidence that a robust recruitment process was in place. However all staff had a valid criminal records bureau check but the records available did not contain the necessary documentation that verified the staff member’s identity. The inspector was offered little evidence of a structured induction for new staff and the exact employment status of some of the individuals on the rotas was not clear, i.e. employed or sub contractor. Springside DS0000016241.V316639.R01.S.doc Version 5.2 Page 20 The files that were observed did contain reference to formal supervision carried out at the service, there was also evidence of training carried out, however not all staff have received statutory training. The staff rotas that were shown to the inspector only showed the hours worked that day and not the times that these hours were worked. Springside DS0000016241.V316639.R01.S.doc Version 5.2 Page 21 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. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39, 42 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Views sought from all involved ensure that there is a clear vision for the home. The service users and staff feel supported by the service EVIDENCE: The service is managed on a family centred basis with most of the staff being recruited through the proprietor’s extended family or network of friends. The service users feel included in this family and the feedback received from them and people important to them confirm that they contribute to decisions that effect them. As this is a small home the important issue of service user choice is easily achieved and evidenced. All self-monitoring by the management is informal Springside DS0000016241.V316639.R01.S.doc Version 5.2 Page 22 and seamless, where even the smallest change to the individuals needs is addressed at the time. The registered manager lives on site and offers good continuity of support for both the service user and staff. The service users informed the inspector that they felt safe at the home and were comfortable with the management arrangements, identifying themselves as one big family. There are currently risk assessments in place with regard to the environment. The sample of these that were observed met the National Minimum Standards required. Health and safety requirements were checked at the previous inspection where the National Minimum Standards were found to have been met. Springside DS0000016241.V316639.R01.S.doc Version 5.2 Page 23 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 Standard No Score 1 2 2 3 3 x 4 x 5 x INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 x 26 x 27 x 28 x 29 x 30 3 STAFFING Standard No Score 31 x 32 2 33 x 34 1 35 x 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 x 2 x LIFESTYLES Standard No Score 11 x 12 3 13 3 14 x 15 3 16 3 17 x PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 x 3 x 3 x x 3 x Springside DS0000016241.V316639.R01.S.doc Version 5.2 Page 24 no 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 YA6 Regulation 15 (1)(2)(a) (b)(c)(d) Timescale for action Unless it is impracticable to carry 01/02/07 out such consultation, the registered person shall, after consultation with the service user, our a representative of his, prepare a written plan (“the service users care plan”) as to how the needs in respect of his health and welfare are to be met. The registered person shall – make the service users plan available to the service user; Keep the service user plan under review; Where appropriate and unless it is impracticable to carry out such consultation, after consultation with the service user or a representative of his, revise the service users care plan and notify the service user of any such revision. This is with specific reference to ensuring that any care plan is reflective of the individual’s needs and aspiration and provides details with regards to how these needs are to be met. Springside DS0000016241.V316639.R01.S.doc Version 5.2 Page 25 Requirement 2 YA9 13(4) (c) The registered person shall ensure that unnecessary risks to health or safety of the service user are identified and so far as possible eliminated. This is with specific reference to carrying out full and comprehensive risk assessments relating to the individual service users and the environment of the service. The registered person shall not employ a person to work at he care home unless full and satisfactory information is available in relation to him in respect of the following matters - each of the matters specified in paraghs1to 6 of schedule 2 and schedule 4 point 6 of the Care Homes for Adults (18-65) National Minimum Standards Care homes regulations. This is with specific reference to ensuring all the above required information is available in relation to the staffs records, such as proof of identity, 2 references etc for all staff who work at the home. 01/02/07 3 YA34 19(1)(5) (d)(i) 01/02/07 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 Refer to Standard YA1 YA23 Good Practice Recommendations The registered person should consider updating the statement of purpose and service user guide to reflect the current practices of the service. The registered manager should consider updating their DS0000016241.V316639.R01.S.doc Version 5.2 Page 26 Springside 3 YA42 training with regards to vulnerable adults procedures The registered manager should consider attending training in relation to risk assessments Springside DS0000016241.V316639.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Somerset Records Management Unit Ground Floor Riverside Chambers Castle Street Taunton TA1 4AL 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 Springside DS0000016241.V316639.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. 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