Inspection on 11/10/05 for Springvale Court

This inspection was carried out on 11th October 2005.

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 found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Springvale Court 17/10/07

Springvale Court 12/09/06

Springvale Court 07/04/05

Springvale Court 13/12/04

Springvale Court 04/06/04

Springvale Court 02/03/04

Similar services:

Turret Villa Retirement Home

Moor House

Mendip House

Beaconsfield Court Care Home

Little Sisters Of The Poor

Manor House

Middleton Hall Ltd

Middlesbrough Intermediate Care Centre

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

CARE HOMES FOR OLDER PEOPLE Springvale Court Springvale Road Wrekenton Gateshead DH9 7AD Lead Inspector Mr Lee Bennett Announced Inspection 11th October 2005 09:30 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 Springvale Court DS0000054914.V250894.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 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. Springvale Court DS0000054914.V250894.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Springvale Court Address Springvale Road Wrekenton Gateshead DH9 7AD 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) 0191 482 4573 0191 487 2927 Barchester Healthcare Care Home 40 Category(ies) of Dementia - over 65 years of age (13), Mental registration, with number Disorder, excluding learning disability or of places dementia - over 65 years of age (1), Old age, not falling within any other category (29), Physical disability over 65 years of age (3), Sensory Impairment over 65 years of age (5) Springvale Court DS0000054914.V250894.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 7th April 2005 Brief Description of the Service: Springvale Court is care home in which personal care can be provided for up to 40 older people, some of whom may have dementia related needs. Nursing care is not provided, but can be arranged with the District Nursing Service where necessary. It is a two storey, purpose built home. Level access is provided to the home and a lift provides access between the two floors. There is a garden area at the rear of the home, which includes a paved seating area. The home located on the southern outskirts of Gateshead and is situated near to a range of local facilities, including a doctors surgery, a supermarket, shops, pubs and places of worship. It is also located close to local public transport links. Springvale Court DS0000054914.V250894.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection was carried out over 8 hours and was a scheduled announced inspection. A tour of the building took place, and staffing and service users records were inspected. Service users, staff, the acting manager and visitors were spoken with, and the two inspectors present both took a meal with service users. The judgements made are based on the evidence available to the inspector on the day of the inspection, the pre-inspection questionnaire supplied by the prospective manager and the comment cards completed by service users and their relatives. What the service does well: There is a member of staff specifically employed to promote and arrange leisure activities in the home. She was observed to work well in motivating service users to become involved in activities. A good atmosphere is apparent in the home. Service users and relatives report that staff and the manager make them welcome. Service users stated that staff are supportive, attentive and addressed their needs. Comments included: • • “(Staff are) second to none.” (The manager) is a lovely woman … makes herself known.” The vast majority of relatives who responded by questionnaire stated that they are satisfied with the overall care provided. What has improved since the last inspection? An experienced and permanent manager has been recruited to the home, and a previous requirement relating to providing evidence of insurance cover has been addressed. Several staff are working to attain their NVQ awards in care, with some also having achieved this since the last inspection. The carpet in the lobby area has been replaced. Springvale Court DS0000054914.V250894.R01.S.doc Version 5.0 Page 6 What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Springvale Court DS0000054914.V250894.R01.S.doc Version 5.0 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 Springvale Court DS0000054914.V250894.R01.S.doc Version 5.0 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): Standard 6. Intermediate care is not provided at Springvale Court. EVIDENCE: At the time of the inspection, the aim and purpose of the home was to offer permanent placements only. Springvale Court DS0000054914.V250894.R01.S.doc Version 5.0 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): Standards 7, 8 and 9. Service users do not always have a plan of care in place, and where these exist do not always reflect observed and recorded need areas, such as healthcare needs and behaviours that challenge the service. This may lead to significant needs not being met in a planned and consistent manner. Medication is administered in a safe manner, but guidance for as required medication to address agitation and difficult behaviour is needed. EVIDENCE: Service users living at Springvale Court have a range of needs, primarily related to aging or dementia. These may include sensory loss, physical frailty, behaviours that challenge the service, loss of appetite, and so on. How the service supports service users in meeting their needs is outlined within their care plans, however those sampled did not always provide guidance in respect of observed or assessed needs. For example, one service user was observed to be verbally challenging and threatening towards other service users, which staff indicated was a common occurrence. There was no care or behaviour support plan in place to guide staff in this area. Similarly, the medical care plan for a service user highlights no need for action other than maintaining contact with the GP, where the person is assessed as having a range of health Springvale Court DS0000054914.V250894.R01.S.doc Version 5.0 Page 10 and physical related needs, including eye surgery, an under-active thyroid, a history of strokes and a cataract. These medical needs may affect the way in which personal care is planned and provided, yet no guidance in respect of a care plan is available. Where another service user had experienced a loss of weight, again there was no plan of care indicating how the service was to respond to this need. The lack of care planning, care plan monitoring and evaluation may mean that the positive work the home undertakes is not evidenced, and that good practice may not be applied consistently and in a planned manner. Medication is in most cases managed and administered by staff on behalf of service users. A member of staff was observed to administer medication in a safe manner, and the storage and recording arrangements are adequate for the types and quantities of medication used in the home. The temperature of the medication fridge is monitored, however the temperature record could not be located on the day of the inspection. The floor in the medication room was sticky, and requires cleaning. The loose stock balance for a service user who requires ‘as and when required’ medication was not clearly recorded (for example by adding a carried over balance from one administrative record (MAR sheet) to another) and clear guidance on it’s use must be developed, made available to staff and subject to frequent review. This is a requirement of this report. Springvale Court DS0000054914.V250894.R01.S.doc Version 5.0 Page 11 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Standard 12, 13 and 15. Recreational and leisure time interests are promoted within the home, which can provide a range of activities and occupation for service users. Service users are able to maintain community and family links, which can help to ensure they do not become socially isolated. Service users are offered a choice of meals, to help promote their general health and wellbeing. EVIDENCE: Throughout the inspection, visitors were observed to call to the home and relatives stated that they are able to visit in private. The activities coordinator is also able to assist service users in accessing local community facilities, and of those service users who commented, 8 stated that the home provides suitable activities, 3 stated this was the case ‘sometimes’, and 1 stated that suitable activities were not provided. Two service users did not respond. Service users are offered choices at meal times, and one service user commented that they are enabled to be independent, but assistance is available when needed. Springvale Court DS0000054914.V250894.R01.S.doc Version 5.0 Page 12 The lunchtime meal was well presented, nutritious, and served in a congenial setting, however the dining rooms upstairs are small for the numbers of people using them. Service users commented positively on the meal provided, with all having a dinner of sausage and leek followed by ice cream. The menus inspected indicate that there is a choice for each meal. On the first floor, staff were available to assist service users where needed. When a service user displayed disruptive behaviour during the meal time this was dealt with by leading this person to an alternative area for them to eat their meal. Consideration may also be given to the seating arrangements (by seating this person nearer the door), thereby enabling staff to more easily encourage this service user to leave the dining room where necessary. Springvale Court DS0000054914.V250894.R01.S.doc Version 5.0 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): Standard 16. The home has a clear and accessible complaints procedure, which can contribute to service users views and concerns being expressed, acknowledged and addressed. EVIDENCE: Those service users (and visiting relatives) spoken with stated that they knew what to do if they were unhappy with any aspect of the service provided. A record of formal complaints received by the home is kept. The information provided on the pre-inspection questionnaire indicates that no complaints have been received in the last twelve month. Of the service users who completed and returned comment cards regarding the home, 12 stated that they were aware of the home’s complaints procedure, 1 stated that they were not. Similarly, 8 relatives were aware of how to complain, 3 were not. Springvale Court DS0000054914.V250894.R01.S.doc Version 5.0 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): Standard 19, 22, 24, 25 and 26. The home is in need of general redecoration and further refurbishment and cleaning arrangement require review. A well maintained environment is important as this can help promote a positive image for service users, and ensure they remain safe. There is inadequate storage available for equipment and laundry skips. This can present trip hazards to service users, staff and visitors. Adaptations and specialised equipment have been sought and obtained, which can contribute to the independence and safety of service users. EVIDENCE: Some refurbishment work has been undertaken in the home, including the replacement of the lobby carpet. New seating has also been obtained, which is designed to help people get up from a seated position more easily. Several carpets were noted to be badly stained, there was an unpleasant and pervasive odour present upstairs, and a bathroom lock was missing. Attention Springvale Court DS0000054914.V250894.R01.S.doc Version 5.0 Page 15 to detail in attending to cleanliness and maintenance issues is required, as although the home appears to be generally clean, areas such as sinks, toilets, kicker plates on doors, and cupboards were all noted to require cleaning. Current domestic staffing arrangements are for domestic staff only work in the morning, with no cover beyond 1:00pm. This is not conducive to the effective cleaning of the home, and staffing arrangements must be reviewed in terms of deployment and numbers. Bathrooms are stark in appearance, and would benefit from a warmer decorative scheme. Several areas of ‘boxing-in’ have bare wood where the paint has worn away. Generally, the home benefits from being a purpose built facility, with each bedroom having an en-suite toilet and wash hand basin. All of the rooms exceed 12 square meters in size, and there are some adapted bathing facilities and a walk-in shower. The ground floor bedrooms to the rear of the home have both an internal and their own external doorways, for which an additional charge applies. Springvale Court DS0000054914.V250894.R01.S.doc Version 5.0 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): 28, 29 and 30. Just under half the staff team have attained an NVQ award in care, which can contribute to their knowledge of service users’ care needs and improve their care practice. Recruitment records do not provide evidence that safe recruitment practices are consistently applied. This can allow unsuitable candidates to be employed in the home. Staff receive a range of training on a range of subjects relevant to the needs of service users and the aims and objectives of the home. This can help ensure that service users are supported in a safe manner, by staff who have an understanding of service users’ needs. EVIDENCE: The pre-inspection information provided by the prospective manager indicates that 10 care staff (including senior carers and the deputy manager) hold an NVQ qualification, at level 2 or above. This is currently just under half of the team. Some staff are working towards the award, but have yet to complete. It is an expectation, as expressed in the National Minimum Standards, that 50 or more of the care team are qualified by the end of this year. The inspection of recruitment records for all staff recruited to the home since the last inspection indicates that new employees routinely commence duties within the home without full Criminal Records Bureau clearances being received. This practice must cease. Recruits do receive two references prior Springvale Court DS0000054914.V250894.R01.S.doc Version 5.0 Page 17 to commencing employment, however for one member of staff this was an open reference rather than one addressed specifically to Barchester Healthcare. Clear records of staff training are maintained, and care staff have attended courses on health and safety related topics, dementia care, depression, adult protection, first aid, and so on. Training records indicate when particular staff need to attend refresher courses, which can aid effective planning and quality checks. New staff also undertake an induction which covers a broad range of topic areas. The amount of time devoted to this process needs to reflect it’s importance, rather than the 45 minutes it took for one employee to complete it. Springvale Court DS0000054914.V250894.R01.S.doc Version 5.0 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): Standard 31 and 36. The home is managed by an experienced manager. This can contribute to the smooth operation and oversight of the care home. Supervision arrangements require clear planning and monitoring to ensure staff are adequately supervised. Infrequent supervisions can lead to issues not being addressed and good practice not being recognised and supported within a formal setting. EVIDENCE: The prospective manager is a registered nurse (although she does not work in a nursing capacity at the home), and has acted in a management / supervisory capacity for over thirty years. She has worked as a care home manager for fourteen years. She is yet to undergo the ‘fit persons assessment’ to become registered by the Commission for Social Care Inspection. Springvale Court DS0000054914.V250894.R01.S.doc Version 5.0 Page 19 Staff supervisions follow a standardised format with areas such as work performance, development, training, and so on discussed. Those sampled were found to be undertaken infrequently, and should be planned to occur six` times a year. It is also recommended that domestic staff benefit from regular supervision, and the role of senior domestic, or housekeeper might assist in this respect. Springvale Court DS0000054914.V250894.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 Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 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 3 13 3 14 X 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 X 2 X X 3 X 2 2 2 STAFFING Standard No Score 27 X 28 2 29 1 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X X X X 2 X X Springvale Court DS0000054914.V250894.R01.S.doc Version 5.0 Page 21 Are there any outstanding requirements from the last inspection? Yes 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(1) Requirement The registered person must ensure that service users care plans are developed to accurately reflect their health and welfare needs. (The previous action plan date for this requirement was 16/8/05) The registered person must ensure that business and financial planning information is made available for inspection. (The previous action plan date for this requirement was 16/9/05) The registered person must review the storage of equipment in the home, to ensure that it does not present a trip hazard to service users, visitors and staff. (The previous action plan date for this requirement was 16/9/05) The registered person must develop a behaviour management plan, and monitor and review the use of ‘as and when required’ medication used to manage specific behaviours. The registered person must DS0000054914.V250894.R01.S.doc Timescale for action 20/01/06 2 OP34 25(2)(ad) 20/01/06 3 OP38 13(4)(a) & 23(2)(l) 20/01/06 4 OP9 13(2) 20/12/05 5 OP9 13(2) 20/11/05 Page 22 Springvale Court Version 5.0 6 OP19 23(2)(b) 7 OP26 23(2)(d) introduce a clear stock balance record for ‘as and when required’ medication. The registered person must refurbish make available for inspection, and implement plans for the maintenance and refurbishment of the home, in particular the dementia unit. The registered person must review the arrangements for cleaning the home, and implement the finding of this review. 20/01/06 20/12/05 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 Refer to Standard OP28 OP30 OP36 Good Practice Recommendations The registered person should ensure that a minimum of 50 iof care staff working in the home are qualified to NVQ level 2 in care by 2005. The registered person should ensure that the staff induction process is paced at a level that allows adequate time to be devoted to this task. The registered person should ensure that staff receive a minimum of six supervision sessions per year. 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