Inspection on 17/10/07 for Springvale Court

This inspection was carried out on 17th October 2007.

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

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Springvale Court 12/09/06

Springvale Court 11/10/05

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 Andrea Goodall Key Unannounced Inspection 10:00 17 , 22 & 29th October 2007 th nd 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.V346729.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Springvale Court DS0000054914.V346729.R01.S.doc Version 5.2 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 anneburns@barchester.com Barchester Healthcare Mrs. Anne Burns 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.V346729.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 12th September 2006 Brief Description of the Service: Springvale Court provides personal care for up to 40 older people, some of whom may have dementia related needs. Nursing care is not provided, but district nursing service can be arranged where necessary. It is a two-storey, purpose built home and has been operating for about 10 years. It provides 40 good sized single bedroom, all with en-suite facilities. There is level access into 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 close to local public transport links. The weekly fees range from £364 (local authority-funded) to £478 (privatelyfunded). Springvale Court DS0000054914.V346729.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. Before the visit: We looked at: • information we have received since the last full visit on 12th September 2006 and a shorter visit on 22nd March 2007 • how the service dealt with any complaints & concerns since the last visit • any changes to how the home is run • the provider’s view of how well they care for people • the views of people who use the service & their relatives, staff & other professionals. The Visit: An unannounced visit was made on date 17th October 2007. Two more visits were made on 22nd and 29th October 2007. During the visit we: • talked with people who use the service, relatives, staff, the manager & visitors • joined residents for two meals and looked at how staff support the people who live here • looked at information about the people who use the service & how well their needs are met • looked at other records which must be kept • checked that staff had the knowledge, skills & training to meet the needs of the people they care for • looked around parts of the building to make sure it was clean, safe & comfortable • checked what improvements had been made since the last visit. We told the manager what we found at each visit. What the service does well: The home always carried out full assessments so that it can make sure that a person’s needs can be met if they move here. The home supports people to have good access to any health care that they need. One visitor commented, “The staff are always able to say how my mum is and what’s happening health-wise. All staff seem to show an interest in how she is.” Staff support residents in a sensitive way and their dignity is respected. For example, sitting with individual residents to help them at mealtimes. Springvale Court DS0000054914.V346729.R01.S.doc Version 5.2 Page 6 The home has a friendly, sociable atmosphere. One resident said, “I’m very happy here, it’s much better that the last place I was at.” Visitors said that they are made welcome and said many good things about the home. One visiting relative said, “It’s excellent. I would be happy to move in anytime!” Residents described the quality of meals as “very good”. One resident said, “It’s generally very good. You can’t please everyone but they make a good try at it. Staff try very hard to please us.” The accommodation is comfortable, warm and well furnished. Residents can bring their own furniture and personal items for their bedroom to make it feel more like home. One relative said, “They are lovely rooms, all fitted out with everything they need.” Staff have good training to make sure that they know how to support people in a safe way. Residents said they get good support from staff. One resident said, “The girls are smashing. They are always friendly and helpful.” One relative said, “All the staff seem genuinely friendly.” The home is well run by the manager with good support from the Provider. The Provider makes regular visits to the home to check that it is running in the right way for the people who live here. What has improved since the last inspection? What they could do better: Springvale Court DS0000054914.V346729.R01.S.doc Version 5.2 Page 7 Each resident (and/or their relative) should have a copy of the Service Users Guide so that they have information about the service at this home. It would also be better if people had a copy of their contract when they move in so they can see the terms and conditions of their stay. Medication records should be filled in when people have had support to use prescribed creams. If people use their own creams without support this should be recorded in their medication assessment. It would be better if new residents were always given a key to their bedroom as soon as they move to the home, if they can manage it. It would be better if people could help themselves at buffet meals, if they can manage this, so that they can keep up their independence. The lighting to bedroom is too dim so light bulbs should be replaced. All the checks and clearance for new staff must be received by the home before a new member of staff starts work. The records of residents’ personal monies must be kept in good order so that it can be properly accounted for. 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. Springvale Court DS0000054914.V346729.R01.S.doc Version 5.2 Page 8 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.V346729.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 3 and 5. (NMS 6 does not apply to this service.) People who use this service experience adequate quality outcomes in this area. Good assessment processes ensure that potential residents’ needs can be met, but people receive insufficient information about the service to help them make an informed decision about whether to move here. We have made this judgement using a range of evidence, including a visit to this service. EVIDENCE: The home provides a clear information pack about the service in an easy-toread Service Users Guide. However, there is only one copy of the guide in the home, which is in the reception area. This information is not currently made available to potential or existing residents. In this way individual residents do not have their own information about the service. Springvale Court DS0000054914.V346729.R01.S.doc Version 5.2 Page 10 Some of the information in the Service Users Guide is now outdated, for example mealtimes and the range of fees. Before any resident moves to the home they are assessed by a care manager of the Social Services Department, and also by senior staff of Springvale Court. The home uses both the social work reports and it’s own assessment processes to ensure that the full details of a potential resident’s needs are obtained before their admission. This means that only people whose needs can be met are admitted to the home. The assessment records that were sampled also included details of each resident’s background, life history, and cultural and spiritual needs. In this way the home aims to support people’s diversity of social care needs. Wherever possible, residents and their relatives are encouraged to come and have a look around the home prior to their move here. Some relatives described how they had chosen this home from a range of other services in the area. They said, “I was really concerned about it before he moved here. I probably chose it because the bedroom was nicely decorated. But he’s settled really well and everyone seems so friendly.” At the end of six weeks a new resident’s placement at the home is reviewed to make sure the service can continue to meet their needs. At that time the resident is provided with written terms and conditions of residence to sign. However this document contains some very important information (for example, the level of fees) that a new resident would benefit from having on admission to the home, and so would have time to consider before signing. Springvale Court DS0000054914.V346729.R01.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10. People who use the service experience good quality outcomes in this area. Overall, residents have good support with personal care and good access to health care services, which ensures that their needs are met. We have made this judgement using a range of evidence, including a visit to the service. EVIDENCE: At a random inspection in March 2007 it was evident that the home had made good improvements to care planning. During this inspection it was demonstrated that this is an area that continues to improve. After a resident has moved to the home a care plan is designed around their assessed needs so that staff know how to provide the right support. Most of the sample of care plans examined clearly outlined each resident’s needs and how these should be supported. (The manager had completed these and were very good examples of care planning). Springvale Court DS0000054914.V346729.R01.S.doc Version 5.2 Page 12 In a small number of care plans staff had not set out clear guidance on how to support residents, for example one simply stated “assist with personal hygiene”. There was no indication of what the resident could still manage themselves and what they required support with. All care plan goals are reviewed on a monthly basis and all were up-to-date. However a smaller number of care plans did not follow-up any changes in need. For example, a couple of residents had lost significant amounts of weight. This was reported in the monthly evaluation but without any indication of what action had been taken. Some risk assessments had not been reviewed even though the circumstances had changed (e.g. a resident who no longer smokes). A risk assessment had not been put in place even where there were potential risks (e.g. a resident bathing without support). Overall, the care files contained clear assessments to monitor residents’ wellbeing, for example with mobility, falls, and nutrition. There were some very good instances of how the assessment and care planning processes led to improved support for residents. For example, clear assessment of one resident’s mobility needs, and a subsequent analysis of falls, led to a referral to the specialist Falls Team and additional staff supervision at particular times. The home ensures that all residents are registered with appropriate community health care services, including GP, dental, ophthalmic and chiropody services. The home has good contact with district nursing services, and requests referrals to specialist services such as dietician and nutritional nurses. It is good practice that the home provides taxis (and a care staff, where necessary) for residents who need to attend outpatient appointments. One visitor commented, “The staff are always able to say how (my relative) is and what’s happening health-wise. All staff seem to show an interest in how she is.” There are self-administration assessments for people who may be able to manage their own medication. However this does not always show the actual outcome of the assessment. For example, one resident had signed an assessment that showed she was capable of managing her own medication. However the assessment did not record that she had chosen not and that staff were actually managing her medication. At this time no-one manages their own oral medication (e.g. tablets and liquids). However some people do manage their own prescribed creams, ointments and inhalers, but this was not recorded within a medication assessment. Springvale Court DS0000054914.V346729.R01.S.doc Version 5.2 Page 13 Senior staff are responsible for the administration of medication, and they are provided with training in the safe handling of medicines. There is secure, suitable storage for medication, and administration of medication was carried out correctly. In most cases prescribed creams are kept in resident’s own rooms for easy access. However on the MARs (medication administration records) there is no record of whether prescribed creams or ointments have been used by a resident (either with or without support from staff). During the inspection visits there were many instances of good practice where staff supported residents in a sensitive and respectful way. For example, sitting with individual residents to provide sensitive and engaging support at mealtimes, and supporting people with their mobility at the resident’s own pace. Residents are supported with their personal grooming and appearance. A weekly hairdressing service is available at the home, which several residents use. Residents can use their own bedrooms for privacy whenever they wish. There are easy-to-use locks on the inside of bedroom doors if residents do not wish to be disturbed, although few people use these. Some people have keys for their bedroom door so they can lock it when they are out of the building. However some newer residents had not been given a key on admission. It was stated that this was an oversight, and by the next visit those residents had been given their own key. Springvale Court DS0000054914.V346729.R01.S.doc Version 5.2 Page 14 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15. People who use the service experience good quality outcomes in this area. Residents have good opportunities to make choices about social activities, daily routines and menus so that they lead a lifestyle that matches their individual preferences. We have made this judgement using a range of evidence, including a visit to the service. EVIDENCE: As reported in the random inspection in March 2007, there have been improvements to leisure and social activities in this home, and this has continued. The home employs an activities co-ordinator who organises a range of activities each afternoon between lunchtime and teatime, as this is when most residents would have least stimulation otherwise. There is a list of the forthcoming activities in each dining room so that residents can refer to these several times a day. Many activities are purposeful occupations that result in a meaningful product. For example, woodwork Springvale Court DS0000054914.V346729.R01.S.doc Version 5.2 Page 15 sessions where residents build old-fashioned shop windows to display in the corridors; cake-baking sessions with the cook; and gardening sessions where residents have created a flower bed area. (Springvale Court garden was in the finals of a ‘Barchester in Bloom’ competition this year.) On the first day of this unannounced visit several residents were going out for an afternoon trip along the coast. Residents were clearly excited and looking forward to their outing. The home provides at least weekly chances for people to go out and this supports their continued motivation for community contact. The home supports people to use the local library, churches, and musical events at the local community hall. Staff also supports people to go out on individual shopping trips for new purchases, for example one person was going out today to buy a new television with a staff member. It was clear from discussions with many residents that their emotional wellbeing is being supported by the homes friendly, sociable atmosphere and their interaction with staff and other residents in the home. One resident said, “I’m very happy here, it’s much better that the last place I was at.” Visitors also had many positive comments to make about the service provided at this home. One visiting relative said, “It’s excellent. I would be happy to move in anytime!” The home invites relatives to residents’ meetings and to social events. The home provides information booklets and contact details of local and national advocacy services to relatives and residents. Residents described the quality of meals as “very good”. One resident said, “It’s generally very good. You can’t please everyone but they make a good try at it. Staff try very hard to please us.” There are colourful written menus on each table in all three dining rooms that show that day’s menu choices. It is very good practice that residents are also visually shown plates of both main dishes at the time of the meal so that they can make an informed choice whilst seated at the table. This supports their decision-making and communication skills. One person has a softened diet and this is appropriately presented in the same way as other meals to make it as appetising as possible. The tables are well presented with condiments, napkins and (where residents capabilities allow) teapots. In these ways, most residents are encouraged to help themselves to condiments and drinks. However, at a buffet teatime meal, residents were asked to choose from a large tray of sandwiches that was then taken away around the other tables. Most residents would have been very able to serve themselves if a tray of sandwiches had been placed on each table. Similarly a tray of chocolate cake Springvale Court DS0000054914.V346729.R01.S.doc Version 5.2 Page 16 was taken from table to table so residents only had the chance of one piece of cake. A tray of cake on each table would have allowed people to help themselves to the amount they wanted. Some cutlery is now quite blunt which made it difficult for residents to cut up their food. Springvale Court DS0000054914.V346729.R01.S.doc Version 5.2 Page 17 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18. People who use the service experience good quality outcomes in this area. Good complaints and protection systems are in place and dealt with effectively so that residents’ rights are safeguarded. We have made this judgement using a range of evidence, including a visit to the service. EVIDENCE: A summary of the complaints procedure is provided in the residents’ terms and conditions statement, which they receive at the six-week review. A fuller version of the complaints procedure is in the Service Users Guide, which is in the hallway. At this time the complaints procedure is not available in other accessible formats at this home, for example on cassette or DVD, for people with reading or visual impairments. During discussions residents and their relatives said that would approach the manager if they had any complaints or concerns, and that they were confident that she would deal with these. Springvale Court DS0000054914.V346729.R01.S.doc Version 5.2 Page 18 The home keeps a record of any complaints received that outlines how these were investigated and resolved. There have been two complaints received over the past year. Records clearly showed how these had been resolved. The most recent concern was about the apparent attitude of a member of staff towards a resident. The manager immediately carried out an investigation, took statements from staff, carried out a disciplinary meeting with a member of staff, and notified all relevant agencies of the outcome. This demonstrates that the home responds quickly to concerns, and takes appropriate action. All staff receive adult protection training as part of their induction training programme with Barchester Healthcare. Most staff (around 70 ) have also attended training in local safeguarding adults procedures provided by the local authority. In discussions the manager was clear in her role and responsibilities in terms of safeguarding adults protocols. There have been no safeguarding issues at this home since the last inspection. Springvale Court DS0000054914.V346729.R01.S.doc Version 5.2 Page 19 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 25 and 26. People who use the service experience good quality outcomes in this area. Overall the standard of decoration and furnishing in the home continues to improve so that residents enjoy good quality accommodation. We have made this judgement using a range of evidence, including a visit to the service. EVIDENCE: There have been considerable improvements to decoration and furnishing in the home since the last inspection. A rolling programme of decoration has meant that many bedrooms and the corridors have been fully refurbished and this is continuing. There are also plans for all bathrooms to be redecorated next year. Springvale Court DS0000054914.V346729.R01.S.doc Version 5.2 Page 20 Overall the building is in a good state of repair and well maintained. The home benefits from having a full-time maintenance staff to attend to minor repairs and redecoration. The home provides 40 good-sized single rooms, all with ensuite facilities. The residents have good access to the home’s garden with staff support, and there is some seating for them to enjoy better weather. The bedrooms examined were comfortable, warm and well furnished. Many have been highly personalised by residents and their relatives with their own antique bed throws, furniture and pictures. One person has brought their own three-quarter bed. Several visitors made very positive comments about the standard of the accommodation. One person said, “They are lovely rooms, all fitted out with everything they needs.” Another visitor commented said, “Since (my relative) moved in they have completely redecorated and refurbished her room. It’s got a new bed, curtains, furniture and carpet – so it’s all matching now and looks very nice.” However several bedrooms have low wattage light bulbs so are dimly lit. The low lighting in bedrooms could present tripping hazards for the people who live here. This was being addressed by the third visit. The living areas of the home also have a good standard of decoration and furnishings. Lounges are comfortable, warm, bright and cheerful. There are also well-used seated areas in corridors. The first floor corridor has many displays of visual interest for the residents, and is referred to as ‘memory lane’. For example, hat stands with different hats and helmets; old shop window-fronts with some traditional old products; and a wedding scene with a couple of life-size mannequins wearing an RAF uniform and wedding dress. There is colour-contrasting and signage to support residents’ orientation. All bedrooms doors are painted different pastels shades. Several residents now have a ‘memory box’ (a small box with small artefacts and photographs that they can relate to) outside their bedroom door. This helps to remind them which is their bedroom. Overall the home was found to be clean and odour control was generally good. Additional cleaning to light pull cords in en-suites, and to dining rooms floors at the end of meals, was fedback to the manager. This was being addressed by the end of the visits. The home has a relatively small laundry area, which is at one end of the ground floor corridor. Although it is directly next to a bedroom there is no noise or vibration in that bedroom. The limited space in the laundry room is compounded by the fact that it also houses the two large heating boilers. As a Springvale Court DS0000054914.V346729.R01.S.doc Version 5.2 Page 21 result there is very little hanging space so some laundered clean clothes are temporarily left in the corridor outside the laundry room. (The manager stated that there are longer-term proposals to address the laundry facilities.) The laundry is well-equipped with washers and tumble driers, but the ironing board cover has clearly been perished for such a long time that it could affect residents’ clothes. Springvale Court DS0000054914.V346729.R01.S.doc Version 5.2 Page 22 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30. People who use the service experience good quality outcomes in this area. The home provides sufficient, competent, well-trained staff to ensure that the needs of the people who live here are met. We have made this judgement using a range of evidence, including a visit to the service. EVIDENCE: The home aims to provide 6 care staff through the day (e.g. 8am-4pm) and 5 care staff through the evening. The daytime staffing levels are designed to provide a senior, or acting senor, and 2 care staff on each floor. The staff rota for the previous week indicated that there had been some occasions when there had only been 4 staff in the evenings due to staff sickness. This was compounded by the fact that the deputy manager was responsible for the management of the home during the annual leave of the manager. This meant there was not enough senior staff on duty for each floor at those times. The manager explained that it is usual practice to use agency staffing on those occasions, but this had not occurred in her absence. Springvale Court DS0000054914.V346729.R01.S.doc Version 5.2 Page 23 There are 4 staff on waking duty through the night. This is good because it allows two staff on each floor to manage any moving and assisting needs of residents during the night. The home employs sufficient domestic, laundry and catering staff. The home also has an administrator (who manages administrative and financial matters), a maintenance staff and an activities coordinator. It was clear from observations and discussions with residents that they enjoy a good relationship with staff. It is good practice that a photograph and name of their keyworker is in some residents’ bedrooms. Many of the residents commented positively on the support they receive from the staff. One resident said, “The girls are smashing. They are always friendly and helpful.” One relative said, “All the staff seem genuinely friendly.” The Provider is an equal opportunities employer and promotes clear equality and diversity procedures when recruiting new staff. There is a mix of age, gender, experience, and nationality amongst the staff team. The home ensures gender-appropriate support by making sure that the 2 male care staff do not provide intimate personal care for female residents. Staff records showed that, in most cases, suitable checks and clearances are received before a new staff is employed. However at the time of the first visit one new member of staff was on duty before their Criminal Records Bureau check had been received. The manager explained that this was an isolated incident where a new staff member had initially come into the home for induction training but due to staff sickness had covered a shift. However the manager accepted that this was contrary to recruitment practices. It was clear from training records and from discussions with staff that Barchester Healthcare provides very good training opportunities. Individual training and development records clearly show the courses that each member of staff has completed. A computerised training events programme also highlights when training certificates will expire so that further training can be arranged in a timely way. All new staff receive in-depth induction training (that complies with Skills for Care Council standards), and have support to go onto further training in care. Of the 19 care staff, 16 have achieved NVQ level 2 (a care qualification). It is also good practice that catering and domestic staff have also achieved, or are undertaking, NVQ qualifications in their areas of work. Around 13 care staff have had training in ‘Positive Dementia Care’, which supports them in their care of people with dementia care needs who live here. Springvale Court DS0000054914.V346729.R01.S.doc Version 5.2 Page 24 The home makes good use of a number of training agencies, as well as Barchester Healthcare’s own training section. The home also has computerised in-house training to support staff in mandatory annual training. Springvale Court DS0000054914.V346729.R01.S.doc Version 5.2 Page 25 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 and 38. People who use the service experience good quality outcomes in this area. Overall the home is well-run in a way that upholds the best interests of the people who live here, and ensures their health, safety and welfare are protected. We have made this judgement using a range of evidence, including a visit to the service. EVIDENCE: The registered manager has many years experience in health and social care settings. She is a qualified nurse who has been a manager of care services for over 15 years and has been the manager at Springvale Court for around 4 years. She has also attained the Registered Managers’ Award, which demonstrates her continuing professional development. Springvale Court DS0000054914.V346729.R01.S.doc Version 5.2 Page 26 There are clear lines of accountability within the home and within the organisation. The manager stated that the home is very well supported by the senior management of Barchester Healthcare. She is supervised by a Regional Operations Director who also visits the home at least once a month and reports back to the organisation on the findings. There are monthly visits by a Clinical Development Nurse, who also carries out audits of the home’s operations. Barchester Healthcare’s comprehensive quality assurance system also includes a number of audits of the service by external consultants, for example health and safety, and catering audits. Residents’ views of the service are sought during the Provider’s monthly visits, as well as via 6-monthly questionnaires. The home holds occasional Residents’ Meetings, although there have only been two this year. Meetings are a good opportunity for people to give their comments and suggestions that can influence the service. For example, during the last Residents’ Meetings some people suggested that they would like to grow their own vegetables and this is to be arranged. Some residents and/or their relatives continue to manage their own financial affairs and this is encouraged by the home. The homes administrator does support some residents with the safe storage of their personal monies, if they wish. These are stored individually. However the handwritten records of transactions carried out by the home on behalf of residents are not well managed. The dates of receipts of transactions carried out on behalf of resident (e.g. for hairdressing) did not correspond to the written record. In some cases monies had been passed to relatives, but receipts indicated the monies had been deposited at the home. This means that residents’ monies cannot be properly audited or accounted for. Computerised systems for recording and accounting or residents’ personal monies are to be introduced in the very near future. This will resolve the current shortfalls in recording, and means that residents will have access to individual printed statements. Staff receive training in statutory health & safety matters so that they know how to support residents in a safe way. It is good practice that the manager is a moving & assisting trainer so that all staff can receive refresher training in this area within the home. All catering and care staff (and some domestic staff) have training in food hygiene. There are sufficient staff trained in first aid to ensure that there is always an appointed first aider on duty. Springvale Court DS0000054914.V346729.R01.S.doc Version 5.2 Page 27 The maintenance staff carries out regular health & safety checks to the building and to equipment used by the people who live here. There are also clear records of the maintenance and servicing of equipment (for example, the lift and bath hoists) by external services. Water temperature records kept by the maintenance staff (and tests carried out during the visit) demonstrated that hot water to washbasins and baths is issued at the correct safe hot water guidelines of around 43°C. However all records of baths taken by the 40 people who live here (recorded by care staff) indicate that the hot water in baths is always exactly 38°C. During this visit all staff on duty were under the impression that hot water should be 38°C. However it is unlikely that hot water to baths is being mixed to always achieve exactly 38°C. In discussions staff stated that bath temperature is mixed to individual preference of the resident. Springvale Court DS0000054914.V346729.R01.S.doc Version 5.2 Page 28 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 2 2 3 X 3 N/a HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X X 2 3 STAFFING Standard No Score 27 3 28 3 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 2 X X 3 Springvale Court DS0000054914.V346729.R01.S.doc Version 5.2 Page 29 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 OP1 Regulation 5(2) Requirement Each resident (or their representative) must have a copy of the Service Users’ Guide. The Service Users Guide must also be made available in audio format that includes the complaints procedure. Timescale for action 01/01/08 2. OP9 13(2) This is to ensure that each person has information about the service at Springvale Court in an accessible format to suit their communication needs. The administration of prescribed 01/12/07 medicated ointments and creams must be recorded within the medication administration records. This is to ensure that residents receive their medication, as prescribed and directed by their GP. The lighting to all bedrooms must achieve a minimum of 150 lux (e.g. the equivalent to a 100 watt light bulb). This is to ensure that the rooms are bright enough for the people 3. OP25 23(2)(p) 01/01/08 Springvale Court DS0000054914.V346729.R01.S.doc Version 5.2 Page 30 4. OP29 19(5) who live here. All new staff must have a 01/12/07 Criminal Records Bureau check before starting work. The commencement of new staff with only a POVAFirst check must be in ‘exceptional circumstances’ and must be first agreed with the CSCI. This is to ensure that only suitable people provide care for the people who live here. The records of resident’s individual personal monies held by the home, and of any transactions carried out on their behalf, must be correctly completed and infallible. This is to ensure that residents’ monies are properly accounted for on their behalf. 5. OP35 17, Sch 4 .(9)(a)&b) 01/12/07 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 OP1 OP2 Good Practice Recommendations The Service Users Guide should be amended to reflect any changes, and should include the full range of fees. Consideration should be given to providing new residents with a copy of the terms and conditions of residence on admission so that they have had time to consider those terms before signing at the six-week review. Care plan objectives should include the level of ability that each resident still retains in daily living skills (as well as the details of staff support they need). Risk assessments records should outline more fully the potential hazards and all possible solutions to show the reason and outcome of the assessment. Where a risk assessment no longer applies it should be changed at the DS0000054914.V346729.R01.S.doc Version 5.2 Page 31 3. 4. OP7 OP7 Springvale Court 5. OP9 6. OP10 7. 8. 9. 10. 11. OP15 OP15 OP26 OP27 OP38 next review. If a medication assessment identifies that a resident has the ability to self-administer their own medication, the record should then make clear whether they choose to do this or not. It should be part of the admission process that residents are given a key to their bedroom door on the day that they move here, unless a written risk assessment determines otherwise. Residents should have the chance to independently serve themselves from buffet meals, wherever capabilities allow. The cutlery should be reviewed so that blunt knives can be replaced. The ironing board cover should be replaced, and staff reminded to report any future equipment needs directly to the manager. Arrangements should always be made for the provision of an additional senior staff to cover the deputy manager’s role when she is deputising in the absence of the manager. Records of the temperature of baths should reflect the actual temperature of the water. Springvale Court DS0000054914.V346729.R01.S.doc Version 5.2 Page 32 Commission for Social Care Inspection South Shields Area Office 4th Floor St Nicholas Building St Nicholas Street Newcastle Upon Tyne NE1 1NB 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 Springvale Court DS0000054914.V346729.R01.S.doc Version 5.2 Page 33 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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