CARE HOMES FOR OLDER PEOPLE
Springwater Lodge Care Home 10 Smithy View Calverton Nottingham NG14 6FA Lead Inspector
Karmon Hawley Unannounced Inspection 13th September 2005 10:00 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information
Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Springwater Lodge Care Home DS0000040348.V250241.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. Springwater Lodge Care Home DS0000040348.V250241.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION
Name of service Springwater Lodge Care Home Address 10 Smithy View Calverton Nottingham NG14 6FA 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) 0115 9655527 0115 9655310 springwaterlodge@highfield-care.com Southern Cross Care Homes No 2 Limited Mrs Susan Joy Francis Care Home 50 Category(ies) of Old age, not falling within any other category registration, with number (42), Physical disability (6), Terminally ill (2) of places Springwater Lodge Care Home DS0000040348.V250241.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION
Conditions of registration: 1. 2. 3. Within the total number of beds, a maximum of 6 beds maybe used for the category of PD Within the total number of beds, a maximum of 2 beds maybe used for the category of TI One bed within the category of OP maybe occupied by a named service user (D.O.B 10.02.1940), who is under 65 years of age. 22/03/05 Date of last inspection Brief Description of the Service: Springwater lodge is a detached two-storey purpose built care home in the village of Calverton, Nottinghamshire. It is set back from the main road and within 500 yards of local amenities. Bus and main road routes support the village, which provides access to the surrounding villages and Nottingham. Springwater Lodge offers personal and nursing care for people over the age of 65 and can cater for a broad range of needs. It is registered for fifty-six beds, six of which may be used for physical disabilities and two for palliative care. The living accommodation comprises of mainly single rooms over two floors, as well as ample bath and toilet facilities, lounge areas and dining space. Springwater is well maintained and decorated in a pleasant and homely manner. As the home is purpose built it is wheelchair accessible and there is a passenger lift to provide access to the first floor. Springwater Lodge Care Home DS0000040348.V250241.R01.S.doc Version 5.0 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. The inspection took place over one day, during which the inspector investigated two complaints received by the commission for social care inspection. Five service users case files, staff training records and other documentation related to care and the environment were examined. Five service users, one relative and two staff members were spoken with. Staff were friendly and there was a caring and relaxing atmosphere within the home. What the service does well: What has improved since the last inspection? What they could do better: Springwater Lodge Care Home DS0000040348.V250241.R01.S.doc Version 5.0 Page 6 There are several areas where improvement is required. Minor improvements are required to ensure all incidents are recorded in the service users daily progress notes and care plans are up to date with regards to any changes that may occur or are negotiated to ensure these are appropriately addressed. Communication with service users and relevant others is to be maintained with regards to incidents or events to ensure all parties are well informed. Staff training requires addressing to ensure staff are fully competent to carry out their job role. The complaints procedure on display requires updating to ensure up to date information is available for service users. 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. Springwater Lodge Care Home DS0000040348.V250241.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 Springwater Lodge Care Home DS0000040348.V250241.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): 3 Service users can be assured their needs will be assessed and met. EVIDENCE: Preadmission assessments are carried out in the community prior to service users being admitted into the home. Relevant assessments and referrals are obtained to ensure needs can be met and preadmission undertaken by the home cover all the requirements of this standard. Springwater Lodge Care Home DS0000040348.V250241.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): 7,8,10 Health, personal and social care needs are addressed in an individual plan of care, and health care needs are fully met. Service users are treated with respect and their right to privacy is upheld. EVIDENCE: Service users undergo various assessments with regards to nutrition, pressure areas and manual handling along with an assessment based upon the activities of daily living. Information gained from these then form the basis of the plan of care. However in one care plan following a complaint the addition to the plan of care had not been actioned despite evidence of this occurring in the progress notes and the communication diary. Service users and relatives are able to access care plans and there was evidence available to demonstrate they had been involved in the care plan. Risk assessments as required were available and corresponded with the plan of care. Progress notes recorded significant events however did not indicate when staff had taken the initiative in responding to events and when relatives had been informed should the need arise. There was evidence of the multidisciplinary team being liaised with and advice actioned. Complex needs were identified and personalised care plans were in place, which took into account choices and preferences.
Springwater Lodge Care Home DS0000040348.V250241.R01.S.doc Version 5.0 Page 10 Service users are facilitated to access health services as required and there was evidence within plans of care to demonstrate this. Appropriate services are liaised with to ensure service users have the required equipment and aids in place. Core values and principles of care are covered within staff training. All service users have access to locked doors on their rooms should they be required and all consultations are carried out in private. A number of service users have their own phones installed, however if not the telephone in the office is available for service users use. Service users spoken with stated staff are nice, they listen, are respectful and their needs are met. Staff spoken with were able to discuss individual service users needs and the core values and principles. Springwater Lodge Care Home DS0000040348.V250241.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): 13,14 Service users are enabled to exercise choice and control over their lives and maintain contact with relevant others. EVIDENCE: Visitors are welcomed into the home at any time; regular visitors are informed of the entrance code on the main door to enable access. The visitor’s policy is discussed prior to admission and is available in the service user guide. Service users are facilitated to choose whom they wish to see and may do so in private, if they choose not to receive visitors this would be dealt with sensitively. Service users and staff spoken with substantiated that visitors are welcomed at any time. There are many service users from Calverton, therefore people form the village visit the home, and also the local school and brownies visit and provide entertainment. A church service is held every month. Relatives’ deal with service users finances, four-service users holds personal money on themselves. There is the facility of safe storage if required and all doors to service users rooms are lockable. Advocates have been used in the past and an advocate has visited the service users meeting to promote this service. Service users may bring in personal items and it was evident that this has been facilitated on the tour of the home as service users room were noted to be personalised.
Springwater Lodge Care Home DS0000040348.V250241.R01.S.doc Version 5.0 Page 12 Springwater Lodge Care Home DS0000040348.V250241.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): 16 Service users and their relatives can be confident their complaints will be listened to, taken seriously and acted upon. EVIDENCE: There have been three complaints received since the last inspection, one that was referred to the Commission for Social Care Inspection via the complainant and another, which links back to a complaint investigated during the last inspection. Both of these were investigated during this inspection and elements of the complaints were upheld, the manager acknowledged this. Findings at the previous inspection demonstrated improvements in the systems and structures employed to address these issues and remedy problems had taken place. Further improvements have continued with regards to staff training. The complaints received by the home have been acted upon accordingly and procedures followed. The complaints notice on display is out of date as it states National Care Standards Commission. Service users spoken with expressed no complaints during the inspection. Staff were able to discuss how they would deal with a complaint should it be received. Springwater Lodge Care Home DS0000040348.V250241.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): EVIDENCE: Not inspected during this inspection. Springwater Lodge Care Home DS0000040348.V250241.R01.S.doc Version 5.0 Page 15 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): 17,30 The number and skill mix of staff meets service users needs, insufficient evidence was available to demonstrate that staff were trained and competent to do their jobs. EVIDENCE: Staff rotas were observed and demonstrated sufficient staff are on duty to meet service users needs. Due to maternity leave, sickness and difficulty in recruitment agency staff have been used and the homes staff have been covering extra shifts. Staff spoken with stated they are aware of these problems but they feel there is sufficient staff available to meet service users needs at a good standard. Staff training records were observed, each member of staff have individual training records in place. Evidence demonstrated deficits in health and safety and first aid training. Staff are working towards updating fire, manual handling and completing dementia care training. Staff have received training in palliative care and the use of syringe drivers since the last inspection. Induction programmes are in place, however the manager expressed there are difficulties in these being completed due to the nature of the package. She stated that work is done but not always evidenced. Staff spoken with stated they felt supported in their training and had undertaken courses with regards to infection control, adult abuse and palliative care in the past few months. Springwater Lodge Care Home DS0000040348.V250241.R01.S.doc Version 5.0 Page 16 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): 35 Service users financial interests are safeguarded. EVIDENCE: Four service users personal finances were checked during the inspection and were correct. Receipts were available and records of all transactions maintained. Two staff sign for all transactions. The manager stated that relatives in the main deal with service users personal finances and she is not responsible for any individual. Springwater Lodge Care Home DS0000040348.V250241.R01.S.doc Version 5.0 Page 17 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 3 X X X HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 X 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 3 14 3 15 X COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 X X X X X X X X X STAFFING Standard No Score 27 3 28 X 29 X 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X X X X 3 X X X Springwater Lodge Care Home DS0000040348.V250241.R01.S.doc Version 5.0 Page 18 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,b) Requirement The responsible individual is required to ensure service users care plans are kept under review and changes applied. The responsible person is required to ensure service users and relevant others are kept informed of incidents and events that occur and these are recorded. The responsible individual is required to ensure the complaints information on display is correct and up to date. The responsible individual is required to ensure staff employed are given training appropriate to the work they are to perform. This is an outstanding requirement since April 2005 and must be addressed to avoid enforcement action. Timescale for action 15/11/05 2 OP7 12(5) 15/10/05 2 OP16 22(5) 15/10/05 3 OP30 18(c,I) 14/09/05 Springwater Lodge Care Home DS0000040348.V250241.R01.S.doc Version 5.0 Page 19 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 Refer to Standard 19 Good Practice Recommendations To reduce the amount of foliage in front of the mentioned service users bedroom window. Springwater Lodge Care Home DS0000040348.V250241.R01.S.doc Version 5.0 Page 20 Commission for Social Care Inspection Nottingham Area Office Edgeley House Riverside Business Park Tottle Road Nottingham NG2 1RT National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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