CARE HOMES FOR OLDER PEOPLE
Springwood 611 Herries Road Sheffield South Yorkshire S5 8TN Lead Inspector
Janis Robinson Unannounced Inspection 08:45 15 March 2006
th 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 Springwood DS0000003014.V276049.R01.S.doc Version 5.1 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. Springwood DS0000003014.V276049.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION
Name of service Springwood Address 611 Herries Road Sheffield South Yorkshire S5 8TN 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) 0114 232 5472 0114 285 2934 Sheffcare Limited Mrs Anita Bland Care Home 40 Category(ies) of Dementia - over 65 years of age (10), Mental registration, with number Disorder, excluding learning disability or of places dementia - over 65 years of age (10), Old age, not falling within any other category (30) Springwood DS0000003014.V276049.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION
Conditions of registration: 1. The 10 DE/E beds are also registered and/or MD/E Date of last inspection 7th September 2005 Brief Description of the Service: Springwood is a purpose built property, providing personal care for up to 40 service users over the age of 65 years. The home is operated by Sheffcare Limited and is situated in a residential area in the north of Sheffield near to Hillsborough. Various shops and a public house are located nearby and Hillsborough shopping centre is easily accessible. The accommodation is provided on three floors with a lift for easy access. All rooms are for single occupancy. The ground floor of the home offers care and support for a small group of people who have a higher dependency due to varying forms of dementia. Easy access is available to all facilities for service users who use wheelchairs, or have other disabilities. There are a number of lounges and sitting areas that are smoking and non-smoking. There is a function room that is available for group activities or private use to entertain family or friends. The organisation has the use of a mini-coach so can offer regular trips and outings. The home has an enclosed patio area. Car parking is provided. Springwood DS0000003014.V276049.R01.S.doc Version 5.1 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This inspection was unannounced and took place over 3 hours from 8.45am to 11.45 am. An inspection of a proportion of the environment took place, and records were sampled, including care plans, staff training and supervision, and fire safety records. The inspector spoke with the majority of staff on duty, and eleven residents. The majority of key standards were assessed and met at the last inspection. What the service does well:
All of the comments made by residents were very positive. Residents said the home was ‘very good’, ‘everything you need is here’, and ‘the staff are wonderful’. The staff spoken with displayed a high level of commitment to residents. Each resident had a care plan, which outlined all personal, social and health care needs. Access to health care professionals was supported, to maintain residents health. Residents confirmed that the staff were respectful towards them. The routines at the home were flexible, residents were able to choose how to spend their day. The home had an open visiting policy, to maintain contact with residents and their family and friends. A varied diet was provided and choices were offered. Residents said the food was good. The home had a complaints procedure, each resident had been provided with a copy to inform them of their rights. All of the residents spoken with said they had confidence in the homes manager, and the staff at the home, to listen to any concerns and take them seriously. The environment was very well maintained. The home was clean. Homely touches were provided in communal areas to create a comfortable environment. Residents’ bedrooms were well decorated and individually personalised. Residents were able to bring personal possessions with them into the home. All of the residents spoken with said the home was comfortable. Agreed levels of staff were being maintained. The home had a commitment to National Vocational Qualifications (NVQ), to ensure staff had the skills needed to meet the needs of residents. A quality assurance system was in operation, to obtain the views of residents and their representatives. All of the residents and staff said the management at the home was supportive and approachable. Health and safety systems were in place at the home, fire equipment had been checked and serviced. Staff had undertaken fire training at the required
Springwood DS0000003014.V276049.R01.S.doc Version 5.1 Page 6 frequency to ensure they had the skills to maintain safety and respond in an emergency. What has improved since the last inspection? What they could do better:
Whilst staff fire drill training had taken place, records kept did not accurately reflect all of the training provided. Some gaps or omissions were apparent in mandatory staff training records. Springwood DS0000003014.V276049.R01.S.doc Version 5.1 Page 7 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. Springwood DS0000003014.V276049.R01.S.doc Version 5.1 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 Springwood DS0000003014.V276049.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 1,2,3 and 5 were assessed and met at the last inspection. Standard 6 does not apply to this home. EVIDENCE: The service user guide and statement of purpose were on display in the entrance area. Copies of contracts were included in the care plans checked. Springwood DS0000003014.V276049.R01.S.doc Version 5.1 Page 10 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 and 11. Each resident had a care plan, to give staff the information needed to ensure all care needs were met. Health care was monitored, assessed and met. Staff appeared respectful towards residents. Each care plan contained information on dying and death EVIDENCE: Two care plans were examined. The plans contained the full range of information required, and included specific information on all aspects of personal, social and health care needs. The plans included information on the staff action required to ensure assessed needs were met. The residents had signed their plans, where able. Risk assessments were undertaken, to reduce any identified risk. The plans were reviewed on a monthly basis. The plans contained detail of all health care contacts, appointments and treatments, and the home supported access to these to ensure health was maintained. Residents said they had regular contact with their GPs, and saw chiropodists, dentists, opticians and district nurses as required. Staff were observed respecting privacy by knocking on doors before entering. The interactions between staff and residents appeared respectful and caring. Staff
Springwood DS0000003014.V276049.R01.S.doc Version 5.1 Page 11 took time to sit and listen to residents. All of the staff displayed a high level of commitment to the residents and the home. Residents spoken to made very positive comments about their care. Residents told the inspector `this is a good home, anything you ask for is there’ ‘the staff are wonderful’ and `I can’t think of how I could be better cared for’. Each plan contained information on the residents’ wishes regarding funeral arrangements, to ensure these would be carried out. At the time of this inspection one resident was seriously ill, staff displayed an awareness of the residents needs and undertook them with respect. A room was available to families to stay overnight if their loved on was seriously ill. Springwood DS0000003014.V276049.R01.S.doc Version 5.1 Page 12 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 and 15. Family involvement within the home is given priority to ensure that residents can maintain contacts with their relatives and friends in a comfortable relaxed environment The routines at the home were flexible, to promote choice. Residents were given sufficient information on advocacy services in case they did not have anyone to act on their behalf. A good diet was provided, residents are given choices on the menu, sufficient quantities were provided to meet their needs. EVIDENCE: Residents said their visitors were able to come to the home at any time, and they could see their visitors in private, if they wished. All of the staff and residents said the provision of family kitchens were well used and enjoyed. When families visited they were encouraged to use the kitchens, facilities were provided so that they could stay for a meal with the residents. Children are catered for with books, games and colouring books and pencils. A leaflet had been produced giving relatives information about the kitchens, which encouraged them to use the homes facilities as if they were visiting their old family home.
Springwood DS0000003014.V276049.R01.S.doc Version 5.1 Page 13 The routines at the home were flexible. Residents were observed to wander freely, and choose when and how to spend their time. Residents were free to join in any organised activity. As part of the admission process residents were given a booklet, which gives details of an advocacy service. Residents spoken to said they liked the food, they were offered a choice and portions were sufficient. Menus were on display giving information about the choices on offer. Staff confirmed that they had access to some food stocks to provide residents with snacks at any time of the day or night. Springwood DS0000003014.V276049.R01.S.doc Version 5.1 Page 14 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. The home had a clear and accessible complaints procedure, to ensure residents’ rights were protected and any concerns listened to and taken seriously. EVIDENCE: Each resident and representative had been provided with a copy of the homes complaints procedure. This contained relevant detail and informed the reader of who to contact outside of the home to make a complaint, should they wish to do so. All of the residents said they had no concerns and could go to the managers and staff to`sort out’ any worries if they had them. The home had not received any complaints since the last inspection. Springwood DS0000003014.V276049.R01.S.doc Version 5.1 Page 15 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): 19,20,21,22,24,25 and 26. The home was maintained to a very high standard. A rolling programme of redecoration was in place. The home was very clean. Appropriate facilities were provided to meet residents needs. All areas of the home were accessible to residents. Homely touches had been provided to create a comfortable environment. Communal areas were well maintained, and residents’ bedrooms were well decorated and personalised. EVIDENCE: An inspection of a proportion of the environment took place. The home was well decorated and clean. Communal areas were attractive, comfortable and the furniture provided was of a good standard. Since the last inspection six bedrooms and one dining room had been redecorated, to maintain standards. The function room on the ground floor was being redecorated at the time of this inspection. Plans were in place to redecorate the exterior of the home. Two benches had been purchased to improve the garden facilities. Springwood DS0000003014.V276049.R01.S.doc Version 5.1 Page 16 All of the bedrooms were well decorated and highly individual, containing personal belongings which enabled residents to have some control over their personal space. Sufficient bathing facilities were available. A Jacuzzi bath was being purchased to provide a relaxation resource for residents. Aids and adaptations were in place to assist with residents moving and handling needs. The laundry was sited away from all food preparation areas. Systems for the control of infection were in place and adhered to. All of the residents said that they were very happy with the accommodation provided. Springwood DS0000003014.V276049.R01.S.doc Version 5.1 Page 17 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): 27,28 and 29. Agreed levels of staff were being maintained. Some staff undertook NVQ training. Recommended levels of NVQ trained staff had been achieved. A thorough recruitment procedure was in operation. EVIDENCE: The homes rota indicated that agreed levels of staff were being maintained to meet the needs of residents. Residents spoken with felt that enough staff were provided. A programme of NVQ training was in place, to develop the skills of staff. Over 50 of the care staff had achieved NVQ level 2 or 3 in care, further staff were undertaking the training. Recruitment procedures ensured residents safety. Two staff files were inspected. All documentation, including application forms, evidence of Criminal records Bureau checks and proof of identity, were scanned and held on the homes computer system. The two files inspected contained all of the required information to ensure safe procedures had been followed. All staff had been CRB checked. Springwood DS0000003014.V276049.R01.S.doc Version 5.1 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): 31,32,33,36,37 and 38. The home is well managed and run by an experienced and qualified manager. Staff, resident and relatives are given the opportunity to be involved in the development of the home through meetings held and a quality assurance system. Staff supervision took place. Records were securely stored. Health and safety systems were in place. Records of mandatory training and fire drills required auditing to ensure they were up to date. EVIDENCE: The manager had many years experience working and managing care homes for the elderly. She was fully qualified and had a Registered Managers Award. All staff spoken to said that the manager was approachable and gave them support and guidance. The manager displayed a strong sense of commitment to improving and developing initiatives to provide residents with a good and happy life.
Springwood DS0000003014.V276049.R01.S.doc Version 5.1 Page 19 A quality assurance system was in operation, to formally obtain the views of residents and their representatives and act on these. An annual survey was undertaken. The results were audited and published. The results of surveys were on display in each corridor, to give residents and relatives this information. Regular meeting are held for residents, relatives and staff. A quarterly news sheet was published to ensure that all residents and relatives are kept informed of any developments or activities that are planned. Relatives were formally invited to join in the events taking place at the home. Staff supervision, to support and develop care workers, took place at the required frequency. The home had health and safety systems in place. On the day of the inspection no fire exits were blocked and hazardous substances were securely stored. A rolling programme of staff mandatory training was in place. All staff undertook mandatory training and a matrix was maintained to enable training to be monitored. The matrix evidenced some gaps, or omissions in recording training that had taken place. The mandatory training matrix must be audited to identify any gaps ands provide training, or ensure training that had taken place was recorded. Fire fighting equipment was checked and serviced. Weekly fire alarm checks were undertaken. Staff had participated in fire drills at the required frequency, however, some drills had taken place and this had not been recorded on the matrix. Springwood DS0000003014.V276049.R01.S.doc Version 5.1 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 3 8 3 9 X 10 3 11 4 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 4 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 X 3 3 3 3 X 3 3 3 STAFFING Standard No Score 27 3 28 3 29 3 30 X MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 3 X X 3 3 2 Springwood DS0000003014.V276049.R01.S.doc Version 5.1 Page 21 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 OP38 Regulation 13 Requirement An audit of mandatory training must take place, and any identified training must be provided. The training matrix must accurately reflect all training undertaken. Records of fire drills must be maintained up to date, and accurately reflect all drills that have taken place. Timescale for action 31/05/06 2 OP38 13 31/05/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Springwood DS0000003014.V276049.R01.S.doc Version 5.1 Page 22 Commission for Social Care Inspection Sheffield Area Office Ground Floor, Unit 3 Waterside Court Bold Street Sheffield S9 2LR National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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