Inspection on 18/10/06 for Springwood House

This inspection was carried out on 18th October 2006.

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

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

Other inspections for this house

Springwood House 10/02/09

Springwood House 27/01/06

Springwood House 05/08/05

Springwood House 25/01/05

Springwood House 25/06/04

Similar services:

Byars Care Home

St Marys Nursing Home

Bramble Lodge

Parkmanor Residential Home

Thornham Grove

Hunter`s Lodge

London Road Neurological and Specialist Care Unit

Carlton Care Home

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

CARE HOMES FOR OLDER PEOPLE Springwood House Duffield Bank Duffield Derbyshire DE56 4BG Lead Inspector Janet Morrow Key Unannounced Inspection 18th October 2006 10:15 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 House DS0000020095.V315247.R02.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. Springwood House DS0000020095.V315247.R02.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Springwood House Address Duffield Bank Duffield Derbyshire DE56 4BG 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) (01332) 840757 01332 840757 Mr Phil Clemens Mrs Karen Clemens Mrs Karen Clemens Care Home 29 Category(ies) of Old age, not falling within any other category registration, with number (29) of places Springwood House DS0000020095.V315247.R02.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 27th January 2006 Brief Description of the Service: Springwood House care home is set on a hillside on the outskirts of Duffield. The home provides personal and social care for 29 people aged 65 years and over. All bedrooms are used as single rooms, with the option of providing shared rooms if required. All rooms with the exception of six have ensuite facilities. The home is on three floors with two shaft lifts in place to ensure access to all areas. The lounge and dining areas are on the ground floor. Residents have access to a large attractive garden, which is well set out. Springwood House DS0000020095.V315247.R02.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was unannounced and took place over 7.25 hours. Eight residents, two members of staff, two relatives, one visiting professional and the manager/provider were spoken with. Seven surveys were received from residents prior to the inspection. A tour of the building was undertaken. Three residents’ care records and three staff files were examined. Written information provided by the home informed the inspection process. An anonymous complaint received at the office of the Commission for Social Care Inspection was also addressed during the visit. What the service does well: What has improved since the last inspection? Recording of fire drills and twice yearly training for night staff was in place. Nutritional assessments were being undertaken on admission. The home’s medication policy had been improved to show how all aspects of medicines were managed in the home. This included a homely remedies policy. A maximum/minimum thermometer was being used to monitor the daily temperatures of the medication refrigerator. Springwood House DS0000020095.V315247.R02.S.doc Version 5.2 Page 6 Staff application forms had been improved to account for gaps in employment and also requested more health details. A staff supervision policy had been created and a record of supervision undertaken was available. What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Springwood House DS0000020095.V315247.R02.S.doc Version 5.2 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 Springwood House DS0000020095.V315247.R02.S.doc Version 5.2 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 and 4 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. There was sufficient admission information available, which established that the home could meet residents’ needs. EVIDENCE: The manager visited all potential residents to ensure that the home was able to meet their needs; information from the pre-admission visit was now being recorded. Staff completed an initial assessment form following a resident’s admission to the home, which contained essential information. Care plans were completed on the computer to enable staff to update changes more easily, and a copy of the current care plan was kept on the resident’s file. Three residents care files were examined and all had an assessment in place, including information from the assessment and care management process, where applicable. Springwood House DS0000020095.V315247.R02.S.doc Version 5.2 Page 9 All residents and relatives spoken with stated that their needs were met and a visiting professional stated that they had ‘no concerns’ about the care provided by the home. Springwood House DS0000020095.V315247.R02.S.doc Version 5.2 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, 9 and 10 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. Care plans were personalised and arrangements were in place to ensure access to health services, which ensured that health needs were met. EVIDENCE: Three residents’ care files were examined and all had a care plan in place that contained useful information. There was plenty of detail about social, cultural and religious needs as well as individual preferences and routines. Staff interviewed stated that they had the opportunity to contribute to care plans and were involved in reviews of care. Staff had completed various written risk assessments for residents, and where risks were identified care plans set out measures taken to minimise the risks. This now included a nutritional risk assessment on admission for all residents and continued monitoring of diet and weight. Residents and their relatives considered that their health and personal care needs were being met and files showed that access to health professionals Springwood House DS0000020095.V315247.R02.S.doc Version 5.2 Page 11 such as district nurses and opticians was available. Access to dentists was discussed with the manager. She stated that there was a current problem with the availability of an National Health Service (NHS) dentist, which meant that residents had to pay privately for any dental treatment required. Repairs to dentures were obtained from a local source. Medication administration record (MAR) charts were checked for accuracy and were signed appropriately. However, two people were not signing and dating handwritten charts. This has the potential for errors to be made and was raised as an issue at the last inspection in January 2006. A new medication policy had been devised that covered all the essential areas of medication management including use of controlled medicines, homely remedies and ordering medicines. Staff spoken with, and the written information provided, showed that training in medication had taken place in the last twelve months. All residents spoken with stated that their privacy and dignity was respected and warm relationships were observed during the inspection visit. Staff were observed to knock on bedroom doors before entering. Springwood House DS0000020095.V315247.R02.S.doc Version 5.2 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): 12, 13, 14 and 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. Activities, meals and contact with the community were all well managed, which ensured that residents had a good quality of life and control over their lives. EVIDENCE: Residents’ individual routines were varied. Some were able to go out with assistance or independently to the local village. Some chose to spend time in their rooms. Others were observed chatting and undertaking hobbies such as reading and knitting. Personal preferences were taken into account. For example, one resident spoken with stated that they felt ‘pampered’ because they had received a face massage and foot spa. A hairdresser visited weekly and manicures were also observed to occur. Games were in evidence and residents spoken with stated that they had the opportunity to undertake games to assist with exercise and communal games such as ‘lotto’. Visitors were observed to visit when they wished. Two relatives spoken with stated that they were made to feel welcome and confirmed that they could visit at any time. Springwood House DS0000020095.V315247.R02.S.doc Version 5.2 Page 13 The owner was aware of how to contact advocacy services if required, although no one in the home currently had an advocate. A relative spoken with stated that care needs were discussed and relatives and residents were able to access personal records if they wished. A sample of menus was provided by the home prior to the inspection. These showed that meals were nutritious and varied. There were alternatives to the main meal available and a choice at tea-time. All seven residents’ surveys received stated that the food was enjoyed. The serving of the lunchtime meal was observed and was nutritious and wholesome. All residents spoken with stated that they had enjoyed their meal. Two residents who had special diets commented that a greater variety of desserts would be an improvement to accommodate their particular needs and preferences. Springwood House DS0000020095.V315247.R02.S.doc Version 5.2 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 and 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. Complaints were handled objectively and safeguarding adult procedures observed, which ensured residents were listened to and protected. EVIDENCE: The written information provided by the home stated that there had been no complaints received during the last twelve months. There had been one anonymous complaint received at the office of the Commission for Social Care Inspection, regarding staff footwear. This was discussed with the manager at the time of the inspection and was upheld. The complaints procedure was seen. This was clear and stated that complaints would be addressed within twenty-four hours initially. There was also a record available to document the action taken. Relative and residents stated that they would take any concerns direct to the manager/owner and were confident of a courteous response. The home had an adult protection procedure and staff had received training in safeguarding adults. The senior carer was in the process of organising further training for staff. There had been no allegations of abuse since the last inspection in January 2006. Springwood House DS0000020095.V315247.R02.S.doc Version 5.2 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 and 26 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to the service. The home was well maintained, well decorated and had well tended grounds, which provided comfortable and appealing accommodation for residents to enjoy. EVIDENCE: Springwood House was clean, tidy and well maintained at the time of this inspection. Residents and relatives commented favourably on the comfortable accommodation and pleasant gardens and stated that this had been one of the deciding factors in choosing the home. Several bedrooms were viewed and were personalised with the furniture recommended by Standard 24. Where this was not supplied, it was recorded in residents’ care records. Springwood House DS0000020095.V315247.R02.S.doc Version 5.2 Page 16 The laundry was viewed and residents’ clothes were well cared for. The home had a washing machine with a sluicing and sanitizing facility, and staff said that all urine/soiled items were washed separately on the appropriate programme to ensure that they are thoroughly cleaned. The written information supplied by the home stated that infection control training had been undertaken by staff in the last twelve months. There was no odour and hygiene standards were high. Communal space was bright and cheerful with good quality furnishings and fittings and was suitable for a range of uses. There was sufficient equipment to assist residents with mobility problems such as handrails, bath hoists, wheelchairs and raised toilet seats. Springwood House DS0000020095.V315247.R02.S.doc Version 5.2 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, 28,29 and 30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to the service. There were sufficient well trained staff to ensure residents’ needs were met. However, there were omissions in recruitment information that had the potential to put residents’ at risk. EVIDENCE: The written information provided by the home included a rota for June 5th 2006 – July 2nd 2006. This showed that there were two care staff and one senior carer on the morning and afternoon shift and one member of staff plus a sleep in member at night. There were two domestic staff and one cook on duty each day. This was consistent with the rota seen for the day of the inspection and the number of staff on duty during the visit. Six of the seven residents surveys also stated that there were ‘always’ staff available to meet needs. The manager stated that there were no current staffing issues and any staff shortages were covered from the existing staff team. This helped to provide consistency of care for residents. The training information provided by the home stated that training in health and safety areas occurred. Training on care related issues such as medicines and dementia had also occurred during the last twelve months. Staff spoke Springwood House DS0000020095.V315247.R02.S.doc Version 5.2 Page 18 with confirmed that they had undertaken this training and that access to relevant courses was good. The written information provided by the home stated that six out of sixteen care staff had achieved a National Vocational Qualification to level 2 or above. This meant that the home had not yet met the target of having 50 of care staff qualified to NVQ Level 2. The management advised that the target was difficult to meet because all staff who had completed their NVQ 2 training at Springwood House had left the home to work in the hospital. Three staff files were examined. These showed that some of the information required for recruitment purposes and detailed in Schedule 2 of the Care Homes Regulations 2001 was not available. One file did not have two written references. Two staff files did not have evidence of a Criminal Record Bureau application and another had an application but no disclosure. There was no Protection of Vulnerable Adults (POVA) check in any of the files pending arrival of the full disclosure. This was raised as an issue at the previous inspection in January 2006 and an immediate requirement notice was therefore issued to ensure this process was commenced. Springwood House DS0000020095.V315247.R02.S.doc Version 5.2 Page 19 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, 33, 35, 37 and 38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. The home was well run with the health and safety needs of all involved in the home being addressed, which ensured that the home was run in the best interests of residents. EVIDENCE: The manager was a registered nurse and had extensive knowledge and skills to manage the home, having worked as the registered manager and joint owner at Springwood House since 1995. The manager had attended a range of training to update her knowledge and skills, and had achieved the Registered Managers award N.V.Q. Level 4. Residents and staff praised the manager’s ability to manage the home well and maintain high standards of care. Staff found the manager approachable and said that she involved them in decisions about the home and provided a good level of support. Springwood House DS0000020095.V315247.R02.S.doc Version 5.2 Page 20 Quality assurance systems were informal and often took the form of obtaining verbal feedback. There were no recent surveys from residents available, although these were said to take place on an annual basis and views of relatives and visiting professinals had not been obtained. However, informal feedback was good and ‘thank you ‘ letters made comments such as staff showing ‘ care and kindness’ and ‘patience, humour and care’. Three residents’ financial records were examined. These were accurate with the money stored corresponding with the written record. Cash was stored securely. The written information provided by the home stated that no-one in the home acted as appointee for any residents. This was seen as a ‘family responsibilty.’ Records were generally up to date and stored securely. However, the information in staff files did not meet the requirements of Schedule 2 of the Care Homes Regulations 2001 as some recruitment information such as two written references and Criminal Record Bureau disclosures was not available. The written information provided by the home stated that maintenance checks were up to date; for example, gas safety was checked in October 2006, fire equipment in April 2006, emergency lighting in January 2006 and the lift in May 2006. Staff spoken with also stated that equipment was in working order ans any repairs were attended to. A visual check of wheelchairs also showed that brakes were working and footplates were available. It was observed during the inspection visit that staff were wearing inappropriate footwear, ‘flip flops’; this posed a potential hazard to both staff and residents when carrying hot drinks, using wheelchairs, assisting residents with mobility problems etc. Staff spoken with confirmed that they undertook mandatory health and safety training in fire safety, infection control, first aid, moving and handling and food hygiene and this was also stated in the written information provided by the home and on training certificates seen in staff files. Springwood House DS0000020095.V315247.R02.S.doc Version 5.2 Page 21 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 3 X 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 4 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 4 X X 3 X X X 3 STAFFING Standard No Score 27 3 28 2 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 2 X 3 3 2 3 Springwood House DS0000020095.V315247.R02.S.doc Version 5.2 Page 22 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 OP29 Regulation 19 Schedule 2 Requirement The registered persons must obtain all information and documents listed in the amended Schedule 2 of the Care Homes Regulations in respect of staff working in the home. The homes recruitment and selection procedure must include all current information and checks obtained for staff. Previous timescale of 30/04/06 not met. Now immediate. Timescale for action 20/10/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard OP9 Good Practice Recommendations Medicines that are handwritten onto residents medication administration record should be checked and counter signed by a second member of staff. DS0000020095.V315247.R02.S.doc Version 5.2 Page 23 Springwood House This is a previous recommendation and has not yet been addressed. 2. OP18 All senior care staff should attend the Local Authoritys training on vulnerable adult procedures. Training records should show that all staff have received training on prevention of abuse. This is a previous recommendation and has not yet been addressed. Arrangements should be put in place to offer all residents regular dental checks. This is a previous recommendation and has not yet been addressed. The home should provide alternative suitable containers to transfer all laundry and soiled items from the floors to the laundry. This is a previous recommendation and has not yet been addressed. 50 of care staff should be to qualified to National Vocational Qualification Level 2. Reference request forms should ask for ‘verification of the reason why the person had ceased to work in a position that involved contact with children or vulnerable adults. This is a previous recommendation and was not assessed on this occasion. A record should be kept of interviews with staff to a consistent and adequate standard. This is a previous recommendation and has not yet been addressed. The registered persons should ensure that all prevention work and checks listed in the home’s legionella risk assessment are carried out. This is a previous recommendation and was not assessed on this occasion. The registered persons should review the home’s risk assessment of the environment This is a previous recommendation and was not assessed on this occasion. 3. OP8 4. OP26 5. 6. OP28 OP29 7. OP29 8. OP38 9. OP38 Springwood House DS0000020095.V315247.R02.S.doc Version 5.2 Page 24 Commission for Social Care Inspection Derbyshire Area Office Cardinal Square Nottingham Road Derby DE1 3QT National Enquiry Line: 0845 015 0120 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 Springwood House DS0000020095.V315247.R02.S.doc Version 5.2 Page 25 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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