Inspection on 27/01/06 for Springwood House

This inspection was carried out on 27th January 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 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

Springwood House 10/02/09

Springwood House 18/10/06

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 Jenny Thornton Unannounced Inspection 27th January 2006 11:30 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Springwood House DS0000020095.V279485.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 House DS0000020095.V279485.R01.S.doc Version 5.1 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.V279485.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 5th August 2005 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.V279485.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection was un-announced and took place over five hours. The inspector spoke to eleven residents, two members of staff, and the manager/provider. The inspector looked around parts of the home and examined various records. All residents spoke highly of the care and services provided at the home. The home has made good progress towards meeting the requirements and recommendations from the last inspection report dated August 2005. What the service does well: What has improved since the last inspection? Good progress has been made to establish 1-1 supervision meetings with all care staff. The home’s initial induction programme for new staff has been updated to include all essential information, and newly appointed staff had completed the approved induction course to ensure they have the skills to care for residents. Springwood House DS0000020095.V279485.R01.S.doc Version 5.1 Page 6 Staff have attended various training to develop their knowledge and skills, and the manager has achieved N.V.Q. Level 4 Registered Manager’s qualification. A good number of the staff were undertaking on-site learning courses on caring for people with dementia and further medicines training. The home had successfully recruited to a care assistant post vacancy. A further bedroom had been redecorated and refurbished. The temperature of the medicines fridge is now monitored daily, and the home had purchased a new reference book on medicines. Additional policies and procedures have been updated to take account of changing legislation and practice. 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.V279485.R01.S.doc Version 5.1 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.V279485.R01.S.doc Version 5.1 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 Procedures have been strengthened to ensure that residents’ needs are fully assessed following admission to the home. EVIDENCE: New assessment and care plan forms were being introduced and resident’s care plans were being transferred onto the new documents. Care plans that had been completed were clearly set out, and contained a good level of information about individuals’ needs and preferences. The manager visits all potential residents to ensure that the home is able to meet their needs; information from the pre-admission visit was not routinely recorded. Staff completed an initial assessment form following a resident’s admission to the home, which contained essential information. The form did not include a section to record the date and signature of the person completing this. The new 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. Springwood House DS0000020095.V279485.R01.S.doc Version 5.1 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, and 9 (partially) Arrangements are in place to ensure that residents’ health needs are met and that resident’s care needs are set out in a clear care plan to enable staff to appropriately meet individual needs. EVIDENCE: As previously stated in Standard 3, new care plans were being completed for all residents, which were detailed and clearly set out individual’s needs and preferences and how they were being met. Care plans showed involvement of the resident’s key worker, and staff said that the residents were also involved in all stages of care planning, although the records did not show this. Staff completed a monthly general statement on resident’s wellbeing, which reported on any significant changes but did not cover all needs. Staff planned to complete a more detailed progress report on all residents, when all the new care plans were completed. Staff had completed various written risk assessments for residents, and where risks were identified care plans set out measures taken to minimise the risks. Staff did not routinely complete a nutritional risk assessment on admission for Springwood House DS0000020095.V279485.R01.S.doc Version 5.1 Page 10 all residents. Senior staff agreed to obtain advice from the district nurses as to the best way of completing this. Residents considered that their health and personal care needs were being met. Newly formed care plans clearly set out how resident’s health and personal care needs were being met. Arrangements were in place to enable residents to be seen by an optician and chiropodist on a regular basis, and a dentist as required. Discussions with residents and records showed that staff promptly contacted resident’s G.P. where required. Care plans contained a list of current medicines residents were prescribed, including what the medicine/s were for, and possible side effects. A couple of medicines that had been handwritten onto resident’s medication administration records had not been checked and counter signed by a second member of staff. The temperature of the medicines fridge was checked daily; the home had yet to purchase a maximum/minimum thermometer. Staff that administered medicines in the home were undertaking further medicines training. The home’s medicines policy did not detail all aspects of how medicines are managed in the home, including administration of nonprescribed medicines to residents. The manager previously reported that the home did not administer any household remedies to residents; the policy therefore needs to clearly state this. Springwood House DS0000020095.V279485.R01.S.doc Version 5.1 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): 12, 15 Resident’s social needs and interests are met and set out in individual care plans. The home provides a good variety and choice of home cooked foods, which residents enjoy. EVIDENCE: Staff and residents reported that the atmosphere at the home is friendly and that daily routines are flexible. The home provides some social activities during the week but does not work to a planned activities programme. Virtually all residents spoken with said that they were satisfied with the level of activities provided in the home, and said that there personal interests were supported. Several residents enjoyed reading and a range of library books were provided. A good number of the residents regularly went out with their family or friends. The weekly catering hours were considered sufficient for the needs of the home; catering staff prepared most of the meals. The menus include a good variety of foods, and resident’s said that an alternative option to the main meal was always available and that individual preferences are accommodated. Springwood House DS0000020095.V279485.R01.S.doc Version 5.1 Page 12 Some changes had been made to the menus in response to comments received from residents. The meals included home cooked foods, which virtually all residents said they enjoyed. The food supplies were of a good quality. Dining tables were well set out, and residents served their own drinks, where able. Springwood House DS0000020095.V279485.R01.S.doc Version 5.1 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): EVIDENCE: The above standards were not fully assessed on this inspection. Residents consider that staff are approachable and that their concerns are listened to and acted upon. Staff said that complaints are dealt with at an informal stage where possible, which results in the home receiving few formal complaints. The Commission has received no formal complaints about the home in the last year. The home’s policy on adult protection was not fully in line with the Local Authority’s procedure, in that it stated that reports of abuse should be immediately investigated and acted upon by the person in charge. It also indicated that if the victim does not want the incident to be taken further there wishes must be respected. The administrator has since confirmed that the policy has been updated, and has forwarded a copy of the to the Commission. The manager had attended the Local Authority’s training on vulnerable adult procedures. Springwood House DS0000020095.V279485.R01.S.doc Version 5.1 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): 26 The standard of cleanliness within the home is high ensuring that all areas are kept clean and free from odours. The home provides a good laundry service ensuring that residents’ clothes are well laundered and ironed. EVIDENCE: The home was clean and free from odours at the time of this inspection. Staff considered that the domestic hours were sufficient for the needs of the home. Systems were in place to ensure that all areas of the home are kept clean and hygienic. Domestic staff carried out the majority of the laundry duties throughout the week. Resident’s said that their clothes were well laundered and ironed. 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. Staff used buckets to transfer items requiring washing from the rooms to the laundry. Urine/soiled items were placed in a separate bucket and pre-soaked in the laundry, prior to washing the items in the machine. Springwood House DS0000020095.V279485.R01.S.doc Version 5.1 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): 27 and 29 The home has an established staff team providing consistency of care for residents, and is suitably staffed to meet residents’ needs. Recruitment procedures require strengthening to ensure that all the required information and documents are obtained for staff, in order to safeguard residents’ interests. EVIDENCE: Staff enjoyed their work and considered that morale was good. The home has a committed and established staff team that work well together to meet residents’ needs. Residents have formed good relationships with staff. The home continues to have a low turnover of staff and does not use relief or agency staff support, resulting in residents receiving care from staff they know. Discussions with staff and records showed that staff have attended a good range of training in the last year, and that further care staff had achieved or were undertaking NVQ Level 2 or 3 qualification to ensure that they are trained and competent to do their job. The inspector checked the files of three members of staff last employed to work in the home, which showed that the home had obtained the required information and documents to safeguard residents except for the following: Springwood House DS0000020095.V279485.R01.S.doc Version 5.1 Page 16 • • • • • • • Three files checked did not provide a full employment history. The home’s application form did not request that applicant’s provide a full employment history, together with a written explanation of any gaps in employment. The administrator agreed to update the application form. The home had obtained a CRB disclosure and check against the Protection of Vulnerable Adults list for new staff, except for one person where they had accepted a copy of a person’s CRB disclosure and check against the POVA list from their previous employer, which is no longer acceptable. One file contained only one written reference; a second reference had been requested but this had not been received. One file did not contain proof of the person’s identity including a recent photograph. Interviews with staff were not recorded. Application forms included a brief health questionnaire; this did not include a statement by the person as to his mental health. Completed application forms contained limited information about the applicants’ previous experience and skills. The inspector discussed with the administrator the need to obtain all documents and information listed in the amended Schedule 2 Care Homes Regulations 2001. The home’s policy and procedure relating to the recruitment of staff required updating to include all current information and checks obtained. Staff files contained a signed statement of terms and conditions, which safeguards their interests. Springwood House DS0000020095.V279485.R01.S.doc Version 5.1 Page 17 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): Staff and residents have a say in the running of the home and their views are sought and acted upon. Arrangements are in place to safeguard staff and residents safety and welfare. EVIDENCE: The manager is a registered nurse and has extensive knowledge and skills to manage the home, having worked as the registered manager and joint owner at Springwood House since 1995. The manager has attended a range of training to update her knowledge and skills, and recently 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.V279485.R01.S.doc Version 5.1 Page 18 Procedures are in place for monitoring the care and services provided at the home. Residents consider that the home is run around their needs and that their views are sought and acted upon. Satisfaction questionnaires are issued to residents and staff, and the results are made available in the form of a report. Resident meetings continue to be held at fairly regular intervals, and minutes of the meetings are made available to the residents. The findings throughout this inspection showed that importance is given to planning and development to ensure the home is well run. The registered providers clearly plan further areas for development, although this is not in the form of an annual development plan. A good number of the home’s policies and procedures have been reviewed in the last year, to take account of changes to legislation and practice. Discussions with staff and records showed that the home has made good progress to establish formal supervision for all care staff. . Records showed that care staff had recently received 1-1 supervision meeting, which covered their training needs. A clear form had been produced to record supervision meetings with staff, which was well completed and had been signed by all relevant persons. Regular 1-1 meetings with care staff were planned. Records showed that the required maintenance checks were carried out. A room-by-room risk assessment of the environment was completed in April 2004, which set out measures taken to minimise further risks. It was not apparent that the risk assessment had been reviewed. Records showed that a legionella risk assessment of the home had been carried out and that some prevention checks were being carried out, although this did not cover all areas listed in the report. Discussions with staff and observations on inspection showed that safe working practices were followed, and that arrangements were in place to ensure that staff attend all mandatory training. The home provides two training sessions on fire safety each year, and staff are required to attend one of the sessions. The home did not carry out separate fire drills, although both fire-training sessions included evacuation procedures. The administrator reported that in view of the reduced staffing levels on nights, night staff received additional instruction on fire awareness in-between the annual training, although this was not recorded. The administrator agreed to keep a record of this. Springwood House DS0000020095.V279485.R01.S.doc Version 5.1 Page 19 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 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 X 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 X 14 X 15 4 COMPLAINTS AND PROTECTION Standard No Score 16 X 17 X 18 X X X X X X X X 4 STAFFING Standard No Score 27 3 28 X 29 2 30 X MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 4 X 3 X X X X 3 Springwood House DS0000020095.V279485.R01.S.doc Version 5.1 Page 20 Are there any outstanding requirements from the last inspection? 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 Timescale for action The registered persons must 30/04/06 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. The registered persons must 30/06/06 ensure that: A minimum of two fire drills are carried out each year involving staff and residents, and that a record is kept of fire drills carried out, including persons on duty, length of time the evacuation took, and any problems incurred. A record is kept of additional fire training provided to night staff. Requirement 2 OP38 23 Springwood House DS0000020095.V279485.R01.S.doc Version 5.1 Page 21 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 OP3 Good Practice Recommendations Information from the pre-admission visit to potential residents should be recorded on a standard form. The initial assessment form should be signed and dated by the person completing the record. 2 OP7 Residents and relatives (where appropriate) should be encouraged to sign their care plan to show that they have been involved in completing this. Senior staff should complete a standard nutritional risk assessment of residents on admission. Arrangements should be put in place to offer all residents regular dental checks. The homes medicine policy and procedures should detail all aspects of how medicines are managed in the home, including the policy on administering non-prescribed medicines. A maximum/minimum thermometer should be used to monitor the daily temperature of the medicines fridge Medicines that are handwritten onto residents medication administration record should be checked and counter signed by a second member of staff The home should provide alternative suitable containers to transfer all laundry and soiled items from the floors to the laundry. In line with current practice and to minimise handling all urine/soiled items should be placed directly into the washing machine and sanitized on the appropriate wash, instead of pre-soaking items prior to washing. All senior care staff should attend the Local Authoritys training on vulnerable adult procedures. Training records DS0000020095.V279485.R01.S.doc Version 5.1 Page 22 3 4 5 OP8 OP8 OP13 6 7 OP13 OP13 8 OP26 9 OP26 10. OP18 Springwood House should show that all staff have received training on prevention of abuse. 11 OP29 Staff application forms should be updated to request a full employment history and an explanation of any gaps in employment, and provide sufficient space to record this information. 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. A record should be kept of interviews with staff to a consistent and adequate standard. All care staff should receive formal supervision at least six times a year The registered persons should ensure that all prevention work and checks listed in the home’s legionella risk assessment are carried out. The registered persons should review the home’s risk assessment of the environment 12 OP29 13 14 15 OP29 OP36 OP38 16 OP38 Springwood House DS0000020095.V279485.R01.S.doc Version 5.1 Page 23 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.V279485.R01.S.doc Version 5.1 Page 24 - 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. 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