Inspection on 05/08/05 for Springwood House

This inspection was carried out on 5th August 2005.

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 27/01/06

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 Derby DE56 4BG Lead Inspector Jenny Thornton Unannounced 5 August 2005 th 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 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 C02 C52 S20095 SpringwoodHouse V239017 050805 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Springwood House Address Duffield Bank Duffield Derby DE56 4BG 01332 840757 01332 840757 Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Mr P Clemens and Mrs K Clemens Mrs Karen Clemens Care Home 29 Category(ies) of Older People registration, with number of places Springwood House C02 C52 S20095 SpringwoodHouse V239017 050805 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: None Date of last inspection 25th January 2005 Brief Description of the Service: Springwood House care home is set on a hillside on the outskirts of Duffield. The home provides social and personel 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 C02 C52 S20095 SpringwoodHouse V239017 050805 Stage 4.doc Version 1.30 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 and a half hours. The Inspector spoke to the owners/manager, four members of staff, sixteen residents and three relatives. The Inspector looked around the home and examined various records. Residents spoke highly of the care and services provided at the home and considered that their needs were well met. The home is well managed and the owner’s daughter has taken on the role of fulltime administrator to support the day-to-day running of the home. What the service does well: What has improved since the last inspection? A further three bedrooms have been redecorated and refurbished, and new staff call system installed. A new carpet had been fitted in the hallway. New passenger lifts have been installed to enable resident’s better access. The garden pathway was being replaced to enable resident’s in a wheelchair to access it more easily. Springwood House C02 C52 S20095 SpringwoodHouse V239017 050805 Stage 4.doc Version 1.30 Page 6 A mobile phone system has been installed in the home to assist staff and resident’s access. The home’s policies and procedures have been updated to ensure that the home is well managed. Staff have attended a good level of training in the last year. Newly appointed staff had completed induction training to ensure they have the skills to care for residents. 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 C02 C52 S20095 SpringwoodHouse V239017 050805 Stage 4.doc Version 1.30 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 Standards Statutory Requirements Identified During the Inspection Springwood House C02 C52 S20095 SpringwoodHouse V239017 050805 Stage 4.doc Version 1.30 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 standard(s) 4 Staff that have the necessary skills, experience and training to meet resident’s needs. EVIDENCE: Residents spoken with said that they had formed good relationships with staff, and that staff couldn’t do enough for them. Residents considered that their needs were well met, and relatives shared this view. Several residents recently admitted to Springwood House said that the home exceeds their expectations. Staff showed a good understanding and a commitment to meeting individual needs. The staff team have considerable experience and were attending a good range of training to ensure they have the skills to care for residents. Springwood House C02 C52 S20095 SpringwoodHouse V239017 050805 Stage 4.doc Version 1.30 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 standard(s) 9 and 10 Resident’s privacy is clearly respected. Procedures are in place for the safekeeping and handling of medicines to safeguard residents’ welfare, although aspects of the home’s procedures require strengthening. EVIDENCE: Residents said that their privacy and dignity is respected; this was observed throughout the inspection. Privacy locks were fitted to bedrooms, bathrooms and toilets to ensure residents privacy. A telephone was available for the sole use of resident’s in the home, and many of the residents had a phone in their bedroom. Discussions with the manager and records showed that all staff that administers medicines at the home had received recent training. The home’s medicines policy did not detail all aspects of how medicines are managed in the home, including administration of non-prescribed medicines to residents. The manager reported that the home did not administer any household remedies to residents. Springwood House C02 C52 S20095 SpringwoodHouse V239017 050805 Stage 4.doc Version 1.30 Page 10 The medicines fridge was in use at the time of the inspection. The recorded temperature of the medicines fridge considerably exceeded the normal range of 2 to 8 degrees centigrade on a number of occasions. The temperature of the medicines fridge was not checked daily using a maximum/minimum thermometer. The home’s manager and administrator agreed to immediately address this issue. Medication administration records checked had been duly signed. The dispensing pharmacist printed the majority of medication administration records. A couple of medicines that had been handwritten onto resident’s medication administration records, did not record the quantity of medicines received, and had not been signed by the member of staff completing the record, or checked and counter signed by a second member of staff. Staff are required to record this information to provide an audit trail of medicines in the home. The home had a reference book relating to information on medicines. The home’s BNF formulary was several years old, and required replacing with an up-to-date copy containing all current medicines. The manager agreed obtain a new copy. Springwood House C02 C52 S20095 SpringwoodHouse V239017 050805 Stage 4.doc Version 1.30 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 standard(s) 13 and 14 Contact with relatives and friends is encouraged are visitors are made to feel welcome at the home. Residents are actively encouraged to maintain personal choice and control over their lives. EVIDENCE: Residents said that they are helped to exercise choice and control over their lives, and are encouraged to handle their own finances for as long as they wish, and are able to do so. The manager confirmed that a good number of the residents managed their own finances and allowances. One resident remained a director of a Company and held board meetings at the home. Discussions with residents, relatives and staff showed that residents are supported to maintain contact with their family, friends and other significant people. Relatives said that they can visit at any time and are made to feel welcome in the home. Springwood House C02 C52 S20095 SpringwoodHouse V239017 050805 Stage 4.doc Version 1.30 Page 12 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 standard(s) 18 Residents are clearly protected from abuse, although the home’s vulnerable adults procedure required updating to safeguard resident’s welfare. EVIDENCE: Residents considered that staff are approachable and that concerns are listened to and acted upon. The manager had a copy of the Local Authority’s initial vulnerable adults procedure, and agreed to obtain a copy of the current procedure. The home’s policy on adult protection was not fully in line with the Local Authority’s procedure, in that it stated that all reports of abuse should be immediately be 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 manager confirmed that she had attended the Local Authority’s training on vulnerable adult procedures; senior care staff had yet to attend this training. The manager said that all staff had received basic training on prevention of abuse. This needs to be recorded in staff’s training files. There has been no reported incidents or allegations of abuse at the home in the last year. Springwood House C02 C52 S20095 SpringwoodHouse V239017 050805 Stage 4.doc Version 1.30 Page 13 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 standard(s) 19 The environment is of a high standard and provides residents with a homely and safe environment to live in. EVIDENCE: All residents considered that the environment is comfortable and homely and is maintained to a high standard throughout; this was apparent on the inspection. A tour of the premises highlighted no issues relating to the environment. Residents said that the environment is kept very clean as was noted on the inspection. Arrangements were in place to ensure that the home is well maintained. The home does not have a written annual refurbishment plan. However it was clear from discussions with the registered persons and a tour of the premises that there is ongoing investment in the building and the facilities. Since the last inspection a further three bedrooms had been refurbished to a high standard and a new call system had been installed. A new carpet had been fitted in the hallway. New passenger lifts have been installed to enable resident’s better access. Springwood House C02 C52 S20095 SpringwoodHouse V239017 050805 Stage 4.doc Version 1.30 Page 14 Resident’s bedrooms contained personal belongings and reflected individual’s preferences. Some residents preferred to spend time in their room, whilst other residents made good use of the lounge areas. The home has extensive gardens, which were attractively set out and contained various seating areas. A section of the pathway was being replaced to enable resident’s in a wheelchair to access it more easily. Residents considered that the garden was spectacular, and enjoyed spending time in the garden when the weather is good. Springwood House C02 C52 S20095 SpringwoodHouse V239017 050805 Stage 4.doc Version 1.30 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27, 28 and 30 The home is sufficiently staffed to meet residents’ needs, and has an established staff team providing consistency of care for residents. Staff were receiving a good level of training to ensure they have the skills to care for residents. EVIDENCE: Residents, relatives and staff spoken with considered that the staffing levels provided were generally sufficient to meet residents’ needs. The Registered Manager is generally supernumerary to the staffing levels. Although the home is registered for 29 people, it usually accommodates a maximum of 24 residents, as all shared rooms are used as singles. Staff reported that the resident’s do not have high level needs and do not require much help from staff at night; therefore one waking and one ‘sleep-in’ night staff is generally sufficient to meet the number and needs of residents. The registered persons/manager lives in the grounds of the home and provides ‘sleep-in’ cover each night, and when they are away their daughters provide sleep-in cover. Staff were clear as to this arrangement, although the staffing roster did not show who provided sleep in cover each night. The staffing rota identified the person in charge of each shift but did not identify in what capacity other staff were working. Staff on duty were identified by their first name and the manager by her initials. Springwood House C02 C52 S20095 SpringwoodHouse V239017 050805 Stage 4.doc Version 1.30 Page 16 The home had a full team of staff and a good number of the staff have worked at the home for several years, which results in residents receiving care from staff they know. Agency staff support was not required. Staff said that the home provides good training opportunities and that they had attended various trained. Training records supported this. All staff had an individual record of training they had attended, including a copy of certificates from courses they had attended. Recent training included fire safety, care skills, administration of medicines, infection control, first aid and health and safety. The manager had identified key areas of training for the year, although this was not in the form of a written training plan. Further care staff were undertaking a national approved qualification (N.V.Q), to ensure they are trained and competent to do their job. The manager confirmed that eight out of nineteen care staff had completed N.V.Q. Level 2 training, and a further two staff were due to start the training in September. Two senior members of staff were undertaking N.V.Q Level 3 training. Records showed that newly appointed staff attend the Local Authority’s induction training programme, to ensure they have the essential training to care for residents. Springwood House C02 C52 S20095 SpringwoodHouse V239017 050805 Stage 4.doc Version 1.30 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 32, 35 and 36 The manager and senior staff provide clear leadership to the team, ensuring the home is well run and that staff carry out their responsibilities. Arrangements are in place to safeguard resident’s financial interests and handling of residents’ money. EVIDENCE: Staff reported that the atmosphere at the home is friendly and relaxed, and that staff worked well together as a team. This was apparent on the inspection. Staff said that they enjoyed their work and that morale was good. Staff were clear as to their role and responsibilities. The home is well managed and the manager provides clear leadership with staff. The registered person’s daughter has taken on the role of fulltime administrator to support the day-to-day running of the home and to further develop the systems in place. Springwood House C02 C52 S20095 SpringwoodHouse V239017 050805 Stage 4.doc Version 1.30 Page 18 As previously stated, the registered person/manager is in the home most days and closely supervises staff in their work, although this is not in form of formal recorded supervision. The manager acknowledges the need to establish one to one supervision meetings with care staff to show that they are appropriately supervised. The home had a policy and procedure relating to the management of residents finances and money. The manager confirmed that resident’s, relatives or an independent person managed their finances and personal allowances. Residents had a lockable storage area in their room to keep any money or valuables. At the time of the inspection six residents had a small sum of money in safe keeping at the home. Appropriate records were kept of money in safekeeping to safeguard resident’s interests. Springwood House C02 C52 S20095 SpringwoodHouse V239017 050805 Stage 4.doc Version 1.30 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score x x x 4 x x HEALTH AND PERSONAL CARE Standard No Score 7 x 8 x 9 2 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 x 13 3 14 3 15 x COMPLAINTS AND PROTECTION 4 x x x x x x x STAFFING Standard No Score 27 3 28 3 29 x 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score x x 3 x 3 x x 3 2 x x Springwood House C02 C52 S20095 SpringwoodHouse V239017 050805 Stage 4.doc Version 1.30 Page 20 No 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 18 Regulation 13 Requirement The home’s policy on adult protection must be in line with the Local Authority’s procedure. Timescale for action 30 September 2005 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 13 Good Practice Recommendations The homes medicine policy and procedures should detail all aspects of how medicines are managed in the home. The policy should cover non-precribed medicines including homely remedies. The temperature of the medicines fridge should be monitored daily using a maximum/minimum thermometer and recorded. The fridge temperature should be between 2 and 8 degrees centigrade for medicines requiring cold storage. Medicines that are handwritten onto resident’s medication administration records, should record the quantity of medicines received, and be signed by the member of staff completing the record, and checked and counter signed by a second member of staff Staff should have access to an updated reference book/source on medicines, containing all current medicines. All senior care staff should attend the Local Authority’s C02 C52 S20095 SpringwoodHouse V239017 050805 Stage 4.doc Version 1.30 Page 21 2. 13 3. 13 4. 5. 13 18 Springwood House 6. 7. 8. 9. 19 27 30 36 training on vulnerable adult procedures. Training records should show that all staff have received training on prevention of abuse. The homes refurbishment programme should be recorded to clearly show all work carried out. The staffing rota should identify staff on duty by their full name, in what capacity they are working and the name of the person providing sleep in cover each night. The homes annual training and development plan should be produced in a written form. All care staff should receive formal supervision at least six times a year. Springwood House C02 C52 S20095 SpringwoodHouse V239017 050805 Stage 4.doc Version 1.30 Page 22 Commission for Social Care Inspection 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 C02 C52 S20095 SpringwoodHouse V239017 050805 Stage 4.doc Version 1.30 Page 23 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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