CARE HOMES FOR OLDER PEOPLE
Well Springs 122 Leylands Lane Heaton Bradford BD9 5QU Lead Inspector
Gillian Sangster Announced 14 06 05 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. Well Springs CS0000042143.V188147.R01.doc Version 1.30 Page 3 SERVICE INFORMATION
Name of service Well Springs Address 122 Leylands Lane Heaton BD9 5QU 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) 01274 488855 01274 544801 Rossefield Nursing Homes Ltd Mrs Jean Ward Care home with nursing 52 Category(ies) of Terminally ill Elderly (3) Terminally ill (1) registration, with number Dementia - over 65 (10) Old age (52) Physical of places disability (10) Well Springs CS0000042143.V188147.R01.doc Version 1.30 Page 4 SERVICE INFORMATION
Conditions of registration: The one place for TI category is for the service user named in the NCSC letter dated 10 December 2003. Date of last inspection 8/02/05 Brief Description of the Service: Well Springs provides nursing care for 52 male and female service users, predominately over the age of 65 years. Accommodation is provided in both single and shared rooms on the ground and first floors. There is a large lounge and two conservatories based on the ground floor. The home is situated in the Heaton area of Bradford approximately 2 miles from the city centre. Local shops and amenities are siutated close to the home. The detached property is set in extensive private gardens with parking space provided within the grounds. Well Springs CS0000042143.V188147.R01.doc Version 1.30 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This announced inspection was the first conducted for the current twelve month period and was carried out by one inspector between 9.30am and 5.30pm. The deputy manager and general manager were present during the inspection and for the feedback session at the end of the visit. The inspector had lunch with the residents and spent time in one of the lounges talking to residents and visitors and observing practice. Discussions were also held with staff and management. Records inspected included recruitment files, duty rotas, residents’ care records, the statement of purpose and service user guide and accident reports. What the service does well: What has improved since the last inspection?
The number of organised activities has increased with the employment of another activity organiser. A new storage room for medications has been completed. Well Springs CS0000042143.V188147.R01.doc Version 1.30 Page 6 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. Well Springs CS0000042143.V188147.R01.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 Well Springs CS0000042143.V188147.R01.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) 1, 3 and 6. Prospective residents are provided with the information they need to make an informed choice about moving in to the home. Residents’ needs are assessed before admission to ensure that they can be met. Intermediate care is not provided. EVIDENCE: Prospective residents are given a brochure and list of the fees when making the initial enquiry and receive the statement of purpose and service user guide when they come to look round the home. Residents are offered a trial visit where they can come in for lunch or spend the day but usually relatives come to look round on behalf of the resident. The deputy manager stated that if the admission is planned she or the manager will go out and assess the resident. Evidence of pre-admission assessments were seen on the care files inspected. The home does not provide intermediate care but takes emergency admissions and people for respite care. The home also provides day care for a maximum of five people, although only person attends presently. Well Springs CS0000042143.V188147.R01.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) 7, 8 and 10. Care plans are generally well recorded but should include information on how individual social and personal needs are met so ensuring quality of life for the residents. Residents’ health care needs are met. Residents are treated with respect and their rights to privacy are upheld. EVIDENCE: Five residents’ care plans were inspected. Care plans are generally well recorded containing good information but this mainly focuses on physical care needs. There is little information recorded to show how social or psychological care needs are met or how residents have spent their days. The deputy manager advised that social care information is kept separately by the activity organisers. Care plans are regularly reviewed and updated by the qualified nurses although care staff said that they had access to these records. Residents and relatives spoken with during the visit were not aware of their care records or that they had access to them. Care records showed that residents’ health care needs are met and specialist advice is accessed promptly as required. New medication storage arrangements have been completed since the last inspection.
Well Springs CS0000042143.V188147.R01.doc Version 1.30 Page 10 Generally residents said that they felt well cared for and described staff as “caring”, “very good” and “helpful”. One resident said “my team of staff go over and above what’s expected and are very kind”. Some residents mentioned how busy staff were and said “there need to be more of them”. One resident was not happy with any aspect of their care, which staff at the home were aware of and are dealing with. Residents said that they felt staff treated them with respect and maintained their privacy, knocking on their doors before entering their rooms and carrying out intimate care in private. Well Springs CS0000042143.V188147.R01.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) 12,13 and 15. There is a good range of organised activities provided inhouse. Opportunities for residents to go out individually or in groups is poor. Residents enjoy the food but information about the menus and alternatives to the main meal would give residents greater choice. EVIDENCE: The home has employed another activity person and several residents said how much they enjoyed playing bingo, dominoes and making things. Activities were taking place with some residents during the afternoon of the visit. Staff and residents said that the level of activities provided has improved. Residents said that staff did not have time to sit and chat with them. This was confirmed by staff who said that the current high dependency levels meant that the only time they got to speak with the residents was when they were attending to their physical care needs. Some residents said that they would like to go out on organised trips and individually. Some residents who have lived at the home for a number of years said that there used to be day trips out which they really enjoyed but there hadn’t been any in the last eighteen months. The deputy manager stated that she has met with some of the residents and is setting up a
Well Springs CS0000042143.V188147.R01.doc Version 1.30 Page 12 residents committee, which she felt will enable these matters to be discussed and moved forward. Visitors spoken with had differing opinions of the home. They confirmed that they could visit at any time but some felt that they were kept informed and found staff to be helpful whereas another felt they weren’t kept updated and thought staff favoured some residents while ignoring others. Observation of practice showed staff to be attentive and prompt in attending to resident’s needs and requests. Lunch was taken with the residents. Lunch is a set meal unlike breakfast and tea where there are is a choice of foods. Tables were laid attractively with tablecloths, napkins, and condiments. Fresh orange juice was provided with the meal. The meal was served ready plated and residents said that they did not know what the meal was until it was served. The food was tasty and nicely presented. Residents said that they generally enjoyed the meals but said that they would like more choice and variety. Lunch was a sociable occasion and staff were attentive but the service could be improved by asking residents what they would like rather than just presenting them with the food. Well Springs CS0000042143.V188147.R01.doc Version 1.30 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 standard(s) 18 Procedures are in place to protect residents from abuse. EVIDENCE: The home has an adult protection policy which links into the Local Authority Adult protection procedures. Concerns were raised by one service user which the deputy manager was asked to refer to the Adult Protection team. Well Springs CS0000042143.V188147.R01.doc Version 1.30 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 standard(s) 19, 20, 23 and 26. The home is furnished and decorated to a good standard providing a comfortable, pleasant and clean environment for residents. EVIDENCE: Only some parts of the home were inspected at this visit. Bedrooms seen were comfortably furnished, personalised and well decorated. Residents said that they were pleased with their rooms and glad to have their own belongings around them. One resident showed me round his room telling me about different family members in his photographs. Residents can choose from a variety of day areas all of which are well furnished and decorated to a good standard. All areas of the home seen were clean and well maintained with no discernible odours. Externally the grounds are well maintained and accessible to the residents.
Well Springs CS0000042143.V188147.R01.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) 27,29 and 30. Minimum staffing levels are maintained but are insufficient to meet the assessed needs of the current residents. Recruitment procedures must be tightened to safeguard the residents by ensuring all staff checks are completed before they start work. The home provides a good standard of training for staff. EVIDENCE: Duty rotas are maintained and there are currently no staff vacancies. Staff were observed to be busy throughout the day. Residents, staff and a visitor stated that they felt that the home was short staffed at times. Staff said that they enjoyed working at the home and wanted to give residents the best care they could. but expressed frustration with the current staffing levels. Dependency levels are high and staff said that they often felt that they were rushing residents in order to get all the work completed and were unable to spend any quality time with the residents. Staffing levels must be reviewed to ensure that sufficient numbers of staff are on duty to meet all the assessed needs of the residents. The recruitment files for three new staff were inspected. The files were well organised and contained all the information required. However criminal record bureau checks and written references had not been received until after the employees had started work. This is not acceptable. The home provides a good level of training with 75 of the staff trained to NVQ level 2 or above. The rest of the staff, bar one, are undertaking NVQ
Well Springs CS0000042143.V188147.R01.doc Version 1.30 Page 16 training. This is a good achievement. Staff showed a good understanding of the individual needs of the residents. Well Springs CS0000042143.V188147.R01.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) 31, 32, 36 and 38. The home is well managed and staff work together well as a team. The introduction of residents and relatives meetings would give people a say in how the home is run. Health and safety is well managed. EVIDENCE: The home is well organised with strong leadership provided by the registered manager. Staff work well together as a team and said that communication was good and that they would have no hesitation in reporting any concerns to the management. Staff confirmed that they received regular supervision. There are currently no residents or relatives meetings although the deputy manager advised that this it is hoped these will be commenced soon when the residents committee is established. Well Springs CS0000042143.V188147.R01.doc Version 1.30 Page 18 Information provided in the pre-inspection questionnaire showed that maintenance and service agreements are in place and are up-to-date. Health and safety consultants advise the home and one of the staff has taken responsibility for health and safety in the home. Well Springs CS0000042143.V188147.R01.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 3 x 3 x x N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 x 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 x 15 3
COMPLAINTS AND PROTECTION 3 3 x x 3 x x 3 STAFFING Standard No Score 27 2 28 x 29 2 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 3 3 x x x 3 x 3 Well Springs CS0000042143.V188147.R01.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 7 Regulation 15 Requirement Timescale for action 31/08/05 2. 12 16 3. 27 18 4. 29 19 The registered person must ensure that the service user plan sets out in detail the action which needs to be taken by staff to meet all aspects of the health, personal and social care needs of the resident. The registered person must 30/09/05 ensure that residents are given opportunities for stimulation through leisure and recreational activities outside the home which suit their needs, preferences and capacities. The registered person must 31/08/05 review the staffing levels and ensure that sufficient staff are on duty at all times to meet the assessed needs of residents. The registered person must 31/08/05 ensure that all the information specified in Schedule 2 & 4 (6) is obtained before the employee satrts work in the home. Well Springs CS0000042143.V188147.R01.doc Version 1.30 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. 2. Refer to Standard 15 33 Good Practice Recommendations Sytsmes should be reviewed to ensure that residents are offered a choice at each meal and that individual choices are ascertained before the meal is served. Residents and relatives meetings should be introduced to give people a say in how the home is run. Well Springs CS0000042143.V188147.R01.doc Version 1.30 Page 22 Commission for Social Care Inspection Aire House Town Street Rodley LS13 1HP National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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