Care Home: Springfield

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What the care home does well What has improved since the last inspection? What the care home could do better: CARE HOMES FOR OLDER PEOPLE Springfield 1-3 Lowther Avenue Garforth Leeds West Yorkshire LS25 1EP Lead Inspector Catherine Paling Key Unannounced Inspection 15th January 2009 10:00a 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 Springfield DS0000001505.V373759.R01.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. Springfield DS0000001505.V373759.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Springfield Address 1-3 Lowther Avenue Garforth Leeds West Yorkshire LS25 1EP 0113 2863415 0113 2870267 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) Springfield Care Services Mrs Glenys Lawson Care Home 55 Category(ies) of Dementia (67), Mental disorder, excluding registration, with number learning disability or dementia (3), Old age, not of places falling within any other category (67) Springfield DS0000001505.V373759.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered provider may provide the following category of srvice only: Care Home only - Code PC To service users of the following gender - Either Whose primary care needs on admission to the home are within the following categories: Old age not falling with any other category - Code OP, maximum number of places, 67 Dementia - Code DE, maximum number of places, 67 Mental disorder excluding learning disability or dementia - Code DE, maximum number of places, 3 The maximum number of users who can be accommodated is 67 2. Date of last inspection 18th January 2007 Brief Description of the Service: Springfield Care Home is situated in a residential area of Garforth, which is located on the outskirts of Leeds. The home and facilities are currently undergoing a major rebuilding and refurbishment programme to provide updated and improved facilities for people. The home is presently registered to care for fifty-five service users in two separate buildings. Springfield accommodates forty residents and Springfield Grange accommodates fifteen residents and is primarily a dementia care unit. Bedroom accommodation is provided in both single and double rooms, many of which have en-suite facilities. There is ramped access to both properties and passenger or stair lifts available to assist residents with mobility problems to reach the bedrooms on the upper floors. Both properties have pleasant communal areas for the residents to relax and/or dine in and communal toilet facilities are conveniently situated in both properties. The home is well served by public transport and there is a car park to the rear of the property. Springfield DS0000001505.V373759.R01.S.doc Version 5.2 Page 5 The current charges range from £417.98 to £525 per week. There are additional charges for such things as chiropody, hairdressing and newspapers. The manager provided this information at the January 2009 inspection. The home should be contacted directly for up to date information about fees. Springfield DS0000001505.V373759.R01.S.doc Version 5.2 Page 6 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 2 stars. This means the people who use this service experience good quality outcomes. This was an unannounced visit by one inspector who was at the home from 10:00 until 17:10 on the 15th January 2009. The purpose of the inspection was to make sure the home was operating and being managed for the benefit and well being of the people who live there and in accordance with requirements. Before the inspection accumulated evidence about the home was reviewed. This included looking at any reported incidents, accidents and complaints. A number of documents were looked at during the visit and all areas of the home used by the people who lived there were visited. A good proportion of time was spent talking with the people at the home as well as with the manager and the staff. An Annual Quality Assurance Assessment (AQAA) was completed by the home to provide additional information. This is a self-assessment of the service provided. Survey forms were sent out to the home before the inspection providing the opportunity for people at the home, visitors and healthcare professionals who visit to comment, if they wish. Information provided in this way may be shared with the provider but the source will not be identified. A number of surveys were returned by the time of this visit. Comments received appear in the body of the report. What the service does well: The manager wrote in the AQAA – “At Springfield, care is provided by well trained staff who promote privacy, dignity, comfort and choice to their 55 clients. Policies and procedures are in place to cover all aspects of the residents needs. Comprehensive care plans. client and outside professional surveys. Client reviews to ensure that the best practice is delivered. Residents’ meetings now take place on a monthly basis.” There is a relaxed and welcoming atmosphere at the home and staff know the people they care for very well. Before people are admitted care needs are fully assessed so that the manager knows that needs can be met. Health care needs are also met with the support of a range of other healthcare professionals. Springfield DS0000001505.V373759.R01.S.doc Version 5.2 Page 7 People said: “they go above just caring” “show affection” Staff recruitment is thorough and the training available to staff is wide ranging and comprehensive. This means that staff have the knowledge they need to look after people properly. The manager and many of the staff have worked at the home for some years. This stable workforce means that there is consistency and continuity for the people living at the home. Visitors are welcomed at the home at any time. What has improved since the last inspection? What they could do better: The manager wrote in the AQAA – “Build our new extension and improvements to Springfield older building. Continue to offer training to our staff over and above what they need. Managers to embark on training on the Mental Capacity Act. To review residents details in care plans to provide a better format.” The planned improvements and renovation is well underway and once completed will greatly improve the service and facilities for people living at the home. Care records could be improved by making sure the information is more detailed, person centred and is kept up to date. This will help to make sure that people are looked after in the way they want. The current system of two hourly daily recording should be reviewed to make sure that information recorded about how people spend their time on a day-today basis is meaningful and informative. This is so people’s health and wellbeing is reflected clearly in the records. Springfield DS0000001505.V373759.R01.S.doc Version 5.2 Page 8 The in house quality assurance systems should be reinstated to make sure that the views of people using the service and other interested parties have the opportunity to comment on the service. Results of any surveys should be made available to everyone together with an action plan of how any shortfalls are going to be addresses. There is a range of activities available but comments received in surveys suggested that the provision of activities should be looked at to make sure that people are given the opportunity to take part in activities they like. Requirements and recommendations appear at the end of the report. 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. The summary of this inspection report can be made available in other formats on request. Springfield DS0000001505.V373759.R01.S.doc Version 5.2 Page 9 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 Springfield DS0000001505.V373759.R01.S.doc Version 5.2 Page 10 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. JUDGEMENT – we looked at outcomes for the following standard(s): People who use the service experience good quality outcomes in this area. People are provided with information to enable them to make an informed choice about the home. The admission process is good and includes introductory visits as part of the pre-admission assessment. We have made this judgement using available evidence including a visit to this service. EVIDENCE: The manager wrote in the AQAA – “Each service user has an individualised pre admission assessment to ascertain whether Springfield can meet their needs. If Springfield feels they cannot, a full explanation is given to explain their decision. As much documentation and information as possible is obtained, eg, care plans from Social Services, hospital information, talking and assessing proposed service user and information gathered from their families. Each service user is invited to Springfield to spend time there before a decision is made, if this is not possible as much information as possible is gathered when doing the initial assessment. On admission Springfield fills in the admission form with all personal details. A Springfield DS0000001505.V373759.R01.S.doc Version 5.2 Page 11 service user guide and welcome pack which explains what Springfield offers and how it is run. A survey is done at the end of the first week and after 3 months to see if the resident is settling in.” There is information available to people before admission and people are welcome to visit. Whenever possible staff told us that people come to spend time at the home themselves before admission to help them to make up their mind about moving in. We looked at records of a recent admission to the home. The pre-admission format in use by the home is a detailed and comprehensive document. There are tick boxes with space for written comment and it includes space for the rationale for deciding whether care needs can be met at the home or not. The sample we looked at was not fully completed, there were few comments to provide detail of care needs and it was undated and unsigned. For example, there was a tick to indicate that this person needed assistance with personal hygiene and with eating and drinking but no information of exactly what support and help would be needed. The lack of detail on the homes assessment made it difficult to see how the home had arrived at the decision that this person’s needs could be met at the home. The local authority care assessment document was available to staff. This person had been at the home for about one week and there were no care plans yet in place. Although this person had a history of falls and had had some minor falls at the home since admission the falls risk assessment had not been completed and there was no interim plan of management for the falls. Staff said that they need to get to know someone before care plans are written but some initial information should be available to staff about how to care for someone. In the absence of detailed care plans, daily records should be detailed and comprehensive to help staff build up their knowledge. Daily recordings are made every two hours throughout the day and night but these did not provide detail of the care needs of this person and what support and assistance was needed from staff. Staff did seem to have built up knowledge of this person from the information they had and from contact since their admission and this should have been reflected in the records. Springfield DS0000001505.V373759.R01.S.doc Version 5.2 Page 12 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. JUDGEMENT – we looked at outcomes for the following standard(s): People who use the service experience good quality outcomes in this area. There is enough detail in the care records for staff to know how to look after people properly and staff know people well. Medication practices are safe. We have made this judgement using available evidence including a visit to this service. EVIDENCE: The manager rote in the AQAA – “At Springfield we use a person centred approach and each service user is encouraged and supported to make their own decisions. Springfield has a comprehensive care plan that with their support and input along with residents relatives meets their individual needs. We have risk assessments to identify any risks that may develop, pressure areas, risk of falling and risk of malnutrition. There is also included a residents’ survey which takes place after 1 week and again after 3 months to ensure that we meet individual needs. When service users are unable to manage their personal and health care, Springfield DS0000001505.V373759.R01.S.doc Version 5.2 Page 13 Springfield identifies any problems as early as possible so they can be dealt with. Service users are able to register with the GP of their choice but it is pointed out to clients and relatives that Garforth Medical Centre is offering the leodis service which has many advantages, this is explained in full when a client is admitted. This offers continuity or care and a wider ranges of services within the home. Extensive training is given to each member of staff to ensure a high standard of personal and health care. Springfield ensure through policies and training and that all residents are treated with respect, dignity and privacy. The Registered Manager ensures that Springfield has a policy for administration, storage and handling of medication and that it is adhered to.” We looked at a small sample of individual records for people living at the home. The current arrangements for record keeping mean that the care plans and daily records are kept separately. Everyone has a file where care plans are kept and then all the daily records are held together in one file. This practice should be reviewed to make sure that it does not breach the requirements of the Data Protection Act. This also suggests that care staff do not refer to care plans regularly. Care plans for people currently being cared for in the two houses across from the main building are kept in the main building. This mean that a carer on shift in a house does not have access to care plans and the daily records are made without reference to care plans. Daily records are made every two hours throughout the day and night. Whilst this could mean that the manager is satisfied that staff have seen everyone regularly in practice it does not always lead to meaningful and effective record keeping. For example, the daily records seen for one person were as follows: 08:00 “full support given” 10:00 “settled morning” 12:00 “good lunch” 14:00 “settled pm” 16:00 “good tea” 18:00 “supper given in lounge” 20:00 “refused to go to bed”. The type of record does not give information of the health and well being of an individual, for example, there was no information of what this person did or how staff supported him when he refused to go to bed and there was no explanation of what “full support” means. The care plans varied in detail and could be further developed to include more person centred detail. For example, the care plans for one person stated “make sure XXX understands the tasks” and “use body language when explaining”. This could be further expanded to detail tasks this person may not understand and also to make clear what this person can do and should be encouraged to do. There were some plans that were vague. For example, in one person’s nutrition plan stated, “assist where necessary” with no indication of when or how help or support might be necessary. Risk assessments were carried out for people but some had not been reviewed for some time or were undated so it was not possible to establish whether they were up to date or not. Springfield DS0000001505.V373759.R01.S.doc Version 5.2 Page 14 Some care plans were also undated and some did not appear to have been updated for over a year. For example, one person’s nutrition plan was dated 2004. Care records should be reviewed to make sure that staff have easy access to the most up to date information about how to look after people properly. The current practice of record keeping to also be reviewed to make sure that care plans are referred to by care staff and daily records are informative and meaningful. There is a largely stable staff group and they do know the people living at the home very well. They are also led by an experienced and stable senior management team who also know people well. There were records of General Practitioner (GP) visits and people’s healthcare needs are met. People said: “very good at getting doctor in………..always on the ball” “ as far as I am aware she is receiving appropriate medical support” “keep you informed” “ staff talked it through with me when she was poorly” “go above just caring” There were safe medication practices in place and all staff have training before they administer medication. Staff do not have an annual refresher in medication administration and this was recommended as an addition the current training programme. Springfield DS0000001505.V373759.R01.S.doc Version 5.2 Page 15 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. JUDGEMENT – we looked at outcomes for the following standard(s): People who use the service experience good quality outcomes in this area. People are supported in maintaining contact with family and friends and to make choices. People are provided with a good, varied and nutritious diet that takes into account individual choice. We have made this judgement using available evidence including a visit to this service. EVIDENCE: The manager wrote in the AQAA – “At Springfield we provide a wide variety of activities within the home and outside, to encourage service users to become involved if they wish. We have now purchaser a larger 12 seater minibus with wheelchair access which enables us to take a larger number of residents on longer journeys, e.g to the east coast. Staff also take residents out into the community in wheelchairs (weather permitting). Springfield practices dementia mapping and person centred approach which enables us to treat service users as individuals and provides us with vital information and allows us to make daily living as flexible as possible. Visitors to Springfield are encouraged to visit at any time and meals are provided if they would like to join their relative or friend for a meal. Phone lines to most rooms are provided and family friends can speak to their Springfield DS0000001505.V373759.R01.S.doc Version 5.2 Page 16 relatives/friend on the home’s mobile phone if so required. Privacy is respected at all times. Clients can personalise their own room to their own choice and bring as much furniture and personal items as possible. Springfield offers three meals per day with a choice of menus. Snacks and drinks are offered at set times and extra snacks and drinks are offered at any time day and night. Special diets are catered for. e.g gluten free, diabetics.” People said: “I think we need more entertainment music is very good one because everyone is able to listen or join in and sing” “Not much goes on at all. This is a part of the home that needs attention” “Not enough activities” “It would be nice to see activities arranged on a more regular basis, possible small group activities.” “All the staff are kind and helpful towards my mother. She is very happy and content I do not think she would be if there was anything wrong in the home.” People are supported to spend their time in the way they want to and visitors are welcomed at the home at any time. On the day before the visit one person had celebrated their birthday with family and staff organising a party with entertainment. On the day of the visit there had been some musical entertainment in the main building and staff were seen playing games with some people in the afternoon. There was information in people’s records about what people liked to do, noting that one person enjoyed music and sing-along. People made positive comments about the food and the lunchtime meal was relaxed and unhurried. The food looked and smelt good. People said: “(the meals) are very good and varied always trying to see what we would like to eat. The standard of food and cooking is excellent” “The meals at the home are fantastic, mum loves them” Springfield DS0000001505.V373759.R01.S.doc Version 5.2 Page 17 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. JUDGEMENT – we looked at outcomes for the following standard(s): People who use the service experience good quality outcomes in this area. There is a robust complaints procedure and people are listened to and issues are acted upon. People are protected by safeguarding procedures. We have made this judgement using available evidence including a visit to this service. EVIDENCE: The manager wrote in the AQAA – “At Springfield we have a clear and accessible complaints procedure. All service users are informed of complaints procedure and are supported by staff in making their complaint. There is a copy in the Service User Guide and in the Welcome Pack. All complaint forms are kept in the office for all to see and are kept as a record. Service Users can be provided with an advocacy service. Policies and Procedures are in place to deal with any complaints that may arise. All staff are trained in the protection of vunerable adults and are aware of the changing daily needs of clients.” The complaints procedure is displayed on the notice boards within the home and the manager told us that everyone gets a copy on admission to the home. A log is kept of any complaints received and showed that any concerns are taken seriously and are dealt with properly. Information from surveys told us that people know how to make a complaint and who to share any concerns with. Springfield DS0000001505.V373759.R01.S.doc Version 5.2 Page 18 Staff all receive safeguarding training during their induction and in more depth following that. The training is detailed and includes a multi-choice questionnaire to check staff understanding of the training. It was suggested the manager should access local authority safeguarding training, which would make sure that the home’s procedures reflect local authority procedures and practices. There are also plans in place to provide training for staff about the implications of the Mental Capacity Act. Springfield DS0000001505.V373759.R01.S.doc Version 5.2 Page 19 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. JUDGEMENT – we looked at outcomes for the following standard(s): People who use the service experience adequate quality outcomes in this area. People live in a safe and comfortable environment. We have made this judgement using available evidence including a visit to this service. EVIDENCE: The manager wrote in the AQAA – “ We now have planning permision to demolish Springfield Grange. This should take place in March/April 2009 when a new 33 bed EMI extension to Springfield will be built. We are at present renovating the older building at Springfield to single ensuite rooms. The residents who occupy this part of the building are at present occupying two houses opposite the main building until all renovations are complete.” Springfield DS0000001505.V373759.R01.S.doc Version 5.2 Page 20 “When the new build and renovations are complete, every room will single en suite giving every resident the privacy they need. The new build will cater for our EMI residents, giving them a very safe environment with day space on each floor for relaxing and dining. A hairdressing salon with space provided so residents can relax and socialise. There will be new staff quarters with a kitchen and changing facilities. New office space and new laundry. Outdoor space for residents in the form of a decking area which will be enclosed for their safety.” We visited many of the areas used by people living at the home. The two houses being used whilst the renovations are completed have been fitted out to a high standard and provide comfortable temporary accommodation for people. The building work in the main house was nearing completion and was being well managed, although one survey did indicate that some people have found this difficult - “even though we are told (what’s happening) it does not stay in my mind so can be confusing at times but staff are good and helpful.” The provider is aware that the accommodation in Springfield Grange needs renovating. Work is already underway to replace to improve accommodation overall and to provide a brand new building for those people with dementia. The completion of all the work will provide a high standard of accommodation for people living at the home and address the environmental shortfalls identified at previous visits. The laundry was clean and tidy and looked well organised and there were good infection control practices in place. Springfield DS0000001505.V373759.R01.S.doc Version 5.2 Page 21 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. JUDGEMENT – we looked at outcomes for the following standard(s): People who use the service experience good quality outcomes in this area. People are cared for by competent and well trained staff. Overall, there are enough staff to look after people properly. We have made this judgement using available evidence including a visit to this service. EVIDENCE: The manager wrote in the AQAA – “The Management and staffing structure highlights the long service record of all managers and the majority of staff providing long term stability and excellent care for springfields clients. Training at Springfield is of a very high standard which offers excellent training over and above mandatory training that is required, this ensures clients have the best care possible. Staff rotas and shift patterns are devised to meet the clients’ needs and to ensure peak periods of the day and night are covered.” “Springfield has a vigorous recruitment procedure which ensures we get the right person to fill the post. All policies and procedures are followed. CRB checks, POVA checks and new immigrations procedures are all adhered to. Medical questionnaires, references, employment history are all required as part of the interview stratergy. All new staff undertake an in depth induction course which covers all mandatory training. Springfield has an ongoing Springfield DS0000001505.V373759.R01.S.doc Version 5.2 Page 22 training plan to ensure all staff are trained to the highest standard. Springfield has the correct levels and above of staff obtaining NVQ qualifications. Rotas and shift arrangements that clearly show what staff are on duty at all times and are of the correct mix to meet all service users needs. All staff have appraisals and staff supervisions. Staff handbook available for all to see. Handovers at start of each shift.” We looked at a selection of individual staff files and found that safe recruitment practices are in place and all the required checks are carried out before staff start working at the home. These checks include the immigration status of overseas staff. Staff complete a detailed two day Skills for Care induction course within the first 6 weeks of employment and produce a portfolio. The home has a goal of reducing this to within the first four weeks. The majority of care staff have achieved a National Vocational Qualification (NVQ) in care at level 2 and many have also achieved NVQ at level 3. There is a comprehensive and established training programme in place run by the company’s own training department. Some suggestions were made for consideration to further enhance this programme, for example, an annual medication administration update and more in depth dementia training for the manager and the staff in preparation for the expansion of the dementia care service. Overall there were enough care staff to look after people. There was good ancillary support for the care staff in the laundry and good domestic support over 7 days. However the current arrangements in the kitchen meant that care staff were involved in the teatime meal with no kitchen staff after 16:00. This means that care staff are taken away from their caring duties and this should be reviewed. Springfield DS0000001505.V373759.R01.S.doc Version 5.2 Page 23 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. JUDGEMENT – we looked at outcomes for the following standard(s): People who use the service experience good quality outcomes in this area. The home is well managed and run in best interests of the people who live there. We have made this judgement using available evidence including a visit to this service. EVIDENCE: The manager wrote in the AQAA – “Registered Care Manager qualified to run the home with 23 years caring experience at Springfield. All managers have level 3 or 4 NVQ and have extensive training in all aspects of caring for the elderly. Springfield has a good management structure and all are aware of all policies and procedures. The Registered Manager ensures that safe working practices are carried out within the home. The Manager ensures all staff are trained to the highest standard and all policies and procedures are understood by staff. The Springfield DS0000001505.V373759.R01.S.doc Version 5.2 Page 24 Registered Manager ensures all staff have an appraisal every 12 months and staff supervisions 6 times a year. The Registered Manager must make sure all staff and residents feel they can approach her with any views or problems they have. The Registered Manager and her team are committed to the service users and staffs needs in all aspects of their care, health, safety and security. Service user surveys and outside professionals are used. All views are listened to and acted upon to Springfields best ability. All residents who wish to manage their own financial affairs are supported and encouraged to do so. The home is also insured to meet any loss or legal liabilities. Management ensures all service users can see their plan of care and are actively involved in reviews that maintain all aspects of their care and outcomes.” The manager and the senior staff are well qualified and experienced. They and several of the care staff team have worked at the home for a long time providing consistency and stability for the people who live there. We looked at the reports of accidents happening to people living at the home. The report format was clear and there was detailed information. We found that a number of accidents should have been reported to us as required under Regulation 37 of The Care Homes Regulations 2001, and had not. For example, one person had fallen and sustained a head wound and staff sought advice from NHS Direct, in another case someone was transferred to hospital following a fall. The manager was referred to the guidance, which makes clear the provider responsibilities about reporting accidents and incidents occurring at the home to us. The manager is a very visible presence in the home and the staff we spoke with said that they felt well supported by management. The manager told us that she has kept people in touch with the changes through a series of individual meetings with people and families of those being directly affected as changes have happened. Residents meetings are held with the most recent being on 12th January 2009 and we saw notes of the meeting. There has been a system in place for regularly surveying people on a 6 monthly basis. However, the major changes underway have meant that this did not happen during 2008. We saw the results of the last survey undertaken in 2007 when there had been a 50 response to survey distributed. Only very generalised feedback had been provided – “on the whole very positive feedback” with a few concerns “dealt with on an individual basis”. We suggested to the manager that more detailed feedback should be provided in the future together with an action plan of how any issues will be dealt with. We saw that the certificate of registration was not properly displayed in that a photocopy of one of the two pages was on display. The manager was reminded that both pages of the original certificate must be displayed in a prominent position in the home. Springfield DS0000001505.V373759.R01.S.doc Version 5.2 Page 25 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 2 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 X X X X X X 3 STAFFING Standard No Score 27 3 28 4 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 2 X 3 X X 3 Springfield DS0000001505.V373759.R01.S.doc Version 5.2 Page 26 Are there any outstanding requirements from the last inspection? No STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP33 Regulation 37 Requirement Notification of death, illness and other events must take place as required under Regulation 37. This is to make sure that CSCI is kept informed of significant events happening at the home. Timescale for action 12/02/09 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 OP7 Good Practice Recommendations The current practice of daily recording should be reviewed to make sure that the records reflect the health and well being of people in a meaningful and informative way. Care plans should be further developed to make sure that they are person centred and up to date. This is to make sure that people are looked after in the way they want. Risk assessments should be reviewed regularly to make sure that any identified risks are being properly managed. This is so that people are not put at unnecessary risk. Springfield DS0000001505.V373759.R01.S.doc Version 5.2 Page 27 2 OP27 3 OP33 A review of staffing arrangements should be done with particular regard to the kitchen staffing arrangements in the evening. This is so that care staff are not taken from their caring duties over the tea time period. The in-house quality assurance programme should be reinstated. This is to make sure that people have the opportunity to share their views about the service in the interests of continued improvement of the service to people. Springfield DS0000001505.V373759.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection North Eastern Region St Nicholas Building St Nicholas Street Newcastle Upon Tyne NE1 1NB National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 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 Springfield DS0000001505.V373759.R01.S.doc Version 5.2 Page 29 - 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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