Care Home: Springfield House

Similar services:

• St Vincents
• The Cotswold Home
• Winton House
• Rush Court
• Hillyfield Rest Home
• The Maypole Nursing Centre
• The Briars

What the care home does well What has improved since the last inspection? What the care home could do better: The service could look actively at how they could provide more single bedroom facilities, thus offering more choice in respect of those people sharing bedrooms. As the number of services offered by the owners grows, additional area management infrastructure is being put in place to support this growth. We were advised of the plan to standardise records and documentation across all similar services, in such areas as operational manuals, staff guidance etc, as well as assessment and care planning formats. On entering the home the certificate of registration was not prominently displayed as it had been removed due to redecoration, and had not been replaced. This was pointed out by the inspector and remedied immediately. The manager was reminded of the need to ensure all statutory certificates are displayed within the home. There were two rooms where there was an odour of urine, and a small corridor to the fire exit by the kitchen, which smelt musty and appeared unkempt. The door butt to the door of the fire escape to this corridor posed a finger trap hazard, and this was pointed out to the manager who agreed to pass this issue onto the maintenance person. It was noted that staff members were not receiving the 6 minimum number of individual supervision sessions per year. CARE HOMES FOR OLDER PEOPLE Springfield House 95/97 Portsmouth Road Woolston Southampton Hampshire SO19 9AF Lead Inspector Richard Slimm Unannounced Inspection 10:30 22nd July 2008 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 House DS0000012321.V367692.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 House DS0000012321.V367692.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Springfield House Address 95/97 Portsmouth Road Woolston Southampton Hampshire SO19 9AF 023 8044 2873 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) Mr Richard Kitchen Mrs Elizabeth Kitchen Mr Richard Edward Kitchen Care Home 23 Category(ies) of Dementia - over 65 years of age (23), Old age, registration, with number not falling within any other category (23) of places Springfield House DS0000012321.V367692.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. One person may be accommodated in the category (A), whose date of birth is 2/2/50, until 31/3/06. 15th November 2006 Date of last inspection Brief Description of the Service: Springfield House is situated in Woolston, Southampton. Mr and Mrs Kitchen who own and run other residential services in the area own the home. The home is registered to provide care and support to twenty-three residents who are elderly and who have dementia. The home has a range of double and single bedrooms over two floors, over 50 of beds are within shared bedrooms. The home has a large lounge, which is divided into three smaller seating areas allowing service users to select a quiet area if they wish. To the front of the property is a small garden and parking for residents’ visitors and to the rear is a larger well-maintained accessible garden. The home has ramped access for people who may be wheelchair dependent and there is a small passenger lift to upper floors. The home is situated close to local facilities and a short journey away from Woolston and the city of Southampton. The weekly fees range from £340 - £475. Springfield House DS0000012321.V367692.R01.S.doc Version 5.2 Page 5 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 inspection was an unannounced ‘Key Inspection’ of the home, a ‘Key Inspection’ being part of the CSCI inspection programme, which measures the service against the key National Minimum Standards, and outcomes for people using the service as part of a process known as “Inspecting for Better Lives” (IBL). This report incorporates information gained from people using the service and/or their advocates / relatives, staff, including managers and comments from eternal stakeholders who completed professional comment cards. We were also provided with the services annual quality assurance questionnaire (AQAA) completed by the manager and other relevant information gained by the inspector during a site visit to the home. The visit to the home was undertaken by one inspector and lasted 5 hours. What the service does well: There were many positive aspects found at the home in the interests of service users. Most people living at the home spoken to were found to be very happy with the quality of care and support they received on a daily basis. People spoke highly of the staff team and the manager / owners. Residents said the quality of food was good, and that there were regular activities arranged for peoples’ entertainment. Most of the home was pleasantly presented providing a valuing environment for residents. The home continues to develop good systems of assessment and care planning to promote a good quality of care, support and continuity of service. Staff members were found to engage well with residents, and there was a range of skills and experience in the team. Staff spoken to had been supported in their training and development, and were found to be keen to continue their training, both at national vocational levels and more specialist courses. Visitors said they were always made to feel welcome, and could visit at any reasonable time. Springfield House DS0000012321.V367692.R01.S.doc Version 5.2 Page 6 There was a good response to surveys included comments such as “ I received enough information about this home before I moved in so I could decide if it was the right place.” – “I receive the care and support I need.” – “Staff listen and act on what I say.” - “Staff are available when I need them.” – Activities are arranged at the home that I like and can take part in if I choose.” – “ The food is very good.” – “The staff are lovely.” – One GP indicated, “I have always been impressed by the care.” – “ The care service seek advice and act upon it to manage and improve individuals health care needs.” Another GP said, “Care goes far beyond requirement. Going the extra mile- all the time!” – “This is where I would be happy for a relative to be; patients are nurtured as well as cared for. Even a sprinkling of love.” Staff survey comments included – “I had a very in depth induction, taking me round the home, meeting all the residents, showing me policies and procedures.” – “We are all very happy at work which makes our residents very happy and comfortable in the home.” – “I really like the way the home organise the hours for staff. The cook is excellent; the clients enjoy the food and the service. Entertainment is organised regularly. Enough protective equipment (gloves, apron). High quality of hygiene in the kitchen.” – “The service promotes the well-being and rights and choices of the service users. It provides good food and excellent care medically, e.g. access to - nurses, doctors. Outside agencies are informed at all times when they are required to enhance the residents needs for a good quality of life.” – “We actively respect the individuals rights, promote well-being and maintain a happy environment, we also promote privacy.” What has improved since the last inspection? Action had been taken to comply with a number of issues identified in the previous inspection report. However, the regularity of staff supervision does not fully meet people’s needs and should be improved further. • • • • • • • The service now actively focuses on resident feedback, especially those who do not have the direct support of social services. There has been refresher training in medication. Changes are made based on the views of people and are based on individual wishes. The home has introduced a food trolley and has updated choices for people at tea and supper times. The home plans to monitor complaints and continually update staff training in complaints and safeguarding. The home management ensure the home looks fresh, presenting a clean and relaxed environment for all who live, visit and work in the home. The home has introduced a new training package for staff. The home has introduced a new working care structure. DS0000012321.V367692.R01.S.doc Version 5.2 Page 7 Springfield House The home’s AQAA states, “Within the last 12 months the home has made various improvements. We have improved the menu system and implemented more choice, following feedback from clients through quality monitoring. We have implemented more activities within the home as clients requested this. The environment has been improved through continual redecoration.” 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. The summary of this inspection report can be made available in other formats on request. Springfield House DS0000012321.V367692.R01.S.doc Version 5.2 Page 8 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 House DS0000012321.V367692.R01.S.doc Version 5.2 Page 9 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): We assessed standard 3. Standard 6 was not assessed, as the home does not provide intermediate care services. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home ensures it can fully meet the needs of prospective residents by undertaking a comprehensive assessment of needs and wishes before admission to the service. EVIDENCE: Springfield House care home produce a statement of purpose for all prospective service users. This includes information to enable prospective residents and/or their advocates to make informed decisions about moving to the home. This was confirmed in both verbal and survey feedback. People spoken to said they were given the opportunity to visit the home before they made a decision. Springfield House DS0000012321.V367692.R01.S.doc Version 5.2 Page 10 There was evidence of good systems for assessment prior to offering a service. In addition to this where the resident is publicly funded social work assessments are carried out and kept on file. Survey feedback indicated that people had been actively involved in the decision to use the service, and had received information about the home before making a decision to move in. Feedback from staff and people using the service confirmed that the home takes care to take account of peoples’ interests as well as their needs and wishes. We looked at 5 peoples records in the case tracking exercise. Assessments consider risks as well as areas of needs and wishes. Documents were detailed and contained information that would enable good quality and continuity of care to be provided. There was also evidence that assessments looked at communication needs of people and considered issues including more complex health care needs. Mechanisms are in place for reviewing that the individual’s needs are met in accordance with the Care Plan. Springfield House DS0000012321.V367692.R01.S.doc Version 5.2 Page 11 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): We assessed standards 7,8,9 and 10. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home ensures residents’ health and personal needs are set out in an individual plan of care, this included attention to the individual residents social care needs and specific guidance to care staff as to how specific care needs are to be met on a daily basis. The home ensures the health care needs of the residents are identified and fully met. People have full access to health care services externally to the home. The home ensures residents’ receive their medication safely and as prescribed with support where needed. The home ensures residents’ rights; dignity and privacy are promoted and upheld. Springfield House DS0000012321.V367692.R01.S.doc Version 5.2 Page 12 EVIDENCE: Case tracking found recorded evidence that care is taken to ensure people get full access to health care services. Plans of care identified clearly the needs of individuals and their specific health care needs. One district nurse told us in a survey that – “All residents have full care plans and communication amongst staff members regarding the health care needs of residents is excellent. I receive regular referrals if staff members need nursing advice or input.” Assessments and ongoing reviews of care plans were in place that ensures the changing health care needs of people are identified and action take to access external support when needed. People spoken to say they could always see their doctor when they requested. Two local doctors responded to our survey and were positive about the arrangements at the home for their patients. There are clear policies and procedures in place in respect of the administration of medication. We spoke to 6 staff members, and observed the staff member carrying out medication administration. Staff members involved in this area of the service were aware of this guidance. The staff member administering medicines at the time of the site visit was observed to follow guidance and best practice. One district nurse told us in a survey that – “Medications are managed very well and as far as I have seen, very accurately.” People said they were happy with the arrangements the home makes to support them with taking their medicines, and felt confident the staff knew what they were doing. We checked 5 medical administration records. Medication records were found to be accurate and up to date, and the storage of medicines including controlled drugs was found to be safe and to follow best practice. Visiting practitioners all confirmed that they were able to see their patients in private. Feedback included the comment – “Yes, all staff keep a high standard of privacy at all times.” Residents said staff at the home always respected their privacy. Case records also identified clear guidance for staff in the areas of privacy and dignity when supporting and caring for people. Springfield House DS0000012321.V367692.R01.S.doc Version 5.2 Page 13 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): We assessed standards 12, 13, 14 and 15. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home provides a range of relevant and stimulating activities for the residents, based on direct feedback from clients their needs, interests and wishes. The home makes all visitors to the home welcome. There are clear visiting policies and guidance in place. The home supports residents to exercise choice and control over their lives, utilising a person centred care planning approach that continues to develop and improve. The home provides the residents’ with a wholesome appealing balanced diet in pleasing surroundings. Menus are displayed and are based on the needs and wishes of people. Springfield House DS0000012321.V367692.R01.S.doc Version 5.2 Page 14 EVIDENCE: The annual quality assurance questionnaire completed by the manager prior to the inspectors visit to the home advised us that the home has a programme of activities to enhance the quality of peoples social lives at the home. We confirmed there is a musical activity twice each. There were regular sessions of bingo and reminiscence. One resident told us she enjoyed the activities and looked forward to the reminiscence. On the day of our visit the regular hairdresser was in and this provided a lot of social interaction and fun for those involved. There were also a lot of visitors in and out of the home throughout the visit. Regular activities are advertised on the notice board, and people spoken to confirmed regular activities took place. Each week there is a session of gentle armchair exercise. Peoples’ spiritual needs are also attended to by visiting clergy, and differing faiths are catered for as the need arises. Staff members are enabled to interact with residents most afternoons by their involvement in such activities as board games and puzzles. Most importantly people are encouraged to continue their individual interests both inside and externally to the home. This was evidenced by the recent provision of a small shed/’arbour in the garden to enable residents to become involved in some gardening and growing tomatoes. A number of visitors were spoken with, and they all confirmed they were always made to feel welcome at the home, and were free to visit at any reasonable time. There is a clear statement in respect of visiting displayed prominently in the home. People living in the home who were spoken with confirmed they had regular visitors and enjoyed this link with the community. Case tracking records confirmed that the service continues to develop person centred approaches to care planning. Individual plans identify what people can do for themselves as well and where they need support/encouragement. Staff members were observed enabling people, rather than simply doing things for people. Other staff member such as the domestic, were aware of differing peoples’ preferences, in respect of room cleaning and the dusting of personal items. People spoken to said they were free to do whatever they liked, the problem was usually that limitations were due to increasing frailty, not any regime in the home, and that staff were very helpful and responsive. Food menus are displayed with the day menu displayed in larger print. People confirmed that they were involved in menu planning, and that they enjoyed the quality of food provided. This was also confirmed in the AQAA. We were able to join residents at lunch. The meal was plated and delivered to the table by staff members. A drink was provided and salt and pepper was available on Springfield House DS0000012321.V367692.R01.S.doc Version 5.2 Page 15 the table. The main course was egg, bacon and cheesy mashed potato with half a tomato, followed by bread pudding and custard. The dessert was made with low sugar as 3 people have dietary diabetic needs, and the manager explained that low sugar desserts help in providing a more healthy diet. People all appeared to enjoy their meal and were happy with the way it was served. More dependent people who needed assistance were provided with help and support in a discreet and sympathetic manner. Case records showed that individual preferences in such areas as diet are recorded. Menus showed that the home was providing as varied diet, based on the wishes of residents. Springfield House DS0000012321.V367692.R01.S.doc Version 5.2 Page 16 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): We assessed standards 16 and 18. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home promotes an open and inclusive environment where residents and relatives feel confident that their concerns and complaints will be listened to and acted upon. The home adopts clear strategies to protect and safeguard the residents from possible abuse or harm. EVIDENCE: The annual quality assurance questionnaire (AQAA) completed by the manager prior to the inspectors visit to the home confirmed that the home had all the necessary policies and procedures to ensure safe systems are in place to promote best practice in the area of safeguarding vulnerable adults. The AQAA also stated that the organisations complaints and concerns policies and procedures were in place. We were told that there were – - The complaints procedure is detailed within the service user guide, which is available to the client, within the terms and conditions of residency and is also displayed in the reception area of the home. - Clients and their families are therefore fully informed of how to make a complaint. Springfield House DS0000012321.V367692.R01.S.doc Version 5.2 Page 17 -The home has a copy of “No Secrets” and also has policies and procedures that link to local authority safeguarding procedures. -Clients are supported to maintain their legal rights, and to participate in the civic process if they wish. -We have policies and procedures about confidentiality, abuse and how to report on suspected incidents and whistle blowing. We found that people spoken to, service users and visitors, were aware of how to make any concerns known, and who to speak to. Visitors also said they were aware of who to speak to if they had any worries or concerns. The complaint procedure was displayed prominently in the home. People spoken with said they felt safe at the home, and confident of the staff who helped and supported them. The home is aware of what to notify us about and of their duties to report safeguarding matters to the relevant agencies when needed. A staff member interviewed confirmed that the recruitment process had paid attention to the protection of vulnerable children/adults. Induction processes cover safeguarding for all new staff members, and further training is provided in conjunction with the local authority responsible for safeguarding. Staff training records indicated that core health and safety related training has been provided and where needed is updated. Case tracking and a review of staff records also confirmed the above. Springfield House DS0000012321.V367692.R01.S.doc Version 5.2 Page 18 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): We assessed standards 19 and 26. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home provides a clean welcoming and well-maintained environment for the residents to live in. The ratio of single to double bedrooms is low as twelve of the twenty-three beds are in shared bedrooms. The home provides a clean and pleasant environment for the residents to live. The management is made aware of problems such as odours quickly by domestic staff and takes action to deal with such matters promptly. EVIDENCE: As identified above the home was cleaned to a good standard with only minor issues of odour that management were aware of and action being taken to overcome the problem. The domestic staff member confirmed that she had all the tools and resources she needed to do her job, and it was evident the job Springfield House DS0000012321.V367692.R01.S.doc Version 5.2 Page 19 was being done well. There is a continual programme of upkeep; repair and maintenance at the home, and the owners employ two staff specifically to keep their care homes in a good state of repair. A challenge for this service is the high ratio of double rooms to single. At present over 50 of beds are within shared bedrooms. We were advised the owners are aware of this issue and are actively seeking ways of increasing single room provision across all their services, including Springfield, in line with best practice and market forces. One staff member commented in the survey that, “The sinks in the rooms A, B, C, D (extension) the sinks should be bigger (we have to go to the bathroom for water, would be easier to get the water in the room).” A nurse commented that – “The home provides a happy, safe, efficient place of care for all residents.” Gel disinfectors were in place to reduce risk of cross infection for people entering and leaving the building. People spoken to were found to be happy with their environment, even those who shared bedrooms were generally contented with these arrangements. Some people in shared rooms while contented did say they would have chosen a single room if one had been available. There were two bedrooms where there was an odour problem, and a small corridor. Management were aware of these matters and were taking action to remedy any unpleasant smells. The door butt to one fire door had a raised edge near the door handle that could be a potential finger-trapping hazard. Springfield House DS0000012321.V367692.R01.S.doc Version 5.2 Page 20 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): We assessed standards 27, 28, 29 and 30. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home provides sufficient numbers of skilled staff to meet the needs of the residents. There is a commitment to staff training, however, there is a need to increase staff numbers trained to NVQ 2 minimum by 10 in order to meet government benchmarks for 50 of care staff trained to this level. Residents are protected by the home’s robust recruitment procedure. Staff members newly appointed receive a thorough induction based on Skills for Care occupation standards and other best practice guidance. EVIDENCE: We noted 4 care staff plus other management and ancillary staff, including the cook and domestic, on duty during the morning of our visit. This reduced in the afternoon. The AQAA advised us there were three staff from 4 pm to 9:30 pm, with 2 waking night staff between 9:30 pm and 7:30 am. And advised us that 464 care hours had been provided for the week up to and including the completion of the AQAA. Springfield House DS0000012321.V367692.R01.S.doc Version 5.2 Page 21 Residents said there are more staff on duty at busier times, and confirmed that they rarely had to wait too long if they needed assistance. There is staff rota but this did not seem to be displayed anywhere to enable residents to see who was going to be on duty and when. Staffing level were found to be sufficient for the needs of the current resident group, and the levels of support and supervision they need. There appeared to be a clear commitment to staff training. The AQAA declared that 5 staff have NVQ 2, one had achieved NVQ 3, and 2 other staff are currently working to obtain NVQ level 2 qualifications. This meant that only 40 of staff have achieved or are actively working toward achieving NVQ 2. Government targets for staff training in care homes is at least 50 NVQ 2, so the home needs to increase staff trained to NVQ 2 by an additional 50 . It was evident speaking to one staff member who had achieved NVQ 2 that the staff member was keen to continue her professional training and development and was looking forward to moving onto her NVQ 3 training. There is a programme of in-house training that cover more specialist areas based on the needs of people living at the home, other statutory requirements such as health and safety / food hygiene etc, and the home’s legal registration. We checked a number of staff files to validate staff recruitment processes, supervision frequency, induction and training and development. It was evident that the home adopts a robust and thorough staff recruitment process that supports the protection of people using the service. We noted that all necessary checks had been carried out prior to employment. Staff interviewed said they had been interviewed, completed application forms, had Criminal Record and Protection of Vulnerable Adult checks and 2 references taken up by the home. Staff members also confirmed that they received thorough induction into their roles. The induction check list follows Skills for Care guidance and includes all essential areas. It was noted that staff supervision is not being provided to the minimum standard of 6 times per year. Records, and staff members interviewed confirmed this. We pointed out the need to ensure all staff received supervision 6 times each year. Annual appraisals of performance were being carried out each year. Staff meetings are carried out every three months, enabling the team to discuss issues in respect of achieving outcomes, and promoting the smooth running of the home to the benefit of residents. Springfield House DS0000012321.V367692.R01.S.doc Version 5.2 Page 22 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): We assessed standards 31, 33, 35, 36 and 38. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home has a registered manager who is also a co-owner of the home. The home considers the views of the residents, staff, relatives and other stakeholders and consultation is formalised as part of the homes quality assurance. The home has appropriate systems in place to enable and support the residents to safely look after their personal monies where needed. The home fails to provide staff with six individual supervision sessions each year that clearly aims to support staff in their roles. Arrangements are in place to carry out annual appraisals of staff members. Springfield House DS0000012321.V367692.R01.S.doc Version 5.2 Page 23 The home provides a safe environment for the residents and staff. EVIDENCE: The owners / registered manager was not available at the time of this site visit. However, the owners had made arrangements for the home to be covered by another manager form one of their other services. The owners have a number of care homes across the area and are developing an area management team to provide additional support and structure to all of the homes including Springfield. The AQAA advises us there is also a duty manager available who is not registered but is undertaking training to NVQ level 4 with the registered managers award. We are advised that feedback from people using the service is positive in respect of this manager’s role and performance. The home carries out the quality assurance survey every six months to actively seek the views of residents and other stakeholders. Where needed a volunteer is used to support people who may not have naturally existing networks, families or friends to help them. Other evidence of people being consulted was available such as people’s involvement in menus and activity choices. Residents spoken to confirmed that their views are sought by the home. People are encouraged to look after their own financial affairs. Where this is not possible, families are encouraged to help residents. In the event of the home having to be involved, action is taken to ensure the development of clear guidance, the maintenance of clear records and receipts of any deposits or expenditure made on behalf of more vulnerable frail residents who cannot manage their own affairs, protect everyone. Staff members do not currently receive the minimum of six individual supervision sessions each year. Annual appraisals do take place each year. Records, and staff members interviewed confirmed this. We pointed out at the time of the visit the need to ensure all staff received supervision 6 times each year. Annual appraisals of performance were being carried out each year. Systems are in place to ensure as far as reasonably practicable that the health, safety and welfare of all who visit, work and live at the home is promoted. Staff training is in place to promote safe practices of staff. The home has a comprehensive fire alarm system, and there are regular tests and drills that are sympathetic to the needs of residents and the home’s work place fire regulation risk assessment. Springfield House DS0000012321.V367692.R01.S.doc Version 5.2 Page 24 The home has maintenance contracts with all relevant utilities and other agencies in respect of more specialist equipment. The home reports all incidents to the relevant agencies in a timely and efficient manner. Springfield House DS0000012321.V367692.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 3 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 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 2 X 3 Springfield House DS0000012321.V367692.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. Standard Regulation Requirement Timescale for action 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 OP36 Good Practice Recommendations The registered manager should review staff support arrangements to ensure all staff receive a minimum of six formal individual supervision sessions a year, including the annual appraisal of performance. Action is recommended to risk assess the door butt to the door of the fire escape to the corridor near the kitchen area as this appeared to pose a finger trap hazard. 2 OP19 Springfield House DS0000012321.V367692.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Maidstone Office The Oast Hermitage Court Hermitage Lane Maidstone ME16 9NT 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 House DS0000012321.V367692.R01.S.doc Version 5.2 Page 28 - 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. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!