Care Home: Springfield House

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What the care home does well Information is available about what can be provided to help people and their families to make decisions about their future care needs. People can visit to help with these decisions. People are given help and support to make choices in their daily lives. A variety of activities are provided and people can choose to take part if they want to. Springfield House helps people to do things they like to do and to try new activities. Springfield House looks after people well and writes down what help everyone needs. People are helped with their medical appointments, and staff work well with other professionals and agencies to provide the health support they need. Staff are trained to help them understand how to meet the needs of people who use the service. Springfield House makes sure that suitable staff are employed and that all checks are made to keep people safe. The management team supports staff working at Springfield House. People are helped to keep in touch with their families and friends. Visitors are made welcome in the relaxed and friendly home. People can choose what they want to eat from the healthy menu. Alternative options to the main menu are provided, and people can have snacks and drinks at all times. Surveys say that people are happy with the care that is given by staff at Springfield House. What has improved since the last inspection? Full assessments are completed for all people before they move into Springfield House and this includes details of the health care and support needs they have. Information gathered during assessment is used to write a plan of care so all staff know what support is needed. Care plans are regularly reviewed and updated as necessary. Staff are trained to know and understand how medication is to be given, checked and stored properly. Regular audits of medication are being done to make sure there are no mistakes. There has been more staff training and guidance on abuse awareness and local adult protection protocols. All safety checks are done on new staff before they start to work at Springfield House. A system is being developed to check on the quality of the service provided at Springfield House. What the care home could do better: The night time records should be further developed to include people`s preferred routines. This will help staff give support in a consistent way. Care plan records should included details of current medication with reasons for taking it, together with any possible side effects. This would make sure staff have information to carry out more effective monitoring CARE HOMES FOR OLDER PEOPLE Springfield House 3-5 Ranelagh Road Malvern Worcestershire WR14 1BQ Lead Inspector Dianne Thompson Key Unannounced Inspection 12th September 2008 09:00 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 DS0000069711.V372175.R03.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 DS0000069711.V372175.R03.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Springfield House Address 3-5 Ranelagh Road Malvern Worcestershire WR14 1BQ 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) 01684 574 248 01684 899 372 yhch@fsmail.net Young@Heart Care Homes Ltd Vicky Louise Lane Care Home 17 Category(ies) of Dementia (17), Old age, not falling within any registration, with number other category (17) of places Springfield House DS0000069711.V372175.R03.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. The maximum number of service users to be accommodated is 17. The registered person may provide the following category of service 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 within any other category - Code OP Dementia - Code DE. Date of last inspection 21st September 2007 Brief Description of the Service: Springfield House is situated in a quiet cul-de-sac on the outskirts of Malvern Link. The property consists of two large semi detached houses that are internally linked to form one care home. There are eleven single rooms, two of which have en-suite facilities, and there are three double bedrooms none of which have en-suite facilities. A chairlift is available to assist people with impaired mobility negotiate steps and stairs. The home is registered to provide care for a maximum of seventeen older people who have needs related to age, physical disabilities and or dementia type illnesses. The new Provider has produced revised information literature describing the service provided at the home. This is presented as an information pack in the main entrance to Springfield House. There is a copy of a Service User guide in each bedroom and spare copies are available on request. Details of the fees for the service are included in the Service Users Guide. The reader may wish to contact the service for up to date fee information. Springfield House DS0000069711.V372175.R03.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 was an unannounced inspection visit to see what the service was like for the people who live at Springfield House. Time was spent talking to some of the people who live at Springfield House and some of the staff working there. We looked at some of the records, policies and procedures in the office. We talked to other people to get their views about the service. The manager completed an Annual Quality Assurance Assessment (AQAA) and sent this to the Commission for Social Care Inspection (CSCI). The AQAA is where the manager tells us about the service provided at Springfield House and the ways they plan to develop the service. We looked at parts of the premises. Information gathered from other sources, such as surveys, monthly visit reports and information sent to the CSCI has been included in this report. What the service does well: Information is available about what can be provided to help people and their families to make decisions about their future care needs. People can visit to help with these decisions. People are given help and support to make choices in their daily lives. A variety of activities are provided and people can choose to take part if they want to. Springfield House helps people to do things they like to do and to try new activities. Springfield House looks after people well and writes down what help everyone needs. People are helped with their medical appointments, and staff work well with other professionals and agencies to provide the health support they need. Staff are trained to help them understand how to meet the needs of people who use the service. Springfield House makes sure that suitable staff are employed and that all checks are made to keep people safe. The management team supports staff working at Springfield House. Springfield House DS0000069711.V372175.R03.S.doc Version 5.2 Page 6 People are helped to keep in touch with their families and friends. Visitors are made welcome in the relaxed and friendly home. People can choose what they want to eat from the healthy menu. Alternative options to the main menu are provided, and people can have snacks and drinks at all times. Surveys say that people are happy with the care that is given by staff at Springfield House. What has improved since the last inspection? What they could do better: The night time records should be further developed to include people’s preferred routines. This will help staff give support in a consistent way. Care plan records should included details of current medication with reasons for taking it, together with any possible side effects. This would make sure staff have information to carry out more effective monitoring Springfield House DS0000069711.V372175.R03.S.doc Version 5.2 Page 7 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 DS0000069711.V372175.R03.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 DS0000069711.V372175.R03.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): 3, 6 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Information is available about the service, and what can be provided to help people and their families making decisions about their future care needs. People are given opportunities to visit and assessments are completed before they move into Springfield House to make sure their individual needs can be met. EVIDENCE: Policies and procedures are in place for assessing potential people to live at Springfield House. Information about the service included in a Statement of Purpose and Service User guide that is available for all enquirers and residents. The Statement of Purpose has been updated to reflect the change of manager and Provider. Springfield House DS0000069711.V372175.R03.S.doc Version 5.2 Page 10 The admissions procedure has been improved to make sure that full community care assessments are received and that Springfield House complete their own assessments for each person admitted to the service. We saw that community care assessments had been completed for the files examined. This meets the requirement of the previous inspection. Care plans are written from the information gathered during assessments, visits and discussions with families and other interested parties. We saw assessments that showed where families have been involved in the assessment process and where information had been obtained from previous homes. People are given an information pack containing a copy of the statement of purpose and service users guide on admission. The service user guide gives information about the service that people can expect, together with details about the fees, the complaints procedure and a copy of their contract with the service. Surveys confirm that information is shared about the service to help people contribute to decisions that involve their relatives. One person who had recently moved into Springfield House confirmed that information had been given about the service and that an assessment had been completed. Springfield House DS0000069711.V372175.R03.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): 7, 8, 9, 10 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Individual health and personal care needs are being well met by the staff at Springfield House. Care plans are completed and reviewed regularly. This makes sure that staff have all the information they need to provide consistent support. Springfield House has a medication policy and procedure for staff to follow to ensure that all medication is administered and stored safely for the protection of everyone who uses the service. EVIDENCE: People who live at Springfield House have care plans that give information about personal care needs and the ways people prefer to be supported. Care plans for three people were checked. This included care plans for a person recently admitted to Springfield House, one person who has used the Springfield House DS0000069711.V372175.R03.S.doc Version 5.2 Page 12 service for many years and another person whose care needs have significantly changed in recent months. The manager states in the services AQAA that ‘a plan is provided for each individual service user’ and this ‘is reviewed at regular intervals’. The review of care planning procedures includes more attention to risk management, consultation and the specialist needs of people with dementia. This meets the recommendation of the previous inspection. We saw that all care plans have indexes to make information easier for staff to follow and that these plans are reviewed and evaluated on a monthly basis. Examples of such reviews were completed on 28/7/08 and 20/8/08. The nighttime record sheets were checked and the manager was advised that these records should be further developed to include people’s preferred routines. This will help staff give support in a consistent way. The manager states in the services AQAA that ‘we have improved on pressure care in the past 12 months and have not had to call the district nurse for help with pressure sores.’ We saw records that show how routine care is given to keep people free from pressure sores as much as possible. Details about each person’s health needs and how they are to be met are recorded. Records show that all physical checks are completed. People are weighed on admission to Springfield House and regular weight checks are completed each month. We saw records to show this such as 21/6/08, 4/7/08, 20/8/08, and 2/9/08. One person weighed 62.9kg on admission and weighed 60.1 4 months later. Care plans advise staff that action is to be taken when a weight loss of 4 kg is identified. We saw that information is given about people’s sight, hearing and how they communicate. We saw guidance to staff on how support is to be provided, for example where a person does not like wearing hearing aids. Records show that handling and mobility risk assessments are completed and updated when changes are identified. For example, on 31/7/08 accident records show that a resident had fallen on the floor in the lounge. This incident is well documented and cross-referenced to the care plan and the revised risk assessment. It was noted however, that an ambulance was called but the resident did not want to go to hospital. There is no record of any action taken in response to this, such as follow up checks with the doctor? This was discussed with the manager who was advised to make sure that all follow up actions are recorded. Springfield House monitors all falls that occur and records show that regular contact with the Primary Care Team is maintained. People have good access to medical support through their Primary Health Care Team (PCT) as required. This includes physiotherapist, dietician, dentist, Springfield House DS0000069711.V372175.R03.S.doc Version 5.2 Page 13 chiropodist and doctors. A record of visits by doctors or other medical professionals is kept. We saw a record that shows the outcome of a doctor’s visit on the 13/7/08. It is stated that staff are to ‘ring if legs still swollen in 1 week’. There is no record to show how this was monitored and whether the swelling to this person’s leg has improved or whether they are still swollen. This was discussed with the manager. A policy and procedure is in place for the administration of medication. All staff involved in the administration of medication receive accredited training that includes basic knowledge of how medicines are used and how to recognise and deal with problems that may occur. Training records confirm medication training takes place, for example some staff completed medication training on 1/4/08. Medication is stored securely and given to people at the right time and full records are kept to show this. Information about medication is included in individual care plans. We saw one record that states that the person ‘takes medication well’. The manager was advised that care plan records should included details of current medication with reasons for taking it, together with any possible side effects. This would make sure staff have as much information as possible to help them monitor people’s health and wellbeing. Regular audits of medication management are now being completed to help identify shortfalls such as stock rotation, double-checking of handwritten entries, and discrepancies in stock balances when checked against administration records. This meets a recommendation from the previous inspection. We saw staff engage with people in a respectful way, making sure that dignity and self-esteem was important for each person. Time was spent with people who live at Springfield House. One person said they had lived in the home for many years. Another person said how she enjoyed living in the home, and talked about her recent holiday with her family. Surveys confirm that staff are ‘very caring’ and ‘look after people well’. Another person said she ‘likes being here’ and that the staff are very good to her ‘especially Vicky, she is one in a million’. Springfield House DS0000069711.V372175.R03.S.doc Version 5.2 Page 14 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): 12, 13, 14, 15 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. People are supported and encouraged to take an active part in their choice of activities. Everyone is encouraged and supported to maintain links with their families and friends. People who use the service are helped to make decisions about their lives and are provided with opportunities to participate in various aspects of life in the home. Dietary needs are well catered for with a varied and healthy menu provided. EVIDENCE: People living at Springfield House are encouraged and supported to take part in social activities that are available. People make choices about how to spend their day and examples of this were observed throughout the inspection visit. During the afternoon people took part in a board game with a prize of a box of chocolates for the winner. People appeared to enjoy the session and staff were seen to be very helpful, making sure everyone could be involved if they Springfield House DS0000069711.V372175.R03.S.doc Version 5.2 Page 15 wanted to be. The manager said that regular trips and outings are arranged and a trip to a pantomime is planned for January. Guitar concerts are held monthly and the records show that people attending these concerts contribute to the fees. A record is kept of the sessions, including who attends and how each person responded to the concerts. For example 13 people attended on 26/8/08. Comments included ‘sang along to all or some of the songs’ or ‘sang with help’. When asked, people said the concerts were ‘great fun’. Other activities provided by the service are varied and include war time sing a long, dominoes, movies, jigsaw puzzles, manicures, board games such as snakes and ladders, talking with staff, playing cards, and reading the daily newspapers. People are supported to take part in community activities such as church group discussions. Staff said they are busy fund raising to purchase more activity equipment. Musical instruments have recently been purchased and include tambourines and cymbals. The manager states in the service’s AQAA that ‘activities are recorded for each individual resident. We can then monitor if a service user enjoyed or disliked the activity. It also aids us to vary the activities’. The activity records however are all kept in one file and are not part of each persons care plan. This was discussed with the manager and advised this is not a confidential way to keep records. The manager said that changes would be made for all information to be included in individual care plans. Care records show that regular contact with friends and family is supported. People who use the service are able to see their visitors in private, and surveys confirm that they are made welcome. People confirmed they have regular contact with their family and friends. The service provides meals that are varied and nutritious, with different choices available where preferred. Snacks and drinks are available throughout the day. People are consulted about their choice of food and diets, and support is given for people who find it difficult to eat and need help. Lunch on the day of the inspection included fish, mashed potatoes and peas with parsley sauce. The manager states in the services AQAA that ‘the home recognises that food and drink play an important part in the social life of the home. Meals are unhurried’. We saw people helping themselves to fruit and drinks from the kitchen as they wanted. Staff said people are encouraged to drink plenty of fluids. Surveys confirm that people who use the service are ‘quite satisfied’ with the choice, variety and amount of food provided. Springfield House DS0000069711.V372175.R03.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): 16,18 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. People have access to information about how to complain and staff support people to express their views and any concerns they may have. There are suitable procedures in place for the management of complaints and to make sure that people who use the service are protected from abuse. EVIDENCE: Springfield House has a complaints policy and procedure which is accessible to people who live at the home and their relatives. The manager says the guidance shows how the service is to respond to any complaints received. We saw a poster in the entrance hallway that clearly shows people how to make a complaint should they wish to, and people who use the service confirmed they know who to speak to should they have any concerns. People said they would talk to the staff if they had any complaints. One person said they had no complaints about the service, and they wouldn’t have ‘lived here for so long if they had. Survey responses show that people are aware of the complaints procedure and that no complaints have been made. We have not received any complaints or safeguarding concerns about Springfield House. The service has a complaints book that records both compliments and any complaints that are made and the manager said that there are plans ‘to make sure that service users families are fully aware of complaints procedure’. Springfield House DS0000069711.V372175.R03.S.doc Version 5.2 Page 17 There are specific policies and procedures in place to guide staff on the protection of vulnerable adults from abuse and on ‘whistle blowing’ for staff. The manager said that policies and procedures are being reviewed on a regular basis. Staff receive training in abuse awareness, and staff training records confirmed this. Further staff training and guidance on abuse awareness and local adult protection protocols has taken place. This meets the recommendation of the previous inspection. Springfield House DS0000069711.V372175.R03.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): 19, 26 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. People who live at Springfield House enjoy a comfortable and homely environment. The home is spacious and is kept clean and well maintained. EVIDENCE: Springfield House is situated in a quiet cul-de-sac on the outskirts of Malvern Link. The property consists of two large semi detached houses that are internally linked to form one care home. There are eleven single rooms, two of which have en-suite facilities, and there are three double bedrooms none of which have en-suite facilities. A chair lift is available to help people to get up and down the stairs where it is needed. Springfield House is registered to provide care for a maximum of seventeen Springfield House DS0000069711.V372175.R03.S.doc Version 5.2 Page 19 older people who have needs related to age, physical disabilities and or dementia type illnesses. We looked at parts of the premises. Springfield House is accessible, comfortable and provides a homely environment for the people who live there. All rooms are clean, tidy and well presented. The bedrooms are a good size, suitably furnished and personalised by people living there. Springfield House is clean and tidy throughout. Policies and procedures for infection control are in place and staff are provided with disposable gloves and aprons. All cleaning materials are locked in the laundry room. Training records show that staff are trained in procedures for the control of infection and health and safety matters. There is a schedule for routine maintenance and upkeep of the buildings and the manager states in the services AQAA that there are plans ‘to install a walk in shower room so the service users can have a choice’. Springfield House DS0000069711.V372175.R03.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): 27, 28, 29, 30 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. There are sufficient staff on duty with the right skills and knowledge to meet the needs of people who live at Springfield House. Staff are well supported and work together to provide consistent and good quality care. Staff receive relevant training to help them meet the needs of people who use the service. Recruitment policy and practices make sure that suitable staff are employed. All necessary checks are made to make sure that everyone living at Springfield House is kept safe. EVIDENCE: Springfield House has a committed and stable staff team. People commented in surveys that they were generally satisfied with the service and the staff. Staff appeared to be enthusiastic and well motivated. Staffing levels have been increased at teatime as recommended at the previous inspection. Springfield House operates a recruitment policy and procedure where everyone completes an appropriate application form and makes sure that suitable references are obtained including one from most recent employers. Appropriate criminal records and other checks are undertaken before appointments are confirmed. All staff are required to work a probationary Springfield House DS0000069711.V372175.R03.S.doc Version 5.2 Page 21 period. Records for three members of staff were checked. All required information was seen and confirmation of identity and suitable references was available. A reference for one member of staff was not fully completed. A ‘no comments’ response to the questions asked was given. This was discussed with the manager who was advised to include a statement on the staff members file to record the action taken in response to this. The manager confirms that all new staff complete thorough training to make sure they can meet the needs of people they support. We saw a completed induction checklist for a recently employed member of staff. The service has a training programme based on the individual training and development assessments for each member of staff. Mandatory training such as Health and Safety, Fire Safety, First Aid, Food Hygiene, Moving and Handling, Infection Control and Vulnerable Adults is provided. We saw copies of certificates for recent training courses completed that included Dementia awareness 7/4/08, Health and Safety 20/4/08 and Manual Handling 26/2/08. Staff said they ‘really like it here’ and that ‘everybody works well together’. Staff spoke about the activities people do such as the tabletop game that was planned for that afternoon. People who use the service said the staff ‘are very kind and helpful’ and confirmed the numbers of staff on duty. Springfield House DS0000069711.V372175.R03.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): 31, 33, 35, 38 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. The service is well managed and staff receive the leadership and support they need. The proprietor monitors Springfield House in various ways to make sure that the health and welfare of people using the service is protected. EVIDENCE: The manager Vicky Lane has many years experience working with older people and has worked at Springfield House for seven years before her appointment as manager of the service. Vicky regularly completes training relevant to her position as registered manager of Springfield House including Dementia Care. Springfield House DS0000069711.V372175.R03.S.doc Version 5.2 Page 23 Surveys confirm that people are made welcome and are able to talk to the manager and staff at any time. The Annual Quality Assurance Assessment (AQAA) was completed and submitted to the CSCI prior to the inspection visit. The AQAA is where the manager tells us about the service provided at Springfield House and the ways they plan to improve the service. The provider regularly visits Springfield House as one of the ways to monitor the service and how it is being run. The manager states in the service’s AQAA that a questionnaire is completed ‘every three months to get the views of the service user, families and any outside service that comes into the home’. These surveys are part of the ongoing quality assessment of the service. Surveys confirm that people are generally happy with the service ‘very satisfied with staffing and personal support’. Surveys from professional people confirm that communication with the staff and service are good, ‘staff always friendly and helpful’. People confirm they are made welcome when they visit Springfield House. People who use the service said the manager ‘is wonderful’ and ‘very caring’. The frequency of supervision of care staff has improved since the last inspection and covers all aspects of care practice and training development needs. Records confirm that supervision takes place. Staff confirm they have regular supervision and said they ‘enjoy working here’ and that ‘the manager is very supportive’. Records show that monthly checks of the fire safety system and equipment, water temperature and storage, fridge, freezers and electrical appliances are completed. We saw records to show that regular fire safety checks are done, with the date of last checks on 12.9.08. Fire drills are completed monthly and the last drill was recorded as 7.9.08. Staff are trained in mandatory health and safety topics and generic risk assessments are completed. Springfield House DS0000069711.V372175.R03.S.doc Version 5.2 Page 24 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 3 X X X X 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 4 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 X X 3 Springfield House DS0000069711.V372175.R03.S.doc Version 5.2 Page 25 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 OP7 Good Practice Recommendations The night time records should be further developed to include people’s preferred routines. This will help staff give support in a consistent way. Care plan records should included details of current medication with reasons for taking it, together with any possible side effects. This would make sure staff have information to carry out more effective monitoring. 2. OP9 Springfield House DS0000069711.V372175.R03.S.doc Version 5.2 Page 26 Commission for Social Care Inspection West Midlands West Midlands Regional Contact Team 3rd Floor 77 Paradise Circus Queensway Birmingham, B1 2DT 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 DS0000069711.V372175.R03.S.doc Version 5.2 Page 27 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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