Care Home: Springwood

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What the care home does well People in the home are provided with a warm, safe and comfortable place to live that welcomes visitors and makes them feel at home. The home is clean and staff work hard to make sure the building is odour free. The home is welcoming and has a relaxed atmosphere. Staff showed a good understanding of what each individual likes and dislikes and care being given was specific to each person’s needs. Individuals who answered our questionnaires said ‘I like the home’, ‘they look after us well here’ and ‘the staff take care of all of my needs’. People being cared for have good access to professional medical staff and are able to access external services such as dentists, opticians, physiotherapists, chiropody and dieticians, so their health is looked after and they are kept well. What has improved since the last inspection? The complaints policy and procedures are regularly audited and people and staff are given regular updates and reminders about the process to follow and who to speak to should any issues arise. The information on how to make a complaint can be produced in a number of different formats to ensure everyone using the service is able to read, understand and access the procedure should they need to. What the care home could do better: Monthly visits must be carried out by the registered provider or the responsible individual, to ensure that the service is being audited and reviewed in accordance with Regulation 26 of the Care Homes Regulations 2002. We would like to thank everyone who completed a survey or spoke to us during this visit. Your comments are very important to us and ensure this report includes the views of people who use the service or work within it. Key inspection report CARE HOMES FOR OLDER PEOPLE Springwood 611 Herries Road Sheffield South Yorkshire S5 8TN Lead Inspector Eileen Engelmann Key Unannounced Inspection 16th December 2009 09:30 DS0000003014.V378618.R01.S.do c Version 5.3 Page 1 This report is a review of the quality of outcomes that people experience in this care home. We believe high quality care should: • • • • • Be safe Have the right outcomes, including clinical outcomes Be a good experience for the people that use it Help prevent illness, and promote healthy, independent living Be available to those who need it when they need it. We review the quality of the service against outcomes from the National Minimum Standards (NMS). Those standards are written by the Department of Health for each type of care service. Copies of the National Minimum Standards – Care homes for older people can be found at www.dh.gov.uk or bought from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop. The mission of the Care Quality Commission is to make care better for people by: • Regulating health and adult social care services to ensure quality and safety standards, drive improvement and stamp out bad practice • Protecting the rights of people who use services, particularly the most vulnerable and those detained under the Mental Health Act 1983 • Providing accessible, trustworthy information on the quality of care and services so people can make better decisions about their care and so that commissioners and providers of services can improve services. • Providing independent public accountability on how commissioners and providers of services are improving the quality of care and providing value for money. Springwood DS0000003014.V378618.R01.S.doc Version 5.2 Page 2 Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report Care Quality Commission General Public 0870 240 7535 (telephone order line) Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CQC copyright, with the title and date of publication of the document specified. www.cqc.org.uk Internet address Springwood DS0000003014.V378618.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Springwood Address 611 Herries Road Sheffield South Yorkshire S5 8TN 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) 0114 232 5472 0114 285 2934 anita.bland@sheffcare.co.uk www.sheffcare.co.uk Sheffcare Limited Mrs Anita Bland Care Home 40 Category(ies) of Dementia (24), Mental Disorder, excluding registration, with number learning disability or dementia - over 65 years of of places age (24), Old age, not falling within any other category (16) Springwood DS0000003014.V378618.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following catergory of service only: Care home only - Code PC to service users of the following gender: Either Old age, not falling within any other catergory - Code OP, maximum number of places: 16 Dementia - Code DE, maximum number of places: 24 Mental Disorder, excluding learning disability or dementia over 65 years of age -Code MD(E), maximum number of places: 24 The maximum number of service users who can be accommodated is : 40 19th October 2006 2. Date of last inspection Brief Description of the Service: Springwood is a purpose built property, providing personal care for up to 40 people over the age of 65 years. The home is operated by Sheffcare Limited and is situated in a residential area in the north of Sheffield near to Hillsborough. Various shops and a public house are located nearby and Hillsborough shopping centre is easily accessible. The accommodation is provided on three floors with a lift for easy access. All rooms are for single occupancy. The ground floor and the second floor of the home offers care and support for people who have a higher dependency due to varying forms of dementia. Easy access is available to all facilities for people who use wheelchairs, or have other disabilities. There are a number of lounges and sitting areas provide for communal living and a dedicated room for individuals who smoke. There is a function room that is available for group activities or private use to entertain family or friends. The organisation has the use of a mini-coach so can offer regular trips and outings. The home has an enclosed patio area where people can sit outside, and there is car parking provided to the front of the property. Information about the service is available in the home’s Statement of Purpose, Service User Guide and the latest inspection report from the Care Quality Commission. These documents are on display in the entrance to the home, Springwood DS0000003014.V378618.R01.S.doc Version 5.2 Page 5 they can be downloaded from the service’s website and copies can be obtained from the manager by request. The manager informed us on 16 December 2009 that the weekly fees range from £335.00 to £410.00 depending on the source of funding and the care needs of the individual. The home charges extra for chiropody, toiletries, clothing, telephone, holidays and hairdressing. Springwood DS0000003014.V378618.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 3* stars. This means that the people who use this service experience excellent quality outcomes. Information has been gathered from a number of different sources over the past 26 months since the service had its last key inspection visit on 19 October 2006, this has been analysed and used with information from this visit to reach the outcomes of this report. We completed an Annual Service Review (ASR) for Springwood on 25 May 2008. We only do an annual service review for good or excellent services that have not had a key inspection in the last year. An ASR is part of our regulatory activity and is an assessment of our current knowledge of a service rather than an inspection. The published review is a result of the assessment and does not come from our power to enter and inspect a service. This unannounced visit was carried out with the manager, staff and people using the service. The visit took place over 1 day and included a tour of the premises, examination of staff and people’s files, and records relating to the service. Questionnaires were given out to a selection of people living in the home, relatives and staff. Their written response to these was good. We received 6 back from staff (60 ), 2 from relatives (40 ) and 8 from people using the service (80 ). Informal chats with a number of staff and people living in the home took place during this visit and comments from the questionnaires and face to face conversations have been put into this report. The manager completed an Annual Quality Assurance Assessment and returned this to us within the given timescale. We have reviewed our practice when making requirements, to improve national consistency. Some requirements from previous inspection reports may have been deleted or carried forward into this report as recommendations – but only when it is considered that people who use services are not being put at significant risk of harm. In future, if a requirement is repeated, it is likely that enforcement action will be taken. Springwood DS0000003014.V378618.R01.S.doc Version 5.2 Page 7 What the service does well: People in the home are provided with a warm, safe and comfortable place to live that welcomes visitors and makes them feel at home. The home is clean and staff work hard to make sure the building is odour free. The home is welcoming and has a relaxed atmosphere. Staff showed a good understanding of what each individual likes and dislikes and care being given was specific to each person’s needs. Individuals who answered our questionnaires said ‘I like the home’, ‘they look after us well here’ and ‘the staff take care of all of my needs’. People being cared for have good access to professional medical staff and are able to access external services such as dentists, opticians, physiotherapists, chiropody and dieticians, so their health is looked after and they are kept well. What has improved since the last inspection? What they could do better: If you want to know what action the person responsible for this care home is taking following this report, you can contact them using the details on page 4. The report of this inspection is available from our website www.cqc.org.uk. You can get printed copies from enquiries@cqc.org.uk or by telephoning our order line – 0870 240 7535. Springwood DS0000003014.V378618.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 Springwood DS0000003014.V378618.R01.S.doc Version 5.3 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): Standards 2, 3, 4 and 6 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People wanting to use the service undergo a needs assessment and are given sufficient information about the home and its facilities prior to admission, to enable them to be confident that their needs can be met. EVIDENCE: Four peoples care and records were looked at as part of this visit, they each have been provided with a statement of terms and conditions/contract on admission and these are signed by the person or their representative. These documents give clear information about fees and extra charges, which are reviewed and kept up to date. Springwood DS0000003014.V378618.R01.S.doc Version 5.3 Page 10 Each person has his or her own individual file and the funding authority or the home, before a placement is offered to the individual, completes a need assessment. The home develops a care plan from the assessments, identifying the individuals problems, needs and abilities using the information gathered from the person and their family. Discussion with the manager indicated she goes out to assess individuals who have expressed an interest in coming into the home, and each person is given information about the service and life in the home. Staff members on duty were knowledgeable about the needs of each person they looked after and had a good understanding of the care given on a daily basis. Information from the peoples surveys showed that they were satisfied with the care they receive and have a good relationship with the staff. Information from the Annual Quality Assurance Assessment and discussion with the manager indicates that people in the home are from a mix of different ethnic backgrounds, although the majority of the people using the service are of White/British nationality. The home does accept people with specific cultural or diverse needs and everyone is assessed on an individual basis. Discussion with the manager indicated that the home looks after a number of people from the local community, although placements are open to individuals from all areas. The home is able to offer a choice of staff gender to people who express preferences about care delivery, as they employ 5 male care staff. The information about peoples preferences is recorded onto their care plan. Information from the training files and training matrix indicates that the majority of staff are up to date with their basic mandatory safe working practice training, and have access to a range of more specialised subjects that link to the needs of people using the service. Staff who completed our surveys said that their training was good and that they felt they provided a high quality of care, which promoted peoples rights to individuality, privacy and dignity. The home does not have any intermediate care beds and therefore standard six does not apply to this service Springwood DS0000003014.V378618.R01.S.doc Version 5.3 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): Standards 7, 8, 9 and 10 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Staff ensure that care is person led, personal support is flexible, consistent and is able to meet the changing needs of the residents. The staff group is balanced to enable a choice of male, female and age related preferences when delivering personal care. Staff respond appropriately and sensitively in all situations involving personal care, ensuring that it is conducted in privacy. EVIDENCE: At our last inspection on 19 October 2006 we made a requirement that ‘The care plans must detail the service users’ preference of the gender of the staff member assisting him/her with personal care tasks’. Checks of the care plans at this visit found the requirement has been met. The care of four people was looked at in depth during this visit and included checking of their personal care plans. Each individual using the service has a care plan, which identifies each persons needs and abilities, choice and Springwood DS0000003014.V378618.R01.S.doc Version 5.3 Page 12 decisions and likes and dislikes. In addition to this information there are risk assessments to cover daily activities of life, behaviour management plans where a risk to the person or others has been identified, and clear information about health and input from professionals and the outcomes for people. Reviews of care with the families, person living in the home and care coordinator from the local authority are taking place every 12 months and minutes of these meetings are in the plans. In addition to these formal reviews the staff review the care plans monthly in consultation with the person themselves or their representative. Included in the care plans is a enhanced care plan’ section, which is taken with the individual if they are admitted to hospital; this contains up to date medical information about the person and ensures that important information is passed to relevant health professionals involved in diagnosis and treatment of people using the service. It also gives important information about the specific behaviours of individuals and how to manage these safely and effectively. We spent some time with the manager discussing how the information in these documents could be made clearer, with bullet point headings and more precise writing. The service has made a start on assessing individuals as to their capacity to make their own choices and decisions around care with regard to the Mental Capacity Act legislation. Discussion with the manager indicated that at the moment no-one using the service requires a deprivation of liberty assessment doing for restriction of liberty or facilities. We found that where there were any restrictions to peoples’ choices, for example one gentleman has his cigarettes and lighter held for him by the staff (for safety and control of the number of cigarettes smoked per day); these need to be clearly documented in the person’s care plan, showing that the reasons for the restriction has been discussed and agreed with the individual or their representative. People said that they have good access to their GP’s, chiropody, dentist and optician services, with records of their visits being written into their care plans. They all have access to outpatient appointments at the hospital and records show that they have an escort from the home if wished. Comments from the people using the service indicate they are satisfied with the level of medical support given to them. Entries in the care plans specify where individuals have dietary needs, and nutrition risk assessments have been completed. The staff weighs everyone on a regular basis and evidence in the plans show that dieticians are called out if the home has particular concerns about an individual. The manager told us that the home has a good working relationship with the district nurses and Springwood DS0000003014.V378618.R01.S.doc Version 5.3 Page 13 local GP services. Pressure areas are monitored carefully and proactive measures include risk assessments and special mattresses and seat cushions. Checks of the medication show the home is using Boots the Chemist as their pharmacy supplier and the medication system in use is a Monitored Dosage System (MDS) where tablets are supplied in a ‘pop out’ sheet. At our last visit on 19 October 2006 we made a requirement about medication practice that ‘Medication administration records must always be signed to show whether medication has been given or not’. Checks at this visit found the requirements have been met. We looked at the medication records and found that on the whole these are up to date and completed to an acceptable standard. We found two areas where staff could improve their documentation and these were: Staff are not always signing in the quantities of medication received, we found that this occurred when medication was received during the four week cycle as additional prescriptions. The registered manager should ensure that staff consistently sign in the medication received from the pharmacy. Where medication is ‘brought forward’ from a previous medication cycle, the staff should record the quantity on the medication sheet to show that the medication in use is prescribed for that individual and create a clear audit trail for anyone checking the medication. Information from the manager is that staff undertake a daily audit of the medication paperwork to ensure it is completed correctly and the manager carries out a monthly audit. Checks of the controlled drugs and register showed that these are up to date, accurate and well managed. People we spoke to were very positive about the service, staff and the care they received. Three people told us ‘the staff are lovely, they are very helpful and always around when you need them’. Observation of the service showed there is good interaction between the staff and people, with friendly and supportive care practices being used to assist people in their daily lives. One relative who answered our survey said ‘my experience is that the staff are extremely friendly and approachable, the rooms are always clean and tidy and my relative is always clean and well cared for’. We found during our visit that people using the service are encouraged to be as independent as possible, and time is taken to ensure that personal skills are not lost. People we met were helping staff with simple household tasks such as polishing and laying the tables after the breakfast meal. Others were seen to be talking to visitors, relatives, staff and each other, Springwood DS0000003014.V378618.R01.S.doc Version 5.3 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): Standards 12, 13, 14 and 15 People using the service experience excellent quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The service actively encourages and provides imaginative and varied opportunities for people using the service to develop and maintain social, emotional, communication and independent living skills where appropriate. EVIDENCE: There is a weekly plan of activities which is on display on notice boards in each of the three units and individuals are able to put forward ideas of any activities/outings they wish to go on. The manager told us that staff encourage people, especially those with dementia, to be as independent as possible and to continue with interests they had when living in their own homes. Each unit in the home has a ‘family kitchen’, which includes toys for children to play with, facilities for visitors to make drinks, and a table and chairs so visitors and people using the service can sit down and have a conversation away from others. Within the family kitchens people can do their own hand washing and ironing (under supervision Springwood DS0000003014.V378618.R01.S.doc Version 5.3 Page 15 where needed) and take part in baking and cookery sessions as part of a group activity. Staff carry out daily activities with individuals and also do group activities on the units. Twice a week the service has activity workers come in to organise craft workshops, bingo sessions and organise trips out using the home’s minibus. The manager told us that individuals can also use taxis and the local bus/tram service to access shopping in the city centre or trips out into the community. People told us they had enjoyed a brass band concert the previous week and that the day we visited the home, there was a Christmas Party planned for the afternoon. Outside entertainers are booked on a regular basis to provide sessions within the home, and families/visitors are welcomed to join in with any entertainment, outings or celebrations. Information from the manager indicates that people have access to a Church of England service held in the home every month, and individuals can attend outside services as wished. The Catholic priest will visit people in the home on request. The home provides special meals and cakes for birthdays and helps people celebrate all major Christian festivals such as Easter, Harvest Festival and Christmas. Information from the care plans indicates that people have good contact with their families and friends. Two relatives told us that they can come into the home when they like and that they are always made welcome. Staff told us that the manager has an open door policy for staff, relatives and visitors which works well and ensures people can talk about any issues they may have. Information from the Annual Quality Assurance Assessment and from the manager indicated that the majority of people had family members who acted on their behalf and took care of their finances. There is some information and advice on advocacy and this is on display in the home. Information from the Annual Quality Assurance Assessment indicates that the home holds meetings for relatives and people using the service where they can discuss any issues around care or the service. Discussion with the manager indicated that she and the team leaders have attended formal training on the Mental Capacity Act and Deprivation of Liberty Standards, and understood how these affected individuals within a care home. We were told that this training would be cascaded down to other staff members as part of their training programme. Leaflets with information about the current legislation and how to access advocates is on display in the home and copies are available from the manager. The manager told us that when a person comes into the home they are given an advocacy form on admission, which can be filled in and sent off to the relevant advocacy centre if needed. Springwood DS0000003014.V378618.R01.S.doc Version 5.3 Page 16 Staff who have completed or are doing their National Vocational Qualification’s in care have received some training around equality and diversity matters, and disability discrimination legislation. This type of training ensures that staff have sufficient knowledge about human rights legislation, so they understand individual rights within the care home and out in the community. We recommended that the registered person should ensure that all staff receive training on equality/diversity and disability discrimination. We saw that daily menus are written onto large ‘wipe clean’ boards on each unit and there is information about the Christmas meals in each dining room. Observation of the midday meal showed it to be well prepared and presented. Staff were organised when serving the meal and we saw staff offer assistance to people who need help with eating and drinking. People and relatives are pleased with the quality and quantity of the meals served, saying the food is very good and there is always a choice given. Springwood DS0000003014.V378618.R01.S.doc Version 5.3 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): Standards 16 and 17 People using the service experience excellent quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Individuals and others associated with the home say they are extremely satisfied with the service, feel safe and well supported. All staff working at the home know the importance of taking the views of the people using the service seriously, and of listening to and responding to raised issues. EVIDENCE: The home has a complaints policy and procedure that is found within the statement of purpose and service user guide, it is also on display within the home. The policy and procedure are available in a clear print version and the manager told us that other format such as easy read and large print can be produced if requested. Peoples survey responses showed individuals have a clear understanding about how to make their views and opinions heard and those people spoken to said the manager comes round every day to see us and will discuss any problems at this time. The home has a suggestion box in the entrance hall and the manager empties this daily and responds to any issues raised. Information in the Annual Quality Assurance Assessment and checks of the complaints record showed that there have been five formal complaints in the past 12 months. Four have been responded to by the manager and the chief Springwood DS0000003014.V378618.R01.S.doc Version 5.3 Page 18 executive of the service is dealing with the fifth complaint. Discussion with the manager indicates that she deals with minor niggles/grumbles on a daily basis. The home regularly audits the views of people using the service and ensures that individuals are aware of who to make a complaint to and what the procedure is, there is an open door policy to enable the manager to deal with concerns before they become complaints. The service has its own complaints form, which is made available to anyone who has a problem, and also welcomes feedback from other organizations such as the Patient Opinion group (run by the NHS) which gives people a chance to air their views about Springwood and other homes on its website www.patientopinion.org.uk The home has policies and procedures to cover adult protection and prevention of abuse, whistle blowing, aggression, physical intervention and restraint and management of peoples’ money and financial affairs. The staff on duty displayed a good understanding of the safeguarding of adults procedure. They are confident about reporting any concerns and certain that any allegations would be followed up promptly and the correct action taken. Information in the Annual Quality Assurance Assessment completed by the manager on 14 September 2009, indicates there is an ongoing training programme for staff to attend sessions around safeguarding of adults from abuse, equality and diversity, deprivation of liberty and dementia. New employees only start work after safety checks such as references and the Criminal Records Bureau (CRB) report have been received by the service and are satisfactory. Springwood DS0000003014.V378618.R01.S.doc Version 5.3 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): Standards 19, 24 and 26 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The standard of environment within the home is good, providing people with a comfortable and homely place to live. EVIDENCE: On our last visit to the home on 19 October 2006 we made a requirement that ‘The ill-fitting windows should be replaced or repaired’. Checks at this visit found that the metal window frames remain in place, there are some concerns from the manager about drafts in winter, but we found the home to be warm and draft free during our visit. The service has put the replacement of the windows onto its capital expenditure plan and the provider is in the process of upgrading a number of services it owns. Springwood is included in this process. We have moved this requirement to a Springwood DS0000003014.V378618.R01.S.doc Version 5.3 Page 20 recommendation as it appears the provider is due to take action as part of its upgrading process. The home has an ongoing maintenance and refurbishment programme and the manager was able to show us the work that has been completed in the past 12 months and discuss work that is planned for this year. Walking around the home we found that the communal living spaces on each of the three units are warm, well decorated and welcoming. Attention to detail on the dementia units ensures that surroundings are familiar to people and homely. All areas that we visited were extremely clean and the whole building was odour free. People and relatives told us that the domestic staff work very hard to keep the building looking ‘spotlessly clean’ and tidy. Bedrooms in the home are all single rooms, although changes can be made to sleeping accommodation to meet the needs of couples. All bedrooms are fitted with door locks, which can be opened by staff in an emergency. Each unit has its own communal assisted bathing facilities, with bathrooms and shower rooms being provided within the home. On the ground floor people have access into an enclosed patio area provided with benches and tables, for sitting out in the better weather. This area also has a green house for use by those who enjoy gardening. Discussions during this visit indicate that people using the service are satisfied with the laundry service provided by the home. Infection control policies and procedures are in place, and staff have access to good supplies of aprons and gloves for use in personal care. Springwood DS0000003014.V378618.R01.S.doc Version 5.3 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): Standards 27, 28, 29 and 30 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The staff induction, training and recruitment practices are good, resulting in an enthusiastic workforce that works positively with people to improve their whole quality of life. EVIDENCE: Checks of the staffing rotas and observation of the service showed that the home employs staff from different ethnic backgrounds, although the majority of staff are of White/British nationality. Discussion with the manager indicated that the home is an equal opportunities employer and there is a diverse mix in the staffing group. Staff members told us that they work as a team and this includes covering shifts when others are on leave or sick. Staff feel that their induction and training helps them meet the needs of people who use the service. At the time of this visit there were 40 people in the home and the staffing levels were as follows, on each unit there are two care staff during the daytime and 1 member of staff at night, making a total of 6 care staff during the day and 3 at night. Springwood DS0000003014.V378618.R01.S.doc Version 5.3 Page 22 Information from the Annual Quality Assurance Assessment about the number of staffing hours provided (945), and information gathered during the visit about the dependency levels of the people using the service, was used with the Residential Staffing Forum Guidance and showed that the home is meeting the minimum hours asked for in the recommended guidelines. 44 of the care staff at the home have an NVQ 2 or above in care and all new starters have to complete an induction which meets Skills for Care criteria. Staff have access to a mandatory training programme, as well as a range of specialist subjects which reflect the diverse needs of the people using the service. The home has an equal opportunities policy and procedure. Information from the staff personnel and training records and discussion with the manager, shows that that this is promoted when employing new staff and throughout the working practices of the home. The home has a recruitment policy and procedure that the manager understands and uses when taking on new members of staff. Checks of three staff files showed that police (CRB) checks, written references, health checks and past work history are all obtained and satisfactory before the person starts work. Springwood DS0000003014.V378618.R01.S.doc Version 5.3 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): Standards 31, 33, 35 and 38 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The management of the home is satisfactory overall and the home regularly reviews aspects of its performance through a good programme of audits and consultations, which includes seeking the views of people using the service, staff and relatives. EVIDENCE: Anita Bland is the registered manager of Springwood. She has over 30 years management experience and holds the Registered Managers Award, NVQ4 in care and holds the certificate in management. Information from our survey questionnaires indicates that people using the service, relatives and staff feel Springwood DS0000003014.V378618.R01.S.doc Version 5.3 Page 24 the manager is apporoachable, professional and fulfills the roll within the home. Individuals said ‘the manager is very good and is always looking for new ideas to improve the service and give people a purpose in life’ and ‘the home is well managed and run with the best interests of the people living there’. The home does not have a formal Quality Assurance System in place but there are robust checks in place to ensure the service runs smoothly and meets the aims and objectives written in the Statement of Purpose. The manager and her deputy carry out monthly audits of the service and this includes analysis of any accidents, incidents or complaints. The manager sends out satisfaction questionnaires to the staff, relatives, people using the service and healthcare professionals on a yearly basis, as part of the home’s quality assurance process. She is aware of the need to produce an annual development plan based on the systematic cycle of planning-action-review, which reflects the aims and outcomes for service users, and the latest one is on display within the home. We found that the monthly visits for the Regulation 26 reports are being carried out by a manager from another home. This individual is neither the registered person nor the responsible individual for the service. This practice is not acceptable to the Care Quality Commission unless we have been notified in writing of the individual’s name and that they are responsible for this task. We raised this as an issue at the time of this inspection and received notification from the provider before this report was published. Checks of the finance systems within the home found that computerised records are kept for people’s personal allowances; the manager on a weekly basis up dates these, and they are checked yearly by an outside auditor. Information from the Annual Quality Assurance Assessment indicates the majority of people have their families looking after their financial affairs, and checks of the system show their relatives top up the person’s individual allowance account on a regular basis. People who have asked the home to look after their personal allowances are able to access their money on request, and receipts are kept for any transactions. All monies are kept safe and secure within the home and only the manager has access to the funds. Maintenance certificates are in place and up to date for all the utilities and equipment within the building. Accident books are filled in appropriately and regulation 37 reports completed and sent on to the Commission where appropriate. Staff have received training in safe working practices and the manager has completed generic risk assessments for a safe environment within the home. Risk assessments were seen regarding fire, moving and handling, bed rails and daily activities of living. Springwood DS0000003014.V378618.R01.S.doc Version 5.3 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 3 3 3 x N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 10 4 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 4 17 x 18 3 3 x x x x 3 x 3 STAFFING Standard No Score 27 3 28 2 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 4 x 3 x 3 x x 3 Springwood DS0000003014.V378618.R01.S.doc Version 5.3 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 OP7 Good Practice Recommendations The registered manager should review the enhanced section of the care plan and decide how the information contained in this section could be improved, to make it easier for health care professionals to read and understand. The registered manager should make sure that if a person has any restrictions made to their activities of daily living or use of facilities, then these should be clearly written into their care plan with the reasons why and the written agreement of the individual or their representative. The registered manager should make sure that staff are consistently signing in quantities of medication received from the pharmacy, to ensure a clear audit trail of medication coming into the home is produced. The registered manager should ensure that staff record on the medication sheets when medication is ‘brought forward’ from a previous medication cycle. This will DS0000003014.V378618.R01.S.doc Version 5.3 Page 27 2 OP7 3 OP9 4 OP9 Springwood 5 6 OP14 OP19 ensure a clear audit trail is produced. The registered person should ensure that all staff receive training on equality/diversity and disability discrimination. The registered person should ensure that the exterior window frames of the building, which have been highlighted in previous reports as a requirement, are replaced as soon as possible. 50 of the care staff should achieve an NVQ 2 in Care by the end of December 2010. 7 OP28 Springwood DS0000003014.V378618.R01.S.doc Version 5.3 Page 28 Care Quality Commission Care Quality Commission Yorkshire & Humberside Region Citygate Gallowgate Newcastle Upon Tyne NE1 4PA National Enquiry Line: Telephone: 03000 616161 Email: enquiries.yorkshirehumberside@cqc.org.uk Web: www.cqc.org.uk We want people to be able to access this information. If you would like a summary in a different format or language please contact our helpline or go to our website. Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CQC copyright, with the title and date of publication of the document specified. Springwood DS0000003014.V378618.R01.S.doc Version 5.3 Page 29 Springwood DS0000003014.V378618.R01.S.doc Version 5.3 Page 30 - 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!