Inspection on 01/07/08 for Spring Grove

This is the latest available inspection report for this service, carried out on 1st July 2008.

CSCI found this care home to be providing an Excellent service.

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Spring Grove 06/12/05

Spring Grove 07/07/05

Spring Grove 25/02/05

Spring Grove 11/05/04

Similar services:

Henry Nihill House

Birchwood

The Infirmary

Orchard House Nursing Home

St Josephs Rest Home

Red Court Nursing Home

Spinney (The)

Queen Elizabeth House

Extracts from inspection reports are licensed from CQC, this page was updated on 28/09/2008.

CARE HOMES FOR OLDER PEOPLE Spring Grove 214 Finchley Road London NW3 6DH Lead Inspector Peter Montgomery Unannounced Inspection 1st July 2008 10:00 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 Spring Grove DS0000010336.V368677.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. Spring Grove DS0000010336.V368677.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Spring Grove Address 214 Finchley Road London NW3 6DH 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) 020 7794 4455 sgreception@btconnect.com Springdene Nursing & Care Homes Limited Mrs Martha Ohene Acquah Care Home 46 Category(ies) of Old age, not falling within any other category registration, with number (46) of places Spring Grove DS0000010336.V368677.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 6th June 2006 Brief Description of the Service: Spring Grove is a private care home, which provides support to vulnerable frail older people aged 65 and over. The home is registered to provide personal care to forty-six service users, the majority of who are privately funded. The home is furnished to a high standard and is one of four care homes owned by Springdene Care Homes Ltd. Charges are £815 for single and £1,345 for double rooms for long-term care, and £875 and £1,345 respectively for shortterm care. Charges are per month, and a reduction is given for payment by standing order. The building is purpose built over three floors with a smart hotel style front entrance and reception area. All floors can be accessed via 2 lifts. The home has forty single and three double en-suite bedrooms. The double rooms are set aside for couples. Residents also have access to communal toilet and bathroom facilities. Each floor has a small self-service kitchen. The homes main kitchen is on the ground floor adjacent to the dining room. A spacious communal lounge, art room and atrium are also on the ground floor. A library is on the 1st floor, which leads out to the upper landscaped garden. The serviced laundry room, parking area and maintenance workshop are on the lower ground floor. The home provides 24-hour personal care. There is a staff team of 47 including the registered manager, one deputy manager, two team leaders, a fulltime housekeeper, activities co-ordinator, qualified chef, kitchen staff and maintenance operatives. The home is situated on Finchley Road NW3, halfway between Swiss Cottage and Golders Green, near to shopping and community facilities. Two parking spaces are available to the front of the home, there is also a basement garage with parking for eight vehicles. Spring Grove DS0000010336.V368677.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 3 star. This means the people who use this service experience excellent quality outcomes. What the service does well: Spring Grove provides a very good standard of personal care to the people living in the home, making them feel valued, and giving an overall sense of well-being. One survey commented that the home provides: “ an excellent level of care and support to maintain X’s quality of life.” Another commented “There is always a happy and friendly atmosphere, very clean, the staff give you confidence that X is being cared for and they give her respect”. One resident told the inspector of the way in which she came to live in the home, first of all coming for a visit and liking it so much that she wanted to stay. Another resident commented they had been coming into the home for respite before living there permanently. It has a “Home from home feel” wrote one relative, whilst another resident wrote: “From the very first day I knew it was the home for me.” Prior to admission residents are assessed to ensure the home can meet their needs, and individuals are encouraged to visit the home before making any decisions. Written information is provided to residents and relatives in the form of a Statement of Purpose and Service Users Guide. Once the decisions has been made and residents come to live at Spring Grove, a care plan with supporting risk assessments is developed to ensure staff have the information they need to provide the care and support. The home ensures the healthcare needs of residents are met with relatives being informed of any concerns, and medication practices ensuring safe administration and promoting the health of the residents. Spring Grove DS0000010336.V368677.R01.S.doc Version 5.2 Page 6 The home also encourages residents to make decisions and choose how to spend their day balancing risks with encouraging independence. “Sometimes I don’t feel like doing things-the staff are very good, allowing me complete freedom but encouraging me when I need it.” stated one individual. Residents are able to raise any concerns or issues with the manager and staff knowing that they will be listened to and their concerns acted upon. The food is of a very good standard, with appropriate choices (including vegetarian) available, all provided in an attractive environment. Staff understand the needs of the residents with a very stable workforce. A relative said of staff: “there is a range of experience across the staff. There is very little staff turnover so the knowledge of each individuals needs is maintained.” Whilst another wrote “Spring Grove has some outstanding staff and I am very happy with X’s care.” Staff feel well supported by the manager and are comfortable in raising concerns. The physical environment is comfortable and well decorated with residents’ own rooms personalised. What has improved since the last inspection? Since the last inspection the information provided to staff regarding the residents’ needs has improved. The care plans and risk assessments provide good information many areas of the residents identified needs, and have been improved since the last inspection. Current formats and information recorded were considered adequate. Staff supervision has improved, with the introduction of formal 1 to 1 meetings with team leaders and staff every two months. All staff also have an annual appraisal by thee manager. Staff training has been improved, with the introduction of a staff training folder, in addition all staff are required to complete NVQ level 2 training (including ancillary staff) and three staff have completed level 3 training. Spring Grove DS0000010336.V368677.R01.S.doc Version 5.2 Page 7 The outcome of this commitment to training by the provider has ensured that 100 of staff are, or will hold an NVQ qualification in care. 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. Spring Grove DS0000010336.V368677.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 Spring Grove DS0000010336.V368677.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): 1,2,3,4,5and6 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Appropriate information is available to those using the service explaining what to expect if they choose to live in the home. The assessment process ensures that the home admits those individuals whose care needs they are able to meet, and that staff have the information undertake an assessment of need, which meets individuals needs. EVIDENCE: Information for prospective residents and their family is provided in the form of a Statement of Purpose and Service Users Guide. It is comprehensive and would help individuals form an accurate picture of services available, although, as many residents are self funding, they do not benefit from a community care assessment. The Statement of Purpose also contained details of the contract. Spring Grove DS0000010336.V368677.R01.S.doc Version 5.2 Page 10 n conversation with a recently admitted resident, I was informed that she felt at home from the first day, and felt comfortable with staff and that they were able to assist her with her needs. This resident had also been given information and told about routines in a relaxed manner. The second resident said that staff cared for her well, and she expressed satisfaction with the range of activities. One other resident who has been in the home for some time said “From the very first day I knew it was the home for me.” All spoken to had only positive comments regarding the care and management staff and were satisfied that their needs were being met. The Provider has also produced a contract that contains sufficient information to enable people to make a decision as to whether or not the home is suitable for them. No residents had been admitted for respite care, although the same degree of information and facilities are available to both short and long term residents. There was appropriate evidence of the funding arrangements and who was responsible for payment of the fees. Spring Grove DS0000010336.V368677.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): 7,8,9,10 and 11 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. All residents have care plans developed together with other information to ensure care staff are able to support them in their day to day lives with minimum risks. Healthcare needs are met through satisfactory medication practices and access to healthcare personnel to ensure the continued health and wellbeing of residents is maintained. EVIDENCE: It was evident from the written and verbal feedback received from relatives and residents that the home provides a very good standard of care to those people living there. A number of residents and relatives wrote of how staff encourage independence, respecting the fact that there are risks involved which they wish to take. One wrote that, the “staff are there if I need their help”. This is also a principle advocated in the Statement of Purpose. One Spring Grove DS0000010336.V368677.R01.S.doc Version 5.2 Page 12 relative said the home was excellent at “ensuring residents were able to continue with an independent lifestyle rather than focussing on the risks all the time.” Staff clearly respect individual rights, and to support individuals to decide upon the risks involved. Another relative wrote that the home provides “a brilliant level of care and support to maintain X’s quality of life.” On visiting the residents the inspector noted that they were well presented and well groomed with clothes befitting the weather. Records viewed in respect of ten residents showed that all of them had a care plan detailing the care required together with an assessment of living providing further information for staff. Discussions with residents showed that the care plans reflected the care and support required, including social and financial needs. It was also positive to note that an integral part of the care plan included the residents’ preferred routines for the day. It was clear from discussion that residents are able to shower or bath whichever is their preference and that this is not restricted to once a week. A number of different aids to daily living available in the home included walking frames and wheelchairs, which had been provided to individual residents, as well as grab rails and handrails. Reviews of the care plans are regularly undertaken with the management staff, the individual’s key worker, residents, relatives and other individuals - such as Care Managers being involved. reviewing the care plans. It was also clear from feedback that residents and relatives felt their health needs are being met. All who commented wrote that their health needs are met. All the relatives’ feedback confirmed that they are kept up to date with anything affecting the resident, with one relative writing that it was: “A rare occurrence (anything happening) but I am always consulted even about less major issues.” Feedback also confirmed that medical needs are being met, and records specific to these recordings noted GP and other health care professionals involvement, which included regular routine visits. There is good evidence of the residents being weighed regularly with records showing weights remaining fairly static or increasing. Risk assessments were in place for falls, moving and handling, nutrition and pressure care. Spring Grove DS0000010336.V368677.R01.S.doc Version 5.2 Page 13 Observations made whilst touring the home during the day showed staff knocking on doors before entering, interacting with residents and ensuring doors remained closed during this time. Those residents spoken to confirmed that during these times staff respected their privacy and felt that their dignity was respected. Medication procedures and practices showed that records were well maintained. All medication was kept secure in a medication trolley or locked cupboard and there is a list of signatures of staff authorised to administer medication. The medication policy and procedures are comprehensive, and a number of staff have received training in the safe handling of medication as part of a distance learning course or training from the pharmacist. Spring Grove DS0000010336.V368677.R01.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 and 15 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Routines in the home are flexible with residents choosing how to spend their days. There are a wide range of stimulating activities, both within and outside the home. The quality of the food is satisfactory with meals that are varied, healthy and nutritious. EVIDENCE: Residents are encouraged to live the life that they choose, and staff help to promote independence as much as possible. Previous comments detailed above show how this was viewed as an important part of one resident’s life where staff respected their right to take risks. Residents spoken to told the inspector how they were able to choose when to get up and got to bed as well as deciding how they wished to spend their days. One resident said “we are not forced to go to bed when staff say”. Another resident said the only routines were mealtimes and activities going on, otherwise they choose how they wish to spend their days. For most, this is Spring Grove DS0000010336.V368677.R01.S.doc Version 5.2 Page 15 choosing their own company, only meeting others at mealtimes or when there is an activity or the hairdresser visits. Many read the daily newspapers or magazines that are delivered, have regular library visits or talking books, listen to the radio or watching TV. One resident commented “Sometimes I don’t feel like doing things - the staff are very good, allowing me complete freedom but encouraging me when I need it.” It is also evident that residents enjoy activities. There are three activity coordinators employed (an activities manager, and two coordinators. They facilitate two types of activities, for example more practical activities for residents who may be confused, and activities with a cultural theme for those residents more interested in these issues. These are seen by everyone in the home as providing a stimulating environment, and that interacting with residents is seen as part of their overall care needs, to help promotes a sense of overall well-being. Visiting is flexible with relatives welcomed into the home and made welcome. There is adequate space in either in residents’ rooms or the communal areas to talk in private and the kitchenette has facilities for making refreshments. Positive relationships are fostered with relatives viewed as an integral part of the individual’s needs. Residents are placed on the electoral register and are able to vote either by postal vote or at the local polling station. Residents commented positively on the quality of the food provided. For many it was healthy and sufficient with plenty of choice. One wrote that the food is exceptional; three always liked food; four said “usually” and one “mostly.” Menus were multi choice, and stated what the alternatives were, although the chef stated almost anything would be provided, should resident request an alternative. The dining area was attractive and well decorated, the kitchen was clean and well organised. Spring Grove DS0000010336.V368677.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): 16,17,18 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Residents are able to raise any concerns with the manager and staff, knowing that they will be listened and responded to without delay and any issues resolved. Residents stated they feel safe and protected in the home, and staff are aware of procedures to manage any allegations, and the responsibilities of all those involved in safeguarding vulnerable individuals. EVIDENCE: The last inspection identified that the home should ensure a copy of the Local authorities safeguarding procedures are provided. This has now been reviewed and amendments made to update policies. A copy of the policies is available, and included in the information given to the residents. The manager also maintains a register to ensure complaints are logged. There are no complaints regarding the quality of care provided and the pre-inspection information detailed that there have been five complaints made in the last twelve months. All have been satisfactorily resolved. Feedback from residents and relatives showed that they were well aware of whom to raise concerns with, and those who commented stated “never needed to” when asking about complaints. All provided positive comments about the way in which the manager enabled residents to discuss any concerns and felt that she was approachable and would have no reservation in discussing issues with her. Spring Grove DS0000010336.V368677.R01.S.doc Version 5.2 Page 17 Adult protection procedures remain in place from the previous provider along with the Inter-Agency Guidelines for the local authorities. There is clear evidence of all staff being trained in protecting adults from abuse and staff had a sound knowledge of how they would deal with such incidents and an understanding their role in referring incidents on. It is clear from discussions with residents that they feel safe and secure in the home and feel comfortable with staff. Spring Grove DS0000010336.V368677.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): 19,20,21,22,23,24,25 and 26 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. The home provides a warm, safe and homely place to live. It is very well maintained, both internally and externally, and is clean and fresh. EVIDENCE: The home provides a warm, comfortable and homely environment for those living there. It is well - and regularly decorated, and is refurbished as needs dictate. Residents’ private rooms are all personalised and have the required furniture. One resident told the inspector that their room had been redecorated since they had been there. Those spoken to felt their rooms met their day-to-day needs with many having TV, radio and telephones for their personal use. Spring Grove DS0000010336.V368677.R01.S.doc Version 5.2 Page 19 Residents have equipment such as mobility aids, and wheelchairs and grab rails etc are fitted throughout the home, and the handyman undertakes regular safety checks. The home clearly benefits from his input and skills. The home employs a number of ancillary staff, and it is noteworthy to comment, all have completed NVQ level 2 training. All the feedback regarding the cleanliness was positive with one relative stating the home was “spotless”. The home was of a satisfactory standard of cleanliness throughout, with no offensive odours. The laundry was similarly well maintained and had adequate washing facilities in place. Spring Grove DS0000010336.V368677.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): Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Staff provide a good quality of care to those living in the home. Training continues to improve to ensure staff are able to fully meet individuals’ needs. EVIDENCE: All Spring Grove staff have - or are completing NVQ level 2 at present. Three members of staff have progressed to NVQ 3. She believed that she had benefited immensely from this period of study. There are no staff vacancies within the home, and the staff structure is very stable. The staff structure is generous, and comprises of the manager, deputy manager, two team leaders, plus five care staff in the morning, and a further five in the afternoon, in addition one extra member of staff is rostered per shift to undertake medication administration duties. Three staff are rostered at night one at night, with senior staff on call. Ancillary staff comprise of the housekeeper, two chefs, a kitchen porter, two dining room staff, six domestic staff, two laundry staff, three activities coordinators, and a handyman. Spring Grove DS0000010336.V368677.R01.S.doc Version 5.2 Page 21 The feedback received about the quality of the staff was positive, stating staff were supportive, and were caring and sensitive to their needs. Some of the feedback also commented on how well the staff balance risk, whilst respecting the independence of individuals. “They are there if I need them” said one. “Excellent staff” said another. Over the last few years the home has had a very stable, consistent workforce with very few changes and this has evidentially ensured residents receive a consistent level of care, with staff teamwork evident in their knowledge of residents needs. As stated the manager has improved the amount of training provided to staff over the last twelve months, and all staff are first aid trained. It also positive to note that all staff are NVQ trained The recruitment checks and employment documentation required were discussed, and these are all well documented. Spring Grove DS0000010336.V368677.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): 31,32,33,34,35,36,37 and 38 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. The management systems have been improved to ensure there is continuous improvement in the quality of care and to ensure systems are monitored to ensure the health, safety and well being of residents. EVIDENCE: The registered manger was on leave, and the team leaders and the operations director ably facilitated the inspection. Spring Grove DS0000010336.V368677.R01.S.doc Version 5.2 Page 23 The manager is very experienced and qualified. All the feedback shows the manager to be caring and approachable to residents, staff and visitors, and has established good relationships. There are formal processes that monitor the quality of care provided, including annual reviews and auditing of the procedures. The staff also facilitate residents and relatives meetings to ensure there is adequate communication on what users of the service expect from the service and where improvements could be made. The Providers visit regularly and discuss issues with the residents, staff etc and tour the home. The AQAA (information provided by the home to the Commission) showed that equipment and services had been checked regularly by the handyman (who is also a CORGI registered plumber) and were found to be satisfactory. These safety inspections included the gas equipment and plant, were serviced in June2008 and the fixed and portable electrical systems in May 2008. Fire systems were checked in April 2008. The home does not manage residents’ monies, these are maintained by residents, their relatives, or a legally appointed representative. A sample of policies and procedures were viewed and it was noted all were regularly updated in some. It was clear from comments made by the team leaders that formal supervision is facilitated, and there is an annual appraisal system in place for all staff. Spring Grove DS0000010336.V368677.R01.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 3 3 3 3 3 3 HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 3 14 4 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 4 17 3 18 3 4 3 3 3 4 4 3 4 STAFFING Standard No Score 27 4 28 3 29 4 30 4 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 4 4 3 3 3 4 4 Spring Grove DS0000010336.V368677.R01.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. Refer to Standard Good Practice Recommendations Spring Grove DS0000010336.V368677.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection London Regional Office 4th Floor Caledonia House 223 Pentonville Road London N1 9NG 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 Spring Grove DS0000010336.V368677.R01.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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