Inspection on 20/08/07 for Larkhall Springs

This inspection was carried out on 20th August 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

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

Larkhall Springs 08/01/07

Larkhall Springs 15/11/05

Larkhall Springs 20/06/05

Larkhall Springs 11/01/05

Larkhall Springs 11/06/04

Similar services:

Fairfields Country Rest Home

Poldhu

Queensmount

Trevaylor Manor

Didsbury Court Rest Home

Belma

Hunters Care Centre

Manor Lodge

Extracts from inspection reports are licensed from CQC, this page was updated on 09/07/2008.

CARE HOMES FOR OLDER PEOPLE Larkhall Springs Swainswick Gardens Larkhall Bath Bath & N E Somerset BA1 6TL Lead Inspector Andrew Pollard Key Unannounced Inspection 20th August 2007 09:30 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 Larkhall Springs DS0000020360.V341675.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. Larkhall Springs DS0000020360.V341675.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Larkhall Springs Address Swainswick Gardens Larkhall Bath Bath & N E Somerset BA1 6TL 01225 466266 01225 478939 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) Cedar Care Homes Limited Vacancy Care Home 35 Category(ies) of Old age, not falling within any other category registration, with number (35) of places Larkhall Springs DS0000020360.V341675.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. May accommodate 35 Persons aged 50 years and over Staffing Notice dated 08/11/2000 applies Manager must be a RN on parts 1 or 12 of the NMC register Date of last inspection 8th January 2007 Brief Description of the Service: Larkhall Springs is a registered care home providing nursing care for up to 35 older people. The home is situated in a suburban position and can be accessed by car or bus, which would be required for easy access to local shops and venues. The home is a converted property providing single and en-suite rooms on two floors and lounge space and a dining room in 3 areas. There is a lift to all parts of the home. Larkhall Springs DS0000020360.V341675.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an announced inspection conducted as part of the annual inspection process. The inspection lasted one day. Following the previous inspection requirements and recommendations were made, there are no outstanding requirements. The following methods of evidence gathering has been used in the production of this report; observation, discussion with residents, relatives and staff, tour of the home and sampling policies, records, care plans and a meals. 13 surveys were returned from residents and relatives, which were positive. Information from these has been collated and are detailed throughout the report. Staff and resident interactions were seen to be friendly and caring upholding the dignity of the residents. A number of residents and visitors were spoken with about the quality of care provided at the home. Members of staff were observed on duty and several were consulted individually. General feedback was given to the manager on the day of inspection. What the service does well: The impression of the home is that it is a friendly comfortable and safe place to live and the staff are respectful and caring. The environment is of a good standard and clean. All of the residents and visitors spoken with during the inspection commented positively on all aspects of the home. The residents/relatives consider the quality of food to be good. Individual aspirations and choice are supported, monitored and encouraged by both the manager and staff employed at the home. Opportunities exist for residents to participate in a range of meaningful activities. Larkhall Springs DS0000020360.V341675.R01.S.doc Version 5.2 Page 6 Larkhall remains a well equipped home with a safe and good standard of accommodation provided for the residents. Personalisation of individual rooms is promoted. What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. Larkhall Springs DS0000020360.V341675.R01.S.doc Version 5.2 Page 7 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. Larkhall Springs DS0000020360.V341675.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 Larkhall Springs DS0000020360.V341675.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): 1,2,3,6 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Prospective clients and their families are given relevant information in written or verbal form about the home. Contracts and terms and conditions of services are provided to all clients. The assessment procedure is clearly written and a thorough assessment of prospective residents needs is carried out. EVIDENCE: A statement of purpose and a home guide plus additional helpful information is made available at the initial stage of enquiry to prospective residents/families. Larkhall Springs DS0000020360.V341675.R01.S.doc Version 5.2 Page 10 This provides good information about the services and facilities available and includes the terms and conditions. The manager is due to carry out a review of the service user guide in the coming weeks. All the residents’ surveys returned stated that they had received adequate information to help them decide if Larkhall was somewhere they would like to live. They also confirmed that they or family member had received a contract on admission to the home. Visits to the home are encouraged either for the day or perhaps for lunch dependent on their wishes. The home has a good admission procedure and maintains a checklist to ensure the smooth running of the initial period for residents within their new home. Pre-admission assessments are comprehensive; covering activities of daily living, a full health screen and personal history. The prospective resident/relatives are involved in the assessment and all information is used to determine the suitability of the placement. Where possible the manager or senior nurse carry out assessments and obtain information and care plans from other professionals for example, social workers, district nurses and hospital staff. Staff spoken with demonstrated understanding of the needs of the resident. A month’s trial period on both sides is usually undertaken to ensure that everyone is happy with the arrangements and to ensure that the placement is suitable. Larkhall Springs DS0000020360.V341675.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): 7,8,9,10,11 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Care plans detail residents care needs and are clearly written and give clear directions to staff. The staff provide appropriate personal and nursing care to maintains residents’ health and well-being and dignity. Proper arrangements are in place for residents to access primary healthcare services. The staff properly store, administer and record medication on behalf of residents. Disposal arrangements need to be improved. Larkhall Springs DS0000020360.V341675.R01.S.doc Version 5.2 Page 12 EVIDENCE: Five care files were reviewed they contained individualised care plans in relation to each assessed need and gave clear direction to staff to enable them to deliver appropriate care to the residents. Where able residents or relatives sign care plans and consents for bed rails. Files are reviewed monthly and when needs change. Entries in the daily progress note showed that care prescription was being followed as per the care plan. Care staff are being encouraged to start making notes about the care of residents or as their role as key workers. The residents surveys evidenced that they receive the care and support they need. Comments received were very satisfactory and complimentary of the staff and the care they provided. All the residents spoken with said, “They were satisfied with the overall level of care being provided”. They spoke highly of the staff saying they were, “Friendly and caring”. The case files had evidence of visits from the health professionals, General Practitioners, Chiropodists and Opticians. There are no arrangements to offer routine dental examinations, although people with particular needs are referred to the dental hospital. The manager is making enquiries to establish if a local dentist will take residents on to their list. Risk assessments were in place with detailed information to ensure good care for example, manual handling, correct use of bed rails and reduction of risk from falls and pressure sores. Health Care assessments included continence, nutritional, waterlow and others. In discussion with the manager it was agreed that after the initial assessments are made it is a matter of clinical judgement how often they are repeated. The assessments should be done where there is a clinical indication for doing so rather than routinely every month. One resident stated, “ I am happy here, staff look after me well. I get up when I like and I go to bed when I like.” Another resident stated, “Staff are very kind.” Staff were observed knocking on the doors before going in to the residents rooms to assist them with personal care. A link nurses with the Dorothy House Hospice oversees end of life care planning. The staff make every effort to establish resident’s wishes concerning palliative care and any provision residents and their families wish for when developing end of life plans. Larkhall Springs DS0000020360.V341675.R01.S.doc Version 5.2 Page 13 The plans are sensitively completed with residents and their families/significant others. The home has adopted The Liverpool Integrated Care Pathway intended as a guide to treatment and an aid to documenting residents’ progress. Policies and procedures for receiving, storing, administering and disposing of medications are in place. There were photographs of each resident on their medication charts to help ensure that medication was dispensed to the correct person. The administration charts were legible up to date and in order. Proper arrangements are in place for receipt and storage and recording of medicines including controlled drugs. The disposal bin for discarded drugs does not have a tamperproof lid to ensure the content are secure prior to disposal. Larkhall Springs DS0000020360.V341675.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): 12,14,15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. A range of social and recreational activities is arranged that seek to enhance the quality of life for the residents. Resident’s families are involved and informed of issues related to their relatives and are able to maintain close contact with families and friends. The food is of a high standard and provides a balanced diet for residents. EVIDENCE: Care plans contained a social assessment form, which is completed by the resident, or their representative on admission to enable the home to plan a suitable activity based on the details given. Larkhall Springs DS0000020360.V341675.R01.S.doc Version 5.2 Page 15 The activities coordinator works 32,5 hours per week and provides a varied programme of activities for the residents. She has become a well-established member of staff who is knowledgeable of the residents’ needs and wishes and is an NVQ assessor. Volunteers also work at various times in the home. The coordinator is responsible for documenting a record of any activities the residents have taken part in. Individuals have records of their social and activity choices and participation in their files. In conjunction with the residents the activities coordinator develops a monthly timetable of activities and forthcoming events. A copy of this is placed in communal areas throughout the home, to ensure that all residents and visitors are aware of the planned events. A summer fete and garden party are planned this month and previous events have been a great success according to residents spoken to. There are annual fund raising events organised and all proceeds go to the residents’ funds. Regular outings are arranged and a variety of entertainers visit the home. Residents spoken with stated that the home supports them to maintain contact with families, friends and that visiting time is not restricted. A resident stated, “Our friends and relatives come to see us when ever they want”. The Vicar or a layperson from the church comes to see the residents who wish it on a regular basis. There are no residents with particular cultural or other faith needs. The menu on the day was displayed on the notice board in the dinning room. The menus consist of a varied, well-balanced choice of traditional home cooked meals. Each day residents have a choice of two meals and in addition to this such things as omelette; fish or ham is also made available on a daily basis. The menu includes alternative choices for residents who are diabetics or those requiring a pureed diet. There was plenty of fresh fruit bowls available from which residents could take their choices. No resident currently requires any culturally specific diet. Residents spoken with after lunch stated that they enjoyed their meal. One resident stated, “The food is very good.” Residents’ surveys expressed that “The food is always very good” and “we have plenty of choice”. Residents assisted by staff during the mealtime were helped in a sensitive and dignified manner. The kitchen was clean and organised. Food hygiene training is up to date for all staff. Records are made to show that required hot and cold temperature checks were being carried. Risk assessments were in place and up to date. An Environmental Health Officer inspection found all to be in good order. Larkhall Springs DS0000020360.V341675.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): 16,18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. There are robust and comprehensive policies in place to protect residents investigate complaints or manage allegations of abuse. There are good arrangements in place for staff training and awareness of Protection Of Vulnerable Adults matters. EVIDENCE: A copy of the complaints procedure is on display in the main foyer and is part of the information provided to people on admission. Relative surveys indicated people knew how to complain. The complaints policy and procedure is detailed and contains all the required information. There have been four complaints received since the last inspection, three resolved to the satisfaction of the complainant and one still in process. Larkhall Springs DS0000020360.V341675.R01.S.doc Version 5.2 Page 17 All residents who completed a survey indicated that they knew who to talk if they were not happy and how to make a complaint. Comments included, “I’ve never had cause to complain “. Residents also said they would speak to their key workers or the manager to discuss any concerns they may have. The home has written procedures for adult protection, whistle blowing and management of money/valuables. The Local Authority ‘No Secrets’ document was available. All staff are instructed in adult protection and prevention of abuse as part of their induction. staff attend update training in dealing with vulnerable adults and the manager is expecting update sessions to be run in the near future. Larkhall Springs DS0000020360.V341675.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): 19,20,22,24,25,26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The standard of furnishing and décor is good to the benefit of residents. The home provides a safe and well-maintained environment for the residents. The bedrooms and communal rooms and facilities are suitable and well presented for their purpose and meet the resident’s needs. The standard of cleanliness is high. Larkhall Springs DS0000020360.V341675.R01.S.doc Version 5.2 Page 19 EVIDENCE: The home was found to be clean, warm, and free from offensive odour and suitable for its stated purpose. The home is well decorated and maintained to ensure that all areas are homely. Residents are supported to personalise their bedrooms with pictures and ornaments and are able to bring items of furniture should they wish. Several areas are set out as lounges and there is a quiet area if needed. Suitable dining room seating and table facilities are provided so that residents can enjoy their meal times comfortably and in a congenial setting. Residents’ surveys confirmed that the home is and clean and one resident stated, “That the cleaning is good and the decoration is nice”. All of the bathrooms and toilets were in good order, clean and fresh. Baths have thermostatic mixer valves and the monitoring hot water temperatures take place, however the temperatures recorded ranged from 38 degrees centigrade to over 48 degrees centigrade. The manager made immediate arrangements to have the maintenance man attends to check all the outlet temperatures and adjust as required to provide comfortably hot but safe water. A letter was received on 28/08/07 confirming the work had been carried out and new monitoring arrangements put in place. Mobile and fixed hoists, adjustable beds, pressure relieving equipment and specialist baths are provided to meet resident’s needs. The laundry was found clean and tidy, there were adequate laundry facilities and the laundry staff met on duty stated that the service was working well and there were no complaints. Soiled clothing is washed separately and staff informs the laundry of any infection at the home. Staff were noted wearing aprons and gloves and washing their hands after attending to the residents. This demonstrated that infection control and principles of good hygiene is well maintained at the home. Larkhall Springs DS0000020360.V341675.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): 27,29,30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The recruitment procedures and records are in good order. The home is well staffed with appropriately trained and experienced staff for the number of residents. Proper training arrangements and clinical updating for RN’s are in place. Good progress is being made training care staff for the benefit of residents. EVIDENCE: Discussion with the manager showed that the home has a sufficient staffing level to meet the needs of the residents. The staffing levels are in accord with or exceed the staffing notice for 31 residents Larkhall Springs DS0000020360.V341675.R01.S.doc Version 5.2 Page 21 Residents spoken with stated that staff are kind, attended them when they rang the bell and treated them with respect. Residents’ surveys agreed that staff were always or usually available when they needed them and always listened and acted upon what the residents had to say. The home operates a key working system to enhance the resident/staff relationships. Residents’ surveys stated that, “the staff work hard to make everyone happy” Visitors’ comments included, “The nurses have a caring nature” and “Staff are friendly and respectful”. At present there are no Nurse or carer vacancies. The home has a small bank of staff and agency use is minimal. The domestic, catering, admin and laundry staffing levels are satisfactory. The induction programme is comprehensive and based on the Skills for Care standards. After completion of the commence foundation training care staff enrol on the National Vocational Qualification (NVQ) programme level 2. Mandatory training including fire safety, food hygiene, first aid, load handling and adult protection was undertaken and course dates had been organised for staff. The manager has done additional training to train staff in load handling. A robust recruitment policy and procedure is in place and the manager has applied to the CRB to become a counter signatory, enabling her to apply for staff CRB’s directly. The staff files inspected showed all the appropriate documents and checks were in evidence. In future CRB’s will be retained until the inspector has signed them off or the counter signatory does so and creates a detailed log. Registered Nurse (RN) verification of registrations has been validated with the Nursing and Midwifery Council (NMC). An electronic check of the NMC list of struck off or suspended staff is carried out. RN training records were not up to date but will be updated as soon as practical and thereafter updated as part of appraisal. Larkhall Springs DS0000020360.V341675.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): 31,33,34,35,36,38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is well managed and run taking into account the views and wishes of the relatives and residents and as they are able. There are good arrangements in place to maintain and service the equipment and facilities in the home. The Home protects the health and safety of residents and staff. The staff supervision and appraisal arrangements are good. Larkhall Springs DS0000020360.V341675.R01.S.doc Version 5.2 Page 23 EVIDENCE: The manager is a registered general nurse who was able to demonstrate an understanding of the needs of the individuals living in the home and has a good team who work with her to ensure that high standards of care are achieved and maintained. The atmosphere in the home was positive and calm. Staff were noted interacting with residents in a caring and friendly manner. Staff spoken with stated that although there has been some disquiet and staff turnover has been high people were now working as a team and morale had improved. A bank nurse on duty said,” This is the best home I have ever worked in”. The manager is enrolling on a manager-training programme to enhance her leadership skills. There are bi-monthly managers meetings and a weekly management report sent to the RI and clinical director. Regulation 26 visits and reports are completed by the clinical director or responsible individual. Staff appraisal and supervision was reviewed. Some staff had received group supervision others on a one to one basis, however it has been ad-hoc and some nurses require training to feel confident in delivering the process before it can be properly established. The manager has completed Manual Handling Training for Trainers Course and First Aid training to enable her to train and update staff as and when necessary. Health and Safety records showed that the home had undertaken generic risk assessments throughout the home. Records showed that relevant inspections and maintenance has been carried out at the required intervals for the fire alarms and equipment, gas and electrical services, hoists and lift. The fire logbook was up to date and in order. Staff fire safety drills and training are taking place at the required intervals. Accidents were noted to be properly recorded and reviewed as required. Discussion relating to the use of informing the Commission for Social Care Inspection through the Reg 37’s forms were discussed and the managers freedom to use judgement about what was serious enough to warrant notification to the Commission. Larkhall Springs DS0000020360.V341675.R01.S.doc Version 5.2 Page 24 The home audits it quality of service using different tools. These include leaflets for feedback from health professionals, relatives and residents; one to one discussions with residents following any concerns raised are resolved as soon as possible; Medication audit; Residents’ money audit; Risk assessment of individual residents and general risk assessment of the home; care plan reviews monthly; monthly health and safety checks; discussions at residents’ and staff meetings. A report was submitted of a recent survey, which showed an overall positive outcome in all areas. There was a high degree of satisfaction expressed by all of the residents spoken with. Based on the comments made and through the inspectors observation it is evident that the home is run in their best interests and to ensure their needs are being met. Larkhall Springs DS0000020360.V341675.R01.S.doc Version 5.2 Page 25 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 3 3 X X x HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 X 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 3 18 x 3 3 X 3 X 3 3 3 STAFFING Standard No Score 27 3 28 X 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 3 3 2 x 2 Larkhall Springs DS0000020360.V341675.R01.S.doc Version 5.2 Page 26 Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP36 Regulation 18.2 Requirement Timescale for action 30/11/07 2. OP9 13.3 Supervision and appraisal arrangements need to be formalised and actioned throughout the staff team so that they take place regularly. The disposal bin for discarded 30/09/07 drugs should have a tamperproof lid to ensure the content are secure. 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. 2. Refer to Standard OP30 OP38 Good Practice Recommendations The nurse clinical training records need to collated and updated. Hot water temperatures need to be monitored at the outlet to ensure they are hot but do not exceed 45 degrees centigrade. Larkhall Springs DS0000020360.V341675.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection South West Regional Office 4th Floor, Colston 33 33 Colston Avenue Bristol BS1 4UA 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 Larkhall Springs DS0000020360.V341675.R01.S.doc Version 5.2 Page 28 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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