Inspection on 13/11/06 for Seven Springs Cheshire Home

This inspection was carried out on 13th November 2006.

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 found no outstanding requirements from the previous inspection report, but made 1 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Seven Springs Cheshire Home 11/11/08

Seven Springs Cheshire Home 09/11/05

Seven Springs Cheshire Home 08/07/05

Seven Springs Cheshire Home 01/12/04

Seven Springs Cheshire Home 23/07/04

Seven Springs Cheshire Home 28/01/04

Similar services:

Thorndene

Sutton Lodge Nursing Home

Wingham Court

Bethany Lodge

17 John Street

Red Oaks

Clare House Nursing Home

Broad Oak Manor Nursing Home

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

CARE HOME MIXED CATEGORY MAJORITY ADULTS 18-65 Seven Springs Cheshire Home Seven Springs Cheshire Home Pembury Road Tunbridge Wells Kent TN2 4NB Lead Inspector Debbie Sullivan Key Unannounced Inspection 13th November 2006 09:30 Seven Springs Cheshire Home DS0000024006.V318139.R01.S.doc Version 5.2 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 Seven Springs Cheshire Home DS0000024006.V318139.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 and Care Homes for Adults 18 – 65*. 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. Seven Springs Cheshire Home DS0000024006.V318139.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Seven Springs Cheshire Home Address Seven Springs Cheshire Home Pembury Road Tunbridge Wells Kent TN2 4NB 01892 531138 01892 533522 sevensprings@lc-uk.org www.leonard-cheshire.org.uk Leonard Cheshire Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Mr Jason Robert Semple Care Home 32 Category(ies) of Physical disability (32) registration, with number of places Seven Springs Cheshire Home DS0000024006.V318139.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registration is restricted to three residents PD (E) whose dates of birth are: 9 February 1935, 18 September 1931 and 20 February 1929 9th November 2005 Date of last inspection Brief Description of the Service: Seven Springs Cheshire Home occupies a large building part of which is within a period house, and part developed around the premises. Accommodation for residents is on two floors with access to the upper level via stairs or a shaft lift. The premises include a day centre, hydrotherapy pool and physiotherapy unit. There are two double bedrooms for residents within the main building of the home that are used for single occupancy only. A vacant room in the refurbished bungalow that adjoins the main building is intended for single occupancy, although a couple could live there if desired. Communal areas are available including one smoking room. There are spacious attractive grounds that include patio areas with seating. A number of independent living bungalows are situated within the grounds of the home, these are not included in the registration. The home is situated approximately one mile from the centre of Tunbridge Wells; a bus service is within a short distance and the train station in the town centre. Substantial refurbishment and improvement to the property commenced in November 2006. The weekly cost of the service ranges from £675 to £1,038 per week. Seven Springs Cheshire Home DS0000024006.V318139.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This report has been compiled using information gained on the unannounced site visit; supplied in the pre inspection questionnaire completed by the manager, and survey forms and comment cards sent in by residents and health and social care professionals. During the site visit a partial tour of the property took place, as did discussion with the manager, some members of staff and residents and records and documentation were inspected. Throughout the day staff were helpful in providing information and were coping well with the slight disruption caused by the commencement of preparation work by contractors on the refurbishment of the home. Some judgements regarding environment outcomes have been made in accordance with the provision of accommodation as it was on the site visit, whilst it is recognised improvements are being made. Comments made on survey forms and during the inspection by residents included, “ I have lived here for ----years and have always been very happy” “Cleaning of bedrooms could be improved” “I have odd dietary needs and the cooks are very good” “We go out a lot and there is a lot going on in the day centre” “ Concerned about lack of consultation about refurbishments” “The staff are brilliant” “ We’ve got a lovely home here” A comment from a health and social care professional included on a comment cards was, “Restructure of staff and management has settled the home------this has improved the overall running” Seven Springs Cheshire Home DS0000024006.V318139.R01.S.doc Version 5.2 Page 6 What the service does well: What has improved since the last inspection? What they could do better: Health and safety procedures need to be improved upon in terms of cleaning materials not being left unattended for substantial periods of time, and unguarded radiators need to be regularly checked to ensure they are not too hot. Seven Springs Cheshire Home DS0000024006.V318139.R01.S.doc Version 5.2 Page 7 The menu board in the dining room would be clearer to see and understand if it was available in larger print, and possibly some photos or illustrations were included. CSCI needs to be provided with the results of the relatives and residents quality assurance survey for 2006, when they are collated. The environment will be substantially improved following refurbishment work. 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. Seven Springs Cheshire Home DS0000024006.V318139.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home Individual Needs and Choices Lifestyle Personal and Healthcare Support Concerns, Complaints and Protection Environment Staffing Conduct of Management of the Home Scoring of Outcomes Statutory Requirements Identified During the Inspection Adults 18 – 65 (Standards 1–5) (Standards 6-10) (Standards 11–17) (Standards 18-21) (Standards 22–23) (Standards 24–30) (Standards 31–36) (Standards 37-43) Older People (Standards 1–5) (Standards 7, 14, 33 & 37) (Standards 10, 12, 13 & 15) (Standards 8-11) (Standards 16-18 & 35) (Standards 19-26) (Standards 27-30 & 36) (Standards 31-34, 37 & 38) Seven Springs Cheshire Home DS0000024006.V318139.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 5 (Adults 18 – 65) and Standards 1 – 5 (Older People) are: 1. 2. 3. Prospective service users have the information they need to make an informed choice about where to live. (OP NMS 1) Prospective users’ individual aspirations and needs are assessed. No service user moves into the home without having been assured that these will be met. (OP NMS 3) Prospective service users’ know that the home that they choose will meet their needs and aspirations. Service Users and their representatives know that the home they enter will meet their needs. (OP NMS 4) Prospective service users’ have an opportunity to visit and “test drive” the home. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. (OP NMS 5) Each service user has an individual written contract or statement of terms and conditions with the home. Each service user has a written contract/statement of terms and conditions with the home. (OP NMS 2) 4. 5. The Commission considers Standard 2 (Adults 18-65) and Standards 3 and 6 (Older People) the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1,2,3,4 and 5 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Prospective residents and their relatives are able to access information about the home and to visit and try out the service before making a decision to move in. EVIDENCE: The home has a statement of purpose and service user’s guide. Needs are fully assessed prior to admission by the manager or head of care and residents only Seven Springs Cheshire Home DS0000024006.V318139.R01.S.doc Version 5.2 Page 10 admitted if needs can be fully met. If the home requires assistance to meet needs a referral is made to or contact maintained with outside professionals. Visits to the home by prospective residents are welcomed, one resident fairly recently admitted said that they had visited Seven Springs and another service and much preferred Seven Springs, since moving in they felt it had met their expectations. They had also been supplied with written information about the service. Reviews are held within several weeks of a new resident moving in so that any initial problems can be addressed. Residents and/or sponsoring authorities have a contract with the home. Seven Springs Cheshire Home DS0000024006.V318139.R01.S.doc Version 5.2 Page 11 Individual Needs and Choices The intended outcomes for Standards 6-10 (Adults 18-65) and Standards 7, 14, 33 & 37 (Older People) are: 6. Service users know their assessed and changing needs and personal goals are reflected in their Individual Plan. The Service Users health, personal and social care needs are set out in an individual plan of care. (OP NMS 7) Service users make decisions about their lives with assistance as needed. Service Users are helped to exercise choice and control over their lives. (OP NMS 14) Service users are consulted on, and participate in, all aspects of life at the home. The home is run in the best interests of service users. (OP NMS 33) Service users are supported to take risks as part of an independent lifestyle. The service users health, personal and social care needs are set out in an individual plan of care. (OP NMS 7) Service users know that the information about them is handled appropriately and that their confidences are kept. Service Users rights and best interests are safeguarded by the home’s record keeping, policies and procedures. (OP NMS 37) 7. 8. 9. 10. The Commission considers Standards 6, 7 and 9 (Adults 18-65) and Standards 7, 14 and 33 (Older People) the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7,8,9 and 10 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Care plans are clear and reflect the health, personal and social care needs of residents. Residents are supported to make decisions and risk take in their daily lives. EVIDENCE: Seven Springs Cheshire Home DS0000024006.V318139.R01.S.doc Version 5.2 Page 12 A sample of care plans were inspected. They were clearly indexed and contained thorough information in the health, personal and social needs of residents. Information is easy to access and includes sections on skills and interests, a personal profile, support assessments relating to support needs in all areas of daily life, risk assessments and information on communication and medication. Some care plans contain information that can be condensed; the manager said that work is underway to reduce them. The small number of residents who are over 65 are now reviewed monthly. Residents had signed most sections of the care plans, and it was clear they were regularly consulted if needs changed. Evidence was in place of regular reviews. Residents spoken with said that they were able to exercise choice in their daily lives and make decisions, one resident spoken with is involved in staff interviewing at the home and another of the organisation’s services, and helps out in the office. Residents can participate in resident’s meetings and the Disabled People’s Forum; the manager said that a quality assurance survey was soon to be distributed. Some residents spoken with did not feel that they had been sufficiently consulted over the home’s refurbishment, whilst recognising it was much needed. Individual choices are recorded on care plans and daily record sheets, and during the site visit staff were seen to be offering choices. Residents are supported in managing their finances if necessary and records of their personal income and expenditure are maintained and kept in order. Information on residents is held securely and confidentially. Seven Springs Cheshire Home DS0000024006.V318139.R01.S.doc Version 5.2 Page 13 Lifestyle The intended outcomes for Standards 11 - 17 (Adults 18-65) and Standards 10, 12, 13 & 15 (Older People) are: 11. Service users have opportunities for personal development. 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. (OP NMS 12) Service users are able to take part in age, peer and culturally appropriate activities. 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. (OP NMS 12) Service users are part of the local community. Service users maintain contact with family/ friends/ representatives and the local community as they wish. (OP NMS 13) Service users engage in appropriate leisure activities. 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. (OP NMS 12) Service users have appropriate personal, family and sexual relationships and maintain contact with family/friends/representatives and the local community as they wish. (OP NMS 13) Service users’ rights are respected and responsibilities recognised in their daily lives. Service users feel they are treated with respect and their right to privacy is upheld. (OP NMS 10) Service users are offered a (wholesome appealing balanced) healthy diet and enjoy their meals and mealtimes. Service users receive a wholesome appeaing balanced diet in pleasing surroundings at times convenient to them. (OP NMS 15) 12. 13. 14. 15. 16. 17. The Commission considers Standards 12, 13, 15, 16 and 17 (Adults 1865) and Standards 10, 12, 13 and 15 (Older People) the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Seven Springs Cheshire Home DS0000024006.V318139.R01.S.doc Version 5.2 Page 14 11,12,13,14,15,16 and 17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents have opportunities to access social, educational and leisure activities of their choice at the home and within the community. Contact with friends and family is supported. Meals are nutritious with choice available and special diets are catered for. EVIDENCE: The home has an integral day centre that some residents and service users from the community attend. Residents spoken with were either keen to attend the centre, or preferred to follow their own particular interests on a day-to-day basis. The day centre was well attended during the site visit; activities on offer were pottery and making Christmas decorations. The home also has a computer room and hydrotherapy pool. Residents can book the home’s transport to access the community, staff support residents in accessing the community, whilst some residents are able to access facilities independently with provision of transport by the home. One resident said they were regularly supported to access the library, and another spoke of going shopping with staff. Three residents were due back from a 60’s weekend away and outings are arranged such as to football matches, musical concerts and the theatre. Currently the home offers two main lounges for residents to access, both have televisions and one is a smoking room that was occupied by residents most of the time. Visitors are welcome and residents are supported to keep in contact with friends and families, a resident went out with a relative for the day during the site visit. Private space is available for visits to take place. Residents are able to access communal areas of the home freely and privacy is respected. There are locks on bedroom doors and staff were observed to knock on doors before entering rooms. Seven Springs Cheshire Home DS0000024006.V318139.R01.S.doc Version 5.2 Page 15 The dining room is spacious and lunch was taken in a pleasant and relaxed atmosphere. The meal was well presented and residents had been offered a choice of a meat or vegetarian option. Special diets are catered for and meal choices recorded. Residents said they liked the meals and if they did not like the daily options they could choose something else. Those requiring assistance with their meal were assisted appropriately. Following the refurbishment the large dining room will be replace by a smaller dining room and kitchen on each of the two floors. Seven Springs Cheshire Home DS0000024006.V318139.R01.S.doc Version 5.2 Page 16 Personal and Healthcare Support The intended outcomes for Standards 18 – 21 (Adults 18-65) and Standards 8 – 11 (Older People) are: 18. 19. 20. Service users receive personal support in the way they prefer and require. Service users feel they are treated with respect and their right to privacy is upheld. (OP NMS 10) Service users’ physical and emotional health needs are met. Service users’ health care needs are fully met. (OP NMS 8) Service users retain, administer and control their own medication where appropriate and are protected by the home’s policies and procedures for dealing with medicines. Service users, where appropriate, are responsible for their own medication and are protected by the home’s policies and procedures for dealing with medicines. (OP NMS 9) The ageing, illness and death of a service user are handled with respect and as the individual would wish. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. (OP NMS 11) 21. The Commission considers Standards 18, 19 and 20 (Adults 18-65) and Standards 8, 9 and 10 (Older People) the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18,19 and 20 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The personal and healthcare needs of residents are well met and documented and medication policies and procedures are in place. Equipment is available to promote and maintain independence. EVIDENCE: Seven Springs Cheshire Home DS0000024006.V318139.R01.S.doc Version 5.2 Page 17 Preferences in respect of the delivery of personal care are recorded and respected, residents spoken with said that staff were always respectful of them and they were complimentary about staff and standard of care they received. Care plans recorded information on contact and input from outside professionals such as chiropdists, the district nurse, speech and language therapist and GP’s. A resident was going to see the GP during the site visit, and another spoke of regular appointments with a health professional. The home has a physiotherapy room and residents can have a physiotherapy assessment, an individually designed programme and treatment if they wish. Specialist equipment to aid and maintain independence for communal or personal use is in evidence throughout the home, the manager was making efforts to ensure that a resident moved to a temporary bedroom during some of the refurbishment was provided with a suitable hoist due to particular moving and handling needs, as unforeseen difficulties arose during the site visit regarding this. Residents are supported to be fully or partially self-medicating if they choose, staff monitor and oversee the use of self-medication and related risk assessments are completed. Lockable space is provided in bedrooms. The medication room provides appropriate and safe storage and the medication trolley is tethered either in the room or the dining room. MAR sheets inspected were properly completed and the home had changed its’ pharmacist since the last inspection. All staff administering medication are trained to do so. Seven Springs Cheshire Home DS0000024006.V318139.R01.S.doc Version 5.2 Page 18 Concerns, Complaints and Protection The intended outcomes for Standards 22-23 (Adults 18-65) and Standards 16-18 & 35 (Older People) are: 22. 23. Service users feel their views are listened to and acted on. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted on. (OP NMS 16) Service users’ are protected from abuse, neglect and self-harm. Service users legal rights are protected. (OP NMS 17) Also Service users are protected from abuse. (OP NMS 18) Also Service users financial interests are safeguarded. (OP NMS 35) The Commission considers Standards 22-23 (Adults 18-65) and Standards 16-18 and 35 (Older People) the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents and others have access to the home’s complaints procedures and concerns and complaints are properly responded to. The home’s adult protection policies and procedures serve to protect residents from abuse. EVIDENCE: The home has a complaints procedure and any complaints are documented and responded to within timescales. Three formal complaints had been recorded since the last inspection and had been responded to in accordance with procedures. Residents spoken with and who were asked about their awareness of it, knew about the procedure, one resident said they felt confident in being able to refer concerns to the manager. Some residents said that they felt the wider Seven Springs Cheshire Home DS0000024006.V318139.R01.S.doc Version 5.2 Page 19 organisation was not responsive to concerns about the work being done on the premises; monthly site progress meetings are to take place as from December 2006 involving representatives from the resident group. There were no adult protection alerts open in respect of the home, as had been the case at the last inspection. New staff are all subject to CRB and POVA checks prior to commencing work and adult protection training is provided and updated given, this was evidenced on staff files. The home has an adult protection procedure that is regularly updated. Seven Springs Cheshire Home DS0000024006.V318139.R01.S.doc Version 5.2 Page 20 Environment The intended outcomes for Standards 24 – 30 (Adults 18-65) and Standards 19-26 (Older People) are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users live in a safe, well-maintained environment (OP NMS 19) Also Service users live in safe, comfortable surroundings. (OP NMS 25) Service users’ bedrooms suit their needs and lifestyles. Service users own rooms suit their needs. (OP NMS 23) Service users’ bedrooms promote their independence. Service users live in safe, comfortable bedrooms with their own possessions around them. (OP NMS 24) Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Service users have sufficient and suitable lavatories and washing facilities. (OP NMS 21) Shared spaces complement and supplement service users’ individual rooms. Service users have access to safe and comfortable indoor and outdoor communal facilities. (OP NMS 20) Service users have the specialist equipment they require to maximise their independence. Service users have the specialist equipment they require to maximise their independence. (OP NMS 22) The home is clean and hygienic. The home is clean, pleasant and hygienic. (OP NMS 26) The Commission considers Standards 24 and 30 (Adults 18-65) and Standards 19 and 26 (Older People) the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24,25,26,27,28,29 and 30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home provides a clean, accessible and safe environment for residents. Current extensive refurbishment work will improve the building when completed, as parts of it have become very worn and in need of repair and redecoration. Seven Springs Cheshire Home DS0000024006.V318139.R01.S.doc Version 5.2 Page 21 EVIDENCE: Extensive refurbishment work on the premises has commenced following a period of planning and consultation. The work is scheduled to last until 2008 and measures are in place to ensure that the safety of residents is maintained during the work and disruption is minimised. The contractors are known to the organisation having worked on other of its premises. The site visit took place on the first day of the work; all residents spoken with were generally in favour of the improvements taking place, whilst views were mixed regarding the future provision of two dining rooms. Three residents needed to temporarily move bedrooms for the first phase involving the upstairs accommodation that no longer provides a suitable environment in terms of décor or bathing and toilet facilities. Care and maintenance staff were involved in this throughout the day. Improvements will include the provision of ensuites in all bedrooms. The overall standard of decoration and upkeep of the home had detiorated since the last inspection, with the delay of some redecoration whilst waiting for improvement work to start. Some bedrooms and communal bathing/washing areas were inspected; all seen were clean, bedrooms and included items that reflected the interests of the occupant such, as football items, CD’s, posters and videos. Bedrooms varied in the standard of decoration, some had been redecorated when new residents moved in whilst they will be included in refurbishment as well. Communal accommodation currently comprises of the dining room, one large lounge and a smoking lounge and a smaller quiet room on the corridor connecting the older and newer parts of the building. There are large well-kept grounds and patio areas that are well used in good weather. The laundry is well away from food preparation areas. Seven Springs Cheshire Home DS0000024006.V318139.R01.S.doc Version 5.2 Page 22 Staffing The intended outcomes for Standards 31 – 36 (Adults 18-65) and Standards 27 – 30 & 36 (Older People) are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported and protected by the home’s recruitment policy and practices. (OP NMS 29) Service users are supported by competent and qualified staff. Service users are in safe hands at all times. (OP NMS 28) Service users are supported by an effective staff team. Service users needs are met by the numbers and skill mix of staff. (OP NMS 27) Service users are supported and protected by the home’s recruitment policy and practices. Service users are supported and protected by the home’s recruitment policy and practices. (OP NMS 29) Service users’ individual and joint needs are met by appropriately trained staff. Staff are trained and competent to do their jobs. (OP NMS 30) Service users benefit from well supported and supervised staff. Staff are appropriately supervised. (OP NMS 36) The Commission considers Standards 32, 34 and 35 (Adults 18-65) and Standards 27, 28, 29 and 30 (Older People) the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31,32,33,34,35 and 36 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Staff are well trained and supported and confident in their roles. The home’s recruitment policies and procedures protect residents and they are involved in the recruitment process. EVIDENCE: Seven Springs Cheshire Home DS0000024006.V318139.R01.S.doc Version 5.2 Page 23 The staffing and management structure at the home is well established and staff are well trained and supported and confident in their roles. Since the last inspection more care staff have been assigned senior roles and have completed or are on NVQ 2 or 3 courses in care. The manager said that for some weeks earlier in the year there was a staff shortage, this is now resolved with recent recruitment. When agency staff are used they are those familiar with the home. Staff observed and spoken with enjoyed their work, had a good rapport with residents and were competent, one staff member spoken with said they felt well supported and that there were plenty of training opportunities. A comment made by a member of the care staff was “I love it here, all the residents are lovely”. Residents spoken with were complimentary regarding staff and said they were treated respectfully. As well as care staff the home employs, catering, housekeeping, administration, activities, physiotherapy and maintenance staff and a number of volunteers assist with activities and fund raising. Some staff files were read, they were indexed with information easily available. The necessary recruitment documentation was in place as well as training and supervision information. Supervision is scheduled and recorded. Recruitment procedures are thorough and include a resident on interview panels and recording of applicants’ responses. The Leonard Cheshire area training co-ordinator manages and tracks training. A training matrix database provides clear information on courses available and which staff require certain courses or updates. A first aid course was taking place during the site visit. Seven Springs Cheshire Home DS0000024006.V318139.R01.S.doc Version 5.2 Page 24 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 (Adults 18-65) and Standards 31-34, 37 & 38 (Older People) are: 37. Service users benefit from a well run home. 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. (OP NMS 31) Service users benefit from the ethos, leadership and management approach of the home. Service users benefit from the ethos, leadership and management approach of the home. (OP NMS 32) Service users are confident their views underpin all self-monitoring, review and development by the home. The home is run in the best interests of service users. (OP NMS 33) Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users rights and best interests are safeguarded by the homes record keeping, policies and procedures. (OP NMS 37) Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. Service users rights and best interests are safeguarded by the homes record keeping policies and procedures. (OP NMS 37) The health, safety and welfare of service users are promoted and protected. The health, safety and welfare of service users and staff are promoted and protected. (OP NMS 38) Service users benefit from competent and accountable management of the service. Service users are safeguarded by the accounting and financial procedures of the home. (OP NMS 34) 38. 39. 40. 41. 42. 43. The Commission considers Standards 37, 39 and 42 (Adults 18-65) and Standards 31, 33, 35 and 38 (Older People) the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Seven Springs Cheshire Home DS0000024006.V318139.R01.S.doc Version 5.2 Page 25 37,38,39,40,41,42 and 43 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 in the best interests of residents and staff. Substantial investment is being made to improve the premises. EVIDENCE: The home is well run in the best interests of residents and staff, staff are well managed and residents spoken with said they were happy at the home, concerns related to the improvements. Policies and procedures are in place to ensure the health and safety of residents, staff and visitors and maintenance records inspected were up to date. Fire practices are held regularly and fire equipment maintained. Throughout the site visit safe working practices were observed, although cleaning materials were left unattended for some time in the newer part of the building and in the laundry, and one unguarded radiator in a corridor was extremely hot. Temperatures are recorded daily for the kitchen fridges and freezers and the drugs fridge. The kitchen had recently been given a gold star award by the environmental health department. The annual quality assurance survey was due to be sent out, the manager will supply the results to the commission. All the recording and documentation inspected was up to date and records pertaining to residents were available to them. Seven Springs Cheshire Home DS0000024006.V318139.R01.S.doc Version 5.2 Page 26 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. Where there is no score against a standard it has not been looked at during this inspection. 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 3 2 3 3 3 4 3 5 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 2 25 2 26 2 27 2 28 3 29 3 30 3 STAFFING Standard No Score 31 3 32 3 33 3 34 4 35 3 36 3 CONDUCT AND MANAGEMENT Standard No Score 37 3 38 3 39 3 40 3 41 3 42 2 43 3 3 3 2 3 3 LIFESTYLES Standard No Score 11 3 12 3 13 3 14 3 15 3 16 3 17 4 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Seven Springs Cheshire Home Score 3 4 3 X DS0000024006.V318139.R01.S.doc Version 5.2 Page 27 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. 1. Standard YA42 Regulation 13(4)(a) Requirement “ The registered person shall ensure that all parts of the home to which service users have access are so far as reasonably practicable free from hazards to their safety” In that cleaning materials must not be left unattended in any area of the home. Timescale for action 14/12/06 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 YA17 Good Practice Recommendations It is recommended that the daily menu board be available in a larger print format and consideration be given to the inclusion of pictorial information. It is recommended that the results of the annual quality assurance survey be forwarded to CSCI. DS0000024006.V318139.R01.S.doc Version 5.2 Page 28 2. YA39 Seven Springs Cheshire Home 3. 4. YA39 YA42 It is recommended that the views of residents are regularly sought and recorded regarding progress on the improvements to the service. It is recommended that the temperatures of unguarded radiators be monitored regularly. Seven Springs Cheshire Home DS0000024006.V318139.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection Maidstone Local Office The Oast Hermitage Court Hermitage Lane Maidstone ME16 9NT National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI. 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