Inspection on 11/10/05 for Spring Bank

This inspection was carried out on 11th October 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Poor. 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 there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Spring Bank 13/11/08

Spring Bank 21/05/08

Spring Bank 27/11/07

Spring Bank 04/06/07

Spring Bank 12/12/06

Spring Bank 16/05/06

Spring Bank 17/05/05

Spring Bank 07/09/04

Spring Bank 05/05/04

Spring Bank 14/01/04

Similar services:

Abbey The

Snydale Care Home

Larchfield Manor

Hawkhills

Beeches The - North Yorkshire County Council

The Grove Waltham

Carentan House

Ravensworth Lodge

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

CARE HOMES FOR OLDER PEOPLE Spring Bank Howden Road Silsden Keighley West Yorkshire BD20 0JB Lead Inspector Ann Stoner Unannounced Inspection 11th October 2005 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 Spring Bank DS0000019888.V255845.R01.S.doc Version 5.0 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 Bank DS0000019888.V255845.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Spring Bank Address Howden Road Silsden Keighley West Yorkshire BD20 0JB 01535 656287 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) Mrs Diane Hudson Mrs Diane Hudson Care Home 33 Category(ies) of Dementia (33), Physical disability (33) registration, with number of places Spring Bank DS0000019888.V255845.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 17th May 2005. Brief Description of the Service: Spring Bank is a converted extended property situated in a residential area above Silsden, close to local bus routes and within easy reach of the railway station and the main road to Bradford and Skipton. The home provides care for thirty one residents who require personal and nursing care. Accommodation is provided in a combination of single and double rooms. The single rooms, with en-suite facilities, are in the newer part of the home, shared rooms are in the older part of the building. Residents have a choice of two lounges, and there is also a dining room. Original features such as oak panelling have been retained where possible. The home is situated in extensive and attractive gardens to which there is level access from the home. There is a car park at the side of the building. Spring Bank DS0000019888.V255845.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. Over an inspection year from April until March, care homes have a minimum of two inspections a year; these may be announced or unannounced. The last inspection was unannounced and took place on the 17th May 2005. There have been no further visits until this unannounced inspection, although the owner/manager (registered provider/registered manager) has attended a meeting, arranged by the Commission of Social Care Inspection (CSCI), where she was warned that failure to comply with identified timescales could lead to enforcement action being taken. The people who live in the home prefer the term resident; therefore this will be the term used throughout this report. Two inspectors carried out this inspection between the hours of 9.30am and 5.00pm. During the inspection, we looked at records, saw care staff carrying out their work and spoke with residents, visitors, staff and the manager. Comment cards/questionnaires are left for residents, visitors and other professionals at each inspection. These provide an opportunity for people to share their views of the home with the CSCI. We discuss any comments received with the manager without revealing the identity of those completing them. None have been returned. Copies of previous inspection reports are available via the Internet at www.csci.org.uk. What the service does well: What has improved since the last inspection? Due to lightening damage a new call system has been installed and the manager has bought some new chairs and bedside tables. Printed MAR (Medication Administration Records) are now used for recording medication and cleaning materials are no longer decanted. Overall there has been very little improvement since the last inspection and a large number of requirements and recommendations remain unmet. The manager was told of the possibility of enforcement action being taken. Spring Bank DS0000019888.V255845.R01.S.doc Version 5.0 Page 6 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. Spring Bank DS0000019888.V255845.R01.S.doc Version 5.0 Page 7 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 Bank DS0000019888.V255845.R01.S.doc Version 5.0 Page 8 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1 & 4. Standard 6 does not apply to this home. The lack of a statement of purpose and service user guide means that residents, relatives and staff have no written information about the home. The home is not in a position to guarantee it can meet identified needs. EVIDENCE: There is no statement of purpose or service user guide, both of which have been identified as requirements at inspections since June 2002. The manager said that she hopes to complete the statement of purpose within the next two weeks. The home cannot demonstrate that it can meet the assessed needs of residents. There is a lack of written information in the home, and guidelines and policies that are available to staff are out of date, do not refer to practices within the home, and are not based on current good practice and clinical guidance. The policy and procedure file contained information from the UKCC, which was replaced by the NMC (Nursing and Midwifery Council) in April 2002; there was information that related to hospital ward based practice, and information that related to another home. There was no evidence that advice from specialised services; such as the tissue viability nurse has been obtained for a resident with a pressure sore. There is no training and development plan Spring Bank DS0000019888.V255845.R01.S.doc Version 5.0 Page 9 and no system for identifying when training, such as moving and handling and fire training should be up-dated. Staff have not completed basic training such as infection control, and training needs based on the specific needs of the residents, such as dementia, are not identified. Spring Bank DS0000019888.V255845.R01.S.doc Version 5.0 Page 10 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 &10 There is no guarantee that residents needs will be met, as care plans are poor and risk assessments are not always in place. The lack of medication policies and procedures does not safeguard and make sure correct and safe practices. Residents are treated with respect, but some practices raise issues about dignity for residents. EVIDENCE: Care plans of five residents were looked at. The care plans are based on the activities of daily living but in most cases do not reflect individual needs, for example one resident had a care plan for breathing despite the fact that no problems with breathing were identified during assessment. There were no care plans in place for residents identified as being at risk of developing pressure sores and it was not clear from the records what, if any, pressure relieving equipment was being used. The care plan for one resident relating to mobility did not contain any reference to the fact that the resident suffers from Parkinson disease. Another care plan relating to continence had a note at the end saying the resident now had a catheter but there were no instructions for staff on the care of the catheter. Spring Bank DS0000019888.V255845.R01.S.doc Version 5.0 Page 11 A wound care plan did not have any description of the wound and there was no evidence that the Tissue Viability nurse had been consulted despite the fact that records dating back to May 05 suggests that the wound is not improving. The home’s pressure area care policy is out of date, and in any case, it is intended for use on a hospital ward. The falls risk assessment does not make it clear whether the resident is at risk or not. Nutritional assessments were in place but some had not been completed. In the records of two residents the nutritional risk assessments had not been reviewed since April 05 and May 05 despite the fact that the residents were losing weight. The care plans had been evaluated but had not been changed to reflect the fact that the residents were losing weight. There were consent forms for bed rails but no risk assessments had been done. The general risk assessments seen in residents’ files consisted of a tick box form and it was unclear how staff used this information. Only one of the care plans showed any evidence of involvement by residents or their representatives. The records showed that a chiropodist visits regularly. Eye tests are done annually. There are records of GP visits but there was very little information about what was actually discussed and agreed during these visits. The daily records contain very little information about how residents actually spend their time. The policies and procedures relating to the management of medication could not be found during the visit, guidelines available for nurses were those issued by the UKCC which was replaced by the NMC (Nursing and Midwifery Council) in April 2002. The pharmacist now supplies printed medication administration records, pre-printed labels are no longer used. No risk assessment had been done for one resident who was self medicating, it was not clear how the resident had obtained the medication, the resident said one of the staff had got it for him and the nurse said it had been provided by a relative. The nurse said the manager was in the process of making arrangements for the disposal of medicines to comply with recent changes to the law. The records relating to the management of controlled drugs were satisfactory. Staff were able to explain how they protect the privacy and dignity of residents, but one care worker was seen walking into a resident’s bedroom without knocking. Absorbent pads were placed in all easy chairs in the lounge. Staff said that this was a measure to prevent, those residents who are incontinent, soiling chairs. These pads were in all of the chairs, regardless of whether the resident was incontinent or not, and were fully visible, raising issues of dignity for those residents sitting in the chairs. Spring Bank DS0000019888.V255845.R01.S.doc Version 5.0 Page 12 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13 & 14. Activities are not available for all residents, and whilst staff try to give residents the opportunity to choose, this is not always standard practice within the home. Visitors are made welcome. EVIDENCE: There was a weekly programme of activities on the wall outside of the office, but this is an area of the home rarely accessed by residents and relatives, and staff said that the programme is not always followed. Entertainers visit the home on a regular basis, but staff said the more dependent residents are usually excluded, because of the lack of space, and by their lack of ability to participate. One inspector spent the morning in the small lounge; all the residents in this lounge had some degree of confusion and were clearly unable to occupy their time meaningfully without help and guidance from staff. During the morning the only interaction that took place between staff and residents was when staff came to attend to physical needs. There were social care plans in the records seen but there was no evidence that these related to the day to day care people received and the daily records had little or no information about how residents actually spent their days. One resident said that he would like outings and trips to be organised by the home, but that there was no way of discussing this because there are no residents meetings. One visitor described the staff as “wonderful” and said residents always look clean and cared for. Another visitor said they were satisfied with the care and Spring Bank DS0000019888.V255845.R01.S.doc Version 5.0 Page 13 were kept informed about their relative’s condition. Visitors said they could visit at any time, one said they used to be offered a drink but this has not happened recently. One visitor said it was a bit upsetting visiting in the small lounge where some of the other residents appeared to be distressed, they had not been offered the opportunity to visit in private. Staff were seen to help with the transfer of one resident to their room so that they could have privacy during their visit. Staff explained that residents are able to choose what to wear and have some degree of choice at meal times. It was noted that on some occasions residents are given supper as early as 5.30pm and are then assisted to bed. During the feedback session we found that the manager was aware of this, but had failed to take any action to address it. She said that she was planning to discuss the issue at a staff meeting. Spring Bank DS0000019888.V255845.R01.S.doc Version 5.0 Page 14 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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 & 18 The systems in place do not guarantee that complaints will be dealt with effectively or that residents are protected from abuse. EVIDENCE: There is a notice on how to complain on the wall outside the office, however this is a part of the home that is rarely accessed by residents and relatives. The procedure on the wall conflicts with an out of date policy seen in the policy and procedure manual. There is still no written guidance for staff to follow when receiving a complaint and a qualified nurse, who is often in charge of a shift, was unsure where to record a complaint. Eventually, the manager and the nurse agreed that complaints are recorded in a compliments and suggestions book, which is in the front entrance of the home at the side of the signing in book. It was suggested that there might be a reluctance to record concerns in a book that could be accessed by others, and that the system breaches the Data Protection Act. Some staff were aware of the different types of abuse and of the importance of reporting any suspicions of abuse, however this was mainly as a result of completing their NVQ (National Vocational Qualification) rather than any training that has been offered. The policy on abuse does not refer staff to the Multi Agency Adult Protection Procedures, and a qualified member of staff was unsure of what action to follow in the event of an allegation. The manager seemed unaware that routines such as giving supper at 5.30pm could be considered as being institutional abuse. The home does not have a whistle blowing policy. Spring Bank DS0000019888.V255845.R01.S.doc Version 5.0 Page 15 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 22, 24, 25 & 26. The home’s approach to fire precautions and staff training put residents at risk in the event of a fire. The facilities do not provide residents with opportunities to maximise their independence. Lack of proper checks and poor infection control measures fail to safeguard residents from risk. EVIDENCE: There has been no attempt to address most of the issues raised at the last and previous inspections. The manager said that a Legionella check would be carried out on the 17th October and that pre-set valves have been fitted, but she was unable to produce any written evidence in the form of invoices to support this. The home has still not confirmed, in writing, that work identified in the fire officer’s report has been completed. The manager said that all the outstanding issues had now been addressed, however signs on some fire doors were not in place, and combustible items were seen at the bottom of one staircase. One bathroom is still used for storing combustible items but there is Spring Bank DS0000019888.V255845.R01.S.doc Version 5.0 Page 16 no smoke detector fitted. The laundry room door on the first floor had a sign saying ‘Fire door - keep locked’. This door was not locked and would not close properly. Staff were unable to confirm how often the fire bells are tested, and the manager was unable to produce any records. The manager said that she is now qualified to train staff in the home on fire safety, but she was unable to produce records to confirm that all staff have fire safety training at intervals of no more than 6 months. There is no system for identifying when fire training is next due. The manager said that she has completed a fire risk assessment, but was unable to produce this. Signs, which might enable those residents with poor vision and/or memory loss to retain some degree of independence, are still not provided on bathroom and toilet doors. The doors to resident’s rooms are not fitted with locks, and some residents still do not have a lockable storage facility in their room. One resident said that he would welcome some facility to store his valuables, and would appreciate being able to lock his door. Not all rooms have both overhead and bedside lighting. Some rooms have a light switch near to the bed, which controls the central light, but in most cases this would be difficult to reach from either a lying or sitting position if in bed. Although there is a call system in each room, the majority of rooms did not have call leads. The manager said not all residents were able to use the call system, but staff said that some service users have to shout or bang on bedside tables to attract the attention of staff. Surplus screen tracking is still fitted in what were triple rooms. There were still some outlets in the home where the water temperature was in excess of 48oc. The manager said that she was unaware that water temperatures should be recorded, despite this be identified at the last inspection. Liquid soap and paper towels are not provided in all areas where clinical waste and foul laundry is handled. Staff were seen leaving a bedroom and having to use a bathroom to wash their hands with liquid soap. Protective clothing such as gloves and aprons are not always available for staff and not all of the toilets have a clinical waste bin. Staff said that sometimes, soiled pads have to be carried along a corridor to an area where they can be safely disposed of. The home’s policy on hand washing is out of date, as it allows the use of bar soap and hand towels. The home still does not have a washer disinfector. Staff have not received training in infection control. There was no liquid soap in the laundry room, and a number of items were on the sink unit, such as used latex gloves placed alongside a pair of Marigold gloves, a number of disposal paper towels underneath a dustpan and brush. Clean items such as pillows, cushions and seat pads were stored in the laundry. The floor is not impermeable and the paintwork on the walls was peeling. There was a message written with felt tipped pen on the wall, asking staff not to peel any more paint off the wall. The manager said that her husband had written this message. There was exposed pipe work in the laundry, with dust and grime hanging from the Spring Bank DS0000019888.V255845.R01.S.doc Version 5.0 Page 17 lagging. The laundry room door was open, and the room next door, which was also open, is used as both a food and cleaning store. All of the above pose a serious risk to the health and safety of the residents. Spring Bank DS0000019888.V255845.R01.S.doc Version 5.0 Page 18 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 28 & 30 Staff are caring but the lack of training does not guarantee that residents are in safe hands at all times. EVIDENCE: The manager said that 25 of the care team have completed an NVQ (National Vocational Qualification) at Level 2, but she was unable to produce evidence to support this figure. She said that one person is due to register for the award in the next month and a further three people would like to start in January 2006. There is no system of identifying training needs within the home, and no training and development plan. Staff do not have three paid training days each year. Spring Bank DS0000019888.V255845.R01.S.doc Version 5.0 Page 19 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 32, 33, 36, 37 & 38. Management and leadership in the home are poor. The manager fails to make sure that regulations are met. There are no systems in place for relatives or residents to comment on the care given by the home. Staff are not properly supervised. The health and safety of residents is compromised by some practices and lack of proper risk assessments. EVIDENCE: The manager is clearly failing in her responsibilities within the home. She is a registered nurse but does not have a management qualification. She said that she is enrolled on the Registered Manager’s Award with a local college and will start the course in January 2006. She has still not developed a quality assurance system. There are no systems in place such as meetings where residents and relatives can voice their opinions. Staff said that senior staff Spring Bank DS0000019888.V255845.R01.S.doc Version 5.0 Page 20 meetings are held about twice a year, but these are informal and no minutes are kept for future reference. Care staff said this also applied to care staff meetings. There have been no meetings in the home since the last inspection and staff have not had the opportunity to read or address any issues in the last inspection report. The last inspection report was not available in the home. There are no up to date policies and procedures for staff to follow. The manager said that she has still not yet established a formal system of supervision for staff and she had not addressed an issue that could be considered as institutional abuse within the home. The manager said that she was unaware of the Care Homes Regulations 2001, despite having a copy of the regulations during the feedback session. She has failed to notify the CSCI (Commission for Social Care Inspection) about occurrences specified within Regulation 37, such as death, illness and other events, despite having an information leaflet about notifications from the CSCI. She was unaware of the legal requirement to display a current registration certificate, and was displaying a certificate that referred to the Registered Homes Act 1984, which is now out of date. She was unable to produce records such as a fire risk assessment and records of fire training for staff within the home, saying that these were locked in her office and she had left her key at home. The manager was unable to confirm that staff have all received training such as moving and handling, food hygiene, infection control and first aid. There is no system of identifying when training updates are required. Staff were seen transferring residents in wheelchairs without footplates, and being left in wheelchairs without the brakes being applied. There are instructions for staff on how to move residents but there are no moving & handling assessments and from discussions with staff they do not always follow the instructions. For example there were instructions in one person’s care plan that staff should transfer her with a hoist, but they were seen using a moving belt instead. COSHH (Control of Substances Hazardous to Health) risk assessments are not completed on all products used in the home. A wooden door wedge was being used to prop open the office door. This is a fire risk and has been pointed out at previous inspections. Where an accident is not witnessed by staff, there is no record kept of when the person was last seen and by whom. The manager does not keep a written analysis on a monthly basis of all accidents in the home, so that trends and patterns can be identified. Spring Bank DS0000019888.V255845.R01.S.doc Version 5.0 Page 21 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 1 X 1 1 X N/A HEALTH AND PERSONAL CARE Standard No Score 7 1 8 1 9 1 10 2 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 2 15 X COMPLAINTS AND PROTECTION Standard No Score 16 1 17 X 18 1 1 X X 1 X 1 X 1 STAFFING Standard No Score 27 X 28 2 29 X 30 1 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 1 1 1 X X 1 1 1 Spring Bank DS0000019888.V255845.R01.S.doc Version 5.0 Page 22 YES 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 OP1 Regulation 4 Requirement A statement of purpose and service user guide must be produced. Timescale for action 01/02/06 2 OP7 15 (1) This is outstanding from inspections on 11th June 2002, 23rd January 2003, 23rd July 2003, 14th January 2004, 5th May 2004, 7th September 2004 and 17th May 2005. The care plan must set out in 31/03/06 detail the action which needs to be taken by staff to make sure that all aspects of health, personal and social care needs of the resident are met. This is outstanding from an inspection on 7th September 2004 and 17th May 2005. Evaluation of care plans must be more robust; evidencing a thorough process, with existing care plans amended and new plans implemented as required. This is outstanding from an inspection on 7th September 2004 and 17th May 2005. 3 OP7 15 31/03/06 Spring Bank DS0000019888.V255845.R01.S.doc Version 5.0 Page 23 4 OP7 13 (4) All areas of risk to residents must be identified and so far as possible be eliminated, with appropriate risk assessments completed. 01/02/06 5 OP8 12 This is outstanding from an inspection on 17th May 2005. Pressure area care plans must be 01/02/06 in place for all residents who are at risk of developing a pressure sore. Where wound care plans are in place the following must be recorded: The date for review of the wound. Instructions on how the wound is to be dressed. Wound mapping. Grading of the wound. Advice from the tissue viability nurse must be obtained. This is outstanding from an inspection on 17th May 2005. Staff must knock on doors before entering a resident’s room. Recreational opportunities must be provided for all residents. The manager must make sure the wishes of individual residents are respected, and that routines and practices are in the best interests of the residents and not for the benefit of staff. A procedure must be produced for staff to follow in the event of a complaint being made. This is outstanding from inspections on 11th June 6 7 8 OP10 OP12 OP14 12 (4) (a) 16 (2) (n) 12 (1) (a) 01/12/05 01/02/06 01/12/05 9 OP16 22 01/12/05 Spring Bank DS0000019888.V255845.R01.S.doc Version 5.0 Page 24 2002, 23rd January 2003, 23rd July 2003, 14th January 2004, 5th May 2004, 7th September 2004 and 17th May 2005. All complaints must be taken seriously. A record must be kept of the complaint, any investigation undertaken, the outcome and any subsequent action taken. This is outstanding from an inspection on 17th May 2005. The homes policies and procedures relating to adult abuse must be updated in line with the No Secrets guidance. This is outstanding from inspections on 11th June 2002, 23rd January 2003, 23rd July 2003, 14th January 2004, 5th May 2004, 7th September 2004 and 17th May 2005. All staff must receive training on adult abuse. Senior staff must receive training on the use of the multi-agency adult protection procedures. This is outstanding from an inspection on 17th May 2005. 12 OP19 23 (4) A suitably qualified person must 01/02/06 carry out fire training at intervals of no more than 6 months. Records of this training must be kept. The recommendations made within the fire officers report must be completed. A fire risk assessment must be Spring Bank DS0000019888.V255845.R01.S.doc Version 5.0 Page 25 10 OP18 13 (6) 01/12/05 11 OP18 13 (6) 01/02/06 completed. This is outstanding from an inspection on 17th May 2005. 13 OP19 23 (4) Combustible items must be removed from the bottom of stairwells. A smoke detector must be fitted in bathrooms on the second floor. Signs must be fitted on both sides of fire doors. The laundry room on the second floor must be kept locked when not in use and must be capable of closing properly. Call leads must be provided in all rooms. Door locks must be provided to residents private accommodation, suited to their capabilities. Keys must be provided unless a risk assessment suggests otherwise. This is outstanding from inspections on 11th June 2002, 23rd January 2003, 23rd July 2003, 14th January 2004, 5th May 2004, 7th September 2004 and 17th May 2005. Lockable storage space must be provided for all residents. This is outstanding from inspections on 11th June 2002, 23rd January 2003, 23rd July 2003, 14th January 2004, 5th May 2004, 7th September 2004 and 17th May 2005. A suitable qualified person must carry out a check of the hot DS0000019888.V255845.R01.S.doc 01/12/05 14 15 OP22 24 16 (2) (c) 12 (4) 01/02/06 01/02/06 16 OP24 16 01/02/06 17 OP25 12, 13 (4) 01/02/06 Page 26 Spring Bank Version 5.0 water system, to prevent the risk of Legionella. This is outstanding from inspections on 23rd January 2003, 23rd July 2003, 14th January 2004, 5th May 2004 and 7th September 2004. 18 OP25 13 (4) The manager must provide evidence to the CSCI that preset valves of a type unaffected by water pressure and which have fail safe devices have been fitted locally to provide water close to 43 degrees centigrade. Weekly checks of all water temperatures must be undertaken, records must be kept and until further notice copies must be sent to the CSCI. This is outstanding from an inspection on 17th May 2005. Food and cleaning materials must be stored in separate areas. Food must not be stored adjacent to the laundry. The laundry floor must be made impermeable. The laundry wall must be painted. The laundry must be clean and tidy at all times. Dispensed soap and paper towels 01/12/05 must be provided in all areas of the home where care is given and clinical waste handled. This is outstanding from inspections on 23rd January 2003, 23rd July 2003, 14th January 2004, 5th May 2004, Spring Bank DS0000019888.V255845.R01.S.doc Version 5.0 Page 27 01/12/05 19 OP26 13 (3) 01/02/06 20 OP26 13 (3) 01/02/06 21 OP26 13 (3) 7th September 2004 and 17th May 2005. Protective clothing must be made available to staff at all times. Suitable disposal facilities must be available in all areas where clinical waste is handled. A washer disinfector must be provided in a separate sluice room, which also incorporates hand washing facilities. This is outstanding from inspections on 11th June 2002, 23rd January 2003, 23rd July 2003, 14th January 2004, 5th May 2004, 7th September 2004 and 17th May 2005. All staff must receive training in infection control. This is outstanding from 17th May 2005. The home must achieve a ratio of 50 of care staff with NVQ level 2 or 3. This is carried forward from an inspection on 7th September 2004 and 17th May 2005. All staff must receive 3 days training per year. This is outstanding from inspections on 11th June 2002, 23rd January 2003, 23rd July 2003, 14th January 2004, 5th May 2004, 7th September 2004 and 17th May 2005. Care staff must undertake training relevant to the needs of the resident group. DS0000019888.V255845.R01.S.doc 22 OP26 23 31/03/06 23 OP26 18 01/02/06 24 OP28 18 01/02/06 25 OP30 18 01/02/06 26 OP30 18 01/02/06 Spring Bank Version 5.0 Page 28 27 OP31 9 (2) (b) (i) The registered manager must obtain a relevant management qualification. This is carried forward from an inspection on 7th September 2004 and 17th May 2005. A system to monitor the quality of the service provided, which actively seeks input and feedback from residents, relatives and friends must be put into place. This is outstanding from inspections on 11th June 2002, 23rd January 2003, 23rd July 2003, 14th January 2004, 5th May 2004, 7th September 2004 and 17th May 2005. All care staff must receive formal supervision at least six times a year. This is outstanding from inspections on 11th June 2002, 23rd January 2003, 23rd July 2003, 14th January 2004, 5th May 2004, 7th September 2004 and 17th May 2005. The practice of wedging doors open, by whatever means, must cease. This is outstanding from 11th January 2005 and 17th May 2005. The manager must make sure that a current registration certificate is displayed within the home at all times. The manager must notify the CSCI of all events in the home in line with Regulation 37 of the Care Homes Regulations. DS0000019888.V255845.R01.S.doc 01/02/06 28 OP33 24 01/02/06 29 OP36 18 01/02/06 30 OP38 13 (4) (A) 01/12/05 31 *RQN CSA 2000 01/12/05 32 *RQN 37 01/12/05 Spring Bank Version 5.0 Page 29 33 OP37 17(2)Sch 4 A record must be maintained of all furniture brought by residents into the home. This is outstanding from an inspection on 7th September 2004. 01/02/06 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 OP2 Good Practice Recommendations Each resident should be provided with a statement of terms and conditions. This is outstanding from inspections on 11th June 2002, 23rd January 2003, 23rd July 2003, 14th January 2004, 5th May 2004, 7th September 2004 and 17th May 2005. The homes pre-admission assessment form needs to be amended further to include: The outcome of the assessment. Justification of how the home is able to meet the needs identified. A record of the offer of a trial visit. An assessment and outcome of the trial visit. The assessment document should record all the prospective residents assessed needs. This is outstanding from an inspection on 7th September 2004 and 17th May 2005. New admissions should be planned, with care staff having access to written information recorded within assessments and care plans. Care staff should be familiar with the care plans of all Spring Bank DS0000019888.V255845.R01.S.doc Version 5.0 Page 30 2 OP3 3 OP3 residents. This is outstanding from an inspection on 17th May 2005. Absorbent incontinent pads should not be used on easy chairs in the lounge. Up to date information about planned activities should be made available to residents and their families. This is outstanding from inspections on 23rd July 2003, 14th January 2004, 5th May 2004, 7th September 2004 and 17th May 2005. Trips and outings outside of the home should be provided for residents. Details of how to access advocacy services should be displayed in the home for residents and their families. This is outstanding from inspections on This is outstanding from inspections on 23rd July 2003, 14th January 2004, 5th May 2004, 7th September 2004 and 17th May 2005. A routine programme of maintenance and renewal of fabric and decoration should be implemented with records kept. This is outstanding from inspections on 5th May 2004, 7th September 2004 and 17th May 2005. Signs should be provided on all bathroom and toilet doors. This is outstanding from an inspection on 7th September 2004 and 17th May 2005. Bedside lighting should be provided in all rooms. The extra screen tracking in what was previously a threebedded room should be removed. This is outstanding from an inspection on 7th September 2004 and the 17th May 2005. The manager should develop an annual training and development for all staff. A matrix should be developed to identify when mandatory training needs to be updated. Senior and care staff meetings should be held at regular intervals and minutes should be recorded. Inspection reports should be made available in the home to residents, relatives, staff and other interested parties. DS0000019888.V255845.R01.S.doc Version 5.0 Page 31 4 5 OP10 OP12 6 OP14 7 OP19 8 OP22 9 OP24 10 OP30 11 12 OP32 OP33 Spring Bank 13 OP38 This is outstanding from the inspection on 17th May 2005. Where an accident is not witnessed, a record should be made of when the person was last seen and by whom. Accidents and incidents should be reviewed and analysed on a monthly basis and a record of the analysis should be kept. This is outstanding from the inspection on 17th May 2005. COSHH (Control of Substances Hazardous to Health) risk assessments should be in place for all cleaning products in use within the home. This is outstanding from the inspection on 17th May 2005. 14 OP38 Spring Bank DS0000019888.V255845.R01.S.doc Version 5.0 Page 32 Commission for Social Care Inspection Aire House Town Street Rodley Leeds LS13 1HP National Enquiry Line: 0845 015 0120 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 Bank DS0000019888.V255845.R01.S.doc Version 5.0 Page 33 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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