Inspection on 17/05/05 for Spring Bank

This inspection was carried out on 17th May 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 11/10/05

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 Springbank Howden Road Silsden Keighley BD20 Lead Inspector Ann Stoner Unannounced 10.00am: 17th May 2005 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 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. Springbank J52 J03 S19888 Springbank V225284 170505 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Spring Bank Nursing Home Address Howden Road Silsden Keighley BD20 Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 01535 656287 Mrs Diane Hudson Mrs Diane Hudson Care Home with Nursing 33 Category(ies) of Physical Disability (33) Dementia (33) registration, with number of places Springbank J52 J03 S19888 Springbank V225284 170505 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: None Date of last inspection 11th January 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 is registered to care for thirty three 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. Springbank J52 J03 S19888 Springbank V225284 170505 Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. Over an inspection year from April until March, regulated care homes have a minimum of two inspections a year; these may be announced or unannounced visits. An unannounced inspection took place on the 7th September 2004, and a monitoring visit to assess progress towards meeting outstanding requirements and recommendations took place on the 11th January 2005. There have been no further visits until this unannounced inspection. The people who live in the home use the term resident; therefore this is the term that will be used throughout this report. During the inspection, records were looked at, some areas of the home were seen, such as bedrooms, lounge, dining room, toilets and bathrooms and care staff were seen carrying out their work. The registered manager was not in the home during this inspection, however discussions were held during the day with two qualified members of staff, six members of care staff, four visitors and seventeen residents. This inspection started at 10.00am and ended at 6.30pm. What the service does well: What has improved since the last inspection? What they could do better: The home must start to address issues raised in this and previous inspection reports. The findings of this, and previous inspections, should be shared with staff. Documentation and record keeping in the home is poor. Care records must improve, written information about the home must be available for anyone considering living there, policies and procedures for staff to follow must be brought up to date, residents must have a copy of the terms and conditions of their stay, information on how to make a complaint must be given to residents and relatives, and the way that accidents records are kept must be changed. Springbank J52 J03 S19888 Springbank V225284 170505 Stage 4.doc Version 1.30 Page 6 The care records for people with pressure sores must contain more detail and the specialist nurse must be contacted for advice. Staff must have training on infection control, fire precautions, how to respond in the event of a fire, and on how to make sure residents are safe from abuse. A number of health and safety issues were a cause of concern. These include, cleaning products not being locked away, unidentified cleaning products being used, doors being wedged open, poor hygiene, very hot water and no proper checks to prevent Legionella. A number of requirements and recommendations have been made to address these issues. 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. Springbank J52 J03 S19888 Springbank V225284 170505 Stage 4.doc Version 1.30 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 Standards Statutory Requirements Identified During the Inspection Springbank J52 J03 S19888 Springbank V225284 170505 Stage 4.doc Version 1.30 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 standard(s) 1,2, 3 & 4. Residents and their relatives are unable to make an informed choice about admission due to the lack of written information about the home. Residents and relatives are unaware of the rights and responsibilities of both the home and the resident as there is no written statement of purpose or terms and conditions. The home does not demonstrate how identified needs are met, which along with an over reliance on verbal information provides the opportunity for needs to be overlooked. EVIDENCE: Two visitors confirmed that they had visited the home on behalf of their respective relatives prior to admission, but had received no written information in the form of a statement of purpose or service user guide. Qualified staff were unable to produce these documents and were unaware of their content. One resident said her son visited the home, and her decision regarding admission was based on what he told her. Three care plans were sampled. Evidence of the Local Authority Residential Care Contract, and Funded Nursing Care Contract were seen within care plans, but there was no evidence of Springbank J52 J03 S19888 Springbank V225284 170505 Stage 4.doc Version 1.30 Page 9 residents being given a copy of the home’s terms and conditions. Qualified staff were unaware of this document. The home carries out an assessment of need before any decision about admission is made, but amendments to the format and the recommendation made at the last visit about specifying specific needs rather than stating ‘needs assistance’, which was seen within one assessment have still to be carried out. From discussions with care staff it was evident that they do not read assessment information or consult the care plans for new residents, instead they rely on verbal information provided by qualified staff at daily handovers. Some of these issues have been identified at previous inspections. One recommendation and two requirements have been made. Springbank J52 J03 S19888 Springbank V225284 170505 Stage 4.doc Version 1.30 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 standard(s) 7, 8, 9, 10 & 11 Care plans do not provide staff with detailed information about how care is to be delivered; this along with the reliance on verbal information creates the potential for needs to be overlooked. Risks are not properly identified, which places some residents at risk. Some health care needs are met, but poor recording on wound care plans and the lack of specialist input places residents at risk of pressure sores. The unsafe method of using labels on Medication Administration Records creates the opportunity for error. The privacy and dignity of residents is upheld and residents near to the end of their life are cared for with sensitivity and respect. EVIDENCE: Within the three care plans sampled the information provided for staff did not identify the precise level of care required and how it should be delivered. One plan stated that a high calorie diet should be provided, but there was no information about the specific calorific content of meals, terms such as drink plenty of fluids and regular checks were used rather than the specific amount of fluids and the timing of checks. A relative of a resident ill in bed described Springbank J52 J03 S19888 Springbank V225284 170505 Stage 4.doc Version 1.30 Page 11 how her mother had a pressure relieving mattress and was receiving mouth care, none of which was recorded in her care plan. Another resident was sitting on a pressure relieving cushion but there was no pressure area care plan in place for her, she used a continence product at night but there was no continence plan in place, and there was no personal hygiene plan in place despite the fact that she needed assistance. One resident who has developed a pressure sore whilst in the home, had a wound care plan in place but there was no date for review, no instructions on how often the wound should be dressed, no wound mapping, grading, or evidence of input from the tissue viability nurse. Care plans are reviewed but there is no evidence provided about what factors have been considered as part of the review. The care plan of a person ill in bed had not been reviewed or updated. From discussions with staff it was evident that they do not consult the care plans, one person said that she never looked at a care plan, other staff said that they relied on memory from the information given at handovers. This approach can result in some needs being missed. The home’s approach to risk assessment is unsatisfactory. Areas of risk are not properly identified, and the appropriate action to minimise the identified risk is not recorded or reviewed at regular intervals. There was evidence within care plans of visits by a chiropodist, speech and language therapist and GPs. During the inspection a physiotherapist visited one resident, and the relative of an ill resident was waiting for the GP who had requested to speak to her. Another relative described how on her husband’s admission to the home, her permission had been sought to register him with a local GP practice. One visitor said that, in the absence of a relative or friend, staff are available to escort residents to hospital appointments. Nurses no longer transcribe on the Medication Administration Record (MAR), instead the prescribing pharmacy print a label so that nurses may attach it to the MAR. The Royal Pharmaceutical Society of Great Britain has issued a policy statement to pharmacists not to continue this practice because there have been occasions when the label has been placed over another item in the MAR, thus obliterating the record of that medicine. Staff were seen to knock on bedroom doors before entering, during the inspection one person saw her GP in private, and staff were able to describe how they respect the privacy and dignity of residents, and knew why this was important. A relative of a resident near to the end of life said that her mother, “Couldn’t be more well looked after, I visit every day from 10am – 1pm, then staff ring me during the afternoon and evening to keep me updated.” Although this person was able to describe the care her mother received, and had been involved in planning and dealing with her mother’s deterioration and impending Springbank J52 J03 S19888 Springbank V225284 170505 Stage 4.doc Version 1.30 Page 12 death, there was no record within the care plan of any arrangements following death, or of any wishes of the resident being taken into consideration. The home’s policies and procedures relating to the care of residents who are dying are still in need of amendment. Some of these issues have been raised at previous inspections. A number of requirements and recommendations have been made. Springbank J52 J03 S19888 Springbank V225284 170505 Stage 4.doc Version 1.30 Page 13 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 standard(s) 12, 13, & 15. Activities are provided for residents, but the lack of a planned programme based around individual need, can leave some residents with little to do. Contact with friends and family is encouraged. Residents receive a well-balanced diet, but their likes and dislikes are not always acknowledged and respected. EVIDENCE: Information about activities was inconsistent. One visitor said an entertainer visits the home twice a week but her relative has never enjoyed singing, therefore misses out, whereas another visitor said that there were plenty of activities provided. One member of staff said that some of her time is devoted to activities, such as dominoes, art and music. She said that rather than consulting the resident’s social and leisure care plan she obtains information about a resident’s past interests from their relatives. She explained how one resident likes organ music and another likes any kind of music, however one resident said, “I get bored, there is not much to do other than read the paper and listen to music.” A planned programme of activities is not made available to residents and relatives. All visitors spoke of how they are welcomed into the home, and one person said that she is always offered refreshments. Springbank J52 J03 S19888 Springbank V225284 170505 Stage 4.doc Version 1.30 Page 14 Residents were seen to have a nutritious lunch, and staff gave assistance when needed. One visitor said that when she came to look around the home she paid particular attention to the food that was served and was impressed by the fact that the home provided home baking and used fresh vegetables. One resident said, “You can have what you fancy, but sometimes they don’t listen, I have told them I don’t like greens, but they still put them on my plate.” One person’s care plan identified that she preferred to be up at about 7 – 7.30am. On the day of inspection she was seen eating her breakfast at 10.00am. Although this level of flexibility is good practice, it was not right for this resident who said, “It is too late to eat breakfast.” Plate covers are still not used when delivering meals to areas other than the dining room. Some of these issues have been identified at previous inspections. A number of recommendations have been made. Springbank J52 J03 S19888 Springbank V225284 170505 Stage 4.doc Version 1.30 Page 15 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 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: The home’s complaints policy is not easily accessible to residents and their relatives. Both visitors and residents confirmed that written information on how to make a complaint has not been made available to them. A qualified member of staff was unsure of where the complaints procedure was located and of how and where to record a complaint. There is no procedure available for staff to follow in the event of a complaint being made. The policy on adult abuse does not refer to the multi-agency adult protection procedures, and qualified staff have had no training on the use of these procedures. One qualified staff member was unsure of how to deal with an allegation of adult abuse, and a member of the care team was unable to explain how she would react if she suspected the registered manager of abuse. The home does not have a whistle blowing policy. Some of these issues have been identified at previous inspections. A number of requirements have been made. Springbank J52 J03 S19888 Springbank V225284 170505 Stage 4.doc Version 1.30 Page 16 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 standard(s) 19, 22, 24, 25 & 26. The homes approach to fire precautions and staff training puts residents at risk in the event of a fire. The facilities provided 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: The home has not responded to a recent request for an action plan following a recent report from the fire officer. Staff were unable to confirm how often the fire bells are tested in the home, 4 staff said that they were tested twice a year, a qualified staff member said that they are tested quite often, but was unable to produce any records. Training for staff on how to respond in the event of a fire consists of watching a video, then answering a questionnaire, which is marked by a colleague. This is unsatisfactory. Two members of staff Springbank J52 J03 S19888 Springbank V225284 170505 Stage 4.doc Version 1.30 Page 17 said that they have not had any fire training for about 12 – 18 months. Up to date records could not be produced. A fire risk assessment was not available. 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. Not all rooms have both overhead and bedside lighting, and surplus screen tracking is still fitted in what were triple rooms. The hot water from outlets in three bathrooms was in excess of 48oc, posing a serious risk of scalding to residents. The nurse in charge was unable to confirm that weekly checks of water temperatures are carried out, and that the required check of the hot water system to prevent Legionella had been undertaken. Liquid soap and paper towels are not available in all areas where clinical waste is handled. A member of staff said, “You can’t always wash your hands in the bathroom, there isn’t always liquid soap.” One member of the domestic staff, although aware of proper infection control procedures, such as the wearing of protective clothing, has received no training in over two years of employment. Similarly, a care worker when asked about her knowledge of infection control, said, “You just pick it up”. A member of the care team, still wearing latex gloves after assisting a resident to the toilet, was seen to accompany this person back to the dining room; she then touched a number of dining chairs, thus creating the potential for cross infection. 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. Some of these issues have been identified at previous inspections. A number of requirements and recommendations have been made. Springbank J52 J03 S19888 Springbank V225284 170505 Stage 4.doc Version 1.30 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) These standards were not assessed on this visit. EVIDENCE: Springbank J52 J03 S19888 Springbank V225284 170505 Stage 4.doc Version 1.30 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 33 & 38. Quality assurance processes do not guarantee that the services provided improve as a result of feedback. The management of the home fails to ensure that regulations are met. Senior staff do not have sufficient information to support the manager to meet the regulations. The health, safety and welfare of residents and staff are not always protected. EVIDENCE: The home has not developed a system, such as satisfaction questionnaires, to obtain feedback from residents, relatives or other professionals. Policies and procedures are not regularly reviewed. The adult abuse policy does not refer to the ‘No Secrets’ guidance, the policy on ‘Prevention of Pressure Sores’ is dated 1992 and relates to a ward based setting, and the policy on ‘Hand washing’ refers to bars of soap and hand towels. Inspection reports are not Springbank J52 J03 S19888 Springbank V225284 170505 Stage 4.doc Version 1.30 Page 20 made available to residents, relatives or qualified nurses and care staff. The home has persistently demonstrated a failure to respond to the requirements and recommendations made in previous inspection reports. Three bedroom doors and the main office door were held open with wooden door wedges, which as identified at the last monitoring visit, poses a serious risk to the health and safety of residents in the event of a fire. Resident’s toiletries, which should be returned to their room after use, were seen in bathrooms. An unlocked cupboard in one bathroom provided easy access to bathroom cleaners, along with other cleaning substances for baths and toilets, which had been decanted from the original container into an unmarked container, without any instructions for use. When asked about these products, one member of staff said, “I have no idea what it is, I just wear rubber gloves.” The current system of storing accident records within the home does not comply with the requirements of the Data Protection Act. Accidents are not reviewed and analysed on a monthly basis. COSHH (Control of Substances Hazardous to Health) risk assessments are not in place for all products in use in the home and general risk assessments do not cover all areas of risk within the home, which includes a fire risk assessment. Springbank J52 J03 S19888 Springbank V225284 170505 Stage 4.doc Version 1.30 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score 1 1 2 x x x HEALTH AND PERSONAL CARE Standard No Score 7 1 8 2 9 2 10 3 11 2 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 x 15 2 COMPLAINTS AND PROTECTION 1 x x 2 x 1 1 1 STAFFING Standard No Score 27 x 28 x 29 x 30 x MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 1 x 1 x x 1 x x x x 1 Springbank J52 J03 S19888 Springbank V225284 170505 Stage 4.doc Version 1.30 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 1 Regulation 4 Requirement A statement of purpose and service user guide must be produced. Timescale for action 1st August 2005. 2. 7 15 (1) This is outstanding from inspections on 11th June 2002, 23rd January 2003, 23rd July 2003, 14th January 2004, 5th May 2004 and 7th September 2004. The care plan must set out in 1st August detail the action which needs to 2005. be taken by staff to ensure 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. 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. All areas of risk to residents must be identified and so far as possible be eliminated, with 3. 7 15 1st September 2005. 4. 7 13 (4) 1st September 2005. Page 23 Springbank J52 J03 S19888 Springbank V225284 170505 Stage 4.doc Version 1.30 5. 8 12 appropriate risk assessments completed. Pressure area care plans must be 1st July in place for all residents who are 2005. 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. The practice of using printed labels on Medication Administration Records must cease. The homes policies and procedures relating to the care of residents who are dying must be updated. This is outstanding from inspections on 23rd July 2003, 14th January 2004, 5th May 2004 and 7th September 2004. 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 2002, 23rd January 2003, 23rd July 2003, 14th January 2004, 5th May 2004 and 7th September 2004. 6. 9 13 (2) 1st July 2005. 1st September 2005. 7. 11 12 8. 16 22 1st July 2005. Springbank J52 J03 S19888 Springbank V225284 170505 Stage 4.doc Version 1.30 Page 24 9. 18 13 (6) All complaints must be taken seriously. A record must be kept of the complaint, any investigation undertaken, the outcome and any subsequent action taken. 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 and 7th September 2004. All staff must receive training on adult abuse. 1st July 2005. 1st September 2005. 10. 19 23 (4) Senior staff must receive training on the use of the multi-agency adult protection procedures. Fire training must be carried out 1st by a suitably qualified person at November intervals of no more than 6 2005. months. The recommendations made within the fire officers report must be completed. A fire risk assessment must be completed. 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 and 7th September 2004. 11. 24 12 (4) 1st November 2005. Springbank J52 J03 S19888 Springbank V225284 170505 Stage 4.doc Version 1.30 Page 25 12. 24 16 13. 25 12, 13 (4) 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 and 7th September 2004. A suitable qualified person, must carry out a check of the hot 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. Pre-set valves of a type unaffected by water pressure and which have fail safe devices must be fitted locally to provide water close to 43 degrees centrigrade. Weekly checks of all water temperatures must be undertaken, records must be kept and until further notice copies must be sent to the Commission for Social Care Inspection. Dispensed soap and paper towels 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 and 7th September 2004. A washer disinfector must be provided in a separate sluice room, which also incorporates hand washing facilities. 1st November 2005. 1st July 2005. 14. 25 13 (4) 1st October 2005. Immediate as advised. 15. 26 13 (3), 23,18 1st July 2005 1st November 2005. Springbank J52 J03 S19888 Springbank V225284 170505 Stage 4.doc Version 1.30 Page 26 This is outstanding from inspections on 11th June 2002, 23rd January 2003, 23rd July 2003, 14th January 2004, 5th May 2004 and 7th September 2004. All staff must receive training in infection control. 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. 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 and 7th September 2004. The registered manager must obtain a relevant management qualification by Dec 2005. This is carried forward from an inspection on 7th September 2004. . 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 and 7th September 2004. All care staff must receive formal supervision at least six times a year. J52 J03 S19888 Springbank V225284 170505 Stage 4.doc 16. 28 18 1st August 2005. 31st December 2005. 17. 30 18 31st December 2005. 18. 31 9 (2) (b) (i) 31st December 2005. 19. 33 24 31st December 2005. 20. 36 18 1st October 2005. Page 27 Springbank Version 1.30 21. 38 13 (4) (a) This is outstanding from inspections on 11th June 2002, 23rd January 2003, 23rd July 2003, 14th January 2004, 5th May 2004 and 7th September 2004. The practice of wedging doors open, by whatever means, must cease. This is outstanding from 11th January 2005. When not in use all cleaning materials must be stored securely. Cleaning substances must not be decanted. A fire risk assessment must be completed. A record must be maintained of all furniture brought by residents into the home. This is outstanding from an inspection on 7th September 2004. Immediate as advised. 22. 23. 24. 25. 38 38 38 38 13 13 13 (4) 17 (2) Schedule 4 Immediate as advised. Immediate as advised. 1st August 2005. 1st October 2005. 26. 27. 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 3 Good Practice Recommendations 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. Springbank J52 J03 S19888 Springbank V225284 170505 Stage 4.doc Version 1.30 Page 28 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. 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 residents. 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 and 7th September 2004. 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 and 7th September 2004. Plate covers should be used when serving meals to areas other than the dining room. This is outstanding from an inspection on 7th September 2004. The individual choice of residents regarding the time of their meal and their likes and dislikes should be acknowledged and respected. A routine programme of maintenance and renewal of fabric and decoration should be implemented with records kept. This is carried forward from inspections on 5th May 2004 and 7th September 2004. Signs should be provided on all bathroom and toilet doors. This is outstanding from an inspection on 7th September 2004. 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. Springbank J52 J03 S19888 Springbank V225284 170505 Stage 4.doc Version 1.30 Page 29 2. 3 7 3. 12 4. 14 5. 15 6. 19 7. 8. 22 24 9. 10. 33 38 Inspection reports should be made available in the home to residents, relatives, staff and other interested parties. 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. Accident records should be stored in accordacne with the Data Protection Act. COSHH (Control of Substances Hazardous to Health) risk assessments should be in place for all cleaning products in use within the home. 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 and 7th September 2004. 11. 12. 38 2 Springbank J52 J03 S19888 Springbank V225284 170505 Stage 4.doc Version 1.30 Page 30 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 Springbank J52 J03 S19888 Springbank V225284 170505 Stage 4.doc Version 1.30 Page 31 - 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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