Inspection on 21/05/08 for Spring Bank

This inspection was carried out on 21st May 2008.

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

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 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 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 28/09/2008.

CARE HOMES FOR OLDER PEOPLE Spring Bank Howden Road Silsden Keighley West Yorkshire BD20 0JB Lead Inspector Mary Bentley Key Unannounced Inspection 21st May 2008 09:00 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Spring Bank DS0000019888.V364930.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Spring Bank DS0000019888.V364930.R01.S.doc Version 5.2 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 Angela Ridley Care Home 31 Category(ies) of Old age, not falling within any other category registration, with number (31) of places Spring Bank DS0000019888.V364930.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category of service only: Care home with nursing - Code N, to service users of the following gender: Either, whose primary care needs on admission to the home are within the following categories: Old age, not falling within any other category - Code OP The maximum number of service users who can be accommodated is: 31 27th November 2007 2. Date of last inspection Brief Description of the Service: Spring Bank is a converted extended property situated in a residential part of the town of Silsden. The town has good road and public transport links. Accommodation is provided on 2 floors. There are double and single 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. There are assisted bathrooms and communal toilets on both floors. There is level access to the home and gardens and inside the home has a passenger lift to the first floor. People have a choice of two lounges, and there is also a dining room. There are attractive gardens for people to enjoy and sit out in, weather permitting. There is a car park at the side of the building. In May 2008 the weekly fees ranged from £545.00 to £580.00. Services such as chiropody and hairdressing are available at an additional cost. Information about the service including inspection reports is available on request from the home. Spring Bank DS0000019888.V364930.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 0 stars. This means the people who use this service experience poor quality outcomes. The inspection process included looking at the information we have received about the home since the last key inspection in November 2007. During that inspection we identified concerns about the way the home employs new staff. We found that the home was not doing all the required checks before new people started work and this was putting people at risk. In December 2007 we issued a statutory requirement notice about this. We visited the home twice in February 2008 to check if the home was taking action to improve recruitment procedures. The reports from these visits are available on request. During these visits we found the home had not done everything they were required to and we are continuing to investigate this. During this visit we found that no new staff had been employed. However, not all the required checks have been completed for staff that are currently working in the home. We have received four complaints about the home since our last visit. These included concerns about the numbers of staff available, the management approach of the registered manager and the use of moving and handling equipment. The purpose of this inspection was to look at how the needs of people living in the home are being met and to look at what progress the home is making in dealing with the requirements made at the last inspection. We did this unannounced visit in one day; one inspector visited the home between the hours of 9.00am and 5.45pm. During the visit we spoke to people living in the home, visitors, staff and management. We looked at various records including care records and looked at parts of the building. Before the visit we sent surveys to the home to be given to people living in the home, their relatives, and health care professionals involved with the home. At the time of writing none had been returned. We did not send a self-assessment form on this occasion; the home provided us with one last year. What the service does well: People living in the home said they are well cared for. One person said, “It’s perfect here”. Daily routines are fairly flexible and people told us they could stay in their rooms and have their meals there if they preferred. Spring Bank DS0000019888.V364930.R01.S.doc Version 5.2 Page 6 People said the food is good and they are always given a choice of meals in the evening. There are regular activities for people who want to take part. People who are more independent go either alone or with family and/or friends. The home is welcoming to visitors. The home provides a clean and comfortable place for people to live and there are lovely views over the local countryside. The grounds are very well tended and there are pleasant places for people to sit outside. What has improved since the last inspection? What they could do better: There are 14 requirements as a result of this inspection; these include the eight requirements outstanding from previous inspections. The home has a lot of emergency admissions and this means that staff do not always have enough information about people’s needs when they arrive in the home. People must be given information about the fees and the terms and conditions of their stay at the time of admission. This is to make sure people know exactly how much they are paying and what they are paying for. The home must provide suitable sluicing facilities to reduce the risk of cross infection. We have discussed this with the home on previous visits and as yet there are no definite plans to deal with it. The home must make sure that the procedures that are in place to protect people are followed and that all allegations and suspicions of abuse are reported to the appropriate authorities. The home must make sure that all the required checks are completed before staff are allowed to work in the home to make sure that people are protected. Spring Bank DS0000019888.V364930.R01.S.doc Version 5.2 Page 7 Staff must be provided with training to make sure they can work safely and to make sure they have the knowledge and skills they need to meet the needs of people living in the home. The concerns about the management approach of the home must be addressed for the benefit of people living and working there. Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Spring Bank DS0000019888.V364930.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Spring Bank DS0000019888.V364930.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 3, 4 and 5. Standard 6 does not apply. People who use the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to the service. The admission of new people is not always done in a planned and considered way and this means that people cannot always be sure the home will be able to meet their needs. EVIDENCE: Information about the home, such as the Service User guide, is available for people in the home. Someone from the home, usually the owner, visits people before they move in to assess their needs. When admissions are planned people are encouraged to visit before making a decision about moving in. The home has a lot of emergency admissions and there is not always time for the information from the pre-admission assessment to be passed onto staff. This means that they are not always able to meet people’s needs once they have moved in. This has been discussed at previous inspections and again during this visit. Spring Bank DS0000019888.V364930.R01.S.doc Version 5.2 Page 10 None of the care records we looked at had a copy of the home’s contract, (terms and conditions). People need this information at the time of admission so that they know what they have to pay and what they are going to get for that payment. The registration certificate is not fully displayed; this has been discussed at previous visits and it has not been dealt with. The certificate must be fully displayed so that people know who is responsible for the service and what type of care the home is able to provide. Spring Bank DS0000019888.V364930.R01.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10. People who use the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to the service. Generally people’s needs are met and the home is continuing to improve the way people are involved in drawing up their plans of care. However, more attention is needed to the way information about people’s needs is communicated to staff particularly when people have just moved in. EVIDENCE: Everyone living in the home has a care plan. We looked at 5 people’s care records. When people move in an initial plan of care is drawn up based on the information obtained during the pre-admission assessment. However, in many cases the pre admission assessment is done on the same day as the person moves in. This means that staff do not always know about people’s needs when they arrive in the home. This can add to people’s distress at time when they are often already feeling unsettled and anxious. On at least one occasion in recent weeks a person who had just moved in did not get the Spring Bank DS0000019888.V364930.R01.S.doc Version 5.2 Page 12 proper care because information about their needs had not been passed onto the staff. People’s needs are fully assessed in the days following admission and this information is used to draw up more detailed care plans. The care plans have information about people’s personal, health and social care needs. The care plans we looked at had been reviewed every month and were up to date. There are risk assessments to identify if people are at risk for example of falling or developing pressure sores. It wasn’t clear how often the risk assessments are being reviewed; the manager said they would be done every month. We saw evidence in two of the care plans that people and/or their representatives are involved in drawing up the care plans. The home told us one person has a pressure sore. This is being treated appropriately with the involvement of the tissue viability specialist nurse. The records showed that people have access to a range of NHS services such as GPs, dieticians, and physiotherapists. Medicines are stored and managed safely. People looked clean and well cared for and the people we spoke said they are well looked after. We observed the way people are cared for and generally the staff were kind and respectful in the way they interacted with people. Some staff took care to speak to people directly and explain what they were doing for example when helping someone to transfer with a hoist. Other staff were less aware of how their actions or comments could be disrespectful and could have a negative affect on people’s self esteem. For example, just before lunch when it was almost time to start helping people to the dining room one care assistant stood in the middle of the lounge and said, “shall we move them over now”? Another example was one care assistant talking to another over a person’s head saying, “Is she staying in the wheelchair or going in a normal chair”. Spring Bank DS0000019888.V364930.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15. People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to the service. Generally people are supported in following their interests and are given the opportunity to take part in a variety of social activities. This could be improved by continuing to develop a more individualised approach to social care. EVIDENCE: Generally daily routines are flexible, for example people can choose when to get up and go to bed and can stay in their rooms if they prefer to. One person said she preferred to stay in her room because there wasn’t anyone she could have a conversation with in the lounges. A visitor said their relative, who had lived alone before moving in, was enjoying the social interaction in the home. Care staff are responsible for arranging most activities for people. In addition to this someone comes in twice a week to do specific activities such as tabletop gardening. The range of activities offered includes music, games, quizzes, and visiting entertainers. People who are more independent go out either on their own or with family and/or friends. One person told us he spends every Sunday with his family and he is pleased to be in a home close to his relatives. Spring Bank DS0000019888.V364930.R01.S.doc Version 5.2 Page 14 It was evident that staff know a good deal about people and what they are interested in. For example we saw them talking to one person about the bet he had on a football game and to another about a puzzle she was doing. The activities records were not up to date and there were no records for some people who have recently moved in. The carer who takes the lead role in planning and doing activities said she doesn’t always have time to keep the records up to date. The home told us that representatives from local Christian churches visit the home and we saw information about people’s religious needs in the care records. People said the food is good and they are given a choice of meals at teatime. The lunchtime meal is a set menu. The lunchtime meal served on the day we visited looked appetising. The dining room tables were nicely set with tablecloths; linen napkins and flowers however there were no condiments available for people. Staff were available to help people or prompt them and they did this discreetly when necessary. People can have their meals in their rooms if they choose to. Spring Bank DS0000019888.V364930.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18. People who use the service experience poor quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to the service. Complaints are not always dealt with properly and this means that people cannot always have confidence in the complaints’ procedure. The procedures that are in place to safeguard people from abuse are not always followed and therefore people may be put at risk. EVIDENCE: Every bedroom has a copy of the Service User guide, which includes information about how to make a complaint. The home’s records show that they have received 2 complaints since our last visit in November 2007. In addition we have sent four complaints to the home, we have received responses to two of them, and one of them is still being investigated. The person who made the other complaint contacted us to say they had not received a response from the home and we are following this up. The home has policies and procedures in place to make sure that people are protected. However, these procedures are not always followed. For example there was a recent incident involving the alleged theft of money, which was not reported to the police, the adult protection unit or the Commission. The manager and owner were both aware of this incident and neither could provide Spring Bank DS0000019888.V364930.R01.S.doc Version 5.2 Page 16 a satisfactory explanation for why they had not followed the procedures. The manager and owner both attended training on the protection of vulnerable adults last year. Therefore it is a matter of great concern that they did not follow the correct procedures in this case. Most of the staff we spoke to couldn’t remember if they had read the policies on safeguarding people but they said they know where they are if they need them. Most of the staff told us they have not received recent training on the protection of vulnerable adults, (safeguarding); some had done this as part of their NVQ (National Vocational Qualification) training. However, the told us they know how to report concerns about abuse and they are aware of the “whistle blowing” procedures. Some staff said they were worried about how to care for one person in particular. They said this person often refuses help and can be aggressive to staff and they didn’t really know how to deal with this. They said they were in a dilemma about how to balance their duty of care with this person’s rights. They said they had talked to the home’s management about their concerns but had not been given clear guidance. We discussed this with the manager and owner. Recruitment procedures are not being followed and new staff are starting work before all the required checks are completed which means people living at the home are not fully protected. Spring Bank DS0000019888.V364930.R01.S.doc Version 5.2 Page 17 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 22 and 26. People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to the service. The home provides a clean and comfortable place for people to live. Suitable equipment must be provided to protect people from the risk of cross infection. EVIDENCE: The home was clean and tidy when we visited. The standard of décor and furnishings is good. The gardens are well maintained. The day we visited was a pleasant sunny day and some people sat outside for a while after lunch. There is no lead attached to the call bell in the lounge and this means it is difficult for people to alert staff if they need help. There is a passenger lift, which gives easy access to the first floor. There are enough assisted bathing facilities to meet people’s needs. The records showed Spring Bank DS0000019888.V364930.R01.S.doc Version 5.2 Page 18 that bath hoists and mobile hoists were serviced in April 2008. The owner said a new company has been contracted to service the hoists every 6 months to make sure they continue to be safe for people to use. Some of the locks on bathroom doors were not working; the owner said this would be dealt with. In most cases people had some of their personal belongings in their rooms. Bedrooms are suitably furnished to meet people’s needs. There is lockable storage space in all the bedrooms so that people have somewhere secure to keep money or valuables. The home has been given a 4 star rating by Environmental Health (5 is the best) for the standards of food safety and hygiene. The home does not have a mechanical sluice for washing and disinfecting equipment such as commode pots therefore there is an increased risk of cross infection. This has been discussed on previous visits and the owner was not able to give us a definite date for when this equipment would be installed. Spring Bank DS0000019888.V364930.R01.S.doc Version 5.2 Page 19 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30. People who use the service experience poor quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to the service. The home is not completing all the required checks before new staff start work and this is putting people at risk. Staff are not getting the training and support they need to make sure they have the skills and knowledge to care for people properly. EVIDENCE: Since the last inspection people have contacted us on two occasions with concerns that there were not enough staff available to meet people’s needs. These concerns were passed to the home to deal with. On the day we visited there were 28 people living in the home. There were 6 care assistants on duty until 2.00pm and 4 for the remainder of the day. There was one nurse on duty all day and the manager and owner were both in the home. The rota for the remainder of that week showed that the number of care assistants on duty on the morning shift varies between 4 and 6. There are usually 4 care assistants for during the afternoon and evening. In addition the home employs separate staff for housekeeping and catering duties. People living in the home did not raise any concerns about the availability of staff. People spoke positively about the staff and one person said some of the staff were “extremely thoughtful”. We observed that staff know people well, Spring Bank DS0000019888.V364930.R01.S.doc Version 5.2 Page 20 they are able to talk to them about their interests and have a laugh and a joke with them. The home is continuing to make progress with NVQ (National Vocational Qualification) training, 40 of care staff have achieved an NVQ at level 2 or above. Two staff are doing NVQ training and the remainder are to be enrolled later this year. There is very little other training for staff. The staff we spoke to told us they are concerned that they are not supported in keeping up to date or given training to help them meet the needs of people living in the home. For example they said they had not received moving and handling training for some time and the records confirmed this. Some of the staff files contained a booklet on dementia care, which suggested that they had received training on this subject. We asked staff about this and they said they had just been given the booklet to read but had not had any opportunity to discuss the subject. When we visited in November last year we found the home was not doing all the required checks before new staff started work and this was putting people at risk. We issued a statutory requirement notice in December 2007 setting out the actions the home must take to make sure the recruitment procedures are thorough enough to protect people. We visited twice in February 2008 to check what action the home was taking. During these visits we found that there were still shortfalls in the recruitment procedures and we are continuing to investigate this. On this visit the home told us they have not employed any new staff since our last visit in February 2008. We looked at the files of 3 of the most recently employed staff. In one we found that all the required checks had been completed. In the second there was only one reference and in the third there were no references. The rotas show that both of the staff without references are working regularly in the home. Spring Bank DS0000019888.V364930.R01.S.doc Version 5.2 Page 21 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 32, 33, 35, 36, 37 and 38. People who use the service experience poor quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to the service. The management team is not conveying a clear sense of direction and leadership and this is not in the best interests of people living and working in the home. EVIDENCE: The owner and registered manager are responsible for the day-to-day running of the home. They acknowledge that they have very different styles of management and this can be good. However, in this case it appears to be causing some tension in the home. We have received information that indicates staff are finding the differences difficult to deal with. Some staff have made allegations about the manager, which include bullying and victimisation. These concerns have been raised with the owner and were discussed with the Spring Bank DS0000019888.V364930.R01.S.doc Version 5.2 Page 22 owner and manager during the visit. They need to be resolved by the management team as a matter of some urgency as conflict within the staff team will inevitably have an impact on the well being of people living in the home. The home does not have meetings for people using the service. They have put a notice up inviting relatives to become more involved in the running of the home. We saw in the care plans that people are being consulted about their care needs. The home sends surveys to people from time to time. They said they send them to new people when they have been in the home for a while and to people who have come in for short stay care. The system needs to be more formalised to make sure that everyone is given the opportunity to share their views of the service and to show that the home is taking action in response to feedback from people. The home does not hold money on behalf of people. Occasionally the home keeps valuables for people, they are kept safe and recorded. Most of the staff we spoke to said they do not have appraisals or regular supervision and the records confirmed this. This was discussed at our last visit and it has not been addressed. This combined with the lack of training means that staff are not getting the support they need to care for people properly. There has been an improvement in the way the home responds to our request for information. However, we are not always being informed about things that affect the well being of people in the home. The home is legally required to keep us informed of such events. A further cause of concern is the lack of progress in dealing with statutory requirements. Eight of the requirements from the last inspection have not been dealt with and some of these are issues dating back to 2002. The maintenance records we looked at were up to date and showed that equipment is being maintained and/or serviced at the required intervals. When we visited in November 2007 we found that most of the staff had not received moving and handling training and this has not yet been provided. The training records showed that most staff receive regular fire safety training and staff confirmed this. Spring Bank DS0000019888.V364930.R01.S.doc Version 5.2 Page 23 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 2 2 2 2 3 N/a HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 2 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 2 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 1 3 X X 3 X X X 2 STAFFING Standard No Score 27 2 28 2 29 1 30 1 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 1 2 X 3 1 2 2 Spring Bank DS0000019888.V364930.R01.S.doc Version 5.2 Page 24 Are there any outstanding requirements from the last inspection? Yes 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 Requirement Timescale for action 29/08/08 CSA Part The registration certificate must 11 Section be fully displayed so that people 28 know who is responsible for the service, what type of care the home can provide, and how many people can be accommodated. Previous timescale of 31/01/08 not met. People must be given information about the fees at the time of admission or before. This must include information on the breakdown of fees (if applicable) and say how the fees are to be paid and by whom. This is to make sure that people know how much they have to pay, how it will be paid, and who will be responsible for payment. Previous timescale of 31/8/07 not met. People’s dignity must be safeguarded at all times. Particular attention must be given to the way staff interact with and speak about people when they are providing care DS0000019888.V364930.R01.S.doc 2 OP2 5A 29/08/08 3 OP10 12(4) 29/08/08 Spring Bank Version 5.2 Page 25 and support. Previous timescale of 31/01/08 not met. All complaints must be fully investigated and responded to. There must be a record of all complaints, which includes information on the action taken so that people can be confident their concerns will be taken seriously and acted upon. Previous timescale of 31/10/07 & 28/02/08 not met. The safeguarding procedures must be followed and all incidents of suspected or alleged abuse must be reported in accordance with these procedures. This is to make sure people are properly protected. A washer disinfector must be provided in a separate sluice room, which also incorporates hand-washing facilities. This is to reduce the risk of cross infection. This is outstanding from previous inspections dating back to June 2002. There must always be enough staff available to make sure that people’s needs are met in a timely way. This is outstanding from previous inspections dating back to March 2006. New staff must not start work until all the required checks have been completed and all the required documents are available. DS0000019888.V364930.R01.S.doc 4 OP16 22 & 17 18/07/08 5 OP18 13(6) 18/07/08 6 OP26 23 19/09/08 7 OP27 18 18/07/08 8 OP29 19 Sch 2 18/07/08 Spring Bank Version 5.2 Page 26 This it to make sure people are protected and that the staff employed are suitable to work with vulnerable people. This is outstanding from October 2006. Nursing and care staff must undertake training relevant to the needs of the people living in the home so that they have the right knowledge and skills to meet people’s needs and there must be a record of all training. This is outstanding from previous inspections dating back to September 2004. The concerns about the management of the home must be addressed so that people working in the home are supported in maintaining professional relationships for the benefit of people living in the home. The CSCI must be provided with a written plan (an improvement plan) setting out in detail how the service will be improved for the benefit of the people living there. This must include details of what action is to be taken, who is to be responsible for the action and the timescale within which it will be done. A system for evaluating the quality of the services provided must be established and maintained so that the home can identify areas of good practice and areas for improvement. This must include getting the views of people using the service. The Commission must be informed of all incidents that DS0000019888.V364930.R01.S.doc 9 OP30 18 & 17 29/08/08 10 OP32 12(5) 18/07/08 11 OP33 24 13/08/08 12 OP33 24 19/09/08 13 OP37 37 18/07/08 Page 27 Spring Bank Version 5.2 14 OP38 13(5) adversely affect the well-being or safety of people living in the home. This is to make sure that people are protected. There must be suitable systems in place to make sure that people are helped to move and transfer safely, this must include appropriate training for staff. This is to reduce the risk of injury to people living and working in the home. 18/07/08 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 OP22 Good Practice Recommendations There should be an accessible call bell in the lounge so that people can summon help from staff if they need to. Spring Bank DS0000019888.V364930.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection North Eastern Region St Nicholas Building St Nicholas Street Newcastle Upon Tyne NE1 1NB National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Spring Bank DS0000019888.V364930.R01.S.doc Version 5.2 Page 29 - 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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