Inspection on 27/11/07 for Spring Bank

This inspection was carried out on 27th November 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. 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 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 09/07/2008.

CARE HOMES FOR OLDER PEOPLE Spring Bank Howden Road Silsden Keighley West Yorkshire BD20 0JB Lead Inspector Mary Bentley Key Unannounced Inspection 27 & 28 November 2007 09:30 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Spring Bank DS0000019888.V355855.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.V355855.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.V355855.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 4th June 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 November 2007 the home told us the weekly fees ranged from £525.00 to £545.00. 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.V355855.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. We did this inspection over 2 days, the first day of which was unannounced. We spent approximately 15 hours in the home. During the visit we spoke to people living in the home, relatives, staff and management. We looked at various records, including people’s care plans and we looked at some parts of the building. Some people living in the home have dementia and are not always able to tell us about their experiences. During this visit we used a formal way to observe a small group of people. This helps us to understand their experiences and to see if care is being given in a way that helps them to make the most of their abilities. Before the visit we sent comment cards to people living in the home, relatives, staff and some health care professionals. Comment cards give people the opportunity to tell us what they think about the service. The information we get is shared with the home but we do not say who has provided it. We received 15 comment cards back from various people. We asked the home to complete a self-assessment form. This was returned before our visit but only after we had sent a reminder letter. Following the last 2 inspection visits we asked the owner to give us an action plan saying how they would improve the service for the benefit of the people living there. This action plans have not been provided and this concerns us, as the owner is legally required to provide us with this information. This report has been put together using information from the home’s selfassessment, comment cards, our site visit, and our records about the service. What the service does well: People using the service told us they are happy with the care provided. Most people said they had been given enough information about the home before they moved in. One person said, “it’s very nice here, and everybody is very nice and polite” another person said the home has “ good, friendly care staff”. People said the food is good, particularly the homemade soup and cakes. Spring Bank DS0000019888.V355855.R01.S.doc Version 5.2 Page 6 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. The home is welcoming to visitors. What has improved since the last inspection? What they could do better: Care homes are required to carry out a number of checks before they allow new people to start work; this is to protect the people living in the home. During this visit we found that the home is not doing this. We have discussed this with the home’s management on previous occasions and in their selfassessment form the home told us this had been dealt with. We gave the home an immediate requirement notice telling them what they had to do to protect people. Following our visit the owner wrote to us and told us what they had done to protect people. However, when we visited again to check if this had been done we found that it had not. We have now issued a statutory requirement notice, which means that the owner is required to take action with regard to recruitment to make sure that people are protected. We will carry out a further inspection to make sure that the action has been taken within the timescale specified in the notice. The home must make sure that people are 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. Spring Bank DS0000019888.V355855.R01.S.doc Version 5.2 Page 7 There has been no significant improvement to the care records since our last visit. The records must be improved to make sure that people are given the opportunity to be involved in planning and reviewing how their care needs will be met. This is to make sure that care is delivered in a way that takes account of people’s wishes. The way complaints are dealt with must be improved to make sure that all complaints and fully investigated and appropriate action is taken. This is to make sure that people can have confidence in the complaints’ procedure. 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 way records are dealt with must be improved so that the home can show it is running in a way that safeguards people’s best interests. 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.V355855.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.V355855.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 & 5. Standard 6 does not apply to this service. 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. There is information available for people to help them decide if the home is the right place for them. People are not always given information about the fees at the time of admission. EVIDENCE: People living in the home told us they had been given enough information before moving in and said they have contracts (terms and conditions). The majority of relatives also told us they had been given enough information about the home and the range of services offered. In three of the care records we looked at people did not have signed contracts. The home said this was because they had recently moved in. People need this Spring Bank DS0000019888.V355855.R01.S.doc Version 5.2 Page 10 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. Information about the home, such as the Service User guide, is available for people in the home. The registration certificate is not fully displayed; this was discussed at the last visit 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. Following our last visit there were concerns that the home was not doing a proper assessment of people’s needs before they moved in. This meant that they were not always able to meet people’s needs once they had moved in. The manager made changes to the way pre-admission assessments are done. Someone from the home now visits people to make sure they have a full picture of their needs before they move in. We saw evidence of this in the records. We also saw evidence that people, or their relatives, are given the opportunity to visit the home before moving in. Spring Bank DS0000019888.V355855.R01.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 & 10 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. However, the care records do not always have enough detail about how people’s needs should be met and are not always up to date. This means that people’s needs may be overlooked. People, or those close to them, are not always involved in planning care therefore care may not be given in a way that takes account of people’s wishes. EVIDENCE: The three people living in the home who returned comment cards and the people we spoke to told us they are happy with the care they receive. Relatives told us they are happy with the care and generally feel they are kept informed. Spring Bank DS0000019888.V355855.R01.S.doc Version 5.2 Page 12 The staff that sent us comment cards said that in most cases they feel people’s needs are met and they are kept up to date with changes in people’s care needs. We looked at the care records of 7 people, 3 of them in detail. Of the 7 we looked at 2 had evidence that people, or those close to them, are involved in planning or reviewing how care needs are being met. The care records for one person who recently moved in showed that there was an initial plan of care. However, this did not address all the person’s needs. The daily notes showed that this person was having difficulty settling into the home and staff were struggling to deal with this. There was no care plan to guide them on what action they should take. Some of the language used in the daily notes suggests a lack of understanding of the anxiety this person was experiencing due to the recent changes in their circumstances. For example phrases such as “unsettled and argumentative”, “very resistive to interventions” and “vocal and annoyed at times” were used regularly. However, there was evidence that the home had asked for help from a community psychiatric nurse and he/she had arranged for an advocate to visit. In another person‘s records we saw that there was no care plan to address the problem of confusion, restlessness and wandering at night although this was recorded regularly in the daily notes. In another person’s records we saw that there were concerns about nutrition. There was very little information about how this was to be dealt with. There was no food chart in place. The daily notes used phrases such as “good breakfast”, “moderate diet” and “small diet” which does not give an accurate measure of what the person is actually eating. The care plan dealing with eating and drinking said the person should have the prescribed diet supplements but none were prescribed. In two other sets of care records we saw that care plans are not reviewed regularly. In one case no review had been done since April this year despite the fact that some care needs had changed. Earlier this year we had concerns about how people with pressure sores were being cared for. The tissue viability nurse did some work with the home and this area of care has improved. There is only one person with a pressure sore and this is being treated appropriately. Generally, the systems for dealing with medicines were satisfactory. The home does not have a photograph for everyone. We noticed that the morning medicines seemed to take a long time; they were still being given out after 11am. We discussed this with the manager because the home needs to be sure that people are given their medicines at the prescribed intervals. Spring Bank DS0000019888.V355855.R01.S.doc Version 5.2 Page 13 People looked clean and well cared for. We had some concerns about how people’s dignity is safeguarded. In particular when people are helped to move with hoists in the lounge areas, some staff are aware that extra care is needed but others are not. Spring Bank DS0000019888.V355855.R01.S.doc Version 5.2 Page 14 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 & 15 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. Activities are provided however not enough attention is given to meeting individual needs. This means that people are not always supported in following their personal interests and that people with dementia are not always supported in making the most of their abilities. EVIDENCE: The home offers a range of activities including music, games, quizzes, tabletop gardening, and visiting entertainers. This works well for people who enjoy group activities and are able to take part. However, not everyone is able or willing to take part in such activities or to fulfil their social needs without support. The care records do not always provide a clear picture of people’s interests, hobbies, past lives, cultural or religious needs. In some cases when this information is recorded it is not used to develop an appropriate social care plan. Spring Bank DS0000019888.V355855.R01.S.doc Version 5.2 Page 15 For example one person’s assessment said they are retired but there was no information about what they had retired from. Another person’s records showed he had an interest in horse racing but there was no information about how he would be supported to keep this interest. His social care plan said staff should “engage in meaningful conversation”. Another social care plan had a lot of background information about the person but nothing to say how this would be used to help him occupy his time in a constructive way. There was no record of activities for this person and very little in the daily notes to show how he spends his time other than sleeping in a chair. The home has individual activities records for people, however there were no records for the three people whose care records we looked at in detail. The records that were available showed gaps where nothing had been recorded between June and October this year. One person who is independent and able to follow his interests had a good social care plan reflecting what he liked to do. Our observations showed us a mixed picture of life in the home. On the first day we saw some very good interactions between staff and people living in the home. A group of people took part in making a Christmas wreath in the afternoon. The carer doing this work took great care to make sure that everyone in the lounge was involved. However, there were some people in another lounge that were not able to take part and it was not clear what opportunity they were given to take part in some sort of leisure activity. On the second day we saw some, but not as many, examples of good interaction. We saw that sometimes staff missed the opportunity to talk to people, for example they did not always talk to people when helping them to move with the aid of a hoist. Relatives told us that they are always welcome in the home and we saw evidence of this during our visit. People told us they like the food. We saw people being offered a choice of meals for the evening meal but we are not clear about how much choice people are given at lunchtime. We saw one person being offered an alternative lunch but staff said this did not usually happen. Spring Bank DS0000019888.V355855.R01.S.doc Version 5.2 Page 16 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16 & 18 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. 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: People using the service told us they know how to make a complaint if they need to; some people said they had no need to complain. Two people told us the home had responded appropriately when they had raised concerns. Staff told us they know what to do if anyone has concerns about the home. We sent 2 complaints to the owner to be investigated; one was in February this year and the other in July. The owner has not responded to us about either of these complaints despite the fact that we have sent reminders Complaints that we have directed to the manager have been dealt with. The majority of staff have attended training on safeguarding people from abuse. Most staff have are doing or have done NVQ (National Vocational Spring Bank DS0000019888.V355855.R01.S.doc Version 5.2 Page 17 Qualification) training and they told us this includes training on how to recognise and promote people’s rights. The manager is going on training on the Mental Capacity Act in January next year. The Act has implications for how care is delivered, particularly to people with limited or varying mental capacity, and therefore it is essential that all staff are made aware of it. Recruitment procedures are not being followed and staff are being recruited without the proper checks being completed which means people living at the home are not fully protected. Spring Bank DS0000019888.V355855.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 22, 24 & 26 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 home is clean and comfortable. However, people may be at risk because some equipment is not regularly maintained and some is not available. EVIDENCE: The home was clean and tidy and people living there said it is always clean and fresh. The standard of décor and furnishings is good. 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 service records for the hoists were not available to confirm that they have been checked and are safe. This includes bath and mobile hoists. This information was asked for at the last visit and has not been provided. Spring Bank DS0000019888.V355855.R01.S.doc Version 5.2 Page 19 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. The majority bedrooms, bathrooms, and toilets have door locks fitted so that people can have privacy. 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 (5 is the best) for the standards of food safety and hygiene. Spring Bank DS0000019888.V355855.R01.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 & 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. EVIDENCE: The majority of people using the service are satisfied that staff are available when needed and that they have the right skills for the job. Some staff said they felt there were not always enough staff on duty. They said the main problem is that when people are absent at short notice there is no contingency plan in place to provide cover. There was an example of this on the day before our visit; one person had not turned up for work leaving 4 care staff on duty on the morning shift. There is always one nurse on duty. Generally, there are 5 care assistants on duty until 2.00 pm, 4 from 2.00pm until 4.00pm and 3 from 4.00pm until 10.00pm. The morning shift starts at 7.30am, however the rota shows that some care staff do not start until 9.00am, some days this is one carer but on other days it can be as many as 3. This has implications for people’s morning routines, which will have to be altered to take account of the number of staff available during the early morning to help them get up and ready for the day. Spring Bank DS0000019888.V355855.R01.S.doc Version 5.2 Page 21 Overnight there are a total of 3 staff, including a nurse. Progress is being made with NVQ (National Vocational Qualification) training. 28 of care staff have achieved NVQ level 2. Seven more staff are doing NVQ training and another 3 are booked to start in February 2008. There has been very little other training this year. The home has introduced the Skills for Care induction training for new staff, this is nationally recognised and is designed to help new staff get the skills and knowledge they need to care for people properly. The files of two newly appointed staff showed that all the required checks had not been done before they started work. The home did not have 2 written references and had not obtained PoVA (Protection of Vulnerable Adults) or CRB (Criminal Records Bureau) checks. These checks are required to make sure staff are suitable to work with vulnerable people. This has been an issue at previous inspections and we have informed the owner and manager of their responsibilities in relation to staff recruitment. On this occasion we asked the provider to take immediate action to make sure people in the home are protected and to inform us in writing of what they had done. Spring Bank DS0000019888.V355855.R01.S.doc Version 5.2 Page 22 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35, 36, 37 & 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 shortfalls in the home’s systems for dealing with records mean that people’s rights and best interests may not be safeguarded. This is of particular concern in the area of staff recruitment where the failure to follow correct recruitment procedures means people are not adequately protected. EVIDENCE: The manager has completed the Registered Managers’ Award and therefore should have the required knowledge and skills for the role. We have seen some improvements since her appointment. However, the continued failure of the home to follow the correct procedures for appointing new staff is a cause of great concern. Spring Bank DS0000019888.V355855.R01.S.doc Version 5.2 Page 23 The home sent questionnaires to people in July, October, and November this year. It is not clear how many were sent in total and what the response rate was. The responses available showed that people are satisfied with the service. Generally people feel they are kept informed about their relatives’ care however there is very little evidence of this in the care records. 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. Some staff said they would like more staff meetings so that they are more aware of what is going on in the home. They said the meetings are always on a Monday so it is nearly always the same staff that attend. There were no notes available for any recent staff meetings. The manager said they are not formal meetings however this means that staff that are not present do not know what has been discussed. The owner is required to carry out and record monthly visits to the home to monitor the quality of the service. Two of these reports have been completed since our last inspection in June 2007. The home has a poor record of responding to our requests for information. An example of this is the failure to provide us with action plans for improving the service following our last two visits. The home does not hold money on behalf of people. Occasionally the home keeps valuables for people, they are kept safe and recorded. Staff told us that they do not get supervision. The records we looked at showed that supervision in taking place although not always as frequently as it should be. The records showed that most equipment is maintained and/or serviced at the required intervals. However, the records for the servicing of the hoists were not available, this is outstanding from our last visit. Staff said they had not had moving and handling training for some time and the training records confirmed this. Staff said they had received fire training although this was not evident from the training records. Spring Bank DS0000019888.V355855.R01.S.doc Version 5.2 Page 24 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 3 X 3 N/a HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 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 2 3 X X 2 X 3 X 2 STAFFING Standard No Score 27 2 28 2 29 1 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 2 X 3 2 1 2 Spring Bank DS0000019888.V355855.R01.S.doc Version 5.2 Page 25 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 31/01/08 2 OP2 3 OP7 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. 31/08/08 5A 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. 15 The care plans must set out in 28/02/08 detail how all people’s assessed needs in relation to health, personal and social care will be addressed. They must be kept under review and must be changed to take accounts of people’s changing needs. The care plans must also show evidence that people are involved in planning care. This is to make sure that people’s needs DS0000019888.V355855.R01.S.doc Version 5.2 Spring Bank Page 26 4 OP10 12(4) 5 OP12 16(2) (m) & (n) are met in a consistent way that takes account of their wishes. People’s dignity must be safeguarded at all times. In particular more care must be taken to protect people’s dignity when they are being helped to move with a hoist in public areas. People must be given the support they need to take part in range of social and leisure activities that reflect their interests, preferences, and abilities. Particular attention must be given to making sure that people with dementia are given the support they need to make the most of their abilities. This is to make sure that people’s individual needs in relation to age, disability, gender, sexuality, race, and religion are 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 not met. 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 DS0000019888.V355855.R01.S.doc 31/01/08 28/02/08 6 OP16 22 & 17 28/02/08 7 OP26 23 28/02/08 8 OP27 18 31/01/08 Page 27 Spring Bank Version 5.2 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. 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. This is outstanding from previous inspections dating back to September 2004. 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. Records required by The Care Homes Regulations 2001 must be kept up to date, accurate and must be available for inspection at all times. This includes all care related records, photographs of people living in the home, staff records, maintenance records, and the DS0000019888.V355855.R01.S.doc 9 OP29 19 Sch 2 31/01/08 10 OP30 18 28/02/08 11 OP33 24 25/02/08 12 OP37 17 31/01/08 Spring Bank Version 5.2 Page 28 records of the owner’s monthly visits. So that the home can demonstrate it is being run effectively and efficiently for the benefit of people using the service. This is outstanding from September 2006. The CSCI must be provided with copies of the hoist service records so that we can be assured that equipment is in good working order and people are not being placed at risk. This is outstanding from January 2007 13 OP38 13(4) 31/01/08 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Spring Bank DS0000019888.V355855.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection Aire House Town Street Rodley Leeds LS13 1HP 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. 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