Inspection on 04/06/07 for Spring Bank

This inspection was carried out on 4th June 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 27/11/07

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 Unannounced Inspection 4 June 2007 09:15 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.V335253.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.V335253.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.V335253.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 12th December 2006 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 people 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. There are two lounges, and 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. The weekly fees in May 2007 ranged from £525.00 to £545.00. Services such as hairdressing and chiropody are available for an extra charge. Spring Bank DS0000019888.V335253.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. I did this unannounced inspection in one day spending approximately 8.5 hours in the home. At previous inspections the outcomes for people using the service have been poor or adequate and the reason for this visit was to see if improvements have been made. Following the last inspection in December 2006 the owner was asked to complete an improvement plan setting out how they would improve the outcomes for people using the service. This information was not provided and this is a concern because it means we do not know how the provider is planning to make sure that people’s needs are met. The home had a random inspection in January 2007 mainly to follow up on reports that there were not enough staff available at weekends. At the time of that visit there were enough staff. The report for this visit can be requested from our office in Rodley. Before the visit we asked the owner to complete a pre-inspection questionnaire. We had to make 3 further requests for the information before it was provided which meant that we did not have feedback from people using the service when we did the visit. We sent comment cards 10 people who live in the home, 13 relatives, and one to a GP. 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 identify who has provided it. In total 14 comment cards were returned and the information we received is included in this report. During the visit I spoke to people who live in the home, visitors, staff and management, I looked at various records relating to care, staff, and maintenance and looked at some parts of the home. During the visit there were concerns that people are being put at risk because the home is not following the correct recruitment procedures. This has been discussed at previous inspections. We wrote to the provider with details of these concerns and asked them to tell us in writing what action they would take to reduce the risk. We did not get a reply within the timescale we specified. We are now considering what action we need to take to make sure that people using the service are protected. What the service does well: Generally people were happy with the care provided, the following are some of the comments made by people who use the service: Spring Bank DS0000019888.V335253.R01.S.doc Version 5.2 Page 6 • “Since having a stroke Mum has communication problems and therefore not in a position to indicate her choosing but is always contented and happy when we visit” “Staff seem happy and motivated, I feel the patients are well cared for”. “Provides a caring and friendly atmosphere and we have every confidence in the staff and management” • • People said the food was good, particularly the homemade soup and cakes. 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? The home has made a lot of improvements since the last inspection and has met 25 of the 34 requirements made at that time. The Statement of Purpose has been updated and gives people clear information about the range of services offered, this will help people to decide if the home is suitable for them. The way in which people’s needs are assessed before admission has improved and initial care plans have been put in place so that staff have information about people’s needs when they move in. The care plans have improved and, although there is still more work to be done on them, they now provide better information for staff on how to meet people’s needs. The way in which people’s social and cultural needs are dealt with is improving and more attention is being given to helping people pursue their interests and spend their time meaningfully. The format for the menus has been changed making it easier for people to see what is available. The home has provided an additional hoist and some new wheelchairs, which means that people do not have to wait an unreasonably long time when they need help to move around. Secure storage has been provided in most of the bedrooms so that people have somewhere safe to keep money or valuables. Spring Bank DS0000019888.V335253.R01.S.doc Version 5.2 Page 7 What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Spring Bank DS0000019888.V335253.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.V335253.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 good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to the service. People are given the information they need to help them decide if the home is suitable to meet their needs. People’s needs are assessed before they are offered a place. EVIDENCE: The Statement of Purpose has been reviewed and now has all the required information. It is well set out and easy to read. The manager said the service user guide was being updated and that was why it was not available in the bedrooms. The three people living in the home who completed surveys said they had been given enough information before they moved in and had contracts (terms and Spring Bank DS0000019888.V335253.R01.S.doc Version 5.2 Page 10 conditions of residency). Five out of nine relatives said they had been given enough information and six said the home always met their relatives’ needs. Records of pre-admission assessments were seen in the care files. They showed that the home considers people’s needs in terms age, gender, and religion. People’s needs in relation to disability are considered in terms of mobility, sight, and hearing. People’s needs regarding culture, sexuality and race are not looked at enough to make sure that they are all met. There was evidence that relatives and other health care professionals are involved in the pre-admission assessments. The Statement of Purpose has information on visiting before making a decision about admission and it offers people the opportunity to have a trial stay if they are not sure that the home will be the right place for them. The manager has developed an initial care plan to cover the first week following admission. This was in place in the records seen and means that care staff have information about people’s needs at the time of admission. It gives the staff time to re-assess the needs identified before admission and to develop more detailed care plans. One person who was in the home for a short stay said the owner had visited her before she moved in. Another person said they had chosen the home for their relative because they knew someone else who had been there. Spring Bank DS0000019888.V335253.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 good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to the service. Overall, people’s needs are met in a way that respects their privacy and dignity. Further improvement of the care records is needed to make sure that they provide an accurate and up to date account of how people’s needs are being met. EVIDENCE: I looked at the four people’s care records. There were initial care plans showing people’s main care needs in the days following admission. These were followed up by more detailed plans setting out how people’s personal, health and social care needs would be met. Generally, the care plans provide clear instructions for staff on how to care for people. More needs to be done to make sure that all areas of identified need are addressed. For example, the daily records for one person showed that staff were having some difficulty managing aggressive behaviour and there was no plan to provide guidance on how to deal with this. The care plan for Spring Bank DS0000019888.V335253.R01.S.doc Version 5.2 Page 12 one person who is diabetic gave instructions on how to treat high or low blood sugar levels but did not make it clear how staff would be able to tell the difference. There are assessments in place relating to nutrition, falls, and the risk of developing pressure sores. In some cases the assessments had not been reviewed for several months. When people are at risk in these areas the assessments should be reviewed every month, if the risk is low and monthly reviews are not necessary the date of the next planned review should be clearly recorded. The care plans for wound care included descriptions, measurements, and grading which are necessary to monitor the effectiveness of treatment. They showed that the home is getting advice from the tissue viability nurse specialist. The records showed that people have access to other health and social care professionals such as dieticians, speech therapists, opticians, and GPs. A private chiropodist visits the home. The care plans are evaluated every month. There was some evidence of discussion with people about how care needs will be met but no evidence that people are involved in developing and reviewing care plans. The manager said she has started work on this. The majority of the nine relatives who completed surveys said they are kept well informed by the home. The three people living in the home who completed surveys said their care needs are met. One person said, “My mother is always clean and groomed, she is well fed and helped kindly to eat her food”. Another person said they would like their relative’s hair to be washed in between the hairdressers visits and would like more attention given to keeping nails clean. The home has just started a new system for dealing with medicines. Medicines are ordered once a month and are dispensed in blister packs, with a separate pack for each medicine. The manager said it was already saving time in giving medicines, which meant that the nurses had more time to attend to other care duties. It will also make it easier to keep track of stocks of medicines. One GP mentioned that the systems for ordering medicines could be improved and this system should help to address that. I observed staff treating people kindly and with respect. Spring Bank DS0000019888.V335253.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 & 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. The home offers people the opportunity to take part in a variety of social events. It is continuing to develop the programme of social activities to take account of the social and cultural needs and interests of the people living there. EVIDENCE: Daily routines are reasonably flexible. In some people’s care records their preferred times for going to bed and getting up are recorded. Some people prefer to stay in their rooms and only go to the communal rooms to join in organised activities. Visitors are welcome at any time and people can see their visitors in their rooms if they choose to. One person’s visitors had brought their dog to visit; they said other people living in the home also enjoyed seeing the dog. Information on social events is displayed and the home offers a reasonable variety of activities including dominos, ball games, bingo, cards, skittles and hand and foot massages. A singer visits the home twice a week and there is a Spring Bank DS0000019888.V335253.R01.S.doc Version 5.2 Page 14 tabletop gardening session once a month. There are individual activities records for some people showing how they spend their time. There were no activities records for three of the four people whose care records I looked at. We asked people living in the home if there were suitable activities for them to join in, two said usually and one said sometimes. The home has church services for people of Christian faiths every two weeks and one person goes to church regularly. The home has changed the way the menus are presented and it is now easier for people to see what is available. Most people say the food is good and they enjoy the home baking. The lunchtime meal on the day I visited looked appetising and people enjoyed it. The meal was well organised and there were enough staff available to help people eat. One person said she likes to visit at lunchtime so that she can help her relative to eat, she thought the food was good and said her relative has put on some weight since moving in. The cook keeps a record of people’s likes and dislikes and said people are always offered an alternative if they do not like the main course. Staff made a bacon and egg sandwich at lunchtime for one person who had stayed in bed late. Spring Bank DS0000019888.V335253.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 & 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. More needs to be done to promote a safe and understanding environment where people are encouraged to express their views and concerns and where there is a greater awareness of people’s rights. EVIDENCE: Three people living the home who completed surveys said they know how to make a complaint. Of the 9 relatives who completed surveys 5 said they know how to make a complaint. One person said they never had any cause to complain. Information about the complaints’ procedure is displayed in the home and included in the Statement of Purpose. Two complaints have been recorded in the home’s complaints file since the last inspection and they have been dealt with. We sent two complaints to the home to be investigated; they were not recorded in the complaints file. The manager responded to us about one of the complaints. The second complaint we sent concerned the manager and the owner was asked to investigate and respond to us. We did not get a response even when we sent reminders. Spring Bank DS0000019888.V335253.R01.S.doc Version 5.2 Page 16 The majority of staff have attended adult protection training. The manager said she had taken action to make sure people left in charge of the home know what to do if there are any allegations or suspicions of abuse. The Statement of Purpose contains information on the role of advocacy services. Spring Bank DS0000019888.V335253.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, 21, 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 provides a clean and comfortable place for people to live. People’s privacy is compromised by the absence of door locks on bedroom, bathroom, and toilet doors. EVIDENCE: The home was clean and tidy and people living there said it was always clean and fresh. A risk assessment has been done for the low windows in the small lounge and measures have been put in place to reduce the risk of injury. Spring Bank DS0000019888.V335253.R01.S.doc Version 5.2 Page 18 A new hoist and some new wheelchairs have been provided. This means that people no longer have to wait an unreasonably long time for the equipment they need, to help them get around, to be available. There is a passenger lift, which gives easy access to the first floor. There are enough assisted bathing facilities to meet people’s needs, however the service records for the bath hoists were not available to confirm that they had been checked and were safe. There are no locks on most of the bedrooms doors and several of the toilets and bathrooms do not have door locks. This compromises people’s privacy. Since the last inspection hotel style safes have been fitted in most rooms, these provide people with a secure place to store money or valuables. Generally the bedrooms are decorated to a good standard and people had some of their personal belongings around them. Some rooms did not have call bell leads and therefore people would not be able to summon help. The manager said that call bell leads were not available in some rooms because there was a risk that people could injure themselves and this was recorded in the care records. It was not recorded in two of the care files looked at. 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. One of the clinical waste bins was not a pedal bin; pedal bins reduce the risk of cross infection. The storerooms in the cellar have been sorted so that food and chemicals are no longer stored in the same place. The laundry was clean and tidy. The kitchen was clean and the home has been awarded a four star rating (the highest rating is 5) by Environmental Health for the standards of food safety and hygiene. Spring Bank DS0000019888.V335253.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 & 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. There are not always enough staff to meet people’s needs in a timely way. Some training has taken place and a training programme is being developed to provide staff with the necessary skills to meet people’s needs. EVIDENCE: We visited the home in January 2007 in response to concerns about staffing levels, particularly that there were not enough staff available at weekends. At that time we found there were enough staff available to meet people’s needs. During this visit some of the people living in the home said there were not always enough staff at weekends. This was discussed with the manager; she said that sometimes the care staff had to cover for absences in the kitchen at weekends. Duty rotas are available for most staff; there are no rotas for housekeeping staff despite the fact that this has been asked for at previous inspections. Spring Bank DS0000019888.V335253.R01.S.doc Version 5.2 Page 20 I looked at the recruitment files for two staff, I asked for the files for three other members of staff and they were not made available. The files showed that the required checks are not being completed before new staff start work in the home and this is putting people at risk. The home had not made the required PoVA ((Protection of Vulnerable Adults) and CRB (Criminal Records Bureau) checks and had not obtained written references. One of the files asked for, but not available, was for a nurse who had been working on the day before the visit. She had recently returned from a 12month break. The manager said a PoVA First had not been obtained and the NMC (Nursing and Midwifery Council) register had not been checked to confirm she had a valid registration. This was not done until after our visit. At previous inspections we have informed the providers of their responsibilities with regard to the recruitment of staff and this was discussed again during this visit. Following this visit we wrote to the providers confirming our concerns about the shortfalls in the recruitment procedures. We asked them to inform us in writing of the actions they would be taking to reduce the risk to people living in the home. There were no records of induction training for 2 staff that started work in January 2007. One file had a completed induction and another had an induction checklist that had been started in October 2006 and not yet completed. The home is introducing the common induction standards for care staff. These are nationally recognised induction training standards set out by Skills for Care and designed to help new staff get the knowledge and skills they need to care for people. The home told us that 25 of care staff have an NVQ (National Vocational Qualification) at level 2 or above. Five staff are working towards achieving an NVQ and 2 more are due to start training. The records showed that staff have had training on dementia care, infection control, fire safety and adult protection. Staff said they had received training on moving and handling from the physiotherapist who visits the home. Four of the nine relatives who completed comment cards said they thought staff had the right skills and experience to look after people properly and one person said they did feel qualified to comment on this. One person said, “Some (staff) are too young and do not have the right skills or experience.” Spring Bank DS0000019888.V335253.R01.S.doc Version 5.2 Page 21 Another person said she had seen 2 young staff arguing with a senior member of staff about something they had been asked to do and said, “This has not given me confidence in these young staff”. Another person said, “We visit at least twice a week. The staff, if not too busy, are always prepared to listen to our concerns or explain things. We have always found them helpful.” Spring Bank DS0000019888.V335253.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, 32, 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 homes systems for dealing with records mean that people’s rights and best interests are not 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: Since the last inspection the manager has successfully completed her application for registration. She is doing the registered managers’ award and hopes to finish this in July this year. At the last inspection we asked the owner to complete monthly visit reports and we gave her a format, which could be used. We also asked her to send us Spring Bank DS0000019888.V335253.R01.S.doc Version 5.2 Page 23 copies of these reports. The reason for this was to help develop a more structured approach to the management of the home, to provide support for the manager and to help us to monitor how the service was being improved. The owner said she had not done any visit reports since December 2006. The home does not get involved with people’s personal finances and does not hold any money for people. Any additional services, such as hairdressing, are added to the monthly invoice. Safes have been fitted to most rooms so that people have somewhere secure to keep money and/or valuables. The records showed that some supervision is taking place for care staff, there is, as yet, no programme of supervision for nursing staff. A copy of the gas safety certificate was provided. Weekly checks on the fire safety systems are done and hot water temperatures are monitored. Portable electrical appliances were checked in the week prior to the visit. Service reports for the passenger lift were available. The electric wiring certificate and the service records for the hoists was not available for inspection. Accidents are recorded but there was no evidence of a system for reviewing accidents and looking at reducing the risk of similar incidents happening in the future. Accidents records are all kept in one book, which is not in line with the recommendations of the Data Protection Act. Spring Bank DS0000019888.V335253.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 3 3 3 X 3 N/a HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 3 2 X 2 2 X 2 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 3 2 2 X 3 2 1 2 Spring Bank DS0000019888.V335253.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 OP16 Regulation 22 & 17 Requirement 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. Call leads must be provided in all rooms, or the reason for not doing so must be explained in the care plan so that people can summon help from staff. This is outstanding from previous inspections dating back to October 2005. Suitable door locks must be provided to people’s private accommodation and keys must be provided unless a documented risk assessment suggests otherwise. To make sure that people’s privacy is respected. This is outstanding from previous inspections dating back to June 2002. Spring Bank DS0000019888.V335253.R01.S.doc Version 5.2 Page 26 Timescale for action 31/10/07 2 OP22 16 (2) (c) 31/10/07 3 OP24 12(4) 31/10/07 4 OP26 23 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. 31/10/07 5 OP27 18 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. Application forms must contain full details of employment history. Any gaps in employment must be explored. Two written references must be obtained before any offer of employment is made. Recruitment files must include all the information specified in Schedule 2. The recruitment policy and procedure must be amended in line with these requirements. To make sure that people living in the home are protected. This is outstanding from October 2006. The home must make sure that nursing and care staff undertake training relevant to the needs of the people living in the home so DS0000019888.V335253.R01.S.doc 31/10/07 6 OP29 19 Sch. 2 31/10/07 7 OP30 18 31/10/07 Spring Bank Version 5.2 Page 27 that they have the right knowledge and skills to meet people’s needs. This must include 50 of the care staff being qualified to NVQ level 2 or above. This is outstanding from previous inspections dating back to September 2004. 8 OP33 24 The home must establish and maintain a quality assurance system based on seeking the views of people who use the service including people living in the home, their representatives and health and social care professionals. The measures must include meetings, surveys, and the use of audit tools. This is to make sure people have the opportunity to share their views of the service, be involved in decision making and contribute to the improvement and development of the service. This is outstanding from previous inspections dating back to June 2002. 9 OP37 17 Records required by The Care Homes Regulations 2001 must be made available for inspection at all times 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. 10 OP38 13(4) The home must provide the CSCI 31/10/07 with copies of the hoist service records so that we can be assured that equipment is in DS0000019888.V335253.R01.S.doc Version 5.2 Page 28 31/10/07 31/10/07 Spring Bank good working order and people are not being placed at risk. This is outstanding from January 2007. 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.V335253.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. Extracts may not be used or reproduced without the express permission of CSCI Spring Bank DS0000019888.V335253.R01.S.doc Version 5.2 Page 30 - 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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