CARE HOMES FOR OLDER PEOPLE
Spring Cottages Stone Moor Bottom, St Johns Rd Padiham Burnley Lancashire BB12 7BW Lead Inspector
Mrs Marie Dickinson Unannounced Inspection 27th April 2006 10:30 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 Cottages DS0000009483.V289541.R01.S.doc Version 5.1 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 Cottages DS0000009483.V289541.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION
Name of service Spring Cottages Address Stone Moor Bottom, St Johns Rd Padiham Burnley Lancashire BB12 7BW 01282 771601 01282 773641 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 Carol Mary Leggett Mrs Nadine Phillips Care Home 23 Category(ies) of Dementia - over 65 years of age (1), Old age, registration, with number not falling within any other category (22) of places Spring Cottages DS0000009483.V289541.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION
Conditions of registration: 1. 2. 3. 4. The service should, at all times, employ a suitably qualified and experienced manager who is registered with the Commission of Social Care Inspection. The service is registered to provide personal care for a maximum of 23 service users A maximum of 22 service users who fall into the category of OP (Older People) One named service user who falls into the category of DE(E). A variation application must be submitted to the CSCI to remove this category when this person no longer resides in the home. 30th November 2005 Date of last inspection Brief Description of the Service: Spring Cottages is a care home registered to provide personal care and accommodation for 21 older people and one older person with dementia. Charges ranged from £324:50 to £372:50. No additional charges are made. The home is an older type detached house with a new extension. It is situated in a semi rural area. There were ample parking facilities at the front of the building, and attractive garden areas on either side of the property, which were used by the service users in fine weather. The home is a two-storey building; the two floors being linked by two chair lifts. There were 18 single bedrooms, 12 of which had an en - suite facility, and 2 double rooms. Communal space consisted of 2 lounges, two dining areas and a conservatory. All were smoke free. There were 3 bathrooms, two with assisted bath equipment. Activities and social events included entertainers, films and board games. Staff escorted individuals and groups on trips out. The registered manager of the home was Mrs Nadine Phillips, who had achieved the Registered Managers Award and had worked in a managerial position since 1999. There was also a deputy manager in post. Mr and Mrs Leggett, the owners of the home, were also involved in the day - to - day running of the establishment. Spring Cottages DS0000009483.V289541.R01.S.doc Version 5.1 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This inspection was unannounced and took place on the 27th April and 5th May 2006. The inspection involved getting information from staff records, care records and policies and procedures. It also involved talking to residents, staff on duty and the registered manager and a tour of the premises. Questionnaires were sent to residents inviting them to ‘have their say about the home’. Ten replies were received and this information was used as part of the inspection process. Visitors to the home were also invited to comment on the provision of care and facilities in the home. Areas that needed to improve from the previous inspection were looked at for progress made. The home was assessed against the National Minimum Standards for Older People. What the service does well:
Sufficient information about the home is available for people to read to help them decide if they would like to stay at the home. Before people are admitted to the home an assessment of peoples needs is completed. This is to make sure the home has the right facilities and staff to care properly for people. Contracts given to residents outlined the terms and conditions of residence. Resident’s healthcare needs were monitored. The home worked with visiting medical professionals for the benefit of residents. Advice was sought where needed, such as pressure care and diets. Residents considered staff as being respectful and described them as ‘nice people’. Activities were enjoyable and varied such as gardening, entertainment in the home and personal preferences such as reading. Special occasions such as Christmas and birthdays were celebrated. Visiting arrangements were satisfactory. The daily routines were flexible and designed to meet the wishes of the residents. Spring Cottages DS0000009483.V289541.R01.S.doc Version 5.1 Page 6 Residents were happy with the catering arrangements. They were offered choices and had a say in menu planning. The residents had access to a complaints procedure, which contained clear information about how to make a complaint. The manager of the home also showed professionalism in managing an adult protection referral correctly. To further protect residents, staff were given further training to help them identify and report any form of abuse. Residents living at the home expressed general satisfaction about their accommodation and facilities provided. They had comfortable bedrooms, which they could personalise to their own tastes and preferences. All the residents spoken to said they liked their bedrooms. Responses sent to the Commission showed residents thought the home was clean and fresh. Sufficient staff were employed who were supervised in their work. Teamwork was evident and the manager worked with the staff. Staff said they enjoyed their work and were confident to ‘speak out and raise issues if needed’. They felt ‘listened to’. Staff worked to a Code of Conduct. Staff were described by residents as ‘good, caring and helpful’. Staff were trained in a good range of topics related to care and the training programme had been developed according to the needs of the residents, the staff and Government guidelines. The home is a family run business, and there is continuity of management from competent and experienced people. Residents considered the manager as being approachable. One resident said ‘she was a bit of fun when she is on duty’. The views of residents and other relevant people influenced the service provided. The residents enjoyed good relationships with the staff, whom they described as “really nice people, nothing is too much trouble” and “very nice”. Resident’s money held by the home for safekeeping was managed properly. Records relating to the health, safety and welfare of residents and staff showed this area was managed well. Spring Cottages DS0000009483.V289541.R01.S.doc Version 5.1 Page 7 What has improved since the last inspection? What they could do better:
The plans for residents’ care must have more details about what staff need to do to look after them. This information must be individual to residents and not generalised. Residents should be given a real choice and opportunity to serve their own tea at meal times. To improve mealtimes the use of a communal teapot should be avoided. To make sure residents can move about safely, the upstairs bathroom should be cleared of surplus items such as laundry bags. Paintwork inside and outside the home should be kept as clean as other areas in the home. It is very important when recruiting staff, the applicant explains gaps in employment and a record of this kept. In addition to this when considering new staff, the manager must keep written details of any convictions and
Spring Cottages DS0000009483.V289541.R01.S.doc Version 5.1 Page 8 cautions to support the decision made to employ. Staff should be given a contract to cover their initial probationary period. To support the current qualifications the manager has already achieved that are linked to management and care, professional clarification is needed to show these are equivalent to the recommended National Vocational Qualification in care level 4. Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Spring Cottages DS0000009483.V289541.R01.S.doc Version 5.1 Page 9 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 Cottages DS0000009483.V289541.R01.S.doc Version 5.1 Page 10 Choice of Home
The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1,2,3 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. Useful information was provided about the home, services and facilities provided. The admission process ensured the residents’ were properly assessed, their needs and wishes known and planned for, prior to moving into the home. Trial periods of stay were offered and people were given individual contracts/terms of conditions of residence. EVIDENCE: Since the last inspection the registered provider had updated the service user guide to include residents views about the home. New residents confirmed they had been given enough information about the home to help them decide. The service user guide provided helpful, well-presented information in a format, which was easy to read. Copies of contracts given to residents were available to look at. The contracts covered the terms and conditions of residence in respect to the trial period and the services provided. This meant residents had clear information about the amount of fees to cover their accommodation and personal care needs.
Spring Cottages DS0000009483.V289541.R01.S.doc Version 5.1 Page 11 Comments sent to the Commission confirmed that in most cases they were issued contracts that outlined the cost of staying at the home and terms and conditions of residency. Details of admissions showed assessments were completed to a satisfactory standard. Spring Cottages DS0000009483.V289541.R01.S.doc Version 5.1 Page 12 Health and Personal Care
The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9,10 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to the service. The care planning system did not fully address the needs of the residents. Residents’ health was monitored and promoted, and the procedures for the management of medication ensured the safe administration of medicines. Residents considered staff respected their privacy. EVIDENCE: It was apparent from looking at residents records as part of the case tracking process, each resident did not have an adequate plan of care based on an assessment of needs. The care plans written by the home did not provide sufficient detail about what staff need to do to look after residents as they wished. The plans were reviewed on a monthly basis. The reviews however for one resident did not include changes in his needs. This was evidenced from comments written in his care notes. Assessment details identified short term memory loss. No management strategy to deal with difficulties in this area could be identified, resulting in negative comments from staff making entries into daily records. The care plans therefore were not supported by records of
Spring Cottages DS0000009483.V289541.R01.S.doc Version 5.1 Page 13 personal care, although these records did provide information on changing needs and any recurring difficulties for management to deal with properly. Risk assessments had been incorporated into the care plan documents. This meant staff knew what to do in difficulte situations such as for example when moving a resident. The residents’ healthcare needs were detailed in the care plan. Residents files showed regular visits from medical professionals. Two residents were receiving visits from the district nurse for pressure sores. One resident said ‘the district nurse visits every week to look to my leg’. All ten responses sent to the Commission show that residents felt they received care and support at the home. They all agreed they received the medical support they needed. Pressure relieving aids were in place and fluid and food intake charts were maintained. Weight was monitored and recorded. One resident unable to use the weighing scales benefited from staff making observations such as clothes sizes and food intake. The residents spoken to felt the staff respected their right to privacy and all made complimentary remarks about the staff, for instance one resident said the staff are realy nice people and nothing is too much trouble for them. The home operated a monitored dosage system for the administration of medication. This was audited by the supplying pharmacist. An appropriate recording system was in place to record the receipt, administration and disposal of medication. A record of medicines received into the home had been maintained and medication had been returned to the pharmacy for disposal. Information sent to the Commission by the manager showed that eight staff were trained in medication procedures and had this responsibility. Spring Cottages DS0000009483.V289541.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14,15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. Residents were able to choose their social activities. They were consulted regularly and kept in good contact with their family and friends. Residents were satisfied with meals provided. EVIDENCE: The residents’ preferences in respect of social activities had been recorded as part of their assessment and participation in any social activities had been documented in the care records. Organised activities were enjoyed by residents and comments received at the Commission read I like taking part , it is a change and I take part when there are activiites taking place. Various resources were available to take into account residents preferences, for example one resident said he enjoyed gardening and another resident liked to place a bet on the horses now and then. It was also evident that those residents who wanted, spent time resting or pursuing their own interests such as reading. Birthday parties were arranged and usual festive days celebrated. Residents were supported to continue with their chosen religion and observances. Representatives from local churches visited the home on a regular basis for prayers and communion. Arrangements were made to hold
Spring Cottages DS0000009483.V289541.R01.S.doc Version 5.1 Page 15 resident meetings and minutes of these meetings showed residents were consulted about various topics such as activities and meals. The residents were able to receive visitors at any time and were able to entertain their guests in private. One visitor said he visited every day. It was apparent from a tour of the premises that the residents were able to bring in personal belongings and arrange their rooms how they wished. The routines in the home were flexible. Residents confirmed this. The residents could choose where to eat their meals and made varied comments about the food. One resident said “the food is good and plenty of it” and another person said “there is no choice at lunch time’. The registered manager said there was a choice at all meal times, and special diets are catered for. Records of meals served showed what each person had. There was no menu board displayed to indicate choices on offer, however the cook said she asked everyone individually for their preference. Residents gave the cook compliments about the food. A cooked breakfast was available on request. The registered manager had maintained a record of actual meals served which had been kept up to date since the last inspection. The practice of serving tea to residents from a catering kettle could be improved and residents given some responsibility within the limits of safe practice to serve themselves. Spring Cottages DS0000009483.V289541.R01.S.doc Version 5.1 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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16,18 The quality outcome in this area is good. This judgement has been made using available evidence including a visit to the service. Residents had access to a simple and clear complaints procedure. The home had appropriate policies and procedures to protect the residents from abuse. EVIDENCE: A copy of the complaints procedure was displayed in the home, and was included in the information given to current and prospective residents. The procedure gave clear directions on whom to make a complaint to and the timescales for the process. The home had a recording system in place and had received three complaints, which had been sent direct to the Commission. Whilst the complaints had been investigated the outcome for one complaint remained unresolved. Comments reveived at the Commission showed that from ten responses seven residents knew how to make a complaint. Responses also showed residents knew who to speak to if not happy and one comment read, I have never even thought about this as I have no problems at all. One referal had been made under adult protectionm protocols and was currently being investigated. The home had acted promptly and was following guidance. Issues raised regarding care staff responsibility to report any incident was managed professionaly by the manager. Further training was provided for staff to support them to confidently use the procedures. The issue of protecting residents was also evidenced as being raised in staff supervision and staff meetings. The home had a copy of “No Secrets in Lancashire” and an
Spring Cottages DS0000009483.V289541.R01.S.doc Version 5.1 Page 17 appropriate internal procedure for staff to follow should they suspect or witness an incident of abuse. A whistle blowing policy was in place for staff reference. One staff interviewed confirmed that she had also received training in respect to the adult protection procedures as part of NVQ training. Spring Cottages DS0000009483.V289541.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19,20,21,23,24,25,26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. The residents were provided with a warm, comfortable, clean environment that suited their needs. EVIDENCE: Spring cottages is a large property, situated in a semi rural area. There were ample parking facilities at the front of the building, and attractive garden areas on either side of the property. The home is a two-storey building; the two floors being linked by two chair lifts. There were 18 single bedrooms, 12 of which had an en - suite facility, and 2 double rooms. Residents had the benefit of two lounges, two dining areas and a conservatory that were bright, pleasantly decorated and furnished to a relatively good standard. An application was made to convert a double bedroom into a single room with en suite facilities has been completed to a satisfactory standard. A change to the registrationis currently being processed by CSCI. Since the last inspection outstanding work required to bring the home up to standard had been completed. This included new floor covering in non slip
Spring Cottages DS0000009483.V289541.R01.S.doc Version 5.1 Page 19 material fitted into bedrooms where there was an odour control management problem. Residents spoken to were ‘very pleased’ with this. The residents were happy with their rooms, which they described as “comfortable and warm”. With the exception of two ensuite facilities, ensuites were open plan in bedrooms. This suited one resident who sent comments to the Commission as part of inspection, as it meant she maintained her independence as she couldn’t manage to open a door. The manager said sinks were to be fitted with thermostacically controlled valves. To protect vulnerable residents, risk assessments had been carried out to help keep them safe. One top floor bathroom required upgrading. The registered provider and registered manager said this room was currently being reviewed. Residents did not use this bath preferring other facilities in the home. The bathroom however did require tidying of surplus items such as laundry bags, as one resident was observed going in to use the toilet. The laundry was equipped with suitable washing machines, and areas were available outside to hang clothes out in finer weather. Driers were available to use and all residents had been given individual baskets for staff to use when clothes had been laundered. To help staff handle soiled laundry and protect residents from the spread of germs, they provided with protective clothing that included disposable gloves and aprons. Responses sent to the Commission show residents thought the home was fresh and clean. One comment read ------is always very particular. Whilst the overall standard of cleanliness was satisfactory there were some areas of the home, which required a more thorough clean for instance better attention was required to keep skirting boards clean. Arrangements were in place however, to show accountability for cleaning. One resident said her accommodation was very good and clean, they employ a cleaner for this. Residents had access to outdoor areas. Seating was provided and the conservatory was pleasant and large overlooking the garden. Residents said they enjoyed sitting there. Spring Cottages DS0000009483.V289541.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29,30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to the service. Sufficient staff were on duty to meet the needs of the residents. Staff were trained. Recruitment procedures did not fully meet statutory requirements. EVIDENCE: At the time of inspection sixteen care staff were employed and three 3 ancillary staff. The registered Manager had maintained a written staff rota, copies of which were sent to the Commission. These showed the level of staffing was suitable for residents needs being met, and senior staff were on duty at all times. A number of staff had left the employment since the last inspection. Reasons for leaving were recorded on information recieved by the Commission. Several new employees records showed how recruitment practice was carried out. Employment checks however need to improve for example, gaps in employment had not been recorded on the application form or interview notes taken to explain these. In addition, evidence to support the manager in making a judgement to employ in view of the content of Criminal Record Bureau (CRB) disclosure had not been documented. Staff confirmed they received induction training that covered policies and procedures and basic care. This was evidenced in staff records. Staff employed working a probationary period should be given a contract to cover this time.
Spring Cottages DS0000009483.V289541.R01.S.doc Version 5.1 Page 21 This will help to make sure they agree with conditions of their employment, for example respecting confidentiality and acceptance of gifts from residents. The manager said all staff received a contract, however one member of staff said she hadnt. The manager said contracts were given when staff finish their probationary period and no tempory contracts were issued. Staff said they had job specifications. Information received at the Commission showed that the percentage of staff having accomplished National Vocational Qualification (NVQ) level 2 and above was 68.75 . Staff had a written training assessment and profile which showed other mandatory training had been provided. Information from the registered manager to the Commission showed other training had been planned for the year. The manager said training was ongoing such as essential training like moving and handling, fire and first aid. Spring Cottages DS0000009483.V289541.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31,33,34,35,36,37,38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. The home was generally well organised and managed efficiently. Residents and relatives influenced how the home was run. Guidance and support was given to staff. The registered person ensured a safe environment and safe working practices for the benefit of residents and staff. EVIDENCE: The manager has many years experience in residential care. She has qualifications in management that includes the Registered Managers Award. She also holds an Assessors Award D32 and D33. This is beneficial for staff in the home studying National Vocational Qualification in care. The manager however has yet to complete NVQ level 4 in care. The registered providers have an active role in management of Spring Cottages and there are clear lines of responsibility for these roles.
Spring Cottages DS0000009483.V289541.R01.S.doc Version 5.1 Page 23 Consultation processes in the home was both formal and informal. Progress had been made to monitor the quality of the service. Residents had completed satisfaction questionnaires, and the results collated and published. A copy was available for inspection. Residents also benefited from having regular meetings to discuss issues they felt were important to them such as meals served and entertainment and activities. Minutes of these meetings were available to look at. Staff had regular meetings. These were focussed on good practice issues in caring for older people. The home achieved an Investors in People Award which had recently been renewed. An annual business and financial development plan had been produced. This showed that there was continuing investment being made to improve overall standards in the home. Staff confirmed they received regular supervision. The format of supervision was good and included topics such as eight points of regulatory practice, principles of care and training needs. The records pertaining to the payment of fees by residents were complete and records to record the payment of fees by privately funded residents were in order. The registered manager was appointee for one resident. This was documented clearly and an audit of money held at the home was correct. There was a set of policies and procedures, and according to written documentation sent to the Commission, these had been reviewed in line with current good practice and legislation. Not all records required by the Care Homes Regulations 2001 were complete and up to date, these included the records referred to in schedule 2 in relation to staff. Arrangements had been made for some mandatory training. Fire safety procedures were evidenced as being given to staff and regular fire drills carried out. Information contained in the pre – inspection questionnaire returned to the Commission indicated that the electrical safety certificate was valid and gas installations had been approved by an engineer. Information received at the Commission during the year verified the manager reported significant events and occurrences when they occurred. The storage of cleaning products was satisfactory, and risk assessments had been completed for hot water taps at residents sinks. Plans to fit thermostatic valves had been made. Spring Cottages DS0000009483.V289541.R01.S.doc Version 5.1 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 X 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 2 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 3 3 X 3 3 2 2 STAFFING Standard No Score 27 3 28 3 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 3 3 3 3 3 3 Spring Cottages DS0000009483.V289541.R01.S.doc Version 5.1 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 OP7 Regulation 15 (1) 17(1a)sch 3 Requirement The registered person must ensure that the care plans set out in detail all the action that care staff need to take to meet all aspects of the health, personal and social care needs. These must be personalised in all matters listed in standard 3.3 Previous timescale 31/01/06 not met. The registered person must ensure that the homes recruitment procedures are fully in accordance with the Care Homes (Amended) Regulations, including satisfactory written explanation of any gaps in employment. Timescale for action 31/05/06 2. OP29 19 (4)(b), sch 2 31/05/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Good Practice Recommendations
DS0000009483.V289541.R01.S.doc Version 5.1 Page 26 Spring Cottages 1 2. 3. 4. 5 6 7. Standard OP7 OP15 OP25 OP26 OP29 OP29 OP31 It is recommended staff are advised to record information about resident care in a manner that shows positive outcomes. It is recommended residents be given the opportunity to serve their own cup of tea at meal times. It is recommended alternative storage be found for laundry bags kept in the upstairs bathroom, and this room be cleared of all surplus articles. It is recommended that painted woodwork is kept clean internally and externally. It is recommended that a record be made during interview that includes details of criminal convictions and cautions of applicants to support the decision to employ. It is recommended temporary staff are given a contract to cover their probationary period of employment. It is recommended the registered manager gain a National Vocational Qualification in Care level 4 or obtains written confirmation that existing qualifications are sufficient. Spring Cottages DS0000009483.V289541.R01.S.doc Version 5.1 Page 27 Commission for Social Care Inspection East Lancashire Area Office 1st Floor, Unit 4 Petre Road Clayton Business Park Accrington BB5 5JB National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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