Inspection on 30/11/05 for Spring Cottages

This inspection was carried out on 30th November 2005.

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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Spring Cottages 27/04/06

Spring Cottages 07/06/05

Spring Cottages 14/12/04

Spring Cottages 02/06/04

Similar services:

Chirnside House

Keer Sands Residential Home

Ruskin Lodge

Bushell House

Langrigg House

Parkside

Dystlegh Grange

Thornton Lodge

Extracts from inspection reports are licensed from CQC, this page was updated on 09/07/2008.

CARE HOMES FOR OLDER PEOPLE Spring Cottages Stone Moor Bottom, St Johns Rd Padiham Burnley Lancashire BB12 7BW Lead Inspector Mrs Pat White Unannounced Inspection 09:30 30 November 2005 th 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.V274280.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.V274280.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.V274280.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. 7th June 2005 Date of last inspection Brief Description of the Service: Spring Cottages is a care home registered to provide personal care and accommodation for 22 older people and one older person with dementia. 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 17 single bedrooms, 11 of which had an en - suite facility, and 3 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.V274280.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. Summary of the Unannounced Inspection on the 30th November 2005 This inspection was an unannounced inspection and the residents and people who work in the home were not expecting the visit. The purpose of this inspection was to assess important areas of life in the home that should be inspected over a 12 month period, check the progress of previous legal requirements and good practice recommendations, and check other matters in the home which came to the inspector’s notice. At the time of the inspection the Commission for Social Care Inspection (CSCI) had received a complaint about the standard of care in the home, and this had been passed to the manager to investigate. This complaint and the results of the investigation will be summarised in the next inspection report. The inspection took 10 hours, 15 minutes and comprised of, talking to residents, a tour of the premises, looking at residents’ care records and other documents, discussion with the manager and 2 members of staff. Six residents were spoken with and others were observed in their routine daily activities. Three visitors were also spoken with. Some “comment cards” were left in the home for residents and visitors to complete and return to the Commission for Social Care Inspection (CSCI). At the time of writing the report one relative had returned a comment card. Note The summary is particularly written for residents, and staff are asked to make sure some of the residents are able to read it or made aware of it. The home should also ensure that the full report is widely available to all those who are interested. What the service does well: Residents described most staff as caring and kind and stated that they felt well cared for and well treated. Comments like “they will do any thing for you” were made. Most residents said they “liked living in the home”. The home provided a good variety of leisure activities and options for recreation. Spring Cottages DS0000009483.V274280.R01.S.doc Version 5.1 Page 6 The food served was appetising and wholesome and the residents benefited from having a choice of two main courses and desserts at lunch time each day and choice of cooked breakfast. Most residents stated that they enjoyed the food. The home provided attractive and well - maintained gardens and outdoor space for the use of residents, who stated that they enjoyed these. The staff training programme had been developed according to the needs of the residents and the staff and Government guidelines. Staff had completed training in looking after people with dementia. Staff spoken with on the inspection praised the opportunities for training that they had. The home is a family run business, and there is continuity of management from competent and experienced people. What has improved since the last inspection? What they could do better: Spring Cottages DS0000009483.V274280.R01.S.doc Version 5.1 Page 7 The way residents are admitted to the home could be improved. All the needs people have for care and support must be obtained and written down. The plans for residents’ care must have more details about what staff need to do to look after them. This information must be specific to individual residents and not general to all residents. The environment of the home could be further improved by, getting rid of the unpleasant odours in some of the bedrooms, replacing a badly stained carpet in one of the bedrooms and repairing the ceiling in another bedroom. Also the manager must make sure that the residents are not at risk from hot water. This is still outstanding from a number of inspections and must be attended to with priority. The way the home recruits staff could be further improved, and two written references from previous employers should be obtained before the staff start work. 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.V274280.R01.S.doc Version 5.1 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 Cottages DS0000009483.V274280.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1 & 3. Standard 6 was not applicable Useful information was provided about the home and this assisted the prospective residents and relatives to make a choice about whether or not they wanted to live there. However the home’s admission procedures, including pre admission assessments, need to be improved in order to determine whether or not the needs of prospective residents can be met. EVIDENCE: The Statement of Purpose and Service User Guide had been reviewed and updated. These gave prospective residents and relatives useful information about the services and facilities at Spring Cottages. The Service User Guide should include residents’ views of the home. Service User Guides were in the residents’ rooms and a visiting relative confirmed that she had a copy of this booklet. The residents’ files viewed showed that for a recently admitted resident a pre – admission assessment had not been documented. An assessment was dated after admission. The in house assessment documentation included all the Spring Cottages DS0000009483.V274280.R01.S.doc Version 5.1 Page 10 matters listed in standard 3.3 but would benefit from greater detail regarding the residents’ needs including health needs. Some residents who were spoken with were able to indicate how they felt about the home. One resident said that, “everything was alright”. One stated that, things were mostly good, but that “some things could be improved”. Another resident said, “I like living here”. One relative spoken with stated that she felt her relative’s needs were well met at Spring Cottages, that “he seemed very happy there” and that “it’s the best place for him”. Another relative stated that the “overall care in the home” was not satisfactory. Spring Cottages DS0000009483.V274280.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 & 10 There was a comprehensive system for recording the health, personal and social care needs of the residents. These care plans need to be completed in more detail, and in a personalised way, in order that staff know all they need to do to meet these needs. Residents’ health was monitored and promoted, and the procedures for the management of medication ensured the safe administration of medicines. EVIDENCE: All residents had a care plan and the care plan format enabled a comprehensive care plan to be drawn up covering all matters recommended in standard 3.3. Some preferences for the residents’ daily routines were recorded. However not all matters were completed in sufficient detail, and not all were sufficiently personalised, for example, social activities, religious observation, mental health and nutrition. Also there were general risk assessments relating to falls and mobility but these did not address individuals’ circumstances. More information should be transferred from the assessment to the care plan. Examples of this were discussed with the manager. Since Spring Cottages DS0000009483.V274280.R01.S.doc Version 5.1 Page 12 the previous inspection the care plans were being reviewed more frequently. There was evidence of monthly reviews. The residents’ files viewed showed that their health was monitored and promoted and that they had access to all necessary health care facilities. The care given by staff for those vulnerable to pressure sores was detailed on the care plan. The district nursing team provided equipment for the relief of pressure areas. Some equipment was also purchased from the home’s own funds. The assessment and care plans also detailed residents’ continence needs. However more details about the residents’ health and diagnoses must be recorded on the assessment and care plan documentation. There was evidence that the residents’ mental health was monitored and appropriate intervention sought, though this should be better recorded. There was information about diet and meals on the care plan but nutritional screening had not been undertaken. Residents were encouraged to exercise, and were seen moving freely around the home. Some aspects of medication management and administration had improved since the previous inspection and procedures were carried out to ensure the well - being and the safety of the residents. Prescriptions were now being checked by the home prior to dispensing, all staff who administered medication had undertaken appropriate training and the manager had set up a system to prompt GP reviews of medication. However the criteria for PRN (“when required”) and variable dose medication was still not clearly defined and documented in all cases, and one MAR sheet showed gaps in the recording of the administration of medication. There was no lockable facility for medication that requires fridge storage. Residents’ rights to privacy and dignity were respected. Members of staff were seen being respectful and kind to residents, and when talking to the inspector demonstrated an understanding and knowledge about the importance of these principles. All residents who were spoken with stated that staff treated them appropriately and respected their right to privacy, though some stated that some members of staff were better than others. Spring Cottages DS0000009483.V274280.R01.S.doc Version 5.1 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 Residents had choices in some areas of their lives such as meals and leisure activities. There were activities that appeared to meet the interests of residents, and the visiting arrangements encouraged and enabled residents to maintain contact with family and friends. EVIDENCE: Some routines of daily living were flexible to suit individual preferences. For example, residents had choices of leisure activities, food served and rising and retiring to bed times. There was evidence that this aspect of life at Spring Cottages had improved since the previous inspection. Some interests and hobbies were recorded on the care plan and there was evidence that these interests were encouraged. For example one resident enjoyed working in the garden and another was encouraged to follow his hobby of horse racing. Residents who were able, went out independently. Leisure activities in the home included film shows, “sing a longs”, “exercise to music” and handicrafts. Activities were discussed at resident’s meetings and weekly activities were posted on doors. Spring Cottages DS0000009483.V274280.R01.S.doc Version 5.1 Page 14 Visitors who took part in the inspection confirmed that they were welcome in the home at any reasonable time. One visitor who was spoken with praised the staff for their friendliness and welcome. She stated that she could visit at any time, and that communication was good between the staff and herself. She also said staff were approachable and kind” Staff spoken with recognised the importance of choice for residents, and there was choice in matters such as food eaten and leisure activities. Two residents stated that they felt they had more freedom in some aspects of their daily lives since the previous inspection. Residents were able to bring small personal items from home for their bedrooms. A recent complaint highlighted the need for a policy on “access to residents’ records” which is in accordance with the Data Protection Act and includes any rights of relatives, other interested parties and under what circumstances. Spring Cottages DS0000009483.V274280.R01.S.doc Version 5.1 Page 15 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 & 18 There was a simple and clear complaints procedure accessible to residents and relatives in the service user guide. The home had appropriate policies and procedures to protect the residents from abuse. EVIDENCE: The home had a simple and clear complaints procedure. There were copies of this in the service user guide. However this must state that people can contact the CSCI directly at any time with concerns and complaints. A relative spoken with stated that she had seen a copy of the complaints procedure but had not had cause to make a complaint. Residents stated that they knew who to speak to if they were unhappy with any aspect of life in the home. One complaint had been made to the CSCI since the previous inspection and just prior to this inspection. The registered person was investigating this complaint and had been instructed to respond to both the person who made the complaint and the CSCI. There were policies and procedures to protect the residents from abuse and which complied with the relevant guidance. Since the previous inspection an incident of concern had been reported to the Social Services Department. After initial investigations by this department it was not dealt with as an “allegation of abuse”. Spring Cottages DS0000009483.V274280.R01.S.doc Version 5.1 Page 16 Spring Cottages DS0000009483.V274280.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 24, 25 & 26 Spring Cottages provided pleasant and clean accommodation that suited the residents’ needs. However, though residents were satisfied with the accommodation, some parts could be improved, such as the unpleasant odours in some bedrooms. There was sufficient indoor and outside communal space, and the gardens provided attractive areas for the residents to enjoy. EVIDENCE: The premises were well maintained and decorated and certain areas of the home had been improved since the previous inspection. For example, some bedrooms had been decorated when they became vacant, and the dining room and one of the lounges had been recently decorated. There were attractive and well maintained gardens on both sides of the house. There was sufficient communal space consisting of two lounges, a conservatory and a two - part dining room, all of which were smoke free. All these areas were bright, pleasantly decorated and furnished. Spring Cottages DS0000009483.V274280.R01.S.doc Version 5.1 Page 18 There was ample outdoor space around the home, and the well - kept gardens were a pleasant area for residents to walk and sit. Some residents spoke of their appreciation of this. One room that had been used as a shared bed room, was being converted to a single room with an en – suite WC. The bedrooms were furnished, decorated and equipped for the comfort of the residents, and residents had brought small items of furniture with them. Bedrooms were redecorated as they become vacant. A few bedrooms would benefit from minor restoration work to the wallpaper and paintwork. An access door in the ceiling of one bedroom needs to be suitably closed. This was outstanding from the previous inspection and must be addressed with priority. One bedroom carpet was badly stained and needs replacing. One resident said that the home was “draughty” in places, and one relative stated that the home was “cold” at times. Hot water temperatures from the outlets in some bedrooms and a downstairs communal toilet were still considerably over 43 degrees. Action to protect service users from the hazards of hot water temperatures had still not been taken, despite previous requirements (see standard 38). This must be addressed with priority. Residents spoken with were complimentary about the accommodation. The home was clean at the time of the inspection but two bedrooms viewed had an unpleasant odour of urine. This has been noted on a number of inspections and must be addressed with priority. Spring Cottages DS0000009483.V274280.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 29 & 30 The home had sufficient staff on duty to meet the needs of the residents, and the staff training programme was being developed according to the needs of the residents and staff. The home’s staff recruitment procedures had improved since the previous inspection but still did not fully meet statutory requirements or ensure that unsuitable staff were not employed in the home. EVIDENCE: The staffing group was not properly assessed at this inspection, but at the time of the inspection the staffing levels were appropriate for meeting the needs of the residents. In addition staff and residents spoken with stated that they thought there were enough staff on duty. Residents said that staff were caring and competent, but one person said “some staff are better than others”. Members of staff had undertaken training in moving and handling, dementia, infection control and safe handling of medicines. New members of staff undertake the home’s induction training. Members of staff spoken with confirmed the training available and stated that they appreciated the training opportunities offered to them. There were plans to purchase a training package which would provide induction training material in accordance with the Skills for Care (the former TOPSS) specifications. The staff records showed that the home’s recruitment policies and procedures had improved since the previous inspection, and that a new member of staff Spring Cottages DS0000009483.V274280.R01.S.doc Version 5.1 Page 20 had not commenced work with residents until the CRB and POVA checks had been obtained. However this person only had one written reference which gave no indication as to the applicant’s ability or character. The registered person must ensure that two written references are obtained prior to people starting work and that any verbal references are documented. It is strongly recommended that the CRB and reference tracking form be completed. Spring Cottages DS0000009483.V274280.R01.S.doc Version 5.1 Page 21 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 38 The registered person ensured a safe environment and safe working practices for the benefit of residents and staff. However this could be further improved by making sure that residents are protected from the hazards of hot water. EVIDENCE: Standards 33 and 35 were assessed at the last inspection and were not assessed at this inspection. The registered person ensured a safe environment and safe working practices for the benefit of residents and staff. Gas and electrical installations and appliances had been serviced appropriately, as had the fire equipment, the stair lift and the bath hoists. The safety aspects of the home could be further enhanced by measures to protect residents from the hazards of hot water at Spring Cottages DS0000009483.V274280.R01.S.doc Version 5.1 Page 22 outlets not yet fitted with pre set valves that ensure water distribution close to 43 degrees. Water temperatures at these outlets were considerably higher than this, and detailed risk assessments on individual residents were still outstanding from previous inspections. The registered person must ensure, and demonstrate to the CSCI by the 31/12/05, that residents are protected from hot water. Spring Cottages DS0000009483.V274280.R01.S.doc Version 5.1 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 2 X 2 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 2 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 x COMPLAINTS AND PROTECTION Standard No Score 16 2 17 x 18 3 3 3 X X X 2 2 2 STAFFING Standard No Score 27 3 28 4 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X X X X X X X 2 Spring Cottages DS0000009483.V274280.R01.S.doc Version 5.1 Page 24 Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP3 Regulation 14(1) 17(1) sch3 1 Requirement Timescale for action 30/11/05 2 OP7 15 (1) 17(1a) sch3 3 OP9 13 (2) 4 OP9 13 (2) 17(1) sch 3 The registered person must ensure that pre admission assessments must be undertaken and documented for all residents by a suitably competent person and that assessments completed by social workers are also obtained prior to admission The registered person must 31/01/06 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, including risk assessments for the prevention of falls. The criteria for the 31/12/05 administration of PRN and variable dose medication must be clearly defined and documented with the MAR sheets (Previous 3 timescales not met) The registered person must 30/11/05 ensure that all MAR sheets are completed accurately and at the DS0000009483.V274280.R01.S.doc Version 5.1 Spring Cottages Page 25 5 OP16 22 (4) & (6) (b) 23 (2)(b) 6 OP24 7 8 OP24 OP25 16 (1)(c) 23 (2)(p) 9 10 OP26 OP29 16 (2)(k) 19 (1)(b), sch 2 11 OP38 13 (4) (a) & (c) time of administration of medication. The complaints procedure must state that the CSCI can be contacted at any time Previous timescales not met). An access door in the ceiling of one bedroom must be suitably closed (Previous timescale of 30/06/05 not met). The registered person must ensure that the carpet in room 15 is replaced. The registered person must ensure that all areas of the home are kept at a suitable warm temperature for the residents’ comfort. The registered person must ensure that all parts of the home are free from unpleasant odours. The registered person must ensure that the homes recruitment procedures are fully in accordance with the Care Homes (Amended) Regulations, including obtaining two written references from former employers (Previous 3 timescales not met) The registered person must ensure that the residents are safe from the hazards of hot water and inform the CSCI by the said date of the action taken. (Previous 3 timescales not met) 31/12/05 31/12/05 28/02/05 31/12/05 30/11/05 30/11/05 31/12/05 Spring Cottages DS0000009483.V274280.R01.S.doc Version 5.1 Page 26 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2 3 4 5 6 Refer to Standard OP1 OP8 OP9 OP9 OP9 OP14 Good Practice Recommendations The Service User Guide should contain information about the residents views of the home. It is recommended that nutritional screening is undertaken on admission and reviewed regularly. It is recommended that the keys to medication storage are kept on a separate key ring It is recommended that medication stored in the fridge is stored in a lockable facility. When eye drops are prescribed, a separate supply for each eye must be obtained to prevent cross infection. The registered person should develop a policy on “access to residents’ records” which is in accordance with the Data Protection Act and includes any rights of relatives, other interested parties, and under what circumstances. It is strongly recommended that the home keeps detailed records tracking CRB/POVA and reference applications, and documents all contact with the said agencies and personnel. 7 OP29 Spring Cottages DS0000009483.V274280.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 © 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 Cottages DS0000009483.V274280.R01.S.doc Version 5.1 Page 28 - 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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