Inspection on 01/03/07 for Spring Gardens

This inspection was carried out on 1st March 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 Gardens 14/12/05

Spring Gardens 28/06/05

Spring Gardens 21/12/04

Spring Gardens 24/06/04

Spring Gardens 25/02/04

Similar services:

Snydale Care Home

Abbey The

Hawkhills

Larchfield Manor

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 Gardens Westbourne Grove Otley Leeds LS21 3LJ Lead Inspector Valerie Francis Unannounced Inspection 10:30 1st March 2007 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 Gardens DS0000033235.V323391.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 Gardens DS0000033235.V323391.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Spring Gardens Address Westbourne Grove Otley Leeds LS21 3LJ 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) 01943 464497 Leeds City Council Department of Social Services Mrs Angela Mosby Care Home 30 Category(ies) of Old age, not falling within any other category registration, with number (30) of places Spring Gardens DS0000033235.V323391.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 14th December 2005 Brief Description of the Service: Spring Gardens is a purpose built local authority care home situated in the small market town of Otley in West Yorkshire. It provides personal care and support for up to 30 older people who are not in need of nursing care. There are 28 permanent places and two places for residents who come for respite care, the home also provides Day Care for three people from the community who uses the home for respite. The home is run by Leeds Social Services Department and managed on its behalf by Angela Mosby. The two-story building enables residents to have bedrooms and utilise communal seating areas on either floor. The majority of rooms, which vary in size, are now single occupancy but there are two double rooms for couples. There are no en-suite toilet facilities. The home is situated in a quiet residential area, which has easily accessible bus services or a short walk into Otley town centre, which has a wide selection of shops, and riverside walks. There are connecting services into Leeds, Bradford and Harrogate. The majority of residents are from the Otley area and have the benefit of being able to retain contacts with friends, family and former neighbours quite easily. The fees range from £70.85 to £ 458.86 per week additional charges are made for chiropody, hairdressing, daily papers, toiletries, some activities and transport. This information was provided by the home on the pre-inspection questionnaire completed in January 2007. Spring Gardens DS0000033235.V323391.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The Commission for Social Care Inspection (CSCI) inspects homes at a frequency determined by how the home has been risk assessed. The inspection process has now become a cycle of activity rather than a series of one-off events. Information is gathered from a variety of sources, one being a site visit. All regulated services will have at least one key inspection between 1st April 2006 and 30th June 2007. This is a major evaluation of the quality of a service and any risk it might present. It focuses on the outcomes for people using it. All of the core National Minimum Standards are assessed and this forms the evidence of the outcomes experienced by residents. More information about the inspection process can be found on our website www.csci.org.uk This visit was unannounced and one inspector was at the home from 10.30 until 18.30 on the 1st March 2007. The care officer in charge facilitated in this inspection process. The purpose of the inspection was to make sure the home was operating and being managed for the benefit and well being of the residents and in accordance with requirements. Before the inspection accumulated evidence about the home was reviewed. This included looking at any reported incidents, accidents and complaints. This information was used to plan the inspection visit. A number of documents were looked at during the visit and all areas of the home used by residents were visited. A good proportion of time was spent talking with residents as well as with the care officer and other staff. A pre-inspection questionnaire (PIQ) had been completed before the visit to provide additional information about the home. Some survey forms were sent to the home, providing the opportunity for residents and/or visitors to comment on the home, if they wish. Information provided in this way may be shared with the provider but the source will not be identified. Comments from residents and their relatives are highlighted in the body of this report. Spring Gardens DS0000033235.V323391.R01.S.doc Version 5.2 Page 6 What the service does well: What has improved since the last inspection? What they could do better: The manager must make sure that the home’s information available to residents and interested parties is up to date. The manager must ensure that the information gathered at the pre assessment is enough to put together a comprehensive plan of care “ life Style Plan”. The manager must make sure that residents plan of care “life Style Plan” is more specific to the specialist care needs of the people with dementia. Spring Gardens DS0000033235.V323391.R01.S.doc Version 5.2 Page 7 The managers must make sure that clear and detailed care plans are in place for all the residents to provide clear instructions for staff and evidence that care needs are met. Some consideration should be given to provide staff with a course that provides them with much more information on the safe handling of medicine. The medication trolley must be stored in a safe area. The manager must ensure that all residents have access to social recreational activities. The registered provider must make sure that there is enough staff available to residents at all time, taking into consideration their care needs and the lay out of the building. 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 Gardens DS0000033235.V323391.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 Gardens DS0000033235.V323391.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): 1.3 and 4 (Standard 6 does not apply to this home). Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Prospective residents and their families have access to information to help them make a decision about moving into the home. Pre-admission information is gathered. EVIDENCE: Information about the home is available to current and prospective residents. There is a brochure as well as a statement of purpose and service user guide. There was no evidence that the statement of purpose and service user guide had been reviewed, as some of the information was out of date such as some staff and responsible person for the organisation information was not correct. Copies of these documents are available in the home and copies can be provided if necessary. Prospective residents and/or their representatives are Spring Gardens DS0000033235.V323391.R01.S.doc Version 5.2 Page 10 welcome to visit the home to help them make a decision. The home has a website where people wanting to live at the home have the opportunity to access more information about the home and the surrounding places of interest. All residents or their relatives and staff signed a document that indicate that they have agreed to have their photograph on the website. The manager or care officer carries out the pre assessment at visits to the person’s home, and the hospital. A visit to the home is also arranged so that prospective residents and their representatives have an opportunity to look around. The individuals have the opportunity to spend the day, looking at home life, meeting other residents and for further assessment, if there was a vacant room the person have the opportunity of an over night stay. Four care files were seen, two of which were people who had recently moved into the home. The information in care files seen indicated that although people had a preassessment, the information gathered was not enough to put together a comprehensive care plan. However, both people had an up to date local authority “Easy care” document and other detailed information gathered from other professionals about the residents which provided staff with good information on the care needs. Information gathered is put in the individual plan of care “Life Style Plan” with instruction to staff how to meet the person’s care needs. From information seen and from discussion with staff it was evident that some training is given to staff with regards to meeting the specific care needs of people accommodated at the home. Spring Gardens DS0000033235.V323391.R01.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this home. Resident’s health and personal care needs are assessed and recorded in their “Life Style” plan of care. Residents are protected by the medication policies and procedure. The staff respect the privacy and dignity of residents. EVIDENCE: The care records of four residents at the home were looked at in detail. All residents have individual care plan in the form of a Lifestyle plan. The standard of recording information about the residents on these documents was variable. There was some good personal detail in some plans clearly indicating personal preferences about care needs and life history. There were summaries of the lifestyle plans, which had been completed and monthly review information seen. Spring Gardens DS0000033235.V323391.R01.S.doc Version 5.2 Page 12 There were regular six weeks and six monthly reviews carried out, involving the resident, family and others involved in their care. Support and guidance is also sought from other healthcare professionals when necessary. Residents, or their representatives had signed lifestyle plans. Nutritional risk assessments were carried out. However if any risks were identified, there was no action plan for staff to follow to manage/minimise the risk. There were records of the involvement of other healthcare professionals. General Practitioner (GP) visits in particular were well documented and in conjunction with daily records gave a picture of the condition of a resident who was unwell, However no changes had been made to his Life style plan and actions for staff to follow to meet the change in care needs. From the information seen in the pre inspection questionnaire the home has a high percentage of residents who have a diagnosis of dementia, however there was no indication on any file how a person centred care will be provided. During discussions with staff it was evident that they were knowledgeable about the individual care needs of the residents who said they felt well looked after by the staff. However, records need to provide clear evidence of the good care provided and any change in care needs. A CD (controlled drug) cupboard is in place and a CD hard back record book, which is signed by two members of staff. The member of staff making the returns and the pharmacist receiving it, sign the record book for medication returned to the pharmacy. Staff administering medication have had a days training on the safe handling of medication, policies and procedures on safe handling of medicine are available. The home uses the Nomad pre packaged system. Each cassette has photo of the resident to identify whose medication they are. The administration sheet also has a photo of the individual. The medication room is a well-organised area and kept locked with the keys held by the person in charge. However, it was noted that medication trolley is kept in the dining room and not stored in a safe place as recommended in accordance with (RPS) Royal Pharmaceutical Society guideline for residential homes. The inspector was told that the trolley is stored in the medicine room after the evening medication is given. Spring Gardens DS0000033235.V323391.R01.S.doc Version 5.2 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this home. Residents are able to exercise choice in their daily routines however not all residents social expectations are always met. Residents are provided with a varied and nutritious diet that they have chosen. EVIDENCE: During the inspection residents were seen moving around the home talking to each other, those who were dependent on staff they were either watching television as or just sitting talking. The television was kept on all day, at the request of some of the residents sitting in this area. Some People spent time with their friends in groups in one of the small sitting rooms watching their favourite programmes or talking amongst themselves. Spring Gardens DS0000033235.V323391.R01.S.doc Version 5.2 Page 14 Items made by residents and a relative were displayed for the forthcoming Easter raffle. One resident was knitting squares; the care officer said that there is a knitting circle where residents were knitting things for the Easter fayre. During the inspection one resident said that she was bored and needed something to do, immediately action was taken to engage her and several other residents in games of dominos. One said she would have liked to go out for a walk with staff assistance but because of the staffing level this was not possible. Planned activities were displayed on the notice board in the hallway for activities such as sing along and weekly motivation exercise sessions. It was obvious from the discussion with some residents that they knew of activities that take place in the home, and were not bored and said they spent their days how they wished. Residents have the opportunity to discuss social activities and other issues that affect them and the day to day running of the home at their monthly meetings. The inspector was told that activities with residents are carried out dependent of the staffing level on the day. The home has a loop system for hard of hearing residents, but for some time now it needed repairing, so that residents can benefit from television and music being played in the home. Visitors are made welcome at the home throughout the day and refreshments are available for them. The home offers day care to three people from the community, who indicated that they were happy with the service they receive and they spent their time talking to the people living at the home that they had befriended. One person having day care said she came to the home for regular respite care said she always looked forward to coming into the home for her stay. Views of residents are taken into account in the menu planning and there is a good choice of food available at all mealtimes. Residents spoke well of the food, saying that they were also able to ask for food not on the menu. It was apparent that the chef works closely with the residents, staff and any professional involved in the dietary needs of residents, to make sure that they receive meals that are nutritious that meet needs. Residents take their meals in the large dining area, however they could if they wish have it in their room or one of the sitting rooms in the different areas of the home. Spring Gardens DS0000033235.V323391.R01.S.doc Version 5.2 Page 15 Spring Gardens DS0000033235.V323391.R01.S.doc Version 5.2 Page 16 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this home. Residents felt confident that their concerns would be listened to and knew how to make a complaint and felt safe. EVIDENCE: Residents were not necessarily aware of the complaints procedure but felt confident that they could tell the manager about any concerns and they would be taken seriously. All residents spoken with felt safe and well cared for at the home. A copy of the complaints procedure is available on the notice boards that are accessible to residents and visitors. The manager should consider putting these in a larger print so that they can easily be read. The copy displayed in the staff room had incorrect details of the regulators and the responsible person for Social Services. Most Staff have received training with regard to adult protection, and they also have access to the whistle blowing procedure. Although there are policies and procedures in the home these are not always readily available to staff. Advice was given that these procedures are more Spring Gardens DS0000033235.V323391.R01.S.doc Version 5.2 Page 17 readily available to staff by displaying a copy on the notice board in the staff room. It was evident from the discussion held with staff that they knew what to do if an allegation of abuse had been brought to their attention. Information leaflet about adult protection and what is abuse is displayed on the notice board in the main setting area. Spring Gardens DS0000033235.V323391.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19 and 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this home service. Residents live in a clean and generally safe environment. All prospective residents bedrooms have the opportunity to personalise their bedroom. EVIDENCE: All areas of the home which were visited during the visit were clean, tidy and in a good state of repair. Bedrooms were comfortable, having been personalised by residents. There was evidence of work carried out to meet the recommendations made by the West Yorkshire Fire Service Schedule 2 with regards to fire compartments at the home. The partition that was built needed decorating. Spring Gardens DS0000033235.V323391.R01.S.doc Version 5.2 Page 19 During the inspection of the premises several issues was seen that needed some work done or replacement. The kitchenette wall tiles needed replacing and the ceiling needed plastering. The dining area was cold, some residents complained of the cold in this area. Many had cardigans and had wrapped themselves in blankets to keep themselves warm because there was only a warm air heater in this room and part it was not working. The wall cupboard in the dining room had broken drawers, was generally showing signs of wear and tear and needed replacing. One resident showed the inspector an area in the carpet next to the bed that was bulging which she had trip on. This health and safety hazard was fedback to the care officer. The chairs in the main sitting areas were showing sign of wear and tear in some cases the cushions were sunken. Some residents said at time they were uncomfortable. It was apparent from the evidence that pressure-relieving equipment is used for those residents needing them. The laundry area was clean, tidy, personal laundry is done on-site, and others sent to an outside laundry service. Hand washing facilities are provided throughout the building in the interests of the prevention of cross infection. Hand gel dispensers in most areas needed refilling. Most staff have received training in infection control, however, staff hand sluice soil laundry before putting them in the washing machine, which has a sluice cycle, to stop this process being done, so that infection control is not, compromised this must cease. Spring Gardens DS0000033235.V323391.R01.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29 and 30. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this home. Presently the staffing level at the home during the night could compromise the health and safety of residents and staff. Recruitment procedures protect service users. EVIDENCE: Duty rotas indicated that there were sufficient staff available to meet the needs of the present resident group during the day, however from the information seen in the pre inspection questionnaire there are two residents who require assistance from two staff and fourteen with a dementia. During the day the care staff are also supported by a team of ancillary staff carrying out domestic, laundry and catering duties. During the night there are two night staff, one is designated as senior care with a designated management staff on call at another home in the city. At the time of the inspection there was several staff vacancies, two 30 hours care assistants and two 20 hours domestic. Spring Gardens DS0000033235.V323391.R01.S.doc Version 5.2 Page 21 One of each of these posts has been held for staff being deployed from a home that is being closed. All vacancies are being covered by over time or agency staff. Risk assessments must be carried out of the staffing levels at the home to make sure that residents have access to enough staff to meet their needs over the 24 hours period, taking into account the changing needs of the people living there. There has been very good progress in staff achievement of National Vocational Qualifications (NVQ) in care at the home. 80 of the care staff have achieved NVQ level 2 in care, far exceeding the standard of 50 . Photocopies of application forms, 2 references, and offer letters were available on files, however, there were no copies of terms and conditions of employment. There was evidence that the required (CRB) Criminal Records Bureau and (POVA) Protection of Vulnerable Adults disclosures checks are carried out before staff commence work at the home. Most of the staff recruitment and selection information is held at the head office. All new staff has undergone an induction programme and all staff have formal supervision sessions and appraisal where training needs are identified. There is also a variety of other training in such topics as dementia. The district nursing team provide staff with a programme of short practical courses in areas such as diabetes, pressures area care and end of life care. Although there was a commitment towards training and making sure that all designations of staff are equipped to carry out their roles and to care effectively for the residents, some staff felt that staffing levels do not always permit them to undertake courses that would help them in their personal development, and their delivery of care to residents. Despite the information in the pre-inspection document sent back to the CSCI that indicated that there was a range of training courses arranged for staff, there was no record in the home of a plan for the forthcoming training courses. Information seen on several staff training plan document, showed that some had not had moving and handling training for over twelve months or longer. Spring Gardens DS0000033235.V323391.R01.S.doc Version 5.2 Page 22 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31,33,35 and 38. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this home. An experience manager manages the home and residents are protected and cared for appropriately. The lack of updated moving and handing training could compromise both residents and staff health and safety. EVIDENCE: The registered manager is experienced, providing leadership and stability at the home. The managers have completed the (MCI) Management Charter Initiative training and the NVQ in care at level 4. Spring Gardens DS0000033235.V323391.R01.S.doc Version 5.2 Page 23 All residents, relatives, staff and visiting healthcare professionals were surveyed in 2006. The results have been made available to all parties involved in the process. A newsletter is produced regularly to provide information about changes at the home and such things as activities and events are recorded. Copies of the newsletter are available on the notice board. There is also a large notice board in the entrance area where useful information about the home is displayed. Communication with residents and relatives is carried out informally with the managers operating an ‘open door’ policy. Regular in house care reviews are also held providing the opportunity for residents and their representatives to share any concerns they might have about care or the facilities. Staff meetings are held monthly, notes are kept of the meetings. The home does not act as appointee for residents. Clear records are kept of any money kept with receipts of all transactions. These procedures are subject to regular in-house checks and external audit. Residents have a lockable draw in their rooms for the safe keeping of their valuables. Regular checks of the building are made to make sure that there is a safe environment for staff and residents. Mandatory training is provided to staff with regard to manual handling the records seen indicated that updated courses were needed. The home had recently purchased a new hoist for safe moving of residents. The chef has been designated the health and safety officer for the home to make sure that the home is safe. Information from the PIQ indicated that the officer team was to undertake the moving and handling facilitators and risk management courses. Records are kept of accidents and incidents involving residents and accident reports are held on the individual files. During the course of the inspection of the premises it was not clear from the record seen if PAT testing of electricity equipment had been carried out, on the fridge in the kitchenette this was due in March 2006. Spring Gardens DS0000033235.V323391.R01.S.doc Version 5.2 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 2 X 2 X X N/a HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 3 2 X X X X X X 2 STAFFING Standard No Score 27 2 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 2 Spring Gardens DS0000033235.V323391.R01.S.doc Version 5.2 Page 25 Are there any outstanding requirements from the last inspection? YES STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP1 Regulation 4 Requirement The manager must make sure that the home’s information that is available to residents and interested parties have the current and up to date information. The manager must ensure that the information gathered at the pre assessment is enough to put together a comprehensive plan of care “ life Style Plan” Timescale for action 31/03/07 2. OP3 14 31/03/07 2. OP7 15 3. OP7 15 4. OP38 13 The manager must ensure that 31/03/07 all care needs identified have a plan of care in place of the action to be taken by staff to meet the individual needs. Previous time scale 27/02/06 The manager must make sure 30/04/07 that residents plan of care “Style Plan” is more specific to the specialist care needs of the people with dementia. The manager must make sure 31/03/07 that staff have updated moving and handing training. Spring Gardens DS0000033235.V323391.R01.S.doc Version 5.2 Page 26 5. OP19 16 6. OP12 16 (2) (ii) 7. OP12 16 8. OP27 18 The manager must make sure that the matters related to the premises identified in this report are resolved. The home has loop system for hard of hearing residents, but for some time now it needed repairing, so that residents can benefit from television and music being played in the home. This work must be carried out. The manager must ensure that residents have access to social recreational activities to meet their individual needs. The risk assessment must be carried out, to make sure there is enough staff available to residents over 24hours taking into consideration the size and layout of the building and during the night. 30/03/06 Staff must have training to meet the needs of residents who are terminally ill. Previous timescale 10/03/06. The trolley must be kept fasten to an outside wall when not in use. The hand sluicing of soiled laundry before putting into the washing machine must cease and the use of appropriate bag for sluicing solid linen must be used. The manager must make sure that hand washing facilities are available through out the home. The registered provider must make arrangement for additional heating in the dining room. A plan to be sent to the CSCI area office. DS0000033235.V323391.R01.S.doc 31/05/07 30/04/07 31/03/07 31/03/07 9. OP30 18 31/05/07 10. 11. OP9 13 (2) 23(2)(k) 25/03/07 25/03/07 OP38 12. OP38 16 25/03/07 13 OP25 23 31/03/07 Spring Gardens Version 5.2 Page 27 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. 3. 4. Refer to Standard OP7 OP9 OP12 Good Practice Recommendations Care plans on the last wishes of residents should be in place. Some consideration should be given to provide staff with a course that provides them with much more information on the safe handling of medicines. Some consideration should be given for staff to spend time to engage residents who wish to take part in recreational activities. Spring Gardens DS0000033235.V323391.R01.S.doc Version 5.2 Page 28 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 Gardens DS0000033235.V323391.R01.S.doc Version 5.2 Page 29 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!