Inspection on 06/06/06 for Spring Grove

This inspection was carried out on 6th June 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. 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 Grove 06/12/05

Spring Grove 07/07/05

Spring Grove 25/02/05

Spring Grove 11/05/04

Similar services:

Henry Nihill House

Birchwood

The Infirmary

Orchard House Nursing Home

St Josephs Rest Home

Red Court Nursing Home

Spinney (The)

Queen Elizabeth House

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

CARE HOMES FOR OLDER PEOPLE Spring Grove 214 Finchley Road London NW3 6DH Lead Inspector Ms Edi O’Farrell Unannounced Inspection 6 & 9 June 2006 11:00 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 Grove DS0000010336.V288040.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 Grove DS0000010336.V288040.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Spring Grove Address 214 Finchley Road London NW3 6DH 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) 020 7794 4455 Springdene Nursing & Care Homes Limited Mrs Martha Ohene Acquah Care Home 46 Category(ies) of Old age, not falling within any other category registration, with number (46) of places Spring Grove DS0000010336.V288040.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: None Date of last inspection 06/12/05 Brief Description of the Service: Spring Grove is a private care home which provides support to vulnerable frail older people aged 65 and over. The home is registered to provide personal care to forty-six service users the majority of whom are privately funded. The home is furnished to a high standard and is one of four care homes owned by Springdene Care Homes Ltd. Charges are £715 for single and £1,080 for double rooms for long-term care, and £775 and £1,150 respectively for shortterm care. Charges are per month, and a reduction is given for payment by standing order. The building is purpose built over three floors with a smart hotel style front entrance and reception area. All floors can be accessed via 2 lifts. The home has forty single and three double ensuite bedrooms. The double rooms are set aside for couples. Residents also have access to communal toilet and bathroom facilities. Each floor has a small self-service kitchen. The homes main kitchen is on the ground floor adjacent to the dining room. A spacious communal lounge, art room and atrium are also on the ground floor. A library is on the 1st floor, which leads out to the upper landscaped garden. The serviced laundry room, parking area and maintenance workshop are on the lower ground floor. The home provides 24-hour personal care. There is a staff team of 47 including the registered manager, two deputy managers, team leaders, a fulltime housekeeper, activities co-ordinator, qualified chef, kitchen staff and maintenance operatives. The home is situated on Finchley Road NW3, halfway between Swiss Cottage and Golders Green, near to shopping and community facilities. Spring Grove DS0000010336.V288040.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This, unannounced, inspection was carried out over the course of two visits made during one week. The second visit was arranged to check on information gathered earlier in the week, and to meet some more residents and staff. The visits lasted a total of just over seven hours. The Registered Manager was on annual leave so the Deputy Manager and Team Leaders assisted, with additional input from the Operations Manager, and on the second visit, one of the company directors. Records, such as care plans, daily logs and accident forms, were examined. The building was toured, including visiting two people in their bedrooms. Some residents were asked for their views on the running of the home and their experience of living there. Staff were observed carrying out their duties, and in the afternoon shift hand over meeting. They were also asked what it was like to work in the home, and about training opportunities. Feedback was given at the end of both visits, and a comment card was left to be completed and returned to the Commission. Everyone at the home is thanked for their hospitality and in-put to the inspection. The Commission usually uses the term ‘service user’ for people who use social care services. The term ‘resident’ has been used in this report instead, as this is the preferred term used in this service. What the service does well: This is a care home that older people actively choose to move into. They know that their needs will be met in the way that they wish, and that they will be treated with respect. Retaining independence and choice is a high priority for the residents, staff, and the company who run the home. Residents are encouraged to continue the lifestyle and relationships they had prior to moving into the home. They are also encouraged to form new friendships with other residents, and to experience new activities. Where they wish to spend time alone, this is respected. The activity programme, which is very varied, is based on the interests of the residents. It includes opportunities for both group and individual activities. The home is arranged in a hotel style and provides spacious, bright, and airy, in-door communal areas. It is decorated, furnished, and maintained, to a very high standard. The bedrooms are all ensuite, and having some double rooms Spring Grove DS0000010336.V288040.R01.S.doc Version 5.1 Page 6 means that couples, siblings, or friends, can continue living together. The standard of cleanliness is high. Current residents say they are very happy living in the home. They enjoy the range of activities, both in the home and the community, that are organised. Many appreciate living in an area they know, close to family and friends. They describe staff as ‘very good’, ‘respectful, and ‘responsive’. Staff enjoy working at the home. They say that the manager ‘guides and gives opportunities’. They feel that they can raise issues and that they are listened to. They know how the residents want their needs to be met. Members of the company running the home have very regular contact. They demonstrate a very active interest in the quality of the service to the residents. What has improved since the last inspection? What they could do better: The improvement in assessment and care planning records needs to be continued. As stated above the company has already recognised this by setting up a working party. The Commission looks forward to the outcome of this piece of work. All care staff need to receive regular one-to-one sessions with their manager, and this needs to be recorded. These sessions should be at least six times a year. They should cover work performance, and professional development. This contributes to the continued development of the staff team, and ultimately to the quality of the service. Staff training records need to be organised so they reflect the training each staff member has received. Also policies and procedures need to be organised more efficiently, so that all staff can easily access them. This protects residents, staff, and the company, as it means that correct procedure is always followed. Please contact the provider for advice of actions taken in response to this Spring Grove DS0000010336.V288040.R01.S.doc Version 5.1 Page 7 inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Spring Grove DS0000010336.V288040.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 Grove DS0000010336.V288040.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, 2, 3, 4, & 5 Quality in this outcome area is good. This judgement has been made using available evidence, including visits to this service. Residents make an active choice to move into the home. Their needs are assessed, but greater detail on health and personal care would improve the quality of care. EVIDENCE: Brochures are provided, and prospective service users are encouraged to visit the home. A sample copy of the individual contracts was seen. The case files of four people admitted since the last inspection were examined. In response to two requirements there have been improvements in the filing of documents and in care plans. A screening form is completed prior to admission, but, in some cases, this has very limited information about needs and how they are to be met. The home is at a disadvantage in that most prospective service users do not undergo community care assessment, as they are self-funding. They therefore often do not have comprehensive information. The company has identified assessment and care planning as a priority for improvement and set up a working party to develop this aspect of care. Spring Grove DS0000010336.V288040.R01.S.doc Version 5.1 Page 10 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 good. This judgement has been made using available evidence, including visits to this service. Care planning has improved since the last inspection, and residents are treated with respect. EVIDENCE: A total of seven care plans were looked at, and nine residents were asked for their views. Managers and care staff were observed interacting with residents, whilst carrying out their duties. The daily records and district nurse records were looked at. At the last inspection a new assessment and care planning system had been put in place. Staff were being trained to use the system, but it was still relatively new. Each resident now has a care plan, which is being reviewed on a monthly basis. Risk assessments are also in place where needed, for such things as mobility, tissue viability (pressure sores), and fluid in-take. Residents are referred to the District Nurse and GP when necessary. One resident was readmitted to the home from hospital the week of the inspection. The deputy manager had carried out a new assessment, and a new care plan was in place. This included the home arranging a visit from a physiotherapist the day following admission. Spring Grove DS0000010336.V288040.R01.S.doc Version 5.1 Page 11 The level of detail in the care plans seen matches the level of need of each of the residents. Retention of independence is a core value of this home, along with dignity, respect, and privacy. As stated in the previous section of this report very few residents have had community care assessments. The home is therefore reliant on residents and their relatives sharing information about health and personal care needs. In some cases the residents wish to make their own arrangements and their wish for privacy is respected. Managers and care staff demonstrated an ability to balance this with ensuring that health and personal care needs are met. Residents described the care as ‘very good’ and ‘excellent’, and the care staff as ‘all very nice’, ‘attentive’, and ‘they do exactly what I want’. A small audit of the medication trolley and medication administration charts was carried out. The procedures, and training, were discussed with one of the Team Leaders. The medication policies, procedures, and practices are of a good standard, and residents are supported to control their own medication where possible. The whole ethos of this home is on residents retaining as much independence as possible. Staff respect their wishes and right to privacy. Observation of staff and resident interaction during the two visits showed a very high level of mutual respect. In discussion with staff they demonstrated obvious warmth and affection for residents, and concern for their well-being. One element of one resident’s care plan did not match other records. This was discussed with the Operations Manager, who agreed to follow it up with the manager. As other care plans were in order no Requirement has been set. The company have recently investigated a complaint and sent a detailed report to the Commission. This was briefly discussed with the Operations Manager, and a Team Leader, during the first visit. In particular, why the resident concerned had been taken to the local hospital, rather than the GP being called. Their view was that if a resident appears to be unwell then it is sometimes better to take this course of action, rather than them having a lengthy wait for a GP. Spring Grove DS0000010336.V288040.R01.S.doc Version 5.1 Page 12 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 excellent. This judgement has been made using available evidence, including visits to this service. The lifestyle in the home matches residents’ expectations and preferences. Family, friends and the local community are encouraged to be involved. EVIDENCE: The home continues to provide a wide range of activities, which service users actively enjoy, and appreciate. Daily records of activities are kept in each care plan. As stated earlier in this report the retention and promotion of independence is a core value of this service. Visitors are encouraged, as is continued involvement with community activities that residents were involved in prior to moving in. Community involvement is also encouraged. The home recently ran a very successful music competition for local schools: the winning school getting a £500 prize. This ran over an eight-week period, and residents greatly enjoyed it. There is shortly to be a ‘Bring and Buy’ sale, with the proceeds being given to a charity chosen by the residents. The types of activities are extremely important as people in care homes are more usually seen as passive recipients, rather than active givers. The residents spoken to during the two visits were extremely clear about their right to choose to take part in activities or not. Spring Grove DS0000010336.V288040.R01.S.doc Version 5.1 Page 13 The menus are varied, with plenty of fresh vegetables and fruit. Residents’ comments about the food were variable, some said it was very good, whilst others felt it varied. Although not a specialist home a large percentage of the residents are Jewish. Festivals are observed to the level that the residents wish. Candles are lit each Friday, the ceremony being carried out by either a resident or Jewish member of staff. Spring Grove DS0000010336.V288040.R01.S.doc Version 5.1 Page 14 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, 17 & 18 Quality in this outcome area is good. This judgement has been made using available evidence, including visits to this service. Although some key documents could not be found in the home residents are protected by the home’s response to complaints and potential abuse. EVIDENCE: Complaint records were examined and staff were asked about their responsibilities in relation to potential abuse. A recent complaint and a concern regarding the potential vulnerability of one resident were discussed with managers. Complaint investigation is thorough, and carried out by either the Responsible Individual or the Operations Manager. In some cases both would be involved. Reports produced for the Commission, and those carried out internally, are comprehensive. They clearly show how investigations have been carried out, and provide supporting evidence for conclusions. Where elements of complaints have been fully or partially substantiated appropriate remedial action has been taken. There is a current investigation by the Local Authority into concerns raised by a relative of an ex-resident. As this is still on-going no conclusions have been reached. The home has co-operated with this investigation. There was evidence in one care plan of the manager having raised concerns about the vulnerability to abuse of one resident. There was a care plan in place to deal with this, but the action agreed with the relative did not match other records. The Operations Manager is looking into this. Spring Grove DS0000010336.V288040.R01.S.doc Version 5.1 Page 15 The home should have a copy of the Local Authority policy and procedure on the protection of vulnerable adults, in addition to their own in-house document. This is important as Local Authorities are the lead agency for this, and must be informed of all suspicions/allegations. Each Local Authority has their own document, which is based on No Secrets, the Department of Health guidance. A copy of a neighbouring authority’s document was available in the home, but not the host authority. A copy must be obtained. This is Requirement 1. Once obtained the Local Authority document will need to be compared to the in-house policy and procedure. This may mean revision, and an updated copy must be sent to the Commission. Refer to Requirement 1. The staff training records did not include any information about recent training on adult protection. However in a group discussion staff were very clear that they had fairly recently watched a video and had discussions about adult abuse. They were also very clear about their responsibilities to report any suspicions to their managers. They were also clear that they could contact social services and the Commission. The in-house policies and procedures on both adult protection and whistle blowing are contained in the company’s operational policy. During the first visit this could not be found in the home. A copy was brought from another home, but this did not contain the full documents, e.g. the whistle blowing policy referred to the need for staff to read the full policy. Copies of the full policies were not available in the home, but were provided by email following the visit. This is covered further in the management section of this report. Refer to Requirement 3. Despite the availability of clear policies and procedures relating to adult protection there is sufficient other evidence, from staff and files, to support the above judgement. Spring Grove DS0000010336.V288040.R01.S.doc Version 5.1 Page 16 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, 22, 23, 24, 25 & 26 Quality in this outcome area is excellent. This judgement has been made using available evidence, including visits to this service. Service users live a wellmaintained environment, which is decorated and furnished to a very high standard. EVIDENCE: The home was toured, including visiting two bedrooms with the permission of residents. Recent problems with lighting were discussed with the handyman. The cleaning of the kitchen was discussed with the chef. There are spacious communal in, and out, door areas. Furnishing and decoration are of a high standard, and any repairs that are needed are carried out promptly. There is access to outdoor seating areas at both ground and first floor level. All bedrooms are ensuite, and there are three double rooms where couples, siblings, or friends, wish to share. Residents can also pay for extra space, such as singly using a double room, if they wish, and if one is available. There Spring Grove DS0000010336.V288040.R01.S.doc Version 5.1 Page 17 are toilets on the ground floor if residents do not wish to go upstairs during the day. There is full disabled access, including two lifts. In addition to the ensuite faculties there are also showers and an assisted bath. This enables the home to meet a range of personal care needs, and the preferences of residents. The home is extremely clean, and the domestic staff were observed to be very diligent in carrying out their duties. The kitchen was deep cleaned approximately two months ago and was sparkling when visited. Spring Grove DS0000010336.V288040.R01.S.doc Version 5.1 Page 18 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 good. This judgement has been made using available evidence, including visits to this service. The staff team, who are trained and competent to do their jobs, meets residents’ needs. The recording of training needs to be more systematic. EVIDENCE: Residents were asked for their views, staff were observed carrying out their duties, and training records were examined. An afternoon hand over meeting was attended and a separate group discussion held with staff. Staff rotas were checked. Staff very clearly know the needs, and wishes, of each resident. This includes the level of independence and privacy that each person wants. It is a very stable staff team, and those spoken to enjoyed working at the home. There is a very clear staffing structure with a manager, deputy, team leaders, senior carers and carers providing personal care. There are also dedicated catering and dinning room staff, a housekeeper, reception and administrative, laundry, and maintenance, staff. Residents spoke highly of staff, and the interactions observed during the visits were professional and caring. Recruitment files were not checked as part of this inspection as HR has been centralised, so staff files are no longer kept in the home. Recruitment was discussed with the deputy, Operations Manager, and one of the Responsible Spring Grove DS0000010336.V288040.R01.S.doc Version 5.1 Page 19 Individuals. Because there is a stable staff team little recruitment has been done since the last inspection, when there were no outstanding Requirements for this Standard. The Commission is satisfied that there continues to be a robust recruitment procedure. Staff confirmed that they receive regular training, and some records were seen. However, the records did not reflect the level of training that staff reported they had received over recent months. Refer to Requirement 3. Spring Grove DS0000010336.V288040.R01.S.doc Version 5.1 Page 20 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, 32, 33, 34, 35, 36, 37 & 38 Quality in this outcome area is good. This judgement has been made using available evidence, including visits to this service. The home is well run, in the interests of service users. However there is a lack of clarity about the most up-to-date policies and procedures. This could place service users at risk, if there are situations where staff are not able to follow correct procedure. Apart from this the health, safety, and welfare of service users are promoted and protected. EVIDENCE: The Registered Manager was on leave, so Team Leaders and The Operations Director took part in the inspection. They are thanked for their input. Residents, staff, and senior management were asked for their views on the management and running of the home. All described a well run home, in the best interests of the people who live there. An ethos of independence, choice, dignity, and respect, was well demonstrated across the two visits. Spring Grove DS0000010336.V288040.R01.S.doc Version 5.1 Page 21 Staff described the manager as approachable, and ‘correcting well’, as well as ‘giving opportunities’. They felt that their views were listened to and acted upon, as did the residents spoken to. The company that owns the home has recently opened a fourth home. It is financially viable. Residents either manage their own finances or have relatives or legal representatives to do so. The Company, senior managers, and staff respect the right of privacy that many residents wish for in relation to their financial affairs. Supervision records were checked, and discussed with the deputy manager. The home is not currently meeting the Standard of at least six times a year for formal, individual, sessions. This is Requirement 2. Several policies and procedures seen were either undated, or dated as produced several years ago, 1997 for instance. It was reported that the most up-to-date documents would be in the Operational Policy. As a copy could not be located in the home, one was brought from another home. This is up-todate, but in some cases does not have the full policy and procedure, but refers to them, such as whistle blowing and adult protection. It is important that all staff are aware of, and have access to company policies and procedures. Otherwise, if they fail to follow correct procedure they may put themselves, service users, and the company at risk. Where policies and procedures have been superseded by new documents, then the old documents must be either destroyed or archived. Similarly training records were not up to date, and information was filed in two separate places. The management of the home is let down by a lack of systematic document storage. This is Requirement 3. A sample of Health and Safety records were examined and found to be up-todate. Spring Grove DS0000010336.V288040.R01.S.doc Version 5.1 Page 22 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 3 3 X HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 4 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 4 14 3 15 X COMPLAINTS AND PROTECTION Standard No Score 16 3 17 3 18 2 4 4 4 4 4 4 4 4 STAFFING Standard No Score 27 3 28 3 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 3 3 3 2 2 3 Spring Grove DS0000010336.V288040.R01.S.doc Version 5.1 Page 23 Are there any outstanding requirements from the last inspection? NO 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 OP18 Regulation 13(6) Requirement Timescale for action 31/08/06 2. OP36 18(2) 3. OP18 13(6), 18(1)c,17 The Registered Persons must obtain a copy of the Local Authority policy and procedure on the protection of vulnerable adults. They must review the inhouse procedure to ensure that it complies with that of the Local Authority. A copy of any revised in-house policy and procedure must be forwarded to the Commission. 31/08/06 The Registered Person must ensure that all care staff receive formal one-to-one supervision at least six times per year. This must cover all aspects of practice, philosophy of care in the home, and career development needs. These sessions must be recorded in writing so that there is evidence they are occurring. The timescale for action date is for the arrangements to have been put in place. The Registered Person must 30/09/06 ensure that all policies and procedures are available for staff to refer to on a day-to-day basis. They must be up-to-date, and DS0000010336.V288040.R01.S.doc Version 5.1 Spring Grove Page 24 comply with legislation and guidance. Records of such things as staff training and supervision must be up to date and accessible. RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Spring Grove DS0000010336.V288040.R01.S.doc Version 5.1 Page 25 Commission for Social Care Inspection Camden Local Office Centro 4 20-23 Mandela Street London NW1 0DU 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 Grove DS0000010336.V288040.R01.S.doc Version 5.1 Page 26 - 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. 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