Inspection on 20/10/07 for Spring Lake

This inspection was carried out on 20th October 2007.

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 found no outstanding requirements from the previous inspection report, but made 6 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Spring Lake 23/11/06

Spring Lake 15/02/06

Spring Lake 28/07/05

Spring Lake 17/02/05

Spring Lake 22/06/04

Similar services:

Ashlong House

Norbury Crescent (30)

Edenvale

Wadham Avenue

Chatsworth Care - Dawson House

Cowden Road, 52 - 54

Chatsworth Care - Tudor Lodge

Foxley Lane (121a)

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

CARE HOME ADULTS 18-65 Spring Lake Spring Lake 17 Forty Lane Wembley Park Middlesex HA9 9EU Lead Inspector Tony Lawrence Key Unannounced Inspection 29th October 2007 09:20 Spring Lake DS0000017450.V352660.R01.S.doc Version 5.2 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 Lake DS0000017450.V352660.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 Adults 18-65. 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 Lake DS0000017450.V352660.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Spring Lake Address Spring Lake 17 Forty Lane Wembley Park Middlesex HA9 9EU 020 8908 5233 020 8908 5233 springlake@talktalk.net 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) Mr Ian Jones Perpetua Mary Caesar Care Home 11 Category(ies) of Learning disability (11) registration, with number of places Spring Lake DS0000017450.V352660.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 23rd November 2006 Brief Description of the Service: Spring Lake is a registered care home that provides accommodation and care for up to 11 adults who have a learning disability. The home is a large detached house located in Wembley Park, and includes two furnished and decorated outbuildings where residents have the opportunity to take part in day care activities. The home is in a residential area, close to local shops, including a large supermarket, banks, a post office, a library, and cafés. Bus routes and an underground station are within a few minutes walk. The bedrooms are all single occupancy and one has en suite facilities. There is a large, enclosed and well-maintained garden. There is parking for several vehicles at the front of the house. All admissions are planned and the home does not accept emergency admissions. Spring Lake DS0000017450.V352660.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced key inspection took place on Monday 29th October 2007 from 09:20 – 16:45. Tony Lawrence, Regulation Inspector, spent time with residents, staff and the home’s Manager. He also saw all parts of the home and checked care records to track the care received by two people. The home’s Manager completed an Annual Quality Assurance Assessment (AQAA) and the Inspector used this information to help make judgements about standards of care in the home. Confidential surveys were sent to all seven people living in the home, seven relatives or advocates and fourteen members of staff. Their responses and comments are included in this report. The weekly fee for the service is £1,980.25. There is an additional weekly fee of £620.10 for residents who use the home’s day service. What the service does well: What has improved since the last inspection? What they could do better: The provider must agree with each service user or their representative a costed contract for services provided in the home. The Manager must clarify with the pharmacist if one medication taken by two people should be taken at regular intervals or as required. Staff members who have been dismissed for gross misconduct must be referred to the Protection of Vulnerable Adults (POVA) register. The arrangements for paying for residents’ holidays must be clarified. More detail is needed in that daily care records completed by staff. The provider must develop all required policies and procedures. Food must be stored at safe temperatures. Spring Lake DS0000017450.V352660.R01.S.doc Version 5.2 Page 6 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 Lake DS0000017450.V352660.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Spring Lake DS0000017450.V352660.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 2 and 5. People using the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. The home has a clear Service User Guide that has been produced in a format that is accessible to some residents. The guide details what residents can expect and gives a clear account of the specialist services provided. Admissions are not made to the home until a full needs assessment has been undertaken. EVIDENCE: When the Inspector visited, there were seven people living in the home and three vacancies. The four men and three women had all lived together for at least 2 years and there have been no new admissions since 2005. Information provided by the Manager in the Annual Quality Assurance Assessment (AQAA) is evidence that the home has clear referral and admission policies and procedures. The home has developed a Service User Guide that was last reviewed in 2006. The Guide makes good use of symbols to make the information more accessible to some people living in the home. During this visit the Inspector checked the care plan files of two residents. One file included a detailed care needs assessment completed by a social worker from the local authority’s multi-disciplinary Learning Disability Team. The file also included a pre-admission assessment completed by managers and staff from Spring Lake. The assessments were detailed and covered all aspects of the person’s personal and health care. The second file did not Spring Lake DS0000017450.V352660.R01.S.doc Version 5.2 Page 9 include a copy of the original care needs assessment as the person had lived in the home for more that nine years. The Inspector did see evidence that the person’s care needs and care plan were regularly reviewed. Both files included some contract information from the local authorities responsible for funding each person’s placement in the home. The information provided did not include specific information about the services provided at Spring Lake or the person’s terms and conditions of residence. The provider must make sure that the service develops and agrees a costed contract with each person living in the home, or their representative, that covers all of the areas detailed in Standard 5 of the National Minimum Standards for Care Homes for Adults (18-65). Spring Lake DS0000017450.V352660.R01.S.doc Version 5.2 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 and 9. People using the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Some care plans are person centred, agreed with the individual, easy to understand and look at all areas of the individual’s life. A key worker system allows staff to work on a one to one basis and contribute to the care plan for the individual. EVIDENCE: During this visit the Inspector checked the care plan files for two people living in the home. The Manager told the Inspector that care plans are developed with the resident concerned, their relatives / representatives and the local authority responsible for funding their care. One care plan was dated December 2006 and considered the person’s housing needs, daytime activities, personal care, daily living skills, physical and mental health. The plan also included details of contact with family members and other significant people and a weekly programme of activities agreed with the home. The second care plan was more person-centred and was written in the service user’s voice. There was clear evidence that the resident, their relatives and staff from the home and day services were involved in developing the plan. The plan included meaningful and appropriate goals and agreement about how these could be met in the home and the wider community. Staff Spring Lake DS0000017450.V352660.R01.S.doc Version 5.2 Page 11 from Spring Lake had added photos of significant people, places and activities to make the information more accessible for the resident. The Inspector discussed with the Manager that this care plan could be used as the standard that all key workers should be looking to achieve for the residents they work with. During the day the Inspector saw that staff supported residents to make choices about aspects of their lives, including activities, what to eat at lunchtime and where to spend time in the home. Both of the care plan files included risk assessments that had been completed in July and October 2007. The risk assessments covered health and safety and behavioural issues and focussed on the benefits of taking risks and maintaining the two residents’ independence. Spring Lake DS0000017450.V352660.R01.S.doc Version 5.2 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, 15, 16 and 17. People using the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Staff help residents with communication skills, both in the home, and when accessing the community to enable residents to fully participate in daily living activities. People who use services are involved in meaningful daytime activities of their own choice and according to their individual interests and capability. EVIDENCE: Both of the residents’ care plan files checked by the Inspector included a weekly programme of activities. These included sessions in the home’s on-site day service and activities in the local community. When the Inspector arrived for this visit, one resident had already left for a local authority day service and a second person was on holiday with their family. During the morning, staff supported the other five residents to go to the local leisure centre in the home’s mini-bus. Staff later told the Inspector that residents also went to a coffee shop after visiting the leisure centre. After lunch all five people went in the minibus to a local park and then returned to the home for organised session in the day service. One person also went out with one member of staff for a travel training session. Spring Lake DS0000017450.V352660.R01.S.doc Version 5.2 Page 13 During a tour of the home, the Inspector saw that residents had bedrooms that reflected their interests and personalities. Most residents had a TV or music system in their rooms and Managers and staff confirmed that some residents did spend time relaxing in their rooms. The Inspector checked the daily care notes completed by staff and there is a need to improve the standard of recording. The home provides good guidance for staff on what should be included in the daily care notes, but this is not happening. The daily notes seen by the Inspector were brief and concentrated on personal care issues. Some information is recorded separately in an activities log, but the daily care notes need to include more information about social care, linked to identified goals in the residents’ care plans. Details of residents’ relatives, advocates, friends and other significant people were included in their care plans. The manager and staff told the Inspector that some people living in the home had varying amounts of contact with relatives and other people and staff said they would support residents to stay in contact, if required. The Inspector felt that the daily care notes should include more detail about residents’ contact with relatives and other people, including visits by and to relatives, phone calls etc. The Manager and staff confirmed that all seven people living in the home had been on holiday during the last 12 months. Some residents had photos of holidays with other people from the home and relatives displayed in their rooms. There is a need to clarify the arrangements for funding holidays to make sure that residents’ personal money is spent appropriately. Financial records showed that one person paid £872 for additional staff support during a 3-day break in the UK. In addition, the resident also had to pay the cost of the holiday plus the cost of the holiday for the member of staff who supported them. The home’s Manager had written to the local authority asking for agreement to spend the person’s own money on the staffing costs and this was agreed by the Social Services Department. The Inspector felt that this expenditure should not have been paid from the resident’s personal money and the arrangements for funding future holidays must be reviewed and agreed with residents’ relatives / representatives and the local authorities responsible for funding placements in the home. The home has a large, comfortable dining room and staff said that residents could also eat their meals in other areas of the home, if they chose. The home has a full-time cook who prepares meals for residents. The cook showed the Inspector recent menus and these showed a variety of nutritious meals were provided, with choices available at each meal. Spring Lake DS0000017450.V352660.R01.S.doc Version 5.2 Page 14 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19, 20 and 21. People using the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Residents’ healthcare needs are clearly recorded in their care plans. Personal support is responsive to the varied and individual needs and preferences of the people living in the home. EVIDENCE: The Inspector saw that residents’ personal care needs were recorded in their care plans. Staff who spoke with the Inspector showed a good knowledge of individual’s care needs and how these should be met in the home. Staff emphasised the importance of consistency and routine for some residents and were able to describe how they supported individuals. During this visit the Inspector saw that all staff treated residents professionally and with respect. Managers and staff dealt with residents’ requests for attention or support promptly and appropriately. The Inspector found that residents’ health care needs were well assessed and recorded as part of their care plans. There was evidence of good joint working with clinicians, including District Nurses, GP’s, speech and language therapists, psychologists and psychiatrists. Both of the care plan files checked by the Inspector included a Health Action Plan (HAP). One HAP was reviewed in August 2007 and the other in October 2007. The HAP’s covered all aspects of the person’s physical and mental health care needs and how they would be met by staff in the home and other professionals. Spring Lake DS0000017450.V352660.R01.S.doc Version 5.2 Page 15 One HAP included clear guidance for care staff on the management of one resident’s epilepsy and the medication they were prescribed. The file also included a good record of the person’s seizures. Both files included a wellmaintained monthly weight chart completed by staff. Staff were able to tell the Inspector what action they would take if they noted any significant weight loss or gain. All prescribed medication is stored in a lockable cupboard in the home’s main staff office. The Inspector also checked the home’s medication procedures and records. The home uses the Boots Monitored Dosage System (MDS) and all prescribed medication is delivered in blister packs each month. The Inspector checked the Medication Administration Record (MAR) sheets for all seven people living in the home. Each MAR sheet includes a photo of the resident and two members of staff sign the record each time medication is given to a resident. The records were well maintained and the Inspector found no errors or omissions. It was unclear from the records if one medication taken by two people should be taken at regular intervals or as required. A requirement is included in this report for the Manager to clarify this with the residents’ GP’s and the home’s pharmacist. The Manager and staff told the Inspector that one resident had died since the last inspection of the home. The provider arranged for all staff to have training in death and bereavement and the trainer worked with staff and residents during the person’s illness. The Manager confirmed that residents who chose to were supported to attend the person’s funeral. The Inspector also saw that staff from the home and social workers had worked with residents and their relatives / representatives to gather and record information about their wishes regarding ageing, illness and death. This information included residents’ cultural and faith wishes and was sensitively recorded as part of each person’s care plan. Spring Lake DS0000017450.V352660.R01.S.doc Version 5.2 Page 16 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23. People using the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. The service has a complaints procedure that is clearly written and easy to understand. It is available in a format that helps anyone living at, or involved with, the service to complain or make suggestions for improvement. The home keeps a full record of complaints and this includes details of the investigation and any actions taken. EVIDENCE: The Manager confirmed that in 2006 the home had sent surveys to residents’ relatives, friends, advocates and professionals involved in their care. The surveys asked for people’s views on the service provided at Spring Lake and the results were discussed with the company’s Directors. It is a recommendation of this report that this exercise is repeated annually, together with the development of a quality assurance policy and procedure (see Standard 40). Most of the people living in the home have limited verbal communication and staff were able to describe for the Inspector the ways in which individual residents communicated their likes, dislikes and preferences. The home has produced a complaints procedure using symbols to make the information more accessible to some people living in the home. The procedure outlines options for people who have concerns about the home and refers to the Commission as the independent regulator. Information provided by the Manager in the Annual Quality Assurance Assessment (AQAA) is evidence that there has been one formal complaint since the last inspection in November 2006. The Inspector was satisfied that the complaint was dealt with in accordance with the company’s procedures and within agreed timescales. Spring Lake DS0000017450.V352660.R01.S.doc Version 5.2 Page 17 During this visit the Inspector checked the personal finance records for two people living in the home. The records were well kept and receipts were in place for any expenditure. Information provided in the AQAA showed that two staff had been dismissed since the last inspection of the home. The Manager must make sure that, where staff were dismissed for gross misconduct, their names are referred to the Protection of Vulnerable Adults register for possible inclusion. Spring Lake DS0000017450.V352660.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 25, 26, 27, 28 and 30. People using the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. The home provides a physical environment that is appropriate to the specific needs of the people who live there. The well-maintained environment provides specialist aids and equipment to meet the needs of the people who use the service. The home is a pleasant, safe place to live and the bedrooms and communal rooms meet the National Minimum Standards or are larger. EVIDENCE: Spring Lake is a large, detached house in a residential area of Wembley, close to local shops, bus routes and an underground station. Bedrooms, communal areas, bath / shower rooms and toilets are provided on three floors and the home has a large garden. The ground floor of the home would be accessible to people with limited mobility, but the first and top floors are not accessible. Hand rails have been fitted throughout the home for those residents who need support walking or using stairs. During this visit the Inspector saw all private and communal parts of the home. The home provides good standards of accommodation and residents’ bedrooms were spacious, well decorated, individual and comfortably furnished. There is a choice of communal areas for residents’ use and these were also well Spring Lake DS0000017450.V352660.R01.S.doc Version 5.2 Page 19 decorated and comfortably furnished. There were sufficient bath / shower rooms and toilets for residents’ use and these were located close to bedrooms and communal areas. The kitchen and laundry were well equipped. The home also has two outbuildings that are used to provide day services for residents. The home has a full-time cleaner and all parts of the home were clean and hygienic when the Inspector visited. Spring Lake DS0000017450.V352660.R01.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 33, 34 and 35. People using the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. The home has a good recruitment procedure that clearly defines the process to be followed. This procedure is followed in practice with the service recognising the importance of effective recruitment procedures in the delivery of good quality services and for the protection of individuals. EVIDENCE: Information provided by the Manager in the Annual Quality Assurance Assessment (AQAA) shows that three permanent and three part-time staff have left the home since the last inspection in November 2006. Two of these staff were dismissed and the others moved to other jobs. The Manager confirmed that two new staff had been recruited and would start work once the Criminal Records Bureau (CRB) checks and references had been received. The Manager also confirmed that all other staff working in the home had an Enhanced Disclosure from the CRB. Throughout the day the Inspector saw staff working well together to support residents with activities in the home and the local community. When the Inspector arrived, three care staff were on duty from 07:00. Other care staff came in during the day to work later shifts and the home’s Manager and Deputy Manager also worked day shifts. The Inspector felt that this level of staffing was appropriate to provide care and support to the existing group of Spring Lake DS0000017450.V352660.R01.S.doc Version 5.2 Page 21 people living in the home. While Managers and staff worked well together to support residents, the Inspector felt that staffing levels would need to be reviewed if some of the four existing vacancies were filled. Evidence from the home’s Annual Quality Assurance Assessment (AQAA) showed that six of the home’s fourteen permanent and bank care staff have completed their National Vocational Qualification (NVQ) Level 2 or Level 3 training. The home had achieved the target of 50 NVQ qualified staff before recent staff recently left. The Manager confirmed that arrangements would be made for new staff to start their NVQ training once they had completed their induction training and probation periods. Information provided in the AQAA is evidence that the Manager, Deputy Manager and Day Services Manager share responsibility for supervising staff working in the home. Staff told the Inspector that supervision took place regularly and they found it helpful. Spring Lake DS0000017450.V352660.R01.S.doc Version 5.2 Page 22 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. 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 are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39, 40, 41, 42 and 43. People using the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. The Manager has the required qualifications and experience and is competent to run the home. The service has developed most of the required policies and procedures and these are reviewed and updated, in line with current thinking and practice. EVIDENCE: The home’s manager confirmed that she had worked with people with a learning disability for a number of years in different settings. The Manager has also completed her National Vocational Qualification (NVQ) Level 4 Registered Managers Award training and has been registered by the Commission as a fit person to manage a care home. The Manager completed the home’s Annual Quality Assurance Assessment (AQAA) and the information provided been used as evidence in this report. The Manager confirmed that the company sends quality assurance questionnaires to residents’ parents, advocates and other professionals Spring Lake DS0000017450.V352660.R01.S.doc Version 5.2 Page 23 involved in the person’s care. The results of the surveys were discussed with the Directors and an Action Plan was produced. Information provided in the AQAA is evidence that the home had produced most of the policies and procedures needed to meet these Standards. The Manager also confirmed that the company has appointed a consultant to review all of the existing policies and procedures. The Inspector discussed with the Manager the need to make sure that all of the required policies and procedures are developed and are available for staff working in the home. During this visit the Inspector checked various care records kept in the home, including residents’ care plans and risk assessments, finance and medication records and the staff rota. Standards of record keeping in the home were generally good, although more detailed information is needed in the daily care notes (see Standard 12). Information in the AQAA is evidence that the home has clear health and safety procedures and regular checks are completed by staff. There is a need to make sure that food is stored at safe temperatures in the fridge. No other health and safety issues were noted during this inspection. Spring Lake DS0000017450.V352660.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 Adults 18-65 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 X 2 3 3 X 4 X 5 2 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 2 23 3 ENVIRONMENT Standard No Score 24 3 25 3 26 3 27 3 28 3 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 3 34 3 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 X LIFESTYLES Standard No Score 11 X 12 2 13 3 14 2 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 3 3 X 3 2 3 2 X Spring Lake DS0000017450.V352660.R01.S.doc Version 5.2 Page 25 No 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 YA5 Regulation 5 (1) c Requirement The provider must make sure that the service develops and agrees a costed contract with each person living in the home that covers all of the areas detailed in Standard 5 of the National Minimum Standards for Care Homes for Adults (18-65). To reflect the daily life experiences of people living in the home, care notes must include more detail about social care, activities, contact with relatives and other people. To make sure that residents’ personal money is used appropriately, the arrangements for funding future holidays for residents must be reviewed and agreed with individual’s relatives / representatives. To make sure that people are cared for safely, the Manager must clarify with GP’s and the home’s pharmacist the arrangements for one prescribed medication taken by two residents. The Manager must make sure that, where staff were dismissed DS0000017450.V352660.R01.S.doc Timescale for action 31/01/08 2. YA12 16 31/12/07 3. YA14 13 31/12/07 4. YA20 13 31/12/07 5. YA23 19 31/12/07 Spring Lake Version 5.2 Page 26 6. YA42 16 for gross misconduct, their names are referred to the Protection of Vulnerable Adults register for possible inclusion. The Manager must make sure that food is stored at safe temperatures in the kitchen fridge. 31/12/07 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. Refer to Standard YA22 YA40 Good Practice Recommendations The quality assurance exercise carried out in 2006 should be repeated annually, together with the development of a quality assurance policy and procedure. The Manager should make sure that all of the required policies and procedures are developed and are available for staff working in the home. Spring Lake DS0000017450.V352660.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Harrow Area office Fourth Floor Aspect Gate 166 College Road Harrow HA1 1BH 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 Lake DS0000017450.V352660.R01.S.doc Version 5.2 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. 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!