Inspection on 13/02/07 for Spring Lodge

This inspection was carried out on 13th February 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 there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Spring Lodge 04/02/06

Spring Lodge 12/09/05

Spring Lodge 01/02/05

Spring Lodge 18/08/04

Similar services:

Claremont House

Oak Ridge

Sun Court Nursing Home

Ashville House

Bilney Hall

Hill Barn

Mabbs Hall Nursing Home

Henrietta House

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

CARE HOMES FOR OLDER PEOPLE Spring Lodge 23 Vicarage Gardens Clacton On Sea Essex CO15 1BU Lead Inspector Pauline Dean Key Unannounced Inspection 13th February 2007 09:10 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 Lodge DS0000061194.V329931.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 Lodge DS0000061194.V329931.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Spring Lodge Address 23 Vicarage Gardens Clacton On Sea Essex CO15 1BU 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) 01255 420045 Black Swan International Limited Mrs Maria Teresa Cardwell Ms Margaret McKeen Care Home 18 Category(ies) of Old age, not falling within any other category registration, with number (18) of places Spring Lodge DS0000061194.V329931.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. Persons of either sex, aged 65 years and over, who require care by reason of old age only (not to exceed 18 persons) 4th February 2006 Date of last inspection Brief Description of the Service: Spring Lodge is an established care home for older people offering accommodation for eighteen service users on the ground and first floor. Fees are £367. 00 per week. This is the cost of a contracted bed. Hairdressing, chiropody, opticians, toiletries and newspapers and magazines are all charged at cost. Communal areas consist of a main lounge and dining room on the ground floor, with a further small lounge on the first floor. Catering and laundry services are in house and are found to the rear of the property. Accommodation is in sixteen single rooms, eight with en suite facilities of wash hand basin and toilet and one double room with en suite facilities of wash hand basin and toilet. Access to the first floor is by a staircase or passenger lift. Toilets and assisted bathrooms are found on each floor. Communal areas consist of a main lounge and dining room on the ground floor, with a further small lounge on the first floor. Catering and laundry services are in house. Spring Lodge is a detached property, located in a tree-lined road in a residential area of Clacton on Sea. It is close to the town centre, which has the usual amenities of shops, post office, library and leisure facilities. The sea front and promenade are within walking distance. Spring Lodge DS0000061194.V329931.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, covering the key National Minimum Standards, took into consideration all recent records relating to the service, including information sent to the Commission by the Providers. A record of inspection was collated prior and during the inspection process. It also included a site visit to the home on 13/02/07, which lasted 9 hours and 50 minutes. At this visit, the inspector was able to speak with service users, Ms Margaret McKeen, the registered manager, Mr Brett Burton of Black Swan International Limited, Mrs Maria Cardwell, joint proprietor, a district nurse and catering, cleaning and care staff. A tour of premises was completed and there was observation of care practice and the sampling of records. Where possible, the site visits focussed on the experience of a sample of three service users, a process known as case tracking. Of the twenty-three National Minimum Standards inspected on this occasion, one was not applicable, nineteen were met and seven were nearly met. Three of the latter are repeat requirements from the last inspection. Whilst it is noted that this is an increase in requirements since the last inspection, two of these requirements are considered to be good practice guidance and are recommendations. What the service does well: Spring Lodge continues to offer a high standard of care. The decoration and maintenance of the home are maintained to a good standard, both inside and outside the property. Furnishings and furniture within the home are of a good quality, with every effort made to ensure that Spring Lodge is homely and bright. Whilst there have been some staff changes, Spring Lodge continues to have an established staff group. A core-training programme has been introduced to ensure all staff have the knowledge and understanding of current working practices. Both care staff and the registered manager were highly praised by service users spoken and within relative comment cards and service users’ surveys. On relative said that they felt that staff “had respect” for the service users and a service user said that “staff are always very helpful and care for me very well.” Spring Lodge DS0000061194.V329931.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: 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 Lodge DS0000061194.V329931.R01.S.doc Version 5.2 Page 7 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 Lodge DS0000061194.V329931.R01.S.doc Version 5.2 Page 8 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): 3 and 6. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Documentation ensures that service users move into the home knowing that their needs will be met. Spring Lodge care home does not offer intermediate care. EVIDENCE: There have been some changes in the resident group since the last inspection and the time of the site visit there were sixteen service users at Spring Lodge. Care planning documentation was sampled and case tracking took place for three service users. Two of the three service users had been admitted to the care home since the last inspection. Documents seen evidenced that a detailed full initial assessment process had been followed and all aspects of care had been considered. Assessments were seen from both the placing authority and the care home. Contracts had been Spring Lodge DS0000061194.V329931.R01.S.doc Version 5.2 Page 9 drawn up and were seen on file for two of the service users. The third contract was in place and the registered manager said that final agreement regarding payment had been obtained and this could now be completed. Spring Lodge does not offer intermediate care. local authority contracted bed rate. Fees are £367 per week, the Spring Lodge DS0000061194.V329931.R01.S.doc Version 5.2 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. 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 service. Care planning documents fully detailed the action to be taken and by whom and regular reviews of care plans took place. Overall medication storage and record keeping offered protection to service users. The only exception being unlabelled medication. Service users are treated with respect and dignity and are actively supported to maintain control of their care and health needs, as appropriate. EVIDENCE: A plan of care had been developed for all three of the service users involved in this case tracking exercise. For the two most recent admissions, care plans had been developed and implemented following the initial assessment process. This was the same as found on the care-planning file of the service user who had come to live at Spring Lodge in 2004. Spring Lodge DS0000061194.V329931.R01.S.doc Version 5.2 Page 11 Care planning objectives covered medical care, personal needs, mobility, moving and handling and transfers, behavioural and emotional care, activities and financial management. There was evidence of monthly reviews taking place with a thorough six monthly review completed. In addition, assessment reviews and care planning notes are considered and linked with these care plans. The involvement of service users was noted in the care planning files with service users’ signatures confirming this. Two service users who were part of this case tracking exercise spoke of their involvement in their care plan both on admission and currently. Medical notes and records were found on all three files inspected in the case tracking exercise. Visits are noted in daily records and within the medical notes. An accident record for one of the sampled service users was seen and this was completed satisfactory. Both new admissions to the home had had to change doctors and in speaking with them it was evident that they had been actively involved in this process and were happy with the arrangements. One service user told the inspector that the home had arranged both an escort and transport for hospital appointments. They were very grateful for this and praised staff for enabling them to attend these appointments, which they chose to attend in private. Records were also seen of hospital appointments to hearing clinics and eye clinic appointments in those files sampled and inspected. As part of this inspection survey forms were left with the registered manager for distribution amongst service users. Five forms have been returned at the time of writing this report and all five said that they received the medical support and care they need. One service user said “The staff do not wait to be asked. All needs are met in a friendly and warm way.” On the site visit, the inspector had an opportunity to speak with a district nurse visiting the home. They said that overall they were very happy with the care offered in the home. They said that staff were attentive and keen to assist and learn from the district nursing team. During the site visit, medication administration, storage and record keeping was sampled and inspected for the three service users who were part of the case tracking exercise. Overall, this was well managed. The one exception found was a cream medication, which was not labelled. This means that there is no indication who this medicine is prescribed for and no dosage instructions. The registered manager acknowledged that this is unacceptable practice. Spring Lodge DS0000061194.V329931.R01.S.doc Version 5.2 Page 12 Medication Administration Records (MAR) sheets were accurate and corresponded with medication administered and held in the home. Records for one service user who self-medicates were seen and they too were in good order. The registered manager said that the home does not currently hold any controlled drugs and is therefore not storing this medication or administering this medication. On the site visit as the inspector went around the home, examples of the ways in which service users’ privacy and dignity was respected was seen. As the inspector was introduced to service users in their rooms, the registered manager was seen to knock at the door and wait for a reply before entering their room. This was practice was also observed as both care staff and domestic staff went about their duties. All three service users spoken to on the day of the inspection, praised staff for their kindness and spoke of ways in which they are treated with respect, particularly when care staff are attending to their personal care needs. Surveys completed also praised both management and staff. One completed survey spoke of staff having patience and skills to work with the service user group and they said that they “were very impressed” with the registered manager. Care planning files evidenced details of the service user’s preferred term of address and during the day, carers were heard to address service users appropriately. Spring Lodge DS0000061194.V329931.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 service. Service users needs and preferences were taken into account in the organisation of daily schedules. Service users were supported to maintain contact with family and friends. Service users were able to exercise choice and control over their lives. Mealtimes were a positive experience for service users. EVIDENCE: Prior to the site visit, comment cards had been sent to the home for distribution to relatives, visitors, General Practitioners (GPs), and health and social care professionals. Whilst there had been some confusion in the distribution, cards completed by relatives were overall very positive with regard to the care of their relative. The only exception being the lack of activities on offer. Spring Lodge DS0000061194.V329931.R01.S.doc Version 5.2 Page 14 This was commented on in the completed service user survey work. When asked if “there are activities arranged by the home that you can take part in?” Two service users said that this was usually the situation, a third said that this was always the case and a fourth said that sometimes activities are arranged by the home and they were able to take part in. A fifth survey completed on behalf of the service user said that activities were arranged sometime and they felt that more opportunities for outings would be appreciated. One completed survey said that whilst “An activity programme is displayed on the notice board” there is “little evidence that it happens.” At the site visit, the inspector noted the activity programme on display. Normally there is an identified activity each day, however from reading daily care planning notes it was difficult to identify what activities did take place. The registered manager did acknowledge that this was one aspect of care, which the care home could improve on. She said that the number of participates had decreased and the home needs to give thought as to how they could encourage service users to take part. Ms McKeen said that come the summer short walks, trips to the beach and the theatre are usually enjoyed. Service users also enjoy sitting in the garden and this will be re-introduced. It was recognised however that some residents do not wish to join in group activities. This was confirmed by all three service users spoken to on the day of the site visit. Each was able to tell the inspector how they chose to spend their time such as watching videos in their room and reading magazines and library books. All three preferred to spend time in the room coming into the communal areas for a chat or for a meal as they wished. On display in the hallway of Spring Lodge the home’s visiting policy is displayed. This clearly states that the home offers an open invitation to relatives and visitors. This was confirmed by the three service users interviewed and comment cards completed by relatives, said that they were able to visit their relative/friend in private. The registered manager said that service users are encouraged to manage their own affairs for as long as they are able. She said that this is normally managed with assistance from family, friends and solicitors, with some in put from a local advocacy service as needed. Recently one service user had had the assistance of an advocate, but this has now ceased as financial management strategies have been implemented. Records were seen of personal possessions brought into the home. The registered manager said that these had been considered and discussed on admission to the home. Spring Lodge DS0000061194.V329931.R01.S.doc Version 5.2 Page 15 Spring Lodge employs two cooks with catering hours from 08.30 hours to 13.30 hours seven days a week. Planned menus are in place with two choices offered at the main meal of the day. Fresh vegetables are used each day with delivery every other day. Orders are placed with the wholesaler and a freezer food shop and these are delivered during the week. All three service users spoken to at the site visit were very happy with the meals served. They were aware of the choices on offer and were able to have their meal in their room or in the dining room as they preferred. Three of the completed service users’ surveys said that they always liked the meals at the home, with the fourth saying that they usually like the meals. Comments such as “They are very varied and good quality” and “The food is always good” were seen in this survey. The only negative response regarding catering in the home came from a relative’s comment card and the district nursing team. The former spoke of the kitchen being closed in the evening, whilst the district nursing team had witnessed restrictions being placed on the serving of snacks to a service user during the day. The registered manager said that she was surprised to have received these concerns for the kitchen remains open at all times even when catering staff go off duty and care staff should be aware that snacks can be served at all times. She said that she would raise these concerns with all staff through supervision and staff meetings. Spring Lodge DS0000061194.V329931.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 service. Overall, service users were well treated and listened to, with robust complaints and adult protection procedures in place. EVIDENCE: Spring Lodge has both a complaints procedure and policy. These were reviewed and revised in June 2006. These documents detail the action to be taken and the response time to action a complaint investigation and contact the complainant. A complaint log is held and since the last inspection there have been no complaints. At the site visit representatives of Black Swan International Ltd. were present and the management and arrangements for managing complaints was discussed in general. All five completed service user surveys stated that they did know who to speak to if they were not happy and they were aware of how to make a complaint. One service user said that if they were not sure who was in charge on the day, “the care staff will get me the person responsible.” The majority of completed comment cards from relative/visitors said that they were aware of the home’s complaints procedure and they had not made a complaint. The adult protection policy for Spring Lodge was reviewed and revised in June 2006. Whilst there was reference to Essex County Council and the local authority’s role in Protection of Vulnerable Adults (POVA) referrals, the Spring Lodge DS0000061194.V329931.R01.S.doc Version 5.2 Page 17 inspector advised the registered manager to review this document alongside local authority guidance and referral forms to ensure that it is fully compliant with local authority guidance as to who referrals are made to in the first instance. The inspector was informed that Black Swan International Ltd. have adopted the Essex County Council training package – ‘Safeguarding Vulnerable Adults’ and four staff are to undertake further Protection of Vulnerable Adults (POVA) training in March 2007 with a local training company. Spring Lodge DS0000061194.V329931.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 service. Overall, the home provides a safe, well-maintained environment that is accessible to service users, homely and meets individual needs. EVIDENCE: A programme of routine maintenance and renewal of fabric and decoration is evident at Spring Lodge. The home is pleasant, homely and bright. Decoration in both the communal areas and bedroom accommodation is of a good standard. The surrounding gardens are well maintained and provided pleasant surroundings throughout the year. The Regulation 26 visit report for February 2007 confirmed planned outside decoration and window replacement. Spring Lodge DS0000061194.V329931.R01.S.doc Version 5.2 Page 19 The registered manager confirmed that a Fire Service inspection had taken place and recommendations regarding fire doors fitted with smoke seals are being fitted over the coming year. This was confirmed by the registered provider in their Regulation 26 visit report of February 2007. An inspection by Environmental Health under the Health and Safety at Work Act 1974 was completed in February 2006. No requirements or recommendations were made. The premises are kept clean and hygienic throughout. Relatives and Visitors complimented the home on the cleanliness of the home in the Commission for Social Care Inspection (CSCI) Comment Cards and two service users spoke highly of the domestic staff. All five completed service users’ surveys said that the home was fresh and clean and one said that “There is never any urine odour in the lounge, hall etc.” Laundry facilities are found at the rear of the property. There is direct access to the garden to hang out the washing as needed. Spring Lodge has two washers and two dryers. Problems had been identified with the outlet pipe from this machinery and temporary hosing was in place to allow the water to drain away, whilst the home was awaiting the plumber’s quotation and work. Spring Lodge DS0000061194.V329931.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 good. This judgement has been made using available evidence including a visit to this service. It was not possible to ascertain whether staff were roistered in sufficient numbers to keep service users safe and address their basic needs, as it was unclear whether service users’ assessed individual needs had been considered. The home has an experienced and dedicated staff team and service users are protected by the home’s recruitment practices and training programme. EVIDENCE: Staff rotas detailed caring, cleaning and catering hours. It was not clear however when carers were doing caring duties or cleaning duties, particularly during the afternoon and evening period. This was raised with the registered manager and the need to detail these hours separately was highlighted. The registered manager said that staffing hours calculations are considered using the Residential Forum Guidance. She said that they are currently calculating the hours for eighteen service users with high dependency needs. Currently the home has sixteen service users. It was clear from discussion however, that the home had not undertaken a thorough individual assessment of each service user. Ms McKeen said that she was to attend training which should assist her with this process and she will then review and revised staff rotas to reflect the required hours. Spring Lodge DS0000061194.V329931.R01.S.doc Version 5.2 Page 21 Within the survey work completed in October 2006, a relative had commented on “staff attitude”. They questioned whether this was because service users had higher dependency needs and therefore presented more demands on care staff. Mrs McKeen acknowledged that during this period the home had had high dependency residents, but at the time of the site visit this had improved. Care staff spoken to and seen on duty appeared relaxed and happy in their work and one care staff member spoke of good teamwork and support from both staff and management. Survey work completed with service users following the inspection had comments such as “The staff are always very helpful and care for me very well” and “Care and support are excellent.” In addition comments such as “There is nothing to fault at all, my mother is treated well at all times” and the “Quality of care is superb” were found in these documents. The registered manager said that there are currently twenty-one care staff working at Spring Lodge. In the past year there are been some staff changes and currently six staff have a National Vocational Qualification level 2 in care and two have started this training in October 2006. The home is therefore not meeting the minimum ratio of 50 trained members of care staff with NVQ level 2 in care. Staff recruitment files for three care staff were sampled and inspected. Two of these files were for new staff who have been employed since the last inspection. Overall, the staff recruitment practice and record keeping was in good order. The registered manager said that changes are to be made to the application form to give greater consideration to the criminal declaration and full employment history details. The registered manager said that all new staff complete the Skills for Care – Common Induction Standards in the first twelve weeks of their employment. She said that currently two new carers are on this training. Spring Lodge has a staff training and development plan file which holds copies of staff training certificates. These certificates are also to be found on the individual’s staff file. The inspector was informed that basic training courses are offered regularly in the home. This was evidenced in the core-training programme of the home. Since the last inspection, care staff have attended basic food hygiene, manual handling, fire safety, infection control, adult abuse/Protection of Vulnerable Adults (POVA) Awareness. In addition two staff have attended Diabetes Awareness training and Catheter Care training in 2006. Spring Lodge DS0000061194.V329931.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 good. This judgement has been made using available evidence including a visit to this service. The home has a competent and experienced manager to run the home. The home has developed a quality assurance and quality monitoring system to help ensure that the home is run in the best interests of the service users. Service users’ financial interests were safeguarded through invoicing service users for additional expenditure. Safe working practices are promoted through ongoing training. Spring Lodge DS0000061194.V329931.R01.S.doc Version 5.2 Page 23 EVIDENCE: Ms McKeen said that she had registered and commenced a unit in a NVQ level 4 in care and management. Unfortunately the company had been unable to manage this work and ceased their assessment. Ms McKeen said that she had been advised to approach the company in February 2007. She was advised to pursue this and confirmation is required from Black Swan International Limited that the registered manager has commenced both a NVQ level 4 in care and management in 2007. An estimation of the completion dates is also required. Comments received in the survey work completed were all very positive as to the management of the home. Ms McKeen was praised and congratulated on as being a caring manager, who is “always ready to update me on my visits”. A Quality Assurance Annual Development Plan for 2007 has been completed and work on the premises has been identified and is to be completed in the coming year. Regulation 26 reports were also said to be completed and a copy of the recent visit was sent to the Commission. The registered provider said that in addition to these visits they conduct a monthly audit of the home. The views of service users are also sought. Residents meetings are held every three months and service users views were seen to be noted and acted upon. In addition, Spring Lodge produces a six monthly questionnaire; the results of which are published and distributed to service users in the Service User Guide. Evidence of this was seen on the site visit. The registered manager said that the home does not operate as an appointee for any service user. Of the three service users who were part of the case tracking only one service user had assistance from the home with regard to the management of their finances. These appeared to be in good order. As stated previously in this report, a core-training programme has been developed. Health and safety certificates with regard to gas safety and maintenance were seen and were current. Hot water temperature checks are completed each month and they were recorded to be within the boundaries of 41° - 43°C. In addition the home conducts a monthly legionella check and a six monthly water tank check. From records seen these were found to be in good order. Spring Lodge DS0000061194.V329931.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 X X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 3 X X X X X X 3 STAFFING Standard No Score 27 2 28 2 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 3 X 3 X X 3 Spring Lodge DS0000061194.V329931.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 OP9 Regulation 13 (2) Requirement Timescale for action 06/04/07 2. OP12 17 (2)(n) 3. OP27 18 The registered person must ensure that all medication is clearly labelled with the service users’ details and dosage instructions. The registered person must 06/04/07 consult service users about the programme of activities arranged by or on behalf of the care home, providing facilities for recreation having regard for service users’ needs. The registered manager must 06/04/07 ensure that staffing levels are appropriate to the individual assessed needs of the service user, the size, layout and purpose of the home. (This is a repeat requirement from the last two inspections. Previous timescale of 23/10/06 and 14/04/06 were not met.) 4. OP28 18 (1)(a) The registered person must ensure that a minimum ratio of 50 of care staff have completed NVQ level 2 in Care. DS0000061194.V329931.R01.S.doc 06/04/07 Spring Lodge Version 5.2 Page 26 5. OP31 18, 19 The registered person must ensure that the registered manager has the required qualification, i.e. NVQ Level 4 in care and management, within 2006. (This is a repeat requirement from the last inspection. Previous timescale of 14/04/06 was not met.) 06/04/07 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 OP15 OP18 Good Practice Recommendations The registered manager should review catering arrangements to ensure that drinks and snacks are available at all times. The registered manager should review the current adult protection procedure and local authority guidance to ensure referrals are made to the appropriate persons. Spring Lodge DS0000061194.V329931.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Colchester Local Office 1st Floor, Fairfax House Causton Road Colchester Essex CO1 1RJ 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 Lodge DS0000061194.V329931.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. 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