Inspection on 13/07/06 for Springbank

This inspection was carried out on 13th July 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Excellent. 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

Springbank 02/11/05

Springbank 12/05/05

Springbank 19/01/05

Springbank 15/04/04

Similar services:

2 Perhaver Park

The Vicarage

St George`s

5 Seafield Road

Credence House

Radfords

Honeybourne House

32 Beaumont Way

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

CARE HOME ADULTS 18-65 Springbank 1 Charlton Lane Brentry Bristol BS10 6SG Lead Inspector Peter Still Key Unannounced Inspection 13th July 2006 09:30 Springbank DS0000026643.V303584.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 Springbank DS0000026643.V303584.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. Springbank DS0000026643.V303584.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Springbank Address 1 Charlton Lane Brentry Bristol BS10 6SG 0117 9505220 0117 9505450 Springbank@Shaw-homes.co.uk 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) Shaw Healthcare (Specialist Services ) Ltd Mrs Kay Marie Williams Care Home 11 Category(ies) of Learning disability (11) registration, with number of places Springbank DS0000026643.V303584.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. May accommodate residents aged 40 Years and Over Date of last inspection 2nd November 2005 Brief Description of the Service: Springbank is a residential care home registered with the Commission for Social Care Inspection to provide accommodation and personal care for 11 service users aged 40 years and over who have a learning difficulty. The home is an adapted bungalow, and accommodation is arranged over two floors. The first floor of the property contains the staff room, office, and a bathroom and toilet facility. Service users’ individual accommodation, communal lounge, conservatory and dining room are situated on the ground floor. To the outside of the property there is a large private garden, and in close proximity are local shops and amenities. The home is owned and operated by Shaw Healthcare (Specialist Services). Springbank DS0000026643.V303584.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection began at 9.30 A.M. and took place over eight hours. Ten residents were at the home and one gentleman was in hospital. Fees charged to residents at this home range from £1120.52 to £1122.70 a week. The conditions of registration were reviewed and no change was needed. Both the manager and her deputy were present throughout the inspection. A range of records was looked at including care plans, risk assessments, healthcare records and daily entries. Three residents were case tracked during the inspection. Staff were spoken with and there was a tour of the premises. Information sent to the Commission before the inspection provided valuable evidence and included a comment card from a local healthcare professional. Other information was also handed to the inspector during the inspection. Due to the nature of the resident’s disabilities, it was not possible to obtain direct feedback concerning their experiences of the care they receive; however residents were observed and some limited communication was possible. All requirements and recommendations from the previous inspection had been responded to. What the service does well: Staff place resident’s at the centre of their work and the home is run in a way that promotes choice and ensures needs are understood and responded to. Residents were observed to be open with staff and relaxed within their environment. Staff were positive, happy and showed a full commitment to their work, demonstrating a strong and well-supported staff team. The manager promotes a constant drive for improvement and development of practice and staff were valued and encouraged to be innovative. Recording and reporting of key information was seen to be organised and new systems developed by the company and staff help to ensure resident’s are safe, their needs known and that communication between staff and other healthcare professionals was good. The staff team have shown a commitment to training, which includes NVQ and a range of other key training to improve practice. Staff have been provided with training concerning abuse and the protection of vulnerable adults and the manager includes this training as a key ongoing topic. Residents benefit from an established and stable staff team and low staff sickness record; agency staff were not required. Springbank DS0000026643.V303584.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. Springbank DS0000026643.V303584.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 Springbank DS0000026643.V303584.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1,2,5 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The manager has reviewed policy and documentation for new admission of residents. A new statement of purpose and service user guide was proving helpful to residents. Further work is needed to ensure it fully meets National Minimum Standards. EVIDENCE: The home has not had any new admissions for a long time. Most residents came to the home as a group from another care facility and are well established at Springbank. Up to date contracts were seen for three residents. The statement of purpose and service user guide are documents in constant use and at the last inspection it was required that they be updated to contain all information as set out within the national minimum standards. The new easy to read pack produced since the last inspection was considered to be excellent. Residents were observed using it and the pictures of the home had made it meaningful to them. (The home is making good use of a new digital camera). The manager was aware of the further work needed and will complete this within the next one to two months, to ensure all points are included. Springbank DS0000026643.V303584.R01.S.doc Version 5.2 Page 9 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7,9 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is focused on positive communication with residents, ensuring that needs are understood and met to ensure individual choice. EVIDENCE: Observation of residents showed they were relaxed and happy with staff. The atmosphere was positive and open and staff were seen to use individual communication approaches to ensure needs were understood and responded to. The training on Intensive Communication for staff had proved valuable and a member of staff is due to cascade the training in greater depth and to continue the learning. Two staff talked about the positive outcomes for residents. One example concerned a resident who was more relaxed and it had been found that a change to the colour of his/her bedroom and a softening of lights had made a significant impact. Springbank DS0000026643.V303584.R01.S.doc Version 5.2 Page 10 The manager has worked hard to develop care planning since the last inspection and a new file system, which had recently been set up with key documentation uses two key files, a Health Support Profile and Care Support Profile/Service User Plan. These were inspected through case tracking and found to show good up to date records, which were clear and easy for staff to use. They were comprehensive and showed significant evidence of care needs and choice. The manager intends to develop this further, using a widget program to help understanding for residents and plans to complete this task within three months. A daily, recorded, handover sheet provides key evidence of all issues identified during the staff shift for action and information. One example was of a missed appointment with a nurse. This new form was seen to be a good method of recording and of staff communication. Ensuring diversity in residents’ lives is a key priority at the home, on planning trips away, residents decide who they go on holiday with. One resident has a fear of large buildings and a caravan holiday was chosen, which provided a happy experience. During the inspection staff were observed to be constantly aware of residents needs and of ways of meeting them, understanding individual communication methods. One resident was seen to be using an audio visual aid to gain information and the administrative staff member moved to another desk to meet the resident’s wishes and enable access; a challenging incident could have arisen but instead the resident was able to undertake the activity of their choice. Risk assessment was seen within case tracking. Staff were involved in providing detailed care planning and a monthly statement to key working groups. Review was seen to be at least monthly. This area of work had developed since the last inspection, with improved outcomes for residents, including systems for the increased involvement of support workers. An example of good risk assessment concerned a resident using a hydrotherapy pool with clear guidance and requirements for staff to adopt. Advice to staff about risk assessment was seen within house and staff meeting minutes. Another resident was observed demonstrating to staff a chosen activity so that it could be undertaken and the person who cleans the home leaves part of their task for the resident to undertake. It had been found that if the resident was not able to undertake tasks, he/she felt unvalued. Staff communication was seen to be very effective. One member of staff said that the improved risk assessment approach with key workers and staff had led to staff being more confident in their work and consistent, leading to a reduction of behaviour which challenges the service and to improved contentment for residents. Springbank DS0000026643.V303584.R01.S.doc Version 5.2 Page 11 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14,15,16,17 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. The strong focus on the individual is the priority for the home and staff show commitment to improving practice and positive outcomes for residents. The new Activities Coordinator develops new opportunities and experiences, to improve the lives of residents. EVIDENCE: A new pictorial activities board was being used by and with residents and new activity includes: Use of a hydrotherapy pool; Art; dance; music therapy; activity and a work placement with horses. One resident is due to spend a day on a fishing trip. The coordinators records were reviewed, and showed planning and communication with providers. The member of staff who has provided a well tended and productive vegetable garden, supported by residents should be commended and her enthusiasm is likely to naturally encourage residents to participate. She has also been able to involve residents in other gardening at the home, providing colour and interest. The large spaces around the home should allow this to develop further. Springbank DS0000026643.V303584.R01.S.doc Version 5.2 Page 12 The daily house meeting ensures staff awareness of activity for residents. An experienced new member of staff encapsulated what was being observed by saying “The management team and those on each shift ensure the complete focus is on the resident, who are also fully involved in the meetings. – I have not seen this to be so evident in other places I have worked at but here it is routine” Family and friends are encouraged and a recent quality audit questionnaire provided positive feedback from one family. The menu for the home was seen and was well balanced. A pictorial menu file was good and being developed further. Records seen show the meals residents have. Where residents decline food, alternatives were provided. The home has a cook, who communicates with residents to find out about food preferences. Concern about the diet of one resident led to significant input from a dietician, including a visit and other recorded communications. The last inspection found the policy regarding payment of staff meals during holidays to be an issue requiring a review of policy. This was undertaken and clear guidance was seen. The new policy states that residents do not pay anything towards the costs of meals and that the activity budget is used to cover the costs. Springbank DS0000026643.V303584.R01.S.doc Version 5.2 Page 13 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18,19,20,21 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. A sound approach was taken including good links with local professionals to ensure residents safety and their needs are known and timely action is taken. Recording was of a good standard. EVIDENCE: Staff were observed to be flexible and sensitive to resident’s individual needs and personal support was provided according to their wishes, often demonstrated by responses. A member of staff was seen to knock on a resident door before entering. Good recording was seen for the resident’s case tracked. One entry concerned a fall and a regulation 37 report to the Commission and was followed up by an appointment with the doctor. A concern about another resident led to a visit by the “Falls Nurse” and a number of steps being taken to protect the resident. Springbank DS0000026643.V303584.R01.S.doc Version 5.2 Page 14 Good links were maintained with external professional agencies and records and case tracking showed evidence of contact. The key local GP submitted a comment card prior to the inspection and was content with all aspects. A comment card handed to the inspector on the day of inspection from a professional working with a resident said that, “Staff are always there to help me” and also that from experience of other homes, “in terms of staff numbers and input, this is probably the best and most efficient home I have visited …”. One member of staff spoken with talked about the good links with external professionals. The medication system was checked by case tracking for the day of inspection and found to have no mistakes. The locked cabinet was clean and well organised, with no inappropriate stock. The last inspection made a recommendation that a pill counter be purchased to support the monthly medication audit and staff said the new counter was proving valuable. None of the residents control their medication. Equality and diversity was promoted. The dignity of residents was protected and residents chose who would undertake personal care tasks, the responses of residents being noted to ensure their wishes were maintained. Male staff do not bath female residents. The home has a very open atmosphere in which residents can feel safe to express themselves. The manager provides guidance to staff about age appropriate responses. The manager has recently been seeking details of final wishes for residents and has been talking to staff about ageing, illness and death. Very sadly the inspector was told that the day following the inspection, a resident died in hospital, which would clearly have a great impact on residents and staff. Springbank DS0000026643.V303584.R01.S.doc Version 5.2 Page 15 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22,23 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The manager demonstrated a rigorous approach to ensuring residents were listened to and any concerns addressed. Most staff had received training for the protection of vulnerable adults. (POVA) EVIDENCE: The ethos of the home ensures openness and residents were seen communicating well with staff who listened to their needs. The key worker system also provides an avenue for issues raised or demonstrated by residents to be picked up at an early stage. The last inspection required that the abuse policy links with local authority policy and that there should be a review. This was complied with and the new policy was seen. The local Bristol alerter and reporters guide was prominently displayed in two places. Three staff spoken with knew of the policy and gave a good response to a role-play on steps to take if they had a concern. Only three of 25 staff had not yet received POVA training. The manager said she is to maintain this topic as a constant one for staff meetings and the new staff training matrix, tracking system shows when staff need to reinforce their training. Springbank DS0000026643.V303584.R01.S.doc Version 5.2 Page 16 Since the last inspection, one incident had emerged, not relating to the home but to another provider, where a Springbank member of staff had correctly reported a matter, which was investigated and another previous matter reported had recently come back for a request that the information be resent since another investigation was being commenced. This demonstrates the value of the staff training. Staff records reviewed confirmed the POVA training had been provided with dates which agreed with those on the staff training matrix and one member of staff was receiving the training on the day of inspection. There had been no complaints or incidents reported at the home. Springbank DS0000026643.V303584.R01.S.doc Version 5.2 Page 17 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24,30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home was comfortable and well equipped for residents with ongoing maintenance ensuring a good quality environment. EVIDENCE: A tour of the premises was made and confirmed the detail provided within the pre inspection questionnaire. A rolling programme of refurbishment and items the provider had identified at the last inspection had been undertaken. The maintenance records were well recorded and up to date. The last fire check was completed on 30/06/06 and no issues were found. A new PAT test had just been completed. The home was found to be clean and tidy and with no odour. The person who undertakes small jobs within the home should be commended for his efforts to ensure a pleasant home for residents and that issues are addressed swiftly. Residents were clearly very much at home in their environment and bedrooms had been decorated and individualised according to the wishes of each resident. Springbank DS0000026643.V303584.R01.S.doc Version 5.2 Page 18 Call alarms had been relocated, where residents had moved their beds and relocation of alarms is a simple job since they are wireless and can be repositioned anywhere. The provider should be commended for installing a flexible system. A problem with the overflow from the drainage system had been causing a problem and consideration was being taken about the best way of dealing with it. The gardens of a good size around the home would easily accommodate a Summer House and it was understood the provider was being supportive to the plan to provide this extra facility for residents. A firm was providing a quotation for the work on the day of inspection. Bearing in mind the different needs of the residents and importance of space and an additional quite area for residents to use, the proposal would seem to provide the home with a valuable resource. Springbank DS0000026643.V303584.R01.S.doc Version 5.2 Page 19 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 33,34,35 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. An established staff team work effectively to support and enhance the lives of residents. Resident’s benefit from the consistency of staffing. EVIDENCE: The home continues to have a low turnover of staff and low sickness record. There was no evidence of agency staff being required. Staff records including recruitment were reviewed for two staff and both were complete, including CRB, written references and application forms. At the last inspection, induction had not been provided to two members of staff within a reasonable timescale. The action plan from the provider said that this had been completed and this was confirmed by records handed to the inspector during the inspection and by a staff member who had received the training. This member of staff said the induction training was of four days and intensive. The content was comprehensive and covered all topics considered to be important. Some topics were felt to need more depth and it was understood that the ongoing staff training at the home would cover these. Springbank DS0000026643.V303584.R01.S.doc Version 5.2 Page 20 The provider and manager should be commended for producing a very effective new staff training matrix. A colour copy was given to the inspector and the IT system was seen. The matrix includes both training, which is mandatory as well as other training considered important. A traffic light system shows staff that have completed training with dates, those who need training to be booked for reinforcement and those who have not completed training within timescales. One member of staff was out of date on a number of training topics and the reason for this was maternity leave. The matrix was considered to be excellent with the possibility of immediate analyses. The training matrix was checked against staff files and course dates and found to be accurate. The staff team should be commended for their hard work to achieve their training objectives. Nine out of fourteen staff had or was completing NVQ level 2 and three hold level three. The deputy had completed the Assessors A1 award and the manager had just completed her Managers Award. Certificates were held by staff and copies were reviewed on staff files. The staff training matrix also provided evidence of course completion dates. Senior staff have responsibility for staff supervision and the same type of matrix is used as for training, which makes it easy to use as a management tool. The company to ensure policy is followed and timescales are met also monitors the systems. Two members of staff spoken with said that supervision was a positive experience. And they felt well supported. One said that the meetings are very open and that they feel listened to. The manager had recently produced a set of key headings to be used for supervision ensuring consistency with key topics. Notes of a staff meeting, which included the changes was seen. A new member of staff said that the staff team were very supportive and had helped with the individual communication approaches for residents, which had been very helpful. Residents were observed to be relaxed and happy with staff that were working well together and clearly knew their responsibilities for the day. One member of staff said that the daily meeting including residents helped with this. Residents expressed themselves with happy smiley faces and were busy with their daily routines. Staffing levels were satisfactory at the home. Springbank DS0000026643.V303584.R01.S.doc Version 5.2 Page 21 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37,39,42 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. An effective, inclusive and supportive management structure led by senior staff at the home and the provider ensures the home is well run and safe for residents. EVIDENCE: Good management systems developed for the home help to ensure the home is well run, these include IT based systems such as the staff training matrix. The company monitors and reviews the IT system to support the manager. The manager demonstrated professional confidence in her work and swiftly accessed key documentation needed for evidence gathering during the inspection. Openness was observed amongst residents and staff and Springbank was clearly the resident’s home and being run for their individual benefit rather than for the ease of staff. Springbank DS0000026643.V303584.R01.S.doc Version 5.2 Page 22 A comprehensive annual home action plan was seen, which included exploring the possibilities of advocacy through People First, also a Summer House for residents with decking, following risk assessment and the mobility needs of two particular residents. The provider carries out the monthly regulation 26 unannounced visits and the support was found to be valuable. One member of staff spoken with said the regional manager who visits the home is easy to talk to. Reports were seen at the home, which show they are being undertaken on a monthly basis. The dates of copies of the reports being faxed to the Commission had been put onto the home copy. The home had been conducting quality assurance work and two questionnaire responses were handed to the inspector. One from a family gave a maximum rating on all aspects of care and said, “We are always extremely happy with the care...” “We never have any concerns over the safety or happiness…We are always welcomed with open arms and treated with great respect whenever we visit or call”. Another questionnaire from an external collage assessor said “A fantastic environment, everyone is made to feel welcome when they visit. On all my visits the clients appear happy, relaxed and more importantly involved in how the home is run…” Springbank DS0000026643.V303584.R01.S.doc Version 5.2 Page 23 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 2 2 3 3 X 4 X 5 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 4 25 X 26 X 27 X 28 X 29 X 30 4 STAFFING Standard No Score 31 X 32 X 33 4 34 3 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 4 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 4 15 3 16 4 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 4 4 3 3 3 X 3 X X 3 X Springbank DS0000026643.V303584.R01.S.doc Version 5.2 Page 24 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. Standard Regulation Requirement Timescale for action 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 Springbank DS0000026643.V303584.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection Bristol North LO 300 Aztec West Almondsbury South Glos BS32 4RG 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 Springbank DS0000026643.V303584.R01.S.doc Version 5.2 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. 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!