Inspection on 02/11/05 for Springbank

This inspection was carried out on 2nd November 2005.

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 8 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Springbank 13/07/06

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 Helen Taylor Announced Inspection 2nd November 2005 09:30 Springbank DS0000026643.V249657.R01.S.doc Version 5.0 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.V249657.R01.S.doc Version 5.0 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.V249657.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Springbank Address 1 Charlton Lane Brentry Bristol BS10 6SG 0117 9505220 0117 9505450 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 To be appointed Care Home 11 Category(ies) of Learning disability (11) registration, with number of places Springbank DS0000026643.V249657.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. May accommodate residents aged 40 Years and Over Date of last inspection 12th May 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, 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). The manager is Mrs Kay Williams whose recent application for registered manager status was successful. Springbank DS0000026643.V249657.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an announced inspection as part of the annual inspection process. The last inspection was conducted in May 2005. No requirements arose during that process, and action has been taken in relation to two recommendations made. There have been no additional visits during this period, and the home has been keeping the Commission for Social care Inspection informed of any incidents that may affect the wellbeing of the residents. The Inspection was conducted over one day and the Inspector had the opportunity to meet with the residents, staff and management team. Evidence was gathered from a review of records held, pre-inspection information completed by the manager, observation and discussion. The Inspector had the opportunity to tour the building. The eight requirements and two recommendations made during this inspection process, should not detract from the quality of care provided, but should be viewed as constructive feedback to enable the home to continue to meet the National Minimum Standards in care provision. What the service does well: The home provides individual care and personal support to individuals with complex communication and care needs. There is a strong commitment to the provision of individualised care, which promotes residents rights and choices. The manager has recently successfully completed the registered manager process conducted by the Commission, and has also completed the NVQ level 4 care award, which means residents benefit from a stable, competent, well supported staff team. Residents live in a warm, homely, comfortable environment, adapted to meet individual needs and choices. The furniture and fittings are of good quality, and the home is well maintained. Springbank DS0000026643.V249657.R01.S.doc Version 5.0 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.V249657.R01.S.doc Version 5.0 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.V249657.R01.S.doc Version 5.0 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): 1,2,4,5. There is adequate information available to enable prospective residents, and/or their representatives to make an informed choice about moving to the home. The information needs to be finalised and available in the home. EVIDENCE: Although there is adequate information about the home and the services and facilities it offers, the statement of purpose and resident guide have not been fully completed since being up dated to reflect changing legislation. The manager was unable to locate a statement of purpose that contained all information in one place. The organisation must ensure the statement of purpose and resident guide are finalised and available in the home. The manager is presently investigating different formats for the information to ensure it is accessible to all prospective residents. This is good practice. Service agreements were seen, and there was evidence that trial visits are offered to prospective service users. Admission is normally through the care management approach; however there have been no recent admissions to the home. The home is able to meet the assessed needs of the individuals accommodated and this was evidenced by assessments and care plans in place. The residents were observed making full use of the facilities and services provided. Springbank DS0000026643.V249657.R01.S.doc Version 5.0 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): 6,7,9,10. Residents needs and choices are the focus of the care provided in this home, with advice and guidance being sought from various professionals in meeting those needs. EVIDENCE: Each resident is allocated a key team of support workers who co-ordinate the implementation of the care plan. The manager demonstrated a commitment to developing the role of the support workers in promoting and encouraging residents to lead active lifestyles. Detailed care plans; risk assessments and monthly care plan reviews, provided evidence that residents changing needs were identified and appropriate action taken to meet those needs. Notes of recent staff and management meetings indicated that the manager is developing systems to encourage support workers, with guidance from team leaders, to be involved in completing risk assessments developing strategies to minimise risks to residents both in and out of the home. Springbank DS0000026643.V249657.R01.S.doc Version 5.0 Page 10 Whilst this is consistent with good practice, the manager must ensure staff are provided with appropriate training and advice, and the management team should closely monitor all such assessments. Through observation and discussion it was evident the staff team had developed positive relationships with the residents, and they were able to meet their needs. Individual methods of communication were understood and used on a daily basis, and the residents appeared confident and relaxed. Those residents present during the inspection process indicated that they were happy in the home. A recent training session on Intensive Interaction had been attended by a group of staff, and the manager explained a further session had been held in the home. The training had been useful in raising awareness of non-verbal communication methods. Confidentiality policies and procedures are in place to ensure that all personal information is handled appropriately. Springbank DS0000026643.V249657.R01.S.doc Version 5.0 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): 11,12,13,14,16. The residents are supported and encouraged to participate in activities of their choice. Daily routines promote independence and choice. EVIDENCE: The home encourages residents to develop social and independent living skills, and support is provided to one resident who attends a work placement, whilst another attends a day centre regularly. Access to public transport and the homes own vehicle enables residents to pursue their chosen interests. The staff members encourage and introduce residents to new ventures, and recently one resident has shown an enthusiastic interest in fishing during a day trip to a local venue where fishing was taking place. This is now being developed, and the resident has purchased some fishing tackle to use on planned fishing trips. This is commendable practice. The involvement of family members in the delivery of care is encouraged and there are no restrictions on visitors to the home. Transport and staff support to visit relatives is available if necessary. Springbank DS0000026643.V249657.R01.S.doc Version 5.0 Page 12 The home has recently appointed an activities worker to co-ordinate and develop the social opportunities available to the residents. The role of this person is solely to support residents participating in activities, and to organise outings on a regular basis. The appointment of this person means individual choices and support for those residents who may not wish to join in community activities will be improved. Recently four residents have been on holidays away from the home. These holidays were organised to suit the needs and preferences of the residents. A review of two of the residents financial expenditure in relation to the holidays raised some questions. Financial records reviewed indicated that residents bore the cost of staff meals, accommodation and other expenses whilst away from the home. The policy on holidays away from the home, contradicts the policy on meals whilst staff are on duty. This policy states that staff must pay for meals whist on duty in the home unless a care plan indicates otherwise. The holiday policy is unclear on this issue, and no allowance was made for meals that the resident would have been provided with if they had remained at home. The organisation must review these policies to ensure they reflect current practice and provide detailed guidance on the financial responsibility to be borne by the organisation, and must state clearly what financial responsibility lies with the resident. Standard 14.4 states service users in long-term placements have as part of the basic contract price the option of a minimum seven-day annual holiday outside the home consideration should be given to this standard in the revised policies. (See Standard 40) The staff team at Springbank are committed to providing residents with opportunities to meet people, make friends and participate in new ventures, and clearly work proactively to promote involvement in the community. Policies should provide clear guidance for staff who have the responsibility for the residents finances. Springbank DS0000026643.V249657.R01.S.doc Version 5.0 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): 19,20. The personal and healthcare needs of the residents are monitored effectively and action is taken promptly when concerns arise, so that residents can be confident their needs will be met. EVIDENCE: Springbank offers the residents flexible, sensitive personal support, delivered with a focus on the residents individual needs and preferences. A healthcare file is in place for each resident, providing adequate guidance and a record of all healthcare interventions. Staff support is provided for attendance at all health appointments, and good relationships with the GP surgery located next door to the home, means quick responses to any queries related to the health of the residents is easily obtained. Periodical health checks are offered to the residents, and any concerns identified are responded to appropriately. Advice and guidance is sought from various health professionals including opticians, dentist, GP and the community learning disability team. Recent training for staff has included sessions on Autism and Intensive Interactions. Springbank DS0000026643.V249657.R01.S.doc Version 5.0 Page 14 The Inspector reviewed the storage and administration of medication that is co-ordinated by a designated staff member. Only senior staff members administer medication and training certificates were seen. Medication is dispensed by the pharmacy in monitored dosage cassettes. These are colour coded for am, midday and pm. A review of the records revealed no errors. For medication not dispensed in the monitored dosage system, it was difficult to audit, as there was no pill counter available. The Inspector recommended a pill counter be supplied to improve the efficiency during audits of medication. An audit of this medication revealed no errors. The maintenance person was in the process of building a cupboard with a locked door where the medication would be kept. The medication is held in a metal cabinet attached to the wall, and locked in the cupboard. There are no controlled drugs in the home, and PRN medication is stored in a separate locked metal cabinet in the office. The designated staff member carries out monthly audits, and quarterly audits are carried out by the organisation. Reports are completed after each audit and these were seen and noted to be comprehensive, and recorded actions taken if any concerns arose. The staff member demonstrated a good understanding of her responsibilities in relation to the storage and administration of medication, and was able to answer confidently any questions asked by the Inspector. Springbank DS0000026643.V249657.R01.S.doc Version 5.0 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. The manager has developed an open door policy: this enables residents to feel safe and confident their views will be listened to and action taken to meet their needs. Although policies and procedures are in place to protect residents from any form of abuse, a review of the abuse policy to include local protocols will provide greater protection for the residents and clearer guidance for staff. EVIDENCE: A comprehensive complaints policy is in place, and the manager continues to investigate pictorial information, which will summarise the policy, ensuring accessibility for all residents. There have been no complaints since the last inspection. The organisation have in place an abuse policy, however this does not reflect local authority protocols. The manager has accessed this protocol and contact number from the internet, and included this information with the abuse policy. All staff have been provided with this up dated information at a recent staff meeting. The organisation must review the abuse policy to ensure it provides adequate guidance in the event of an incident taking place. A review of staff training in relation to the protection of vulnerable adults from abuse (pova) revealed that not all staff have received this training. Comments from staff about a recent training session on abuse, provided by an internal trainer, were mixed and some staff indicated that they had not understood the session. The Inspector noted the staff-training matrix did not record attendance on abuse training, it was therefore difficult for the manager to assess which staff had yet to receive this training. Springbank DS0000026643.V249657.R01.S.doc Version 5.0 Page 16 The Inspector advised that all staff should attend abuse training and recommended it be added to the staff-training matrix. The manager had information and dates of pova training being delivered by the local authority, and stated an in-house training budget would be used to ensure all staff attends. The Inspector advised that the manager and the deputy must also attend abuse training with the addition of Alerter Training designed specifically for home managers. Policies and procedures are in place regarding the safe handling of residents personal finances and valuable personal possessions. A review of the records revealed no errors. A receipt is obtained for each transaction, and each is numbered and recorded on the balance sheet. The records reviewed were up to date and in order. The manager, with support from the organisation, was in the process of reviewing the system for each resident to have an individual bank account. Although a system is in place and each resident receives an individual bank statement showing each transaction, the newly appointed manager was unsure of the legality of the accounts as they are set up. This concern arose when the manager attended the bank to change the name of the appointees for the residents. A change to the present system is being made to promote and protect the rights and interests of the individuals accommodated. Training for staff includes Positive Response Training, and adequate guidance is in place for the development of behavioural management strategies within a risk assessment framework. Springbank DS0000026643.V249657.R01.S.doc Version 5.0 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): 24,25,26,27,28,29,30. The residents live in a homely, comfortable environment, with furniture and fittings of a good standard, however the safety of the residents would be assured if all call bells were accessible. EVIDENCE: The property is set in its own grounds with a private garden to the rear. Each resident has a single room, and the furniture and fittings were of a good standard. The decoration and personalisation of the rooms reflects the personality and preferences of each resident. It was evident staff members care for and support residents to keep their rooms homely and comfortable. Furniture and beds have been moved to ensure maximum use of space, and create a warm, comfortable and spacious look. This is good sensitive practice, however, the call alarms are now not accessible to the residents if they are in bed and felt unwell. The call alarms must be accessible and should be relocated when furniture is moved. There have been many improvements to the environment including the replacement of flooring in bedrooms and the dining room, the kitchen area has recently been revamped, and new gates have been fitted to the front driveway to improve security. Springbank DS0000026643.V249657.R01.S.doc Version 5.0 Page 18 The home has a rolling programme of re-decoration, and a maintenance person is employed to carry out minor repairs and alterations. During the inspection process the maintenance person was in the process of building a new cupboard to be used for the storage of the medication trolley. The work was of a very good standard. A recommendation from the previous inspection to improve bathing facilities and replace worn furniture has been implemented. The manager stated that new furniture had been ordered for the large communal lounge, and delivery was imminent. The flooring in the smaller lounge has been replaced. This was a very pleasant room, and was well used by the residents. A new bathing facility was also on order and would be fitted in January 2006, and would improve accessibility and safety for those residents who may require extra support. The revamping of this bathroom area would improve the use of space. The home was clean, tidy and very homely; there were no unpleasant odours in the bedrooms or communal areas, however a slight odour in one toilet was noted. The cladding on the pipes to the rear of this toilet was in a state of disrepair and needs replacing, this will help to reduce any odours in this area. A social skills kitchen used by residents with support from staff to develop independence skills was being used to store wheelchairs. The organisation must provide a separate area for the storage of equipment and wheelchairs, to ensure safe maximum use of communal areas. The residents were observed making full use of all facilities in the home, and moved confidently around the building, clearly at ease in the home. Springbank DS0000026643.V249657.R01.S.doc Version 5.0 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): 31,32,33,34,36. A stable, competent staff team, who are supervised by an effective management team, support the residents; however, inconsistent implementation of the induction and mandatory training programme does not fully protect the residents. EVIDENCE: The organisation operates a corporate robust recruitment procedure, and the personnel department ensure all appropriate employment information is collated prior to the start date for any new employee. Documentation seen during this inspection confirmed all relevant checks are carried out. In contrast to the rigorous recruitment procedure being implemented, a comprehensive indcution and training programme is not being implemented for all new staff members. A staff training matrix provided evidence that two staff members appointed some months earlier had not received this training. There was evidence that the manager had carried out an in-house induction, and supervision was being provided. However, only manual handling and positive response training had been provided to date. Springbank DS0000026643.V249657.R01.S.doc Version 5.0 Page 20 This issue had been discussed at a recent managers meeting, and it was noted that homes were failing in this area. The training is provided by the organisation and action needs to be taken to ensure all staff are appropriately trained within required timescales. The managers have no influence over the timing of the courses. The management team consists of, the manager, a deputy and four team leaders, who each take responsibility for the supervision and support of the staff team. A supervision matrix has been developed to enable the manager to monitor consistency, and regular monitoring of the contents of sessions is also carried out. As a result of close monitoring the manager has met with the team leaders to offer guidance and support to ensure consistency of the supervision content. Evidence that annual appraisals were taking place was also seen. A review of the format used to record supervision is in process. The Inspector is happy to meet with the staff team to provide guidance, support and generate discussion around the implementation of the supervision in the home. A system to review each staff members understanding of their role within the home on a six monthly basis has been introduced, and this is monitored by the organisation as part of the quality assurance process. Those staff spoken with were clear about their role and responsibilities in the home, and conveyed to the inspector a positive committed attitude to the provision of care. Springbank DS0000026643.V249657.R01.S.doc Version 5.0 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): 37,38,39,40,41,42,43. A stable management structure means the residents can be confident the staff are supported to enable them to meet the aims and objectives of the home. EVIDENCE: Mrs Kay Williams has successfully completed the registered manager process, and a new registration certificate has been issued with this information. During the inspection process the manager was able to demonstrate her competence to run the home promoting the rights and interests of the residents. The manager has many years experience in the provision of care, and has recently completed the NVQ level 4-care award. Confirmation of successful completion is awaited, and it is her intention to complete the registered manager award. Springbank DS0000026643.V249657.R01.S.doc Version 5.0 Page 22 The manager is supported by a deputy who has achieved NVQ level 2and 3. The deputy is also an NVQ assessor, and supports staff members completing NVQ awards as part of the organisational training programme. The deputy hopes to complete the Internal Verifier Award to provide further consistent support to staff on the NVQ programme. There was evidence of good systems of support, and staff members spoken with confirmed good communication systems in place at the home. Positive interactions between the management team, the residents and the staff were observed throughout the inspection process. Team leaders have delegated areas of responsibility, and recently one team leader has received health and safety training to enable co-ordination of statutory environmental checks. One focus of this role is implementing and recording fire safety systems in the home. A review of the fire safety records revealed comprehensive, clear information. All fire safety checks including: fire drills, evacuation, equipment checks and any concerns identified, were clearly recorded with actions taken to rectify any issues. Health and safety audits are completed monthly and sent to head office, and regular visits by the registered provider are carried out in line with Regulation 26, and reports sent to the Commission. The organisation have policies and procedures in place to ensure the health and safety of all persons living and working in the home, and robust auditing systems, training for staff, and adequate guidance for the management team, ensure implementation is consistent. However, some policies require review as discussed earlier in this report to ensure guidance reflects local protocols and adequate protection of residents rights and best interests. Springbank DS0000026643.V249657.R01.S.doc Version 5.0 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score 2 3 X 3 3 Standard No 22 23 Score 3 2 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 3 3 X 3 3 Standard No 24 25 26 27 28 29 30 STAFFING Score 3 3 3 3 3 2 2 LIFESTYLES Standard No Score 11 3 12 3 13 3 14 3 15 X 16 3 17 Standard No 31 32 33 34 35 36 Score 3 2 3 3 X 3 CONDUCT AND MANAGEMENT OF THE HOME X PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Springbank Score X 3 3 X Standard No 37 38 39 40 41 42 43 Score 3 3 3 X 3 3 3 DS0000026643.V249657.R01.S.doc Version 5.0 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. 1 Standard YA1 Regulation 4 Requirement A statement of purpose and resident guide must contain all information as detailed in the National Minimum Standards and be available in the home. The policy on residents holidays must be reviewed to provide adequate guidance to staff and reflect current practice. The abuse policy must be reviewed to reflect local authority protocols. All staff must receive abuse training. The manager and deputy must attend abuse alerter training. Storage must be provided for wheelchairs. Call alarms must be accessible to residents. Action must be taken to reduce the odour in the small toilet. Newly appointed staff must be provided with induction and mandatory training within appropriate timescales. Timescale for action 30/12/05 2 YA40 16 30/01/06 3 4 YA23 YA23 13.6 13.6 30/12/05 30/03/06 5 6 7 8 YA29 YA29 YA30 YA32 23.2(I) 23.2(n) 16.2(k) 18.1(a) 30/01/06 30/11/05 30/12/05 30/12/05 Springbank DS0000026643.V249657.R01.S.doc Version 5.0 Page 25 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 YA20 YA23 Good Practice Recommendations A pill counter to be provided for use during medication audits. Abuse training should be added to staff training matrix. Springbank DS0000026643.V249657.R01.S.doc Version 5.0 Page 26 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.V249657.R01.S.doc Version 5.0 Page 27 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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