Inspection on 24/04/07 for Springbank House

This inspection was carried out on 24th April 2007.

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

Similar services:

Byars Care Home

St Marys Nursing Home

Bramble Lodge

Parkmanor Residential Home

Thornham Grove

Hunter`s Lodge

London Road Neurological and Specialist Care Unit

Carlton Care Home

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

CARE HOMES FOR OLDER PEOPLE Springbank House 17 Ashgate Road Chesterfield Derbyshire S40 4AA Lead Inspector Susan Richards Unannounced Inspection 24th April 2007 09:30 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 Springbank House DS0000069548.V333867.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. Springbank House DS0000069548.V333867.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Springbank House Address 17 Ashgate Road Chesterfield Derbyshire S40 4AA 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) 01246 237 396 Hill Care Ltd Miss Deborah Fry Care Home 40 Category(ies) of Old age, not falling within any other category registration, with number (40) of places Springbank House DS0000069548.V333867.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. Hill Care Limited may provide the following categories of service:Care Home with nursing – PC, N To service users of the following gender:Either Whose primary needs on admission to the home are within the following categories:2. Old age, not falling within any other category - OP The maximum number of service users to be accommodated is 40 First inspection of this service since registration with Hillcare Limited on 06 March 2007. Date of last inspection Brief Description of the Service: Springbank House provides nursing and personal care and support for up to 40 older persons. The home has operated as a registered care/nursing home for many years, initially under the Registered Homes Act 1984, transferring under the provisions of the care Standards Act in 2002. Hillcare Limited became the registered provider in March 2007. The home is located within walking distance of Chesterfield town centre with level access into well-kept grounds, including a garden with seating areas and car parking provision. Accommodation is over two floors, with thirty-two single bedrooms and four shared. Seventeen of the single bedrooms have an en suite facility. There are a number of bedrooms to the first floor, located in the older part of the building, which do not provide suitable access for residents who may have mobility problems/ those receiving nursing care. Internal adaptations have been made to many areas of the environment to assist those with physical disabilities and mobility problems. These include a passenger lift, hand rails to corridors, grab rails in bathrooms and toilets and an emergency call system throughout. There are suitable bathing and toilet facilities, some of which have been recently upgraded, although two of these may are not accessible to service users with significant mobility problems. There is a choice of lounge and dining rooms on each floor, including a smokers’ lounge. The registered manager has the support of a team of Registered Nurses, carers and hotel services staff and also external management arrangements. The current scale of charges as 24 April 2007 is as follows: Springbank House DS0000069548.V333867.R01.S.doc Version 5.2 Page 5 £325.05 - £489.50 for those funded via Derbyshire County Council (NB those with en suited rooms are subject to an additional £10.00 top up fee in addition to the fees determined by Derbyshire County Council. £380.00 - £490.00 for those who are privately funded. Fees are determined in accordance with level of need and care provided. There are additional charges for private chiropody, in house visiting hairdresser and newspapers and magazines delivered to the home. All are as charged by the vendor. It is understood that the home plan to provide access to inspection reports by way of a written notice advising of its availability and to provide a retained copy in the reception area. Springbank House DS0000069548.V333867.R01.S.doc Version 5.2 Page 6 SUMMARY This is an overview of what the inspector found during the inspection. At the time of the inspection site visit there were thirty-one service users accommodate, including 13 receiving nursing care. This key inspection report has been collated using the following: Current and up to date information the Commission holds about the home. Some information provided by way of a pre-inspection questionnaire completed by the manager. Information collected during the site visit for this inspection, which included case tracking as part of the methodology. This involved the sampling of a total of three service users accommodated whose care and service provision was more closely examined. Discussions were held with those service users as able, together with a number of others about the care and services the home provides. Their care planning and associated care records were also examined and their private and communal facilities inspected. Discussions were also held with staff about the arrangements for their care and also for staffs’ recruitment, induction, deployment, training and supervision. A total of forty service user questionnaire surveys were forwarded to the registered manager at the home for distribution to and completion by service users or their representatives. None of these were returned. What the service does well: Service users health care needs are reasonably well met and they are treated with dignity and respect. There are suitable systems and arrangements in place to promote service users’ protection from abuse and to ensure their health, safety and welfare and the effective recruitment, induction and training of staff employed. Service users live in a safe, clean and comfortable environment, which suits their needs. Springbank House DS0000069548.V333867.R01.S.doc Version 5.2 Page 7 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. Springbank House DS0000069548.V333867.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Springbank House DS0000069548.V333867.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 3, 4 & 6 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. Admission information and needs assessment records are not always obtained or maintained in accordance with recognised practise, which does not consistently promote the best interests of existing or potential service users. EVIDENCE: Case tracking was undertaken in respect of three service users. Discussions were held with two of those about the arrangements for their admission and their care needs, which they said were discussed with them with assistance and support via care management arrangements and/or their relative. The Inspector was unable to hold any meaningful discussions with the third service user due to their level of need and mental capacity. Springbank House DS0000069548.V333867.R01.S.doc Version 5.2 Page 10 The recorded admission and needs assessment information was examined for those service users case tracked. There were inconsistencies and variances of recording, such as conflicting information, inaccurate information or a lack of information with regard to specific areas of need, including that relating to service users individual choices and lifestyle preferences. However, discussions with staff confirmed that they were sufficiently aware of the needs of those service users and work was underway to introduce a new needs assessment (and care planning) methodology via external management arrangements, for which staff training and instruction is proposed. Service users spoken with said that on the whole, they felt their needs were being met. For two of the service users case tracked there was no relevant needs assessment and care-planning information in place as provided via care management arrangements. For one of those service users the information provided related to their pre-admission care support arrangements in the community and for another, who was a fairly recent emergency admission to the home via care management arrangements, a copy of the single assessment and care planning summary had not been obtained. Equality and diversity needs of service users were not routinely recorded and although there was a format in place to record individual’s religious beliefs, these were often not completed, or their needs effectively identified. The Inspector was advised that there were no service users accommodated with diverse cultural or religious needs. The home does not provide for intermediate care. Springbank House DS0000069548.V333867.R01.S.doc Version 5.2 Page 11 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 & 10. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Service users health care needs are reasonably well met and they are treated with dignity and respect. The proposals for the introduction of a different care planning methodology should better promote a person centred approach care. EVIDENCE: The care plans of service users case tracked were examined and discussed with those who were able to do so and also with staff. As stated under Section One of this report, ‘Choice of Home’, work was underway to introduce a new (needs assessment) and care-planning methodology via external management arrangements, for which staff training Springbank House DS0000069548.V333867.R01.S.doc Version 5.2 Page 12 and instruction is proposed. This was discussed with the regional and project management for the home. For the most part care plans were reasonably well maintained with individual’s required clinical interventions recorded. They also had regularly recorded reviews, although they were not person centred (did not sufficiently reflect individual choices and lifestyle preferences) and care planning in respect of individual’s social needs was minimal (see also Social Care and Activities, Section 3 of this report). However, the planned introduction of a new careplanning format as discussed with management will better promote this. Changes in individual’s required care interventions were mostly identified within their care plan reviews. Although service users said that staff did consult them at times about their care, to their knowledge they had not been directly consulted about their written care plans and (with the exception of care planning for the use of bed rails), they was not routinely signed by them or their representative. However, a notice was recently displayed in the reception area advising service users and their representatives of their planned involvement in their care plans. Staff spoken with was conversant with the care to be delivered to service users case tracked, including use of individual aids and equipment, such as aids to mobility and pressure relieving equipment. The use of bedrails in the home was also under review in consultation with service users and their representatives in accordance with recognised guidance. Service users access to outside health care professionals was well accounted for, including that relating to specialist advice and also routine health care screening and service users spoken to knew of their own arrangements in respect of these. The arrangements for the management and administration of service users medicines were examined, including discussion with staff responsible and focusing on those service users case tracked, whose medicines were retained and administered by the home. These arrangements were in accordance with their individual choices and capacities. A full audit of medication systems had recently been undertaken by the home and further staff training was planned. There were suitable arrangements in place for the ordering, receipt, storage, administration and disposal of service users medicines, in accordance with recognised guidance, although component’s of the home’s medicines policy and Springbank House DS0000069548.V333867.R01.S.doc Version 5.2 Page 13 supplementary guidance was significantly out of date. The medicines policy’s last recorded review as detailed in writing on that policy was dated 2002. Information provided by the manager on the pre-inspection questionnaire indicated that the medicines policy was last reviewed in November 2006. Service users spoken with said that staff were usually ‘’kind and helpful’ and that ‘nothing was too much trouble.’ All said that staff addressed them courteously and respectfully. Springbank House DS0000069548.V333867.R01.S.doc Version 5.2 Page 14 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 & 15 Quality in this outcome area is poor. This judgement has been made, using evidence available, including a site visit to the home. Service users social, cultural, religious and recreational interests and needs are currently not effectively determined or met, although food provided is to a reasonable standard. EVIDENCE: The arrangements for social care were discussed with service users and staff and individual’s needs assessment and care planning information examined for those service users case tracked. Some service users said that although activities and entertainments were occasionally organised, that staff were not regularly available to provide assistance and support in this respect as they were busy assisting service users with their personal and healthcare. Staff comments received was also reflective of the above and all staff spoken with said that this was a key area, which could be improved. Springbank House DS0000069548.V333867.R01.S.doc Version 5.2 Page 15 Needs assessment and care planning information recorded for those service users case tracked in respect of their social care and daily living preferences was scant. However, the manager advised that a post for an activities co-ordinator, providing 16 hours per week during the afternoons) was now recruited to and was due to commence, although some staff and service users were not aware of this. The manager advised that library services were also being reestablished for service users and there were plans to develop trips out during the summer months. Since registration the provider has established a newsletter, recently distributed around the home. Feedback regarding this was positive and some service users particularly liked the quizzes contained in the newsletter. However, this was available in standard type format only. The religious needs and preferences of service users case tracked were not always recorded. Although service users spoken with said they did not practise their religion, the manager was vague regarding the arrangements to assist any service user who may wish to do so. Service users said they could receive visitors in private whenever they chose. Information was not provided for service users or their representatives regarding access to advocacy although some information was provided by way of a displayed notice regarding access to care plans, although this was directed at relatives. All service users spoken with said they enjoyed meals provided, which were sufficient in quantity with an alternative offered at each meal, with snacks and drinks available at all times. Some service users attended the dining rooms for meals and some chose to remain in their own rooms. Staff was observed to serve and assist service users in various locations around the home at lunchtime. Food was reasonably well presented, although on the first floor staff was rushed to serve these and to assist those service users as required. One of the service users case tracked complained that he had been left sat waiting at his table for over half an hour for his lunch to be served. However, positive comments were received regarding the ‘hotel style’ table settings provided. Menus were not provided with the pre-inspection questionnaire. Springbank House DS0000069548.V333867.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): NMS 16 & 18 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Service users are protected from abuse, although their rights to complain could be better promoted. EVIDENCE: There is a written complaints procedure in place for the home, which was displayed, although this was in standard format only. Service users spoken with said they were unsure as to whether there was a formal procedure, but said that if they wished to do so they would complain to the nurse in charge or the manager. One of the service users case tracked, was blind and said they had not been provided with information as to how to complain in any alternative format. Discussions with external management indicated that two complaints had been received by the home since the previous inspection and records were kept of these, including action taken and outcomes. However, only one of these was Springbank House DS0000069548.V333867.R01.S.doc Version 5.2 Page 17 recorded on the pre-inspection questionnaire completed by the registered manager. One of these related to staff skill mix provided in the home, which was not upheld. The other complaint was raised directly with the Commission regarding insufficient staffing levels and the need for repair or replacement of a specialist bed used by a resident in the home. The Commission wrote to the registered provider and asked them to investigate this and act accordingly. A written response was received from the provider. This advised that the bed was replaced but refuted at that time (March 2007) that staffing levels were insufficient. (See staffing section of this report). Staff spoken with was generally conversant with their responsibilities with regard to recognising and reporting any suspicion or direct witnessing of the abuse of any service user. All said they were provided with training and updates in this respect. Staff advised that the use of restraint, particularly with regard to the use of bed rails was under review in accordance with recognised practise guidance. This was confirmed by two of the service users case tracked who had been involved in discussions about these. Springbank House DS0000069548.V333867.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, 22, 24 & 26. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users live in safe, clean and comfortable surroundings, which suits their needs. EVIDENCE: The private and communal facilities accessed by those service users case tracked, were inspected together with the laundry. All areas seen were clean, hygienic and odour free, well ventilated, warm and well lit and suitably decorated and equipped in accordance with service users assessed needs. Bedrooms were personalised and some service users had chosen to bring in some items of their own furniture. Springbank House DS0000069548.V333867.R01.S.doc Version 5.2 Page 19 Service user spoken with said they were satisfied with their own rooms and their overall environment, which they felt suited their needs. Many gave positive comments with regard to the programme of redecoration and upgrading being undertaken in the home by the new provider, who had provided a programme of routine maintenance and renewal for the home. There is choice of lounge and dining rooms in the home, which enables service users to live in smaller clusters. One married couple had chosen to share a room and also had their own separate living room. All other rooms were single occupancy with many providing en suite facilities. Springbank House DS0000069548.V333867.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 & 30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The arrangements for staff deployment do not always in accordance with service users best interests, although they are suitably protected by the home’s recruitment, induction and training arrangements. EVIDENCE: The arrangements for the recruitment, induction, deployment and training of staff employed were examined. This included discussions with staff about those arrangements and inspection of related records. Discussions were also held with some service users about staffing arrangements and staff availability. At the time of the site visit to the home there were thirty-one service users accommodated, including a total of thirteen who received nursing care. Management advised that using the home’s dependency assessment tool, that this included fourteen service users with medium dependencies and seventeen with low dependencies. However, for those service users case tracked, their individual needs assessment information was sometimes not accurately or effectively recorded (see Choice of Home section of this report). This sometimes resulted in their individual dependency assessment scoring being incorrect, indicating for two of them that their actual dependencies were in fact Springbank House DS0000069548.V333867.R01.S.doc Version 5.2 Page 21 higher that recorded. This suggested that the evidence being used by management to determine staffing levels was unreliable. Concerns were raised during discussions with staff about staff deployment and the numbers of staff on duty, who felt that service users needs and dependencies were not being effectively taken into account to effectively determine this. All staff said that until recently they had often been working with one registered nurse and four, sometimes five care staff during the morning and one registered nurse and three care staff during the afternoons. They felt during the afternoons particularly, that these were insufficient leaving only time to try to address basic care needs and with no time to spend with service users on an individual or group basis, including for the purposes of meeting their social care needs. However, all agreed that the very recent increase to four care staff and one registered nurse during the afternoon periods, together with the support via an external project manager (registered nurse) had improved matters, although still did not leave time to organise activities and social care for service users. (See also the Social Care section of this report). Some staff felt that one registered nurse and two care was insufficient at night given the care needs of service users and the layout of the building, although not all staff shared this view. The regional manager advised that clinical auditing had not indicated any increase in the number of accidents or falls and that there were not adverse trends in these areas. The residential forum staff guidance indicates that for thirty-one service users (dependencies as provided by the home), that there should be a total of 706.98 care staff hours provided per week. (This does not include registered nurses, who should be additional to that calculation). This is not currently being achieved, although the additional provision of the proposed activities coordinator should go some way toward achieving this. The regional manager advised that the activities co-ordinator post had been recently been recruited and was due to commence, which will provide a total of 16 hours per week for social, recreational and cultural activities. The residential forum guidance calculates that this should be 20.24 hours (included within the 706.98). See also complaints section of this report relating to a complaint made via Commission during March 2006 regarding insufficient staffing levels. This was passed to the provider to investigate and act upon accordingly. The registered manager felt that the arrangements for the organisation and delivery of care had improved someway with four care staff during the afternoon, but also felt that a review of routines was needed. Staff also had Springbank House DS0000069548.V333867.R01.S.doc Version 5.2 Page 22 differences of opinion as to their own roles and responsibilities and those of others. Service users spoken with said that staff were usually available, although they may have to wait for a time as they were very busy. However, all that said that they did not feel that they had to wait an unreasonable amount of time for assistance. Service users observed were well presented and appeared well cared for and appropriately dressed. During lunchtime for service users, staff were stretched and rushed whilst serving meals around the home and assisting service users, sometimes in their own rooms and some in the dining rooms. Periods were also observed where there was no staff presence in lounge and dining rooms. The staff files of four if the most recent staff starters were examined. With the exception of one staff member, employed by the previous registered provider and for whom there was only one written reference in their file, these contained satisfactory information regarding their recruitment, induction and training. The manager assured that this would be followed through. However, written verification of staff’s reasons for leaving their previous employment where working with vulnerable adults was not routinely obtained. The home operates an equal opportunities policy and equal opportunities monitoring is undertaken as part of the recruitment process. A staff training needs assessment had been undertaken and a training matrix and training plan produced, which was satisfactory and included the reintroduction of NVQ training for staff. Satisfactory information was not provided as requested within the preinspection questionnaire regarding staff employed or the NVQ training status of care staff. Springbank House DS0000069548.V333867.R01.S.doc Version 5.2 Page 23 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, 32, 33, 35, 36, 37 & 38. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Service users health, safety and welfare is sufficiently promoted and protected and the extensive management review of the home, which is currently being undertaken, may better ensure that that it is run in the best interests of service users. EVIDENCE: The management arrangements in the home are currently being totally reviewed by the registered provider under the direction of an external project manager who is temporarily seconded into the home from within the company. The registered manager has worked at the home for a number of years and Springbank House DS0000069548.V333867.R01.S.doc Version 5.2 Page 24 details of training and development undertaken by her during the last twelve months were provided. However, in agreement with this manager, advertising is currently underway to recruit a new registered manager. Once successfully appointed to the current manager will take up the post of deputy manager. Under the new ownership of the home a formal system of quality monitoring and assurance was in the process of being introduced with initial development plans in place. These include the intention to introduce formal consultation mechanisms with service users and their representatives, including satisfaction surveys and regular meetings. A notice was posted in the reception area of the home advising of proposed consultation regarding individual’s care plans. A newsletter had been introduced and service users felt this was a good idea and would be beneficial. Progress will be assessed at the next inspection of this service. The home did not handle or manage personal monies for those service users case tracked, as they had alternative private arrangements. However, systems and arrangements for the management and handling of service users monies were generally discussed and examined and were satisfactory. A formal system of individual staff supervision was also being rolled out to staff. Progress with this will be assessed at the next inspection of this service. A number of records, which are required to be kept by the home, were examined during the course of the inspection. These included the following: Service users needs assessment and care plans and associated care records. Medicines records. Complaints records. Staff records (recruitment, induction, training and deployment) Visitors record. Accident records Reports of the monthly visits of the registered provider (or representative). These were safely and securely stored. Deficits in record keeping are identified under the relevant sections of this report, although in the main these were satisfactory. Discussions were held with staff regarding the arrangements for ensuring safe working practises in the home, including staff training and staff practises were also observed during the course of the site visit, together with environmental safety. These were satisfactory. Springbank House DS0000069548.V333867.R01.S.doc Version 5.2 Page 25 Springbank House DS0000069548.V333867.R01.S.doc Version 5.2 Page 26 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 1 2 X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 1 13 3 14 2 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 3 3 X X 3 X 3 X 3 STAFFING Standard No Score 27 2 28 2 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 2 2 X 3 2 2 3 Springbank House DS0000069548.V333867.R01.S.doc Version 5.2 Page 27 Are there any outstanding requirements from the last inspection? N/A 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 OP3 Regulation 14 Requirement The registered provider must not provide accommodation to any service user unless, as far as practicable, their needs have been assessed by a person suitably qualified to do so and a copy of the assessment is obtained. It must be ensured that the recorded needs assessment for each service user, is kept under review and is revised at any time where necessary Policy and procedural guidance provided for staff responsible for the management and administration of medicines must be kept under review so that it and accurately reflects current practise and guidance. Service users must be consulted about their social interests and spiritual needs in order for them to be able to engage/participate in local, social and community activities of their choice. It must be ensured that at all times there are suitably qualified, competent and DS0000069548.V333867.R01.S.doc Timescale for action 30/06/07 2. OP3 14 30/06/07 3. OP9 13 31/07/07 4. OP12 16 31/07/07 5. OP27 18 30/06/07 Springbank House Version 5.2 Page 28 6. OP29 17 experienced persons working in the home in such numbers as are appropriate for the health and welfare of service users. Copies of both references 30/06/07 obtained for staff employed must always be kept as a measure of their fitness for employment in the home. (In this instance relates to one identified staff member only). 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 OP3 Good Practice Recommendations The diversity needs of service users should be routinely recorded by inclusion in their personal/needs assessment information (ie culture and religion). Service users care plans should be developed and detail the action which needs to be taken by care staff to ensure that their (health & personal) and social care needs are met in accordance with their individual choices and lifestyle preferences. Up to date information about activities should be circulated to all service users in formats suited to their capacities. Information should be provided for service users and their representatives regarding access to advocacy services. Information as to how to complain should be provided in suitable/alternative formats for service users. Written verification of staff’s reasons for leaving their previous employment where working with vulnerable adults should be routinely obtained. OP7 3. 4. 5. 6. OP12 OP14 OP16 OP29 Springbank House DS0000069548.V333867.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection Derbyshire Area Office Cardinal Square Nottingham Road Derby DE1 3QT 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 Springbank House DS0000069548.V333867.R01.S.doc Version 5.2 Page 30 - 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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