Inspection on 01/03/07 for Springbank Nursing Home

This inspection was carried out on 1st March 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector 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 Nursing Home 11/11/05

Springbank Nursing Home 16/02/05

Springbank Nursing Home 07/09/04

Springbank Nursing Home 09/03/04

Similar services:

Maple Lodge

Heathlands

Aston Court Nursing Home

Breme

Ravenhurst

Bank House

Inspirations

Ashcroft Hollow Nursing Home

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

CARE HOMES FOR OLDER PEOPLE Springbank Nursing Home Mill Hayes Road Knypersley, Biddulph Stoke-on-trent Staffordshire ST8 7PS Lead Inspector Mrs Yvonne Allen Key Unannounced Inspection 1 March 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 Nursing Home DS0000026966.V331999.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 Nursing Home DS0000026966.V331999.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Springbank Nursing Home Address Mill Hayes Road Knypersley, Biddulph Stoke-on-trent Staffordshire ST8 7PS 01782 516889 01782 523382 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) Care Consortium (Biddulph) Limited Mrs Pamela Pope Care Home 42 Category(ies) of Dementia (10), Dementia - over 65 years of age registration, with number (10), Mental Disorder, excluding learning of places disability or dementia - over 65 years of age (20), Old age, not falling within any other category (20), Physical disability (42), Physical disability over 65 years of age (42) Springbank Nursing Home DS0000026966.V331999.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. PD minimum age 60 yrs DE minimum age 60 yrs Date of last inspection 11 November 2005 Brief Description of the Service: Springbank is a care home that provides personal and nursing care to a variety of people within the categories detailed on the previous page. The home was opened in 1988. It is set in a rural location just off the A527 within close proximity to Biddulph town centre. The home offers accommodation on 2 floors with access by stairs or shaft lift. At present the home are reducing their 6 double bedrooms to 2 doubles and increasing the current 30 single bedrooms. Some rooms will have en-suite facility. Communal accommodation is provided with the availability of 2 lounges (one on each floor) and a large dining area. There are sufficient and appropriate washing and bathing facilities throughout the home and a hairdressing salon. The gardens are very well maintained and there is a large seating area, which is accessible to wheelchair users. There is ample parking space. The fees charged by this home range from £317.00 - £445.00. Additional charges would be incurred for private chiropody, hairdressing and transport (escort). This information was provided by the manager on 19/07/06. Springbank Nursing Home DS0000026966.V331999.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced key inspection was carried out over one day by one inspector. The inspection visit commenced at 09.30am and was completed by 2.45pm. All the key standards were assessed and the methods of collecting evidence were as follows – Direct observation Examination of records and documentation Discussions with service users Discussions with the manager and staff A tour of the home Analysis of comment cards received from service users, relatives and the GP prior to the inspection visit. There were no immediate requirements made and most of the key standards were fully met. In respect of the standards that were not fully met, requirements have been made and are included at the end of this report. Service users felt very happy with the home and that their needs were being met there. The staff team was dedicated and caring and they felt supported by the manager of the home. What the service does well: The manager is skilled and competent to run the home and has experience of nursing and care of the elderly in various settings. She runs an open door policy and deals with concerns and complaints service users might have. The manager is supportive of staff training needs and ensures that the staff team have the skills and expertise to meet the needs of the service users accommodated in the home. The manager had a good rapport with the service users, as did the rest of the staff team. There is good medical assistance at the home and the GP service is accessible and supportive. Springbank Nursing Home DS0000026966.V331999.R01.S.doc Version 5.2 Page 6 One of the GPs was very complimentary about the personal and nursing care provided at the home and felt that this home offered a good standard of care for his patients. Health care needs are well documented and monitored. There are presently no pressure area management problems in the home as a result of good assessments and preventive action. The service users spoken to felt happy with the services provided and felt that their care needs were being met at the home. One of the service users stated – “I don’t know what I would have done without this home”. Staff training meets requirements and the standard for NVQ training has been exceeded. What has improved since the last inspection? What they could do better: Attention to detail with some aspects of health and safety is required – The wheelchair policy was not being adhered to and service users were being transported in wheelchairs with no footrests in place. This was placing individual service users at risk of injury whilst being transported in the chairs. Service users were being nursed with bedrails in place and there was no evidence of a risk assessment having been done prior to their use. Neither was there any evidence that the home had consulted with the service user and/or their representative about their use. Springbank Nursing Home DS0000026966.V331999.R01.S.doc Version 5.2 Page 7 Not all staff had received the required number of fire drills and this was particularly evident in relation to night staff. This lack of basic instruction and fire safety training may put lives at risk in the event of a fire at the home. Although it was pleasing to see that a comprehensive quality auditing system has been put into place since the last inspection, the Provider will need to ensure that, wherever possible, this involves seeking the views of the service users. Also there will need to be evidence of work signed off and where areas in need of improvement have been identified-then there is evidence to show what has been done in order to improve these. The activities co-ordinator had left the home in January of this year and there had been no recording of individual activities since then. The Provider will need to evidence that the social and therapeutic needs of individuals are being met. The odour of cigarette smoke was quite evident on entering the home and this needs to be kept under control for the comfort of the service users and staff in the home. Discussions with the manager of the home identified that the Provider was addressing this by installing air purifier units. Comments from some relatives and staff members indicate that there are some occasions where staff sickness is not covered and minimum staffing requirements are not met. This will need to be improved and staff must be provided according to occupancy and dependencies of the service users in the home. 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 Nursing Home DS0000026966.V331999.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 Nursing Home DS0000026966.V331999.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): Standards 2, 3 and 4 were assessed. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Prospective service users are given enough information about the home to enable them to make a decision and can be assured that the staff at the home will meet their assessed needs. EVIDENCE: A random selection of care plans was examined and found to contain evidence of pre-admission assessments. These were initial assessments of personal, nursing and healthcare needs. Where service users were funded there were examples of initial and follow-up assessments by the funding bodies. Springbank Nursing Home DS0000026966.V331999.R01.S.doc Version 5.2 Page 10 The manager commented that, where the needs of individuals change, then reassessments by other professionals are arranged. This ensures that the home continues to meet individual needs. Service users spoken to at the time of the visit were satisfied with the care provided and felt that their needs were being met. Comment cards returned to CSCI before the inspection visit confirmed the above. Service users had also ticked that they were happy with the information provided by the home prior to admission and that they had received a contract. Three comment cards had been completed by other healthcare professionals prior to the inspection visit – 2 from GPs and 1 from a district nurse and all three felt the overall care needs were being met at the home. Springbank Nursing Home DS0000026966.V331999.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): Standards 7,8,9 and 10 were assessed. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Personal and nursing care is planned and delivered with dignity and respect. Service users can be assured that their healthcare needs will be met. The recording procedure relating to the administration of medication needs tightening up. EVIDENCE: Discussions with service users identified that they felt that their needs were being met at the home. Observation of the delivery of care identified that service users were receiving care and attention from staff as required and as per their plan of care. Care was delivered in a dignified manner by the staff and staff were heard talking to service users in a polite and respectful manner. Springbank Nursing Home DS0000026966.V331999.R01.S.doc Version 5.2 Page 12 There was evidence of good nursing care and measures were in place to help protect service users form developing pressure ulcers. The inspector was informed that there were currently no service users in the home with pressure ulcers. Comments from a GP in relation to the delivery of care read – “I believe this to be the old persons’ home with the best medical and nursing and continuity of care components in the area of my practice. There is a generally happy atmosphere and gracious feel to the home”. Another GP commented – “We have had some problems with one member of the nursing team who will not follow our normal procedures for requesting advice and visits. Otherwise I am not aware of any problems and the care seems good”. Comments from service users and relatives read – “My mother has been at Springbank since 11/05. She has settled in very well. There is a very pleasant, caring atmosphere in the home and the staff are always helpful when I visit. I am satisfied with the level of care my mother is receiving”. A random selection of care plans was examined. Each one had a plan of care developed from an initial assessment of needs. There were signatures in place to document monthly evaluation. There was little evidence of consultation with service users and/or their representatives in relation to evaluation/review of the care plans and it is a recommendation that this is further developed. There was evidence of the use of bedrails for some individuals but no risk assessment had been undertaken before their use and there was no evidence of consultation with service users/representatives about this. There is a requirement for a risk assessment to be carried out for each individual who uses bedrails and there must be evidence of consultation about their use. There were records of consultation with health care professionals including visits by the GP as and when required. Each plan had evidence of a full assessment of need, daily records, accident records (where applicable) and safeguarding referrals. Springbank Nursing Home DS0000026966.V331999.R01.S.doc Version 5.2 Page 13 The manager stated that some of the nurses had received training in the administration of sub-cutaneous fluids and that the home had the necessary equipment to administer this. This was encouraging and should avert some unnecessary hospital admissions and discomfort for individuals in the future. The medication process was assessed and the nurse was observed administering the lunchtime medication. This procedure was carried out as required and in accordance with medication guidelines. Examination of Medication Administration Record (MAR) charts identified that there were 2 gaps where required medication had not been signed as given. These were relating to Loperimide on 22 and 23 February. It is a requirement that a signature is in place for all medication whether administered or omitted. Samples of medication stored in the medication trolley were inspected and found to be in date and correctly labelled. Springbank Nursing Home DS0000026966.V331999.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): Standards 12, 13, 14 and 15 were assessed. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Service users are able to exercise choice and autonomy is promoted at the home. The Provider will need to improve the programme and delivery of activities in order to ensure that the social and therapeutic needs of individuals are met. EVIDENCE: The inspector was informed that the activities co-ordinator had left recently and, up to the time of the inspection visit, she had not been replaced. Examination of the recording of individual activities identified that nothing had been recorded since January 2007. Comment cards received also highlighted that social activities are an area where the home could improve and that individuals were not totally satisfied with what they received. Springbank Nursing Home DS0000026966.V331999.R01.S.doc Version 5.2 Page 15 There is a requirement for the Provider to improve in this area in order to evidence that the social and therapeutic needs of individuals are being met. There is a recommendation to employ another activities co-ordinator for the home. The manager stated that regular Church services are held in the home including the receiving of Holy Communion. She also confirmed that the spiritual needs of all the current service users are met. The home ran an open visiting policy where visitors could come and go at any time and could visit their relatives in the privacy of their own rooms if so desired. Examination of individual plans, discussions with service users and comments on comment cards, identified that autonomy; privacy and dignity were all promoted by the staff at the home. Service users were offered choices in all aspects of their daily life wherever possible. This area would be improved by addressing social and therapeutic needs. The lunchtime meal was observed as it was served to service users. This meal appeared nutritious and appetising. There was a choice at each mealtime and service users stated that preferences were catered for in relation to food and drink. Special diets were also catered for. Service users were able to choose where to take their meals – either in the dining room or the privacy of their own rooms. The menus were examined and were seen to offer variety and nutritious dishes. Springbank Nursing Home DS0000026966.V331999.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): Standards 16 and 18 were assessed. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users can be assured that they will be protected from harm and that any concerns they might have will be listened to and taken seriously. EVIDENCE: The registered manager stated that she deals with any concerns and complaints regarding the home. Comments contained in comment cards from service users and representatives identified that the manager would be the point of contact should they have any concerns. The manager had dealt with 3 complaints within the last 12 months, 1 of which had been substantiated and 1 partly substantiated and there was 1 pending an outcome. There had been 1 POVA issue since the last inspection, which CSCI had attended and which had resulted in a satisfactory outcome. The service users are protected from harm or abuse at the home. Staff are carefully selected to work at the home and undergo police Criminal Records Bureau and Protection Of Vulnerable Adults checks. Springbank Nursing Home DS0000026966.V331999.R01.S.doc Version 5.2 Page 17 Discussions with a senior care staff member identified that she was familiar with the protocol for the reporting of abuse or suspected abuse. The staff members spoken to confirmed that training in this area is given to staff on induction. Springbank Nursing Home DS0000026966.V331999.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): Standards 19 and 26 were assessed. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home provides a homely environment for service users, which has been adapted to suit their needs. Further refurbishment and elimination of cigarette odour would help improve the environment. EVIDENCE: On entering the home there was a distinct odour of cigarette smoke. This was present throughout the ground floor around the dining room and reception area. This was as a result of the service users’ smoking room being located off the reception area and opposite the dining area. There was no extractor fan Springbank Nursing Home DS0000026966.V331999.R01.S.doc Version 5.2 Page 19 installed in this room but the manager stated that air purifier units had been ordered for the ground floor and the staff room upstairs. The requirement to replace the carpet along the corridor area had been addressed. The kitchen had received an inspection by Environmental Health since the last CSCI inspection and the Provider had addressed all the requirements contained in their report. A selection of bedrooms were inspected and found to be personalised and adapted to meet the needs of the individual service users. The new bedrooms (located in the extended section of the home) were attractive and well-presented and offered en suite facilities. Some of the furniture in bedrooms located in the original part of the home was looking worn and in need of replacement. A comment contained in a comment card from a service user read – “Furniture in older rooms shabby and in need of replacement especially in the sink area.” In the bathroom (Spode) the toilet seat was worn and in need of replacement. Examination of an audit carried out in 2006 identified that this, and other toilet seats should have been replaced in November 2006. The dining room carpet was also very badly stained and in need of replacement. The manager stated that replacement of the flooring in this area was planned. Dining room furniture was looking worn and the manager stated that there were plans in place to replace the tables and chairs. The service users were seen enjoying all of the communal areas at the time of the visit and were sitting in both lounges – ground floor and second floor as preferred. The laundry is located in a separate building next to the home and was not visited on this occasion but the laundry assistant was interviewed. This is outlined under the next outcome area. Springbank Nursing Home DS0000026966.V331999.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): Standards 27, 28, 29 and 30 were assessed. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Staff were found to be provided in minimum numbers and had the required skills and expertise to care for the service users in the home but comments indicate that staff are not always provided in sufficient numbers to cover staff sickness. EVIDENCE: At the time of the inspection visit there was a total of 32 service users accommodated in the home, 15 of who were receiving nursing care and the remainder personal care including 6 service users with mental health needs (personal care). The staff on duty included the registered manager – who was supernumery, the registered general nurse and 4 care assistants from 7.30am-2.30pm then 3 care assistants from 2.30pm-9.30pm. On the night shift there was 1 registered nurse and 2 care assistants. The above figures were in keeping with minimum staffing levels but, due to the dependency needs of some individuals seen at the time of the visit – especially Springbank Nursing Home DS0000026966.V331999.R01.S.doc Version 5.2 Page 21 those wandering and requiring supervision, it is recommended that the levels be increased by 1 care staff for the daytime. Discussions with staff members identified that, due to staff sickness, staffing could be a problem. It was identified that, should a care staff member ring in sick, then it was often too late to arrange for staff cover and the shift continued with 1 carer short. This must not be allowed to happen – and minimum staffing must be provided at all times. Comment cards received from service users and their representatives indicated that the home is sometimes short staffed and that this can cause delays with service users receiving care when needed. – “There have been numerous events where there is not enough staff. Occasionally there has only been two staff for the whole home after tea”. There were sufficient numbers of kitchen, domestic, laundry and maintenance staff provided at the time of the visit. The inspector was informed that the activities co-ordinator had left the previous month but that the Provider was looking to replace her. It is a recommendation that this goes ahead soon in order for the home to meet the social and therapeutic needs of the service users. At the time of the visit there was an abundance of administrative staff seen and the inspector was informed that they all had different roles in the running of the home/company. There was a staff training and development programme in the home and records were seen to confirm that training takes place. The training is geared to meeting the needs of the service users and has included – Manual Handling - training the trainer NVQ in care – levels 2 and 3 First aid Dementia care and Challenging behaviour Falls and risk management Safe handling of medicines Future training planned – A1. Communication – Standex Manual Handling trainer’s update Palliative Care Springbank Nursing Home DS0000026966.V331999.R01.S.doc Version 5.2 Page 22 Staff members spoken to stated that they felt that their training needs were met and supported at the home. The registered manager had completed her RMA award and the deputy manager was undergoing A1 training. The staff recruitment procedure was assessed. The first 2 employee files examined did not have the required 2 written references in place – discussions with the manager identified that these 2 staff members had been employed at the home many years ago – before the manager was in post. Both were considered to be suitable employees and had undergone the required CRB checks. A further employee file was examined in respect of a staff member employed since the last inspection. This was found to contain all the required information including 2 written references, one from the last employer. This was well organised and easily inspected. It is recommended that all staff files be organised in this way. Springbank Nursing Home DS0000026966.V331999.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): Standards 31, 32, 33, 35, 36 and 38 were assessed Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. The home is well managed by a manager who is skilled and competent to do so. Some aspects of health and safety will need to be tightened up. EVIDENCE: The registered manager had been in the post for several years now and possessed the necessary skills and expertise to run the home. She had recently completed the RMA award. Springbank Nursing Home DS0000026966.V331999.R01.S.doc Version 5.2 Page 24 The manager was supported by administration staff and a deputy manager. The service users spoken to were all complimentary about the manager and intimated that they would go to her if they had any concerns. Comment cards received from service users and relatives prior to the inspection visit confirmed the above. The manager was observed to have a good rapport with the service users. Staff members also stated that they felt supported by the manager and that she ran an open door policy. There was a comprehensive quality auditing system in place at the home where the operational manager had audited services. Relevant records were examined and found to be very thorough, covering areas including care plans, kitchen and maintenance of the home. Audits were honest and unbiased and highlighted areas in need of improvement. Planned dates were included for some areas, but in some cases these dates had not been met, and in others it was difficult to ascertain what action had been taken to resolve areas highlighted for improvement. The audits were in need of completion with work being signed off when it had been done. Also audits will need to evidence that, wherever possible, the views of service users have been sought. The inspector raised concerns with the manager that the CSCI had not been receiving any monthly Regulation 26 reports from the Provider. It was agreed that these would be done and the reports would be kept at the home and made available for inspection as and when requested by the CSCI. The maintenance of personal allowances was examined in respect of service user’s money. A running balance of individual accounts was kept together with receipts and invoices. Although each service user had their own separate statement of account, these were not separate personal accounts but formed part of one large bank account. Individual service users were therefore not accruing any interest on their money. It is a recommendation that each service user have their own individual bank account and that, wherever possible, service users or their representatives deal with their own finances. Springbank Nursing Home DS0000026966.V331999.R01.S.doc Version 5.2 Page 25 The staff members spoken to stated that they received one to one appraisals but were unsure how often they had received formal supervision sessions. Discussions with the manager identified that these had started but were behind and needed further developing in order to ensure that all care staff received 6 sessions per year. Discussions with the ancillary supervisor identified that she had some concerns in relation to health and safety. Her concerns were that she worked alone in the laundry, which was separated from the main building. She had recently sustained an injury following an accident whilst working in the laundry and she was concerned that, an accident could occur again whilst she or the other laundry assistant was working alone and that it might be some time before the alarm could be raised. As there was quite a lot of electrical equipment in the laundry this again increased the risk of an accident occurring. The matter was discussed with the manager during feedback and it is a recommendation that advise be sought regarding lone working from the Health and Safety Executive and a lone working policy implemented. It is also a recommendation that ancillary staff receive basic moving and handling training. Examination of records relating to health and safety in the home identified that equipment used at the home had been regularly serviced and checked by outside Companies. This included fire safety and fire fighting equipment. Records had also been maintained of the testing of hot water and emergency lighting. The regular testing of the fire alarm system had also taken place and records had been maintained. Staff had received regular update sessions in mandatory training including fire safety. The ancillary supervisor stated that her staff had received COSHH training. The recording of staff fire drills identified that not all staff had received an adequate number of drills and this was especially in relation to night staff. It is a requirement that all staff receive 2 fire drills per year and that this is recorded. It was noted, during the visit, that wheelchairs were being used to transport service users with no footrests in place. On one occasion, a care staff member was heard telling the service user to “keep her feet up”. Springbank Nursing Home DS0000026966.V331999.R01.S.doc Version 5.2 Page 26 This is a dangerous practice and can increase the risk of falls and injuries from the wheelchair. Discussions with the manager identified that staff were aware that they should have footrests in place on wheelchairs but that they keep taking them off. She stated that there was a wheelchair policy at the home of which staff were aware. The manager also pointed out that some individual service users do not like footrests and asked for them to be removed. The inspector reminded her that service users refusing to have footrests on their wheelchairs must have a risk assessment in place in their care plan outlining this. Again advice could be sought from the Health and Safety Executive about this. Springbank Nursing Home DS0000026966.V331999.R01.S.doc Version 5.2 Page 27 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 x x 3 3 x n/a HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 x 18 3 2 x x x x x x 2 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 2 x 3 3 x 2 Springbank Nursing Home DS0000026966.V331999.R01.S.doc Version 5.2 Page 28 Are there any outstanding requirements from the last inspection? no 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 OP38 Regulation 13(4) Requirement There is a requirement for a risk assessment to be carried out for each individual who uses bedrails and there must be evidence of consultation about their use with the service user or their representative. It is a requirement that a signature is in place on the medication record chart for all medication administered or omitted. There is a requirement for the Provider to evidence that the social and therapeutic needs of individuals are being met. There is a requirement to eliminate the odour of cigarette smoke from the home. There is a requirement to provide a new toilet seat in the bathroom known as “Spode” The wheelchair policy must be adhered to by all staff It is a requirement that all staff receive regular fire drills and that these are recorded. It is a requirement that the Provider completes a monthly DS0000026966.V331999.R01.S.doc Timescale for action 10/04/07 2 OP9 13(2) 20/03/07 3 OP12 16(2)(m, n) 16(2)(k) 23(2)(b) 13(4) 23(4)(e) 26 10/04/07 4 5 6 7 8 OP26 OP19 OP38 OP38 OP33 20/03/07 20/03/07 20/03/07 20/03/07 20/03/07 Springbank Nursing Home Version 5.2 Page 29 9 OP27 18(1) report about the home as per regulation 26 and makes this available for the CSCI on request Staff must be provided in sufficient numbers to cover sickness or absence 20/03/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 2 3 4 5 Refer to Standard OP12 OP19 OP27 OP29 OP35 Good Practice Recommendations There is a recommendation to employ another activities co-ordinator for the home. There is a recommendation to replace the dining room furniture and carpet. There is a recommendation to increase the numbers of care staff by 1 on the day shift. There is a recommendation to reorganise staff files. It is a recommendation that each service user have their own individual bank account and that, wherever possible, service users or their representatives deal with their own finances. There should be a lone working policy developed. Basic moving and handling training should be provided for ancillary staff. Quality Assurance should include the views of the service users and there should be evidence that audits are effective in bringing about improvements 6 7 8 OP38 OP38 OP33 Springbank Nursing Home DS0000026966.V331999.R01.S.doc Version 5.2 Page 30 Commission for Social Care Inspection Stafford Office Dyson Court Staffordshire Technology Park Beaconside Stafford ST18 0ES 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 Nursing Home DS0000026966.V331999.R01.S.doc Version 5.2 Page 31 - 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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