Inspection on 11/11/05 for Springbank Nursing Home

This inspection was carried out on 11th 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 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 01/03/07

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 Peter Dawson Unannounced Inspection 09:00 11 November 2005 th 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.V265197.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 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.V265197.R01.S.doc Version 5.0 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 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.V265197.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. PD minimum age 60 yrs DE minimum age 60 yrs Date of last inspection 19th July 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. Springbank Nursing Home DS0000026966.V265197.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection was carried out with the Deputy Manager who provided all required information to complete the inspection. The Registered Manager who was off duty called and stayed towards the end of the inspection. A proprietor who is also the Responsible Individual joined the discussions towards the end of the inspection. Verbal feedback was given to the Manager, Deputy and Proprietor at the close of the inspection. There were 27 people in residence with up to 15 places vacant. Fourteen people were assessed as requiring nursing care and 17 requiring personal care. There was an inspection of the whole of the physical environment and a sample of bedrooms were seen. A large proportion of residents were seen and around 12 residents spoken to in either the lounge areas or their bedrooms. There was a steady stream of visitors throughout the morning of the inspection and 4 were spoken to. This included one visitor for a long-standing resident with total dependency and 3 visitors whose relatives had been admitted recently into the home. All indicated high levels of satisfaction with the care provided at Springbank. They said that their relatives had settled well and swiftly into the home, that visiting times were totally flexible and that they were kept informed of all events affecting the lives of residents. All residents spoken to commented positively about food provision and chosen lifestyles. All said that they were treated with respect and dignity in provision of personal care and also spoke warmly about relationships with staff. Good engagement was observed between residents and staff on duty. Samples of records seen relating to the inspection included care plans, staff files, medication records, fire safety records and training records. There was a discussion with the proprietor about future provision of EMI nursing care in the home. The proprietor was advised of an under-usage of the existing categories for dementia and mental health care in the home. (there are presently only 4 people in this category). What the service does well: Visitors are received well into the home and there are very relaxed exchanges with staff. Recently admitted residents commented very positively about assistance in settling into the home. Staff had offered good support and reassurance to them. Springbank Nursing Home DS0000026966.V265197.R01.S.doc Version 5.0 Page 6 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. Palliative care is being provided and relatives comment upon the exceptionally high standards of care and sensitivity in providing that care. A relative commented that on an unexpected visit to the home she was pleased to see a member of staff sitting with her mother, simply holding her hand and offering reassurance. There is a well recorded and safe system of medication in place. Staff training meets required standards and updated training recently provided in some important areas of training. The required number of NVQ trained care staff has been exceeded. What has improved since the last inspection? What they could do better: The provision of regular activities must be improved and all recorded. The appointment of a dedicated activities worker would be desirable. Alternatively specific allocated staff time for activities. The large kitchen freezer should be either replaced or new seals fitted for efficient operation. Springbank Nursing Home DS0000026966.V265197.R01.S.doc Version 5.0 Page 7 The registered person should establish a system for reviewing and improving the quality of care. This should be specifically related to resident/relative feedback. Risk assessments must be carried out for all residents who smoke. Provision of additional points for the nurse call system in the large lounge area must be actioned. All required information outlined in Schedule 2 must be provided for all staff. 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 Nursing Home DS0000026966.V265197.R01.S.doc Version 5.0 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.V265197.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 3–5 Dementia care training for all staff has now been provided. Standards inspected relating to Choice of Home were found to be met. EVIDENCE: Pre-admission assessments are reported to be always carried out prior to admission, this was evidenced in records inspected in relation to recently admitted residents. The assessment tool was seen and all required aspects of assessment required in Standard 3.3. were included. Pre-admission visits to the home for prospective residents is the preferred option, but this is not always possible. A recently admitted resident did not visit prior to admission but her relatives visited several times before making a decision regarding admission. Springbank Nursing Home DS0000026966.V265197.R01.S.doc Version 5.0 Page 10 The home has a wide range and number of approved admission categories, although at this time only 4 people were considered to be requiring dementia care and none care for their mental health needs. There is presently no one under the age of 65 years, although the home has category to admit from age 60 years. At the time of the last inspection a requirement was made for all staff to receive training in dementia care. This has been done to ensure that needs in this particular area can be met by the home. The statement of purpose was not inspected on this visit but a copy is reported to be readily available in the home for prospective residents and their representatives. Springbank Nursing Home DS0000026966.V265197.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7 - 10 Care plans should be agreed and signed by residents or their representatives as stated in standard 7.6. and this practice has commenced in the home. Standards relating to Health and Personal Care were seen to be met. EVIDENCE: Several care plans were inspected including recently admitted residents and a long-term highly dependent resident. The care planning format is on the Standex system and provides the comprehensive information required to provide care. Pre-admission assessments by staff and Care Management assessments had been carried out and provided the basis for care planning information. A requirement of the last report to include residents and relatives in care planning and reviews has been addressed in part – some are now signing care plans and this should become the norm. Care plans were seen to be reviewed on a monthly basis. Springbank Nursing Home DS0000026966.V265197.R01.S.doc Version 5.0 Page 12 Risk assessments were in place but not in relation to smoking residents and this is referred to in Standard 38. There are 2 entries daily for all residents in contact notes. There is a named nurse and key worker appointed for all residents. Keyworkers record some information additional to nursing staff where this is appropriate. It was reported that night checks are documented, although these were not inspected, the assumption is that they are provided in a separate log. There was concern about regular weighing of residents who may have weight loss, at the time of the last inspection , and a requirement made for alternative tool to assess weight where is was not physically possible to weigh a resident. The home have consulted the hospital dietician who has provided a protocol for recording weight in those circumstances. This has been introduced as required. There has been staff training in Peg feed care since the last inspection. There was evidence of regular monitoring and referrals to health care professionals. A good service is reported from local GP’s who visit each Thursday morning and review as required and also on demand at other times. The home reports an excellent service from the GP’s and a pro-active approach. The care plan of a highly dependent resident receiving palliative care was reviewed. All assessments relating to tissue viability and nutrition were in place with recorded fluid inputs daily. An alternating mattress was provided and additional 2 hourly turns with resultant no pressure area sores present. The home has 4 alternating pressure relieving mattresses – 2 of which are presently in use. Additionally there are several pro-pad mattresses/cushions in use indicated by assessments. There are no tissue viability issues in the home at this time. The visiting relative of a highly dependent resident spoke very highly of the care provided at Springbank for her mother whose condition had deteriorated to a terminal point but had made unexpected recoveries which she stated were due to the excellent care provided by staff at Springbank. She said that on an unexpected visit she made to the home she was delighted to see staff simply sitting and holding her mothers hand. Observations throughout the inspection indicated that care was carried out with dignity and respect. Medication was inspected and is provided to the home in blister pack from by the Coop Pharmacy. A good service was reported with direct contact with the pharmacy ongoing. MAR sheets had been completed accurately and satisfactorily and this applied to records for controlled drugs. Springbank Nursing Home DS0000026966.V265197.R01.S.doc Version 5.0 Page 13 Stock control was good and the current changes in disposal of medication for nursing homes discussed with the Deputy Manager. It was agreed that disposal by a contractor reduces the total reliability of disposal - but the home could only provide records for disposal witnessed by 2 staff which they were proposing to do. There was evidence of a good, safe system of medication in place with excellent recording. Springbank Nursing Home DS0000026966.V265197.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12 - 15 Chosen lifestyles were evidenced to be known and accommodated, this was confirmed by residents. Visiting is central to care requirements and several visitors confirmed they were welcomed into the home and kept informed of events affecting the lives of their relatives. Improvements must be made in the area of activities for residents. This is a weak area in the home at this time. All residents spoken to confirmed that they were satisfied with food provision in the home. EVIDENCE: There was evidence of chosen lifestyles being known and accommodated by staff. Care planning information contained information concerning likes, dislikes, rising, retiring and general choices. These were known to staff and ensured that residents preferred routines were followed. This was confirmed by residents spoken to during the inspection. A fiercely independent 98 year old lady was seen and spoken to with her visiting son. She stated that her independence was vital and stated that staff understood this and supported land promoted her wishes and choices. Springbank Nursing Home DS0000026966.V265197.R01.S.doc Version 5.0 Page 15 She and her son confirmed that staff had helped her settle well into the home, although she had had initial reservations about living in a home. She goes to visit her relatives outside the home each week and relatives visit virtually daily where she receives them in her bedroom or other area of the home as she wishes. They were both very complimentary about the care offered at Springbank, had no reservations or complaints and spoke highly about staff commitment to her personal needs and choices. A resident who prefers to spend most of the day in his bedroom, going to the dining room only for meals is supported in his wish. He has TV/music facilities/telephone installed in his bedroom where he likes to read and receive visitors. He confirmed his choices were totally accommodated. There is an activities programme posted in the home. The activity for the day of inspection was bingo. There is no record of activities undertaken and the alternatives provided. This is an area which the home need to improve. This was discussed with the Manager and Proprietor following a requirement of the last report to improve activities and consider the appointment of an Activities Worker. This is still being considered, although presently low occupancy levels in the home restrict availability of resources for this purpose and the options of providing either a dedicated activities worker or whether to provide additional hours to existing care staff allocated solely for this purpose is still being evaluated. Several visitors were seen arriving at the home throughout the morning of this unannounced inspection. Four were spoken to and confirmed they were able to visit at any reasonable time, were greeted and accommodated well by all staff. They confirmed that they were kept informed of all aspects of daily living affecting the lives of their relatives. Very relaxed and friendly exchanges were noted between visitors and staff - arriving at peak times of care need but received in a warm and friendly way. Visitors were moving freely around the home seeing residents in either the communal areas or their bedrooms. All residents spoken to confirmed that they were very satisfied with the quantity and quality of food provided. Residents spoken to in the dining room at 9 a.m. confirmed there was a choice of food at all mealtimes and the standards of food were high. Some residents were seen to have meals served in their bedrooms also. Menus are 4 weekly and rotational and were flexible and varied. The kitchen was not inspected on this visit. Springbank Nursing Home DS0000026966.V265197.R01.S.doc Version 5.0 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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 & 18 Standards relating to Complaints and Protection were found to be met. EVIDENCE: The complaints procedure was seen to be posted in the reception area and complies with the requirements of Regulation 22. There is a copy of the complaints procedure in the Service Users Guide. No complaints have been received by the home or the Commission since the last inspection. Recruitment procedures ensure the protection of residents from abuse and staff are aware of the procedures to be followed in the event of suspected or actual abuse. These are covered in the policy/procedures relating to abuse. There is a copy of the vulnerable adults policy in the home for reference. Springbank Nursing Home DS0000026966.V265197.R01.S.doc Version 5.0 Page 17 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19 - 26 The home offers a comfortable, safe environment. Redecoration is reported to be ongoing and relatively easy, most areas being artexed. There are good assisted bathing facilities and well personalised bedrooms. There are some en-suite bedrooms and others planned in the reduction of double rooms to single. The standards of hygiene throughout the home were high and there were no mal-odours. EVIDENCE: An inspection of the physical environment included all communal areas and a sample of bedrooms. Springbank Nursing Home DS0000026966.V265197.R01.S.doc Version 5.0 Page 18 The home is furnished to a good standard and redecoration an ongoing process. There is a separate dining area and two lounge areas (one on each floor). The ground floor lounge area is used by most residents and the first floor lounge used by a smaller minority of less dependent residents and also for entertaining visitors. The ground floor lounge area provides seating for the majority of residents and staff are concentrated on that area during the day. However there is one “pull cord” nurse call point only, at the entrance to the room. Residents were asked how they would summon staff if they needed to and it was evident that they would be restricted by only one call point in the event. The home must consider additional call points in this area. Bedrooms were well furnished and comfortable and there were many examples of personalisation with photos and memorabilia relating to past events and family presence. Some bedroom furniture has been provided and more to be provided relating to lockable facilities for residents. TV’s are provided in bedrooms by the home. All bedrooms have doors which can be left open but have self-closing devices fitted in the event of fire. There are 2 bathrooms on each floor and there is a walk-in shower, all have toilets. There is a Parker bath on each floor reported to be preferred and widely used by residents. Bathrooms were generally spacious and were well located and equipped. Additionally toilets are located at strategic points throughout the building and easily accessible from the communal areas also. TVs were switched on in the ground floor lounge area and also in two rooms where palliative care was in evidence. It is suggested that background music may be an alternative in the lounge area at times and a certainly a preferred option in the bedrooms mentioned. The TV screen at one end of the lounge area was relatively small and probably not visible to all anyway, from the further points of the room. The exterior of the home provides a pleasant sitting area with well maintained garden/planted areas. Access is good for wheelchair users also. It was reported that the garden area had been used consistently throughout the good summer months of this year. The carpet has been replaced in the first floor corridor area as identified in the last report. The laundry is housed in a separate building adjoining the home and found to meet required standard relating to infection control practices. All areas of the home are easily accessible to residents and are safe. Appropriate aids/adaptations are provided as required in communal areas throughout the home. Springbank Nursing Home DS0000026966.V265197.R01.S.doc Version 5.0 Page 19 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27 – 30 The numbers of staff are satisfactory. Training and the skill mix of staff are good. There has been required training since the last inspection. Staff records showed appropriate references and checks had been carried out. Other documentation in relation to staff is required as listed in Schedule 2 of the regulations. EVIDENCE: There is a nurse on duty throughout the 24 hour period. Additionally there are 4 care staff (sometimes 5) from 7.30 – 2.30 and from 2.30 – 9.30pm 3 care staff (sometimes 4). There are 2 care staff throughout the night with a nurse. At this time there are 27 people in residence – 16 requiring nursing care and 11 requiring non-nursing care. The staffing levels are adequate for the present perceived dependency levels of residents. Staffing rosters were not inspected in detail but the staffing levels comply with the last staffing notice, as required prior to 2002. The hours of the Registered Manager are supernumerary. There are 3 Deputy Managers (2 share a post during the day) and one at night. There are 4 Senior Carers on the day shift and 1 at night. There are adequate numbers of ancillary staff employed for housekeeping, catering, laundry and administration. Springbank Nursing Home DS0000026966.V265197.R01.S.doc Version 5.0 Page 20 The home has exceeded the target of 50 of NVQ trained staff by 2005. Statutory training for staff was checked and found to be satisfactory. There has been training in Infection Control, First Aid, Health & Safety, Food Hygiene and Verification of Expected Death since the last inspection. This training is provided across the levels of nursing and care staff. The Manager and a Deputy Manager have commenced training in NVQ4 since the last inspection. All nursing staff undertook First Aid Training in May this year, ensuring a trained first aid person on duty at all times. Fire training is reported to be annual for all staff (not checked). The home have 2 approved Moving & Handling Trainers. A recently appointed member of staff had received induction training to NTO standards which was evidenced. Staff files relating to 2 recently appointed members of staff showed that all references and checks had been provided prior to employment – POVA First checks carried out prior to commencing duties and CRB checks received subsequently. Two documents not provided for was a recent photograph and proof of qualification. These should be provided as required under Schedule 2 of the Regulations for all staff. Staff spoken to an observed had clear positive and relaxed relationships with both residents and staff. There was evidence of close working between nursing and care staff. Staff meetings are held on a regular basis. The last staff meeting (for all staff) was 13th October 2005. Prior to that there was a staff meeting for nursing staff in August and for Care Staff in May this year. (Minutes were not seen). Springbank Nursing Home DS0000026966.V265197.R01.S.doc Version 5.0 Page 21 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31 – 33, 36 and 38 There was evidence of good leadership and management in the home with a well supervised care team. Two requirements are made in relation to Health & Safety: To replace the seals on the kitchen freezer and to provide risk assessments for residents who smoke. EVIDENCE: This unannounced inspection was carried out with the Deputy Manager. The Registered Manager (day off) later arrived and also a Proprietor who is the Responsible Individual. There was ultimate discussion and feedback with all three people. The Registered Manager has the required experience to run the home. She has recently commenced a course of training leading to the Registered Managers Award, which is a required qualification. Springbank Nursing Home DS0000026966.V265197.R01.S.doc Version 5.0 Page 22 There appeared an open management style in the home evident from speaking to residents, staff, managers and proprietor. There are clear lines of responsibility between managers and proprietor. Good administrative support is provided to the home. There was a lengthy discussion with the proprietor who is considering the possibility of providing EMI nursing care in the home. Advice was given and he will further discuss this with the homes allocated inspector. The proprietor explained that he has employed someone to carry out quality surveys in relation to policies/procedures and maintenance. There are no quality surveys seeking the views of residents or relatives and this should be established to provide a system for reviewing quality of care. Formal staff supervision is in place on a regular basis. In relation to Safe Working Practices: The home has 2 trained Moving & Handling Trainers and all staff provided with the required training prior to involvement in personal care. Regular updates are also provided. Fire records were inspected and all checks of the system and equipment carried out as required. A requirement of the last report to check the emergency lighting system on a monthly basis has been done. Fire training is provided annually for all staff. Staff have received first aid training since the last inspection. All nursing staff have completed this training allowing one trained person on duty at all times. There has been some staff training in food hygiene since the last inspection and four staff are presently completing Health & Safety courses. All staff have completed Infection Control training at Stoke College. The freezer in the kitchen is not operating effectively. A requirement of the last report to replace the freezer was pursued and an alternative to replace the seals on the freezer is in process but not been completed at this time. A further requirement is made. COSHH records and general maintenance records were not inspected on this visit. Risk assessments relating to resident activity were inspected and generally in place but the home must complete risk assessments for all residents who smoke. Documentation relating to accidents was not inspected on this visit. Staff training is to required NTO standards. Springbank Nursing Home DS0000026966.V265197.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 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 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 2 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 x 18 3 3 3 3 2 3 3 3 3 STAFFING Standard No Score 27 3 28 3 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 2 x x 3 x 2 Springbank Nursing Home DS0000026966.V265197.R01.S.doc Version 5.0 Page 24 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. Standard Regulation Requirement Timescale for action RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Springbank Nursing Home DS0000026966.V265197.R01.S.doc Version 5.0 Page 25 Commission for Social Care Inspection Stafford Office Dyson Court Staffordshire Technology Park Beaconside Stafford ST18 0ES 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. 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