Inspection on 12/05/04 for Springfield Court Nursing Home

Care Home For Older PeopleSpringfield Court Nursing HomeSpringfield Court Springfield Road Aughton Ormskirk Lancashire L39 6STAnnounced Inspection12th May 2004 Commission for Social Care InspectionLaunched in April 2004, the Commission for Social Care Inspection (CSCI) is the single inspectorate for social care in England. The Commission combines the work formerly done by the Social Services Inspectorate (SSI), the SSI/Audit Commission Joint Review Team and the National Care Standards Commission. The role of CSCI is to: · Promote improvement in social care · Inspect all social care - for adults and children - in the public, private and voluntary sectors · Publish annual reports to Parliament on the performance of social care and on the state of the social care market · Inspect and assess `Value for Money of council social services · Hold performance statistics on social care · Publish the `star ratings for council social services · Register and inspect services against national standards · Host the Childrens Rights Director role.Inspection Methods & FindingsSECTION B of this report summarises key findings and evidence from this inspection. The following 4-point scale is used to indicate the extent to which standards have been met or not met by placing the assessed level alongside the phrase Standard met? The 4-point scale ranges from: 4 - Standard Exceeded (Commendable) 3 - Standard Met (No Shortfalls) 2 - Standard Almost Met (Minor Shortfalls) 1 - Standard Not Met (Major Shortfalls) O or blank in the Standard met? box denotes standard not assessed on this occasion. 9 in the Standard met? box denotes standard not applicable. X is used where a percentage value or numerical value is not applicable. ESTABLISHMENT INFORMATION Name of establishment Springfield Court Nursing Home Address Springfield Court, Springfield Road, Aughton, Ormskirk, Lancashire, L39 6ST Email address Name of registered provider(s)/company (if applicable) Springfield Court Limited Name of registered manager (if applicable) Mrs Janet S Nixon Type of registration Care Home No. of places registered (if applicable) 51 Tel No: 01695 424344 Fax No:Category(ies) of registration, with (number of places) Old age, not falling within any other category (49), Physical disability (2) Registration number F080000139 Date first registered 30th July 2002 Was the home registered under the Registered Homes Act 1984? Do additional conditions of registration apply ? Date of last inspectionDate of latest registration certificate 1st April 2002 YES YES 01/03/04 If Yes refer to Part CSpringfield Court Nursing HomePage 1 Date of inspection visit Time of inspection visit Name of inspector Name of inspector Name of inspector 1 2 312th May 2004 09:30 am Anne TaylorID Code075535Name of inspector 4 Name of specialist (e.g. Interpreter/Signer) (if applicable) Name of establishment representative at the time of inspectionJanet NixonSpringfield Court Nursing HomePage 2 CONTENTSIntroduction to Report and Inspection Inspection Visits Brief Description of the Services Provided Part A: Summary of Inspection Findings Inspectors Summary Statutory Requirements/Good Practice Recommendations from last Inspection Conditions of Registration Statutory Requirements/ Good Practice Recommendations from this Inspection Part B: Inspection Methods & Findings National Minimum Standards For Older People: Choice of Home Health and Personal Care Daily Life and Social Activities Complaints and Protection Environment Staffing Management & Administration Part C: Part D: D.1. D.2. D.3. Compliance with Conditions (if applicable) Providers Response Providers Comments Action Plan Providers AgreementSpringfield Court Nursing HomePage 3 INTRODUCTION TO REPORT AND INSPECTION Every establishment that falls within the jurisdiction of the Commission for Social Care Inspection (CSCI) is subject to inspection, to establish if the establishment is meeting the National Minimum Standards relevant to that setting and the requirements of the Care Standards Act 2000. This document summarises the inspection findings of the CSCI in respect of Springfield Court Nursing Home. The inspection findings relate to the National Minimum Standards (NMS) for Care Homes for Older People published by the Secretary of State under the Care Standards Act 2000. The Regulations applicable to the inspected service are secondary legislation, with which a service provider must comply. Service providers are expected to comply fully with the National Minimum Standards. The National Minimum Standards will form the basis for judgements by the CSCI regarding registration, the imposition and variation of registration conditions and any enforcement action. The report follows the format of the NMS and the numbering shown in the report corresponds to that of the Standards. The report will show the following: · Inspection methods used · Key findings and evidence · Overall ratings in relation to the standards · Compliance with the Regulations · Required actions on the part of the provider · Recommended good practice · Summary of the findings · Providers response and proposed action plan to address findings This report is a public document. INSPECTION VISITS Inspections are undertaken in line with the agreed regulatory framework with additional visits as required. This is in accordance with the provisions of the Care Standards Act 2000. The report is based on the findings of the specified inspection dates.Springfield Court Nursing HomePage 4 BRIEF DESCRIPTION OF THE SERVICES PROVIDED. Springfield Court is a purpose built care home for service users over the age of sixty-five requiring personal and nursing care. The home has fifty permanent places and one dedicated respite bed. At the time of inspection there were forty-seven people living at the home. Forty-six requiring nursing care and one needing personal care. The home is privately owned by Springfield Court Limited. The day-to-day management of the home is the responsibility of Mrs Janet Nixon, the registered manager. Most rooms are single with an en-suite facility. Five companion rooms are available for service users who wish to share. Three of these are en-suite. Accommodation is all at ground floor level and ramps are provided to enable access for wheelchair users. There are two lounges. The largest provides a suitable venue for activities. The smaller one provides a quieter area and could be used to receive visitors. The home is set in its own gardens that include a lawn and an enclosed courtyard area with seating.Springfield Court Nursing HomePage 5 PART A SUMMARY OF INSPECTION FINDINGSINSPECTORS SUMMARY (This is an overview of the inspectors findings, which includes good practice, quality issues, areas to be addressed or developed and any other concerns.) This was an announced inspection that took place over a full day May 2004. The inspector spoke to service users, visitors to the home, staff and the manager. Service users personal files and policies and procedures were examined. The inspector undertook a tour of the premises. The management team had completed a significant amount of work following the last inspection. As a result most of the requirements and recommendations made at the last inspection had been acted upon and progress towards meeting all the standards was good. Throughout the report there are references to case tracking, this is a process whereby the inspector focuses on a small group of service users. All records relating to these people are inspected, along with the rooms they occupy in the home. Service users are invited to discuss their experiences of the home with the inspector; however, this is not to the exclusion of the other service users. Prior to the inspection the Commission sent comment cards to the home for service users to complete. At the time of inspection none of the cards had been returned. However, The Commission had received comment cards from the General Practitioners who attended the home. Choice of Home (standards 1 to 7), standard 6 not applicable to this service 3 of the 4 standards assessed were fully met one partially met. A statement of purpose and service user guide had been produced. However some further work is needed before the standard could be considered fully met. The format of these two documents should be suitable to the needs of service users. Service users were able to visit the home before admission. Terms and conditions of residency were in place for service users. Health and personal care (standards 8-11) 1 of the 2 standards assessed was fully met 1 partially met Arrangements were in place for meeting the health and personal care needs of service users. Service users or their representatives had been included in the care planning process on all case files tracked. Adequate arrangements were in place for the provision of health services to service users. Some improvements should be made regarding the risk assessment process. Daily life and social activities (standards 12-15) 2 of the 2 standards assessed were partially met. The routines of the home were seen to be flexible to meet the wishes and preferences of the service users. The employment of an activities organiser had improved the scope of activities available to service users. Service users spoken to were satisfied with the quality of meals provided and the range of activities offered. Springfield Court Nursing Home Page 6 Complaints and protection (standards 16-18) 3 of the 3 standards assessed were fully met. There was a complaints procedure in place and service users spoken to know whom to approach if they had any concerns or complaints. Satisfactory policies and procedures regarding the protection of vulnerable adults were in place and accessible to staff. Members of staff spoken to were aware of the polices and procedures and confident that any issues identified would be investigated and resolved by the manager. Environment (standards 19-25) 5 of the 8 standards assessed were fully met 3 partially met The location and layout of the home was suitable for the service user group. The home was clean and well maintained with evidence of personalisation in most bedrooms. Staffing (standards 27-30) 1 of the 3 standards was fully met 2 partially met. At the time of the inspection the home was adequately staffed with employees who were suitably qualified and experienced. National Vocational Training for care staff was in place. The home held regular staff meetings and communication within the home was good. Some work was still required around the recruitment process, which must be improved to ensure the protection of service users. Management and administration (standards 31-38) 5 of the 7 standards assessed were fully met 2 partially met. The registered manager had substantial experience of managing a care home and was appropriately qualified. Positive comments relating to the open style of management in the home were received from members of staff interviewed. Clear lines of accountability were evident and the home was well managed. Comment cards received from General Practitioners that attend the home noted I am really impressed with the way the home is run and an exceptionally well run home. Consideration should be given to introducing a system to obtain feedback about the quality of service delivered.Springfield Court Nursing HomePage 7 Requirements from last Inspection visit fully actioned? If No please list belowNOSTATUTORY REQUIREMENTS Identified below are areas not addressed from the last inspection report which indicate a non-compliance with the Care Standards Act 2000 and accompanying Regulations. The code in Standard is a cross-reference to the Standards described in full in the section Inspection Findings. No. Regulation Standard Required actions Timescale for action 1 4 (1)(c), 5 Schedule1 OP1 The registered person must ensure that the statement of purpose and service user guide contain all the information detailed in Regulations 4, 5, 16 and Schedule 1 of the Care Homes Regulations 2001 and that the format is appropriate to the needs of service users. The registered person must operate a thorough recruitment procedure, which includes obtaining and retaining all the requirements of schedule 2 and schedule 4 of the Care Home Regulations 2001. 30th June 2004219(1) Schedule 2 17(2) Schedule 4OP2930th June 2004Action is being taken by the Commission for Social Care Inspection to ensure compliance in regard to the above requirements. RECOMMENDATIONS Identified below are recommendations from the last inspection that have not been implemented No. Refer to Good Practice Recommendations Standard 1 OP8 It is recommended that the risk assessment for the use of bed rails include the reason for their use, regular monitoring and be appropriately documented. The assessment should also identify the risks presented by the use of bed rails and how that risk will be managed. It is recommended that in rooms occupied by service users adequate furniture and other furnishings including comfortable seating for two and a table to sit at be provided unless a risk assessment suggests otherwise. Page 82OP24Springfield Court Nursing Home 3OP26It is recommended that the registered manager ensure that facilities and services comply with the Water Supply (Water Fittings) Regulations 1999. It is recommended that fifty per cent of care staff are trained to NVQ level two by 2005. It is recommended that the home consider developing strategies to seek feedback from service users, their families /representatives and other stakeholders in the community about the quality of service delivered.4 5OP28 OP33CONDITIONS OF REGISTRATION THAT APPLY (OTHER THAN NUMBERS AND CATEGORY OF SERVICE USERS).Met (Yes / No)Springfield Court Nursing HomePage 9 STATUTORY REQUIREMENTS IDENTIFIED DURING THE INSPECTION Action Plan: The Registered Person is requested to provide the Commission with an Action Plan, which indicates how requirements are to be addressed with the time scale within which such actions will be taken. This action plan will be made available on request to the Area Office.STATUTORY REQUIREMENTS Identified below are areas addressed in the main body of the report, which indicate noncompliance with the Care Standards Act 2000, and accompanying Regulations 2001 and the National Minimum Standards. The Registered Provider(s) is/are required to comply within the given time scales. The code in Standard is a cross-reference to the Standards described in full in the section Inspection Findings. No. Regulation Standard * Requirement Timescale for action 4 (1)(c), 5 Schedule1 1 OP1 The registered person must ensure that the statement of purpose and service user guide contain all the information detailed in Regulations 4, 5, 16 and Schedule 1 of the Care Homes Regulations 2001 and that the format is appropriate to the needs of service users. The registered person must ensure that a record of items of furniture brought by a service user into the room occupied by him is kept. 30th June 2004217(2) Schedule 4OP1430th June 2004323(2)(g)OP20The registered person ensure that there is 31st adequate sitting, recreational and dining August space provided separately from service users 2004 private accommodation. The registered person must operate a thorough recruitment procedure, which includes obtaining and retaining all the requirements of schedule 2 and schedule 4 of the Care Home Regulations 2001.19(1) 4 Schedule 2 17(2) Schedule 4 OP2930th June 2004513(4)(c)OP38The registered person must ensure that unnecessary risks to the health and welfare of 30th June service users are, wherever possible 2004. eliminated. Access to the kitchen area must be restricted to kitchen staff only. Page 10Springfield Court Nursing Home RECOMMENDATIONS Identified below are areas addressed in the main body of the report, which relate to National Minimum Standards and are seen as good practice issues which should be considered for implementation by the registered Provider(s). The code in Standard is a cross-reference to the Standards described in full in the section Inspection Findings. No. Refer to Good Practice Recommendations Standard * It is recommended that the risk assessment for the use of bed rails include the reason for their use, regular monitoring and be appropriately documented. The assessment should also identify the risks presented by the use of bed rails and how that risk will be managed. It is recommended that the homes entry onto the data protection register should be renewed as the certificate had expired. It is recommended that the home notifies the Commission for Social Care Inspection when work on the conservatory is complete. It is recommended that in rooms occupied by service users adequate furniture and other furnishings including comfortable seating for two and a table to sit at be provided unless a risk assessment suggests otherwise. It is recommended that the registered manager ensure that facilities and services comply with the Water Supply (Water Fittings) Regulations 1999. It is recommended that fifty per cent of care staff are trained to NVQ level two by 2005. It is recommended that the home consider developing strategies to seek feedback from service users, their families /representatives and other stakeholders in the community about the quality of service delivered. It is recommended that the home consider extending the scope of the risk assessments for safe working practice topics. Advice regarding this should be sought from a person competent in health and safety matters.1 2 3OP8 OP14 OP204OP245OP266OP287OP338OP38Springfield Court Nursing HomePage 11 PART BINSPECTION METHODS & FINDINGSThe following inspection methods have been used in the production of this report Direct observation Indirect observation Sampling · Pre-inspection questionnaire · Records · Care plans / Care pathways · Meals · Activities · Other (Specify) `Tracking care and support Group discussion with service users Individual discussion with service users Group discussion with staff Individual discussion with staff Discussion with management Service user survey Relatives/significant others survey/feedback Visiting professionals survey / feedback Tour of premises Formal interviews Document reading Additional inspection information: Number of service users spoken to at time of inspection Number of relatives/significant others the inspectors had contact with Number of letters received in respect of the service CRB check for the responsible individual seen CRB check for the manager seen Certificate of registration was displayed at the time of the inspection Certificate of registration accurately reflected the situation in the service at the time of inspection Total number of care staff employed (excluding managers) Total number of staff with nursing qualifications employed Date of inspection Time of inspection Duration of inspection (hrs) YES YES YES YES YES YES NO NO YES NO YES NO YES YES YES NO YES YES NO YES 4 3 X NO YES YES YES 33 13 12/05/04 09:30 6.5Springfield Court Nursing HomePage 12 The following pages summarise the key findings and evidence from this inspection, together with the CSCI assessment of the extent to which the National Minimum Standards for Care homes for older people have been met. The following scale is used to indicate the extent to which standards have been met or not met by placing the assessed level alongside the phrase Standard met? The scale ranges from: 4 - Standard Exceeded 3 - Standard Met 2 - Standard Almost Met 1 - Standard Not Met (Commendable) (No shortfalls) (Minor shortfalls) (Major shortfalls)0 or blank in the Standard met? box denotes standard not assessed on this occasion. 9 in the Standard met? box denotes standard not applicable. X is used where a percentage value or numerical value is not applicable.Springfield Court Nursing HomePage 13 Choice of HomeThe intended outcomes for the following set of standards are: · · · · · · 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.Standard 1 (1.1 ­ 1.3) The registered person produces and makes available to service users an up to date statement of purpose setting out the aims, objectives, philosophy of care, services and facilities, and terms and conditions of the home; and provides a service users guide to the home for current and prospective residents. The statement of purpose clearly sets out the physical environmental standards met by a home in relation to standards 20.1, 20.4, 21.3, 21.4, 22.2, 22.5, 23.3 and 23.10: a summary of this information appears in the homes service users guide. Range of fees charged From (£) 430 To (£) 515Any charges for extrasYESIf yes, please state what the extras are: Hairdressing (perms and cuts), chiropody, incidental toiletries, escorts. 2 Key findings/Evidence Standard met? The statement of purpose must be revised to include all the information required in Schedule 1 and Regulations 4, 16 of the Care Homes Regulations 2001. The registered manager was given a written copy of guidance produced by the Commission to assist with developing the statement of purpose. The service user guide must be revised and should include a copy of the most recent inspection report and service users views of the home. It was agreed that the registered manager would send a copy of the revised statement of purpose and service user guide to the Commission of Social Care Inspection. (CSCI) The home had produced a colour brochure that was given to prospective service users and their families and representatives.Springfield Court Nursing HomePage 14 Standard 2 (2.1 ­ 2.2) Each service user is provided with a statement of terms and conditions at the point of moving into the home (or contract if purchasing their care privately). 0 Key findings/Evidence Standard met? Not assessed at this inspection. This standard was considered met at the last inspection and will continue to be monitored through the inspection process.Standard 3 (3.1 ­ 3.5) New service users are admitted only on the basis of a full assessment undertaken by people trained to do so, and to which the prospective service user, his/her representatives (if any) and relevant professionals have been party. 3 Key findings/Evidence Standard met? The inspector looked at the files of three service users chosen for case tracking. Since the last inspection the format had been revised to include a detailed social care assessment and a document signed by the service user or a representative to say whether they wished to be involved in the assessment and care planning process. The revised format contained all the information needed to meet this standard. Care plans from the funding authority for service users funded via care management arrangements had been obtained and kept in the service users personal file. All service user case files tracked had plan of care based on information obtained from the pre admission assessment. A registered nurse from the local Primary Care Trust had determined the level of trained nursing input required by service users needing nursing care. Copies of the assessments were made available to the inspector.Springfield Court Nursing HomePage 15 Standard 4 (4.1 - 4.4) The registered person is able to demonstrate the homes capacity to meet the assessed needs (including specialist needs) of individuals admitted to the home. 3 Key findings/Evidence Standard met? The home is currently registered to accommodate a range of categories of service users as noted in the introduction of this report. From discussion with the Manager and staff and from examination of records the inspector was able to establish that where appropriate, service users were in receipt of appropriate specialised services. Care plans seen at the time of inspection showed that specialist needs were being met. Adaptations had been made to equipment to meet specific needs of service users. Access to services had been arranged for service users with a visual impairment. The home employed a manager, trained nursing staff, and care assistants, who had experience of caring for older people and were appropriately qualified. This would suggest that staff individually and collectively had the skills and experience to deliver the services and care which the home offers to provide. At the time of inspection the home did not accommodate any service users from specific minority social or ethnic groups. Religious preferences were recorded in the care plans of the service users chosen for case tracking purposes.Standard 5 (5.1 ­ 5.3) The registered person ensures that prospective service users are invited to visit the home and to move in on a trial basis, before they and / or their representatives make a decision to stay; unplanned admissions are avoided where possible. 3 Key findings/Evidence Standard met? The registered manager said that service users were offered a trial period before making the decision to move into the home. This information needs to be included in the statement of purpose. Prospective service users met staff when the pre admission assessment was carried out. The home did not usually take emergency admissions and the registered manager said that the home would only take an emergency admission if they had received sufficient information from the referring body. However, a policy covering emergency admissions was in place.Springfield Court Nursing HomePage 16 Standard 6 (6.1 - 6.5) Where service users are admitted only for intermediate care, dedicated accommodation is provided together with specialised facilities, equipment and staff, to deliver short term intensive rehabilitation and enable service users to return home. 9 Key findings/Evidence Standard met? This standard is not applicable as Springfield Court does not have an intermediate care facility.Springfield Court Nursing HomePage 17 Health and Personal CareThe intended outcomes for the following set of standards are: · · · · · The service users health, personal and social care needs are set out in an individual plan of care. Service users make decisions about their lives with assistance as needed. Service users, where appropriate, are responsible for their own medication, and are protected by the homes 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.Standard 7 (7.1 ­ 7.6) A service user plan of care generated from a comprehensive assessment (see Standard 3) is drawn up with each service user and provides the basis for the care to be delivered. 3 Key findings/Evidence Standard met? The care plans of the three service users chosen for case tracking were examined during the inspection. The plans seen set out the service users individual needs and contained appropriate risk assessments. Since the last inspection an assessment of social needs had been included in the assessment and care planning process. As requested at the last inspection risk assessments relating to service users at risk of falls had been made specific to the individual. Each service user had a plan of care formulated from the pre admission assessment and information gained on or shortly after admission. All plans had been reviewed monthly. Following the last inspection the registered manager had developed a system to determine who wished to be involved in the planning and reviewing of individual care plans (Please see standard 3 of this report). The plans contained details of action needed to meet service users needs. Risk assessments had been carried out on or shortly after admission.Springfield Court Nursing HomePage 18 Standard 8 (8.1 ­ 8.13) The registered person promotes and maintains service users health and ensures access to health care services to meet assessed needs. No. of incidents where service users have been taken to Accident and Emergency since the last inspection months No. of service users with pressure sores at time of inspection (from information given by the registered manager)032 Key findings/Evidence Standard met? Care plans of the three service users chosen for case tracking purposes were examined. The plans were clear, organised and well structured. It was easy to obtain information. Individual needs, were identified and instructions for staff easy to follow. Information from the pre admission assessment had been incorporated into the care plan. Care provided was recorded on a daily statement for each service user. There was evidence in the care plans to confirm that service users had access to advice from other health care professionals. A trained nurse, using a recognised assessment tool, had assessed service users at risk of developing pressure sores. Equipment necessary for the promotion of tissue viability was available. There was evidence to confirm that professional advice about the promotion of continence had been sought. Assessments had been carried out and recorded. Care plans seen had information relating to the management of psychological health. Nutritional screening for all service users had been introduced and records maintained. Opportunities for physical exercise were available to service users. Assistance was given, if needed, by staff or the activities organiser. A private physiotherapist attended the home weekly to see several service users. Service users were able to keep their own G.P. within the constraints of the locality. The G.P visited every month to clinically review all the service users registered with him. At the last inspection it was recommended that the risk assessment for the use of bed rails should include the reason for their use and that the use of bed rails should be regularly monitored and appropriately documented. The assessment should also include identification of the risk presented by the use of bed rails and how that risk will be managed. Protective bumpers used on bedrails should be on both rails and fitted correctly. The manager had previously been advised to obtain guidance about the use of bed rails from the medical devices agency. This recommendation remains outstanding. There was a sufficient number of adjustable beds available to service users who required nursing care.Springfield Court Nursing HomePage 19 Standard 9 (9.1 ­ 9.11) The registered person ensures that there is a policy and staff adhere to the procedures for the receipt, recording, storage, handling administration and disposal of medicines, and service users are able to take responsibility for their own medication if they wish, within a risk management framework. 0 Key findings/Evidence Standard Met? Not assesses at this inspection. This standard was considered met at the last inspection and will continue to be monitored through the inspection process. The homes local pharmacist last visited on the 27th April 2004 and the report was made available to the inspector.Standard 10 (10.1 ­ 10.7) The arrangements for health and personal care ensure that service users privacy and dignity are respected at all times, and with particular regard to: personal care giving, including nursing, bathing, washing, using the toilet or commode, consultation with, and examination by, health and social care professionals, consultation with legal and financial advisors, maintaining social contacts with relatives and friends, entering bedrooms, toilets and bathrooms, and following death. 0 Key findings/Evidence Standard met? Not assessed at this inspection. This standard was considered met at the last inspection and will continue to be monitored through the inspection process.Standard 11 (11.1 ­ 11.12). Care and comfort are given to service users who are dying, their death is handled with dignity and propriety, and their spiritual needs, rites and functions observed. 3 Key findings/Evidence Standard met? Not fully assessed at this inspection. However a recommendation was made at the last inspection regarding the recording of service users ` wishes in relation to terminal care and death and dying. Discussion with the manager and staff demonstrated that consultation took place with service users and significant others when appropriate. Information obtained would then be recorded in the individual plan of care. At the time of inspection the home was caring for a service user with a terminal illness. Evidence was seen to show that the home had adopted a multi-disciplinary approach to the management of this service user and that specialist advice had been sought and acted upon.Springfield Court Nursing HomePage 20 Daily Life and Social ActivitiesThe intended outcomes for the following set of standards are: · · · · 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.Standard 12 (12.1 ­ 12.4) The routines of daily living and activities made available are flexible and varied to suit service users expectations, preferences and capacities. 3 Key findings/Evidence Standard met? Not fully assessed at this inspection. However a recommendation was made at the last inspection regarding the recording of individual choices and preferences. Since the last inspection the home had developed and introduced a social assessment for everyone living in the home. (Please see standard 3 of this report.Standard 13 (13.1 ­ 13.6) Service users are able to have visitors at any reasonable time and links with the local community are developed and/or maintained in accordance with service users preferences. 0 Key findings/Evidence Standard met? Not assessed at this inspection. This standard was considered met at the last inspection and will continue to be monitored through the inspection process.Springfield Court Nursing HomePage 21 Standard 14 (14.1 ­ 14.5) The registered person conducts the home so as to maximise service users capacity to exercise personal autonomy and choice. 2 Key findings/Evidence Standard met? The statement of purpose contained information regarding service users right to exercise personal autonomy and choice. This included information about handling personal finances, bringing personal possessions into the home and the right to access personal records. Polices and procedures were in place that covered individual choice, autonomy and rights. The home should ensure that a record of items furniture brought by a service user into the room occupied by him is kept. The homes entry onto the data protection register should be renewed as the certificate had expired. Standard 15 (15.1 ­ 15.9) The registered person ensures that service users receive a varied, appealing, wholesome and nutritious diet, which is suited to individual, assessed and recorded requirements, and that meals are taken in a congenial setting and at flexible times. 3 Key findings/Evidence Standard met? Service users were offered three full meals daily. The main cooked meal was at lunchtime with a lighter meal served at teatime. Services users were offered a suppertime snack and night staff had access to food stocks. The time interval between all meals, including supper and breakfast was acceptable. The inspector observed mealtimes to be relaxed and unhurried, with staff available to give assistance if needed. The lunchtime meal served was well presented hot and appetising including liquidised food. A four weekly rotating menu was in operation. The menu was set, however, service users were told of the menu every morning and offered an alternative of they wished. The kitchen had adequate supplies of dry, frozen and fresh food. Discussion with the cook showed that there were no restrictions on obtaining food and that service users could have any type of food they asked for. Specialist diets were available for service users with specific medical conditions or cultural preferences. A list of personal likes and dislikes was kept in the kitchen. Birthdays and other special occasions were celebratedSpringfield Court Nursing HomePage 22 Complaints and ProtectionThe intended outcomes for the following set of standards are: · · · 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.Standard 16 (16.1 ­ 16.4) The registered person ensures that there is a simple, clear and accessible complaints procedure which includes the stages and time-scales for the process, and that complaints are dealt with promptly and effectively. No. of complaints made to the home since the last inspection No. of these complaints fully substantiated No. of these complaints partly substantiated No. of these complaints not substantiated No. of these complaints not yet resolved No. of complaints sent direct to CSCI Percentage of complaints responded to within 28 days 2 2 X X 1 0 100 3 Key findings/Evidence Standard met? The home had a clear and accessible complaints procedure. A copy of this procedure was included in the homes statement of purpose. Service users spoken to confirmed that they knew whom to approach if they had any concerns or complaints. A record of all complaints, investigations and outcomes was kept. There had been two complaints since the last inspection, which had been investigated and appropriate records kept. Timescales for action and Information for referring a complaint to the Commission of Social Care Inspection (CSCI) was included in the complaints policy. Since the last inspection the complaints policy had been amended to make sure that the complainant was clearly informed that they could refer a complaint to CSCI at any stage.Springfield Court Nursing HomePage 23 Standard 17 (17.1 ­ 17.3) Service users have their legal rights protected, are enabled to exercise their legal rights directly and participate in the civic process if they wish. 3 Key findings/Evidence Standard met? The home had a range of polices and procedures in place that covered the rights of service users. Following the last inspection information about advocacy had been included in these polices. In addition leaflets were available to service users and a poster regarding advocacy services was displayed in reception. Service users rights to participate in the political process were protected by the homes policy, which clearly stated that service users must all be registered to vote and be given the opportunity to vote in local and national elections if they so wished. Standard 18 (18.1 ­ 18.6) The registered person ensures that service users are safeguarded from physical, financial or material, psychological or sexual abuse, neglect, discriminatory abuse or self harm, inhuman or degrading treatment, through deliberate intent, negligence or ignorance, in accordance with written policies. The home has an Adult Protection procedure (including Whistle Blowing) which complies with the Public Disclosure Act 1998 and the Department of Health Guidance No Secrets No. of staff referred for inclusion on POVA lists YES X3 Key findings/Evidence Standard met? The home had satisfactory policies and procedures in place for the protection of vulnerable adults, including whistle Blowing. Policies also covered the use of restraint and management of aggression and included reference to management of service users who may be aggressive to staff. Policies and Procedures relating to the handling of money and the financial affairs of service users were contained in the quality procedures manual. Staff spoken to were aware of the adult protection policies and procedures. Some staff had been on adult protection training. All were aware of the homes whistle blowing policy and were clearly confident that they would report any concerns.Springfield Court Nursing HomePage 24 EnvironmentThe intended outcomes for the following set of standards are: · · · · · · · · 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.Standard 19 (19.1 ­ 19.6) The location and layout of the home is suitable for its stated purpose; it is accessible, safe and well maintained; meets service users individual and collective needs in a comfortable and homely way and has been designed with reference to relevant guidance. 3 Key findings/Evidence Standard met? The home was clean, tidy and well maintained. Grounds were tidy with a lawn and courtyard areas for service users to enjoy. Ramps and the outdoor paths provided wheelchair access for the less mobile and surfaces were flat. The registered provider maintained a programme of renewal and replacement of major refurbishment items. A fault report book was kept in reception, in which staff were able to record any routine repairs or maintenance needed. When the fault identified had been repaired the book was signed and dated by the handyperson. The last visit by an environmental health officer was on 25th March 2004. Some minor recommendations were made which the report said would be monitored at the next environmental health inspection in twelve months time. The home had sought advice from the local fire department regarding the development of a fire risk assessment. The registered manager said that completed fire risk assessment had been seen and accepted by the fire officer. CCTV cameras were used to monitor the front entrance.Springfield Court Nursing HomePage 25 Standard 20. (20.1 ­ 20.7) In all newly built homes and first time registrations the home provides sitting, recreational and dining space (referred to collectively as communal space) apart from service users private accommodation and excluding corridors and entrance hall amounting to at least 4.1 sq. metres for each service user. 2 Key findings/Evidence Standard met? The home had recently converted a small lounge into a bedroom, (although an increase in the number of persons who can be accommodated at the home has not been agreed by the Commission for Social Care Inspection), thereby reducing the total amount of available communal space. In order to address this the registered provider intends to add a conservatory to the main lounge. At the time of inspection work on the conservatory was almost complete. The local planning, building and fire departments had all carried out a site visit to ensure compliance with the relevant legislation. The registered provider was asked to notify the Commission when work on the conservatory was complete. The outdoor areas were well maintained and accessible to service users, including the less mobile and wheelchair users. The inspector observed that the lighting in communal rooms was sufficiently bright to facilitate reading and other activities. The furnishings throughout the home were domestic in character and of good standard. Standard 21 (21.1 ­ 21.8) Toilet, washing and bathing facilities are provided to meet the needs of service users. 3 Key findings/Evidence Standard met? Most bedrooms had an en-suite facility. Toilet facilities were located appropriately and clearly marked. The home had three bathrooms all with assisted baths and three shower rooms. Since this standard was last assessed the home had replaced the floor covering in two shower rooms and one of the bathrooms.Springfield Court Nursing HomePage 26 Standard 22 (22.1 ­ 22.8) The registered person demonstrates that an assessment of the premises and facilities has been made by suitably qualified persons, including a qualified occupational therapist, with specialist knowledge of the client groups catered for, and provides evidence that the recommended disability equipment has been secured or provided and environmental adaptations made to meet the needs of service users. 3 Key findings/Evidence Standard met? All accommodation was at ground floor level and service users were able to access all areas of the home and garden areas via ramps. Grab rails were provided throughout the home and each room, including the communal areas, had a nurse call bell complete with an emergency facility. A sufficient number of aids, hoists and other equipment were provided to meet the assessed needs of service users in the home at the time of inspection. Corridors and doorways were wide enough to accommodate wheelchair users. A sufficient amount of storage space, for equipment, wheelchairs and other aids was available.Springfield Court Nursing HomePage 27 Standard 23 (23.1 ­ 23.11) The home provides accommodation for each service user which meets minimum space as prescribed Total number of single bedrooms with at least 10 sq.m usable space or additional compensatory space Pre-existing homes only (1 April 2003) - single bedrooms below 10 sq.m usable space or additional compensatory space Total number of wheelchair users accommodated for in rooms at least 12sq.m Total number of wheelchair users accommodated for in rooms at less than 12sq.m Total number of shared rooms at least 16 sq.m Total number shared rooms less than 16 sq.m Percentage of places within single rooms: 100 80 - 99 Less than 80 Total number of single bedrooms Total number of single rooms with en suite Total number of double rooms Total number of double rooms with en suite NO NO YES 40 30 5 3 38 28 0 5 03 Key findings/Evidence Standard met? The home had five shared rooms. Measurements provided by the home indicated these rooms were all above 16sqm. Since the last inspection the registered manager had introduced as system to demonstrate that service users who shared accommodation had made a positive choice to do so. The home had two single rooms under 10square metres, excluding en-suite facilities, however the environmental standards relating to existing homes were relaxed on1st June 2003 to indicate that pre existing homes with single rooms that did not provide 10sqm of space as at 16th August 2002, provide at least the same usable space as was provided as at 31st March 2002. This was found to be the case. Room dimensions and layout allowed access for carers and equipment. Springfield Court Nursing Home Page 28 Standard 24 (24.1 ­ 24.8) The home provides private accommodation for each service user which is furnished and equipped to assure comfort and privacy, and meets the assessed needs of the service user. 2 Key findings/Evidence Standard met? A number of service users bedrooms were seen during the inspection, including those chosen for case tracking. The rooms were comfortable and appropriately decorated. Not all rooms had comfortable seating for two and a table to sit at. All bedrooms seen were carpeted. Screens were provided in shared rooms to afford privacy for service users. There were a sufficient number of adjustable beds for service users who required nursing care. Since this standard was last assessed small lockable safe boxes had been purchased by the home. This enabled service users who wished, to store money, valuables or medication safely. Bedroom doors had been fitted with locks and service users offered a key unless a risk assessment suggested otherwise.Standard 25 (25.1 ­ 25 8) The heating, lighting, water supply and ventilation of service users accommodation meet the relevant environmental health and safety requirements and the needs of individual service users. 3 Key findings/Evidence Standard met? Standard 25.3 was not applicable to this inspection as the home is not a new build. The home was well ventilated with windows conforming to recognised standards. The home had a gas central heating system. Each room had a radiator that could be individually controlled and was of a type that had a guaranteed low surface temperature. Most of the pipe work in the home was guarded, however, some pipes in bathrooms remained exposed. The manager said that a rolling programme of maintenance work had started with regard to this. Water temperatures had been checked regularly and recorded to ensure water was delivered at a temperature close to 43º c. Emergency lighting was provided through out the home and lighting in service users accommodation was domestic in character. Design solutions to control the risk of legionella were in place.Springfield Court Nursing HomePage 29 Standard 26 (26.1 ­ 26.9) The premises are kept clean, hygienic and free from offensive odours throughout and systems are in place to control the spread of infection, in accordance with relevant legislation and published professional guidance. 2 Key findings/Evidence Standard met? The home was clean and free from offensive odours on the day of inspection. Laundry facilities were appropriately located and separate sinks for hand washing provided. Satisfactory policies and procedures were in place for the control of cross infection and protective clothing was available to staff. The registered manager had recently obtained a new and up to date booklet about infection control and had made sure it was available to all staff. The washing machine had a sluicing and disinfection programme. Instructions regarding the laundering of soiled linen were in place. The registered manager was still in the process of seeking to confirm that the home complied with the Water Supply (Water Fittings Regulations) 1999.Springfield Court Nursing HomePage 30 StaffingThe intended outcomes for the following set of standards are: · · · · 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 homes recruitment policy and practices. Staff are trained and competent to do their jobs.Standard 27 (27.1 ­ 27.7) Staffing numbers and skill mix of qualified/unqualified staff are appropriate to the assessed need of the service users, the size, the layout and purpose of the home, at all times. Number of staff /hours in respect of service user needs based on guidance recommended by Department of Health. Personal Nursing Care No. service users High No. staff hours 19 X X needs allocated No. service users Medium needs No. service users Low needs No. of staff hours required No. of full time equivalent first level registered nurses No. of care staff No. of ancillary staff Key findings/Evidence 15 15 X No. staff hours allocated No. staff hours allocated No. of staff hours provided X X X X X X6 34 13 Standard met? 3Springfield Court Nursing HomePage 31 The information requested above will be identified when the consultation on formulae for staffing levels has been completed by the Department of Health. Staffing rosters were kept that identified which staff were on duty and the capacity in which they were employed. Staffing levels met the minimum requirements laid down by the previous regulatory body. Additional staff were on duty at peak times of activity and the registered managers hours were mainly supernumerary. Service users spoken to said that the staff were helpful and kind. The home did not employee any staff under the age of eighteen and no member of staff under the age of twenty-one was left in charge. Domestic and kitchen staff hours were adequate. Standard 28 (28.1 ­ 28.3) A minimum ratio of 50 trained members of care staff (NVQ Level 2 or equivalent) is achieved by 2005, excluding the registered manager and/or care manager, and in care homes providing nursing, excluding those members of the care staff who are registered nurses. No. care staff (excluding registered nurses) with NVQ level 2 or equivalent of care staff with NVQ level 2 34 44 2 Key findings/Evidence Standard met? A number of staff had completed National Vocational Training (NVQ) level two. The manager was aware of the requirement to have fifty percent of staff trained to NVQ level two by 2005. The manger stated that there were no trainees employed at present.Springfield Court Nursing HomePage 32 Standard 29 (29.1 ­ 29.6) The registered person operates a thorough recruitment procedure based on equal opportunities and ensuring the protection of service users. 2 Key findings/Evidence Standard met? A satisfactory recruitment policy and equal opportunities policy was in place. The files of two new members of staff were examined. There had been some improvements since the last inspection, however, all the information detailed in Schedules 2 and 4 of the Care Homes Regulations had not been obtained. The registered person must ensure that all relevant information relating to potential employees is obtained prior to the start of employment and that the information is retained by the home. The importance of complying fully with this standard in order to protect service users was discussed with the manager. The inspector advised that a follow up visit would be arranged to check progress towards meeting this standard. Since the last inspection all staff had received a statement of terms and conditions of employment and a copy had been retained on file. A copy of the GSCC code of conduct had been obtained and was available to staff for reference. The registered manager said that the home was awaiting additional copies so that each member of staff could be issued with their own copy. The manager was also advised to consider holding all staff information in one file with divided sections for ease of use. The manager stated that the home did not have any volunteers. Standard 30 (30.1 ­ 30.4) The registered person ensures that there is a staff training and development programme which meets the National Training Organisation (NTO) workforce training targets and ensures staff fulfil the aims of the home and meet the changing needs of service users. 0 Key findings/Evidence Standard met? Not assessed at this inspection. This standard was considered met at the last inspection and will continue to be monitored through the inspection process.Springfield Court Nursing HomePage 33 Management and AdministrationThe intended outcomes for the following set of standards are: · · · · · · · · 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 homes record keeping policies and procedures. The health, safety and welfare of service users and staff are promoted and protected.Standard 31 (31.1 ­ 31.8) The registered manager is qualified, competent and experienced to run the home and meet its stated purpose, aims and objectives. 3 Key findings/Evidence Standard met? The registered manager is a first level registered nurse with many years experience of caring for elderly people, including at least two years in a management position. She had successfully completed a number of post registration courses including a nursing diploma and a teaching certificate. She had maintained the requirements of professional registration She was responsible for the management of only one home and worked very closely with the registered providers. Discussion with staff showed that there were clear lines of accountability within the home and responsibility was delegated appropriately. Since this standard was last assessed the registered manager had started to study fir the Registered Managers Award, which she said included a National Vocational Training Qualification on management at level four.Springfield Court Nursing HomePage 34 Standard 32 (32.1 ­ 32.7) The registered manager ensures that the management approach of the home creates an open, positive and inclusive atmosphere. 3 Key findings/Evidence Standard met? There were clear lines of accountability in the home and staff at all levels were aware of their role and how they fitted into the organisation. This was underpinned by the organisational structure described in the homes statement of purpose. Regular staff meetings had been held and minutes were made available to the inspectors. Topics discussed included differing staff roles and responsibilities, the outcomes of the previous inspection, and a discussion on training opportunities. Staff spoken to confirmed that they were able to voice their opinions at staff meetings, and that they were kept informed of any developments in the home. Staff also described that home as `well run and very well organised. Service users spoken to described staff, as `very good, very caring and that staff were respectful and courteous. The home had obtained copies of the Code of Practice published by the General Social Care Council and distributed them to staff. Discussion with staff, service users and visitors showed that the home was managed in an open and inclusive way and that the manager was approachable and supportive. An equal opportunities policy was in place. Standard 33 (33.1 ­ 33.10) Effective quality assurance and quality monitoring systems, based on seeking the views of service users, are in place to measure success in meeting the aims, objectives and the statement of purpose of the home. 2 Key findings/Evidence Standard met? Not fully assessed at this inspection. However, at the last inspection a requirement was made that registered provider must undertake regular monitoring visits in line with Regulation 26 of the Care Homes Regulations 2001. The Commission has since received a written report that met this requirement. However, the registered person is reminded that these reports are required to be completed and submitted to the Commission every month. It was also recommended that the home consider developing strategies to seek feedback from service users, their families /representatives and other stakeholders in the community about the quality of service delivered. The manager said that the home was working towards developing an appropriate system and this will continue to be monitored through the inspection process. The inspector noted that action is not always progressed within agreed timescales to implement requirements identified in The Commissions inspection reports.Springfield Court Nursing HomePage 35 Standard 34 (34.1 ­ 34.5) Suitable accounting and financial procedures are adopted to demonstrate current financial viability and to ensure there is effective and efficient management of the business. 3 Key findings/Evidence Standard met? Adequate insurance cover, including business interruption costs was in place. The public liability certificate was on display in the home. A business and financial plan was produced annually as part of the IS0 9001/ 2000 process. Satisfactory management accounting procedures were in place including monthly profit and loss accounts and production of an annual budget. The registered provider said that she maintained written records off all transactions entered into. They were not examined at the time of inspection. Standard 35 (35.1 ­ 35.6) The registered manager ensures that service users control their own money except where they state that they do not wish to or they lack capacity and that safeguards are in place to protect the interests of the service user. Number of service users subject to Power of Attorney processes Number of service users subject to Enduring Power of Attorney processes Number of service users subject to Guardianship Orders 0 0 03 Key findings/Evidence Standard met? Satisfactory polices and procedures were in place regarding the handling of any money belonging to service users. The registered manager said that service users personal allowances were not handled by the home. Spending monies brought into the home for service users had been recorded properly and receipts kept of any purchases made. A secure facility was available for the safe keeping of money and valuables. A record was made of any items handed in for safekeeping.Springfield Court Nursing HomePage 36 Standard 36 (36.1 ­ 36.5) The registered person ensures that the employment policies and procedures adopted by the home and its induction, training and supervision arrangements are put into practice. 3 Key findings/Evidence Standard met? Since this standard was last assessed the home had developed and introduced a formal supervision programme for trained nurses and care staff. Each member of care staff had a supervision book and supervision notes had been made by the supervisor. The book was signed and dated by the supervisor and the carer. The supervision records of three members of staff were made available to the inspector. The records seen covered all the information needed to meet this standard. All other staff had been appraised as part of the normal management processes. At the time of inspection the home had one volunteer whose main duty was to push the sweet trolley around the home and assist any service user who wished to buy anything. The volunteer did not replace a paid member of staff. Standard 37 (37.1 ­ 37.3) Records required by regulation for the protection of service users and for the effective and efficient running of the business are maintained, up to date and accurate. 0 Key findings/Evidence Standard met? Not assessed at this inspection. This standard was considered met at the last inspection and will continue to be monitored through the inspection process.Springfield Court Nursing HomePage 37 Standard 38 (38.1 ­ 38.9) The registered manager ensures so far as is reasonably practicable the health, safety and welfare of service users and staff. 2 Key findings/Evidence Standard met? The home had a health and safety manual containing a statement about safe working practices. Most staff had undertaken moving and handling, first aid and health and safety training. The manager said that mandatory training for all staff was ongoing. Satisfactory measures were in place to prevent the spread of infection. Including an infection control policy, the safe segregation and disposal of waste, control of legionella and offering vaccination against influenza. Fire equipment checks and fire drills had been carried out and smoke and heat detectors were installed throughout the home. Since the last inspection a fire risk assessment had been carried out following consultation with the local fire officer Certificates were seen to confirm that systems and equipment in the home were regularly serviced. However, when this standard was last assessed the electrical installation inspection was unsatisfactory. Since then the registered manager had obtained written confirmation from an electrician that all recommended work had been satisfactorily completed. Accidents and injuries had been recorded. The manager was aware of the Reporting and Dangerous Occurrences Regulations (RIDDOR) 1985. The home had a manual for staff in relation to the control of substances hazardous to health, although it needed updating. Staff induction included instruction on safe working practices. The registered manager felt that the risk assessments for safe working practice topics already in place were sufficient, these included COSHH, fire and moving and handling assessments. The inspector advised that the home consider extending the scope of the assessments carried out and that advice from a relevant health and safety expert would be beneficial. During the course of the inspection the inspector noticed that there was a constant stream of non-kitchen staff, including care staff and visitors wandering in and out of the kitchen. This was considered to be very bad practice as it increases the risk of cross infection, interferes with the work kitchen staff are trying to do and presents a general health and safety risk. The registered manager was told about this issue and agreed to take action to address it. The kitchen area must be restricted to use by kitchen staff only.Springfield Court Nursing HomePage 38 PART C(where applicable)COMPLIANCE WITH CONDITIONSCondition Compliance Up to 49 service users in the category of OP who need nursing care CommentsYESCondition Compliance Up to 3 service users in the category of OP who need personal care only. CommentsYESCondition Compliance Up to 2 service users in the category of PD who need nursing care. CommentsYESYES Condition Compliance The service should at all times employ a suitably qualified and experienced manager who is registered with the Commission for Social Care Inspection. CommentsLead Inspector Second Inspector Regulation Manager DateAnne Taylor Dorothy SmithSignature Signature SignatureSpringfield Court Nursing HomePage 39 Public reports It should be noted that all CSCI inspection reports are public documents.Springfield Court Nursing HomePage 40 PART DD.1PROVIDERS RESPONSE TO IDENTIFIED STATUTORY REQUIREMENTSRegistered Persons comments/confirmation relating to the content and accuracy of the report for the above inspection.We would welcome comments on the content of this report relating to the Inspection conducted on 12 May 2004 and any factual inaccuracies: Please limit your comments to one side of A4 if possibleSpringfield Court Nursing HomePage 41 Action taken by the CSCI in response to provider comments: Amendments to the report were necessary NOComments were received from the provider Provider comments/factual amendments were incorporated into the final inspection report Provider comments are available on file at the Area Office but have not been incorporated into the final inspection report. The inspector believes the report to be factually accurateYESNOYESNote: In instances where there is a major difference of view between the Inspector and the Registered Provider both views will be made available on request to the Area Office. D.2 Please provide the Commission with a written Action Plan by 12 July 2004, which indicates how requirements are to be addressed and stating a clear timescale for completion. This will be kept on file and made available on request. You will also note that the Commission has identified in the inspection report good practice recommendations and it would be useful to have some indication as to whether you intend to take any action to progress these. Status of the Providers Action Plan at time of publication of the final inspection report: Action plan was required YESAction plan was received at the point of publicationYESAction plan covers all the statutory requirements in a timely fashion Action plan did not cover all the statutory requirements and required further discussion Provider has declined to provide an action planYESNONOOther: enter details here Springfield Court Nursing HomePage 42 D.3PROVIDERS AGREEMENT Registered Persons statement of agreement/comments: Please complete the relevant section that applies.D.3.1 I, Wendy Wilkinson of Springfield Court Nursing Home confirm that the contents of this report are a fair and accurate representation of the facts relating to the inspection conducted on the above date(s) and that I agree with the requirements made and will seek to comply with these. Print Name Signature Designation Date Or D.3.2 I, Wendy Wilkinson of Springfield Court Nursing Home am unable to confirm that the contents of this report are a fair and accurate representation of the facts relating to the inspection conducted on the above date(s) for the following reasons:Print Name Signature Designation Date Note: In instance where there is a profound difference of view between the Inspector and the Registered Provider both views will be reported. Please attach any extra pages, as applicable.Springfield Court Nursing HomePage 43 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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