Inspection on 26/09/06 for Springfield House

This inspection was carried out on 26th September 2006.

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

The inspector found no outstanding requirements from the previous inspection report, but made 6 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Springfield House 07/11/07

Springfield House 01/03/06

Similar services:

2 Perhaver Park

The Vicarage

St George`s

5 Seafield Road

Credence House

Radfords

Honeybourne House

32 Beaumont Way

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

CARE HOME ADULTS 18-65 Springfield House 255d Stroud Road Gloucester Gloucestershire GL1 5JZ Lead Inspector Ms Lynne Bennett Key Unannounced Inspection 26th September 2006 10:00 Springfield House DS0000063470.V307429.R01.S.doc Version 5.2 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 Springfield House DS0000063470.V307429.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Springfield House DS0000063470.V307429.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Springfield House Address 255d Stroud Road Gloucester Gloucestershire GL1 5JZ 01452 312385 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) www.orchardendltd.co.uk Orchard End Limited Mrs Lorraine Sarah Williams Care Home 6 Category(ies) of Learning disability (6) registration, with number of places Springfield House DS0000063470.V307429.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 1st March 2006 Brief Description of the Service: Springfield is a newly registered home for six people with a learning disability who may also have additional mental health needs. The home is located on a main road close to Gloucester city centre and within walking distance of local amenities and pubic transport routes. It is part of the Orchard End Group that is a subsidiary of C.H.O.I.C.E. Ltd. The house has been refurbished and decorated and is furnished in a comfortable and stylish way. Individual en suite accommodation is provided with access to a range of communal rooms. The Statement of Purpose and Service User Guide are displayed in the entrance hall and further copies are available from the registered manager. Fees for the home range from £1,486 to £2,040 per week. Springfield House DS0000063470.V307429.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The judgements contained in this report have been made from evidence gathered during the inspection, which included a visit to the service and takes into account the views and experiences of people using the service. This inspection took place in September/October 2006 and included visits to the home on 26th September and 2nd October. The registered manager and quality assurance manager were present at the second visit. The operations manager was present for part of the first visit. The care of people living at the home was observed on both occasions and some people were spoken to about their home. Not all people living at the home are able to verbally express their views. Four members of staff discussed the care they provide. Comment cards were returned from two people living at the home and two relatives. Comment cards were also returned from healthcare professionals. A range of records were examined including care plans, staff files, health and safety records and quality assurance information. What the service does well: What has improved since the last inspection? Administration of medication has significantly improved safeguarding people living at the home from possible harm. Observation of medication administration during the visit confirmed it is completed in a satisfactory manner. Springfield House DS0000063470.V307429.R01.S.doc Version 5.2 Page 6 A formal complaints log has been put in place. There has been an improvement in the validation of staff records for new staff being employed. What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Springfield House DS0000063470.V307429.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Springfield House DS0000063470.V307429.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 2. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The admissions process does not fully assess the needs and wishes of people wishing to move into the home. Obtaining an assessment of need from the placing authority would significantly improve the current system. EVIDENCE: The home has an admissions policy and procedure that is in the process of review at present. Since the last inspection one person has moved into the home. A comprehensive assessment was completed by the home prior to admission that involved visiting the person and obtaining information from their carers and family. There was also evidence of reports from healthcare professionals involved in their care as well as a school report. There was no evidence that an assessment or care plan had been obtained from the placing authority prior to admission. This information must be obtained in addition to the home’s own admission information. The registered manager immediately contacted the placing authority to obtain a copy. A placement review is scheduled including representatives of the person living at the home and the placing authority. There was evidence that training had been provided to staff prior to the person moving into the home about their specific needs. Observation of staff interacting with the person confirmed their understanding of their needs. Springfield House DS0000063470.V307429.R01.S.doc Version 5.2 Page 9 Relatives said that this person has settled in well and that their needs were considered prior to the move. Springfield House DS0000063470.V307429.R01.S.doc Version 5.2 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7 and 9 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Care planning in the home is generally good promoting the development of skills and independence. Any limitations on the rights of freedom or choice are negotiated with people living at the home, or their representatives, promoting their best interests. Expanding the range of risk assessments will enable people living at the home to challenge and deal with problem areas in their lives safeguarding them from possible harm. EVIDENCE: The care for three people was case tracked. Each person has a main file, a care plan and other files containing additional daily recordings. Each person also has a daily diary. Incident and behaviour management records are also kept in separate files. Care plans provide a holistic overview of each person’s needs. There was evidence that these are being regularly reviewed. One person living at the Springfield House DS0000063470.V307429.R01.S.doc Version 5.2 Page 11 home said they discuss their needs with their key worker and there was evidence that people living at the home are signing parts of their care plan. The registered manager said that she is hoping to implement Person Centred Planning in the future. She has completed training and is planning for staff to also attend training. Staff are asked to sign to say that they have read any changes to care plans. A communication book indicates when changes have been made to care plans. This is good practice. Those staff spoken with have a good understanding of the needs of people they support. One person was observed to be in distress during the visit and staff supported them in line with their care plan with sensitivity and patience. Distraction was also used with another person and again this was done in a way that reflected guidelines in their care plan. There was evidence of restrictions placed on people living at the home that have been drawn up in consultation with the person and/or their representative, key worker and the manager. One care plan indicated that a person living at the home would at times not be able to use the kitchen due to concerns that they may cause harm to themselves. This was observed during the visit and staff followed guidelines informing the person why this was being done whilst also enabling other people living at the home to continue to have access to the kitchen. It was evident that any restrictions are in place to safeguard people living at the home and wherever possible the impact of these restrictions on others is being minimised. For instance since the last inspection a key pad has been installed on the front door to protect one person who is at risk when leaving the house unsupervised. Another person is able to access the keypad when they wish to leave the home maintaining their independence. People living at the home were observed being supported to manage their money. Comprehensive records are maintained which are spot checked by the registered manager. Receipts are numbered and cross-referenced with amounts withdrawn. Those examined were satisfactory. The registered manager is looking into setting up savings accounts for two people who presently only have current accounts. Use of symbols and pictures are evident around the home to enable people to communicate their needs and wishes and to understand their environment. Kitchen doors are labelled with pictures of what each contains. One person showed pictures they use to help understand what they have planned for the day. Staff receive training in makaton sign language. People’s communication needs are clearly identified in their care plans. Risk assessments are in place that are regularly reviewed. Those examined identified hazards and guidelines indicated what staff should do to minimise these risks. In the care plans examined there appeared to be standard risk assessments which although individualised for each person did not provide a Springfield House DS0000063470.V307429.R01.S.doc Version 5.2 Page 12 complete assessment of the risks they face. Additional risk assessments need to be put in place for one person with epilepsy and for possible self-harm. Although a fire risk assessment is completed for each individual, guidelines indicated that a person might at times be at risk using a lighter. There was no reference to this in their fire risk assessment. This must be amended. There is a missing person’s procedure in place and each person has a profile with photograph and pen picture should they be needed. Springfield House DS0000063470.V307429.R01.S.doc Version 5.2 Page 13 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,15,16 and 17. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People living at the home have access to a range of local community facilities and activities providing opportunities for them to be involved in their local community and lead active lifestyles. Relationships with family and friends are developed and maintained with the help of staff. People living at the home are encouraged to maintain a healthy diet by giving them informed choice about the options available. EVIDENCE: Each person has a schedule of activities that staff said are being reviewed to reflect current changes. One person said that they no longer attend college. Staff confirmed that several people are waiting to start courses at a local college. These courses were confirmed for people during the second visit to the home. People have access to a range of activities including social clubs, Springfield House DS0000063470.V307429.R01.S.doc Version 5.2 Page 14 art and craft courses and use of a local leisure centre. Daily diaries confirm that people go swimming, to the spa and sauna, use local shops, cafes and pubs. On the day of the first visit, one person went into Gloucester for lunch and two other people were going out for tea. The home’s vehicle is being repaired at present. People have access to a small replacement vehicle and are also using taxis. Care plans contain contact details of family and friends. Daily diaries and review reports comment on how contact is maintained. One person’s diary indicated that they keep in touch by telephone and are supported to make visits to family in London. Family members visited on the day of the first visit. Feedback from relatives said that “the home facilitates visits to the family and this is really positive for my daughter”. Daily routines within the home appear to be flexible. The routines of people are highlighted in their care plans. Some like a leisurely start to the day and this was observed with support being provided when needed. Others like to stay up late and daily diaries confirmed that waking night staff provide assistance as requested. Some people have keys to their rooms. There is ample communal space for people to spend time on their own if they wish or to be in the company of others. On the day of the visits good use was made of the patio. Menus provide a range of healthy options including freshly prepared meals with fresh vegetables. Fresh fruit was available during the visits. People living at the home were observed being offered a choice of snacks and drinks throughout the day. Staff said that they offer healthy options including fresh vegetables and salads. People choose to eat their meals at different times, this was observed during the visits. A person of Afro-Caribbean descent is given the option of Jamaican meals. Recipes are provided of typical cuisine. They indicated that if they want a Jamaican meal then staff would provide one but that they are happy with the menu at present. They said that a scheduled cooking session to prepare Jamaican meals does not take place at their request. One person is diabetic and their records indicate that this is controlled through their diet. The registered manager confirmed that a record of their dietary intake is kept in addition to occasional notes made in the daily records. Springfield House DS0000063470.V307429.R01.S.doc Version 5.2 Page 15 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18,19 and 20. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The way in which the people living at the home would like to be supported is clearly recorded and managed ensuring that staff have access to the information they need to meet their personal care needs. People living at the home have access to healthcare professionals and to a satisfactory medication system, making it possible to meet their healthcare needs. EVIDENCE: The way in which people would like to be supported is indicated in their care plans. Each person has guidelines that are individualised to reflect their needs for bathing, continence and personal health support. Staff indicated that they have sufficient information about the needs of people living at the home. On the day of the first visit one person was having a massage and beauty treatment. A person of Afro-Caribbean descent also visits a specialist hairdresser and uses creams for their skin. They said that staff also help them with their hair. The staff team reflect the cultural backgrounds of people living at the home. Springfield House DS0000063470.V307429.R01.S.doc Version 5.2 Page 16 There are six females living at Springfield House and female staff provide personal care. Daily records and review forms confirm regular appointments with Doctors, Dentists, Opticians and a visiting Chiropodist. One person is nervous about visiting their Dentist and staff described the ways in which they are working with the Dentist to increase their confidence. One person was supported to attend an outpatient’s appointment at Gloucester Royal Hospital during the first visit. They took responsibility for their medical notes and letters. Each person also has a Health Action Plan. There was evidence of close working with the local Community Learning Disability Team and Mental Health Team. This was observed during the visits and confirmed in records on files. The systems for administration of medication were found to be satisfactory. Robust records are in place for each person giving an outline of their medication needs including protocols for the use of ‘as necessary’ or PRN medication and for refusals of medication. Where medication is refused or PRN medication is administered this is noted on the medication administration record as well as an additional recording sheet. Staff were observed administering medication during the visits. Staff complete training in the ‘Safe Handling of Medications’. Copies of books being worked through were available for inspection. Springfield House DS0000063470.V307429.R01.S.doc Version 5.2 Page 17 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home has a satisfactory complaints system in place with some evidence that people living at the home feel they are listened to. Systems and procedures are in place for the protection of people living in the home safeguarding them from possible harm. EVIDENCE: People living at the home were observed talking to staff about any concerns they may have. Comment cards indicated that people know about the complaints procedure and who to speak to. They also indicated that staff listen to them and act upon their concerns. One person said that they would talk to the manager if they had a problem. The registered manager keeps a record of complaints and outcomes. Four complaints were received over the past 12 months two of which were partially substantiated. The registered manager described the outcome of one complaint although this information was not logged on the records. It was advised that any action taken as a result of complaint investigations is recorded. Incidents observed during the visit were recorded in line with the organisation’s policies and procedures. An accident record was followed up with a body map and an incident record. Information about this was passed over to a team leader at handover. The deputy manager took preventative steps accessing healthcare professionals. It was noted however that despite this action being taken there was an absence of clear guidelines for this person Springfield House DS0000063470.V307429.R01.S.doc Version 5.2 Page 18 with mental health problems should they need to be admitted to hospital in an emergency. These must be put in place so that all staff are clear about what procedures are to be followed. Staff receive training in the Management of Response to Emotion (M.O.R.E.) which teaches the use of diversion, de-escalation and distraction as well as the use of physical intervention. The use of physical intervention is recorded and the Commission receives notification under Regulation 37. Staff confirmed that physical intervention is used as a last resort. Staff were observed using distraction and de-escalation techniques during the visits. The organisation employs a healthcare professional to provide advice and guidance to staff. Staff described the way in which they implement the guidelines on a daily basis to reduce anxieties and reward positive behaviour. Charts were examined confirming this. One person has dedicated time with staff at the end of the day to record their mood. There was evidence that as well as talking about their emotions the person is encouraged to draw and write in the book. Another person also has 1:1 time with staff throughout the day to explore their feelings. This is also recorded. Staff also confirmed they attend training in the Protection of Vulnerable Adults. Springfield House DS0000063470.V307429.R01.S.doc Version 5.2 Page 19 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24 and 30. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The environment is homely and comfortably furnished. There is an ongoing maintenance programme in place making sure that the home continues to meet the needs of the people living there. Monitoring the collection of waste disposal bins will improve standards of hygiene. EVIDENCE: Springfield House provides spacious comfortable accommodation set in its own private grounds. Each person has a bedroom with en suite facilities and access to a communal bathroom and disabled toilet. The kitchen is domestic in size and there is a separate laundry. Aids and adaptations have been provided throughout to support people with mobility difficulties. A first floor room is to be used as an additional lounge but is currently used for storage. Springfield House DS0000063470.V307429.R01.S.doc Version 5.2 Page 20 Day to day repairs are identified in a general maintenance book and appear to be dealt with quickly and efficiently. There are ongoing problems with the hall carpet that is stained. Staff said that they had purchased a steam cleaner but this had no effect. The carpet needs to be cleaned perhaps with an industrial cleaner. On the day of the visit concerns were raised about the storage of incontinence pads under the stairwell and duvets that were stored at the top of the stairs. Both could be fire hazards and should be stored elsewhere. These items were removed at the time of the second visit. The fire risk assessment must identify that the areas below and above the stairwells are a high-risk area for the storage of inflammable materials. A waste disposal bin in the downstairs toilet was full. Staff said that this was due for collection and that it was a temporary problem. This needs to be monitored. Other parts of the home were clean and tidy at the time of the visit. Soap and paper towels are provided in all communal toilets and hand washbasins. Good infection control measures were observed in the laundry with linen baskets identified for soiled and clean clothes. Springfield House DS0000063470.V307429.R01.S.doc Version 5.2 Page 21 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32,34 and 35. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Over two thirds of the staff have a NVQ Award in care providing a competent and qualified team to support people living at the home. Quality in the outcome for this standard is excellent. Further improvements in the standard of vetting and recruitment practices would protect people living at the home from possible harm. Staff have access to a range of training providing them with the knowledge and skills to meet the needs of people at the home. EVIDENCE: There have been considerable changes to the management of the home and to the staff team since it opened in July 2005. A deputy manager has just been appointed who is supported by three team leaders. Staff spoke positively about the team dynamics and the strengths of existing staff. New staff confirmed that they complete an induction followed by the Learning Disability Award Framework and then registration for NVQ Awards. Some staff did however think that they would have benefited from completing Learning Disability Award Framework as part of their induction programme. Over 60 of the staff team have NVQ Awards in Care. This exceeds the National Minimum Standards. Springfield House DS0000063470.V307429.R01.S.doc Version 5.2 Page 22 Staff files were examined for staff who had joined the organisation since the last inspection. Application forms requested employment history for the past 20 years. After the visits the registered manager supplied a copy of the revised application form that asks for a full employment history. There was evidence that some staff had starting working before the CRB check had been received. The Commission had been informed and each person had two references, plus a povafirst check and a risk assessment in place. One of the references that had been received for one person was missing at the time of the visit. The registered manager stated that if this could not be found another copy would be requested. This must be obtained. Staff confirmed that they have access to a range of training including mandatory training as part of their induction and training specific to the needs of people living at the home such as mental health awareness, makaton and epilepsy. A training portfolio is kept listing training courses attended and identifies training to be completed. This had not been updated since February 2006. Staff confirmed that training identified as needing to attend had mostly been completed. A list of training made available to staff was provided with the pre-inspection questionnaire. Additional information specific to each individual is available in their main files. Springfield House DS0000063470.V307429.R01.S.doc Version 5.2 Page 23 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37,39 and 42. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The registered manager has a clear developmental plan for the home that promotes the rights and best interests of people living there. The home’s quality assurance programme involves people staying at the home in the review of services being provided. Systems are in place ensuring that the home provides an environment promoting the welfare and safety of people. EVIDENCE: Since the last inspection the manager has been confirmed as the registered manager for the home. She is completing a Registered Managers Award and NVQ Level 4 Award in Care. In addition to the she will be completing an applied behaviour analysis course and disciplinary and grievance training. The registered manager plans to introduce person centred planning. She meets Springfield House DS0000063470.V307429.R01.S.doc Version 5.2 Page 24 regularly with people living at the home on a 1:1 basis to ascertain their wishes and views about the service they receive. Staff indicated that the management of the home was good creating an environment that promotes positive and open communication between the staff team. Those spoken with said that if they have any concerns they would address these to the manager and they are confident that they would be dealt with. The organisation is developing a quality assurance system that involves the views of people using the service. Their representatives and healthcare professionals are also involved and a report will be produced of the outcome of these surveys. There was evidence that surveys have been distributed and are being collated. In addition to this monthly-unannounced visits are completed by the quality assurance co-ordinator. Procedures are in place for the monitoring of health and safety systems. The pre-inspection questionnaire confirmed that servicing takes place as scheduled. Good practice was observed to be in place in the kitchen, with fridge and freezer temperatures being recorded as well as the temperatures of hot food. Night staff complete additional checks on fridges and freezers. Food in the fridge was labelled with the date of opening. Hazardous products are stored in a locked cupboard. A fire risk assessment is in place and it is recommended that this states how often staff receive fire training. At present it states regularly and the preinspection questionnaire indicated every 2-3 years. It is recommended that staff have refresher training at least 6 monthly with an annual fire lecture. Waking night staff should have training every 3 months. Springfield House DS0000063470.V307429.R01.S.doc Version 5.2 Page 25 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 X 2 2 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 2 ENVIRONMENT Standard No Score 24 2 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 4 33 X 34 2 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 2 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 3 X 3 X X 3 X Springfield House DS0000063470.V307429.R01.S.doc Version 5.2 Page 26 No Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard YA2 Regulation 14(1)(a) Requirement The registered manager must obtain an assessment of needs of new service users from their placing authority. The registered manager must ensure that risks to service users are identified and recorded. The registered manager must ensure that there are clear guidelines in place to protect people at risk of self-harm. The registered manager must ensure that carpets are maintained in a clean state. The registered person must ensure that the fire risk assessment identifies all areas of high risk and how hazards are minimised. The registered manager must ensure that two written references are obtained for new staff. Timescale for action 01/11/06 2. 3. YA9 YA23 13(4) 13(6) and 17 23(2) 23(4)(b) 01/12/06 01/12/06 4. 5. YA24 YA24 01/12/06 01/12/06 6. YA34 19(1)(b) Sch2.3 01/11/06 Springfield House DS0000063470.V307429.R01.S.doc Version 5.2 Page 27 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. 3. Refer to Standard YA30 YA22 YA23 Good Practice Recommendations Waste disposal bins need to be monitored to ensure that they are regularly collected. Action taken as a result of complaint investigations should be recorded. Consideration should be given for obtaining guidance about emergency admission and detention under the Mental Health Act 1983 and subsequent legislation. Duvets and incontinence pads should not be stored near to stairwells. The fire risk assessment should state how often training is provided for staff. This should be provided every 3 months for night staff and every 6 months for care staff with an annual fire lecture. 4. 5. YA24 YA42 Springfield House DS0000063470.V307429.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Gloucester Office Unit 1210 Lansdowne Court Gloucester Business Park Brockworth Gloucester, GL3 4AB National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Springfield House DS0000063470.V307429.R01.S.doc Version 5.2 Page 29 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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