Inspection on 30/01/07 for Springfield House

This inspection was carried out on 30th January 2007.

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

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Springfield House 21/03/06

Springfield House 14/09/05

Springfield House 23/02/05

Springfield House 22/09/04

Springfield House 04/03/04

Similar services:

Snydale Care Home

Abbey The

Larchfield Manor

Hawkhills

Beeches The - North Yorkshire County Council

The Grove Waltham

Carentan House

Ravensworth Lodge

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

CARE HOMES FOR OLDER PEOPLE Springfield House Springfield Avenue Morley Leeds West Yorkshire LS27 9PW Lead Inspector Stevie Allerton Key Unannounced Inspection 30th January 2007 10:15 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Springfield House DS0000001507.V323123.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Springfield House DS0000001507.V323123.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Springfield House Address Springfield Avenue Morley Leeds West Yorkshire LS27 9PW 0113 252 1969 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) Mrs Susan Elizabeth Hart Mrs Susan Elizabeth Hart Care Home 22 Category(ies) of Mental Disorder, excluding learning disability or registration, with number dementia - over 65 years of age (6), Old age, of places not falling within any other category (22) Springfield House DS0000001507.V323123.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 21st March 2006 Brief Description of the Service: Springfield House provides accommodation for up to 22 older people who are in need of personal care rather than nursing care. It was first established in 1985 by the owner and her late husband and has always been managed by the owner. The home is a large, stone-built detached property, which stands in its own grounds, situated in a quiet residential area of Morley, on the outskirts of Leeds. It is fairly close to shops and public transport links into Morley town centre and to Leeds. The original house had a large ground floor extension added in the late 1990s, constructed in stone to blend in with the original building. The home now provides 18 single bedrooms in total (9 with en-suite facilities) and 2 doubles (1 with en-suite). Communal living space is in four large rooms on the ground floor of the original house, providing flexible dining and sitting arrangements. Many of the service users are from the local area, which enables them to maintain contacts within the community. Current fees are £360 to £407 per week. Springfield House DS0000001507.V323123.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was carried out without prior notification and was conducted by one inspector over the course of a day, starting at 10.15am and finishing at 5.30pm. The Registered Manager was present for part of the day, the Care Manager was on duty throughout the day and other staff team members also assisted the inspector. Survey forms were sent out to a sample of residents prior to the visit and seven were returned. Survey forms were also sent out to a selection of health and social care professionals and two were returned. The inspector would like to thank everyone who took the time to talk and express their views. Before the visit, information about the home since the last inspection was reviewed. This included looking at any notified incidents or accidents and other information passed to CSCI, including reports from other agencies, such as the Fire Officer. This information was used to plan this inspection visit. The inspector case tracked four residents. Case tracking is the method used to assess whether people who use services receive good quality care that meets their individual needs. Where appropriate, issues relating to the cultural and diverse needs of residents and staff were considered. Using this method, the inspector assessed all twenty-two key standards from the Care Homes for Older People National Minimum Standards, plus other standards relevant to the visit. The inspector spent time with residents and spoke to relevant members of the staff team who provide support to them. Documentation relating to these service users was looked at. Where possible, contact was also made with external professionals, to obtain their opinions about the quality of services provided at the home. What the service does well: Residents express very high levels of appreciation in the staff team. They feel they are treated with respect, which is also in evidence when observing staff with the residents. People said: “The staff support us very well”, “I’m happy with all the staff, they’ve made me feel very welcome and at home”. The home aims to give care to the residents for as long as is possible, if they can continue to meet their needs. They work well with doctors and community nurses to make sure that people at the end of their lives are well looked after and have all the equipment they need to remain comfortable. Springfield House DS0000001507.V323123.R01.S.doc Version 5.2 Page 6 Residents are given the opportunity to lead interesting and fulfilling lives, with activities and interests encouraged outside the home as well as within. Residents are also consulted about how their home is run and have the opportunity to contribute their views through meetings and quality surveys. Food is of a good standard and residents speak highly about the quality and choice that is provided: “There’s a good choice and the meals are wellcooked”, “The food is excellent”. The home has a commitment to staff training and continues to encourage and help staff to achieve National Vocational Qualifications. Over half of the staff are now qualified in this way. What has improved since the last inspection? What they could do better: Staff could give more importance to making sure that rooms are fully prepared for new residents being admitted, so that essential items are not overlooked. Some parts of the care planning documents could be used better by the staff, particularly the way that night care plans are not being used to the full. It has been some time since staff had training in Adult Protection, so refresher training is advised. Attention needs to be given to making sure that staff are recruited in line with good practice, that application forms are fully completed and that independent references are taken up. Some attention needs to be given to ensuring that all staff receive fire safety training at least twice a year and that events that are reportable to CSCI under the regulations are reported accordingly. Springfield House DS0000001507.V323123.R01.S.doc Version 5.2 Page 7 The results of the quality survey and the action planned to respond to suggestions made, should be made available to residents, visitors and other interested parties. Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Springfield House DS0000001507.V323123.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Springfield House DS0000001507.V323123.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2 & 3 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Prospective service users have a good level of information in order to help them decide whether or not this home will be able to meet their needs. Information about costs and the facilities that can be provided is clear. Staff could improve practice by having a checklist that includes room preparation, in order that the new service user has everything they will need ready for them. EVIDENCE: The Statement of Purpose was seen; there had been no changes since the last inspection. The document is freely available to read, kept in a folder in the hallway. One service user commented that they had had a choice of three homes and chose this one because they liked it when they came to look round. Service users’ care files contained evidence of comprehensive assessment prior to admission, mostly through the Social Services core assessment process. Springfield House DS0000001507.V323123.R01.S.doc Version 5.2 Page 10 Copies of contracts were seen – these were clear about extra charges that may be levied, for example, escorts to hospital appointments where relatives are not available to accompany, charged at an hourly rate. Two copies of the contract are sent to the relatives, one to sign and one to return to the home; they are also signed by the service user where possible. The care notes for one person recently admitted showed that room preparation could be given more attention by the staff; for example, staff had noted that when they had helped the person to bed that evening, there was no buzzer for the call system and they had to find one from another room. Springfield House DS0000001507.V323123.R01.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9, 10 & 11. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users are treated with respect and their privacy and dignity is upheld by all levels of staff. Personal care is given to a good standard and the home works well with health care professionals in order to make sure service users get the right treatment. The home handles end of life care well and ensures the right levels of care and comfort are provided. Medication is well managed. Some aspects of care plan documentation could be improved. EVIDENCE: Three current service users were case tracked, their care plans examined and verified through observation and discussion. The care plan for one person who had died a few days previously was also examined, in relation to Standard 11. When a new service user is admitted, a short-term care plan is put in place, based on the pre-admission assessment. The care plan proper is developed from this. There is also a night care plan within the file, however, the majority Springfield House DS0000001507.V323123.R01.S.doc Version 5.2 Page 12 of those seen did not make best use of this document – many night staff were using it as a record of events, rather than a plan of what care the person needs during the night. It was clear from the records that a number of residents are not disturbed for routine checks during the night, but again this was not clearly stated within the night care plan that this is the individual’s preference. The care plan of the person who died recently provided a comprehensive record of her care, including the family’s involvement in the decision making process regarding how palliative care was to be given. There was evidence that the service user and the staff had received appropriate support from other health care professionals and had been able to access specialist home nursing equipment to keep the person comfortable. A relative of the person said they felt very comforted by how well the staff had looked after her at the end of her life. The home operates a key worker system, with each service user having a named staff member who carries out various roles; information about the expected role of the key worker was displayed on the staff notice board. In one of the care plan files seen, there was reference to the key worker making sure that the service user was kept supplied with puzzle books. It was clear from some of the comment cards that were returned that service users know and trust their key workers. Staff were observed as being very respectful in their dealings with the service users. One of the housekeeping staff was overheard negotiating with a service user when would be the best time to go in and clean her room. Staff were overheard knocking on bedroom doors as a matter of course, even though they knew the room was probably unoccupied. There was evidence in service users’ records that the GP regularly reviews prescribed medication. The Team Leader on duty was observed giving medication at lunchtime and the accompanying records sheets were seen. The home’s Statement of Purpose states that residents are welcome to take charge of their own medications, and some do. It was clear where service users selfmedicate and the staff were clear about how they monitor that this is going well for the individual. In discussion with service users, they expressed high levels of satisfaction with the care they receive. Individuals said they felt “the staff support us very well”, “there is a good atmosphere and we generally get on well with each other”. Springfield House DS0000001507.V323123.R01.S.doc Version 5.2 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 & 15 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Service users are given the opportunity to lead interesting and fulfilling lives. The routines of daily life and the activities provided are flexible and varied, which allow service users to exercise their choice in all matters affecting them. Visitors are positively encouraged, which increases contact with the community. Food is of a good standard and is to the satisfaction of the service users. EVIDENCE: There is a good level of information around the home, informing service users, visitors and staff about activities and weekly events, not only in the home but those accessible in the Morley area, such as coffee mornings, tea dances, etc. A notice also advises visitors that wheelchairs are available if they wish to take service users out. A computer is now available in the dining room, and staff are encouraging those who have families living long distances away to communicate via email as well as phone. Springfield House DS0000001507.V323123.R01.S.doc Version 5.2 Page 14 The activities co-ordinator was working in the home during the inspection, most of the service users joining in a game of bingo in the sitting room. Some service users are able to go out independently. One lady spoken to in the afternoon said she tried to get out most days and she had been out for lunch with her daughter that day. Only two visitors were in the home on the day of inspection, but they said they were welcomed at all times and were able to see their relative in private in the comfort of her own room. There was a high level of satisfaction expressed about life in the home, comments such as, “ I’m very happy here”, “it’s a nice atmosphere”, “I’m very contented …I like the company, but also my own privacy when I want”. There were also positive comments about the food, “There’s a good choice and the meals are well cooked”, “We tell Barbara (the cook) if we’re getting fed up of something and she changes it”, “The food is excellent”. It was clear that choices are offered as a matter of course, even the school student on work experience demonstrating good practice by showing service users both choices of dessert and asking them which they preferred. A discussion took place with the cook and food records were examined. Most general groceries are purchased on-line and delivered by one of the supermarket chains; other fresh items are purchased locally and the meat delivered by a butcher. The cook said that she has good quality ingredients to work with and tries to keep a good variety on the menu. She also likes to incorporate peoples’ favourites where possible; the food records confirmed that there was plenty of variety and choice. It was one of the current favourites for lunch that day – scampi & chips; unfortunately, the deep fat fryer fused during cooking the chips, so these had to be supplied from the local fish & chip shop instead, but service users still enjoyed their meal, even though it was a bit later than expected. Springfield House DS0000001507.V323123.R01.S.doc Version 5.2 Page 15 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16 & 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Staff are aware of potential adult protection issues and the system of Team Leaders on each shift ensures that new staff are trained in good practice. There is an open culture that assists in the management of concerns or complaints, these being dealt with as they arise. Service users and visitors have confidence in the provider and other senior staff. EVIDENCE: Two of the senior staff did a course in Adult Protection, then cascaded it to the staff team. This was in October 2005, however, and the Assistant Manager acknowledged that it was probably time for a refresher, as there had been some new staff since then. The complaints procedure is fully accessible, on display and within the staff policies & procedures file. There is a good policy for staff in dealing with incidents of aggressive behaviour or violence, also a clear “no restraint” policy. Staff and visitors said that they felt the service users were very happy to complain if something wasn’t right. This was confirmed by the service users themselves, who said they knew who to tell if they were unhappy about something, and had every confidence that they would put things right. Springfield House DS0000001507.V323123.R01.S.doc Version 5.2 Page 16 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19 & 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. There is good attention to hygiene and cleanliness in the home. The provider continues to look at ways of improving facilities for those who live there. Staff are provided with the resources they need to move people safely and to prevent cross-infection. Importance is given to making sure the building is safe for people to live in and that the risk of fire is minimised. EVIDENCE: A tour of the premises was carried out and the rooms of the people who were case-tracked were seen. The new fire door was in place on the ground floor corridor, as advised by the Fire Officer. This had just been completed but still needed to be fitted with an automatic release (Dor-guard). Springfield House DS0000001507.V323123.R01.S.doc Version 5.2 Page 17 Since the last inspection, the electrical wiring has been checked and a partial re-wire carried out. The dining room has been fitted with a wood laminate floor and the communal rooms re-decorated. The service users commented that the new floor was much better for moving around on with wheelchairs and walking aids. A mobile hoist is in regular use for one of the service users and is located in her room for ready access by the staff. There are plans to equip one of the sitting rooms with an induction hearing loop to assist those with hearing impairments, also to refurbish a WC on the first floor and remove the unused shower to make it more accessible. The bathroom upstairs is only accessible to the more mobile service users. There are privacy signs displayed when the bathrooms are in use. Protective gloves, aprons and sanitising hand rub are located at the points where staff need them. Visitors are also urged to use the hand rub on entering home. Cleaning schedules were seen, that show what tasks are to be done daily or weekly throughout the home. The laundry is located in the basement, with the washing & drying machines on lease. The washing machine has a disinfection programme for fouled linen. Many of the service users have their own bedding, which makes their rooms very personalised. Maintenance and repairs are carried out on a regular basis, the records showing how staff report deficiencies and record when they have been rectified. Springfield House DS0000001507.V323123.R01.S.doc Version 5.2 Page 18 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 & 30. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Staff training and support is at a good level; however, recruitment practices are not always in line with best practice and could lead to people being employed that have not been adequately checked out. This has the potential to put service users at risk. EVIDENCE: Recruitment records were looked at for four staff members. The home requests candidates to complete an application form and requests two written references; however, these were not found to be in place for all of those looked at. Application forms were not always fully completed and gaps in employment history not followed up. Not everyone had two written references and in one file, the only reference was from a family member. Criminal Records Bureau checks are completed and there are records of induction training. Supervision now happens on a regular basis – one of the night staff had come in for her supervision meeting with the Manager that morning. Records showed that this was now happening at the required frequencies. NVQ training has not really been able to progress as was expected, as the home finds it has been repeatedly let down by external assessors. However, 50 of the care staff have now qualified at level 2 and there are another 3 Springfield House DS0000001507.V323123.R01.S.doc Version 5.2 Page 19 staff commencing level 3. Other care staff are keen to start but feel let down as there has been no visit from the assessor since Sept 2006. The Deputy Manager is starting NVQ level 4 and the Care Manager is starting the Registered Managers Award. All staff have had updates in Fire, COSHH and Manual Handling. Staff of various roles were spoken to during the day. They all demonstrated a competence in their approach to work. In discussing training, some said that they had progressed further than they would have thought they would, that training has increased their confidence and helped them to better achievements. Springfield House DS0000001507.V323123.R01.S.doc Version 5.2 Page 20 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35, 37 & 38. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is well managed and supporting policies and records are in place to assist the smooth running of the home. Residents are consulted and have the opportunity to be involved in decisions affecting them in the home. The results of the quality monitoring surveys that are carried out should be publicised, so that residents, relatives and staff can see that their suggestions are being considered, and acted upon where possible. Good attention is paid to health and safety and action has been taken to ensure that the residents are protected from risk of fire. Records are generally well kept, but greater attention to detail is needed in some areas, to ensure that all staff have fire training at the required intervals and that CSCI is notified of both routine and serious events that occur. Springfield House DS0000001507.V323123.R01.S.doc Version 5.2 Page 21 EVIDENCE: The registered provider continues to manage the home 3 days a week, supported by a full time Care Manager who has recently signed up to undertake the Registered Managers Award. The Deputy Manager and one of the Senior Care Assistants have also signed up to undertake NVQ level 4. The Care Manager’s and Deputy’s roles have continued to develop, with more involvement in the business and administrative side of the work, and supervision of other staff. It could be seen from the care records that the notes made by staff are read through and checked in case any follow up action has been missed. One to one supervision is shared between three of the senior staff team, who have a group of workers each. Recent and forthcoming topics for discussion are staff training, issues of confidentiality, and ideas for summer activities. The home has recently undertaken a quality survey, getting a better response from the residents than previously. Action has been taken in response to all of the suggestions made, such as “brighten up the place”, or to have some different activities. The results of the survey are not publicised anywhere in the home. The last residents’ meeting was just before Christmas; they had more direct input into organising the Christmas activities, which the staff say worked very well. The Registered Person has a plan for continued improvements to the environment during 2007 (see Environment section). The Deputy Manager has a lead for Health & Safety within the home. Records showed that hot water temperature checks are carried out monthly by her, as well as weekly fire alarm and emergency lighting tests. The last staff fire drill took place in July 2006, but there were no names recorded to show who had taken part. A selection of regulatory and operational records were seen, including: • Service users’ care plans • Medication records • Accident records • Menus • Fire safety records • Health & safety records • Staff recruitment files • Staff training records • Minutes of staff meetings • Financial records All were readily available. Most were up to date and accurate; however, there were some areas where the records could be improved. Springfield House DS0000001507.V323123.R01.S.doc Version 5.2 Page 22 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 3 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 4 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X 2 2 Springfield House DS0000001507.V323123.R01.S.doc Version 5.2 Page 23 Are there any outstanding requirements from the last inspection? NO STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP29 Regulation 19 Requirement All staff must be recruited in accordance with the home’s own policies, with application forms fully completed and two independent references sought. The Registered Manager must ensure that all incidents and events that fall under the remit of this regulation are notified to CSCI without delay. All staff must receive fire instruction at least twice a year. Timescale for action 01/03/07 2. OP37 37 01/03/07 3. OP38 23(4)(e) 01/03/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard OP7 Good Practice Recommendations Some aspects of care plan documentation could be improved, in particular the night care plans, which should be more detailed with regard to nightly checks; staff should also be given guidance in how to keep nightly notes alongside the plan of care. DS0000001507.V323123.R01.S.doc Version 5.2 Page 24 Springfield House 2. 3. 4. OP18 OP24 OP33 All staff should receive Adult Protection refresher training on a regular basis. Staff could improve practice by having a checklist that includes room preparation, in order that the new service user has everything they will need ready for them. The results of the quality monitoring surveys that are carried out should be publicised, so that residents, relatives and staff can see that their suggestions are being considered, and acted upon where possible. Springfield House DS0000001507.V323123.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection Aire House Town Street Rodley Leeds LS13 1HP National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Springfield House DS0000001507.V323123.R01.S.doc Version 5.2 Page 26 - 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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