Inspection on 07/11/07 for Springfield House

This inspection was carried out on 7th November 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 found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 2 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Springfield House 26/09/06

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 7 and 9th November 2007 10:00 th Springfield House DS0000063470.V348569.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.V348569.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.V348569.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.V348569.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 26th September 2006 Brief Description of the Service: Springfield is a home for six people with a learning disability who may also have additional mental health needs. The home at the time of the inspection accommodated six women. Springfield is located on a main road close to Gloucester city centre and close to 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 is pleasantly decorated and is furnished in a comfortable and stylish way. Individual en suite accommodation is provided with access to a range of communal rooms. There are gardens to the rear of the home. 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.V348569.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 November 2007 and included two visits to the home. The registered manager was present throughout. Time was spent observing the care provided to people living at the home and talking to some people about the service they receive. A walk around the home and gardens was done with a person living at the home. A sample of records were examined which included care plans, medication and financial records, staff files and the complaints log. The registered manager completed an AQAA (Annual Quality Assurance Assessment) as part of the inspection, providing considerable information about the service and plans for further improvement. Surveys were received from two people living at the home, three relatives and two healthcare professionals. What the service does well: People are involved in putting together their care plans with input from other people connected with their care. These are regularly monitored and reviewed. Routines are flexible and the choices people make about their everyday lives are respected. People have the opportunity to take part in a range of activities. One person said they enjoy “vital therapy” and another person likes “going to the pub”. Spacious and comfortable accommodation is provided. People said they are involved in choosing colour schemes for their rooms. Everyone has en suites attached to their rooms that include either a bath or shower and toilet. Staff have access to a robust training programme which includes courses in learning disability, epilepsy and mental health. A quality assurance system is in place which involves people living at the home. Springfield House DS0000063470.V348569.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? 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. The summary of this inspection report can be made available in other formats on request. Springfield House DS0000063470.V348569.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.V348569.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. JUDGEMENT – we looked at outcomes for the following standard(s): 2 People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. The needs and wishes of people wishing to move into the home are assessed prior to them being offered a place. EVIDENCE: There have been no new admissions to the home. The registered manager stated that an initial assessment and care plan had been requested on numerous occasions from the placing authority for the last person admitted but had not been supplied. This person had since had a review with the placing authority and a care plan had been supplied. The organisation has a comprehensive admissions process in place that includes a referral manager completing an initial assessment before the home’s manager visits them to assess their needs. The AQAA indicated that “transition meetings are held to ensure referrals, transitions and admissions are as smooth as possible. Visits and stays to Springfield House are encouraged.” Springfield House DS0000063470.V348569.R01.S.doc Version 5.2 Page 9 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. JUDGEMENT – we looked at outcomes for the following standard(s): People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. People’s changing needs are monitored and reflected in their care plans. Most restrictions that affect people living at the home are recorded with the rationale for this. Risk assessments and management plans safeguard people from possible harm. EVIDENCE: Three people were case tracked. This involved observing or talking to them during the visits, reading their care plans and other associated records and talking to staff about the care they provide to them. Care plans were being developed involving people living at the home, their relatives, key worker and other professionals associated with their care. They provide a holistic analysis of each person’s physical, social, emotional and intellectual needs. There was evidence that these documents were being reviewed on a regular basis. Some people had signed records on their files. Although there is no formal assessment tool in place there was evidence that the changing needs of people Springfield House DS0000063470.V348569.R01.S.doc Version 5.2 Page 10 were being monitored and where necessary the appropriate people were involved in discussions about the care they receive. Care plans clearly link to other relevant documents such as risk assessments and behaviour management guidelines. Daily diaries also referred to the use of monitoring records such as behaviour observation charts and incident records. Staff appeared to have a good understanding of the needs of the people they support. They were observed supporting people in line with strategies identified in their care plans. However there were some incidents during one visit that might have been prevented if the care plan had been followed. For instance one person’s care plan stated that when they wished to use the kettle they must have 1:1 support from staff. This was not in place and an incident ensued. This was discussed with the registered manager who said that 1:1 support was not always available when needed due to the complexities of the needs of people living at the home. This was evident during the visits. At times during one visit the kitchen door was locked. Staff stated that this was because one person needed to be supervised with their meal due to risks of choking and that they had to be kept calm. Another person had become agitated and the door was locked to ensure they did not disturb this person whilst eating their meal. Although the reasons for the risk of choking for one person were noted in their care plan there was no evidence of the rationale for restricting the other person’s access to the kitchen. Care plans stated that this person had unrestricted access to the kitchen but may be asked to leave if the kitchen was busy or they were assessed as being at risk of harm. People were being supported to manage their personal finances. Records were examined which clearly record debits and credits for people. Receipts were numbered and could be cross-referenced with spending. The registered manager confirmed that she audits financial records. Communication profiles were included in care plans and health action plans also indicated how people’s non-verbal or verbal communication could be interpreted. There was good use of symbol and pictures around the home to enable people to communicate their needs. Risk assessments were in place that were being regularly reviewed. Each person had a summary of each risk area that was colour coded giving instant access to the reader. This was then supported by a comprehensive risk management plan. Further risk assessments were in place minimising other hazards. A missing person procedure was in place and staff described what systems were in place should a person not return home when expected. Springfield House DS0000063470.V348569.R01.S.doc Version 5.2 Page 11 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14,15,16 and 17. People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. People who live at the home make choices about their lifestyle, and are supported to develop life skills. They have the opportunity to take part in social, educational and recreational activities and keep in touch with family and friends. People have a nutritional diet and their diverse needs are catered for. EVIDENCE: People were observed going out for a walk around their local area. Care plans for several people identified their religious beliefs but that they had chosen not to go to church. The AQAA stated that people were supported to use local community facilities and public transport. One person was observed going out to catch a bus into the town. Some people have attended college courses and others attended “Express yourself” at the Gloucester Guildhall. People had been supported to take on Springfield House DS0000063470.V348569.R01.S.doc Version 5.2 Page 12 jobs within the home such as helping with office administration for which they received payment. Each person had an activity schedule that the registered manager stated was regularly reviewed. Staff said that although the schedules were in place people often refused to participate in activities or go out. The AQAA recognised that “activities are poorly attended” and that “better motivational skills are required to encourage individuals to attend recreational activities”. Comments from parents indicated that the home “revises day plans to reflect mood swings”. Daily diaries indicate what people have done during their day and some record when people have refused an activity. House meeting minutes confirmed discussion with people living at the home about whether they wish to have a weekly activity schedule or decide what activities they would like to do on a daily basis. Some people said they would prefer to choose each day. Activities people said they enjoyed doing were pottery, vital therapy, tutorials, going shopping and to the pub. During the visits one person went into Gloucester and others went for a drive. People were being supported to maintain close contact with family and friends. One person was observed using the telephone in the quiet lounge to speak to family. Daily diaries also verified visits from their family and visits home on a regular basis. A great deal of flexibility was evident during the visits with staff responding to people’s choices in relation to getting up or staying in bed, participating in scheduled activities or refusing to be involved. Daily diaries also indicated that some people like to stay up late and have access to waking night staff. Some people were observed using keys to their rooms. People were also observed choosing where to spend their time and with whom. Good use was being made of the new quiet room. People said that they help with the cleaning and laundry. One person said they like to help with the cooking. People also help with the shopping. A four-week rolling menu was in place with evidence of a range of freshly produced meals including fresh vegetables and salad. People were observed helping themselves to snacks and drinks during the visits. The menu includes Caribbean meals and snacks, as well as a soft diet for those who require it. Daily diaries keep a record of meals eaten although this appeared to be inconsistent. Where people’s diet was being closely monitored additional records were in place. Good food hygiene practice was observed to be in place. Temperatures of cooked foods, fridges and freezers and water were regularly monitored. Prepared or open food in fridges was labelled with the date of preparation. The home has recently been awarded four stars by the local Environmental Health Unit. Springfield House DS0000063470.V348569.R01.S.doc Version 5.2 Page 13 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. JUDGEMENT – we looked at outcomes for the following standard(s): People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. People’s health and personal care needs are being met helping them to stay well. Their health and wellbeing are promoted by satisfactory arrangements for the handling of medication. EVIDENCE: Care plans indicated people’s likes and dislikes and how they would like to be supported with their personal care. Female staff support people living at the home with their personal care needs. People’s diversity is acknowledged and specialist care and access to specialist facilities are facilitated. The cultural background of staff reflects that of people living at the home. Each person had a completed health action plan in place. There was evidence of regular appointments with Doctors, Dentists, Chiropody and members of the local Community Learning Disability Team and Mental Health Team. Comprehensive records were being kept for all healthcare appointments noting the outcome of each visit and any changes to medication or other needs. During the visits people attended appointments with their doctor and dentist. Springfield House DS0000063470.V348569.R01.S.doc Version 5.2 Page 14 Comments from health care professionals indicated that the home “liaises with the team”. People were being supported with continence issues and referred to specialists where required. Continence pads were being stored discreetly and disposed of in an appropriate manner. Accident and injury records were being kept. Where an incident had occurred records were being completed using body charts if needed. Outcomes of incidents were recorded and cross-referenced with any changes in care plans or risk assessments. Systems for the administration of medication were examined and found to be satisfactory. Staff complete accredited training from several sources. Medication audits were being completed with evidence that any discrepancies or concerns were being identified and dealt with. Stock records were being maintained for all medication on the administration form. Liquids and creams were labelled with the date of opening. Protocols were in place for the use of homely remedies and these had been authorised by the doctor. Guidance for the use of “as necessary” medication had been produced and staff had a good understanding of its use. The temperature of the medication cabinet was being monitored. Springfield House DS0000063470.V348569.R01.S.doc Version 5.2 Page 15 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. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23 People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. People are confident in the knowledge that any concerns they may express will be listened to and acted upon. Systems are in place that safeguard people from possible harm or abuse. EVIDENCE: The home has a complaints system in place which was accessible to people living at the home. Those spoken with said they would talk to staff or the manager if they had any concerns. Relatives confirmed that they had been provided with information when their daughters moved into the home. Comprehensive systems were in place monitoring complaints and listing the outcome of the complaint. Additional information obtained during investigations was provided where necessary. Nine complaints had been received from a variety of sources over the past twelve months (five from one person living at the home). The outcomes of these were well evidenced. Procedures have been put in place to deal with allegations from one of the people living at the home. It was evident from records examined that these guidelines were being followed by staff when an allegation was received. Where appropriate further investigations or referrals to the adult protection team have been made. Staff confirmed that they had attended training in the safeguarding of adults with the local team. New staff complete this as part of their induction. Other Springfield House DS0000063470.V348569.R01.S.doc Version 5.2 Page 16 staff were booked on this course. Staff spoken with had a good understanding of the safeguarding policy and procedure and had confidence that the manager would challenge and deal with inappropriate or poor practice. The management team have attended training in the mental capacity act and have been involved in a best interests meeting concerning the protection of one person living at the home from potential financial abuse. Staff complete training in the Management of Response to Emotion (MORE). Behaviour management plans and strategies were in place. The home have access to a Psychologist who works alongside staff and people living at the home. A risk management plan had been put in place for a person who was at risk of self-harm. A protocol had been established should a person require admittance to hospital in an emergency. As mentioned staff have protocols in place providing guidance about the support to be given to people at times of distress or anxiety. Staff spoken with had a good understanding of these strategies and said they would only use physical intervention when all other techniques had failed and as a last resort. Comments from health care professionals indicated that the home “manages challenging behaviour well”. A relative stated that “dual diagnosis care is always exceptionally difficult and in the main they discharge their responsibilities effectively and efficiently, with care and sympathy.” Springfield House DS0000063470.V348569.R01.S.doc Version 5.2 Page 17 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. JUDGEMENT – we looked at outcomes for the following standard(s): 24,29 and 30. People who use the service experience excellent quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. The physical design and layout of the home enables people to live in a wellmaintained and comfortable home that suits the lifestyles of the people living there. EVIDENCE: Springfield House is situated on a busy main road with access to a small car park to the front of the house and gardens to the rear. People have en suite accommodation with access to a shared bathroom. Spacious communal areas consist of a kitchen with a small dining table, dining room with three tables and additional comfy seating, a quiet lounge and a television lounge. There are two offices on the ground floor and first floor. Records on people’s files confirmed referral to an occupational therapist for advice about specialist adaptations or equipment to help them cope with their Springfield House DS0000063470.V348569.R01.S.doc Version 5.2 Page 18 mobility and safety around the home. Equipment had been provided as suggested. The home has recently been redecorated and new floor put down in the hallways and dining room. Carpets in the lounge were scheduled for replacement. An ongoing maintenance programme was in place. The home has a small laundry. Good infection control measures were seen to be in place. Personal protective equipment was provided. Colour coded mops and buckets were in use. The soap dispenser was not accessible having fallen off the wall. People have individualised laundry baskets with their photographs and names on. The AQAA stated that the home was using the Department of Health’s Essential Steps to assess infection control management. Regular audits were seen to be in place. Springfield House DS0000063470.V348569.R01.S.doc Version 5.2 Page 19 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. JUDGEMENT – we looked at outcomes for the following standard(s): 32,34 and 35. People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. People’s needs are met by a competent staff team, who have access to a satisfactory training programme that provides them with knowledge about the diverse needs of people living at the home. Recruitment and selection procedures help to safeguard people from possible harm. EVIDENCE: There have been changes to the staff team over the past twelve months but staff spoken with thought that they had been managed effectively and that morale within the team was good. Over 40 of the staff team either have a NVQ in Health and Social Care and a further 30 were working towards their awards. This will exceed the National Minimum Standards. New staff were completing the Learning Disability Award Framework foundation programme which includes all mandatory training and the ‘alerters guide’ (Safeguarding Adults). Copies of certificates were kept on staff files. The home also had its own induction programme. There was evidence on staff files that this was being completed. New staff were also expected to complete questionnaires about people living at the home. Springfield House DS0000063470.V348569.R01.S.doc Version 5.2 Page 20 The processes of recruitment and selection of staff were being dealt with by an employment agency. Each person had an application form including full employment history and there was evidence that any gaps were being verified with the applicant. There were two references in place that had been received prior to employment. On three occasions people had been appointed before receipt of their Criminal Records Bureau check. For each person there was evidence of a povafirst check having been completed and a risk assessment was in place. We had been informed. Staff described their duties during this time that included shadowing staff and being mentored by a named person on shift. Two members of staff had been appointed prior to their povafirst check coming through. The registered manager stated that this was due to the postal strikes and that they had not worked in the home until the check was received but had commenced training at head office. This had not been recorded on their files but was noted during the visits. The group manager stated that this was done under extreme circumstances and they would normally not appoint without the check in place. The manager had a training matrix in place that clearly showed what courses staff had completed, their future training needs and whether courses had been booked. Staff complete mandatory training with refreshers provided when necessary and also had access to more specialised training such as epilepsy and mental health. Staff had access to additional information about people’s specific conditions that was kept with their care plans. Equality and diversity training was being arranged. Copies of certificates were kept on staff files confirming attendance on these courses. Springfield House DS0000063470.V348569.R01.S.doc Version 5.2 Page 21 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. JUDGEMENT – we looked at outcomes for the following standard(s): 37.39 and 42. People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. People benefit from a well run home. Effective quality assurance systems are in place involving people who live at the home. Amendments to fire risk assessments will ensure that the health, safety and welfare of people is promoted and protected. EVIDENCE: The registered manager has the Registered Managers Award and NVQ Level 4 in Health and Social Care. She had completed a course with the Institute for Applied Behaviour Analysis. She was continuing her professional development with courses in risk assessment and recruitment. Staff confirmed that communication at the home was good with evidence of regular staff meetings and supervision sessions. Positive feedback from the manager congratulating Springfield House DS0000063470.V348569.R01.S.doc Version 5.2 Page 22 staff on the recent four stars from Environmental Health was displayed in the entrance hall. Excellent systems were in place in the home providing a clear audit trail for care planning, staff recruitment and training and health and safety. Quality assurance systems were in place. The registered manager confirmed that monthly-unannounced regulation 26 visits took place. Copies of these visits were being kept in the home. A quality audit was completed last year and a quality assurance report was produced. A copy of this was supplied to the Commission. The area manager confirmed that an audit was underway for the current year, involving people living in the home and their representatives. The registered manager was conducting medication audits on a regular basis and a health and safety audit was also being completed. The AQAA confirmed that servicing was in place for equipment within the home. Robust monitoring was in place for fire systems with evidence of regular drills and training for staff and people living at the home. Staff had completed fire questionnaires every six months. The fire risk assessment had been reviewed and the group manager confirmed that she was in communication with the fire brigade to clarify what the risk assessments should state for people who refuse to leave the building at a time of fire. Springfield House DS0000063470.V348569.R01.S.doc Version 5.2 Page 23 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 3 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 3 ENVIRONMENT Standard No Score 24 4 25 X 26 X 27 X 28 X 29 4 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 3 35 4 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 2 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 4 X 4 X X 2 X Springfield House DS0000063470.V348569.R01.S.doc Version 5.2 Page 24 Yes 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 YA7 Regulation 17(1)(a) Sch 3.3(q) Requirement Reasons for any restrictions to freedom of choice or access to facilities such as the kitchen must be recorded, wherever possible in a multi agency forum. The registered person must ensure that the fire risk assessment identifies all areas of high risk and how hazards are minimised. (This requirement has been repeated from the last inspection-timescale for action 01/12/06. Progress is in place to meet this requirement). Timescale for action 31/12/07 2. YA42 23(4)(b) 31/12/07 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 YA6 Good Practice Recommendations Support should be provided to people living at the home in line with their identified needs as noted in their care plans. DS0000063470.V348569.R01.S.doc Version 5.2 Page 25 Springfield House 2. 3. 4. YA6 YA17 YA30 A formal tool should be used for the ongoing assessment of people. A comprehensive record of meals eaten should be kept so that an assessment can be made about the nutritional content of the meal. The soap dispenser in the laundry should be accessible. Springfield House DS0000063470.V348569.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection South West Regional Office 4th Floor, Colston 33, 33 Colston Avenue Bristol BS1 4UA 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. 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