Inspection on 20/02/07 for Springfield Nursing Home

This inspection was carried out on 20th February 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 but made no statutory requirements on the home.

Other inspections for this house

Springfield Nursing Home 04/12/07

Springfield Nursing Home 30/01/06

Springfield Nursing Home 09/08/05

Springfield Nursing Home 29/03/05

Springfield Nursing Home 06/07/04

Springfield Nursing Home 10/03/04

Similar services:

Chirnside House

Keer Sands Residential Home

Ruskin Lodge

Bushell House

Langrigg House

Parkside

Dystlegh Grange

Thornton Lodge

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

CARE HOMES FOR OLDER PEOPLE Springfield Nursing Home 191 Spendmore Lane Coppull Chorley Lancashire PR7 5BY Lead Inspector Jane Craig Unannounced Inspection 20th February 2007 09:30 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 Nursing Home DS0000025577.V326208.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 Nursing Home DS0000025577.V326208.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Springfield Nursing Home Address 191 Spendmore Lane Coppull Chorley Lancashire PR7 5BY 01257 470140 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) Mr Ghulam Qadir Mrs Janet Lawes Care Home 48 Category(ies) of Old age, not falling within any other category registration, with number (42), Physical disability (6) of places Springfield Nursing Home DS0000025577.V326208.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 4. Up to 42 Service users in the category OP (Old Age, not falling within any other category) who require nursing care. Up to 6 service users in the category PD (Physical Disability) who require nursing care. Up to 17 service users in the category OP (Old Age, not falling within any other category) who require personal care only. The service should, at all times, employ a suitably qualified and experience manager who is registered with the NCSC. 30th January 2006 Date of last inspection Brief Description of the Service: Springfield is a care home with nursing, currently registered to accommodate forty-eight residents. The registration allows the home to accommodate fortytwo older residents of either sex and six young physically disabled people of either sex. The home is situated on the main road, which passes through the village of Coppull, two miles from Chorley town centre and Standish. Springfield is a purpose built home offering accommodation over two floors, which can be accessed by the passenger lift. There are single and double bedrooms, a lounge/dining room and assisted bathing facilities on each floor. All of the double rooms were being used for single occupancy. The ground floor houses the administrative offices, reception area, kitchen and laundry. There is a conservatory that is designated as the residents’ smoking area. The home has a large garden to the rear and side of the home that has a large patio and water feature fountain and greenhouse. A brochure about Springfield is sent out to prospective residents when they enquire about admission. Anyone who comes to look around the home has access to more comprehensive information, including the service user’s guide. At 20th February 2007 the weekly fees ranged from £320 to £460.50. The higher rate was charged for double rooms and rooms with en-suite facilities. There were additional charges for hairdressing, personal newspapers, none hospital transport and incontinence aids for some residents. Springfield Nursing Home DS0000025577.V326208.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. A key unannounced inspection, which included a visit to the home, was conducted at Springfield Nursing Home on the 20th February 2007. At the time of the visit there were 40 residents accommodated. The inspector met with a number of residents and, wherever possible, asked them their views and experiences of living in the home. Four visitors also contributed to the inspection. Eight residents and eight visitors had completed questionnaires before the inspection. Their comments were taken into account when writing the report. Discussions were held with the registered manager and other staff. A partial tour of the premises took place and a number of records and documents were viewed. This report also includes information submitted by the home prior to the inspection visit. What the service does well: Residents were assessed before they were admitted to the home. This meant that staff understood what care the person needed. Prospective residents had access to information to help them to make a choice about whether the home was right for them. Relatives who filled in surveys and those spoken with during the visit said that the staff were good at letting them know if there were any changes in their relatives health or care. Residents said that they were well looked after and received the care they needed. Relatives agreed that the health care at the home was very good. One said, “I am at peace when I leave at night because I know they will look after her.” Residents were satisfied with the routines in the home. They said that they had choices about what to do and where to spend their time. A resident said, “some places have too many rules and regulations but not here.” Most residents said that there were enough organised activities and they had enough to do. One resident said that a new keep fit group was “good fun,” and another resident said they enjoyed the entertainment. Springfield Nursing Home DS0000025577.V326208.R01.S.doc Version 5.2 Page 6 The meals suited most residents. One described the food as, “plain but good”. A relative commented that there was always plenty of fresh meat, fish and vegetables. The environment was clean and tidy. Furnishings and décor were comfortable and homely. A resident described the home as “spotlessly clean.” Residents and staff had opportunities to make suggestions for improvements to the service. Residents and relatives knew who to complain to if they were not happy about something. The manager made sure that complaints were dealt with properly. There were enough staff on duty to meet the needs of the residents. Residents and relatives were very complimentary about the staff. One resident said, “we have a splendid team,” and a relative wrote, “an excellent caring staff run Springfield with great efficiency.” What has improved since the last inspection? What they could do better: The manager must make sure that all residents have a written care plan. This is to instruct staff about the care the resident needs and to make sure that they are all providing the same level and quality of care. Some of the assessments used to measure risks to residents’ health and safety should to be more detailed so that staff can draw up plans to try to control the risk. Improvements must be made to the way medicines are recorded and administered to minimise the risk of drug errors and make sure that residents are safeguarded. Not all the staff were clear about what to do if a resident accused a member of staff of being abusive. The manager must take steps to address this to ensure the safety of residents. In order to safeguard residents the registered person must also ensure that all new staff have complete background checks before they start work at the home. Springfield Nursing Home DS0000025577.V326208.R01.S.doc Version 5.2 Page 7 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 Nursing Home DS0000025577.V326208.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 Nursing Home DS0000025577.V326208.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): 3 and 6 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The admission procedure ensured that residents had sufficient information to help them to make a decision about moving in and staff had enough information to understand the new resident’s care needs. EVIDENCE: Most residents who completed questionnaires said that they received enough information about the home. Prospective residents were assessed before being offered a place at the home. Residents or relatives were involved in the assessment process. One relative said that the manager had spoken to her a few times before her mother moved in. Staff said that the registered manager made sure they had access to information before the resident came in. Intermediate care is not provided at Springfield Nursing Home. Springfield Nursing Home DS0000025577.V326208.R01.S.doc Version 5.2 Page 10 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 and 10 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Despite shortfalls in care plan records, residents’ health and personal care needs were met in accordance with their wishes. Medication records were not of a good standard which increased the risk of drug errors. EVIDENCE: The care records for three residents were inspected and others were viewed in less detail. The quality of care plans varied greatly. One newly admitted resident did not have any care plans. Another resident did not have a plan to assist staff to support them through periods of agitation. The lack of care plans meant that staff had to rely on verbal directions, which increased the risk of misinterpretation and misunderstanding. However, in this instance, the newly admitted resident said that staff provided the right care from the start and she did not have to keep giving explanations of what she needed. Care plans for other residents provided staff with clear directions as to how the residents’ individual health, social and personal care needs were to be met. Springfield Nursing Home DS0000025577.V326208.R01.S.doc Version 5.2 Page 11 Care plans included risk assessments for moving and handling, nutrition and risk of developing pressure sores. There were no specific risk assessments for the use of bed rails or for residents at risk of falls, although both were partially addressed within a general risk assessment. Care plans were reviewed monthly and there was evidence that they were updated or added to if necessary. Residents or their relatives could be involved in drawing up and reviewing plans if they wished. One resident said that the manager had altered one of her plans when she pointed out that it was not quite right. Another resident said that staff told them they could go through their plans every month. Relatives who returned comment cards said they were kept informed of any changes. Most residents who returned surveys indicated that that they always received the care and medical support they needed. One resident, who had a recent problem with their health, wrote, “all the staff have been aware of my new condition and always seem to anticipate my needs.” One resident spoken with during the inspection described the care as, “wonderful”. Relatives all indicated that they were happy with the overall care. One person wrote that their relative had “considerable problems both physically and mentally and these were treated in a caring and professional way.” There was evidence that residents’ ongoing health care needs were monitored and met. Referrals were made to external professionals as necessary and care plans showed that any advice resulting from the referrals was acted upon. One resident said that the care was excellent and a relative said she wasn’t afraid to leave her mother at night because she knew she would be well looked after. Registered nurses administered all medication. As previously required, care staff who assisted had been provided with training. There were records of medication received into the home. However, there were no clear systems in place to assist staff to audit the administration of medicines not included in the monitored dose system. There were appropriate facilities for disposing of medicines and records were kept. There were gaps on MAR charts with no explanation as to why medication had not been given. Dosage changes were not dated which meant that it could not be identified from the MAR chart how long the resident had been taking the altered dose. Handwritten entries and amendments were not always signed and witnessed which increased the risk of errors in records. Storage was clean, tidy and secure. Storage temperatures were monitored. There were no excess stocks of oral medication. There were no controlled drugs in use. Residents had their own glucose monitoring and lancing devices which were stored in their rooms. Springfield Nursing Home DS0000025577.V326208.R01.S.doc Version 5.2 Page 12 Staff received training in care values, including promoting residents’ privacy and dignity, during their induction training. Staff gave examples of knocking on doors and helping residents to dress appropriately. During the course of the inspection staff were seen to speak with residents in a polite and friendly manner and all personal care was carried out in private. Residents said that staff helped them to stay independent. One said that although she needed a lot of help with most things staff still let her do whatever she could. Another resident confirmed that staff treated her with dignity and said, “we have jokes but they never go too far.” Springfield Nursing Home DS0000025577.V326208.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 and 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents had choice and control over their daily lives. Daily routines and meals suited residents. The programme of organised activities met the majority of residents’ social and recreational needs. EVIDENCE: Residents who returned surveys had mixed views about whether there were always sufficient activities in the home. However, at time of inspection visit all the residents spoken with said there was enough to suit them. They gave examples of drawing, games, entertainers and a new keep fit activity that had started on the day, which one resident said was “good fun”. There were also several individual activities, for example one resident helped with the garden and another said she had a job setting tables. Residents said they were satisfied with the routines in the home. Their usual times for getting up and going to bed were recorded on their assessments but none of the care plans seen had this information included. Residents spoken with said they could go to bed when they wanted and one said, “if you want a Springfield Nursing Home DS0000025577.V326208.R01.S.doc Version 5.2 Page 14 lie in just say so.” Another resident said, “some places have too many rules and regulations but not here.” The manager, staff and residents confirmed that people were given choices about what to do, what to wear, what and where to eat and where to spend their time. One resident said he preferred to spend most of his time in his room but always came to watch the entertainment. There was an open visiting policy. All the relatives who completed surveys indicated that they felt welcome in the home. A number of visitors spent a lot of time at the home and were involved in the practical care of their relative. One relative said that she was never made to feel in the way and another said she did it because she wanted to not because she felt she needed to. The manager stated that a large number of residents went out. Those who were able to go out alone did so. Others went out on group trips, individual outings with staff or accompanied by relatives. Residents who returned surveys had mixed views about meals. Comments at the time of the inspection were generally positive. One resident said the meals were grand, another said they were usually good and another said they were plain but good. Several residents acknowledged that it was difficult to please everyone all the time. The records of meals showed that residents had variety and meals were nutritionally balanced. There were choices at each meal. Springfield Nursing Home DS0000025577.V326208.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 and 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents were confident that complaints would be dealt with appropriately. The lack of understanding of procedures for reporting suspected abuse may result in allegations being mishandled. EVIDENCE: There was a clear complaints procedure on display in the home. Residents who completed surveys indicated that they knew who to speak to if they were unhappy about anything and most knew how to make a complaint. One wrote, “matron is an excellent listener; sympathetic with good advice.” One relative said she had raised concerns about the cleanliness of the resident’s bedroom. She said the manager gave her an explanation and action had been taken to remedy the situation. There had been one complaint to the home since the previous inspection. Records showed that it was investigated and followed up appropriately. Staff had access to guidance about safeguarding vulnerable adults but the majority had not had any recent training. The adult protection procedure included clear directions for reporting any allegations of abuse. However, not all staff were clear about the procedure for reporting outside the home. Springfield Nursing Home DS0000025577.V326208.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 and 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home was clean and well maintained. The standard of décor and furnishings provided residents with a safe, comfortable and homely place to live. EVIDENCE: The home was well maintained and the registered manager confirmed that any repairs were carried out quickly. The previous requirements to clean the corridor carpets and replace a broken bath panel had been actioned. Communal spaces were comfortable and homely and many of the residents’ rooms were personalised with furniture, pictures and ornaments. Springfield Nursing Home DS0000025577.V326208.R01.S.doc Version 5.2 Page 17 The home had very attractive grounds. The gardens had won awards in the best-kept nursing home competition for a number of years. Residents were happy with the environment and their bedrooms. One resident said, “I think this place is lovely and my room’s lovely.” All areas seen during the tour of the premises were clean, tidy and fresh smelling. Several residents and relatives commented about the standard of cleanliness and they were appreciative of the lack of odour. One resident wrote, “the house and my room are always clean. There are rarely any odours around the place.” A relative said, “The bedding is clean, the room’s lovely and there is no smell anywhere.” The laundry was adequately equipped for the size of the home. One resident said some of their clothes sometimes went missing but when they arrived back they were nicely laundered. Staff had written guidance on infection control procedures. There were suitable procedures for handling laundry and clinical waste. Protective clothing was available. The manager said that all staff had received infection control training in the last year. Springfield Nursing Home DS0000025577.V326208.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 and 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. There were sufficient staff and the majority had relevant training and qualifications which meant that they understood residents’ needs. Staff recruitment practices did not completely safeguard residents. EVIDENCE: Duty rosters provided an accurate record of staff on duty. All residents who completed surveys indicated that staff were always available when they were needed. All but two visitors said there were enough staff on duty. Staff themselves said there were sufficient numbers of staff to meet the needs of the current resident group but there were occasions when they were short of staff, usually when there were a high number of residents with complex needs. The manager said that extra staff could be rostered if residents’ needs and dependencies increased. Residents and visitors who completed comment cards were positive about the staff. One relative wrote, “I believe Springfield staff really do their best for all the residents.” Residents spoken with during the inspection said they got on with all the staff. One resident said, “staff are superb,” and another described them as, “grand”. Springfield Nursing Home DS0000025577.V326208.R01.S.doc Version 5.2 Page 19 There was a stable staff team and only two staff had been employed since the last inspection. Despite a previous requirement, one of the staff had commenced employment before their CRB disclosure or POVA first check had been received. Although the manager stated that the staff member was supervised at all times, this practice placed residents at risk. Evidence of other employment checks and information was on staff files. The manager checked that nursing staff held a current registration. All new staff had an initial induction to the home, which included emergency procedures. The twelve-week induction training for new care staff met the standards of the national training organisation. The manager carried out a skills scan after the induction training which highlighted whether the carer had any gaps in their knowledge and identified any need for further training. Staff had access to other training relevant to their job roles. The manager stated that all staff had been provided with update training in safe working practice topics but because the training matrix was not up to date this could not be verified. The manager submitted information confirming that over 50 of staff were qualified to NVQ level 2 or above. Springfield Nursing Home DS0000025577.V326208.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 and 38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home was managed in the best interests of the residents. The health and safety practices protected residents, staff and visitors. EVIDENCE: The registered manager, who was a first level nurse, held a relevant management qualification. She kept her clinical practice up to date by attending courses and reading current literature. The manager had also started an online course about employment issues. Residents, relatives and staff said the home was well managed and the manager approachable and supportive. Springfield Nursing Home DS0000025577.V326208.R01.S.doc Version 5.2 Page 21 There were systems in place to monitor the quality of the service. Results of a recent service user’s survey were on display in the home. There were regular residents’ meetings and staff meetings. The manager carried out various health and safety audits and audits of some systems and procedures. Areas for development identified by any of these sources were put on a list of quality initiatives for the year. For example, residents had suggested a facility for visitors to help themselves to drinks. This had been added to the list and actioned. Two residents managed their own finances. The administrator for the home acted as an appointee for one resident. There were records to show how the resident’s finances were managed. Other residents had small amounts of money in the safe. Each resident had a separate account sheet. Although amounts handed over for safekeeping were recorded, receipts were not always given to the resident or relative. There were health and safety policies and procedures in place and the manager was aware of her responsibilities to protect the health and safety of residents, staff and visitors. All staff had received training in fire safety. The fire procedure on display around the home did not reflect the procedure that staff had been taught to follow. For example, the written procedure specified that anyone hearing the fire alarm should exit the building but staff were taught a procedure of horizontal evacuation. The manager stated that the fire officer and the insurance company had seen and agreed the procedure on display. Servicing and maintenance of fire safety systems and equipment was up to date and the fire risk assessment had been agreed with the fire authority. Information provided by the registered person indicated that the servicing and maintenance of other installations and equipment in the home was up to date. Springfield Nursing Home DS0000025577.V326208.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 X X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 4 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 2 X X 3 Springfield Nursing Home DS0000025577.V326208.R01.S.doc Version 5.2 Page 23 Are there any outstanding requirements from the last inspection? YES 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 OP7 Regulation 15 Requirement All service users must have a written plan outlining how their needs in respect of health and welfare are to be met. The records of medication received must be sufficient to provide an audit trail. Medication must be given in accordance with the prescriber’s instructions. Written reasons must be given for any omissions. The registered person must ensure that all staff are aware of how to respond to any allegation of abuse in accordance with the homes policy. Timescale for action 31/03/07 2. OP9 13(2) 31/03/07 3. OP9 13(2) 31/03/07 4. OP18 13(6) 30/04/07 5. OP29 19(1)Sch A thorough recruitment process 217(2)Sch must be in place, which includes 4 obtaining a criminal record check prior to the start of employment. (Timescale of 30/09/05 not met) 31/03/07 Springfield Nursing Home DS0000025577.V326208.R01.S.doc Version 5.2 Page 24 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. Refer to Standard OP7 OP9 Good Practice Recommendations The risk assessments for falls and use of bed rails should be further developed. Dosage changes on MAR charts should be dated. Handwritten amendments to MAR charts should be signed and witnessed. Criteria for variable dose and when required medication should be clearly recorded. 3. OP30 The staff training matrix should be brought up to date and any shortfalls in safe working practice training should be addressed. Anyone handing over money or valuables for safekeeping should be given a receipt. 4. OP35 Springfield Nursing Home DS0000025577.V326208.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection East Lancashire Area Office 1st Floor, Unit 4 Petre Road Clayton Business Park Accrington BB5 5JB 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 Nursing Home DS0000025577.V326208.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. 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