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Inspection on 27/07/05 for Springfield Nursing & Residential Home

Also see our care home review for Springfield Nursing & Residential Home for more information

This inspection was carried out on 27th July 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. 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.

What follows are excerpts from this inspection report. For more information read the full report on the next tab.

What the care home does well

Residents and staff got on well together, which led to a friendly atmosphere in the home. Residents and visitors commented on how caring the staff were. One resident said of the staff, "they`re very attentive and look after me well." Another said "the staff are excellent, they`ll do anything for you." Residents and their relatives were pleased with the open visiting arrangements. One visitor said the staff were very friendly and they were able to talk to them if they had any problems about the home. Residents were satisfied with their rooms. One said, "I`m happy with my room, what more can I want." Bedrooms were nicely decorated and furnished and many of the residents had brought in ornaments, pictures and small items of furniture to make their rooms homely. The manager made sure that residents were assessed before they came to live at the home. This helped to make sure that no one was admitted unless their needs were understood and the staff would be able to care for them.

What has improved since the last inspection?

Even though some of the standards remain unmet, there had been slight improvements in many areas since the last inspection. There had been some improvements in the way that care plans were written. This meant that staff had clearer instructions to let them know what help the resident needed. Residents or their relatives were asked to check that the plans were right. The way that residents` medication was stored and handled had improved since the last inspection. The manager had introduced a system to ensure that all staff had meetings with their line manager. This gave them opportunities to talk about their work with residents and to look at any areas where they might need extra guidance or training.

CARE HOMES FOR OLDER PEOPLE Springfield Nursing & Residential Home Preston New Road Blackburn Lancashire BB2 6PS Lead Inspector Jane Craig Unannounced 26 & 27 July 2005 08:30 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 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 & Residential Home F58 F07 S22482 Springfield Nursing Residential Home V233294 260705 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Springfield Nursing & Residential Home Address Preston New Road Blackburn Lancashire BB2 6PS 01254 263668 01254 690461 Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Four Seasons Healthcare Limited Mrs Helen Sellars Care Home with Nursing 70 Category(ies) of Physical Disability (PD) - 26 registration, with number Dementia (DE) - 2 of places Dementia Over 65 Years of Age (DE(E)) - 20 Terminally Ill (TI) - 5 Mental Disorder, excluding learning disability or dementia - over 65 years of age (MD(E)) - 20 Old Age, not falling within any other category (OP) - 26 Springfield Nursing & Residential Home F58 F07 S22482 Springfield Nursing Residential Home V233294 260705 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: 1) Within the overall total of 70, a maximum of 26 service users requiring personal care who fall into the category of OP. 2) Within the overall total of 70, a maximum of 20 service users requiring personal care who fall into the categories of MD(E) or DE (E). 3) Within the overall total of 70, a maximum of 25 service users requiring nursing care who fall into the category of PD(E). 4) Within the overall total of 70, a maximum of 5 service users requiring nursing care who fall into the category of TI. 5) Within the overall total of 70, 2 named service users requiring personal care who falls into the category of DE. 6) When either named person (see condition 5 above) no longer falls within the category of DE an application for variation to the registration must be made. 7) Staffing for the service users requiring nursing care will be in accordance with the Notice issued dated 31 August 2001. Date of last inspection 19 September 2004 Brief Description of the Service: Springfield Nursing and Residential Home is owned by Four Seasons Health Care (England) Limited. The home is registered to provide care to up to 70 adults who require help with personal care or who have nursing needs. Springfield is a detached building standing in its own grounds. Accomodation is provided on four floors. Each floor is regarded as a separate unit and accommodates a different resident group. At the time of the inspection Level 4 was closed following a full refurbishment. Each floor has its own communal facilities, including lounges, dining areas, snack kitchens and bathrooms. Sixteen bedrooms have en-suite facilities, the remainder have hand-wash basins installed. The home stands in its own grounds with ample parking facilities. It is situated in a residential area close to local amenities. The main road to Blackburn town centre runs outside the driveway and bus stops are a short walk away. Springfield Nursing & Residential Home F58 F07 S22482 Springfield Nursing Residential Home V233294 260705 Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place over two full days. There had been one additional visit since the last statutory inspection in October 2004. The additional visit was in response to a complaint about the home and took place on 25th May 2005. The complaint was partially upheld and the registered person was required to ensure that the areas of concern were addressed. These issues were monitored during this inspection. At the time of the inspection there was a total of 50 residents accommodated on Levels 1, 2 and 3. The inspector met with residents from each level and spent time observing interactions between staff and residents. Wherever possible residents were asked about their views and experiences of living in the home and several of their comments are quoted in this report. Discussions were held with the registered manager, 6 members of staff and three visitors. A tour of the premises took place and a number of documents and records were viewed. Detailed notes were taken, which have been retained as evidence of the inspection findings. What the service does well: Residents and staff got on well together, which led to a friendly atmosphere in the home. Residents and visitors commented on how caring the staff were. One resident said of the staff, “they’re very attentive and look after me well.” Another said “the staff are excellent, they’ll do anything for you.” Residents and their relatives were pleased with the open visiting arrangements. One visitor said the staff were very friendly and they were able to talk to them if they had any problems about the home. Residents were satisfied with their rooms. One said, “I’m happy with my room, what more can I want.” Bedrooms were nicely decorated and furnished and many of the residents had brought in ornaments, pictures and small items of furniture to make their rooms homely. The manager made sure that residents were assessed before they came to live at the home. This helped to make sure that no one was admitted unless their needs were understood and the staff would be able to care for them. Springfield Nursing & Residential Home F58 F07 S22482 Springfield Nursing Residential Home V233294 260705 Stage 4.doc Version 1.30 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. Springfield Nursing & Residential Home F58 F07 S22482 Springfield Nursing Residential Home V233294 260705 Stage 4.doc Version 1.30 Page 7 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 Standards Statutory Requirements Identified During the Inspection Springfield Nursing & Residential Home F58 F07 S22482 Springfield Nursing Residential Home V233294 260705 Stage 4.doc Version 1.30 Page 8 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 1, 2 and 3. The written information available to prospective residents was not specific enough to enable them to make a judgement as to whether Springfield was suitable to meet their needs. Residents were not made aware of the terms and conditions of their residency. The pre-admission assessment processes meant that residents’ needs were identified before they were offered a place at the home. EVIDENCE: The statement of purpose provided some relevant information for prospective service users who may be entering a care home belonging to Four Seasons. However, none of the information was specific to Springfield. There had been minor changes to the service users guide since the previous inspection but it still did not contain all of the information recommended within this standard. One newly admitted resident had received the service users guide and said that the information was useful but not detailed enough and they had requested a copy of the statement of purpose. Another resident said they couldn’t remember receiving any written information about the home. Springfield Nursing & Residential Home F58 F07 S22482 Springfield Nursing Residential Home V233294 260705 Stage 4.doc Version 1.30 Page 9 None of the residents accommodated at Springfield had either a contract or terms and conditions of residency. Requirements to address this situation were made following the previous two inspections. The majority of residents were assessed by health or social care professionals prior to their referral to Springfield. Senior staff from the home had also assessed the most recently admitted residents. A new assessment tool, which assisted staff to clearly identify the resident’s needs, had been implemented. Residents received written confirmation that their needs could be met at the home. Springfield Nursing & Residential Home F58 F07 S22482 Springfield Nursing Residential Home V233294 260705 Stage 4.doc Version 1.30 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 7,8,9 and 11 Further improvements were needed to ensure that all health risks are identified and plans provide up to date information about how residents’ needs are to be met. Medication practices safeguarded residents. EVIDENCE: The care files for 8 residents were inspected and several others were viewed in less detail. There had been improvements in the level of detail recorded on care plans and most provided staff with clear information about what assistance should be offered to meet residents’ personal care needs. Other plans did not address identified needs. For example, the daily notes for one resident stated that they were unsettled and aggressive at times but there was no care plan for staff to follow. Not all residents had plans to address their psychological or social care needs. Plans were evaluated every month. Some plans had been updated to reflect changes in the resident’s needs but others contained directions for staff that were no longer relevant. There were improvements in the level of involvement that residents and/or their relatives had in the care planning process and several plans contained signed agreement to the plans. Springfield Nursing & Residential Home F58 F07 S22482 Springfield Nursing Residential Home V233294 260705 Stage 4.doc Version 1.30 Page 11 A recommendation made following the last inspection to seek and record residents’ wishes regarding terminal illness and after death had been partially met. This information was included in the care plans for residents on Level 2. Most care files contained a range of assessments to identify risks to residents’ health. These included; moving and handling, developing pressure sores, nutritional risks and continence. Assessments were reviewed every month but one resident’s moving and handling plan was inaccurate and, if followed, could result in harm to the resident. Risk of falls was highlighted on several plans but there were no assessments. In most cases risk management strategies were not adequate. Other aspects of residents’ physical health were also monitored and addressed but not all care plans showed evidence of this, for example, one resident who had gynaecological problems. Residents had access to specialist services where necessary. Those residents spoken with said they were well looked after and had the care and attention they needed. Visitors spoken with said the care was very good. Medication practices had improved and medicines were handled according to Royal Pharmaceutical Society of Great Britain guidelines. However, there were some concerns that one resident was administering their own medication without having been assessed. Other recommendations were made for further improvement to practice. Springfield Nursing & Residential Home F58 F07 S22482 Springfield Nursing Residential Home V233294 260705 Stage 4.doc Version 1.30 Page 12 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12 and 13 Insufficient time allocated to activities and the lack of a varied programme meant that some residents’ social and recreational needs were not met. Residents and their relatives were satisfied with the visiting arrangements for the home. EVIDENCE: Residents’ comments about the home were, in the main, positive. One said, “it’s like home from home.” Another said, “I like it here, the staff are very attentive and look after me.” Some residents said that they kept themselves occupied during the day by reading, watching TV or listening to music but all the residents spoken with said that there was a shortage of suitable activities organised in the home. One resident said that he enjoyed a game of draughts the previous day with one of the activity co-ordinators but that had never happened before. Another resident said “the biggest problem here is boredom.” A recently admitted resident said that so far she had been invited to bingo and a sing-a-long but she didn’t like either. Two visitors said that they were concerned about the lack of stimulation for residents. There was a limited activity programme organised by 2 part time co-ordinators. However, the amount of time allocated to activities was insufficient to cater for the number of residents over the three floors and to meet their various needs. Springfield Nursing & Residential Home F58 F07 S22482 Springfield Nursing Residential Home V233294 260705 Stage 4.doc Version 1.30 Page 13 Residents and visitors said they were satisfied with the open visiting arrangements. Several residents went out regularly with their families but there were few opportunities for others to go out. There were some links with local churches. Springfield Nursing & Residential Home F58 F07 S22482 Springfield Nursing Residential Home V233294 260705 Stage 4.doc Version 1.30 Page 14 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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 16 and 18 Residents and their relatives were satisfied that staff would deal with their concerns but a lack of awareness of the complaints procedure may result in them being unable to take the issues further. Staff had a clear understanding of adult protection issues, which provided safeguards for residents. EVIDENCE: An appropriate complaints procedure was available in the service users guide. Residents spoken with named staff they would talk to if they had any concerns but only one of them was aware of the complaints procedure. A visitor to the home said that they had not been made aware of how to make a complaint, despite having talked to staff on a number of occasions about a concern they had. The same visitor said the staff were always helpful when approached and they never felt “stonewalled.” Staff received training on how to receive complaints and the policy clearly stated their role. Staff said they would always report any complaints to the person in charge. One complaint was made directly to the Commission since the previous inspection. The complaint was partially upheld. Staff received training on the protection of vulnerable adults during their induction and were provided with updates. Appropriate guidelines and procedures for recognising and reporting abuse were available. Most of the staff spoken with showed a clear understanding of the issues. However, one member of staff was still unclear about their role in reporting any allegation of abuse. A recommendation was made that adult protection issues were recapped during staff supervision. Springfield Nursing & Residential Home F58 F07 S22482 Springfield Nursing Residential Home V233294 260705 Stage 4.doc Version 1.30 Page 15 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 19, 24, 25 and 26 The standard of the environment had deteriorated and the lack of repairs in some areas may place residents and staff at risk of harm. Residents were satisfied with their bedrooms and the standard of cleanliness in the home. EVIDENCE: The home had been without regular maintenance staff for several months. Consequently there were some repairs outstanding and some areas that required redecoration. These were discussed with the manager. An immediate requirement was issued to conduct urgent repairs to the ceiling in the shower room on Level 2. The room must not be used until it is made safe. Radiators on levels 2 and 3 were not fitted with guards. The risk assessments to support this decision did not take into account the needs of the residents currently accommodated and must be updated. Bedrooms were decorated and furnished to a good standard. Some were personalised to a high degree. One resident said “I’m happy with my room, Springfield Nursing & Residential Home F58 F07 S22482 Springfield Nursing Residential Home V233294 260705 Stage 4.doc Version 1.30 Page 16 what more could I want?” Another said, “my room’s alright, I’m building it up to make it more homely.” Only one resident said they did not like their room, which was in part due to the view from the window of the waste bins. The manager said this would be addressed. Not all bedroom doors had locks. One recently admitted resident said they had asked for a lock to be fitted but so far it had not been put on. There was no evidence that other residents had been asked about their preferences. At the time of the inspection there was a temporary shortage of domestic staff and some areas of the home were a bit untidy and dusty. The corridors on Level 2 were slightly malodorous. Residents said that their rooms were usually cleaned every day and there were no complaints about the level of cleanliness throughout the home. Infection control was covered during induction training. The laundry was adequately equipped and the hours allocated to laundry staff exceeded those agreed by the previous registering authority. However, one visitor and two residents had concerns about the laundry. Clothes going missing or being spoilt were the chief concerns. One resident said, “it’s a bit hit and miss.” A visitor said that things had improved slightly but were still not right. Springfield Nursing & Residential Home F58 F07 S22482 Springfield Nursing Residential Home V233294 260705 Stage 4.doc Version 1.30 Page 17 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27, 29 and 30 There were not always sufficient numbers of staff in one area of the home to ensure that daily routines met the needs and wishes of the residents. Recruitment practices provided safeguards for residents. Training for new employees ensured that they understood the needs of the residents and were competent to do their jobs. EVIDENCE: Examination of duty rosters showed that the staffing numbers of nursing and care staff on each level of the home met the minimum agreed by the previous registration authority. Residents’ views about the staffing numbers on level 2 were mixed. One resident said he thought there were enough staff and whatever he needed they had always provided. Another said “they are hard pushed for staff sometimes” and a third said he would like staff to have more time to talk. Staff on Level 2 said that there were not always enough staff in the mornings to meet the needs of the residents. This had resulted in the night staff being asked to get some residents up before the day staff came on duty. Whilst staff said that residents would not be made to get up if they did not want to, there were concerns that routines may be centred around the needs of staff rather than residents. Staffing levels must be reviewed to ensure that the needs and preferences of residents are met. Residents were very complimentary about the staff. One resident said “the staff are excellent”. Another said “they always knock on to say good morning Springfield Nursing & Residential Home F58 F07 S22482 Springfield Nursing Residential Home V233294 260705 Stage 4.doc Version 1.30 Page 18 or good night, it’s lovely.” One remarked that it was nice to have the same staff and said “you get to know them all.” The files of three new employees demonstrated that all pre-employment checks were obtained before new staff commenced work. However, not all of the required information and documents were retained on staff files. There were systems in place to verify the registration status of trained nurses. There were two induction-training programmes in use but only one met the national training organisation standards. Neither programme included a written assessment of competencies although staff said that newly employed carers worked alongside their mentor until they were deemed competent to work on their own. The foundation-training programme had not been implemented at the time of the inspection. There were opportunities for other training, relevant to the resident group. Individual training records were kept but there were no systems in place to highlight when update training was due for individual members of staff. Springfield Nursing & Residential Home F58 F07 S22482 Springfield Nursing Residential Home V233294 260705 Stage 4.doc Version 1.30 Page 19 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 36 and 38 Progress had been made towards ensuring staff were appropriately supervised to make certain that they were aware of their roles and responsibilities. Health and safety policies and practices safeguarded residents. EVIDENCE: At the time of the inspection the programme of formal staff supervision was new and only half of the staff had been involved. Records showed that the sessions covered appropriate topics. Informal supervision took place on a dayto-day basis where senior staff worked alongside junior staff. The manager confirmed that all staff had received updated training in safe working practice topics. However, an inappropriate moving and handling technique was observed during the course of the inspection. Springfield Nursing & Residential Home F58 F07 S22482 Springfield Nursing Residential Home V233294 260705 Stage 4.doc Version 1.30 Page 20 Maintenance and servicing of electrical, gas and fire appliances and equipment was up to date. Other maintenance records were not accessible and will be looked at during the next inspection. Some environmental risk assessments were in place. There were COSHH assessments and data sheets available for cleaning products. The manager confirmed that there was a qualified first aider on duty at all times. The method of recording accidents did not comply with Data Protection legislation. Springfield Nursing & Residential Home F58 F07 S22482 Springfield Nursing Residential Home V233294 260705 Stage 4.doc Version 1.30 Page 21 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score 2 1 3 x x x HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 2 10 x 11 2 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 x 15 x COMPLAINTS AND PROTECTION 2 x x x x 2 2 2 STAFFING Standard No Score 27 3 28 x 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 2 x 2 x x x x x 2 x 2 Springfield Nursing & Residential Home F58 F07 S22482 Springfield Nursing Residential Home V233294 260705 Stage 4.doc Version 1.30 Page 22 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 2 Regulation 5(1)(b-c) Schedule 4 (8) Requirement Timescale for action 31/10/05 2. 3. 7 7&8 4. 9 5. 6. 9 12 7. 8. 19 25 All residents must be provided with a contract or statement of terms and conditions. (Timescale of 31/05/04 not met) 14(2)(b) Care plans must be revised in accordance with any changes. (Timescale of 31/05/04 not met) 13(4)(b-c) The registered person must ensure that any potential risks are fully assessed and strategies to control the risk drawn up. This would include the risk of falls. 13(2) Risk assessments must be completed before selfmedication. They should be reviewed on a regular basis. (Timescale of 31/05/04 not met) 13(2) Records must be kept of all creams and other topical medicines administered. 16(2)(mFollowing consultation with n) residents the current programme of activities must be revised. There must be sufficient appropriate activities to meet the needs of the residents. 23(2)(b&d All parts of the home must be ) kept in a good state of repair and reasonably decorated. 13(4)(a&c The registered person must ) conduct risk assessments in F58 F07 S22482 Springfield Nursing Residential Home V233294 260705 Stage 4.doc 31/10/05 31/10/05 31/07/05 31/07/05 31/10/05 27/07/05 and ongoing 31/12/05 Page 23 Springfield Nursing & Residential Home Version 1.30 9. 10. 26 27 16(2)(k) 18(1)(a) 11. 29 19(4) Schedule 2 13(5) 12. 38 respect of the unguarded radiators in the home. Guards must be fitted where a risk is identified. The home must be kept free from offensive odours. The registered person must review the staffing numbers on Level 2 to ensure that they are sufficient to meet the needs of the residents. Documents specified in Schedule 2 of the Care Homes Regulations must be obtained and retained on staff files. (Timescale of 31/12/04 not met) The registered person must make arrangements for the safe moving and handling of all residents. 31/07/05 31/07/05 31/10/05 31/07/05 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. 3. 4. 5. 6. 7. 8. Refer to Standard 1 7&8 9 11 16 19 24 30 Good Practice Recommendations The service users guide should include all the information specified in this standard. Care plans should contain interventions to meet the residents social and psychological needs. All handwritten amendments on MAR sheets should be signed and witnessed. A record should be kept of resident wishes regarding terminal illness and after death. The complaints procedure should be made more accessible to residents and visitors. The registered manager should ensure that the contents of the POVA training is understood by all staff. Residents wishes regarding locks on their bedroom doors should be sought and actioned. The programme of foundation training should be implemented. A training matrix should be developed in order to identify F58 F07 S22482 Springfield Nursing Residential Home V233294 260705 Stage 4.doc Version 1.30 Page 24 Springfield Nursing & Residential Home 9. 10. 36 38 when update training is required for individual members of staff. All staff should receive formal supervision at least six times per year. Accident records should comply with data protection legislation. Springfield Nursing & Residential Home F58 F07 S22482 Springfield Nursing Residential Home V233294 260705 Stage 4.doc Version 1.30 Page 25 Commission for Social Care Inspection 1st Floor, Unit 4 Petre Road, Clayton Business Park, Clayton-le-Moors, Accrington, Lancashire, BB5 5JB National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Springfield Nursing & Residential Home F58 F07 S22482 Springfield Nursing Residential Home V233294 260705 Stage 4.doc Version 1.30 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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