Inspection on 31/05/07 for Springfields

This inspection was carried out on 31st May 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is (sorry - unknown). 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

Springfields 24/08/06

Springfields 20/01/06

Springfields 25/05/05

Springfields 17/11/04

Springfields 15/07/04

Similar services:

Claremont House

Oak Ridge

Sun Court Nursing Home

Ashville House

Bilney Hall

Hill Barn

Mabbs Hall Nursing Home

Henrietta House

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

CARE HOMES FOR OLDER PEOPLE Springfields Easthorpe Road Copford Green Colchester Essex CO6 1DH Lead Inspector Diana Green Unannounced Inspection 31st May 2007 10:00 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 Springfields DS0000017935.V342311.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. Springfields DS0000017935.V342311.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Springfields Address Easthorpe Road Copford Green Colchester Essex CO6 1DH 01206 212261 01206 213238 springfieldsmail@btconnect.com 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) Springfields Residential Homes Limited Mrs Patricia Ann Green Care Home 16 Category(ies) of Mental Disorder, excluding learning disability or registration, with number dementia - over 65 years of age (1), Old age, of places not falling within any other category (16) Springfields DS0000017935.V342311.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. Persons of either sex, aged 65 years and over, who require care by reason of old age only (not to exceed 16 persons) One service user aged 65 years and over with a mental disorder whose name was made known to the Commission on 14/03/06 The total number of service users accommodated in the home must not exceed 16 persons 24th August 2006 Date of last inspection Brief Description of the Service: Springfields is a residential home providing care for up to 16 older people. The home is located in the village of Copford, close to Marks Tey where there are shops, a train station and access to the A12.Springfields is a three storey building previously a house. It has 16 single en-suite rooms. On the ground floor are communal rooms two lounges and a dining area. There is a passenger lift to reach the upper floors. The home has extensive, landscaped gardens to the rear of the property and ample visitor parking at the front of the house. This unit does not accommodate wheelchair users. Adjacent to the home is a nursing home managed and owned by the same company. Laundry and catering facilities are shared between the two establishments. The fees range from £393.00-£554.00 weekly. Additional costs apply for chiropody, toiletries, sundries, hairdressing and newspapers. This information was provided to the CSCI on 11/07/07. Springfields DS0000017935.V342311.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced key inspection that took place on the 31/05/07. The inspection process included: discussions with the deputy manager, the proprietor, care staff, six residents, feedback from residents, relatives and health and social work professionals; a tour of the premises including a sample of residents’ rooms, bathrooms, communal areas. The kitchen and laundry are shared with the nursing home on the same site and were inspected during the inspection of Springfield Nursing Home on 9/05/07; and inspection of a sample of policies and records (including any records of notifications or complaints sent to the CSCI since the last inspection). Twenty-five standards were inspected, seven requirements and two recommendations made. The staff were welcoming and helpful throughout the inspection. What the service does well: What has improved since the last inspection? Care plans continue to develop and are discussed with the resident and/or their representative. There is evidence of risk assessments being undertaken and risks minimised. Weights are closely monitored and appropriate action taken where there is undue weight loss. All staff have received training in Protection of Vulnerable Adults, fire safety and moving and handling. The quality assurance programme has been developed to include consultation with residents, relatives and health professional. Springfields DS0000017935.V342311.R01.S.doc Version 5.2 Page 6 Arrangements had been made to provide management cover to ensure care staff were not taken away from care work. Staff files were made accessible during the 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. Springfields DS0000017935.V342311.R01.S.doc Version 5.2 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 Outcomes Statutory Requirements Identified During the Inspection Springfields DS0000017935.V342311.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good based upon sampled inspected standards 1, 3 & 4. Residents were well informed and had their needs assessed prior to moving in to the home. Changing/developing needs were assessed to ensure they were appropriately met. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home has a statement of purpose and service user guide. Copies are provided in residents’ rooms and in the reception area of the main building. However none were on display in the entrance of the home. The statement of purpose did not fully describe the service provided at Springfields and should therefore be reviewed. A copy of the last inspection report was on display. Springfields DS0000017935.V342311.R01.S.doc Version 5.2 Page 9 The deputy manager stated that potential residents were invited to view the home and could stay for afternoon tea and meet with current residents should they wish. Assessments were undertaken prior to admission and the care needs discussed with them and their representatives and a pre-admission form completed to determine their needs and dependency. This was also confirmed from the four residents’ files were sampled. All had an assessment of needs undertaken by the manager/deputy manager on admission. Residents were mainly funded privately rather than through the local authority. A full assessment was undertaken following admission to the home. Feedback obtained from residents and their representatives indicated they were confident the home would meet their needs. This home does not provide intermediate care. Springfields DS0000017935.V342311.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): Quality in this outcome area is adequate based upon sampled standards 7, 8, 9 & 10 The health and personal care needs of residents are generally well met but issues with medication place them at risk. Residents’ privacy and dignity is upheld by staff who are sensitive to their needs. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Four care plans were reviewed during the site visit. Care documentation had been reviewed since the previous inspection to include evidence that the care plan was agreed with residents and /or their representative. A resident’s profile/family tree was recorded together with their medical history and how they had spent their life. A full range of care plans for daily living needs (personal care, medication, daily life/social needs, personal care etc.) were recorded. Some care plans had too much detail and others lacked clear instruction for staff. All were regularly reviewed but this was thorough as some Springfields DS0000017935.V342311.R01.S.doc Version 5.2 Page 11 had not been updated to include changing needs; for instance one resident had a broken wrist that was in plaster but this was not referred to in the care plan to keep dry etc., although it was evident the appropriate care was being given. Daily records provided some evidence that care needs were monitored and the action taken. Risk assessments were undertaken for general risks, moving and handling, care of skin, continence, nutritional risk and falls but these were not referred to in the care plans. The records did provide evidence that residents were seen regularly by a GP who attended the home weekly and had access to regular chiropody treatment. District nurses also visited regularly to provide nursing care and community psychiatric nurses as relevant. Annual eye tests were organised and residents attended outpatients as needed. The home had a policy and procedures for administration and recording of medication. This did not contain sufficient guidance for administration of controlled drugs and referred to the UKCC rather than the Nursing & Midwifery Council (NMC) and should therefore be reviewed. There was no controlled drug register available. All care staff, only six of which had received training, gave medication. Medication was stored in a trolley secured to the wall of the office and in a cupboard on the first floor of the home. There was no drug refrigerator and medication was stored in the kitchen fridge as required. Daily monitoring and recording of the cupboard and the office was undertaken and recorded. The temperature was recorded at 26.4°Centigrade in both areas, which exceeds the recommended temperature. A review of medication storage should therefore be undertaken and this may require installation of an air conditioning unit. Medication was received in individual containers. Stock levels were in excess to those required. The medication for four residents was inspected. Each had a photograph of the resident and a medication profile on their individual record. Staff were secondary dispensing for one resident which is unsafe practice. Prescribed creams were documented on one chart for several residents and there was no record on their care plans. One entry handwritten on the MAR sheet had been incorrectly recorded as 7.5mgms rather than 75mgms. Two further errors were noted that had been incorrectly recorded on the MAR sheet. No date of opening was recorded on some individual containers and several omissions had no reason recorded. One GP letter was observed requesting a change of medication. This had not been recorded on the MAR sheet, only in the daily record. Staff were observed to knock before entering residents’ rooms and to be respectful towards them. Comments received from residents included they treat me “with kindness thoughtfulness and consideration”; “they always listen to me”; “the staff are always very helpful”; “staff are very polite and I am very contented at the home”. There were no shared rooms. All residents’ rooms were single and treatment was therefore provided in their room ensuring their privacy was respected. Springfields DS0000017935.V342311.R01.S.doc Version 5.2 Page 12 Springfields DS0000017935.V342311.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): Quality in this outcome area is good based upon sampled standards 12, 13, 14 & 15 The social activities are in need of development to meet residents’ needs and enhance their daily lives. Visitors were warmly welcomed into the home. The home provided residents with a well-balanced and nutritious diet with choices acommodated. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Information received from the provider stated that residents’ lifestyle and cultural needs are discussed on admission and this was confirmed from the records inspected. Social activities were arranged but these were limited to music to movement twice weekly, quizzes/word games and some individual activities or spending time in the garden and did not provide enough daily stimulation for residents. There was no plan of activities on display for resident’s information; therefore residents did not know what was happening day to day. During the inspection residents were socialising during the Springfields DS0000017935.V342311.R01.S.doc Version 5.2 Page 14 morning when coffee was being served but there was no organised activity session. Staff said they found it difficult to motivate residents. A singer had provided entertainment in February and May and several residents went to the local amateur theatre one afternoon. The local library visited the home monthly. An annual strawberry tea had been arranged to which relatives were invited and during recent months three events (i.e. a hat demonstration, a cheese and wine party and a flower arranging demonstration) had been arranged. Several residents and their relatives said they would like more activities and more excursions. One said the home did well in organising social events to which families were invited. The home had open visiting hours and several relatives were seen to visit throughout the inspection. Relatives spoken with said they were made to feel welcome and they could visit at anytime. Arrangements could be made to for visitors to have a meal when visiting if they wished. Staff reported that some local schools had arranged carol services to entertain residents at Christmas. Residents were observed to have choices about their daily life in the home (i.e. where they spent their day, where they ate, taking part in activities etc.). Several residents regularly went out of the home to have lunch out or spend time with their families. All residents’ rooms seen were well personalised, showing that people could bring their own possessions into the home with them, including items of furniture. Feedback from residents was generally positive about the meals served at the home although one said the meat was sometimes not tender enough. The main meal served on the day of the inspection was sampled and comprised liver and bacon, potatoes, courgettes, and mixed vegetables, followed by bread and butter pudding, or pudding and ice-cream. The meal was appetising, well cooked and tasted delicious. Residents were observed to be enjoying their meal and to be engaged in social interaction with others. Hot and cold drinks were seen being served during the day and residents said they had plenty to eat and drink. The home’s menus had recently been reviewed in consultation with residents and a copy of the day’s menu was observed displayed in the dining area. The kitchen is shared with the nursing home on the same site and was not inspected on this occasion The home’s domestic size kitchen is used to serve meals and drinks from and was clean and well organised. Springfields DS0000017935.V342311.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): Quality in this outcome area is good based upon sampled standards 16 & 18 Appropriate policies, procedures and practices were in place to promote the protection of residents from abuse. The manager actively promoted awareness of protection issues through staff training, recruitment practices and respecting individual rights. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home had a complaints procedure that was included in the statement of purpose and service user guide. Feedback received from relatives indicated they knew there was a complaints procedure and who to refer to if they had a complaint. Residents spoken to were clear that they felt able to tell someone if they had any concerns. No complaints had been received by the home or the CSCI since the previous inspection. The home had a protection of vulnerable adults policy and procedures and a whistle blowing policy. The policy needed to be updated to accurately reflect the home’s responsibility in referring to the PoVA list where relevant rather than the National Care Standards Commission (NCSC), which has been superseded by CSCI. The records confirmed that all staff had received training in protection of vulnerable adults since the previous key inspection. There had been no allegations or incidents of abuse. Springfields DS0000017935.V342311.R01.S.doc Version 5.2 Page 16 Springfields DS0000017935.V342311.R01.S.doc Version 5.2 Page 17 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): Quality in this outcome area is good based upon standards 19, 22 & 26. Springfields is clean and hygienic and aims to provide a safe, well-maintained and homely environment, but some infection control risks prevent this always being achieved. The privacy and dignity of residents was upheld by skilled and sensitive staff. This judgement has been made using available evidence including a visit to this service. EVIDENCE: A partial inspection of the premises was made that included communal areas, bathrooms, a number of residents’ rooms and the home’s domestic kitchen. Regular decoration and maintenance of the premises were undertaken and confirmed from discussion with the proprietor and records inspected. Evidence of building of checks by the fire officer and environmental health officer were seen. Feedback received from residents indicated they felt safe and secure. Springfields DS0000017935.V342311.R01.S.doc Version 5.2 Page 18 The home had a well-maintained passenger lift and stair-lift that were cleaned to a high standard. There were grab rails, and aids in bathrooms, toilets and communal rooms. The home had assisted baths and showers. Call systems were provided throughout all individual rooms and in communal rooms. Pressure relieving equipment was available and the district nursing service also provided specialist mattresses as needed. The home had its own health and safety policies and procedures and a copy of the Essex Health Protection Agency guidance was also available. The home was clean and hygienic with no malodorous smells. Positive feedback was received from residents and relatives. Typical comments made were “the home is always fresh and clean”; the home is always spotless”. Hand washing facilities (liquid soap and paper towels) were provided in the kitchen and bathrooms but not in all residents’ en-suites where personal care was provided by staff. The laundry room is shared with the nursing home on the same site and was not inspected on this occasion. Residents spoken with said the laundry service was very good. Arrangements were in place for collection of clinical waste. Springfields DS0000017935.V342311.R01.S.doc Version 5.2 Page 19 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): Quality in this outcome area adequate based upon sampled standards 27, 28, 29 & 30. Staffing levels were adequate but further training and development is needed to ensure residents’ needs are fully met. Residents were protected by robust recruitment practices. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The manager was not on duty and arrangements had been made for the deputy manager to attend the home so that staff were not taken away from their care duties. Staffing levels were observed to be appropriate to meet the needs of the thirteen people in residence. Feedback from residents indicated that there were times when they had to wait but these were infrequent. The home employed 19 care staff. Ten care staff had NVQ level 2 training. Information received indicated that a further two were undertaking NVQ level 2 or above. The percentage of staff with NVQ level 2 training was 64 and therefore more than the 50 recommended. The recruitment files of one recently employed staff member was inspected. There was evidence that the required checks had been obtained (two Springfields DS0000017935.V342311.R01.S.doc Version 5.2 Page 20 satisfactory references, CRB/POVA checks) and evidence of identification obtained before the individual commenced employment at the home. One member of staff had recently been appointed and worked a number of supernumery shifts shadowing other staff. The Skills for Care induction booklet was available and it was stated that this was being introduced. Since the previous key inspection training had been provided on Protection of Vulnerable Adults, manual handling, fire safety and care planning for two staff. The manager and two staff also attended seminars for medication handling and the manager and deputy attended a health and safety seminar. However there were no training provided on care issues i.e.conditions relevant to a care home for older people. Springfields DS0000017935.V342311.R01.S.doc Version 5.2 Page 21 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): Quality in this outcome area is good based upon sampled standards 31, 33, 35, 37 & 38 The home is well managed with good health and safety standards that promote the safety of residents and staff. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The registered manager had been employed at the home for several years and had a qualification in NVQ level 4. The manager was on leave and arrangement had been made for the deputy manager to attend to ensure care staff were not taken away from their care duties. The manager operated an open door policy and residents spoken with said they found her very available. Springfields DS0000017935.V342311.R01.S.doc Version 5.2 Page 22 The quality assurance programme is under being development. Service user questionnaires have been distributed and feedback used to improve services (e.g. menus). The home monitored all complaints and compliments. Relatives meetings are not routinely held but the proprietor is in regular attendance in the home and meets with residents and their visitors for sherry on Sunday mornings. Positive feedback was obtained form residents and relatives “ the home is well run, clean and the staff are caring. Annual quality questionnaires have also been distributed to next of kin, doctors and district nurses and there re plans for a report to be produced. Service users’ monies were not managed by the home. All residents had a relative/advocate to manage their finances on their behalf. From discussion with the deputy manager it was evident that action would be taken to protect any resident who was the subject of financial abuse. Records held on behalf of residents were kept up to date and stored safely in secure facilities in a locked office in accordance with the Data Protection Act 1998. Records viewed at this inspection included the statement of purpose, the service user guide, medication records, care plans, staff files, activities records, and fire safety records, maintenance records and accidents records. There was a health and safety policies and procedures. All staff had received updated training on fire safety and moving and handling since the previous key inspection, but care staff had not received training on food hygiene(reference standard 30). All accidents, injuries and incidents were well-recorded and appropriate action taken. However these had not been notified to the CSCI as required under regulation 37. The premises were secure and there was evidence of risk assessments of the premises having been undertaken. Evidence of a sample of records viewed showed that there were systems in place to ensure the servicing of equipment and utilities (e.g. electrical safety, gas safety, lift maintenance, servicing of fire extinguishers etc.). Springfields DS0000017935.V342311.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 Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 1 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X 3 X X X 2 STAFFING Standard No Score 27 3 28 4 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X 3 3 Springfields DS0000017935.V342311.R01.S.doc Version 5.2 Page 24 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 OP3 Regulation 15(1) Requirement Timescale for action 30/07/07 2. OP9 13(2) To ensure residents’ needs are met care plans must: 1.provide clear instruction for staff. This is a repeat requirement Timescale of 30/09/07 not met. 2. be updated to reflect changing needs. 31/07/07 To ensure the safe administration of prescribed medication: 1.the temperature of medication room storage must be monitored and action taken to ensure it remains below 25° Centigrade. This may need installation of an air conditioning unit. This is a repeat requirement Timescale of 30/09/06 not met 2.omissions must be monitored and the reason recorded on the Medicine Administration Record (MAR) sheet. 3. an accurate record must be made on the MAR sheet when a new supply of medication is started, to enable an audit trail to be made. DS0000017935.V342311.R01.S.doc Version 5.2 Springfields Page 25 4. all medicines with a limited shelf life are dated on opening. 5. medication that is no longer prescribed must not be retained as “stock”. 6. there must be no secondary dispensing. 7. a controlled drugs register must be available for recording administration of controlled drugs. 8.prescribed creams must be recorded on the individuals MAR sheet or care plan by the person administering the cream. 3. OP9 13(6) To ensure that knowledgeable and competent staff will handle and administer medicines safely, ensure that all staff authorised to administer medicines have been trained and assessed as competent to do so. Provide an active programme of social activities and outings that are displayed so that residents receive social stimulation and have an improved quality of life. To protect residents and staff from infection: 1. hand washing facilities(liquid soap & paper towels) must be provided in en-suites. 2. all care staff must receive training in food hygiene. To ensure residents are cared for by skilled and knowledgeable staff, training must be provided on conditions relevant to a care home for older people. Regulation 37 notifications must be forwarded to the CSCI in the event of any serious illness, injury or death. 30/07/07 4. OP12 16(2)(m) & 16(2) (n) 13(3) 30/07/07 5. OP26 30/07/07 6. OP30 13(6) 30/07/07 7. OP38 13(4) 30/07/07 Springfields DS0000017935.V342311.R01.S.doc Version 5.2 Page 26 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 OP1 OP1 Good Practice Recommendations The statement of purpose should be reviewed to describe the service provided in the home. The statement of purpose should be displayed in the entrance of the home. Springfields DS0000017935.V342311.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Colchester Local Office 1st Floor, Fairfax House Causton Road Colchester Essex CO1 1RJ 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 Springfields DS0000017935.V342311.R01.S.doc Version 5.2 Page 28 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!