Inspection on 07/12/07 for Springfields Residential Home

This inspection was carried out on 7th December 2007.

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.

Other inspections for this house

Springfields Residential Home 28/09/09

Springfields Residential Home 14/09/09

Springfields Residential Home 12/05/08

Springfields Residential Home 27/07/07

Springfields Residential Home 21/08/06

Springfields Residential Home 12/09/05

Springfields Residential Home 05/02/05

Similar services:

The Shelley

Springfield House

Sutton Lodge Nursing Home

St Helier`s Residential Hotel

St Joseph`s

Ridgemount

Wingham Court

Old Hastings House

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

CARE HOMES FOR OLDER PEOPLE Springfields Residential Home Hengist Road Westgate On Sea Westgate Kent CT8 8LP Lead Inspector Sue McGrath Unannounced Inspection 6th December 2007 09:00 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 Residential Home DS0000064212.V354257.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 Residential Home DS0000064212.V354257.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Springfields Residential Home Address Hengist Road Westgate On Sea Westgate Kent CT8 8LP 01843 831169 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) Macari Home’s Limited Vacant Care Home 20 Category(ies) of Mental Disorder, excluding learning disability or registration, with number dementia - over 65 years of age (2), Old age, of places not falling within any other category (18) Springfields Residential Home DS0000064212.V354257.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. To admit one (1) Service User whose date of birth is 29.06.1932. Date of last inspection 27th July 2007 Brief Description of the Service: Springfield is a detached three-storey property, which provides personal care and support for up to twenty older people. Accommodation is provided in both single and double bedrooms. There is a non-smoking lounge and a smoking lounge and two dining rooms. Communal areas are large and furnished in a domestic nature. To the front, side and rear of property there are considerable gardens. The home is located within a short walk from the sea front and local amenities. Fees are £310 - £345 per week. Springfields Residential Home DS0000064212.V354257.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was a key unannounced inspection that took place on 7th December 2007 and was conducted by Sue McGrath, Regulation Inspector for the Commission for Social Care Inspection. The key inspections for care home services are part of the new methodology for The Commission For Social Care Inspection, whereby the home provides information through a questionnaire process and discussions with residents and where possible families and other professionals connected to the home. The actual date of the site visit is unannounced. This was the second inspection this year, as the service has a current rating of poor. At the site visit, service users and staff were spoken to, records were viewed and a tour of the environment was undertaken. Some judgements have been made through observation only. The requirements made at the last inspection had not been fully complied with but it recognised that the majority had been complied with and that work was ongoing on the remaining ones. It is recognised that the manager and staff had worked diligently to improve the service and many residents confirmed the service had improved. This is now an adequate service. What the service does well: The manager and staff have worked hard since the last inspection to improve the quality of life at the home. Considerable investment has been undertaken to improve the environment and to raise the standards of health and safety. It was noticed that staff have the residents well being at heart and try to meet their needs where possible. Staff were seen to be courteous, polite and caring. Residents were well presented and looked appropriately dressed and cared for. Visitors confirm they are happy with the current level of care in the home and most of the residents spoken with are happy to be there. The meals seen on the day looked wholesome and tasty and residents confirm choices are given. A new chair lift has been installed and several bedrooms have new furniture and carpets. The home is now fully compliant with the requirements of fire legislation. Springfields Residential Home DS0000064212.V354257.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: The development of care plans needs to continue and professional guidance for specialist needs must be included. The home still has some residents who have needs the home is not registered for and not all staff have the specialist skills to manage professionally. Staff must receive this specialist training in order for needs to be met. Staff are not trained in mental health issues and some residents fall into this category. Some residents would benefit from moving to a more specialist unit who have these skills. Residents with specialist needs must be identified and reassessed by a professional. The electrical wiring must be made safe and a certificate from a qualified electrician be obtained. Springfields Residential Home DS0000064212.V354257.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. Springfields Residential Home DS0000064212.V354257.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 Springfields Residential Home DS0000064212.V354257.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 3, 4 and 5 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Prospective residents and their families are provided with the information they need to make an informed choice about moving into the home. New service users benefit from a comprehensive assessment of their needs prior to moving into the home to ensure their assessed needs can be met. Residents and relatives cannot be confident the home can meet specialist needs. EVIDENCE: The manager has updated the statement of purpose and this document is very comprehensive but very bulky. The purpose of the statement of purpose is that Springfields Residential Home DS0000064212.V354257.R01.S.doc Version 5.2 Page 10 it is a current working document that can be given to any prospective resident to help them make an informed choice about the home. It should also contain precise confirmation on what the service offers against Schedule One of the Care Homes Regulations 2001. It is therefore advised that the working document be more realistic and user friendly. The manager may wish to consider the document she has diligently prepared as part of the service user guide. The home’s assessment process continues to be robust and the home is again reminded that it must not admit residents outside its category. Any prospective resident and/or their representatives are invited to view the home and to stay for a meal if they wish. Arrangements can be made for them to stay overnight. There is a four week settling in period to ensure both the home can met their needs and that the residents is happy to remain in the home. The manager confirmed again that any new resident is given a written contract that details the service offered and the costs. Examples were seen on resident’s files. The manager confirmed all residents now have such documents. As stated in the previous report the home has a number of residents with differing needs e.g. schizophrenia, depression, visual impairment, and dementia. The home’s staff have not received specialist training to help support residents with these complex needs, and whilst caring and sensitive, have little or no understanding of ways in which they could improve the quality of support and stimulation to specific residents. Residents and relatives cannot be confident the home can met these specialist needs. It is recognised that staff have undergone a considerable amount of mandatory training since the last inspection and the manager confirmed specialist training is being planned for the coming year. Springfields Residential Home DS0000064212.V354257.R01.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Whilst residents benefited from detailed care plans some areas of the plans need to improve. Whilst residents’ specialist needs are not always met their health care needs are mainly met. Residents can be confident that they will be treated with respect. The residents’ welfare was protected by the home’s policy and procedures with regard to the handling and administration of medication Springfields Residential Home DS0000064212.V354257.R01.S.doc Version 5.2 Page 12 EVIDENCE: Several care plans were viewed and were fairly comprehensive and in areas give good guidance to staff. The manager confirmed that the home has recognised the limitations of providing residential care and is no longer taking nursing observations. Staff are not trained to do this. Discussion took place on how these care plans could be improved and the manager confirms she is planning to introduce completely new care plans. A sample was viewed and found to be comprehensive. It is the manager’s intention to phase these new plans in over the next three months to ensure each one is completed individually and comprehensively. Evidence was seen that either residents or families are involved in drawing up the care plans and in the regular reviews. Evidence was seen that the residents have the opportunity for chiropody, dental examinations and optical tests. Weights are nutritional assessments are mainly recorded. It is recognised that a considerable amount of work has been undertaken with regards to the home’s care plans and that the work is ongoing. Records were seen of GP and DN visits and the manager confirmed that a good relationship continues between the staff and the District Nurses. Outcomes of visits are also recorded. As stated earlier in the report some of the complex needs of some of the residents continue not have been fully assessed or guidance requested from other professionals and staff would benefit from some training in challenging behaviour training and in behaviour management. The manager did confirm that work was in hand to look at the needs of a resident who has special needs and to decide if his placement at Springfields is still appropriate. The staff are very supportive and caring and several residents stated they now feel happy at the home and that conditions had improved recently. All of the residents presented as being clean and tidy, clothing was clean and appropriate for the weather. Medication was again viewed and the system is still an MDS (Monitored Dose System) arranged by a local Chemist. This provides an audit trail, which indicated that the residents were given their medications in an appropriate manner. Records are complete, signed and dated. Some staff training has been undertaken including The Safe Administration of Medication, which is a Springfields Residential Home DS0000064212.V354257.R01.S.doc Version 5.2 Page 13 distance-learning course over several weeks, for two members of staff. Other staff have received a one-day training course. The storage of medication is still problematic and the advice given at the last inspection regarding the use of a dedicated medical room has not been followed. It is again strongly advised that a dedicated medical be used to house all medication including excess medication and dressing. A dedicated fridge should also be supplied. Springfields Residential Home DS0000064212.V354257.R01.S.doc Version 5.2 Page 14 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 are able to maintain contact with family and friends as they wish. Residents receive a wholesome, appealing, balanced diet in pleasing surroundings. EVIDENCE: The home has employed an activities co-ordinator who is still developing new ideas and is involving residents in deciding what activities they would like. There is a range of organised activities on offer and residents say the amount offered is about right. On the day of the inspection the home was decorated for Christmas and residents were looking forward to their Christmas Party. The home has joined NAPA, which is the National Association for Providers of Activities for Older People and provides training and advises on activities for older people. Springfields Residential Home DS0000064212.V354257.R01.S.doc Version 5.2 Page 15 Relatives met with during the inspection confirmed they could visit at any time and were always made very welcomed. One visitor confirmed the home kept in regular contact with them and they still felt involved with the care of their loved one, which was important to them. One visitor stated he often stayed and had lunch with his wife who was a resident in the home and this was very much appreciated. All of the comments from visitors were positive. Discussion with staff, residents and direct observations confirmed that, where possible, residents are encouraged to continue to make choices over daily living arrangements and routines are flexible and resident led. One resident confirms she likes living at the home’s because her room is her own personal space and she can come and go to it as she chooses. She chooses to keep her room locked at all times. All residents now have lockable rooms and a lockable drawer within their rooms. Bedtimes are flexible to met the residents wishes, as are rising times. Staff have recently undertaken training on the Mental Capacity Act, so have a good understanding of its implications when caring for residents. The kitchen was viewed again and it was noted that improvement have been made. The sink has been attached back to the wall and the missing drawer fronts and cupboard doors have been replaced. A new stainless steel worktop, with shelving, has been fitted and the kitchen looked generally cleaner. A new gas shut off valve has been fitted along with extra ventilation and new cooker rings. There is evidence that fresh fruit and vegetable are in regular use and the cupboards are well stocked. The home is still trying to find extra cooks to ensure all shifts are covered and were hoping to be interviewing in the very near future. Springfields Residential Home DS0000064212.V354257.R01.S.doc Version 5.2 Page 16 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 17 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents are protected by a robust complaints system and service users and relatives feel their views are listened to and acted upon. Whilst service users are protected from the risk of abuse the home’s adult protection policy further staff training introduced. EVIDENCE: The manager confirmed the new complaints procedure was in place. The manager has not received any complaints since the last inspection and the Commission has received none. The manager stated she encourages both staff and relatives to discuss any issues they may have with her as soon as possible. At the last inspection they were concerns over the level of staff without appropriate recruitment checks being employed, including some without CRB checks. This situation has been remedied and all staff currently working at the home have the documentation required by the Care Home’s Regulations 2001. The manager is the lead practitioner in the protection of vulnerable adults and is currently implementing training for all. Four staff have already completed Springfields Residential Home DS0000064212.V354257.R01.S.doc Version 5.2 Page 17 the course. This is a mandatory training and all staff will need to be trained as soon as possible. Policies and procedures within the home continue to be reviewed and assistance is being sought from an outside company. Springfields Residential Home DS0000064212.V354257.R01.S.doc Version 5.2 Page 18 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, 23, 24, 25 and 26 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents benefit from the environmental improvements made in recent months. The levels of cleanliness and infection control procedures have improved and now ensure residents live in a safe, hygienic environment. EVIDENCE: At the last inspection it was recorded that some areas of the home were in a very poor condition. It is now recognised that a considerable amount of work had been undertaken to improve the internal environment. New bedroom carpets and furniture have been fitted in many of the bedrooms, which has made them safer and more comfortable. New beds have also been provided, Springfields Residential Home DS0000064212.V354257.R01.S.doc Version 5.2 Page 19 some with specialist mattresses. The towels have also been replaced and bedding is under an ongoing replacement programme. Following an environmental assessment the handyman was fitting handrails in the corridors and evidence was seen that three new ramps have been ordered for all external doors. A new stair lift has been installed and new windows have been fitted to the lounge and dining room. The furniture in the dining room has been replaced. All of the requirements made by The Fire Officer following the last inspection have been complied with and evidence was seen that the Fire and Rescue Service now consider the home fully compliant. A professional consultant has completed a Fire Risk Assessment and staff have received training in fire awareness. The room highlighted as being damp in the last inspection has been treated and redecorated, with the resident being given the choice of colour schemes. There is now an ongoing maintenance plan in place. The outside guttering has been cleared, although the outside remains in need of decoration. The provider is aware of the problem and hopes to decorate the outside by the summer. The home was generally cleaner that at the last inspection. The bath hoist noted at the last as needing repair had been dealt with and was now operational. He hoists noted as being rusty at the last inspection remains the same, but it is recognised that a considerable amount of work has been undertaken. The home was visited by the Infection Control Nurse following the last inspection and notice has been taken of the advice given and there have been some improvements in infection control. The home is still advised to consider the purchase of a sluicing machine. At the last inspection it was noted that some of the radiator guards were of a poor quality, some new ones have been fitted. All of the windows now have appropriate window restrainers fitted, as recommend in the last report. The call system is currently being updated and some new call points and central monitoring stations have been fitted. The provider has received quoted for the hard wiring as required from the last inspection. It is considered essential this work be completed. Springfields Residential Home DS0000064212.V354257.R01.S.doc Version 5.2 Page 20 The home is to be congratulated for achieving the improvements since the last inspection and this is recognised in the overall rating. The manager is aware that there is still some work to be done but was confident that given time the work will be done. Springfields Residential Home DS0000064212.V354257.R01.S.doc Version 5.2 Page 21 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. Staffing arrangements provide for a suitable mixture of care staff, domestic, catering, and maintenance staff. The safety and well being of residents has been improved because of the home’s improved recruitment procedures. EVIDENCE: An immediate requirement was made at the last inspection that two night staff must be employed on all night shifts. This has been complied with. There have been some recent changes to the staffing group and several new staff have been appointed. The manager is currently trying to recruit an extra cook and domestic staff. The reliance on agency staff has been reduced. Regular staff meetings are now arranged and the staff spoken with confirmed they feel well supported now. Staff morale has improved since the last inspection. Springfields Residential Home DS0000064212.V354257.R01.S.doc Version 5.2 Page 22 Staff training has been a priority at the home and has improved since the last inspection. There are still some gaps in the mandatory training, but it is recognised that considerable investment has been made in staff training. The manager was hopeful that specialist training could start in the coming year. More staff are now working towards their National Vocational Award in care. The home has over 50 of staff trained to NVQ level two or above. All new staff are recruited in accordance with the requirements from the Care Home Regulations 2001 and this was evidenced in the staff files. Files are now stored in a locked file in the managers office. The home is currently using an induction programme that is in line with ‘Skills for Care’. A new comprehensive staff handbook has recently been produced and it is expected that all staff will be given a copy within the next week. Springfields Residential Home DS0000064212.V354257.R01.S.doc Version 5.2 Page 23 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, 32, 33, 35, 36, and 38 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The residents benefit from living in a home where the manager is competent, enthusiastic and experienced with the care of older people. Residents do not benefit from having all staff receiving regular supervision. The health, safety and welfare of residents and staff are now promoted and respected. Springfields Residential Home DS0000064212.V354257.R01.S.doc Version 5.2 Page 24 EVIDENCE: The manager, and her team, have worked extremely hard to improve the home and the lives of the residents. Major improvements have been seen. She has worked diligently with some very challenging problems and has developed as a manager. Although at the previous inspection it was hoped that registration with the Commission would be a priority, this has still not happened. This will affect the score awarded for Standard 31. The provider now appears to be more supportive and has invested in the environment and staff training. Staff also confirm the atmosphere and morale has improved. There are clear lines of responsibility in the home but the manager does lack administrative support. This takes up a lot of her time that could be better spent working on more important management issues. The provider is strongly advised to consider employing an administrator to assist the manager. The senior care team in the home also needs to be strengthened to enable the manager to concentrate more on management issues. Quality Assurance was again discussed with the manager who has prepared basic questionnaires, but has not had the time to implement them. Meetings are arranged with both residents and families, which is a positive move. This was confirmed by visiting relatives. Staff meetings are also happening. Residents’ personal monies were audited at this inspection and were found to balance with basic records kept. Issues raised at the last inspection regarding fire safety and the stair lift have been resolved and evidence was seen from The Fire Officer that the home is now compliant with legislation. A new stair lift has been installed. Residents are no longer at risk from these issues. Supervision continues to be haphazard, but this is mainly due to the pressure of work on the manager, not on a lack of willingness to comply. The manager is confident that she does cover this standard in practise, but does not record sufficient evidence to confirm this. Staff say they feel well supported and can discuss any issue with the manger on a daily basis. Handover times at each shift have been introduced which has helped with communication. The home now has a staff handbook, which looks comprehensive. This is a new development and when checked will be given to all staff. Issues regarding health and safety raised at the last inspection have been mainly dealt with apart from the hard wiring certificate. The provider has received estimates for the required work and will be required to have the work completed. Springfields Residential Home DS0000064212.V354257.R01.S.doc Version 5.2 Page 25 Fire drills are now happening and the Fire Risk Assessment is current and staff have received training in fire awareness. The manager has confirmed with specialists that the home does not require a legionellas certificate, as is does not have any water tanks and water comes direct from the mains. Water temperatures are recoded to ensure they do not constitute a risk to residents. The home’s accident book was viewed and evidence was seen that the manager monitors accidents and that appropriate action is taken to prevent further accidents where possible. Springfields Residential Home DS0000064212.V354257.R01.S.doc Version 5.2 Page 26 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 2 2 2 1 3 X 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 2 17 X 18 2 2 X X X 2 2 2 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 2 1 X 3 2 X 2 Springfields Residential Home DS0000064212.V354257.R01.S.doc Version 5.2 Page 27 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 Home’s Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP27 Regulation 18 Requirement The registered person shall having regard to the size of the home, the statement of purpose and the number and needs of the service users ensure that at all times suitably qualified and experienced persons are working at the care home in such numbers as are appropriate for health and welfare of service users. This refers to working with service users with specialist needs such as mental health issues and dementia. Previous compliance dates of 15/11/05, 01/10/06 and 31/03/07 and 31/08/07 NOT Fully MET 2. OP4 12,14 The registered person must be able to demonstrate the home’s capacity to meet the assessed needs (including specialist needs) of individuals admitted to the home. A firm diagnosis must be made for those service users DS0000064212.V354257.R01.S.doc Timescale for action 31/01/08 31/01/08 Springfields Residential Home Version 5.2 Page 28 demonstrating cognitive inability and an application made to vary the home’s registration in regard of this. Compliance date of 21/10/06 and 31/03/07 and 31/08/07 NOT FULLY MET 3. OP22 23 Facilities, including communication aids (e.g. a loop system), and signs are provided to assist the needs of all service users, taking account of the needs, for example, of those with hearing impairment, visual impairment, dual sensory impairments, learning disabilities or dementia or other cognitive impairment, where necessary. Previous compliance dates of 31/03/07 NOT FULLY MET 31/01/08 4. OP33 10, 12, 15,24 The provider must develop and implement an annual quality monitoring system, producing a report, a copy must be sent to the Commission. Previous compliance date of 30/11/06 and 31/03/07 NOT MET 31/03/08 5. OP36 18 The provider must ensure that all staff must have regular formal supervision Previous compliance date of 01/10/06 and 31/03/07 NOT FULLY MET 31/01/08 Springfields Residential Home DS0000064212.V354257.R01.S.doc Version 5.2 Page 29 6. OP38 16 The provider must ensure that the electrical system is safe and maintained. A dedicated medical room must be provided to ensure the safe storage of medication. This must include a dedicated medication fridge. 29/02/08 7 OP9 13 (2) 20/02/08 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 Refer to Standard OP27 Good Practice Recommendations The provider is strongly advised to employed administrative staff. Springfields Residential Home DS0000064212.V354257.R01.S.doc Version 5.2 Page 30 Commission for Social Care Inspection Maidstone Local Office The Oast Hermitage Court Hermitage Lane Maidstone ME16 9NT 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 Residential Home DS0000064212.V354257.R01.S.doc Version 5.2 Page 31 - 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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