Inspection on 12/09/06 for Springvale Court

This inspection was carried out on 12th September 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Springvale Court 17/10/07

Springvale Court 11/10/05

Springvale Court 07/04/05

Springvale Court 13/12/04

Springvale Court 04/06/04

Springvale Court 02/03/04

Similar services:

Turret Villa Retirement Home

Moor House

Mendip House

Beaconsfield Court Care Home

Little Sisters Of The Poor

Manor House

Middleton Hall Ltd

Middlesbrough Intermediate Care Centre

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

CARE HOMES FOR OLDER PEOPLE Springvale Court Springvale Road Wrekenton Gateshead DH9 7AD Lead Inspector Mr Lee Bennett Key Unannounced Inspection 09:30 12 and 20 September 2006 th th 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 Springvale Court DS0000054914.V302931.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. Springvale Court DS0000054914.V302931.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Springvale Court Address Springvale Road Wrekenton Gateshead DH9 7AD 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) 0191 482 4573 0191 487 2927 Barchester Healthcare Mrs. Anne Burns Care Home 40 Category(ies) of Dementia - over 65 years of age (13), Mental registration, with number Disorder, excluding learning disability or of places dementia - over 65 years of age (1), Old age, not falling within any other category (29), Physical disability over 65 years of age (3), Sensory Impairment over 65 years of age (5) Springvale Court DS0000054914.V302931.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: None Date of last inspection 11th October 2005 Brief Description of the Service: Springvale Court is care home in which personal care can be provided for up to 40 older people, some of whom may have dementia related needs. Nursing care is not provided, but can be arranged with the District Nursing Service where necessary. It is a two storey, purpose built home. Level access is provided to the home and a lift provides access between the two floors. There is a garden area at the rear of the home, which includes a paved seating area. The home located on the southern outskirts of Gateshead and is situated near to a range of local facilities, including a doctors surgery, a supermarket, shops, pubs and places of worship. It is also located close to local public transport links. Fee rates range between £ 364 and £370. Self-funding service users are chanrged £442. Service users with their own ‘front door’ are no longer charged extra fees for this facility. Springvale Court DS0000054914.V302931.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was carried out over two days in September 2006 and was a scheduled unannounced inspection. The inspection included a separate look at the pre-inspection questionnaire (completed by the manager), and comment cards received from service users and their relatives. The care experienced by a sample of service users was ‘case tracked’, (a method used by inspectors to look at the service provided at the home, which specifically focuses on individual service users experience of all aspects of their care from admission). This is where their views are sought, their care needs examined, and the care they receive is inspected. A tour of the building also took place, and a sample of staffing and service users’ records was inspected. Service users, staff, the registered manager and visitors were spoken with, and both the inspectors took a meal with service users on the ground floor. The judgements made are based on the evidence available to the inspector during the inspection, the pre-inspection questionnaire supplied by the registered manager and the comment cards completed by service users and their relatives What the service does well: Staff were observed to have a good rapport with service users, and to make visitors welcome. Service users and their relatives have the opportunity to look around the home and are offered information before they decide to move in. Service users and their relatives made many positive comments about the service they receive. These included: • • • • • • • • • I’m treated well, the staff are very good. I’m very happy here. I always have a choice of meal. My family are very happy about me staying here and so am I. The beds are always clean and tidy and fresh linen is available. The manager and senior staff have a good listening ear when I’m concerned or upset. The carers are always cheerful and helpful. Visitors are made welcome and tea is also available. There is a lovely atmosphere around, the rooms are very pleasant and clean. My family and I looked at quite a few other homes, but found Springvale the most pleasant. Springvale Court DS0000054914.V302931.R01.S.doc Version 5.2 Page 6 The staff are aware of my husband’s medical requirements, and help all the time. The majority of relatives stated that they were satisfied with the overall care provided. • 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. Springvale Court DS0000054914.V302931.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 Springvale Court DS0000054914.V302931.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 3, and 6. Quality in this outcome area is good. This judgment has been made using available evidence including a visit to this service. Service users are offered a good level of information about the home and enabled to visit and / or meet with staff prior to their admission. This can help them to decide if the home is right for them. The admissions process ensures that a good level of information regarding service users’ needs is obtained prior to care being offered, but only adequately translated to care plans. This can help to ensure that service users are offered the right type of care at the home. Intermediate care is not provided at Springvale Court. Springvale Court DS0000054914.V302931.R01.S.doc Version 5.2 Page 9 EVIDENCE: Before moving to the home service users and their relatives confirmed that they received information to decide if the home was suitable for them. This includes a service users’ guide. Service users are able to visit the home prior to their admission. The majority of service users moving to the home benefit from the help and guidance of a social worker in making this decision. For those service users most recently admitted to the home (whose placement and needs were case tracked), a ‘Care Managers’ (social workers) assessment was received before care was offered to them. Following this a plan of care was developed, and a review planned to take place after six weeks. This involves the service user, their social worker and other relevant representatives. Care plans are, thereafter reviewed by a senior member care staff on what is planned to be a regular basis. Should a reassessment of need be required, this can be arranged with the relevant Social Services Department. The home’s management staff also undertake a care needs assessment. However, some of those inspected contained information contradictory to that in the social workers assessment, and those undertaking such assessments must be careful they these and the associated care plans provide accurate information relating to service users needs. For example two service users who had a falls history noted in the social workers assessment were noted as not having this in the homes own ‘fall assessment’. Another service users mental health needs were also not acknowledged in the home’s own assessment. Springvale Court DS0000054914.V302931.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10. Quality in this outcome area is adequate. This judgment has been made using available evidence including a visit to this service. Service users’ care plans are in place, and generally reflect their observed needs to an adequate level. Effective care planning can offer guidance to care staff regarding care practice and ensure consistency where necessary. Adequate assessments of health care, pressure care and falls are in place but quality of care planning is variable. There is also an level of adequate supervision and care practice. Care staff are good at seeking medical advice where it is needed. This can help contribute to the welfare of service users. Medication storage and administered arrangements are adequate. The effective management of service users’ medication can help contribute to their general health and wellbeing. Arrangements to preserve the privacy and dignity of service users are adequate. Staff undertake appropriate care practice, but this is let down by the condition of some service users rooms, which due to odours and the need for refurbishment does not always promote a positive image. Springvale Court DS0000054914.V302931.R01.S.doc Version 5.2 Page 11 EVIDENCE: Each service user (whose needs and experience of care was ‘case tracked’) has a plan of care in place, and the manager and senior carers have undertaken considerable revisions of these documents into new standardised formats. A system whereby assessments are used to guide the development of care plans, which are then monitored, evaluated and reviewed, has been developed for service users, although this is at an early point of development. Care plans and assessments include information on issues of religious and cultural diversity. Specific advice was offered (through the inspection process) to the manager regarding individual care plans, such as those relating to falls prevention, challenging behaviours and mental health. Such care plans need to accurately reflect assessed needs, and thereby provide the guidance necessary to ensure consistent care practice, and offer a mechanism to monitor service users’ needs and thereafter monitor and review their progress. Monitoring of specific needs occurs by using monitoring charts (for falls, weight, continence, and so on) and through daily progress notes. Highlighted risk areas, such as falls, are also care planned/risk assessed. Personal and health care needs are outlined within service users’ assessments and care plans. Service users stated that they receive the care and support they need. All service users also stated that they receive the medical support they need. This is supported by the notifications received from the care home, that indicate that if urgent medical advice or assistance is needed this is sought. Arrangements for ensuring service users privacy is upheld during care giving are in place, such as lockable bedrooms and WCs and bathing areas. Staff knock on doors before entering service users’ rooms and confidential information is now stored in a secure manner. The management and administration of service users’ medication is governed by a set of policies and procedures, available to staff responsible for this task. Medication is, in the vast majority of cases, handled and administered by senior care staff. Medication rounds take place during the morning, after lunchtime, in the early evening ant before bedtime. A monitored dosage system (Manrex) is used, whereby the dispensing pharmacist supplies each service users’ medication within colour coded blister packs. These correspond to the four medication rounds of the day, over a twenty-eight day period. Printed ‘medication administration records’ are also supplied by the pharmacist. An audit of the medication used by those service users who were case tracked was concluded successfully, and medication administrations are appropriately recorded. However, the administering member of staff needs to Springvale Court DS0000054914.V302931.R01.S.doc Version 5.2 Page 12 remember to sign for each service user after, rather than before, they have administered the medication to them. Springvale Court DS0000054914.V302931.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15. Quality in this outcome area is adequate. This judgment has been made using available evidence including a visit to this service. Arrangements to provide activities and occupation have been good, but due to there currently being no activities worker are less frequent and have scope for further development within the home. The development of a planned, structured and well delivered activities programme can contribute to a more interesting and stimulating lifestyle for service users. Service users are able to maintain family and other contacts to a good degree should they wish. This can help ensure they do not become socially isolated. Service users on the ground floor are encouraged by staff to an adequate degree in exercising choice and control over their lives. This is less so for those service users accommodated on the first floor By encouraging independence, choice and control each service users independence can be promoted. On the whole, service users receive a good, varied and well presented, choice based, menu. This can help promote their general health and wellbeing. Further work is needed to promote the independence of service users on the first floor at meal times. Springvale Court DS0000054914.V302931.R01.S.doc Version 5.2 Page 14 EVIDENCE: The home previously had a worker specifically employed to plan and coordinate activities for service users, although they have recently left, resulting in fewer activities occurring, although staff were observed to be providing a more limited range, such as ball throwing, TV and board games. Therefore, there is is currently no detailed assessment of activities linked to each service users assessed preferences and needs. However, a new worker is to be recruited to fill this vacant post. Visitors regularly call to the home and they confirmed that they are able to visit their relative or friend in private. During the inspection several visitors called to the home. The home has a variety of communal lounges available, should service users wish to meet people in private outside of their own room. Meals are provided within three lounge areas, with a large one on the ground floor and two smaller ones on the first floor. Some service users take meals within their own bedrooms. Service users are offered a range of choices for meal times and on the day of the inspection the choice consisted of steak pie or sausages, boiled potatoes and carrots, ice cream or blancmange. Downstairs one service user became upset and disruptive, and consequently had to be encouraged to leave the dining area. There appeared to be no consistent strategy to manage this behaviour, which was reported to be a regular occurrence. And their care plan did incorporate a specific management plan to address this issue and offer a consistent approach for staff to follow to adequately support this person. Upstairs, for those service users with dementia care needs, they were provided with plastic cups (as opposed to glasses). They were only provided with cold drinks, in contrast to the broader choice offered to other service users. Choice was further limited by one of the pudding options running out. Staff were attentive to service users needs, in terms of cutting up food and providing assistance to sit into the table, but were also observed to ‘do for’ rather than ‘promote the independence’ of service user, for example by applying condiments and by not promoting self-service. There were no finger foods incorporated into the menu and one service user having difficulty in using cutlery, and consequently used her hands to eat. Springvale Court DS0000054914.V302931.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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18. Quality in this outcome area is adequate. This judgment has been made using available evidence including a visit to this service. A clear complaints procedure is available which is accessible to service users and their relatives. This can allow service users’, and their relatives, confidence in the process, and provide opportunity for the management team to improve the service provided. Adult protection and abuse awareness procedures are in place and include staff awareness training. EVIDENCE: Those service users (and visiting relatives) spoken with stated that they knew what to do if they were unhappy with any aspect of the service provided. A record of formal complaints received by the home is kept. The information provided on the pre-inspection questionnaire indicates that three complaints have been received in the twelve months up to April. None have been referred to CSCI to investigate. An examination of these records indicated that complaints are acknowledged and action taken to address the issue of concern. Of the service users who completed and returned comment cards regarding the home, all stated that they are aware of who to speak to if they are unhappy and how to raise a complaint. 5 of the relatives who completed a questionnaire stated they are aware of the home’s complaints procedure, three stated that they are not. Springvale Court DS0000054914.V302931.R01.S.doc Version 5.2 Page 16 The host local authority (Gateshead) publishes clear adult protection procedures, of which the registered manager and staff are aware. Staff receive training and guidance on adult protection from the local authority, internally, and through their work to attain an NVQ award in care. Springvale Court DS0000054914.V302931.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19 and 26. Quality in this outcome area is adequate. This judgment has been made using available evidence including a visit to this service. Service users have access to safe and comfortable indoor space. Service users’ bedrooms adequately suit their needs. While the standard of décor and cleanliness of the facilities is generally adequate, there were some areas where this was poor. A clean and well-maintained home can help promote a positive image for, and is respectful to service users. EVIDENCE: Some continued refurbishment work has been undertaken in the home, including the replacement of a corridor and lounge carpet. Non-slip laminated flooring has been laid in the upstairs dining area and new dining chairs obtained. The adequacy of these for individual service users need to be reviewed, as several service users find it hard to sit into the dining table and need assistance from staff. The previous chairs fitted with glide rails helped in Springvale Court DS0000054914.V302931.R01.S.doc Version 5.2 Page 18 this respect, however the new ones are of a standard design and several may benefit from the fitting of these rails. New lounge seating has been obtained, which is designed to help people get up from a seated position more easily. The continued refurbishment of the upstairs of the home has been a longstanding requirement, and appropriate design that reflects current recognised good practice for people with dementia has not continued throughout the upstairs communal and private areas. This was agreed as a pre-requisite of extending the registration of dementia care beds in the home, to encompass the whole of the first floor. Development in this area would help service users retain skills, help orientate, provide stimulation and support for people with dementia. Of the bedrooms inspected, several of those on the first floor were stained, and an unpleasant odour present throughout the duration of the inspection and during the second visit. Attention to detail in attending to cleanliness and maintenance issues continues to be required, as although the home is generally clean, areas such as kicker plates on doors, cupboards and wardrobe tops were all noted to require cleaning. Several wardrobes were unattached from the wall, and some bedside cabinets and chest of drawers need replacement. The main upstairs bathroom is stark in appearance, and would benefit from a warmer decorative scheme. Several areas of ‘boxing-in’ have bare wood where the paint has worn away. Generally, the home benefits from being a purpose built facility, with each bedroom having an en-suite toilet and wash hand basin. All of the rooms exceed 12 square meters in size, and there are some adapted bathing facilities and a walk-in shower. The ground floor bedrooms to the rear of the home have both an internal and their own external doorways, for which an additional charge applies. Springvale Court DS0000054914.V302931.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30. Quality in this outcome area is adequate. This judgment has been made using available evidence including a visit to this service. Staffing levels are poor in ensuring service users’ needs are promptly met. The staff team benefits from a good level with care qualifications, which can help ensure that a competent staff team is available to meet service users’ needs. Service users are protected by the home’s recruitment procedures, which are robust and implemented to a good standard. This can help ensure that unsuitable candidates do not gain employment in the home. Training is well planned and has highlighted where staff require broader and more frequent training opportunities. A range of appropriate training can contribute to staffs’ understanding of service users’ needs and ensure sufficient competence to undertake their job. EVIDENCE: On the day of the inspection there were five staff on duty through the day (including a senior staff member), reducing to three care staff working through the night. At this level it was observed that the needs of service users could not always be promptly met, and minimal support was available at meal times, Springvale Court DS0000054914.V302931.R01.S.doc Version 5.2 Page 20 therefore an immediate requirement was issued at the time of the inspection to highlight this, which was subsequently addressed by the manager. Staff records indicate that the manager receives an ‘enhanced’ Criminal Records Bureau disclosure prior to staff commencing duties. ‘POVA first’ checks are also being received. Two references are always obtained prior to employment being offered. Staff recruitment practices are governed by a policy that aims to ensure equal opportunities practices are adhered to. Staff recruitment processes include equal opportunities monitoring, and staff are recruited from a range of gender, age and cultural backgrounds. Care staff have received training in fire safety and adult protection, food hygiene, manual handling, infection control, aging and disability, dementia care, first aid and medication during 2005 and 2006. Several have undertaken a course of study to attain an NVQ award in care. Awareness training on equality and diversity is incorporated in the Skills for Care induction. The manager has indicated that 50 of the care staff team have attained an NVQ qualification in care, at level 2 or higher. Springvale Court DS0000054914.V302931.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 and 38. Quality in this outcome area is adequate. This judgment has been made using available evidence including a visit to this service. External management support and oversight arrangements operate at a good level, and can help ensure that the service is run in the best interests of service users. Internal quality assurance systems have been developed to an adequate level, but with scope for further improvement. This can allow the views of service users, relatives and others to be sought and the internal quality management of the service to be progressed. Risks to the health and safety of service users, visitors and staff are minimised and managed to an adequate level. Springvale Court DS0000054914.V302931.R01.S.doc Version 5.2 Page 22 EVIDENCE: The registered manager is a registered nurse (although she does not work in a nursing capacity at the home), and has acted in a management / supervisory capacity for over thirty years. She has worked as a care home manager for fifteen years. She has successfully undergone the ‘fit persons assessment’ to become registered by the Commission for Social Care Inspection. An Area Manager also provides regular, professionally based support, oversight and supervision of the home. Monthly inspections of the home by this person are also being progressed, which includes a focus on the quality, practices and procedures operated within the home. This can contribute to an effective quality assurance and management system focusing on service processes and outcomes. Service users, relatives and other interested people have been surveyed by questionnaire to gain their views on the quality of the home, although this has yet to be compiled into a report. This, along with other quality checks would benefit from being incorporated into a more detailed quality assurance system, linked to monitoring, action planning and review. The home is kept generally clear of hazards to the health and safety of service users, visitors and staff, although storage is limited, resulting in laundry skips being inappropriately located in a bathroom and the downstairs corridor. Springvale Court DS0000054914.V302931.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 3 10 2 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 2 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 X X X X X X 2 STAFFING Standard No Score 27 2 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 2 Springvale Court DS0000054914.V302931.R01.S.doc Version 5.2 Page 24 Yes Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP7 Regulation 15(1) Requirement The registered person must ensure that service users care plans are developed to accurately reflect their health and welfare needs. It is acknowledged that considerable effort has been invested in developing care plans, but some omissions remain. (The previous action plan dates for this requirement were 16/8/05 and 20/1/06). The registered manager should review mealtime arrangements to: - incorporate finger foods for service users who require these, - promote effective choice for service users with dementia, including a wider choice of beverages, - more effectively encourage the independence of service users with dementia, for example by providing more self service. (This is a new requirement). The registered manager must review the availability of adapted DS0000054914.V302931.R01.S.doc Timescale for action 27/01/07 2. OP15 16(2)(i) 27/12/06 3 OP38 16(2)(c) 27/12/06 Page 25 Springvale Court Version 5.2 4. OP38 13(4)(a) & 23(2)(l) 6. OP19 23(2)(b) dining chairs in the first floor dining area to ensure these meet the moving and handling needs of service users. (This is a new requirement) The registered person must 27/12/06 review the storage of equipment in the home, to ensure that it does not present a trip hazard to service users, visitors and staff. (The previous action plan dates for this requirement were 16/9/05 and 20/01/06). The registered person must 27/12/06 refurbish make available for inspection, and implement plans for the maintenance and refurbishment of the home, in particular the dementia unit. (The previous action plan date for this requirement was 20/01/06). 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 OP12 OP15 Good Practice Recommendations The registered manager should review the activities arrangement to reflect the needs and preferences of service users. The registered manager should develop a plan of care to guide staff on how they can effectively manage behaviours that challenge the service, in particular during meal times. Springvale Court DS0000054914.V302931.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection South of Tyne Area Office Baltic House Port of Tyne Tyne Dock South Shields NE34 9PT 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. 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