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Inspection on 16/07/07 for Springwater Lodge Care Home

Also see our care home review for Springwater Lodge Care Home for more information

This inspection was carried out on 16th July 2007.

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

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

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

What the care home does well

Experienced, well-trained and committed staff provide good quality of care, and service users indicated that they were happy with the overall standard of care provided by the home. Service users spoken with said that they feel safe living at the home and are confident that any concerns that they raise will be listened to and acted upon. A varied, nutritious and wholesome menu is offered to meet the dietary requirements of people living in the home. Services users are offered choices in pastime activities and hobbies. The environment is maintained to a very high standard, which creates a safe, clean and homely environment for people living at the home. St. Wilford`s walk is a separate unit of the home, which provides a stimulating and pleasant environment for service users with dementia

What has improved since the last inspection?

There is adequate, suitable, nutritious and varied menu available, and fresh fruit is made available to service users at all times, which has improved the choices of food available to people living in the home. New staff have been recruited to ensure that sufficient numbers of staff with skills and experience are on duty at all times to meet the needs of service users. St Wilford`s Walk has been decorated and refurbished to a high standard, sensory materials and displays have been introduced, which has enhanced the lives of people living in the unit.

What the care home could do better:

To protect service users from potential abuse, written consent to care plans should be obtained from service users or their representatives. To ensure that service users are protected from potential harm, procedures for the administration and recording of dispensed medication must be reviewed and improved to ensure there is a clear audit trail for all medicines. The equipment for recording the temperature readings from the medication fridge and the readings themselves should be closely monitored to ensure they meet required standards to maintain medicines safely. Communal bathrooms and toilets should be kept free from the storage of equipment and laundry.

CARE HOME MIXED CATEGORY MAJORITY OLDER PEOPLE Springwater Lodge Care Home 10 Smithy View Calverton Nottingham NG14 6FA Lead Inspector Michael Williams Key Unannounced Inspection 16th July 2007 10:00 X10029.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 Springwater Lodge Care Home DS0000040348.V345729.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 and Care Homes for Adults 18 – 65*. 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. Springwater Lodge Care Home DS0000040348.V345729.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Springwater Lodge Care Home Address 10 Smithy View Calverton Nottingham NG14 6FA 0115 9655527 0115 9655310 springwaterlodge@highfield-care.com www.southerncrosshealthcare.co.uk Southern Cross Care Homes No 2 Limited 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) Manager post vacant Care Home 50 Category(ies) of Dementia (12), Old age, not falling within any registration, with number other category (50), Physical disability (6) of places Springwater Lodge Care Home DS0000040348.V345729.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 4. 5. No one falling within category OP to be admitted into Springwater Lodge Care Home when there are 50 persons of category OP already accommodated in the home No one falling within category PD to be admitted into Springwater Lodge Care Home when there are 6 persons of category PD already accommodated in the home No one falling within category DE to be admitted into Springwater Lodge Care Home when there are 14 persons of category DE already accommodated in the home The maximum number of persons accommodated within Springwater Lodge Care Home is 50 The minimum age of people falling within the category DE shall be 55 years. 4th July 2006 Date of last inspection Brief Description of the Service: Springwater Lodge is a detached, two storeys and purpose built care home in the village of Calverton, established in 1990. It is set back from the main road, within 500 yards of local amenities. It offers personal care for people over the age of 65 years and can cater for a broad range of needs. The home is registered for fifty beds six of which may be used for people with physical disabilities. The living accommodation comprises of 41 single and one double room all with ensuite facilities spread over two floors, as well as bathing and toilet facilities and a lounge and dining room. A passenger lift provides access to the first floor. There is a visitor’s lounge, which is also utilised by service users as a quiet/reading room. The home’s registration includes the category of dementia, and provides a separate unit for residents with dementia. St Wilford’s Walk is a separate unit of the home for residents with the primary need of dementia. It is pleasant and clean with doors of residents bedrooms colour coded to ensure residents are able to find their bedroom. The fees range £334 -£600; this does not include chiropodist, hairdressing, newspapers and personal allowance. This information together with last inspection report is available to located in the foyer of the home or upon request. Springwater Lodge Care Home DS0000040348.V345729.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The focus of the inspection undertaken by the Commission for Social Care Inspection is upon outcomes for service users, and their views on the service provided. This process considers the providers capacity to meet regulatory requirements, minimum standards of practice, and focuses on aspects of service provision that require further development. This was an unannounced key inspection undertaken by one inspector. The main method of inspection used is called ‘case tracking’ which involved selecting two residents and tracking the care they receive through checking their records and discussion with them, and observations of the care received and asking staff about their needs. Two residents and two members of staff were spoken with as part of the inspection. Other residents who were not part of the case tracking were observed and also spoken with. Documents and medication policy and practice were examined as part of the inspection to gain evidence and form an opinion about the residents’ health and safety. A partial tour of the premises was undertaken which included communal areas, and a sample of bedrooms to ensure that the environment was pleasant, homely and safe. The annual quality assurance assessment or pre inspection questionnaire were not supplied before the date of the inspection. A review of all other information about the home received by the Commission since the last inspection was taken into consideration in planning this inspection and helped in deciding what areas of care were looked at. What the service does well: Experienced, well-trained and committed staff provide good quality of care, and service users indicated that they were happy with the overall standard of care provided by the home. Service users spoken with said that they feel safe living at the home and are confident that any concerns that they raise will be listened to and acted upon. A varied, nutritious and wholesome menu is offered to meet the dietary requirements of people living in the home. Services users are offered choices in pastime activities and hobbies. The environment is maintained to a very high standard, which creates a safe, clean and homely environment for people living at the home. St. Wilford’s walk is a separate unit of the home, which provides a stimulating and pleasant environment for service users with dementia. Springwater Lodge Care Home DS0000040348.V345729.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Springwater Lodge Care Home DS0000040348.V345729.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home Health and Personal Care Daily Life and Social Activities Complaints and Protection Environment Staffing Management and Administration Scoring of Outcomes Statutory Requirements Identified During the Inspection Older People (Standards 1–6) (Standards 7-11) (Standards 12-15) (Standards 16-18) (Standards 19-26) (Standards 27-30) (Standards 31-38) Adults 18 – 65 (Standards 1–5) (Standards 6, 9, 16 and 18–21) (Standards 7, 15 and 17) (Standards 22–23) (Standards 24–30) (Standards 31–35) (Standards 8, 10 and 37–43) Springwater Lodge Care Home DS0000040348.V345729.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 (Older People) and Standards 1 – 5 (Adults 18 – 65) are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. (YA NMS 1) Each service user has a written contract/ statement of terms and conditions with the home. Each Service User has an individual contract or statement of terms and conditions with the home. (YA NMS 5) No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Prospective Service Users’ individual aspirations and needs are assessed. (YA NMS 2) Service users and their representatives know that the home they enter will meet their needs. Prospective Service Users know that the home they choose will meet their needs and aspirations. (YA NMS 3) Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Prospective service users have an opportunity to “test drive” the home. (YA NMS 4) Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. 6. The Commission considers Standards 3 and 6 (Older People) and Standard 2 (Adults 18-65) the key standards. JUDGEMENT – we looked at outcomes for the following standard(s): 3 and 6 Quality in this outcome area is good. Individual needs are assessed, sufficient information is available for prospective service users to make an informed choice about moving into the home, This judgement has been made using available evidence including a visit to this service. EVIDENCE: The statement of purpose provides information about the aims and objectives and philosophy of the home. There is also additional information about the staffing structure, and the facilities that the home offers to service users. A service user guide is provided to service users on admission to the home. Springwater Lodge Care Home DS0000040348.V345729.R01.S.doc Version 5.2 Page 9 Pre admission assessments of individual need are undertaken before placement is offered, and opportunities are available for service users to have trial visits before taking up residency in the home. Files viewed contained a copy of the terms of agreement, and written confirmation that the home could meet the identified needs of service users. The home does not provide intermediate care. Springwater Lodge Care Home DS0000040348.V345729.R01.S.doc Version 5.2 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 (Older People) and Standards 6, 9, 16, 18 –21 (Adults 18-65) are: 7. The service user’s health, personal and social care needs are set out in an individual plan of care. Service Users know their assessed and changing needs and personal goals are reflected in their individual plan. (YA NMS 6) Also Service Users are supported to take risks as part of an independent lifestyle. (YA NMS 9) Service users’ health care needs are fully met. Service Users physical and emotional health needs are met. (YA NMS 19) 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, retain, administer and control their own medication where appropriate and are protected by the home’s policies and procedures for dealing with medicine. (YA NMS 20) Service users feel they are treated with respect and their right to privacy is upheld. Service Users rights are respected and responsibilities recognised in their daily lives. (YA NMS 16) Also Service Users receive personal support in the way they prefer and require. (YA NMS 18) Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The ageing, illness and death of a Service User are handled with respect and as the individual would wish. (YA NMS 21) 8. 9. 10. 11. The Commission considers standards 7, 8, 9 and 10 (Older People) and Standards 6, 9, 16, 18, 19 and 20 (Adults 18-65) are the key standards. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10 Quality in this outcome area is adequate Personal health care needs are identified and reviewed. However, the monitoring of medication procedures may place service users at risk. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Files examined evidenced that care plans are developed from pre admission assessments and risk assessments. Files viewed contained a range of care plans for individual need such as, moving and handling, pressure care, Springwater Lodge Care Home DS0000040348.V345729.R01.S.doc Version 5.2 Page 11 nutrition, social and personal care. Care plans provide some specific details about how service users are to be supported by staff; however, some information was prescriptive and not person centred. Care plans are regularly reviewed, and there was evidence that service users and their representatives are involved in the reviewing process. There was no evidence to indicate that service users or there representative had consented to care plans. There was evidence that other health professionals such as GP’s, tissue viability nurse, chiropodist, district nursing team and dietician are involved in maintaining the health care of people living in the home. Service users spoken said that their health needs were being met “if I ‘m not well staff will get the doctor out to see me” Staff spoken with had a good understanding of individual health needs, and were aware of the importance of maintaining service users dignity and privacy, this was confirmed by service users spoken with. Observations of people living in the home were that they were clean and tidy in their appearance, and appropriately dressed. There is a medication policy in place, and the home is registered with a local pharmacist. Procedures are in place to identify if service users wish to self medicate, and an appropriate risk assessment is undertaken to assess whether service users who wish to self medicate, are able to do so safely. Medication administration is appropriately dispensed, and staff have received appropriate medication management training. An audit trail of one service users medication found an incorrect number of tablets against what was recorded on the medication administration records (MAR). It was unclear in the MAR chart as to when errors had occurred or when medication had been refused. Temperature recordings from the medication fridge were outside recommended Royal Pharmaceutical Society parameters. The battery to the thermometer was replaced; the medication fridge was checked again during the inspection, temperature readings were within recommended limits. Springwater Lodge Care Home DS0000040348.V345729.R01.S.doc Version 5.2 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 (Older People) and Standards 7, 11– 15 and 17 (Adults 18-65) are: 12. 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 have opportunities for personal development. (YA NMS 11) Also Service Users are able to take part in age, peer and culturally appropriate activities. (YA NMS 12). Also Service users engage in appropriate leisure activities. (YA NMS 14) Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service Users are part of the local community. (YA NMS 13) Also Service Users have appropriate personal, family and sexual relationships. (YA NMS 15) Service users are helped to exercise choice and control over their lives. Service Users make decisions about their lives with assistance as needed. (YA NMS 7) Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. Service Users are offered a healthy diet and enjoy their meals and mealtimes. (YA NMS 17) 13. 14. 15. The Commission considers standards 12, 13, 14 and 15 (Older People) and Standards 12, 13, 15 and 17 (Adults 18-65) the 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 Service users are provided with choices and opportunities and live the lifestyle that they choose. A varied and balanced diet is offered. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Files examined contained records of activities, and service users said that they are able to choose how they spend their day. During the inspection people living in the home were observed listening to music, reading and undertaking meaningful interaction with staff. Springwater Lodge Care Home DS0000040348.V345729.R01.S.doc Version 5.2 Page 13 The home employs an activity coordinator; who devises an activities programme with service users. A copy of the weekly activities is available on the notice board in the main foyer of the home, which includes fashion show, art and craft, floral arrangements, and motivation. Children from the local school have visited the home to sing, which service users said that they enjoyed, monthly church services are also held at the home. There have also been recent outings to White Post farm, garden centres and a boat trip; service users spoken with confirmed this. Service users said that visitors can visit at any convenient time, and are made welcome. Menus are varied and nutritious, with fresh fruit offered daily, service users said that the quality of food is good, and that there is enough food available. “The food is quite good” There are set mealtimes, however, service users said that they can choose to have meals at alternative times if they wish. Springwater Lodge Care Home DS0000040348.V345729.R01.S.doc Version 5.2 Page 14 Complaints and Protection The intended outcomes for Standards 16 – 18 (Older People) and Standards 22 – 23 (Adults 18-65) 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 feel their views are listened to and acted on. (YA NMS 22) Service users’ legal rights are protected. Service Users are protected from abuse, neglect and self-harm. (YA NMS 23) Service users are protected from abuse. Service Users are protected from abuse, neglect and self-harm. (YA NMS 23) The Commission considers standards 16 and 18 (Older People) and Standards 22 and 23 (Adults 18-65) the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 Quality in this outcome area is good. Appropriate policy and procedures are in place to ensure that service users are protected from abuse or harm. Service users are confident that their complaints will be listened to. This judgement has been made using available evidence including a visit to this service. EVIDENCE: There is copy of the Nottinghamshire adult protection procedures available in the main office; there is a copy of the complaints policy; in the statement of purpose and service user guide. Information about making a complaint is also available in the main foyer of the home. Since the last inspection the Commission has received one complaint, which is being investigated by the provider. The home has received two complaints that have been satisfactorily resolved. Service users spoke with said that they would inform a member of staff if they felt unhappy, and were confident that any complaints would be listened to, and dealt with appropriately. “The staff will deal with any complaint”. Staff spoken with were clear in their understanding of their role in dealing with complaints, and their responsibilities regarding safeguarding adults. Springwater Lodge Care Home DS0000040348.V345729.R01.S.doc Version 5.2 Page 15 Environment The intended outcomes for Standards 19 – 26 (Older People) and Standards 24 – 30 (Adults 18-65) are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service Users live in a homely, comfortable and safe environment. (YA NMS 24) Service users have access to safe and comfortable indoor and outdoor communal facilities. Shared spaces complement and supplement service users’ individual rooms. (YA NMS 28) Service users have sufficient and suitable lavatories and washing facilities. Service Users toilets and bathrooms provide sufficient privacy and meet their individual needs. (YA NMS 27) Service users have the specialist equipment they require to maximise their independence. (YA NMS 29) Service users’ own rooms suit their needs. Service Users’ own rooms suit their needs and lifestyles. (YA NMS 25) Service users live in safe, comfortable bedrooms with their own possessions around them. Service users’ bedrooms promote their independence. (YA NMS 26) Service users live in safe, comfortable surroundings. Service Users live in a homely, comfortable and safe environment. (YA NMS 24) The home is clean, pleasant and hygienic. The home is clean and hygienic. (YA NMS 30) The Commission considers standards 19 and 26 (Older People) and Standards 24 and 30 (Adults 18-65) the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 21,23, 25 and 26 Quality in this outcome area is good Service users benefit from living in a pleasant, hygienic and safe environment This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home provides a pleasant, comfortable and clean environment for service users. The home is well maintained and decorated to a good standard, with sufficient communal space and amenities to meet the needs of people living in the home. However, there were towels and equipment inappropriately stored Springwater Lodge Care Home DS0000040348.V345729.R01.S.doc Version 5.2 Page 16 in communal bathrooms viewed. St. Wilford’s Walk has undergone extensive decoration, and photographs, tactile shop and flower displays have also been introduced. Art and craftwork completed by service users are also displayed around the unit, which has improved the environment for people living in the unit. Bedrooms viewed were clean, tidy and personalised with a fresh odour. Service users spoken with said that they liked their rooms. “My room is nice, and it is kept clean and tidy”. The kitchen area provides adequate space, and is clean and hygienic with food stored safely. The laundry has been extended and is sufficient for the needs of service users, however, the floor is showing signs of wear and needs replacing. The provider has agreed approval for the renewal of the laundry flooring. A sample of health and safety records examined evidenced that appropriate checks, maintenance, and servicing are being undertaken to maintain the health and safety of service users and staff. Springwater Lodge Care Home DS0000040348.V345729.R01.S.doc Version 5.2 Page 17 Staffing The intended outcomes for Standards 27 – 30 (Older People) and Standards 31 – 35 (Adults 18-65) are: 27. 28. 29. Service users needs are met by the numbers and skill mix of staff. Service users are supported by an effective staff team. (YA NMS 33) Service users are in safe hands at all times. Service Users are supported by an effective staff team. (YA NMS 32) Service users are supported and protected by the home’s recruitment policy and practices. Service Users benefit from clarity of staff roles and responsibilities. (YA NMS 31) Also Service Users are supported and protected by the home’s recruitment policy and practices. (YA NMS 34) Staff are trained and competent to do their jobs. Service Users individual and joint needs are met by appropriately trained staff. (YA NMS 35) 30. The Commission considers standards 27, 28, 29 and 30 (Older People) and Standards 32, 34 and 35 (Adults 18-65) the 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 Trained and experienced staff supports service users. Staffing levels are sufficient to meet the needs of people living in the home. Recruitment procedures are robust and ensure that service users are protected. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The staff rota evidenced that there are sufficient numbers of staff on duty at all times to meet the needs of people living in the home. The manager said that sickness is covered through using other staff from Southern Cross, or by using from bank or agency staff. Since the last inspection additional staff have been recruited, staff spoken with felt that there were sufficient staff on each shift to meet the needs of people living in the home, and complete allocated tasks. Service users said that staff are always available when they needed them “most of the staff are very nice”. Springwater Lodge Care Home DS0000040348.V345729.R01.S.doc Version 5.2 Page 18 There was evidence that staff receive an induction on commencement of employment at the home. The annual training plan indicated that over 50 of staff has completed NVQ2 social care, staff files evidenced that recent training provided for staff included, customer care, food hygiene, moving and handling, pressure care and Safeguarding adults. Staff spoken with confirmed this. Staff files examined indicated that appropriate recruitment procedures are being undertaken to protect service users. Records regarding appropriate completion of Criminal Record Bureau checks (CRB) are maintained centrally by the organisation, with reference numbers made available to management at the individual service. Examples of this process were viewed at the inspection and confirmed. Springwater Lodge Care Home DS0000040348.V345729.R01.S.doc Version 5.2 Page 19 Management and Administration The intended outcomes for Standards 31 – 38 (Older People) and Standards 8, 10, 23, 37 – 43 (Adults 18-65) are: 31. 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 a well run home. (YA NMS 37) Service users benefit from the ethos, leadership and management approach of the home. (YA NMS 38) The home is run in the best interests of service users. Service Users are consulted on and participate in, all aspects of life in the home. (YA NMS 8) Also Service Users are confident their views underpin all selfmonitoring, review and development by the home. (YA NMS 39) Service users are safeguarded by the accounting and financial procedures of the home. Service Users benefit from competent and accountable management of the service. (YA NMS 43) Service users’ financial interests are safeguarded. Service Users are protected from abuse, neglect and self-harm. (YA NMS 23) Staff are appropriately supervised. Service Users benefit from well supported and supervised staff. (YA NMS 36) Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. Service Users know that information about them is handled appropriately, and that their confidences are kept. (YA NMS 10) Also Service Users rights and best interests are safeguarded by the home’s policies and procedures. (YA NMS 40) and (YA NMS 41) The health, safety and welfare of service users and staff are promoted and protected. The health, safety and welfare of service users and staff are promoted and protected. (YA NMS 42) 32. 33. 34. 35. 36. 37. 38. The Commission considers standards 31, 33, 35 and 38 (Older People) and Standards 37, 39 and 42 (Adults 18-65) the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31,33, 34,35, 36 and 38 Quality in this outcome area is good. The home is run in the best interest of service users, the safety and welfare of service users and staff are protected. This judgement has been made using available evidence including a visit to this service. Springwater Lodge Care Home DS0000040348.V345729.R01.S.doc Version 5.2 Page 20 EVIDENCE: There is an acting manager in post and she has applied for the registered manager position. The acting manager has 9 years experience of working in professional care; she has attained the diploma qualification in adult nursing, and is currently completing the NVQ4 care management qualification. The acting manager is supported by the Operations manager, who offers guidance and advice in the effective running of the home. An ‘open door’ policy is operated, which both service users and staff feel is suited to the culture of the home. Evidence was seen of regular service users meetings, monthly manager surgeries are also offered to service users and their representatives. A sample of health and safety records was examined, maintenance and servicing records are effectively maintained, and appropriate procedures are in place to protect the health and safety of people living in the home. Staff receive regular supervision and appropriate training to meet the needs of service users, and develop their roles. The home does not act as Power of Attorney for service users and will only keep money for personal allowance. Robust procedures are in place to protect service users from financial abuse. Documents examined evidenced that appropriate procedures are being followed for dealing with accidents and incidents. The home is part of the Southern Cross group, and uses their quality control system. This information is fed back to service users through service user meetings, and is used in the development of the home’s business plan. Springwater Lodge Care Home DS0000040348.V345729.R01.S.doc Version 5.2 Page 21 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 X 2 X 3 3 4 X 5 X 6 3 HEALTH AND PERSONAL CARE Standard No Score 7 3 8 2 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 X 17 3 18 3 ENVIRONMENT Standard No Score 19 3 20 3 21 3 22 X 23 3 24 X 25 3 26 3 STAFFING Standard No Score 27 X 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No Score 31 2 32 X 33 3 34 3 35 3 36 3 37 X 38 3 Springwater Lodge Care Home DS0000040348.V345729.R01.S.doc Version 5.2 Page 22 No 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 OP9 Regulation 13(2) Requirement To ensure that service users are protected from potential harm, procedures for the administration and recording of dispensed medication must be reviewed. A clear audit trail of all medication must be maintained and clearly recorded in medication administration records (MAR) chart. To ensure that service users are protected from potential harm, appropriate measures must be taken of ensure that medication fridge temperatures are closely monitored and remain within recommended Royal Pharmaceutical Society parameters and that equipment to carry this out is maintained fit for purpose. Timescale for action 16/09/07 2. OP9 13(2) 16/09/07 Springwater Lodge Care Home DS0000040348.V345729.R01.S.doc Version 5.2 Page 23 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. 3. Refer to Standard OP7 OP7 OP12 Good Practice Recommendations Service users or their representatives should sign in consent to care plans. The Registered Person remind residents at regular intervals that they are entitled to see their care plans. Equipment and laundry should not be stored in communal bathrooms. Springwater Lodge Care Home DS0000040348.V345729.R01.S.doc Version 5.2 Page 24 Commission for Social Care Inspection Derbyshire Area Office Cardinal Square Nottingham Road Derby DE1 3QT 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. Springwater Lodge Care Home DS0000040348.V345729.R01.S.doc Version 5.2 Page 25 - 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!