Inspection on 22/04/05 for Springwater Lodge Care Home

This inspection was carried out on 22nd April 2005.

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

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

Other inspections for this house

Springwater Lodge Care Home 16/07/07

Springwater Lodge Care Home 04/07/06

Springwater Lodge Care Home 13/09/05

Springwater Lodge Care Home 18/02/05

Springwater Lodge Care Home 01/06/04

Springwater Lodge Care Home 09/03/04

Similar services:

Byars Care Home

St Marys Nursing Home

Bramble Lodge

Parkmanor Residential Home

Thornham Grove

Hunter`s Lodge

London Road Neurological and Specialist Care Unit

Carlton Care Home

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

CARE HOMES FOR OLDER PEOPLE Springwater Lodge Care Home 10 Smithy View Calverton Nottingham NG14 6FA Lead Inspector Karmon Hawley Unannounced 22 April 2005 @ 10:00 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Springwater Lodge Care Home C53C03S40348 Springwater V224016 220405 stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Springwater Lodge Care Home Address 10 Smithy View, Calverton, Nottingham, NG14 6FA Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 0115 9655527 0115 9655310 Donna Lyons Susan Joy Francis Care Home with Nursing (N) 50 Category(ies) of Terminally ill (TI) registration, with number Physical disability (PD) of places Old age, not falling within any other category (OP) Springwater Lodge Care Home C53C03S40348 Springwater V224016 220405 stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: 1 Within the total number of beds, a maximum of 6 beds maybe used for the category of PD 2 Within the total number of beds, a maximum of 2 beds maybe used for the category of TI 3 One bed within the category of OP maybe occupied by a named service user (D.O.B 10.02.1940), who is under 65 years of age. Date of last inspection 18 February 2005 Brief Description of the Service: Springwater Lodge is a detached, two storey, 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 and two beds for palliative care. The living accommodation comprises of thirty six single and seven double ensuite rooms spread over two floors, as well as bathing and toilet facilities and a lounge and dining room. The accommodation is well maintained, decorated in a pleasant and homely manner. A passenger lift provides access to the first floor. There is a visitors lounge, which is also utilised by service users as a quiet/reading room. Springwater Lodge Care Home C53C03S40348 Springwater V224016 220405 stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection took place over one day and five service users care notes and other relevant records with regards to their care and the environment were examined. Five service users and three relatives were spoken with. What the service does well: What has improved since the last inspection? What they could do better: There have been recent concerns expressed with regards to quality of care within the home. Many issues arise around staffing levels, training and Springwater Lodge Care Home C53C03S40348 Springwater V224016 220405 stage 4.doc Version 1.30 Page 6 communication systems as well as preadmission assessments and care plans. Several requirements have been set to address these issues. 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. Springwater Lodge Care Home C53C03S40348 Springwater V224016 220405 stage 4.doc Version 1.30 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Standards Statutory Requirements Identified During the Inspection Springwater Lodge Care Home C53C03S40348 Springwater V224016 220405 stage 4.doc Version 1.30 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 1,2,3,4,5 The statement of purpose and terms and conditions of admission are sufficient and service user friendly to ensure an informed choice. However with regards to medication it is stated that medication must be given to the nurse in charge on admission, this must be readdressed to ensure service users rights are taken into consideration. Pre admission assessments are insufficient and do not provide enough information with regards to service users needs and preferences consequently detracting from quality of care. EVIDENCE: The manager stated that the statement of purpose is available in both written text and on audiocassette. The written version was examined and it covered that required within this standard. Information is also extracted from this and placed in the service user guide, which is in all service users rooms, this also covers more personal issues that services users may wish to know with regards to daily living and community involvement. There is also a definition of terms to enable better understanding. With regards to trial visits the manager stated that service users might come to the home for lunch or for a few weeks, however most service users are booked in as respite for this period, one service users was currently in the home under this arrangement. The manager Springwater Lodge Care Home C53C03S40348 Springwater V224016 220405 stage 4.doc Version 1.30 Page 9 or registered nurses visit potential service users within the community and assess whether needs may be met within the home. Five case files were examined; within each there was not a fully completed pre admission assessment to identify needs and preferences. Emergency admissions are not accepted very often, if however they are, the manager stated that relevant information is obtained via the phone, from the family or the hospital first and a care plan received from the social worker if applicable. One service user was able to substantiate they had received all relevant information when admitted into the home. Springwater Lodge Care Home C53C03S40348 Springwater V224016 220405 stage 4.doc Version 1.30 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 7,8,9,11 Service users needs with regards to health and personal needs are partially met; this could be improved if further information is gained. Care is offered in specialist areas and despite staff being able to discuss basic principles, further training would promote up to date practices and enhance care offered. Despite an activities coordinator being available some service users did not benefit from a structured programme, resulting in their needs not being fully met. Medication procedures have been improved; however further attention is required to address risk assessments ensuring self-medication is appropriately managed. A new review system is currently being implemented; this must be developed so as to demonstrate how concerns and complaints are to be dealt with to ensure this is effective. To ensure service users wishes with regards to death are appropriately recorded and taken into consideration the practices and policies within the home need to correspond. EVIDENCE: Five case files were examined; within each there was not a fully completed pre admission assessment to identify needs and preferences. However all service users had undergone various assessments using recognised tools. There was evidence of these being reviewed on a monthly basis. Care plans are devised using this information and the Roper Logan and Tierney activities of daily living model. There was evidence that specialist service had been accessed when Springwater Lodge Care Home C53C03S40348 Springwater V224016 220405 stage 4.doc Version 1.30 Page 11 required. Relevant contacts for each service user were in place as was referrals to relevant services. Each service user had undergone a physical and social profile, which was again based upon the activities of daily living, it was of a circle type format, which ascertained limited information; therefore social and physical profiles had been completed in varying degrees. With regards to bed rails, there was evidence these were being used, however within one file examined there was no signed consent form. With regards to identified complex needs, these were not followed up in the care plan. Daily records were not completed on a daily basis, however these were in depth and reflected relevant care and current conditions. The manger is in the process of implementing a new review system following the last inspection; evidence of this was within the care files and there was evidence of previous reviews that had taken place, these did not demonstrate how concerns or complaints were dealt with. Senior carers responsible for the administration of medication have undertaken training in the administration of medication in 2001. A new policy has been implemented following an incident with a service user, all residential service users are now assessed with regards to the need to be observed taking medication, however a care plan in place did not actually state to observed the service user. Medication records with regards to administration, receipt, storage and administration were examined and were satisfactory. The manager has registered with a new pharmacy following difficulties with supplies, new procedures are now also in place to ensure medication stock is sufficient. The manager stated that service users wishes with regards to death were discussed at the last staff meeting where minutes were recorded and filed. It was stated that wishes are recorded within care plans, however within those files examined this was not completed on each occasion. The manager states that this is not normally completed on admission due to the sensitive nature unless prepaid plans are in place, however the policy within the home states that this is done on admission. There was no evidence of specific staff training with regards to caring for terminally ill service users, however staff were able to discuss the basic principles of care which they deliver. The Macmillan nurse and district nurses support staff in delivering care, there has been minor altercations in the past due to lack of knowledge of the registered nurses but the manager stated that this had been resolved. The manager and staff stated that relatives may stay over night if required. Springwater Lodge Care Home C53C03S40348 Springwater V224016 220405 stage 4.doc Version 1.30 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12.15 As the activities coordinator has not considered the use of service user information, life experiences, likes and dislikes these have not been fully appreciated in order to deliver appropriate activities to some service users. Meals provided within the home offers a satisfactory choice, however concerns have been expressed and further advice may be sought and service users opinions taken into consideration and recorded so as to address this matter. Consistency of communication with regards to meals has lead to some upset; this must be addressed to ensure remedied. EVIDENCE: The home employs an activities coordinator who works 20 hrs a week. There is also now an allocated budget of £30 per month to spend on activities. On speaking with the activities coordinator she expressed that her job was enjoyable, however some service users did not wish to join in activities, therefore she spends individual time with them talking or doing their nails. Activities such as trips out, dominoes, games, beanbags, sing alongs are available. She stated that access to care plans was given but she had not used this source of information, but would consider doing so, however as previously Springwater Lodge Care Home C53C03S40348 Springwater V224016 220405 stage 4.doc Version 1.30 Page 13 stated this information in the majority of files examined was not sufficient. Church services are held once a month and she devises a newsletter every two to three months, which informs service users of forthcoming events, which was displayed on the notice board. She was observed providing nail care to a service user during the inspection. On speaking with a service user it was stated that a lot of time had been spent in her room of late due to illness, it was stated that care staff do not always tell her what activities are going on and she felt she had no company and just sat in her room reading but was happy doing so. Several voting cards and proxy votes were observed to have been delivered and the activities coordinator had been instructed by the manager to facilitate the distribution of these. Several service users stated they wished to vote and explained that this had been arranged for them, staff were taking them to the polling station. The manager stated that age concern advocacy services had been used in the past and they would be contacted again if needed, however there were no details of this or any other service displayed within the home. The manager stated that service users may bring in any items, which will fit in rooms as desired, and there was evidence of this as rooms were personalised and personal items were evident. The menu follows a four-week rota; individual meal plans were completed for service users. Following concerns with regards to frozen vegetables advice was sought from the environmental health officer on their last visit to the home, according to the manager she stated that it was felt that frozen vegetables were as nutritious as fresh, no evidence of this documentation was observed. Relevant checks with regards to goods inspection, temperature control and cleaning rotas had been carried out, however it was observed that there were gaps in both the cleaning rota and fridge/freezer temperatures. On speaking with service users it was stated that meals are not as good as they used to be and there was not enough food, another service users stated she enjoyed her meals and there was always plenty to drink, whereas a third service user and her relative were concerned with regards to the lack of consistency in the diet offered due to being on a liquidised soft diet, it was stated that this was not always maintained and caused upset to the service user. Springwater Lodge Care Home C53C03S40348 Springwater V224016 220405 stage 4.doc Version 1.30 Page 14 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 16,18 There have been complaints received within the home, these are documented and appropriate action is taken. It may be of benefit if service users care plans were more through with regards to complex needs such as dealing with aggressive behaviour and care of those who may be suffering with dementia, thus meeting needs more appropriately and reducing concerns and complaints arising. EVIDENCE: There have been seven recorded complaints within the last 12 months three of which were substantiated, three partly substantiated and one unresolved. There are also current ongoing concerns, which are being investigated at present. The manager stated that following complaints the home identifies areas, which need changing and act upon them. There was evidence of this occurring as the drugs policy and service users care plans had been updated following this. The complaints procedure is within the terms and conditions of admission and displayed on the wall outside the managers office. On speaking with one relative she stated she was not aware of the complaints procedure but felt she could approach staff should she have any concerns, another as previously mentioned had received all information required on admission. Staff were aware of and able to discuss the actions they would take should they encounter abuse and the whistle blowing policy. Six members of staff have attended adult abuse training and two have attended protection of vulnerable adult training. No staff member employed is appointee for any service users money. Springwater Lodge Care Home C53C03S40348 Springwater V224016 220405 stage 4.doc Version 1.30 Page 15 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 21,22,24,25,26 In general the home is clean and well maintained ensuring safe and comfortable surroundings. There is ample equipment and adaptations within the home to meet needs. However the dining area was dark and uninviting and may cause difficulty for some service users, lights need repairing to address this matter. Safety may be compromised as a door was propped open, therefore further advice may be sought from the relevant authority to readdress this practice and protect service users. EVIDENCE: The Shires is a purpose built building providing accommodation within 41 single ensuite rooms. There are also ample toilet, bathroom and shower facilities to meet service users needs. Adaptations and specialist equipment needed to meet service users needs are available. Access through the home is satisfactory however a side lounge door was noted to be propped open with a chair. On the day of inspection the home was clean, tidy and well maintained. Each radiator is fitted with guards and can be adjusted individually. Natural light is available within all areas of the home and where required is Springwater Lodge Care Home C53C03S40348 Springwater V224016 220405 stage 4.doc Version 1.30 Page 16 supplemented with domestic lighting, within the main lounge some lights were noted to be out of use and causing the lounge to be dark, the manager stated this has been reported to the estate to be mended. Emergency lighting is also available throughout the home. The laundry room is currently being extended to include another washing machine and tumble dryer to the current one of each. The washing machine has a hot wash facility and hand-washing facilities are available within this area. There are three sluice areas within the home all of which were clean and tidy and free from offensive odour, storerooms are fitted with keypad locks to ensure the safety of service users. Springwater Lodge Care Home C53C03S40348 Springwater V224016 220405 stage 4.doc Version 1.30 Page 17 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27,28,29 Staffing within the home at present is insufficient to fully meet the needs of service users; both staff and service users substantiated this. Therefore the use of resources such as registered nurses, available staff and the dependency of service users must be examined so that sufficient staff are provided. Staff training must also be addressed to ensure staff have the necessary knowledge and skills to deliver a quality care to meet needs of service users. EVIDENCE: Staffing rotas were inspected and showed that on occasion staff numbers were insufficient. The manager stated that she aims to have five care staff and one trained on both morning and afternoon shifts and 3 care staff and one registered nurse on the night shift. There are currently only 37 service users in the home all of which were medium band nursing, however on the day of the inspection there were only four care staff on duty plus a registered nurse. On speaking with staff they expressed concerns with regards to staffing levels and that there is no period allocated for handover hence creating a lack of communication and consistency in care. It was generally felt that there was no quality time to spend with service users and the job is very stressful. It was stated that care staff feel that some registered nurses do not help enough with the day-to-day care of service users needs. Long shifts are worked and on occasion staff do not get their allocated breaks. On discussing training issues the general consensus was that it was difficult to get all the staff together for training sessions but manual-handling issues had been discussed and practices improved as all are now using equipment provided. Staff were able to discuss the core values and principles of care. Springwater Lodge Care Home C53C03S40348 Springwater V224016 220405 stage 4.doc Version 1.30 Page 18 Two service users and one relative substantiated that there are at times not enough staff to fully meet needs and there is a lack of communication and difficultly communicating with overseas staff, although staff were friendly; whereas three service users were happy with all aspects of the home. Four Staff files were observed and contained the relevant information and checks required in this standard. Each staff member had a training file. Manual handling training was sufficient as was fire safety training, whereas adult abuse training, first aid and health and safety, care of the terminally ill, infection control, and specialist care needs was not. Three staff members have attained the national vocational qualification in care level 2 one level 3 and six members of staff have just started level two. Springwater Lodge Care Home C53C03S40348 Springwater V224016 220405 stage 4.doc Version 1.30 Page 19 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31,33,34,37,38 With regards to the deputy manager overseeing the manager’s post the company must ensure that he is supported in this role to ensure the smooth and continued running of the home and a consistent high quality care is delivered. Whilst it is recognised that audits take place it is required that quality assurance is monitored by service user feedback in an official manner to identify that service users needs are being met and the home is run in the service users best interest. Service users records are currently not stored in compliance with the data protection act thus infringing on the service users right to confidentiality. EVIDENCE: The manager is currently working out her notice to terminate her employment; the deputy manager will be running the home in the absence of a manager with the support of the regional manager. The deputy manager stated he is a little anxious but feels competent and confident to carry out the job role. Records with regards to health and safety were observed and all maintenance and checks were satisfactory. The manager carries out audits within the home, Springwater Lodge Care Home C53C03S40348 Springwater V224016 220405 stage 4.doc Version 1.30 Page 20 which cover activities, food, induction, risk assessments and reviews, housekeeping, she does not carry out general quality assurance questionnaires with service users and was unsure as to whether the company does this annually. The manager stated that service users meetings are carried out and three have been held since October, minutes for which were available, it was felt that these were supportive and positive. Any negative points drawn to her attention are looked at and an action plan devised so these can be remedied. Budgets for the next six months were seen and the manager stated that she is also authorised to spend an allocated amount of money in the case of requirements being set by the commission or in an emergency. She also stated that service users have access to records during their reviews but not at any other time, there is not an access to records policy within the home and very little evidence of service users having access. With regards to the data protection of information the nurses station is located off the main lounge, this is lockable, however the manager stated this is kept unlocked as staff are generally around. Service users confidential information is stored on shelves within this room. Springwater Lodge Care Home C53C03S40348 Springwater V224016 220405 stage 4.doc Version 1.30 Page 21 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score 2 3 2 2 3 x HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 x 11 2 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 x 14 x 15 2 COMPLAINTS AND PROTECTION 3 x 3 3 x 3 2 3 STAFFING Standard No Score 27 2 28 2 29 3 30 x MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 2 x 3 2 x 2 3 x x 2 2 Springwater Lodge Care Home C53C03S40348 Springwater V224016 220405 stage 4.doc Version 1.30 Page 22 yes Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP 1 Regulation 12 Requirement The ethos of staff requires attention with reference to the wording in the Statement of Purpose to ensure it does not infringe upon service users rights. Preadmission assessments require adjustment to ensure all necessary information is obtained. Staff training deficits must be addressed. This is an outstanding requirement from the previous inspection and must be addressed to avoid enforcement action.. Service users plans of care must accurately reflect identified complex needs. It is required that bed rails are not used without consent being obtained. Reviews must highlight how concerns or complaints will be ddealt with and records available for inspection. Service users must undergo an appropriate risk assessment with regards to self administration to demonstrate how the risk will be managed. C53C03S40348 Springwater V224016 220405 stage 4.doc Timescale for action 22nd July 2005 2. OP3 14 22nd July 2005 22nd July 2005 3. OP4 18 4. 5. 6. OP7 OP7 OP36 15 13 24 Immediate Immediatel 22nd July 2005 Immediate 7. OP9 13 Springwater Lodge Care Home Version 1.30 Page 23 8. OP15 12 9. 10. OP25 OP27 23 18 11. OP31 9 12. 13. 14. OP33 OP37 OP38 9 17 23 To ensure that adequate safety measures are in place with regards to storage, preparation and serving of food. Sufficient lighting is to be made available in the dinning area Staffing levels must be addressed to ensure sufficient staff are available to meet service users needs. This is an outstanding requirement from the previous inspection and must be addressed to avoid enforcement action. The responsible individual must provide a written plan as to how the deputy manager will be supported in managing the home and also how handover periods will be developed to ensure consistency of care . Records of quality assurance audits are to be made available for inspection Guidelines of the Data Protection Act must be adhered to with regards to the storage of records Further advice is to be sought with regards to fire safety and the propping open of doors to ensure health, safety and welfare is maintained. Immediate 5th July 2005 Immediate Immediate 22nd July 2005 Immediate 22nd July 2005 15. 16. 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 OP15 Good Practice Recommendations With regards to meals provided it is reccommended as good practice that service users views are obtained and further advice from a specialist source, with necessary C53C03S40348 Springwater V224016 220405 stage 4.doc Version 1.30 Page 24 Springwater Lodge Care Home 2. 3. 4. 5. 6. OP12 documentary evidence is obtained. It is considered good practice that activities are further developed to become more structured and individualised to meet expressed needs. Springwater Lodge Care Home C53C03S40348 Springwater V224016 220405 stage 4.doc Version 1.30 Page 25 Commission for Social Care Inspection Riverside Business Park Tottle Road Nottingham NG2 1RT 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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