Inspection on 30/11/06 for The Spinney Hop

This inspection was carried out on 30th November 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

The Spinney Hop 28/12/05

The Spinney Hop 14/06/05

The Spinney Hop 19/10/04

The Spinney Hop 29/06/04

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 The Spinney Woodlands off Lansdowne Road Brimington Chesterfield Derbyshire S43 1BE Lead Inspector Denise Bate Unannounced Inspection 30th November 2006 09:15 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 The Spinney DS0000035801.V320698.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. The Spinney DS0000035801.V320698.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service The Spinney Address Woodlands off Lansdowne Road Brimington Chesterfield Derbyshire S43 1BE 01246 347530 01246 347533 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) www.derbyshire.gov.uk Derbyshire County Council Vacant Care Home 37 Category(ies) of Old age, not falling within any other category registration, with number (37) of places The Spinney DS0000035801.V320698.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 28th December 2005 Brief Description of the Service: The Spinney is a care home registered to provide personal care and accommodation for up to 37 older people. It is a purpose built care home located at the head of a residential cul-de-sac in its own private grounds. The home is near to the local shops and the village of Brimington. Residents at the home are all accommodated in single, ground floor rooms. The rooms are arranged in 3 wings of the home, each wing having its own kitchen, lounge and dining areas. The home provides 3 short-term care beds and 5 en-suite bedrooms for rehabilitation. There is a large lounge and reception area. The home has well-maintained gardens with accessible seating areas for residents. Fees are £364 per week for permanent service users, but a range of prices for short term care service users. Extra charges are made for hairdressing, chiropody, magazines and newspapers. The Spinney DS0000035801.V320698.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection was unannounced and took place over seven hours. During the inspection seven residents, two relatives, and four staff members were spoken with. The acting manager, two deputies, and the service manager were present during part of the inspection and provided assistance and information. Written information was provided by the manager on the day of inspection. Nine surveys were received prior to the inspection providing feedback on the service. An assessment was made of the progress by the registered persons to address the requirements made at previous inspections. A number of records were examined, including care planning documentation, minutes of meetings, regulation 26 visit records, staff files, health and safety and medication records. Four residents were case tracked. A tour of the building took place. As part of this unannounced inspection the quality of information given to people about the care home was looked at. People who use services were also spoken to, to see if they could understand this information and how it helped them to make choices. The information included the service user’s guide (sometimes called a brochure or prospectus), statement of terms and conditions (also known as contracts of care) and the complaints procedure. These findings will be used as part of a wider study that CSCI are carrying out about the information that people get about care homes for older people. This report will be published in May 2007. Further information on this can be found on our website www.csci.org.uk. It was noted that the condition relating to a resident who was not in the homes registration category no longer applied. Arrangements will be made to amend the registration document outside the inspection process. What the service does well: The Spinney provides a comfortable, homely, and relaxed environment for both long term and short term care residents. It also provides intermediate care/rehabilitation where health professionals have a substantial input. Residents and relatives spoken with made positive comments about the home and the staff and said they were provided with good care. Comments included, ‘I have everything I need’, ‘if I didn’t like it I wouldn’t come here’. The home was found to be generally well maintained. The inspector was told by residents that the food was good and they were given choice. The Spinney DS0000035801.V320698.R01.S.doc Version 5.2 Page 6 Residents and staff said that the acting manager and management team were supportive and approachable. Staff spoken to were experienced and committed. They feel they have good access to training over a wide range of topics. There is a well established ‘key worker’ system. There are regular residents meetings. The home are working hard to improve the variety and availability of activities; and the importance of activities, entertainment and continuing contact with family and friends is recognised by staff. The home follow Derbyshire County Council’s recruitment and selection procedures, although copies of some documents are not kept at the home. There is a corporate complaints procedure, although minor concerns are dealt with on an informal basis. Residents and relatives said that any concerns would be dealt with promptly and appropriately by the managers and other staff. The home have regular staff and resident meetings and these are minuted. There are systems in place for monitoring hospital admissions and falls. What has improved since the last inspection? What they could do better: The kitchen needs refurbishment and this is due to take place in January/February 2007. A quality assurance exercise had been carried out, but the results were not available on the day of inspection. It is understood that they will be available in the near future for the manager to draw up a plan under ‘Your Views, Our Actions’. The provision of some extra staffing hours would enable activities to be carried out consistently. A dependency tool would provide evidence on whether staffing was sufficient to meet residents’ needs at all times. The provision of a security lock on the front door would improve security. The Spinney DS0000035801.V320698.R01.S.doc Version 5.2 Page 7 Medication risk assessments should be done on residents who manage their own medication. The temperature in the medication room should be monitored to ensure it does not get too hot. 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. The Spinney DS0000035801.V320698.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection The Spinney DS0000035801.V320698.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 3, 6 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Information is available to ensure residents can make an informed choice about where they live. EVIDENCE: Three residents were interviewed about the information given to them prior to coming to the home. Two residents could not remember if they were given any written information, one out of three residents could remember being given a service user guide. All felt they had sufficient information to make a positive decision to choose this particular home. In practice residents had obtained information about the home in a variety of ways, e.g. they had been for short term or intermediate care or had been a volunteer at the home previously. Residents had been assisted by their families in their choice of home. Copies of the service user The Spinney DS0000035801.V320698.R01.S.doc Version 5.2 Page 10 guide are in all residents’ bedrooms and in the communal area, together with the statement of purpose. No residents interviewed were sure of how information about changes in the cost of their care was communicated as their finances were dealt with by their families. All were satisfied that the financial system worked well and fairly, and all were clear about what extras they had to pay for, e.g. hairdressing. No residents could remember whether they had been given a written contract or if it had changed as financial matters were dealt with by members of the family. Copies of contracts were seen on residents’ care planning files. Contracts referred to the statement of purpose, service user guide, and residents rights document and had been signed by residents. Finances are dealt with the Derbyshire County Council Central Assessments Team. Feedback from the resident questionnaire indicated that some residents were aware they had formal contracts. While residents’ awareness of the statement of purpose and service user guide was not high, residents did generally express a high degree of satisfaction with the services provided and felt that they had made informed choices when they moved into the home. The documents were available and the home’s policy is to bring them to the attention of residents and their families prior to and at the time a resident moves into the home. The statement of purpose will be updated when the new registered manager takes up her post in the new year. Two of three residents remembered having their needs discussed with them by someone from social services and/or health. One person could not remember, but she had been very ill at the time and was much better now. There was evidence on file of needs assessments being carried out, of risk assessments and personal service plans which had been signed by the resident and reviewed. Two social care professionals were visiting the home on the day of inspection. They felt that the contracts for short term care were straightforward, and also felt that the system of potential residents spending an assessment day at the home was extremely helpful. The home provide an intermediate treatment/rehabilitation service on one wing. There are five en suite bedrooms, and services are provided by a variety of health professionals as well as care staff. One resident was case tracked and the relevant assessments and records of care were in place. The Spinney DS0000035801.V320698.R01.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9, 10 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Care plans are suitably completed to demonstrate that residents health, personal and social care needs are being fully met. EVIDENCE: Three residents were casetracked. All residents had sufficient care planning documentation to enable staff to carry out caring tasks. Intermediate care documentation included confirmation that the process had been explained to them, and permission given for assessment and liaison with other The Spinney DS0000035801.V320698.R01.S.doc Version 5.2 Page 12 professionals. Services are provided by a by range of health professionals including nurses and occupational therapists. Permanent residents files included a front sheet, photo, medication consent/self custody form, review minutes, personal handling risk assessment, accident sheet, nutrition and daily logs. Current care plans (personal service plans) for all residents are held on one file. Personal service plans had been signed by residents. Wihin the care planning documentation and on the assessments seen there was little information on residents’ social history, e.g. past life events, interests, hobbies, etc. Health information was included in care plans Feedback from residents was that health needs are looked out for; ‘they keep an eye on me and look after me if I’m ill’. There is a key worker system and this system works well. There was a monthly update on case tracked residents files giving information about any significant events or changes. However, it is possible that staff’s detailed knowlegde of individual residents is not fully reflected and written up in some care plans. Feedback on the day of inspection and from the resident questionnaires indicates that residents are generally happy with the standard of care, ‘I have a good relationship with my carer’, ‘staff are very caring’. However, it was also said that staff ‘very busy’ and ‘don’t always have time to talk to you’, ‘when I ring my bell it takes a while for staff to come’. The level of staffing required to enable them to continue to meet residents’ needs will depend on close monitoring of dependency levels. This is particularly relevant at night when there are only routinely two staff on duty. Staff were observed interacting with residents in a cheerful and responsive way while assisting them with day to day tasks. Residents indicated that they are treated with dignity and respect. Personal service plans included information on choices in relation to daily routines. Medication records for case tracked resdients were seen and were satisfactory. The home did not have a risk assessment on a resident who administers their own medication, as advised by the Royal Pharmaceutical Society and Derbyshire County Council Guidance on the administration of medication in care homes. There was a record of signatures of staff who dispense medication. A new trolley had been purchased for the medication of short term care and intermediate/rehabilitation residents. On the day of inspection the medication room was very hot. Further advice has been sought from both the CSCI pharmacist and the supplying pharmacist. The home will be monitoring the temperature in the medication room and further action will be taken to regulate the temperature if necessary. The Spinney DS0000035801.V320698.R01.S.doc Version 5.2 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Activities are provided that generally suit the expressed preferences of residents. This assists in contributing to a pleasant atmosphere and the overall good level of satisfaction for service users. Dietary needs of residents are catered for with a balanced and varied selection of food available that meets service users’ tastes and choices. EVIDENCE: An activities book is kept and there is a range of activities that residents refer to and enjoy. However, they would like to do more and this is reflected in the comments by residents on the day of inspection, on the residents questionaires and in the notes of the resident meetings, e.g. having progressive movement every week rather than every fortnight. Both staff and residents confirm that staff are very busy and dont always have time to talk. Some activities dont always happen if care needs take priority. The Spinney DS0000035801.V320698.R01.S.doc Version 5.2 Page 14 Residents and staff are going out for Christmas lunch and a range of seasonal activities is planned, e.g. carols. A big Christmas fayre is being held at the home on the Saturday after the day of inspection, and residents and relatives are taking part. Relatives spoken to said that they were made welcome and they gave positive feedback about standards of care, ‘staff are very helpful’. Relatives said that the home always communicate any changes to them, and examples of this were given. As noted previously, residents’ preferred routines are noted on personal service plans. All residents were very positive about the standard of food which was said to be ‘good’. Each wing has a kitchenette and care staff serve breakfasts and teas, then wash up by hand, which can be time comsuming. However, the arrangements do mean that residents are served their meals in a homely environment as each wing had a separate lounge/dining area. The kitchen is to be refurbished in the new year enabling it to be used over the Christmas/New Year period. The Spinney DS0000035801.V320698.R01.S.doc Version 5.2 Page 15 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16, 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Clear and accessible complaints and safeguarding adults procedures are in place to ensure residents can be confident that any issues raised would be acted on effectively and promptly. EVIDENCE: Residents spoken to on the day of inspection said they had no complaints about the home. No resident out of three interviewed could remember if they had been given a copy of the complaints procedure, which is in fact in the Service User Guide in each bedroom. In addition the complaints procedure is displayed in each lounge. All three residents felt they had sufficient information to make a complaint about their care. All said they would discuss any difficulties with the staff, manager or people in the office. The homes system is to use the communication book for minor items, e.g. lost laundry. Residents are consulted via a series of residents meetings held on each wing and written up. The minor complaints book identified 2 complaints The Spinney DS0000035801.V320698.R01.S.doc Version 5.2 Page 16 and action taken, and one concern regarding laundry was discussed on the day of inspection and was being addressed. There have been no official complaints. Derbyshire County Council has clear procedures for dealing with the safety of residents and safeguarding them from harm. Staff spoken to showed an awareness of safeguarding adults issues and would pass any concerns on to their line manager. Training in safeguarding adults has been provided for staff. There has been a safeguarding adults incident which was dealt with appropriately by the home. The CSCI was kept fully informed of this matter. The Spinney DS0000035801.V320698.R01.S.doc Version 5.2 Page 17 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 21, 24, 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home provides residents with an attractive and homely place to live. EVIDENCE: The home is organised into ‘wings’ with a lounge/dining area, bathrooms and toilets available on each ‘wing’. There is a larger lounge at the entrance to the home where some activities and entertainment take place. Some minor redecoration is needed, but the home is generally well presented. After consultation with the residents some attractive new pictures have been purchased for some of the corridors. A security system with access code to the The Spinney DS0000035801.V320698.R01.S.doc Version 5.2 Page 18 front door is needed to improve security, and the home are also considering improved lighting outside the home. The home has pleasant gardens and several seating areas are available to residents in good weather. A water feature and other improvements have been added to the amenities this year. Residents spoken to felt the standard of accommodation was good. All liked their bedrooms, which had been personalised. Several residents spoken to had been given a choice of bedroom to enable better wheelchair access. Bathrooms and toilets were seen and were satisfactory. Some had been recently redecorated. There is an amenities fund and money was given to refurbishing the hairdressing room which is now attractive and convenient for residents use. At a previous inspection on 28 December 2005 it was found that some areas of the kitchen were poorly decorated with flaking paint; some cupboards had no doors, and some work surfaces were uneven. There are outstanding requirements regarding the upgrading of the kitchen, which is planned for January and February. There was a recent problem with the drains which has now been addressed satisfactorily. The Spinney DS0000035801.V320698.R01.S.doc Version 5.2 Page 19 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29, 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. A trained and competent workforce are in place which meet the dependency needs of residents currently accommodated within the home. EVIDENCE: Staff training records indicate that staff undertake mandatory, induction and other training to enhance their skills. Staff spoken to said that induction training was excellent and very relevant to their job. They felt they were offered good opportunities and support. Fire training will be up to date when some staff have attended a planned training session at another home. Although extra hours have been made available staff are still very busy.There are generally four or five staff on duty in the day time, and two waking night staff. As previously noted, the pressure on staff was been raised on the day of inspection, in the residents questionnaires, and in some residents meetings. There are currently two vacancies, one care and one domestic. These posts are being covered with relief staff at present. The Spinney DS0000035801.V320698.R01.S.doc Version 5.2 Page 20 The home are not formally monitoring dependency levels and need to do so to ensure that staffing levels meet the assessed needs of all residents at all times. This is particularly important given the service provided to intermediate care and short term care residents. Staff acknowledge that overall dependency levels fluctuate and this impacts on their ability to consistently provide activities. The home are committed to providing a service for as long as possible and this can include end of life care. The home try to balance this commitment with the need to ensure that, where appropriate, nursing asessments are carried out promptly. Two staff files were seen and were well organised. They had copies of contracts and other matters relating to individual members of staff, but did not have copies or evidence of CRB checks, application forms or references. This information is held centrally and is seen by managers at interview. The Spinney DS0000035801.V320698.R01.S.doc Version 5.2 Page 21 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35, 38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Arrangements are made for a suitably qualified and experienced manager to be in post and staff demonstrate an awareness of their roles and responsibilities, thus ensuring the home is run in the best interests of residents. EVIDENCE: A permanent manager will be starting in January. The current acting manager has been running the home for some time. She is experienced and has completed her registered managers training. The Spinney DS0000035801.V320698.R01.S.doc Version 5.2 Page 22 Service users, relatives and staff spoke positively about the manager and the management team. There is an ‘open door’ policy and several service users and relatives called into the office on the day of inspection, as well as health and other professionals who were visiting the home. There is good communication between staff and effective handover arrangements. Relatives said that they were always informed of any matters pertaining to residents’ well being. Each deputy takes responsibility for a particular aspect of the home, e.g. medication, hotel services, care planning. There are regular staff meetings for all groups of staff, and minutes of these meetings indicated that day to day matters were generally raised and dealt with appropriately. The home is visited regularly by a representative of the registered person and Regulation 26 visit reports were made available to the inspector. These indicated that matters of day to day management are dealt with, and residents and staff spoken to on a regular basis. In addition the home have monitoring forms regarding such matters as hospital admissions, falls, and permanent admissions. There has been a quality assurance exercise but the results of the survey have not yet been made available to the home or to residents. Residents meetings are held on each wing, and the minutes were made available to the inspector. Residents’ monies are kept in the safe and manual records kept. The inspector was informed that this system is working satisfactorily. Staff confirmed that they have regular supervision and they felt their supervisors were approachable and supportive. The requirement to reorganise the health and safety folder has been met. Information on maintenance and health and safety records was seen on the file and indicates that, apart from the electrical hard wiring certificate, matters pertaining to maintenance and health and safety are satisfactory. The electrical hard wiring certificate indicates that some electrical work needs to be carried out. Environmental risk assessments have been carried out and updated. Standards of cleanliness were satisfactory on the day of inspection. The Spinney DS0000035801.V320698.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 3 HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X 3 X X 3 x 3 STAFFING Standard No Score 27 3 28 3 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 x 3 X x 3 The Spinney DS0000035801.V320698.R01.S.doc Version 5.2 Page 24 Are there any outstanding requirements from the last inspection? yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. 2. Standard OP15 OP15 Regulation 23 2 (b) 23 2 (b) Requirement The kitchen must be redecorated. (Original timescale 30/06/06 extended) Consideration must be given to replacing and/or upgrading work surfaces and cupboards. (Original timescale 30/06/06 extended) Timescale for action 28/02/07 28/02/07 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 OP9 OP9 Good Practice Recommendations Information on residents’ personal histories, interests and hobbies should be recorded to enhance the quality of service provided. Risk assessments should be carried out for any residents who administer their own medication. The temperature in medical room should be monitored to ensure that it remains within guidelines for the storage of medication. DS0000035801.V320698.R01.S.doc Version 5.2 Page 25 The Spinney 4 5 6 7 8 9 10 OP12 OP19 OP27 OP27 OP29 OP33 OP38 The programme of developing activities should continue. A security lock should be in place on the front door. Resident dependencies should be monitored to ensure staffing levels continue to meet residents’ assessed needs. Consideration should be given to increasing night staffing levels. Copies of application forms and evidence of CRB checks having been done should be available on all staff files. The results of the quality assurance questionnaire should be made available to service users and a plan prepared to action any improvements needed. A satisfactory programme for carrying out work identified on the recently electrical hard wiring certificate should be drawn up. The Spinney DS0000035801.V320698.R01.S.doc Version 5.2 Page 26 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 The Spinney DS0000035801.V320698.R01.S.doc Version 5.2 Page 27 - 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!