Care Home: Spring Lane Care Home

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What the care home does well This home is well run and staff work very hard to provide a very good level of care and support for residents. Residents are treated as individuals and with respect and dignity. Those residents with dementia showed good levels of wellbeing and were being appropriately engaged by staff. Residents have a say in how their care is to be delivered and the management of the home quickly responds to any concerns they may have. Residents are encouraged to live as independently as possible and can choose from a wide range of activities provided by the home. The building is clean, well maintained and decorated to a high standard. What has improved since the last inspection? Two requirements were issued at the last inspection. The registered person has complied with both of these. The home makes sure that people`s needs are assessed in detail before they move into the home so that the prospective resident knows the home will be able to meet all their needs. The results of any quality monitoring reviews are now compiled and published by the home and given to all residents and other stakeholders. This means that people who use the service can see how well the home is doing to achieve the aims and objectives of the service. Two good practice recommendations, issued at the last inspection, have also now been complied with. This means that resident`s individual social interests are being recorded so the staff know how to keep people suitably occupied andengaged. The labelling of people`s clothes has improved and the home receives fewer complaints about this issue. CARE HOMES FOR OLDER PEOPLE Spring Lane Care Home Spring Lane Care Home 170 Fortis Green Muswell Hill London N10 3PA Lead Inspector Mr David Hastings Unannounced Inspection 09:30 28 August 2008 th X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Spring Lane Care Home DS0000061606.V365571.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. Spring Lane Care Home DS0000061606.V365571.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Spring Lane Care Home Address Spring Lane Care Home 170 Fortis Green Muswell Hill London N10 3PA 020 8815 2000 020 8815 2001 spring_lane@btconnect.com 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) Springdene Nursing & Care Homes Ltd Marilyn Prenilla Amrill Belgrave Care Home 63 Category(ies) of Dementia - over 65 years of age (63), Old age, registration, with number not falling within any other category (63), of places Physical disability (1) Spring Lane Care Home DS0000061606.V365571.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. One (1) place for a service user under the age of 65, with a physical disability, can be accommodated. 12th February 2007 Date of last inspection Brief Description of the Service: Springlane is owned by Springdene Nursing and Care Homes Ltd who own three other residential homes in North London. Springlane is the companies’ most recent development and has undergone a comprehensive refurbishment. This is the second inspection since the home has been registered with the CSCI. The home is divided into five floors. The main lounge, activities room and dining area are situated on the ground floor. The rooms on the ground floor are currently not occupied. The first and second floors each have fifteen rooms for older people. The second and third floors have fifteen and twelve rooms for people with dementia. Both these floors have a separate lounge and the forth floor has it’s own dining room. The entire home has been refurbished to an excellent standard. All sixty-three rooms have a wash hand basin and toilet. Fifty-one of the rooms are fully en-suite. There is a small lounge on both the first and second floor. There is a reception area on the ground floor and there is a pleasant garden at the rear of the home. There are two lifts to all floors. The home is situated in a residential area close to local shops and public transport. The stated aims and objectives of the organisation are to provide homes that are safe, social, comfortable and healthy to live in. The home will be run for the benefit of the residents: that is its prime purpose. The current scale of charges are £650 - £850 per week. Copies of this report are available form the home or from the CSCI website. Spring Lane Care Home DS0000061606.V365571.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 3 stars. This means the people who use this service experience excellent quality outcomes. This Key Unannounced inspection took place on Thursday 28th August 2008 and was completed on the same day. The inspection lasted seven hours. We spoke with ten staff on duty during the inspection. We spoke with fourteen residents of the home and three visitors. We observed the interactions between staff and residents. We inspected the building and examined various care records as well as a number of policies and procedures. The home completed an Annual Quality Assurance Assessment (AQAA) prior to the inspection at the request of the CSCI, and this was used to form part of the overall inspection process. What the service does well: What has improved since the last inspection? Two requirements were issued at the last inspection. The registered person has complied with both of these. The home makes sure that people’s needs are assessed in detail before they move into the home so that the prospective resident knows the home will be able to meet all their needs. The results of any quality monitoring reviews are now compiled and published by the home and given to all residents and other stakeholders. This means that people who use the service can see how well the home is doing to achieve the aims and objectives of the service. Two good practice recommendations, issued at the last inspection, have also now been complied with. This means that resident’s individual social interests are being recorded so the staff know how to keep people suitably occupied and Spring Lane Care Home DS0000061606.V365571.R01.S.doc Version 5.2 Page 6 engaged. The labelling of people’s clothes has improved and the home receives fewer complaints about this issue. 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. Spring Lane Care Home DS0000061606.V365571.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Spring Lane Care Home DS0000061606.V365571.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1 and 3 (6 not applicable) People who use this service experience excellent outcomes in this area. This judgement has been made using available evidence including a visit to this service. Prospective residents have accurate information about the home in order to make an informed choice about where to live. People are confident that the care home can support them. This is because there is an accurate assessment of their needs that they, or people close to them, have been involved in. This tells the home all about them and the support they need. EVIDENCE: We examined the home’s “Statement of purpose” and “Service user guide”. These documents describe the aims and objectives of the home and the facilities available to people coming into the home. These documents also inform social workers looking for placements for people. The documents contained clear information to prospective residents about what services are available as well as the aims and objectives of the home. Spring Lane Care Home DS0000061606.V365571.R01.S.doc Version 5.2 Page 9 There is a clear statement about how the home encourages people from different backgrounds and cultures to use this service. The manager was able to describe how the needs of people from different backgrounds and cultures can be met at the home including appropriate diets and religious observance. We examined three assessments of people who have recently moved into the home. The manager told us that someone from the home would visit a prospective resident and carry out an assessment of their needs before they moved in. These assessments were detailed and covered all the elements required by this Standard including the assessment of physical, emotional, social and cultural needs. These assessments did not include potential residents with mental health problems as their primary need. The home is not registered to accept people who have a mental health problem as their primary need. This was a requirement from the last inspection that has now been complied with. People who use the service and their relatives told us that they were involved in this assessment process and, where possible, had visited the home before moving in on a trial basis. The manager told us there were times when a potential resident would visit the home on a number of occasions to ensure that they felt safe and comfortable at the home. It was clear from discussion with the manager that people would only be admitted to the home if it was right for them. We also found that the information from these assessments was being recorded on peoples’ care plans as well. There was evidence that people moving into the home have a review of their placement after four to six weeks to see if they are happy at the home and whether they decide to move in on a permanent basis. Spring Lane Care Home DS0000061606.V365571.R01.S.doc Version 5.2 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10 People who use this service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. Care plans clearly set out residents’ health, personal and social care needs so that staff know how best to support everyone at the home. Residents have good access to health care professionals and they are treated with respect. Residents get the medication they require, at the right times and by appropriately trained staff. EVIDENCE: Eight care plans were examined. Each plan gave clear instructions to staff about how best to care for each person. Staff that we spoke with had a good understanding of the care needs of residents and how the care plan enables all staff to provide a consistent approach to the care provided. People’s health, personal and social care needs were recorded on each plan. Care plans seen were “Person centred” in approach and contained information about how to maintain an individual’s privacy and dignity. Care plans also detailed people’s cultural needs. The manager told us that all plans are given Spring Lane Care Home DS0000061606.V365571.R01.S.doc Version 5.2 Page 11 to residents or their representatives to look at and amend if needed when they first move in. Although care plans were being reviewed, there was little evidence that residents had been involved in the review of their plans. Although all the people we spoke with said they were generally happy with their care, it is important that people are given an opportunity to decide if they want changes to their plan of care. A requirement has been issued that people are consulted about their care and the quality of the care they receive on a regular basis when their care plan is being reviewed. This should include asking people who use the service about their social and recreational needs as well as their physical care needs. Each person’s plan of care included an assessment of the risk of falling and how staff are to reduce this risk, for example, having two staff to help with personal care tasks or by supervising the resident when they walk around the home. The manager carries out an analyse of the incidents of falls to see if any patterns emerge that could help staff to reduce the number of falls at the home. We saw evidence that people are being referred to the “Falls Clinic” in order that they can be further assessed. Other risk assessments were seen including moving and handling, pressure care and nutrition. People who have been assessed as being at risk from developing pressure sores had special mattresses to reduce this risk. There were also risk assessments in place to support people with dementia. Visits by health care professionals such as doctors, district nurses, chiropodists, dentists and opticians were being recorded on plans we examined. These showed that people had good access to these professionals. This was also confirmed by residents and relatives we spoke with. The doctor visits once a week and staff record any problems in the “Doctors’ book”. The doctor was visiting the home on the day of the inspection. Satisfactory records were examined in relation to the receipt, administration, storage and disposal of medication. Records indicated that staff have undertaken medication training and only qualified staff administer medication at the home. The CSCI pharmacist undertook an inspection of the home’s medication receipt, administration, storage and disposal at the last key inspection. The report was sent to the home and kept on the CSCI file. There were no major issues identified and three recommendations were given as a result of the inspection. We saw a number of examples of supportive staff interactions with people and staff were able to describe to us how they ensure the privacy of people they support. We saw staff knocking on resident’s bedroom doors before entering. People we spoke with told us that the staff were respectful and kind towards them. One Spring Lane Care Home DS0000061606.V365571.R01.S.doc Version 5.2 Page 12 resident told us, “The staff are very good”. As a result of a good practice recommendation, issued at the last inspection, the home has reviewed the policy of labelling residents’ clothes. As a result of this complaints about clothes going missing have reduced considerably. Spring Lane Care Home DS0000061606.V365571.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 and 15 People who use this service experience excellent outcomes in this area. This judgement has been made using available evidence including a visit to this service. The home provides varied activities for people who use the service in order to keep them suitably occupied and engaged. The home encourages visitors, which ensures an interesting and lively atmosphere. Residents are able to exercise choice and control over their lives. The home provides people with a wholesome appealing balanced diet. EVIDENCE: The home employs two activities coordinators. Records indicated that people could choose from a range of activities including trips out of the home. Most group activities take place on the ground floor. The activities coordinators also work some of the time on the dementia units. We also saw staff carrying out activities with residents on the forth and third floor. It was clear that residents were benefiting from the kind and supportive interactions from staff. On the morning of the inspection a pianist was entertaining the residents in the ground floor lounge. One person told us that the ground floor lounge was closed to residents after 6 o’clock but the manager said this was not the case as the receptionist worked till 9 o’clock and the lounge was open to residents at all times. Spring Lane Care Home DS0000061606.V365571.R01.S.doc Version 5.2 Page 14 People’s individual interests and hobbies were recorded on all care plans we examined. This was a good practice recommendation that was issued at the last inspection to ensure that staff are aware of how residents at the home like to spend their day. There was also evidence that residents go out of the home and are accompanied by staff if needed. We saw a number of visitors to the home during the inspection. Visitors told us that they could visit at any reasonable time and that they were made welcome by the management and staff. Residents we spoke with confirmed this. One visitor told us they were, “Very impressed” by the home and the staff. Another visitor told us the home was, “Well run”. Care plans gave good examples of how choice is offered to residents in relation to activities, food, clothes and personal care. People told us that they felt they had choice and control over their lives. Records of residents’ meetings also provided evidence that people could have a say in the running of the home. Staff we interviewed were able to give us practical examples of how they offer choice to people living at the home. This included times that residents wanted to get up in the morning and making sure that residents were able to choose the clothes they wanted to wear. There was evidence that service users could choose the menu they wanted and service users told the inspector that the chef would make them something else if they did not want what was on the menu for that day. There was evidence that residents regularly discussed the menu plan at their meetings. Snacks are available throughout the day. Residents were observed enjoying their lunch in relaxed and pleasant surroundings. Staff were giving discreet assistance were needed. People commented that the food was very good at the home. One person told us, “We eat well”. We visited the kitchen during the inspection. It was found that fridge temperatures were being routinely recorded. The kitchen was clean and well maintained and there was plenty of fresh fruit and vegetables available. The chef was interviewed and had a good knowledge of individual resident’s dietary needs and preferences. The menus seen contained a choice of meal as well as a vegetarian option. Cakes are prepared for all residents’ birthdays. The kitchen has recently been inspected by the local Environmental Health department and has been awarded 5 “Scores on the doors” which is the highest possible score obtainable. Spring Lane Care Home DS0000061606.V365571.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 and 18 People who use this service experience excellent outcomes in this area. This judgement has been made using available evidence including a visit to this service. All complaints are taken seriously and dealt with in an open manner within set timescales. People who use the service are protected from abuse by clear policies and procedures and by a well-informed, trained staff group. EVIDENCE: The home has satisfactory policies and procedures in relation to complaints and the protection of residents from abuse. The record of complaints was inspected. The manager records all complaints and concerns, however minor. Records seen indicated that they had been dealt with according to the home’s complaints procedure. There was a written record of the outcomes of these complaints so that it was clear what action the manager had taken. All the residents and visitors we spoke with said they had no complaints about the service but were clear that they would say something if they had a concern. Staff were able to describe how vulnerable people could be at risk of abuse in a residential care setting. All staff interviewed were clear of their responsibility to report any suspicions of abuse to the appropriate authorities. Residents that we spoke to said they felt safe and well supported at the home. Records indicated that staff have undertaken training in the protection of vulnerable people. Spring Lane Care Home DS0000061606.V365571.R01.S.doc Version 5.2 Page 16 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 and 26 People who use this service experience excellent outcomes in this area. This judgement has been made using available evidence including a visit to this service. The home is well maintained, safe and decorated and furnished to a high standard. Service users have safe, comfortable bedrooms with their own possessions around them. The domestic staff work hard to ensure the home is always clean and free from offensive odours. EVIDENCE: The manager showed us around the home and we met with some residents in their rooms. We also looked at the bathroom and toilet facilities in the home. All areas of the home are decorated and furnished to a very high standard. The garden provides a paved area with seating. The garden has recently been extended and now provides more seating for people and a small fishpond. Residents that we spoke with said they were happy with the layout of the home and their individual bedrooms. Rooms that we visited had been individualised with the person’s own furniture and personal possessions. There is a large communal lounge on the ground floor with a dining area and smaller Spring Lane Care Home DS0000061606.V365571.R01.S.doc Version 5.2 Page 17 lounges on the other floors, some with large screen televisions. Residents said they liked to sit in the ground floor as they could see what was going on. The fourth floor has a self contained lounge and dining area. There is a maintenance book to record any problems so the maintenance person knows what needs fixing around the home. We saw the laundry area, which has satisfactory equipment including facilities for sluicing bedding and clothes as required. All toilets and bathrooms contained anti-bacterial soap and electric hand dryers to limit the risk of cross infection. Mandatory training in infection control is also provided for staff. People we spoke with said the home was clean and there were no offensive odours present on the days of the inspection. One resident told us, “It’s spotless”. Another resident commented, “They keep it nice and clean”. Spring Lane Care Home DS0000061606.V365571.R01.S.doc Version 5.2 Page 18 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30 People who use this service experience excellent outcomes in this area. This judgement has been made using available evidence including a visit to this service. The staff at the home work very hard to meet the needs of the residents and are provided with good training opportunities to further enhance their knowledge and skills. Recruitment practices are sufficiently detailed in order to protect residents at the home. EVIDENCE: On the day of the inspection there were thirty-nine people residing at the home. Staffing levels appeared sufficient for the number of residents and their level of dependency. The rota was examined and matched the names of staff on duty. There are eight care staff on duty throughout the day and four waking night care staff on duty during the night. Both residents and visitors were very positive about the staff group. One resident commented, “The care is good, excellent”. The manager informed us that 70 of care staff have obtained NVQ level 2 or equivalent. This exceeds the requirements of Standard 28 of the National Minimum Standards for Older People. We examined a satisfactory training programme and there were copies of relevant certificates on file. Training covered mandatory training as well as training in dementia and diversity. Spring Lane Care Home DS0000061606.V365571.R01.S.doc Version 5.2 Page 19 Staff interviewed were positive regarding the training they had undertaken at the home and the training opportunities available to them. One staff member told us, “I’ve done a lot of training since I started here. It’s good it will help me a lot”. Three staff files were examined from staff recently employed by the home. We checked these files to see if the home’s recruitment procedures were being followed so that residents are protected from unsuitable staff working at the home. The files examined contained all the information needed to protect residents including two written references, proof of identity and criminal record checks. Spring Lane Care Home DS0000061606.V365571.R01.S.doc Version 5.2 Page 20 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 and 38 People who use this service experience excellent outcomes in this area. This judgement has been made using available evidence including a visit to this service. Residents and staff benefit from a manager who takes her responsibilities seriously and makes sure the home is well run. People who use the service are able to have their say in the way the home is run and their input is used by the management to improve the quality of the service. Residents’ financial interests are safeguarded by clear policies and procedures. The home has good systems in place to monitor health and safety compliance. EVIDENCE: It was clear from discussion with the manager that she has the competences and skills required to run the home effectively. The manager was able to describe in detail each person’s individual needs and we observed excellent interactions between the manager and residents. Staff, visitors and residents Spring Lane Care Home DS0000061606.V365571.R01.S.doc Version 5.2 Page 21 were very positive regarding the manager’s abilities. A number of staff commented that the manager was, “Very supportive”. There was evidence that the manager updates her training as and when required. There was evidence from regulation 26 reports, residents meetings and six monthly customer satisfaction surveys that residents’ views are sort and used to monitor the quality of the care provided by the home. The information from these sources is now being compiled and published for existing as well as prospective service users and their representatives and other stakeholders. This was a requirement from the last inspection that has now been complied with. It was clear from discussion with the manager and the directors of the service that they are very proactive with regard to improving the quality of care at the home. We examined the latest customer satisfaction report for the home. This indicated that 100 of respondents were very satisfied or satisfied with the physical environment, the standard of care, communications and staff at the home. Small amounts of money are held by the home on behalf of residents. This money is used to buy various items for individuals such as toiletries and to pay for hairdressing and outings. A sample of these accounts were examined and found to be accurate with clear audit trails. The fire logs were inspected. Weekly fire alarm checks and regular fire drills are recorded as taking place both for day and night staff. A fire risk assessment was carried out of the home in April 2008. Satisfactory records were examined in relation to gas safety, electrical installation, PAT testing, Legionella tests and fire alarm maintenance. We also saw records of regular health and safety meetings and monthly health and safety checks of the home by the manager. Staff training records indicated that staff are undertaking the required health and safety training in order to protect both residents and staff. Spring Lane Care Home DS0000061606.V365571.R01.S.doc Version 5.2 Page 22 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 4 X 4 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 4 9 4 10 4 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 4 14 4 15 4 COMPLAINTS AND PROTECTION Standard No Score 16 4 17 X 18 4 4 X X X X X X 4 STAFFING Standard No Score 27 4 28 4 29 4 30 4 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 4 X 4 X 4 X X 4 Spring Lane Care Home DS0000061606.V365571.R01.S.doc Version 5.2 Page 23 Are there any outstanding requirements from the last inspection? No STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP7 Regulation 15(2) c The registered person must ensure that residents or their representatives are consulted about their care and are given the opportunity to comment on the quality of the care each time their care plans are reviewed. This is to ensure that people have a say in how they would like their care to be delivered. Requirement Timescale for action 01/12/08 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Spring Lane Care Home DS0000061606.V365571.R01.S.doc Version 5.2 Page 24 Commission for Social Care Inspection London Regional Office 4th Floor Caledonia House 223 Pentonville Road London N1 9NG 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 Spring Lane Care Home DS0000061606.V365571.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. 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