Care Home: Spring Mount

What the care home does well The comments made by everyone connected with the home support our observations that the home is well managed and run in the best interests of the people who live there. The people who live at the home all made positive comments about the care and support they receive. People said the staff listen to them and act on what they say. One relative said that `...the owners and staff are always friendly and helpful, and are able to tell me how my (relative) has been...`. Another relative said that `The level of care and the attitude of the staff is excellent, as is communication between them and myself`. One member of staff said that the home `...promotes the well-being of the person with dementia`. Staff said that the home promotes and supports the equality and diversity of the people who live at the home and the staff. They said everyone is treated equally. One healthcare professional said that the home `Accepts each individual on their own merits and personalises the approach to each`. They said the home offers a `...warm, accepting environment...`. People said they know how to make a complaint or raise a concern if they are not satisfied with any aspect of the service. They said they would either speak to the manager or discuss their concerns with their family or the staff. The care and support plans reflect each individual`s preferences and needs. People are involved in making decisions about the way the home they live in is run, and the management and staff make sure their views are central to any decisions. It was clear during the inspection that the staff know and understand each person and do everything they can to support people`s individual needs. People`s right to make individual choices is respected and supported. People`s cultural and spiritual needs are understood and met. The recruitment procedures are thorough, making sure that the staff who are appointed are safe and suitable to work with the people who live at the home. The staff are well qualified and are encouraged to keep up their professional development by taking training to keep their skills and knowledge up to date. What has improved since the last inspection? The registered providers have introduced a programme of management experience, training and qualifications for senior staff. One of the staff is now a National Vocational Qualifications (NVQ) assessor. This means that staff`s work can be assessed more effectively and will support staff to gain their NVQ award. Since the last inspection, more staff have gained their NVQ award at levels 2 and 3 and one member of staff is studying for a Diploma in Dementia Care at Bradford University. A `memory` garden has been created. The home has improved its access to outreach services, in order to widen people`s social lives and experiences, as well as improving the range of activities available in the house. The care plan review processes have been revised to make them more effective. What the care home could do better: It is important that care plans and reviews not only reflect the individual and their needs, but are always written in a way that shows respect and understanding for the person. An accurate record of all medicines received, as well as a `brought forward` system should be introduced. This would make it easier to check the medicines, to confirm that administration is always accurate and keep an accurate record of all medicines in stock. People`s personal information is stored on open shelves in a downstairs office that is not always locked when the room is empty. This means that personal information is potentially accessible to people who have no right to see these files. CARE HOMES FOR OLDER PEOPLE Spring Mount Parsons Road Heaton Bradford West Yorkshire BD9 4DW Lead Inspector Liz Cuddington Key Unannounced Inspection 22nd December 2008 12:00 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 Mount DS0000001147.V373701.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 Mount DS0000001147.V373701.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Spring Mount Address Parsons Road Heaton Bradford West Yorkshire BD9 4DW 01274 541239 01274 772000 info@springmount.org 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) Mrs Janet Bell Mrs Jacqueline Taylor Smith Mrs Janet Bell Mrs Jacqueline Taylor Smith Care Home 24 Category(ies) of Dementia (24), Dementia - over 65 years of age registration, with number (24) of places Spring Mount DS0000001147.V373701.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 5th January 2007 Brief Description of the Service: Spring Mount was established and first registered in 1987. Janet Bell and Jacqueline Taylor Smith are the registered providers and also manage the home. It is a large detached house situated in its own half acre of well-maintained garden. The grounds are secure in order to ensure the safety of people, whilst enabling free movement. To gain access to the grounds callers have to ring an intercom at the gate for staff to open the automatic gates. Spring Mount’s aim is to provide a homely environment for individuals of all ages suffering from memory disorder and dementia. Accommodation is provided on three floors. There are eight ground floor bedrooms, one on the third floor and the remaining rooms are on the first floor. Those with mobility needs have rooms on the ground floor, as there is no passenger lift. The local area has a variety of shops, pubs and Lister Park. The home can be reached using public transport. The overall philosophy at Spring Mount is to care for people with a diagnosis of dementia, without the effects created by the administration of sedating medication. Staff in the home use a holistic, psychotherapeutic approach toward problems associated with dementia, enabling the person to come to terms with, and learn to live with their dementia in a positive way, retaining dignity and self-respect. Spring Mount DS0000001147.V373701.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 2 stars. This means the people who use this service experience good quality outcomes. We have reviewed our practice when making requirements, to improve national consistency. Some requirements from previous inspection reports may have been deleted or carried forward into this report as recommendations, but only when it is considered that people who use the service are not being put at significant risk of harm. In future, if a requirement is repeated it is likely that enforcement action will be taken. The current weekly charge at the home is £510. This charge does not include chiropody, hairdressing, private dental treatment, optical or medical fees, newspapers, meals out or telephone calls. The purpose of this inspection was to assess the quality of the care and support received by the people who live at Spring Mount. The visit to the home was carried out over one day by one inspector. Since the last inspection in January 2007, no complaints or concerns have been made to us about the home. Two adult protection referrals have been made to Bradford Social Services. These have been resolved satisfactorily. The methods used to gather information included conversations with the people living at the home and the staff, looking at care plans and examining other records. Many of the people who live and work at the home returned questionnaires to us and we also received the home’s self-assessment questionnaire before the inspection visit. We also received a questionnaire from a healthcare professional. These questionnaires provide valuable information to help us form a judgement about the quality of the care and support the home provides. Their views and comments are reflected in the report. We would like to thank the people who live at Spring Mount and the staff, for their welcome and hospitality and for taking the time to talk and share their views during the visit. Spring Mount DS0000001147.V373701.R01.S.doc Version 5.2 Page 6 What the service does well: The comments made by everyone connected with the home support our observations that the home is well managed and run in the best interests of the people who live there. The people who live at the home all made positive comments about the care and support they receive. People said the staff listen to them and act on what they say. One relative said that ‘…the owners and staff are always friendly and helpful, and are able to tell me how my (relative) has been…’. Another relative said that ‘The level of care and the attitude of the staff is excellent, as is communication between them and myself’. One member of staff said that the home ‘…promotes the well-being of the person with dementia’. Staff said that the home promotes and supports the equality and diversity of the people who live at the home and the staff. They said everyone is treated equally. One healthcare professional said that the home ‘Accepts each individual on their own merits and personalises the approach to each’. They said the home offers a ‘…warm, accepting environment…’. People said they know how to make a complaint or raise a concern if they are not satisfied with any aspect of the service. They said they would either speak to the manager or discuss their concerns with their family or the staff. The care and support plans reflect each individual’s preferences and needs. People are involved in making decisions about the way the home they live in is run, and the management and staff make sure their views are central to any decisions. It was clear during the inspection that the staff know and understand each person and do everything they can to support people’s individual needs. People’s right to make individual choices is respected and supported. People’s cultural and spiritual needs are understood and met. The recruitment procedures are thorough, making sure that the staff who are appointed are safe and suitable to work with the people who live at the home. The staff are well qualified and are encouraged to keep up their professional development by taking training to keep their skills and knowledge up to date. Spring Mount DS0000001147.V373701.R01.S.doc Version 5.2 Page 7 What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Spring Mount DS0000001147.V373701.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 Spring Mount DS0000001147.V373701.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): 2 Standard 6 does not apply People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People are assessed before they are admitted to the home, to make sure their needs can be met. EVIDENCE: People said that they were given enough information about the home before deciding to move in, and they have also received a contract. Where possible the home encourages people and their families to visit and talk to the people who already live at the home, their relatives and the staff. The home invites them to come and spend time there, share a meal and maybe take part in the days activities. Some people may stay for short visits or attend for day care before deciding to move in. Everyone said they had enough information about the home before they made a decision. Spring Mount DS0000001147.V373701.R01.S.doc Version 5.2 Page 10 Before moving into Spring Mount, peoples needs are assessed to make sure that the home is able to meet their needs. This assessment forms the basis for the individual plan of care and support. Any Social Services’ assessments are also taken into account when assessing people’s needs and developing initial care plans. These measures mean that the home can get to know the persons needs and the individual has the information he or she needs in order to make a decision. People said they had received a contract, detailing the terms and conditions of their stay. Spring Mount DS0000001147.V373701.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 People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Peoples personal and healthcare needs are met. People are generally protected by the medication administration systems. Staff treat people with respect, care and consideration at all times. EVIDENCE: People receive the medical and healthcare support they need and any concerns about their health are followed up. Everyone we spoke to said the care and support is of a good standard. Peoples relatives said they are very satisfied with the care offered. They felt that the staff know what they are doing and understand peoples needs. Spring Mount DS0000001147.V373701.R01.S.doc Version 5.2 Page 12 Our observations confirmed that the staff understand peoples care needs. For example, when supporting someone to carry out a task such as eating a meal, the staff clearly understood how the person likes to be assisted. Two care and support plans were looked at, to make sure that peoples health and personal care needs are being met in the way each person prefers. The plans cover each area of the individuals needs. They all contain enough information to guide staff in how to care for and support each person. The care plans are straightforward, well organised and easy to follow and each area of a persons needs is detailed. The plans include risk assessments and management plans where someone is at risk of falling, developing a pressure sore, becoming malnourished or any other area the staff feel may put the individual at any risk. The people themselves, and their relatives if they wish, are involved in reviewing and updating the care plans. The plans are reviewed every month by the staff, to make sure they still reflect each individuals care and support needs. The language used in one person’s review was somewhat judgemental, using words such as ‘selfish’ and saying that the person only considers themselves. It is important that care plans and reviews reflect the individual and their needs, but they should always be written in a way that shows respect and understanding for the person. The daily records are kept up to date and include information on significant occurrences. Staff said they are kept informed through handover meetings at the start and end of each shift, as well as by other means. One person said that their relative’s file is always available, is kept up to date and lets them know what their relative has been doing on the days since their last visit. People said that staff are very good and understand their needs. They said staff do what people want, in the way they prefer. People said they are happy with the care they receive. There are systems for highlighting information that needs to be passed onto the next group of staff. The staff confirmed that communications within the home work very well and they are always kept up to date. Detailed medical records are kept showing, for example, when the GP visited and the outcome, as well as any further healthcare support that is needed. One healthcare professional said they felt that individual’s healthcare needs are always met at Spring Mount, saying that ‘…staff have a high level of expertise…’. Spring Mount DS0000001147.V373701.R01.S.doc Version 5.2 Page 13 The medicines are kept safe and secure and the Medicines Administration Record (MAR) charts are securely stored. For security, the medicine cabinet was locked during the time between giving each person their medication. Most of the medicines are supplied by the pharmacy in a monitored dosage system, but some is received in the original packaging. The MAR charts, which must show clearly the quantities of medicines received and in stock for each person, were examined. The medicines supplied in the monitored dosage system appeared to be administered and recorded accurately. There were signatures to confirm that staff had administered the medicine. There were no records on the MAR charts of the quantities received or brought forward from the last recording period. It is essential that the quantities of all medicines received into the home are recorded, in order to be able to keep an accurate check on the numbers administered and remaining. The records of amounts received, administered and in stock of some medicines that were supplied in their original packaging were not accurate. We found a number of medicines where the amounts remaining in the packets did not tally with the quantities received and signed for as administered. For example, the home had received 28 tablets for one person on 13/12/08. The MAR chart showed that only 10 tablets had been administered, but the packet in the medicine trolley was empty. If theses tablets have been returned to the pharmacy, or transferred to a monitored dosage system, then this should be clearly recorded. An accurate record of all medicines received, as well as a brought forward system, would make it easier to check all quantities of medicines, to confirm that administration is always accurate and keep an accurate record of all medicines in stock. During the visit, all the staff were seen to treat people with respect and maintain their dignity. One healthcare professional confirmed this. The people who commented said that they receive the care they need and are supported to maintain their independence for as long as they are able. Peoples relatives confirmed this. Everyone said the staff listen and act on what they say. Spring Mount DS0000001147.V373701.R01.S.doc Version 5.2 Page 14 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 People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People are supported to take part in a range of activities. People are offered a good choice of meals, to make sure their dietary needs and preferences are met. EVIDENCE: Everyone confirmed that people are supported to make their own decisions about all aspects of their life. People are able to choose what they prefer to do each day and are supported to follow their own interests. Most people enjoy individual activities such as playing dominoes, knitting and going out for walks. Some people like to work in the garden helping the caretaker potting plants and maintaining the garden. A physiotherapist comes in on most days and spends time on individual physiotherapy and taking group exercise sessions, which everyone seemed to Spring Mount DS0000001147.V373701.R01.S.doc Version 5.2 Page 15 enjoy. This helps people’s physical well-being and co-ordination, as well as being a fun activity with music that people remember from their younger days. People said they like the meals and thought they were very good with generous portions. The meals are planned to include the wishes of the people who live at the home and to meet any special dietary needs. Drinks are available throughout the day and there is a cooler where people can help themselves to cold drinks. People are also offered ‘smoothies’ and freshly squeezed orange juice. Fresh fruit and homemade cakes are also provided. At lunchtime there is a choice of main course and dessert and the menus are flexible, to suit peoples preferences. There is always food available for staff to make a snack for people during the night. The chef was knowledgeable about peoples different dietary needs and makes sure that special diets are provided for those who need them. People are involved in menu planning and different methods, such as photo cards, are used to prompt people’s memories and help them make informed choices. People said they enjoy their meals and staff were on hand to discreetly assist people who needed some help to eat and to encourage people to finish their meal. Conversations with people confirmed that the staff support people to maintain and meet their cultural needs. People are supported to attend religious services and follow their beliefs within the home, if they wish. Visitors are always welcomed to the home. There is a relaxed atmosphere and a good relationship between people who live at Spring Mount and the staff. Spring Mount DS0000001147.V373701.R01.S.doc Version 5.2 Page 16 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 People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People are aware of how to raise a concern or make a complaint if they are dissatisfied with the service. The staff have received suitable training and understand the adult protection policies and procedures, which makes sure that people at the home are safe. EVIDENCE: Any complaints or concerns are recorded in a complaints file. The actions taken and the outcomes are recorded. Staff said they know what to do if anyone has concerns. Everyone said they know what to do if they have a concern or complaint, one person said they ‘Would speak to the manager’. Newly employed staff are made aware of the home’s whistle blowing policies and procedures, to be used if they suspect abuse or see examples of poor practice. The care staff have had adult protection training, and further refresher training is planned. All the appropriate policies and procedures are in place to guide staff. Spring Mount DS0000001147.V373701.R01.S.doc Version 5.2 Page 17 The two referrals to Bradford Social Services’ Adult Protection staff were investigated and resolved satisfactorily. Spring Mount DS0000001147.V373701.R01.S.doc Version 5.2 Page 18 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, 20, 25 & 26 People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home provides a safe, comfortable, attractive and well-maintained environment. EVIDENCE: The home is clean and well maintained and everyone we spoke to said the home is always kept fresh and clean. The rooms are comfortably furnished and have a welcoming feel. There are sufficient, accessible toilets and bathrooms throughout the house. Staff are employed to help look after the maintenance of the house and grounds as well as keeping the gardens tidy. Spring Mount DS0000001147.V373701.R01.S.doc Version 5.2 Page 19 People said they are happy with their bedrooms and said they are very comfortable. The lounge and dining rooms are comfortably furnished and the home has a warm and welcoming atmosphere. The gardens are attractive, there is plenty of seating for people to use in the better weather and a ‘memory garden’ is being developed. There is also a large conservatory where people can enjoy seeing the garden when it is not warm enough to sit outside. The laundry is well organised and staff make sure that peoples personal clothing, as well as bedding and towels, are properly cared for. Protective gloves and aprons are available for staff to use, as part of the home’s infection control measures. Spring Mount DS0000001147.V373701.R01.S.doc Version 5.2 Page 20 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 People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Sufficient staff are employed to meet peoples needs. People are protected by thorough recruitment procedures, which ensure that staff are suitable to work with people who live at the home. Suitable training is provided to make sure staff have the skills and knowledge they require, to be able to meet peoples needs. EVIDENCE: The staff rotas, and peoples comments, confirmed our observations that there are enough staff on duty to meet peoples care needs. The staff who commented also confirmed this. All new staff complete an application form and provide two written references. Criminal Records Bureau (CRB) and Protection of Vulnerable Adults (POVA) register checks are obtained and no new staff begin work until these checks have been completed satisfactorily. Spring Mount DS0000001147.V373701.R01.S.doc Version 5.2 Page 21 There is plenty of training available for staff. All the staff we spoke to said the training is good and keeps them up to date and the home keeps good records of staff training. The staff said the home provides the training they need and one said ‘…all staff are being trained in areas related to dementia…and the working environment…’. The training planned for 2009 includes courses in palliative care, epilepsy awareness and the philosophy of dementia. All new care staff complete induction training, which meets the Skills for Care criteria. This gives them good basic training to help them do their job effectively, and provides a sound basis for taking a National Vocational Qualification (NVQ) course. In addition staff attend training courses covering all areas of the general principles of care. The staff confirmed that their induction training was thorough and one said that ‘…all important areas are covered…’. Eleven of the seventeen permanent care staff have achieved an NVQ level 2, or above, in care and two staff are currently taking the level 2 award. Two staff are enrolled to start the level 3 NVQ course in the New Year and two are to take the level 4 award. A senior member of staff is now an NVQ assessor and one staff member said ‘…she helps a lot (with) training’. Staff said they are encouraged to take an NVQ qualification. Spring Mount DS0000001147.V373701.R01.S.doc Version 5.2 Page 22 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, 32, 33, 35, 36, 37 & 38 People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home is safe and well managed, in the best interests of the people who live there. EVIDENCE: The managers, who also own the home, have the necessary experience and qualifications to manage the home effectively and in the best interests of the people who live there. Their expertise in the care and support of people living with a diagnosis of dementia, or other related condition, is based on a wealth and depth of Spring Mount DS0000001147.V373701.R01.S.doc Version 5.2 Page 23 experience and knowledge. They keep up their professional development in a number of ways, including working closely with the Bradford dementia team at Bradford University. The records, and the staff, confirmed that all the staff have regular one to one supervision meetings with their line manager. This supports staff to plan their personal and professional development and gives them the opportunity to discuss any areas of concern in a confidential setting. The home has a range of quality assurance systems in place, to help determine the quality of service the home offers and plan further improvements. These include regular staff meetings and questionnaires for people’s relatives to complete. Peoples personal information is stored on open shelves in a downstairs office that is not always locked when the room is empty. This means that personal information is potentially accessible to people who have no right to see these files. Staff files are kept in the manager’s office, which is locked when unattended. Where the home helps people to manage their personal finances, accurate records are kept of all transactions and all monies are securely stored. The homes policies and procedures are kept up to date; to make sure they provide relevant information to guide staff on how to act in every situation. All the regular health and safety checks for the home are carried out in a timely manner. The fire safety checks are carried out regularly and staff have had the necessary training and practice fire drills. These measures make sure that the health, safety and welfare of the people at the home is promoted and safeguarded. The homes kitchen has recently had an inspection by an Environmental Health Officer and was awarded the maximum of five stars. Spring Mount DS0000001147.V373701.R01.S.doc Version 5.2 Page 24 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 X 3 X X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 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 3 X X X X 3 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 4 4 X 3 3 2 3 Spring Mount DS0000001147.V373701.R01.S.doc Version 5.2 Page 25 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. Standard Regulation Requirement Timescale for action 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 Mount DS0000001147.V373701.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection North Eastern Region St Nicholas Building St Nicholas Street Newcastle Upon Tyne NE1 1NB 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 Mount DS0000001147.V373701.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. 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