Inspection on 01/12/03 for Connie Lewcock Resource Centre

Care Home For Older PeopleConnie Lewcock Resource CentreWest Denton Road Lemington Newcastle upon Tyne Tyne & Wear NE15 7LQUnannounced Inspection1st December 2003 Commission for Social Care InspectionLaunched in April 2004, the Commission for Social Care Inspection (CSCI) is the single inspectorate for social care in England. The Commission combines the work formerly done by the Social Services Inspectorate (SSI), the SSI/Audit Commission Joint Review Team and the National Care Standards Commission. The role of CSCI is to: · Promote improvement in social care · Inspect all social care - for adults and children - in the public, private and voluntary sectors · Publish annual reports to Parliament on the performance of social care and on the state of the social care market · Inspect and assess `Value for Money of council social services · Hold performance statistics on social care · Publish the `star ratings for council social services · Register and inspect services against national standards · Host the Childrens Rights Director role.Inspection Methods & FindingsSECTION B of this report summarises key findings and evidence from this inspection. The following 4-point scale is used to indicate the extent to which standards have been met or not met by placing the assessed level alongside the phrase Standard met? The 4-point scale ranges from: 4 - Standard Exceeded (Commendable) 3 - Standard Met (No Shortfalls) 2 - Standard Almost Met (Minor Shortfalls) 1 - Standard Not Met (Major Shortfalls) O or blank in the Standard met? box denotes standard not assessed on this occasion. 9 in the Standard met? box denotes standard not applicable. X is used where a percentage value or numerical value is not applicable. ESTABLISHMENT INFORMATION Name of establishment Connie Lewcock Resource Centre Address West Denton Road, Lemington, Newcastle upon Tyne, Tyne & Wear, NE15 7LQ Email Address Name of registered provider(s)/Company (if applicable) Newcastle upon Tyne Social Services Name of registered manager (if applicable) Mrs Pamela Margaret Vickers Type of registration Care Home No. of places registered (if applicable) 24 Tel No: 0191 264 3439 Fax No: 0191 267 1169Category(ies) of registration, with (number of places) Dementia - over 65 years of age (3), Old age, not falling within any other category (21) Registration number B030000454 Date First registered 9th May 2003 Was the home registered under the Registered Homes Act 1984 Do additional conditions of registration apply ? Date of last inspectionDate of latest registration certificate 3rd July 2003 NO NO 30/7/03 If Yes Refer to Part CConnie Lewcock Resource CentrePage 1 Date of Inspection Visit Time of Inspection Visit Name of Inspector Name of Inspector Name of Inspector 1 2 31st December 2003 09:15 am Lesley Scriven N/A N/A N/AID Code141015Name of Inspector 4 Name of Lay Assessor (if applicable) Lay assessors are members of the public independent of the NCSC. They accompany inspectors on some inspections and bring a different perspective to the inspection process Name of Specialist (e.g. Interpreter/Signer) (if applicable) Name of Establishment Representative at the time of inspectionN/A N/A Ms Pam Vickers, ManagerConnie Lewcock Resource CentrePage 2 CONTENTSIntroduction to Report and Inspection Inspection Visits Brief Description of the Services Provided Part A: Summary of Inspection Findings Inspection Summary Statutory Requirements/Good Practice Recommendations from last Inspection Conditions of Registration Statutory Requirements/ Good Practice Recommendations from this Inspection Inspection Findings National Minimum Standards For Older People: Choice of Home Health and Personal Care Daily Life and Social Activities Complaints and Protection Environment Staffing Management & Administration Compliance with additional conditions of registration (if applicable) Lay Assessors Summary (where applicable) Providers Response Providers comments Action Plan Providers AgreementPart B:Part C: Part D: Part E: E.1. E.2. E.3.Connie Lewcock Resource CentrePage 3 INTRODUCTION TO REPORT AND INSPECTION Every establishment that falls within the jurisdiction of the National Care Standards Commission (NCSC), is subject to inspection, to establish if the establishment is meeting the National Minimum Standards relevant to that setting and the requirements of the Care Standards Act 2000. This document summarises the inspection findings of the NCSC in respect of Connie Lewcock Resource Centre. The inspection findings relate to the National Minimum Standards (NMS) for Care Homes for Older People published by the Secretary of State under the Care Standards Act 2000. The Regulations applicable to the inspected service are secondary legislation, with which a service provider must comply. Service providers are expected to comply fully with the National Minimum Standards. The National Minimum Standards will form the basis for judgements by the NCSC regarding registration, the imposition and variation of registration conditions and any enforcement action. The report follows the format of the NMS and the numbering shown in the report corresponds to that of the standards. The report will show the following: · Inspection methods used · Key findings and evidence · Overall ratings in relation to the standards · Compliance with the Regulations · Required actions on the part of the provider · Recommended good practice · Summary of the findings · Report of the Lay Assessor (where relevant) · Providers response and proposed action plan to address findings This report is a public document. INSPECTION VISITS Inspections are undertaken in line with the agreed regulatory framework with additional visits as required. This is in accordance with the provisions of the Care Standards Act 2000. The report is based on the findings of the specified inspection dates.Connie Lewcock Resource CentrePage 4 BRIEF DESCRIPTION OF THE SERVICES PROVIDED. The Connie Lewcock Resource Centre is a Local Authority owned residential care home, which provides accommodation and care for up to twenty-four older people, some of whom may have dementia needs. This includes ten community rehabilitation beds, three long-term residential care beds and eleven emergency/respite beds. A thirty-place day resource centre for older people is also operated on the same site. The property is situated in Lemington, west of Newcastle, and is within walking distance of a small range of local amenities, including a Post Office, newsagent and Chinese food takeaway. The area is well served by public transport. The single storey building is designed in a square around well-maintained pleasant courtyard garden. There is limited car parking available to the front. Internally, the accommodation is divided into small homely units, each with its own self-contained facilities including a kitchen/dining room, lounge and bathrooms. All bedrooms are single and two of these are equipped with en-suite WC facilities. Access to the building is ramped. Closed circuit television (CCTV) is not used within the home, however it is installed outwith and controlled access at the main entrance is used to ensure the security of Service Users.Connie Lewcock Resource CentrePage 5 PART A SUMMARY OF INSPECTION FINDINGSINSPECTORS SUMMARY (This is an overview of the inspectors findings, which includes good practice, quality issues, areas to be addressed or developed and any other concerns.) This is the report of an unannounced inspection. The purpose of the inspection is: a) to assess progress made towards meeting requirements and recommendations (where applicable) from the previous inspection; b) to assess the service against the National Minimum Standards all of which will be covered between the two statutory inspections required each year. This inspection took place over one day on December 1st 2003. Not all of the National Minimum Standards were inspected, but of the thirty-three that were, nineteen were met (58 ). The views of people living at the Centre, their families and some visiting professionals were gathered during the day of inspection and many positive interactions between staff and Service Users were observed. Staff were seen treating Service Users with respect and described by people living and staying at the Centre as friendly. Choice of Home (Standards 1 - 6) Of the five standards assessed, three were met. The Resource Centres Statement of Purpose and Service User Guide require further development, however it is commendable that both documents can be provided in different languages and also in Braille. The Centre is well designed and equipped and staff have the necessary collective skills and experience to meet the general personal and social care needs of Service Users. A dedicated intermediate care facility is also on site and a good example of joint working between Social Services and Health professionals was observed during the inspection. One Service User receiving rehabilitative care commented positively about the support and encouragement provided by the friendly staff team. Health and Personal Care (Standards 7 ­ 11) Of the five standards assessed, three were met. Care-plans are drawn up in respect of everyone using residential services at the Connie Lewcock Resource Centre, on the basis of pre and post admission assessment of individual needs and abilities. Service Users healthcare needs are well met in partnership with community health care professionals and the Centre works to satisfactory policy and procedural guidance for the safe receipt, storage, administration and disposal of medication. Interactions between staff and Service Users are respectful and it was noted that on the whole, personal care is also delivered sensitively and discreetly. Daily Life and Social Activities (Standards 12 ­ 15) All of the four assessed standards were met. Daily routines are sufficiently flexible to accommodate individual preferences and a good range of activities is on offer at the Centre. Trips to the theatre are sometimes arranged and Service Users enjoy the visiting the pub for lunch. Activities of daily living are incorporated as a key part of the care-planning process for intermediate care Service Users, with an emphasis on regaining independent mobility, shopping, cooking and life skills in readiness Connie Lewcock Resource Centre Page 6 for return home following a period of rehabilitation. `City Cuisine provide catering services to the Centre and offer Users a good choice of hot and cold meals every day, accommodating individual preferences and special dietary requirements wherever possible. Complaints and Protection (Standards 16 ­ 18) Of the three standards assessed, two were met. The Connie Lewcock Resource Centre operates to Newcastle Social Services Departments procedures for the Protection of Vulnerable Adults and many staff have attended the related training course. Complaints policy and procedural guidance are presented in a satisfactory format and accessible to all Service Users and visitors. However, because proper records have not been kept, it is not possible for the Inspector to determine whether thorough investigations have been undertaken in response to each complaint received. Service Users legal and citizenship rights are upheld. Environment (Standards 19 ­ 26) Of the eight standards assessed, four were met. The Connie Lewcock Resource Centre is comfortable and homely and the location, design and layout of the building are suited to the Centres stated purpose. All areas are accessible, and appear safe and generally well maintained, with only some minor repairs identified at the time of inspection. The Centre is well equipped with adaptations and facilities and specialist equipment is provided for Service Users on the basis of professional assessment. Day care and intermediate care services are located in separate `wings or corridors of the home so that they do not impinge on the lives of permanent Service Users and this is to be commended. Staffing (Standards 27 ­ 30) Of the two assessed standards, one was met. Examination of past staff rosters confirmed that agreed staffing levels have been maintained, but not always exceeded, as was the case at the time of the last inspection. The level of ancillary support is consistently good. The Centre is currently carrying two staff vacancies and operates to the Newcastle Social Services Departments protocol for the recruitment of staff. Procedures in this respect will be examined at the next announced inspection, when the necessary records will be made available from the Civic Centre. Management and Administration (Standards 31 ­ 38) Of the six assessed standards, two were met. The Registered Manager at the Connie Lewcock Resource Centre, Ms Pam Vickers has demonstrated that she has a good knowledge of her role and responsibilities and has provided evidence of ongoing training to update her skills. On the day of inspection, procedures and practices in relation to health and safety were satisfactory, with the exception of some matters noted regarding the control of substances hazardous to health (COSHH) and provision of fire training for staff, which require immediate resolution.Connie Lewcock Resource CentrePage 7 Requirements from last Inspection visit fully actioned? If No please list belowNOSTATUTORY REQUIREMENTS Identified below are areas not addressed from the last inspection report which indicate a non-compliance with the Care Standards Act 2000 and accompanying Regulations. No. Regulation Standard Required actions Timescale for action · The heating arrangements for Service Users bedrooms must be able to be suitably controlled within the building. The requirements of the Fire Officer for a suitable record of staff training to be maintained must be implemented. Testing of portable appliances must be carried out. 01.12.2003123OP25OP 38·01.10.2003· 17 Schedule 401.10.2003 01.10.20032OP29Staff records must be available at the Centre.Action is being taken by the National Care Standards Commission to ensure compliance in regard to the above requirements. RECOMMENDATIONS Identified below are recommendations from the last inspection that have not been implemented No. Refer to Good Practice Recommendations Standard A minimum ratio of 50 trained members of care staff (NVQ Level II or equivalent) should be achieved by 2005, excluding the Registered Manager. The Registered Manager should continue and complete elements of the Registered Managers (Adults) Award to ensure qualification at National Vocational Qualification Level IV or above by 2005.1OP282OP31CONDITIONS OF REGISTRATION THAT APPLY (OTHER THAN NUMBERS AND CATEGORY OF SERVICE USERS). Connie Lewcock Resource CentreMet (Yes / No) Page 8 N/AConnie Lewcock Resource CentrePage 9 STATUTORY REQUIREMENTS IDENTIFIED DURING THE INSPECTION Action Plan: The Registered Person is requested to provide the Commission with an Action Plan, which indicates how requirements and recommendations are to be addressed with the time scale within which such actions will be taken. This action plan will be made available on request to the Area Office.STATUTORY REQUIREMENTS Identified below are areas addressed in the main body of the report, which indicate noncompliance with the Care Standards Act 2000, and accompanying Regulations 2001 and the National Minimum Standards. The Registered Provider(s) is/are required to comply within the given time scales. No. Regulation Standard * Requirement Timescale for action The Statement of Purpose and Service User Guide must be further developed to include the following. 1 4, 5 Schedule 4 · OP1 The sizes of rooms which may be accessed by people living at the Centre; and · the age range of people who may use the service, to include any variation previously granted by the National Care Standards Commission. 01.01.04 01.01.0425OP2Service Users must be issued with individual contracts and a statement of terms and conditions. Care-plans must be evaluated on a monthly basis and be sufficiently detailed to reflect the needs of the Service User and facilitated delivery of individualised support. Care-plans wherever possible should be developed with each individual Service User, or his/her representative, in order to ensure that personal aims and aspirations are clearly identified and met.315 (2) 17 (1) (2)OP7OP3701.12.03415 (1)OP701.12.03Connie Lewcock Resource CentrePage 10 ·In order to protect Service Users dignity, the Registered Manager is advised to review storage facilities for continence aids in WCs/bathrooms. The Registered Manager must ensure that staff carry out their work with discretion and disposable gloves must not be worn whilst escorting Service Users through communal areas to WCs. 01.12.03512 (4 (a))OP10·22 (7) 6 Schedule 4 OP16 (11) 23 (20 (b)) 23 (2) (b,d) OP21The Registered Manager must ensure that all complaints are fully investigated and proper records must be kept in this regard. A bathroom (as identified) is in need of minor redecoration. The Registered Manager must ensure redecoration of the bedroom ceiling identified at inspection. The heating arrangements for Service Users bedrooms must be able to be suitably controlled within the building. The Registered Manager must ensure that all staff practice is in accordance with Control of Substances Hazardous to Health (COSHH) and Health and Safety requirements. Staff recruitment records and documents required by Schedule 2 of the Care Homes Regulations 2001 must be available in the home for examination at the next announced inspection. Information gathered as part of quality monitoring must be further analysed and published along with plans for future service improvements/developments. This must be made available for current and prospective Service Users and other interested parties, including the National Care Standards Commission. The Registered Manager must remind staff that information kept about Service Users is confidential and often sensitive in nature, and must be stored and accessed in accordance with the Data Protection Act 1998.01.12.03701.03.048OP2401.03.04923OP25OP3 801.01.041013 (4)OP26OP3 801.12.031119 (1)OP29OP3 Schedule 2 72004 date to be announced1212 (1)(a) 24OP3301.03.041317 (1 (b))OP3701.12.03Connie Lewcock Resource CentrePage 11 ·1423(4)OP38 ·The homes fire log must be kept up to date. The Registered Manager must accurately carry out and record fire drills and instructions for day and night staff within the timescales prescribed by the Fire Authority. Testing of portable appliances must be carried out.01.12.03RECOMMENDATIONS Identified below are areas addressed in the main body of the report, which relate to National Minimum Standards and are seen as good practice issues which should be considered for implementation by the registered Provider(s) No. Refer to Good Practice Recommendations Standard * A minimum ratio of 50 trained members of care staff (NVQ Level II or equivalent) should be achieved by 2005, excluding the Registered Manager. The Registered Manager should continue and complete elements of the Registered Managers (Adults) Award to ensure qualification at National Vocational Qualification Level IV or above by 2005.1OP282OP31Connie Lewcock Resource CentrePage 12 PART BINSPECTION METHODS & FINDINGSThe following inspection methods have been used in the production of this report Direct Observation Indirect Observation Sampling · Pre-inspection Questionnaire · Records · Care Plans / Care Pathways · Meals · Activities · Other (Specify) `Tracking care and support Group discussion with service users Individual discussion with service users Group discussion with staff Individual discussion with staff Discussion with management Service user survey Relatives/significant others survey/feedback Visiting Professionals survey / feedback Tour of Premises Formal Interviews Document reading Additional Inspection Information: Number of Service Users spoken to at time of inspection Number of Relatives/significant others the inspectors had contact with Number of letters received in respect of the service CRB check for the Responsible Individual seen CRB check for the Manager seen Certificate of registration was displayed at the time of the inspection Certificate of registration accurately reflected the situation in the service at the time of inspection Total number of care staff employed (excluding managers) Total number of staff with nursing qualifications employed Date of Inspection Time of Inspection Duration Of Inspection (hrs) YES YES NO YES YES NO YES NO YES YES YES YES YES YES NO NO NO YES NO YES 9 2 1 YES YES YES YES 24 0 01/12/03 9:15 8.15Connie Lewcock Resource CentrePage 13 The following pages summarise the key findings and evidence from this inspection, together with the NCSC assessment of the extent to which the National Minimum Standards for Care homes for older persons have been met. The following scale is used to indicate the extent to which standards have been met or not met by placing the assessed level alongside the phrase Standard met? The scale ranges from: 4 - Standard Exceeded 3 - Standard Met 2 - Standard Almost Met 1 - Standard Not Met (Commendable) (No shortfalls) (Minor shortfalls) (Major shortfalls)0 or blank in the Standard met? box denotes standard not assessed on this occasion. 9 in the Standard met? box denotes standard not applicable. X is used where a percentage value or numerical value is not applicable.Connie Lewcock Resource CentrePage 14 Choice of HomeThe intended outcomes for the following set of standards are: · · · · · · 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.Standard 1 (1.1 ­ 1.3) The registered person produces and makes available to service users an up to date statement of purpose setting out the aims, objectives, philosophy of care, services and facilities and terms and conditions of the home; and provides a service users guide to the home for current and prospective residents. The statement of purpose clearly sets out the physical environmental standards met by a home in relation to standards 20.1, 20.4, 21.3, 21.4, 22.2, 22.5, 23.3 and 23.10: a summary of this information appears in the homes service users guide Range of fees charged From (£) X To (£) 305.00Any charges for extrasYESIf yes, please state what the extras are: Hairdressing, some toiletries, some newspapers, and occasionally a contribution towards outings. 2 Key findings/Evidence Standard met? Although benefiting from further development since the last inspection, two elements of information required by Regulation 4, Schedule 1 of the Care Homes Regulations 2001 are missing from the homes Statement of Purpose and Service User Guide. · The sizes of rooms which may be accessed by people living at the Centre; and · the age range of people who may use the service, to include any variation previously granted by the National Care Standards Commission. It is commendable that both documents can be provided in different languages and also in Braille, on request from Newcastle Civic Centre, since this makes them more accessible to a wider range of existing and potential Service Users. Inspection reports will also be made available by the Local Authority on their website. Connie Lewcock Resource Centre Page 15 Standard 2 (2.1 ­ 2.2) Each service user is provided with a statement of terms and conditions at the point of moving into the home (or contract if purchasing their care privately). 2 Key findings/Evidence Standard met? A new format for the Centres Service User contract has been drafted and is presently with the National Care Standards Commission for approval. Publication is imminent. Service Users must be issued with a copy of this, along with a statement of terms and conditions on admission to the service.Standard 3 (3.1 ­ 3.5) New service users are admitted only on the basis of a full assessment undertaken by people trained to do so, and to which the prospective service user, his/her representatives (if any) and relevant professionals have been party. 3 Key findings/Evidence Standard met? Discussion with staff and examination of a selection of Service User files confirmed that people who use services at the Connie Lewcock Resource Centre are accepted only on the basis of an assessment first undertaken by Social Services or Health professionals, unless there are exceptional circumstances necessitating emergency accommodation. In addition, the Centre has its own assessment tool, which helps staff to build up a more comprehensive picture of each individuals needs to aid the care-planning process. Each Service User has a plan of care for daily living, and records for regular respite Users are records updated as necessary on every subsequent admission. Standard 4 (4.1 - 4.4) The registered person is able to demonstrate the homes capacity to meet the assessed needs (including specialist needs) of individuals admitted to the home. 3 Key findings/Evidence Standard met? During discussions with the Centres Manager and staff, the Inspector was able to determine that the care team has the necessary collective skills and experience to meet the general personal and social care needs of Service Users. It is commendable that staff are provided with a broad range of developmental training, which clearly enhances their practice. Both the residential areas of the building and the day centre are well equipped with a good range of environmental adaptations and aids to daily living. Service Users are encouraged in accordance with agreed individual plans of care to utilise these towards the aim of promoting and maintaining independence wherever possible. Standard 5 (5.1 ­ 5.3) The registered person ensures that prospective service users are invited to visit the home and to move in on a trial basis, before they and / or their representatives make a decision to stay; unplanned admissions are avoided where possible. 0 Key findings/Evidence Standard met? Standard 5 was not assessed as part of this unannounced inspection.Connie Lewcock Resource CentrePage 16 Standard 6 (6.1 - 6.5) Where service users are admitted only for intermediate care, dedicated accommodation is provided together with specialised facilities, equipment and staff to deliver short-term intensive rehabilitation and enable service users to return home. 3 Key findings/Evidence Standard met? One `wing of the Connie Lewcock Resource Centre is dedicated to provision of intermediate care. The wing is suitably equipped (see Standard 3 above) and the staff team work in close partnership with Health professionals, including District Nurses and on site Physiotherapists and Occupational Therapists to deliver programmes of intensive short-term rehabilitation, most commonly for people who are recovering from hospital treatment, but who no longer have an acute medical need. A good example of joint working was observed during the inspection and one Service User spoken with commented positively about the support and encouragement provided.Connie Lewcock Resource CentrePage 17 Health and Personal CareThe intended outcomes for the following set of standards are: · · · · · The service users health, personal and social care needs are set out in an individual plan of care. Service users make decisions about their lives with assistance as needed. Service users, where appropriate, are responsible for their own medication, and are protected by the homes 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.Standard 7 (7.1 ­ 7.6) A service user plan of care generated from a comprehensive assessment (see Standard 3) is drawn up with each service user and provides the basis for the care to be delivered. 2 Key findings/Evidence Standard met? Care-plans are drawn up in respect of everyone using residential services at the Connie Lewcock Resource Centre, on the basis of pre and post admission assessment of individual needs and abilities. These documents outline the areas of staff support and care required by each person, and are used in conjunction with individual daily reports, where any action taken to implement the plans is recorded by staff, along with details of any significant events. During the inspection as part of a case-tracking exercise, a number of plans were examined. It was noted that whilst care-plans for people receiving intermediate care were particularly detailed and evidence a multi-disciplinary approach, this was not consistently the case for respite Service Users. The following points were discussed with the Centres Manager who was given advice about how the system might be improved. · Care-planning documents for some respite and permanent Service Users are holistic in nature and clearly based upon assessed needs, however they lack the level of detail required to enable staff to provide individualised care and support. With the exception of intermediate care Users plans, which are updated on a daily basis, respite and permanent Service Users plans should be evaluated at least monthly. Although those Service Users spoken with were clearly aware of the care-planning process, the Inspector was unable to find sufficient documentary evidence to show that people using the Centres services are involved in the drawing-up of plans. Careplans wherever possible should be developed with each individual Service User, or his/her representative, in order to ensure that personal aims and aspirations are clearly identified and met.··On a positive note, risk assessments are well utilised in relation to physical health needs.Connie Lewcock Resource CentrePage 18 Standard 8 (8.1 ­ 8.13) The registered person promotes and maintains service users health and ensures access to health care services to meet assessed needs. Number of incidents where service users have been taken to Accident and Emergency during last 12 months Number of service users with pressure sores at time of inspection (from information taken from care notes)3 13 Key findings/Evidence Standard met? Accident books kept by the home were examined and over the last twelve months, 129 entries have been made, most of these relating to minor injuries. Entries have been recorded satisfactorily and there is evidence to show that follow-up evaluations are being made and comprehensively audited by the homes Manager as part of a wider risk management strategy. Community healthcare services are accessed for people living and staying at the Centre, including GPs, Dieticians and District Nurses, who also provide advice on diabetic care, continence management and pressure wound care. Two Physiotherapists and one Occupational Therapist work on site and a service dedicated Community Psychiatric Nurse will soon be appointed by the Health Care Trust. In addition to arranging for domiciliary services, e.g. Chiropodist, Optician, Dentist, to visit the Connie Lewcock Resource Centre, transport and an escort can be provided for those individuals who prefer to attend appointments at services based in the local community. Good links have been established with City Cuisine, the Local Authoritys contract caterer and nutritional screening forms an important part of care provision. Standard 9 (9.1 ­ 9.11) The registered person ensures that there is a policy and staff adhere to the procedures for the receipt, recording, storage, handling administration and disposal of medicines, and service users are able to take responsibility for their own medication if they wish, within a risk management framework. 3 Key findings/Evidence Standard Met? The Centre works to satisfactory policy and procedural guidance for the safe receipt, storage, administration and disposal of medication. Systems are also in place to support Users to self-administer medication if this is required. As part of the inspection an examination of stock and administration records was undertaken and found to be in good order. Ample suitable storage is provided for the types and quantities of medication used, and staff have completed accredited training on the `safe handling of medication at a course piloted with Newcastle Social Services Department by Newcastle College.Connie Lewcock Resource CentrePage 19 Standard 10 (10.1 ­ 10.7) The arrangements for health and personal care ensure that service users privacy and dignity are respected at all times, and with particular regard to: personal care giving, including nursing, bathing, washing, using the toilet or commode, consultation with and examination by health and social care professionals, consultation with legal and financial advisors, maintaining social contacts with relatives and friends, entering bedrooms, toilets and bathrooms, and following death. 2 Key findings/Evidence Standard met? During the inspection, many positive interactions between staff and Service Users were observed. On the whole, staff were seen treating Service Users with respect and those care staff spoken with demonstrated an understanding of the importance of maintaining Users dignity at all times. With the exception of one occurrence, which was discussed with the Centres Manager, it was noted that personal care was also delivered sensitively and discreetly. Appropriate arrangements are made for GP consultations and visits by the District Nurse and other health professionals. Staff were seen knocking on bedroom doors before entering and one permanent Service User confirmed that post is delivered unopened. Assistance to read correspondence is only given where requested. As a matter of good practice, and in order to further protect Service Users dignity, the Registered Manager was advised to review storage facilities for continence aids in communal WCS/ bathrooms. Standard 11 (11.1 ­ 11.12). Care and comfort are given to service users who are dying, their death is handled with dignity and propriety, and their spiritual needs, rites and functions observed. 3 Key findings/Evidence Standard met? The Connie Lewcock Resource Centre has in place a policy and procedural guidance for staff in relation to handling advancing illness, dying and death. However, because the majority of Service Users access the facility on a short stay respite or intermediate care basis, this aspect of assessment is rarely addressed in detail. For permanent Service Users staff ensure that there is sufficient documentary evidence on personal files to show that individual feelings and wishes for the future will be respected and carried out.Connie Lewcock Resource CentrePage 20 Daily Life and Social ActivitiesThe intended outcomes for the following set of standards are: · · · · 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.Standard 12 (12.1 ­ 12.4) The routines of daily living and activities made available are flexible and varied to suit service users expectations, preferences and capacities. 3 Key findings/Evidence Standard met? Service Users confirmed that daily routines within the Centre are sufficiently flexible to accommodate individual preferences. For example, people living permanently or staying for respite or rehabilitation may bathe, rise and retire when they wish and meals may be taken either in communal dining areas, or in Service Users own rooms. The Registered Manager has stated that a good range of activities is on offer, including arts and crafts, flower arranging, baking sessions, card games, bingo and `sing-alongs. Themed afternoons/evenings are also held with suitably matched food and music or videos and Ms Vickers is looking into the possibility of subscribing to a satellite sports channel. Activities programmes are posted onto notice boards in each of the Centres dining areas and revised according to User feedback. The Inspector was informed that trips to the theatre are sometimes arranged and that Service Users enjoy utilising local leisure facilities including the pub, which is a popular venue for lunch. This information was confirmed through discussion with people living at the Centre, who added that there are also opportunities for shopping trips and visits to families and friends. Only one Service User spoken with described life at the home as boring. Activities of daily living are very much incorporated into the care-planning process for intermediate care Service Users, with an emphasis on regaining independent mobility, shopping, cooking and life skills in readiness for return home following a period of rehabilitation.Connie Lewcock Resource CentrePage 21 Standard 13 (13.1 ­ 13.6) Service users are able to have visitors at any reasonable time and links with the local community are developed and/or maintained in accordance with service users preferences 3 Key findings/Evidence Standard met? During the inspection visitors were observed to come and go freely and it was confirmed by staff and Service Users alike that visiting times are not restricted. To ensure that Service Users spiritual needs are met, the Manager has arranged for members of the local Church to visit regularly, whilst others may continue to attend the Church of their choice in their home community. Links with the local community are also maintained via people who attend for `day-care at the on site resource centre. Standard 14 (14.1 ­ 14.5) The registered person conducts the home so as to maximise service users capacity to exercise personal autonomy and choice. 3 Key findings/Evidence Standard met? On inspection it was apparent that even regular respite Service Users are encouraged to bring their own possessions into the Centre. Many bedrooms are personalised and reflect individual preferences. People living or staying at the Connie Lewcock Resource Centre are able to exercise choice and establish their own preferred daily routines. For example, people can rise, retire and bathe at whatever time they wish and although mealtimes are `set, alternative arrangements can be made suit individual requirements. Similarly, people can choose to eat in their bedrooms, rather the communal dining areas, if this is what they prefer. Throughout the day of the inspection, staff were observed asking Service Users what music they would like to listen to, and which activities they would like to participate in. Service Users who wish to handle their own medications and finances are encouraged to do so, although suitable arrangements are in place for those who require support with these activities.Connie Lewcock Resource CentrePage 22 Standard 15 (15.1 ­ 15.9) The registered person ensures that service users receive a varied, appealing, wholesome and nutritious diet which is suited to individual, assessed and recorded requirements and that meals are taken in a congenial setting and at flexible times. 3 Key findings/Evidence Standard met? Catering services are provided for the Connie Lewcock Resource Centre by `City Cuisine. A five-week series of menus is in place, which offers people living and staying at the Centre a good choice of hot and cold meals every day, and individual preferences and special dietary requirements may also be accommodated. The menus are nutritionally well balanced and appealing. During the lunch period, the Inspector took the opportunity to make some discreet observations. The kitchen/dining areas throughout the centre are nicely decorated with a homely atmosphere and the mealtime appeared to be a sociable and enjoyable experience for Service Users. Where needed, one to one support was offered in a discreet and dignified way. Ample supplies of fresh fruit and cold drinks are also available throughout the Centre and facilities are available for Service Users and their visitors to make hot refreshments.Connie Lewcock Resource CentrePage 23 Complaints and ProtectionThe intended outcomes for the following set of standards are: · · · 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.Standard 16 (16.1 ­ 16.4) The registered person ensures that there is a simple clear and accessible complaints procedure which includes the stages and time-scales for the process and that complaints are dealt with promptly and effectively. No. of complaints made to the home during last 12 months No. of these complaints fully substantiated No. of these complaints partly substantiated No. of these complaints not substantiated No. of these complaints not yet resolved No. of complaints sent direct to NCSC Percentage of complaints responded to within 28 days 5 3 0 1 1 0 X 2 Key findings/Evidence Standard met? The Resource Centres complaints policy and procedural guidance are presented in a satisfactory format and accessible to all Service Users and visitors. There is documentary evidence to show that complaints are responded to, however because proper documentation has not been consistently kept in this respect, it is not possible for the Inspector to determine whether thorough investigations have been undertaken in each case. The Manager was advised accordingly. Standard 17 (17.1 ­ 17.3) Service users have their legal rights protected, are enabled to exercise their legal rights directly and participate in the civic process if they wish. 3 Key findings/Evidence Standard met? People living or staying at the Connie Lewcock Resource Centre are able to access independent advocacy services if these are required. Permanent Service Users are able to participate in local and general elections by postal vote and contact will be made with local Councillors for individuals where this is requested.Connie Lewcock Resource CentrePage 24 Standard 18 (18.1 ­ 18.6) The registered person ensures that service users are safeguarded from physical, financial, or material, psychological or sexual abuse, neglect, discriminatory abuse or self harm, inhuman or degrading treatment through deliberate intent, negligence or ignorance, in accordance with written policies. The home has an Adult Protection procedure (including Whistle Blowing) which complies with the Public Disclosure Act 1998 and the Department of Health Guidance No Secrets No. of staff referred for inclusion on POVA lists YES 03 Key findings/Evidence Standard met? The Connie Lewcock Resource Centre operates to Newcastle Social Services Departments procedures for the Protection of Vulnerable Adults and many staff have attended the related training course. A copy of the Department of Health No Secrets publication is also available for staff reference, along with advice about the Centres whistle blowing policy. There are clear guidelines in place to assist staff in understanding physical and verbal aggression and what actions they should take if they encounter this type of behaviour.Connie Lewcock Resource CentrePage 25 EnvironmentThe intended outcomes for the following set of standards are: · · · · · · · · 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.Standard 19 (19.1 ­ 19.6) The location and layout of the home is suitable for its stated purpose; it is accessible, safe and well maintained; meets service users individual and collective needs in a comfortable and homely way and has been designed with reference to relevant guidance. 3 Key findings/Evidence Standard met? The Connie Lewcock Resource Centre is comfortable and homely and the location, design and layout of the building are suited to the Centres stated purpose. All areas are accessible, and appear safe and on the whole, well maintained. Day care and intermediate care services are located in separate `wings or corridors of the home so that they do not impinge on the lives of permanent Service Users and this is to be commended. The building complies with the requirements of the Fire Authority and Environmental Health Department.Connie Lewcock Resource CentrePage 26 Standard 20. (20.1 ­ 20.7) In all newly built homes and first time registrations the home provides sitting, recreational and dining space (referred to collectively as communal space) apart from service users private accommodation and excluding corridors and entrance hall amounting to at least 4.1 sq. metres for each service user. 3 Key findings/Evidence Standard met? There is a choice of communal lounges and other sitting areas throughout the Centre. These include television lounges, dining areas, two smoking rooms, and places where people can go for peace and quiet. All of these areas were well used by Service Users and visitors during the inspection. Furnishings and fitments throughout are domestic in appearance, of good quality, and there is an obvious attention to detail, providing an environment where people can relax in comfort. The internal courtyard garden is well laid out with plants and seating arrangements, providing a safe environment for enjoying the better weather. The door to this area currently has a very small step, however to ensure safety, this is to be levelled in the very near future. Access to the front and rear of the Centre is ramped. Standard 21 (21.1 ­ 21.8) Toilet, washing and bathing facilities are provided to meet the needs of service users. 2 Key findings/Evidence Standard met? Toilets and bathrooms are provided in sufficient quantity for the number of Service Users at the Centre and these are located in close proximity to bedrooms and communal areas. Suitable technical aids and adaptations e.g. raised toilet seats, bath chairs and hoisting equipment are provided to aid safe/independent use, and baths and showers are also fitted with a thermostatic regulating device to prevent the risk of scalding. All of these areas are as domestic and homely in style as possible, however one bathroom (as identified) would benefit from some minor redecoration. Standard 22 (22.1 ­ 22.8) The registered person demonstrates that an assessment of the premises and facilities has been made by suitably qualified persons including a qualified occupational therapist, with specialist knowledge of the client groups catered for and provides evidence that the recommended disability equipment has been secured or provided and environmental adaptations made to meet the needs of service users. 3 Key findings/Evidence Standard met? Service Users have access to all areas of the Centre and handrails have been installed throughout the wide corridors. Specialist equipment and adaptations are provided for Service Users on the basis of professional assessments undertaken for some individuals. An alarm call system is provided throughout the Centre to allow Service Users and staff to summon help when needed. An induction loop system is also in place in communal TV lounges and bedrooms for the benefit of people who have a hearing impairment.Connie Lewcock Resource CentrePage 27 Standard 23 (23.1 ­ 23.11) The home provides accommodation for each service user which meets minimum space as prescribed Total number of single bedrooms with at least 10 sq.m usable space or additional compensatory space Pre-existing homes only (1 April 2003) - single bedrooms below 10 sq.m usable space or additional compensatory space Total number of wheelchair users accommodated for in rooms at least 12sq.m Total number of wheelchair users accommodated for in rooms at less than 12sq.m Total number of shared rooms at least 16 sq.m Total number shared rooms less than 16 sq.m Percentage of places within single rooms: 100 80 - 99 Less than 80 Total number of single bedrooms Total number of single rooms with en suite Total number of double rooms Total number of double rooms with en suite YES NO NO 24 2 0 0 24 00 0 0 03 Key findings/Evidence Standard met? The Connie Lewcock Resource Centre continues to comply with the requirements of this Standard.Connie Lewcock Resource CentrePage 28 Standard 24 (24.1 ­ 24.8) The home provides private accommodation for each service user, which is furnished and equipped to assure comfort and privacy and meets the assessed needs of the service user. 2 Key findings/Evidence Standard met? Service Users bedrooms were noted to be nicely individualised to reflect personal preferences and lifestyle interests. Only one room identified at the time of inspection required minor redecoration and of those examined, each was equipped in accordance with the requirements of this Standard. Standard 25 (25.1 ­ 25 8) The heating, lighting, water supply and ventilation of service users accommodation meet the relevant environmental health and safety requirements and the needs of individual service users. 2 Key findings/Evidence Standard met? The windows in Service Users bedrooms provide natural light and may be opened by the occupant (within a safe limit) for ventilation. The lighting is domestic in character and includes small table lamps placed around the Centre. Emergency lighting is installed throughout. Service Users do not yet have the facility to control the ambient temperature in individual bedrooms, although this was made a requirement of the last inspection. Newcastle Social Services Department has stated that this is due to the layout of existing pipe work in the building, which would require major renewal before individual thermostats could be installed. Standard 26 (26.1 ­ 26.9) The premises are kept clean, hygienic and free from offensive odours throughout and systems are in place to control the spread of infection in accordance with relevant legislation and published professional guidance. 2 Key findings/Evidence Standard met? There was a good standard of cleanliness throughout the Centre, and all areas that were visited by the Inspector were free from odour. Laundry and kitchen facilities are sited away from communal and bedroom areas. It was noted however, that Control of Substance Hazardous to Health (COSHH) and Health and Safety requirements were not being properly adhered to by ancillary staff, who had decanted hazardous cleaning chemicals into unlabelled containers. This was brought to the attention of the Registered Manager who agreed to resolve the matter through staff training.Connie Lewcock Resource CentrePage 29 StaffingThe intended outcomes for the following set of standards are: · · · · 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 homes recruitment policy and practices. Staff are trained and competent to do their jobs.Standard 27 (27.1 ­ 27.7) Staffing numbers and skill mix of qualified/unqualified staff are appropriate to the assessed need of the service users, the size, the layout and purpose of the home, at all times. Number of staff /hours in respect of service user needs based on guidance recommended by Department of Health. Personal Nursing Care No. service users High No. staff hours X X 0 needs allocated No. service users Medium needs No. service users Low needs No. of staff hours required No. of full time equivalent first level registered nurses No. of care staff No. of ancillary staff Key findings/Evidence X X X No. staff hours allocated No. staff hours allocated No. of staff hours provided X X 402 Plus an additional 74 hours for day care. This figure includes day centre staff. 0 0 0024 6Standard met?3Connie Lewcock Resource CentrePage 30 Examination of past staff rosters confirmed that agreed minimum staffing levels have been maintained, but not always exceeded, as was the case at the time of the last inspection. The level of ancillary support is consistently good. The Centre is currently carrying two staff vacancies. On the day of inspection, four care staff were on duty throughout the residential areas of the Centre, (including one Senior) and one Senior and one care worker were deployed at the day resource. The Registered Manager and Team Leader were also present; both of whose hours are supernumerary. At night, two waking and one sleep-in staff members are present. Two Physiotherapists, one Occupational Therapist and a Social Worker are also based at the Connie Lewcock Resource Centre, although their working hours are not considered as part of the staffing establishment for the purposes of assessing this Standard. Standard 28 (28.1 ­ 28.3) A minimum ratio of 50 trained members of care staff (NVQ Level 2 or equivalent) is achieved by 2005, excluding the registered manager and/or care manager, and in care homes providing nursing, excluding those members of care staff who are registered nurses. No. care staff (excluding registered nurses) with NVQ level 2 or equivalent of care staff with NVQ level 2 1 4 2 Key findings/Evidence Standard met? Newcastle Social Services Department is committed to meeting this standard within the prescribed timescale and steady progress is being made. There are presently four members of staff working towards NVQ Level II, two working towards Level III and a further two towards Level IV.Standard 29 (29.1 ­ 29.6) The registered person operates a thorough recruitment procedure based on equal opportunities and ensuring the protection of service users. 0 Key findings/Evidence Standard met? Standard 29 was not assessed as part of this unannounced inspection. The Connie Lewcock Resource Centre operates to Newcastle Social Services Departments protocol for the recruitment of staff. However, because personnel records are not kept on the premises in accordance with the requirements of Schedules 2 and 4 of the Care Homes Regulations 2001, the Inspector is unable to determine whether staff working at the Centre have been appointed in accordance with this standard. An agreement has therefore been made that these will be made available at the home for examination at the next announced inspection.Connie Lewcock Resource CentrePage 31 Standard 30 (30.1 ­ 30.4) The registered person ensures that there is a staff training and development programme, which meets the National Training Organisation (NTO) workforce training targets and ensures staff fulfil the aims of the home and meet the changing needs of service users. 0 Key findings/Evidence Standard met? Standard 30 was not assessed as part of this unannounced inspection.Connie Lewcock Resource CentrePage 32 Management and AdministrationThe intended outcomes for the following set of standards are: · · · · · · · · 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 homes record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected.Standard 31 (31.1 ­ 31.8) The registered manager is qualified, competent and experienced to run the home and meet its stated purpose, aims and objectives. 2 Key findings/Evidence Standard met? The Registered Manager at the Connie Lewcock Resource Centre, Ms Pam Vickers is a qualified Registered General Nurse with 15 years experience of working in residential care settings. She also has a management qualification to which she will be adding three elements of the Registered Managers (Adults) Award to achieve the necessary qualification required by National Minimum Standard. Ms Vickers has demonstrated that she has a good knowledge of her role and responsibilities as Manager and has provided evidence of ongoing training to update her skills. Standard 32 (32.1 ­ 32.7) The registered manager ensures that the management approach of the home creates an open, positive and inclusive atmosphere. 0 Key findings/Evidence Standard met? Standard 32 was not assessed as part of this unannounced inspection.Connie Lewcock Resource CentrePage 33 Standard 33 (33.1 ­ 33.10) Effective quality assurance and quality monitoring systems, based on seeking the views of service users are in place to measure success in meeting the aims, objectives and the statement of purpose of the home. 2 Key findings/Evidence Standard met? Newcastle Social Services Department produce an annual development plan for the Connie Lewcock Resource Centre. Systems are in place to seek feedback from Service Users, their relatives and representatives and other stakeholders about the quality of services provided and the Centres Service User Guide includes some of the compliments received in this way, as does its newsletter. Whilst this is commendable, it remains that the information gathered must be analysed overall and the results of this analysis, along with plans for further improvement/development published for interested parties, including the National Care Standards Commission. Standard 34 (34.1 ­ 34.5) Suitable accounting and financial procedures are adopted to demonstrate current financial viability and to ensure that there is effective and efficient management of the business. 3 Key findings/Evidence Standard met? Evidence has been submitted to National Care Standards Commission to verify compliance with this Standard.Connie Lewcock Resource CentrePage 34 Standard 35 (35.1 ­ 35.6) The registered manager ensures that service users control their own money except where they state that they do not wish to or they lack capacity and that safeguards are in place to protect the interests of the service user. Number of service users subject to Power of Attorney processes Number of service users subject to Enduring Power of Attorney processes Number of service users subject to Guardianship Orders 0 0 03 Key findings/Evidence Standard met? The Inspector examined a random sample of records kept in relation to this area of service delivery. Record keeping practices are satisfactory and in accordance with the Centres policies and procedures. All expenditure is documented and corresponding receipts are held to evidence spending. Records of additional monies put into safekeeping for Service Users and withdrawn by them are signed by the User themselves wherever possible, or alternatively by two members of staff. Secure facilities are in place for the safekeeping of money and valuables and access to these is properly controlled. Standard 36 (36.1 ­ 36.5) The registered person ensures that the employment policies and procedures adopted by the home and its induction, training and supervision arrangements are put into practice. 0 Key findings/Evidence Standard met? Standard 36 was not assessed as part of this unannounced inspection.Connie Lewcock Resource CentrePage 35 Standard 37 (37.1 ­ 37.3) Records required by regulation for the protection of service users and for the effective and efficient running of the business are maintained, up to date and accurate. 2 Key findings/Evidence Standard met? Records required by Regulation for the protection of Service Users and for the effective and efficient running of the home were noted to be in place and well maintained, with the exception of the following (refer to standards 7, 16 and 29 above). · Some care-plans lack the level of detail required to enable staff to provide individualised care and support. These documents should be drawn-up with Service Users and reviewed on a monthly basis. Because proper documentation has not been consistently kept in respect of complaints received by the Centre, it is not possible for the Inspector to determine whether thorough investigations have been undertaken. Staff personnel files and those documents required by Schedules 2 and 4 of the Care Homes Regulations 2001 were not available for inspection.··Additionally, it was noted that some case files had been left unattended in one of the Centres kitchen/dining areas. The Registered Manager must remind staff that information kept about Service Users is confidential and often sensitive in nature, and must be stored and accessed in accordance with the Data Protection Act 1998. Standard 38 (38.1 ­ 38.9) The registered manager ensures so far as is reasonably practicable, the health, safety and welfare of service users and staff. 2 Key findings/Evidence Standard met? On the day of inspection, procedures and practices in relation to health and safety were satisfactory, with the exception of the following matters, which were discussed with the Registered Manager. · · · All staff must observe and work in accordance with Control of Substances Hazardous to Health (COSHH) and Health and Safety requirements. The Centres fire log must be kept up to date. The Registered Manager must accurately carry out and record fire drills and instructions for day and night staff within the timescales prescribed by the Fire Authority. Testing of portable appliances must be carried out. This is an outstanding requirement of the last inspection.Connie Lewcock Resource CentrePage 36 PART C(where applicable)COMPLIANCE WITH CONDITIONSCondition N/A Comments N/AComplianceCondition N/A Comments N/AComplianceCondition N/A Comments N/AComplianceCondition N/A Comments N/AComplianceLead Inspector Second Inspector Locality Manager DateMrs Lesley Scriven N/A Mrs Jan CollisSignature Signature SignatureConnie Lewcock Resource CentrePage 37 PART D(where applicable) N/ALAY ASSESSORS SUMMARYLay Assessor Date Public reportsSignatureIt should be noted that all NCSC inspection reports are public documents.Connie Lewcock Resource CentrePage 38 PART EE.1PROVIDERS RESPONSE TO IDENTIFIED STATUTORY REQUIREMENTSRegistered Persons comments/confirmation relating to the content and accuracy of the report for the above inspection.We would welcome comments on the content of this report relating to the Inspection conducted on 01/12/03 and any factual inaccuracies: Please limit your comments to one side of A4 if possibleConnie Lewcock Resource CentrePage 39 Action taken by the NCSC in response to provider comments: Amendments to the report were necessary YESComments were received from the provider Provider comments/factual amendments were incorporated into the final inspection report Provider comments are available on file at the Area Office but have not been incorporated into the final inspection report. The inspector believes the report to be factually accurateYESYESNONote: In instances where there is a major difference of view between the Inspector and the Registered Provider both views will be made available on request to the Area Office. Please provide the Commission with a written Action Plan by 15th April 2004, which indicates how requirements are to be addressed and stating a clear timescale for completion. This will be kept on file and made available on request. You will also note that the Commission has identified in the inspection report good practice recommendations and it would be useful to have some indication as to whether you intend to take any action to progress these. E.2 Status of the Providers Action Plan at time of publication of the final inspection report: Action plan was required YESAction plan was received at the point of publicationYESAction plan covers all the statutory requirements in a timely fashion Action plan did not cover all the statutory requirements and required further discussion Provider has declined to provide an action planYESNONOOther: enter details here NOConnie Lewcock Resource CentrePage 40 E.3PROVIDERS AGREEMENT Registered Persons statement of agreement/comments: Please complete the relevant section that applies.E.3.2 I Mrs R A Shimmin of Newcastle Upon Tyne Social Services (Connie Lewcock Resource Centre) am unable to confirm that the contents of this report are a fair and accurate representation of the facts relating to the inspection conducted on the above date(s) for the following reasons:Print Name Signature Designation Date Note: In instance where there is a profound difference of view between the Inspector and the Registered Provider both views will be reported. 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