Inspection on 28/02/05 for Connie Lewcock Resource Centre

Care Home For Older PeopleConnie Lewcock Resource CentreWest Denton Road Lemington Newcastle upon Tyne Tyne & Wear NE15 7LQUnannounced Inspection28th February 2005 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 24th March 2004 NO NO 05/10/04 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 328th February 2005 09:00 am Jackie BurkeID Code156426Name of inspector 4 Name of specialist (e.g. Interpreter/Signer) (if applicable) Name of establishment representative at the time of inspectionPamela 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 Inspectors Summary Statutory Requirements/Good Practice Recommendations from last Inspection Conditions of Registration Statutory Requirements/ Good Practice Recommendations from this Inspection Part B: Inspection Methods & 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 Part C: Part D: D.1. D.2. D.3. Compliance with Conditions (if applicable) Providers Response Providers Comments Action Plan Providers AgreementConnie Lewcock Resource CentrePage 3 INTRODUCTION TO REPORT AND INSPECTION Every establishment that falls within the jurisdiction of the Commission for Social Care Inspection (CSCI), 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 CSCI 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 CSCI 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 · 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. 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 who may have dementia needs. This includes twelve community rehabilitation beds, one 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 and newsagent. The area is well served by public transport. The single storey building is designed in a square around wellmaintained 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 selfcontained 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 outside 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 February 28th 2005. Not all of the National Minimum Standards were inspected, but of the 25 that were, 19 were met ( 76 ). The views of people using the Centre and that of two family members were gathered during the day of inspection and positive interactions between staff and Service Users were observed. Staff members were observed treating Service Users with respect and described by people living and staying at the Centre as really supportive, they couldnt be more helpful. One service user commented that he would recommend the service to anyone who was coming out of hospital and that rehabilitation was helping him to get back on his feet. Choice of Home (Standards 1 - 6) Of three standards assessed, all were met. The Centre is suitably 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 on site providing services to people using the resource centre. Health and Personal Care (Standards 7 ­ 11) Of four standards assessed, all were met. Care-plans are drawn up in respect of everyone using residential services at Connie Lewcock Resource Centre, on the basis of pre and post admission assessment of individual needs and abilities. Service Users healthcare needs are 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. Daily Life and Social Activities (Standards 12 ­ 15) One standard was assessed and met. Visitors are welcomed at Connie Lewcock Resource Centre and residents are encouraged to participate in activities on offer in the care home. Complaints and Protection (Standards 16 ­ 18) Of the two standards assessed, both were met. Connie Lewcock Resource Centre operates to Newcastle Social Services Departments procedures for the Protection of Vulnerable Adults and many staff have attended related training courses. Complaints policy and procedural guidance are presented in a satisfactory format and accessible to all Service Users and visitors. Connie Lewcock Resource Centre Page 6 Environment (Standards 19 ­ 26) Six standards were assessed, of which five were met. Connie Lewcock Resource Centre is comfortable and homely and the layout of the building is suited to the Centres stated purpose. All areas are accessible, safe and are well maintained. 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 areas of the building thus retaining separate identities, which is commendable. Staffing (Standards 27 ­ 30) Of the four standards assessed, two were met. Satisfactory staffing levels have been maintained and on the day of the inspection six care staff were on duty in addition to the management team and ancillary staff. Personnel records were not available at the Resource Centre in accordance with the requirements of Schedules 2 and 4 of the care Homes Regulations 2001, therefore this standard was not met. Management and Administration (Standards 31 ­ 38) Five standards assessed, two were met. The Registered Manager 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.Connie Lewcock Resource CentrePage 7 Requirements from last Inspection visit fully actioned?NACONDITIONS OF REGISTRATION THAT APPLY (OTHER THAN NUMBERS AND CATEGORY OF SERVICE USERS).Met (Yes / No)Connie Lewcock Resource CentrePage 8 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 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. The code in Standard is a cross-reference to the Standards described in full in the section Inspection Findings. No. Regulation Standard * Requirement Timescale for action Outstanding 1 23 OP25OP3 8 The heating arrangements for Service Users bedrooms must be able to be suitably controlled within the building. Outstanding Staff records must be available at the Centre. 01/06/05217OP29OP3 Schedule 4 6OP3701/05/05Connie Lewcock Resource CentrePage 9 RECOMMENDATIONS 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). The code in Standard is a cross-reference to the Standards described in full in the section Inspection Findings. 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 2005.1OP282OP31* Note: You may refer to the relevant standard in the remainder of the report by omitting the 2-letter prefix e.g. OP10 refers to Standard 10.Connie Lewcock Resource CentrePage 10 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 NO NA YES YES YES NO YES YES NO NO NO YES YES YES 5 2 0 NO NO YES YES 24 0 28/02/05 11.30 4Connie Lewcock Resource CentrePage 11 The following pages summarise the key findings and evidence from this inspection, together with the CSCI assessment of the extent to which the National Minimum Standards for Care homes for older people 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 12 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 (£) XAny charges for extras If yes, please state what the extras are:YESHAIRDRESSING, TOILETRIES, NEWSPAPERS 0 Key findings/Evidence Standard met? This standard was not assessed during this unannounced inspection.Connie Lewcock Resource CentrePage 13 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). 0 Key findings/Evidence Standard met? This standard was not assessed during this unannounced inspection.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? Examination of a selection of Service User files confirmed that people who use services at Connie Lewcock Resource Centre are accepted on the basis of an assessment initially undertaken by Social Services or Health professionals, dependant on the point of referral. The Resource Centre utilises its own assessment tool, which enables staff to develop a 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 updated as required on each 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? Discussion with management confirms that collectively staff have the necessary skills and experience to meet the personal and social care needs of Service Users. Staff members receive a broad range of developmental training, which enhances their practice. The Resource Centre is well equipped with a good range of adaptations and aids to daily living. Service Users are encouraged in accordance with agreed individual plans of care to use these to promote and maintain 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? This standard was not assessed during this unannounced inspection.Connie Lewcock Resource CentrePage 14 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 Connie Lewcock Resource Centre is dedicated to provision of intermediate care. The wing is suitably equipped 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, for people recovering from hospital treatment, who no longer require hospital accommodation. One service user spoken to during the inspection was complimentary about the standard of care he received and described the service as first rate and something he would recommend to anyone.Connie Lewcock Resource CentrePage 15 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. 3 Key findings/Evidence Standard met? Care-plans are drawn up in conjunction with service users at Connie Lewcock Resource Centre, on the basis of pre and post admission assessment of individual needs and abilities. These documents outline areas of staff support and care required by each person, and are used in conjunction with individual daily reports. A number of care plans were examined during the inspection and contained sufficient detail and reflect the multi disciplinary approach to care fundamental to the service. Evidence suggests that service users and significant others are involved in the development of their individual care plans and, risk assessments are well utilised in relation to physical health needs.Connie Lewcock Resource CentrePage 16 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. No. of incidents where service users have been taken to Accident and Emergency during last 12 months No. of service users with pressure sores at time of inspection (from information taken from care notes) 14 13 Key findings/Evidence Standard met? Accident books kept by the home were examined and over the last twelve months, 150 entries have been made, the majority of which relate 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 a variety of specific conditions. 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 has in place 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; staff who administer medication have completed accredited training on the safe handling of medication.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. 0 Key findings/Evidence Standard met? This standard was not assessed during this unannounced inspection.Connie Lewcock Resource CentrePage 17 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? Connie Lewcock Resource Centre has in place a policy and procedural guidance for staff in relation to handling advancing illness, dying and death. Information leaflets relating to bereavement and grief are displayed in the foyer and the manager demonstrated awareness and sensitivity with regard to this issue and the needs of service users and carers. Given the nature of the service the resource centre provides, this aspect of assessment is rarely addressed in detail; however care plans examined indicate that end of life planning has been discussed and recorded where appropriate.Connie Lewcock Resource CentrePage 18 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. 0 Key findings/Evidence Standard met? This standard was not assessed during this unannounced inspection.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? Visitors were observed to come and go freely during the inspection and discussion with service users and one family member confirmed that visitors are encouraged to visit as they wish. Advocacy services have been requested for one permanent service user however this service is subject to resource restrictions and a waiting list applies. Church and religious visitors may be arranged by request. 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. 0 Key findings/Evidence Standard met? This standard was not assessed during this unannounced inspection.Connie Lewcock Resource CentrePage 19 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. 0 Key findings/Evidence Standard met? This standard was not assessed during this unannounced inspection.Connie Lewcock Resource CentrePage 20 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 CSCI Percentage of complaints responded to within 28 days 1 0 0 1 0 0 100 3 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. Documentary evidence indicates that complaints are responded to in a satisfactory manner and within the timescales required.Connie Lewcock Resource CentrePage 21 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. 0 Key findings/Evidence Standard met? This standard was not assessed during this unannounced inspection.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? Connie Lewcock Resource Centre operates to Newcastle Social Services Departments procedures for the Protection of Vulnerable Adults and staff have attended related training courses. 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. Newcastle City Councils Vulnerable Adults Coordinator has visited the Resource Centre and staff have been designated places on the next available training relating to Vulnerable Adults Awareness.Connie Lewcock Resource CentrePage 22 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? 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. 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. 0 Key findings/Evidence Standard met? This standard was not assessed during this unannounced inspection.Connie Lewcock Resource CentrePage 23 Standard 21 (21.1 ­ 21.8) Toilet, washing and bathing facilities are provided to meet the needs of service users. 3 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. 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. 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 specific individual needs. 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 24 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 NO NO NO X X X X 0 X XX X X XKey findings/Evidence Standard met? This standard was not assessed during this unannounced inspection.Connie Lewcock Resource CentrePage 25 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. 3 Key findings/Evidence Standard met? A tour of the premises indicated that individual bedrooms were clean and decorated to a good standard reflecting individual personal preferences and tastes. Each of the rooms examined 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? Windows in Service Users bedrooms provide natural light and may be opened by the occupant for ventilation; restrictors are fitted to all windows. Lighting throughout the resource centre gives a homely feel to the building and includes small table lamps to create ambient areas for conversation and relaxation. Emergency lighting is installed throughout. An outstanding requirement from the last three inspections relates to the control of temperature in individual bedrooms enabling service users to have a choice in the ambient temperature within their private domain. Newcastle Social Services commissioned a feasibility study by Cityworks in November 2004 which concluded that the costs involved and the disruption to service users would be unacceptable and consequently there are no plans to amend this shortfall. This standard continues to represent an unmet requirement of the service. 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. 3 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. Cleaning materials are stored in a locked cupboard and staff adhere to COSHH guidelines.Connie Lewcock Resource CentrePage 26 Connie Lewcock Resource CentrePage 27 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 0 X X 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 1 14 815.5 No. staff hours allocated No. staff hours allocated No. of staff hours provided X X 815.5 X X X0 24 73 Key findings/Evidence Standard met? Discussion with the registered manager confirmed that agreed minimum staffing levels have been maintained and that staffing levels have improved. Care at Home staff have been used to cover staff absence having received induction prior to joining the resource centre team in addition to their induction as Newcastle City Council employees. On the day of the inspection six care staff were on duty within the building covering residential and day care services, the registered manager and team leaders were also present, whose hours are supernumerary. At night two waking staff are on duty and one sleep in staff member cover the resource centre with an on call back up system in place. The level of ancillary support is consistently good.Connie Lewcock Resource CentrePage 28 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 the 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 8 33 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. 8 staff have achieved NVQ level 2 with a further 8 staff members undergoing NVQ studies.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. 2 Key findings/Evidence Standard met? It was not possible to assess this standard as the documentation required was not available on the day of inspection. It is an outstanding requirement that documentation should be made available for the next inspection. The manager has given assurances that files are in preparation and required information will be available by the next inspection which will include copies of references, when CRB checks have been undertaken, and personnel details which will be held on site. The 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. 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. 3 Key findings/Evidence Standard met? Supervision files examined during the inspection confirm that there is a good level and standard of training provided at Connie Lewcock Resource Centre. A comprehensive training needs analysis is undertaken with each staff member during supervision and recording of training needs and achievements is clear and relevant. Mandatory training is provided to all staff members and specific training needs are addressed appropriately.Connie Lewcock Resource CentrePage 29 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 is a qualified Registered General Nurse with over 15 years experience working in residential care settings. Ms Vickers is working toward achieving the Registered Managers (Adults) Award and anticipates achieving this award within the required timescale. Ms Vickers has demonstrated that she has a good knowledge of her role and responsibilities as Manager . Standard 32 (32.1 ­ 32.7) The registered manager ensures that the management approach of the home creates an open, positive and inclusive atmosphere. 3 Key findings/Evidence Standard met? Supervision is provided for all staff at the Resource Centre via formal structures and the management team operate an open door policy and a system of regular team meetings to ensure that communication is encouraged between team members. Staff spoken to during the inspection confirmed that this is the case and commented positively on access to training and the supervision structure.Connie Lewcock Resource CentrePage 30 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. 0 Key findings/Evidence Standard met? This standard was not assessed during this unannounced inspection.Standard 34 (34.1 ­ 34.5) Suitable accounting and financial procedures are adopted to demonstrate current financial viability and to ensure there is effective and efficient management of the business. 0 Key findings/Evidence Standard met? This standard was not assessed during this unannounced inspection.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? 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 and subject to financial audit undertaken by Newcastle City Council. The majority of service users exercise control over their own money. Secure facilities are in place for the safekeeping of money and valuables and access to these is properly controlled.Connie Lewcock Resource CentrePage 31 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. 2 Key findings/Evidence Standard met? It has not been possible to examine the employment practices within the home in relation to policies and procedures as all personnel documentation is held centrally at the Civic Centre. Supervision and training files assessed during the inspection demonstrate a good standard of recording and reflect an understanding of the importance of training and supervision to the effective management and development of the team. Supervision is facilitated via the management structure and staff members receive a good standard of formal supervision at least 6 times per year as required under this standard. 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 were noted to be in place and well maintained, with the exception of the following, which relates to Standard 29. Staff personnel files and those documents required by Schedules 2 and 4 of the Care Homes Regulations 2001 were not available for inspection.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. 0 Key findings/Evidence Standard met? This standard was not assessed during this unannounced inspection.Connie Lewcock Resource CentrePage 32 PART C(where applicable) Condition CommentsCOMPLIANCE WITH CONDITIONSComplianceCondition CommentsComplianceCondition CommentsComplianceCondition CommentsComplianceRegulatory Inspector Second Inspector Regulation Manager Date Public reportsJackie Burke Gill BestSignature Signature SignatureIt should be noted that all CSCI inspection reports are public documents.Connie Lewcock Resource CentrePage 33 PART DD.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 28 February 2005 and any factual inaccuracies: Please limit your comments to one side of A4 if possibleConnie Lewcock Resource CentrePage 34 Action taken by the CSCI in response to provider comments: Amendments to the report were necessary NOComments 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 accurateYESNOYESNote: 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. D.2 Please provide the Commission with a written Action Plan by 26 April 2005, 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. 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 35 D.3PROVIDERS AGREEMENT Registered Persons statement of agreement/comments: Please complete the relevant section that applies.D.3.1 I Mrs R A Shimmin of Newcastle upon Tyne Social Services (Connie Lewcock Resource Centre) 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) and that I agree with the requirements made and will seek to comply with these. 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. Please attach any extra pages, as applicable.Connie Lewcock Resource CentrePage 36 Connie Lewcock Resource Centre / 28th February 2005Commission for Social Care Inspection 33 Greycoat Street London SW1P 2QF Telephone: 020 7979 2000 Fax: 020 7979 2111 National Enquiry Line: 0845 015 0120 www.csci.org.ukS0000032762.V209077.R01© This report may only be used in its entirety. Extracts may not be used or reproduced without the express permission of the Commission for Social Care Inspection The paper used in this document is supplied from a sustainable source - 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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