Inspection on 04/12/07 for Connie Lewcock Resource Centre

This inspection was carried out on 4th December 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Connie Lewcock Resource Centre 26/10/06

Connie Lewcock Resource Centre 28/02/06

Connie Lewcock Resource Centre 20/09/05

Connie Lewcock Resource Centre 28/02/05

Connie Lewcock Resource Centre 05/10/04

Connie Lewcock Resource Centre 01/12/03

Similar services:

Turret Villa Retirement Home

Moor House

Mendip House

Beaconsfield Court Care Home

Little Sisters Of The Poor

Manor House

Middleton Hall Ltd

Middlesbrough Intermediate Care Centre

Extracts from inspection reports are licensed from CQC, this page was updated on 08/07/2008.

CARE HOMES FOR OLDER PEOPLE Connie Lewcock Resource Centre West Denton Road Lemington Newcastle upon Tyne Tyne & Wear NE15 7LQ Lead Inspector Elaine Malloy Key Unannounced Inspection 09:40 4th to 11th December 2007 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Connie Lewcock Resource Centre DS0000032762.V353538.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Connie Lewcock Resource Centre DS0000032762.V353538.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Connie Lewcock Resource Centre Address West Denton Road Lemington Newcastle upon Tyne Tyne & Wear NE15 7LQ 0191 264 3439 0191 267 1169 andrea.marshall@newcastle.gov.uk Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Newcastle upon Tyne Social Services Mrs Andrea Mary Marshall Care Home 24 Category(ies) of Dementia - over 65 years of age (3), Old age, registration, with number not falling within any other category (21) of places Connie Lewcock Resource Centre DS0000032762.V353538.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category of service only: Care home only - Code PC To service users of the following gender: Either Whose primary care needs on admission to the home are within the following categories: Old age, not falling within any other category - Code OP, maximum number of places: 21 Dementia, over 65 years of age - Code DE(E) , maximum number of places: 3 The maximum number of service users who can be accommodated is: 24 26th October 2006 2. Date of last inspection Brief Description of the Service: Connie Lewcock Resource Centre is a registered care home for older people, including people with dementia. It is operated by Newcastle City Council Social Services. The centre is located at Lemington in Newcastle upon Tyne. It provides short stays for community rehabilitation, respite care and emergencies. A range of health and social care professionals supplement the staff team. Accommodation is provided at ground floor level. The centre is separated into units with their own lounge and kitchen/dining areas. All service users have single bedrooms, and 2 rooms have en-suite facilities. A guide to the centre’s services and inspection reports are readily available at the centre. The current weekly fee for respite care is £66.85. Fees for service users admitted for emergency stay are dependent upon an assessment of their finances. Service users admitted for community rehabilitation stays do not pay fees for the first six weeks. Fees after six weeks are dependent upon financial assessment. Connie Lewcock Resource Centre DS0000032762.V353538.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection was carried out by: • Looking at information received since the last inspection on 26th October 2006. • Getting the provider’s view of the service and how well they care for and support people. • An inspector visiting the centre on 4th December 2007. • Talking to the management about the service. • Looking at records about the people who use the service and how well their needs are met. • Looking at a range of other records that must be kept. • Checking that staff have the knowledge, skills and training to meet the needs of the people they support. • Getting the views of people who use the service, their relatives, and staff by talking to them and from surveys they completed. • Checking whether improvements needed from the last inspection have been followed up. What the service does well: People who stay at the centre are offered personalised care and support that respects their privacy and dignity. They said, “The help is excellent” and “Staff are very good”. Relatives are happy with the service provided. They said, “They have looked after my wife, while staying there, and I am really pleased with the way she has come on”, and, that the centre, “Looks after residents with care and helps them get back to a normal routine at home”. People have their health, personal and social care needs thoroughly assessed. They have individual care plans that are well recorded and show how their needs will be met. The therapy team based at the centre and other medical professionals provides a good level of health care support to service users. There are appropriate medication procedures and trained staff administers medication. A variety of social activities take place that service users have chosen and contact with family, friends, and the local community is maintained. Each person is encouraged to make choices and decisions and lead their preferred lifestyle. There is a good choice of nutritious meals and service users enjoy the food. Clear systems are in place to make complaints, protect vulnerable people from abuse, and deal with personal finances. There are safe working practices to promote service users’ health, safety and welfare. Connie Lewcock Resource Centre DS0000032762.V353538.R01.S.doc Version 5.2 Page 6 There is sufficient staff to meet the needs of the number of people staying at the centre. Service users are supported by skilled workers who receive a good level of training on meeting the diverse needs of older people. Fifty-five percent of staff have completed care qualifications that are nationally approved. There are effective methods to monitor the quality of the service that ensures service user views are listened to and acted upon. What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Connie Lewcock Resource Centre DS0000032762.V353538.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Connie Lewcock Resource Centre DS0000032762.V353538.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 3 and 6. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. There is a comprehensive assessment process that clearly identifies the care and support needs of people using the service. People are well supported to become independent enough to return to their own homes. EVIDENCE: A sample of service user care records was examined. This showed that assessments from social work and medical professionals are obtained. People referred to the service have a ‘Baseline Assessment’ completed within 48 hours of admission. This is a comprehensive document that assesses the person’s holistic needs and risks and establishes where care plans are needed. It also identifies where further assessment is required and prompts referral to other professionals. Connie Lewcock Resource Centre DS0000032762.V353538.R01.S.doc Version 5.2 Page 9 The majority of assessments were completed on the person’s first day at the centre. Differences between dates of assessments and care plans for one service user were brought the attention of the manager. Staff who completed surveys said they are ‘always’ or ‘usually’ given up to date information about the needs of the people they support or care for. One person said, “Information is exchanged on a need to know basis. Support or input from staff pertaining to existing care plans is recorded to monitor if care plans are, or not, successful in meeting individual needs of a service user, and if necessary are adjusted”. The majority of service users who completed surveys said they received enough information before being admitted so they could decide if it was the right place for them. One person indicated their relative had been given information and another commented, “I knew it was the right place for me it’s a feeling you get”. People who stay at the centre for community rehabilitation are provided with intermediate care. Each person’s stay is tailored to his/her needs with the aim of being able to return home. They are supported by staff and a team of health and social care professionals. In the past year 143 service users have received community rehabilitation services. Following their stays 94 service users returned home, 12 moved into care homes, 21 went into hospital, eight moved to another category within the service or another resource centre, and the remaining eight people were still staying at the centre. Connie Lewcock Resource Centre DS0000032762.V353538.R01.S.doc Version 5.2 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Health and personal care is planned to a good standard to make sure the diverse needs of people using the service are met. EVIDENCE: Each person has a ‘Care Action Plan’ that is a summary of their care plans, with issues, goals and actions. People using the service are involved in their individual care planning. Their comments on aims and priorities are recorded and they sign to agree their care plans. The care plans examined were well-recorded and personalised, and based on needs and risks identified from assessments. They addressed a wide range of needs including health, moving and handling, mobility, risk of falls, foot care, skin condition, nutrition, personal hygiene, dressing, continence, leisure, communication and needs associated with physical and mental frailty. There Connie Lewcock Resource Centre DS0000032762.V353538.R01.S.doc Version 5.2 Page 11 was evidence of care plans being updated as the person’s needs change and plans are regularly evaluated. A recommendation was made at the previous inspection for day and night reports to correspond to care plans to aid evaluations of plans. This has been followed up and the quality of reports was much improved, and entries are now numbered to correspond to care plans. The majority of staff who competed surveys said that the ways they pass information about service users between staff usually works well. Service users retain their own GP where possible during their stay, or can be temporarily registered with a local practice. The District Nursing Service provides input to individuals when needed. There is an on-site therapy team of medical professionals that consists of a geriatrician, physiotherapist, occupational therapist, and dietician. Arrangements are in place for a podiatrist, dentist and optician to visit. Physical and mental health needs, and risks associated with supporting individuals are assessed and set out in care plans. All contact with health care professionals is recorded. Service users who completed surveys said they always receive the medical support they need. People who spoke to the inspector praised the input from the therapy team, and one lady said that the dietician would continue to visit her when she returned home. People using the service are encouraged to continue to take responsibility for their prescribed medication, and risks are assessed. Staff who administer medication have completed training and some are on a working party with a pharmacist looking at systems, policy and practice. In the past year the Commission was notified of five medication errors/issues. Audits are being carried out three times a day to check medication has been properly administered and recorded. Each service user has a photograph on their record for identification purposes. Current medication records were examined; these were appropriately recorded. The manager is part of a ‘dignity in care’ working group and is planning to cascade training to staff. Person-centred care planning and promoting dignity is discussed at staff meetings and supervisions. All staff have had in-house training on equality and diversity to give them understanding of the different needs people may have. Service user personal care and medical examination/treatment is carried out in private. The centre provides all single bedroom accommodation. Service users can have keys to their rooms and have a lockable piece of bedroom furniture. Staff are instructed to knock on bedroom doors and wait for an answer before Connie Lewcock Resource Centre DS0000032762.V353538.R01.S.doc Version 5.2 Page 12 entering the room. The pay telephone has been re-sited to a quiet area to enable people to make and receive calls in private. People using the service told the inspector that staff are respectful and kind towards them. Privacy and dignity issues are discussed at weekly service user meetings and included in questionnaires that are given to people at the end of their stay. Connie Lewcock Resource Centre DS0000032762.V353538.R01.S.doc Version 5.2 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People using the service are actively encouraged to make choices and decisions and lead their preferred lifestyle. EVIDENCE: People using the service have their social and cultural needs assessed and care planned. There are weekly meetings with service users to determine their views on daily life in the centre, including choice of social activities. Staff are allocated responsibility each day for providing activities and recording these in a diary. Recent examples were exercise groups, quiz, crafts, crossword, dominoes, reminiscence and bingo. Outings and visiting entertainment are usually arranged on a monthly basis. The previous recommendation to continue to improve social activities, outings and entertainment has been followed up and records of activities are being audited. Service users told the inspector that there are flexible routines and they are offered plenty of choices. A good example was given of how an interpreter was organised to visit a Japanese service user each day to enable her to express Connie Lewcock Resource Centre DS0000032762.V353538.R01.S.doc Version 5.2 Page 14 choices in daily living and dietary requirements. Most of the people who completed surveys said there is always activities arranged that they could take part in. One person said, “Due to eye sight difficulties I respond better to quizzes and sing songs”. There is an open visiting policy and visitors are welcomed at any time. They can help themselves to drinks and be provided with meals. The centre encourages family and friends to support service users, advocate on their behalf if needed, and take part in the person’s care reviews. Relatives who completed surveys said they always get enough information about the service to help them make decisions. They said they are kept up to date with important issues affecting their relative. People using the service are offered opportunities to go out individually and in small groups. Staff support service users to maintain contact with the local community and use facilities such as the post office, shops and a social club. The centre has forged links with local clergy and schools. A good range of information is made available to service users on issues relevant to older people. Leaflets are displayed on council services and other agencies, for example an advocacy service, a carer centre, and Help The Aged. The service aims to ensure that people keep control over their lives by providing information and encouraging them to make choices and decisions. Service users can access their personal care records and are involved in the process of assessment, care planning, reviews and discharge. A lady service user who was going home that day confirmed this and told the inspector she had been consulted throughout her stay. Relatives who completed surveys said the service supports people to live the life they choose and meets the different needs of people. One person said, “They have looked after my wife, while staying there, and I am really pleased with the way she has come on.” There is a 3-week menu that has been devised using good practice guidance for meeting the nutritional needs of older people. The menu offers good choice and variety of meals and is reviewed on a regular basis. Special diets for medical and cultural reasons, and seasonal events and special occasions are catered for. There are small dining areas where service users can help themselves to drinks and snacks. People using the service have their nutritional needs assessed and weights are monitored. They are consulted about food at service user meetings and asked their preferences for meals each day. Staff work closely with a dietician and catering staff to ensure each person’s dietary requirements are met. Mealtime practices have been improved and staff have received nutritional training. The inspector dined at lunch with service users. The day’s menu was displayed on a board. Tables were nicely set and had condiments and serviettes. Food was served from a hot trolley and there were tureens on tables for people to Connie Lewcock Resource Centre DS0000032762.V353538.R01.S.doc Version 5.2 Page 15 help themselves. The mealtime was a sociable occasion with plenty of conversation and staff were attentive towards service users. People spoken with said they are always offered choice of food and they enjoy the meals. The majority of service users who completed surveys said they always like the meals. Comments included, “Well served”, and “Excellent”. Connie Lewcock Resource Centre DS0000032762.V353538.R01.S.doc Version 5.2 Page 16 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People using the service are protected from harm by clear complaints and safeguarding procedures. EVIDENCE: Comments and complaints leaflets are on display in the centre. The complaints procedure is included in the Service User Guide that is provided to each service user in their bedroom. The procedure is also explained and discussed at service user meetings. All service users and relatives who completed surveys said they know how to make a complaint. Each of the staff who completed surveys indicated they know what to do if a service user/relative/advocate has concerns about the service. The Commission has not received any complaints about the service since the last inspection. Two complaints were made directly to the centre during this time. These were dealt with internally and appropriately resolved. However the details of one of the complaints was not fully recorded. A tracking system is used to make sure that complaints are acknowledged and responded to within the procedure timescales. Connie Lewcock Resource Centre DS0000032762.V353538.R01.S.doc Version 5.2 Page 17 There are a range of policies and procedures on recognising the signs of, and preventing abuse, protecting vulnerable adults, and ‘whistle blowing’ (informing on bad practice). The manager is a trainer for safeguarding adults and has provided all staff with refresher training. Service users told the inspector they feel safe staying at the centre, and one person said it was comforting to know that staff are available at night. Connie Lewcock Resource Centre DS0000032762.V353538.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 25 and 26. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users stay in a safe, clean and comfortable building that is maintained to a good standard. EVIDENCE: The centre has recently been refurbished with redecoration and new carpets/floor coverings to corridors, communal areas and five bedrooms. Service users have chosen a range of attractive pictures for corridor walls. All bedrooms have new curtains, bed linen and towels. New garden furniture has been bought. There are plans to redecorate more bedrooms, re-site the medication room, and create a double bedroom. Connie Lewcock Resource Centre DS0000032762.V353538.R01.S.doc Version 5.2 Page 19 Health and safety checks are carried out and there are servicing agreements in place for facilities and equipment. Records are kept of maintenance and repairs. All parts of the building seen were clean and appropriately furnished and equipped. Ventilation needs to be checked to make sure it is working in all areas. The centre has five full time domestic staff. All service users who completed surveys said the building is always clean and fresh. There are policies and procedures on hygiene and control of infection. A team leader takes a lead role infection control. Staff have been provided with training sessions on hand hygiene, infection control, MRSA and Clostridium Difficile. A new sluice machine has been installed. The building has suitable hand-washing facilities and staff are provided with supplies of disposable aprons and gloves. Arrangements are in place to dispose of clinical waste. Connie Lewcock Resource Centre DS0000032762.V353538.R01.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. There are sufficient, well-trained staff to meet the needs of people who use the service. EVIDENCE: The centre maintains staffing levels of at least four carers across the waking day and two carers at night. The manager’s hours are in addition to these levels. There are good weekly domestic and catering hours. Full time administrative support is provided. Service users told the inspector that staff are “very nice”, “caring” and “competent”. People who completed surveys said they always receive the care and support they need, staff are available when they need them, and listen and act on what they say. Comments included, “The help is excellent” and “Staff are very good”. Relatives said the centre meets the needs of their family member, gives the support/care they expected and they feel staff have the right skills and experience. One person commented, “Quite satisfied”. Connie Lewcock Resource Centre DS0000032762.V353538.R01.S.doc Version 5.2 Page 21 The majority of staff who completed surveys said there is usually enough staff to meet the individual needs of all service users. Comments on issues about working ‘overtime’ were relayed to the centre management. Staff said they feel they ‘always’ or ‘usually’ have the right support, experience and knowledge to meet the different needs of service users. The centre exceeds the standard for the ratio of care staff with National Vocational Qualifications (NVQ), or equivalent. 55 of care staff have achieved NVQ in care at Levels 2-4. No new staff have been recruited externally since the last inspection therefore staff files were not examined. Staff who completed surveys said their employer had completed all necessary checks before they started work. Each staff member has a file with details of training they have undertaken and training certificates. There is a rolling programme of staff training. Managers and Team Leaders in Social Services Resource Centres have designated responsibilities to cascade training as a result of completing ‘Train the Trainer’ courses. In the past year staff have completed training in health and safety, moving and handling, fire safety, food hygiene, first aid, infection control, medication, safeguarding adults, falls prevention, nutrition and fluid intake, equality and diversity, palliative care, personal safety at work, care planning, and customer services. Training is planned on caring for people with dementia, the Mental Capacity Act, foot care, and dignity. Staff who completed surveys indicated they had received suitable induction training. Comments included, “Times have changed! New starters now have a comprehensive introduction”, and, “Attended a one day a week course for six weeks after Id first started and also worked alongside an experienced member of staff to offer me support and guidance”. They said they are given training relevant to their role, that helps them understand and meet the needs of individual service users, and keeps them up to date with new ways of working. Connie Lewcock Resource Centre DS0000032762.V353538.R01.S.doc Version 5.2 Page 22 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 and 38. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. There are effective management systems to support the delivery of a service that is run in the best interests of service users. EVIDENCE: In April 2007 Mrs Andrea Marshall was approved as the Registered Manager for the centre. She has worked in health and social care services for 25 years and has six years of management experience. She has achieved NVQ Level 4 in Care and Management, the Registered Manager Award and an Advanced Diploma in Management Practice. The management team have concentrated efforts in the past year on improving systems and ensuring staff are up to date Connie Lewcock Resource Centre DS0000032762.V353538.R01.S.doc Version 5.2 Page 23 with training and policies. All staff who completed surveys said their manager meets with them regularly to give support and discuss how they are working. The centre has a system for quality assurance. Action plans are put into place that set out what is to be done, who is responsible and short and long-term measures. The plan is regularly reviewed and revised. Methods of monitoring quality include a range of audits, meetings and questionnaires to get feedback. A senior worker takes responsibility for collating questionnaire results and following up on issues. Findings from questionnaires are discussed at staff and service user meetings. Visits and reports on the conduct of the service are not being consistently carried out on a monthly basis, as required. Service users who spoke to the inspector and completed surveys said they were satisfied with the support they receive and are well looked after. One relative said the centre does most things well, another said, “Looks after residents with care and helps them get back to a normal routine at home”. No service users or relatives gave comments on how the service could improve. Staff who completed surveys gave comments on what they feel the service does well. They said it promotes independence and privacy and dignity, provides valued support and care that leads to people being able to remain in the community, and relieves carer stress. Some staff felt the service could improve by staggering admissions, having therapy staff at weekends, and improving information to minimise inappropriate referrals. Service users can choose to keep cash in the centre safe. Personal finances records were examined. Individual sheets for each person’s account were suitably recorded. Two staff signs each entry and wherever possible the service user also signs. Receipts are obtained for purchases. Daily audits of balances and cash are carried out. There is a health and safety policy and a wide range of associated procedures. Risks assessments are conducted for safe working practices. Service users have an assessment of risks according to individual vulnerabilities. Where necessary care plans to manage or minimise risks are drawn up. All staff receive training in health and safety and safe working practices. The centre has a designated health and safety representative who attends meetings and shares information with the staff team. Fire safety records showed that checks, tests and instructions to staff are carried out at the required frequency. Checks of fire fighting equipment were being recorded on the wrong sheet but this has since been rectified. Accident and incident reports are appropriately recorded including follow up action and treatment. Some analysis of accidents is carried out to establish any patterns. Connie Lewcock Resource Centre DS0000032762.V353538.R01.S.doc Version 5.2 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 3 X X 3 HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 3 3 X X X X X 2 3 STAFFING Standard No Score 27 3 28 4 29 X 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 2 X 3 X X 3 Connie Lewcock Resource Centre DS0000032762.V353538.R01.S.doc Version 5.2 Page 25 NO Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP33 Regulation 26 Requirement The Registered Person, or their representative must visit the centre at least monthly and prepare reports on the conduct of the service. Timescale for action 04/12/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. Refer to Standard OP16 OP25 Good Practice Recommendations All complaints about the service should be fully recorded. Ventilation should be checked throughout the building to make sure it is working properly. Connie Lewcock Resource Centre DS0000032762.V353538.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Cramlington Area Office Northumbria House Manor Walks Cramlington Northumberland NE23 6UR National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Connie Lewcock Resource Centre DS0000032762.V353538.R01.S.doc Version 5.2 Page 27 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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