Inspection on 08/08/06 for Newbrae Eventide Home

This inspection was carried out on 8th August 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. 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 found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Newbrae Eventide Home 16/10/08

Newbrae Eventide Home 25/10/05

Newbrae Eventide Home 20/04/05

Newbrae Eventide Home 12/10/04

Similar services:

Claremont House

Oak Ridge

Sun Court Nursing Home

Ashville House

Bilney Hall

Hill Barn

Mabbs Hall Nursing Home

Henrietta House

Extracts from inspection reports are licensed from CQC, this page was updated on 09/07/2008.

CARE HOMES FOR OLDER PEOPLE Newbrae Eventide Home 41 Crowstone Road Westcliff On Sea Essex SS0 8BG Lead Inspector Mrs Bernadette Little Key Inspection 8th August 2006 10:00 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Newbrae Eventide Home DS0000061527.V307428.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. Newbrae Eventide Home DS0000061527.V307428.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Newbrae Eventide Home Address 41 Crowstone Road Westcliff On Sea Essex SS0 8BG 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) 01702 430431 01702 213414 Mr Moussajee Assrafally Mrs Salmah Assrafally Mr Moussajee Assrafally Care Home 10 Category(ies) of Dementia - over 65 years of age (10), Old age, registration, with number not falling within any other category (10) of places Newbrae Eventide Home DS0000061527.V307428.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 25th October 2005 Brief Description of the Service: Newbrae provides accommodation for up to ten older people, including those with dementia, and is situated close to the towns of Southend, Westcliff on Sea, and Leigh on Sea. The home has a lounge/dining area, two bathrooms, one shower room and six single and two shared bedrooms, mostly with ensuite facilities. The home offers a small rear garden. There is no off street parking. The home has a passenger lift that provides access to all floors. Newbrae has easy access to local shops and amenities and there are good bus and train links in the area. The weekly fee ranges from £325 to £425 as advised by the registered manager in the Pre-inspection questionnaire. Additional charges/costs are incurred by residents relating to chiropody and hairdressing. The above information was not detailed within the home’s Service Users Guide. Newbrae Eventide Home DS0000061527.V307428.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This site visit was undertaken as part of the key inspection of Newbrae. Eight hours were spent at the home on a Tuesday. Two care staff and the registered manager were spoken with. All residents were seen and four were spoken with. A tour of the premises was undertaken and records, policies and procedures were sampled. Care files for three residents were case tracked. A pre-inspection questionnaire was received from the registered provider prior to the site visit and information from that document was also used to inform this report. Discussion of the inspection findings took place with the registered manager throughout the inspection and guidance and advice was given. Completed questionnaires were received from four residents, with assistance from relatives, prior to the site visit. Some residents at Newbrae have varying degrees of dementia. Information on the views possible to obtain as well as observations made during the inspection are also reflected throughout the report. A completed comment card was received from a relative and two others were completed by telephone with another relative and healthcare professional. All comments regarding the staff were positive and complimentary, and all were satisfied with the standard of care provided at Newbrae. Comments included “staff and management provide excellent care and support”, “never had any needs to complain”, “it’s like a hotel here”, “staff are very caring and considerate and treat me as an individual with respect and dignity”. Request for comments were also sent to three care managers/social work teams, a GP and a chiropodist. No responses were received to any of these requests within the requested timescale. What the service does well: The small number of residents accommodated at Newbrae provides a more family type setting and this was commented positively upon by a relative spoken with. The premises are generally homely in appearance. Newbrae provides residents with home-cooked food that they said they enjoyed. Both relatives and professionals felt welcomed and said that the home keeps them up-to-date with all appropriate information. Newbrae Eventide Home DS0000061527.V307428.R01.S.doc Version 5.2 Page 6 Staff were seen to talk to residents with respect, to give them time, and to explain things in a patient and gentle manner. Residents said that staff were nice. 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. Newbrae Eventide Home DS0000061527.V307428.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 Newbrae Eventide Home DS0000061527.V307428.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 3, 4, 5, 6 The judgement in this outcome group is good. This judgement has been made using available evidence including a visit to this service. Prospective residents and other interested people were given information about the home so they could know whether it was right for them. Pre-admission assessments had been undertaken and staff were being provided with basic training in conditions relating to older people to make sure the home could meet residents needs. EVIDENCE: A Statement of Purpose and Service User Guide was available. Advice was provided to the registered manager on areas where there was inadequate information, for example the Statement of Purpose required information on the number of staff and their qualifications, and also needed to be more accurate in relation to the provision of a Roman Catholic Mass in the home on a regular basis. The Service User Guide did not contain a description of the accommodation, information on the number of places, reference to inspection reports, the Newbrae Eventide Home DS0000061527.V307428.R01.S.doc Version 5.2 Page 9 complaints procedure and information on the fees. The size of the print on this document could be bigger to make it easier to read. The registered provider/manager advised that these are provided to interested parties prior to coming to the home. A relative spoken with advised that they had not received the documents prior to admission. A recent letter, confirming the placement of the prospective resident, included reference to the inclusion of a Service User Guide. Contracts were sampled on two files and were noted positively to be available, and had been signed by the resident. The files for two more recently admitted residents contained assessments that had been completed prior to admission, even in the case of an emergency. The files also evidenced that the registered manager had written to the prospective resident to confirm that, based on the assessment, the home could meet their needs. The staff training matrix indicates that staff have had some training in issues specific to the conditions of older people, including dementia care, management of behaviour that challenges and diabetes. Training needs identified include Parkinsons disease and pressure area care and training for some staff is planned in these and other areas. A relative spoken with advised that staff are willing, but do not always evidence full understanding of the residents particular condition. The registered manager and a relative confirmed that they were able to visit the home prior to admission. The registered manager was advised to ensure that these are recorded in the visitor’s book. A questionnaire received from a resident confirmed a visit had taken place prior to their recent admission. This included a tour of the premises and introduction to the other residents. Newbrae does not offer intermediate care. Newbrae Eventide Home DS0000061527.V307428.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9, 10, 11 The judgement in this outcome group is good. This judgement has been made using available evidence including a visit to this service. The records about each residents care had adequate information to help staff give this but could be better. Implementation could be better evidenced in care notes. Healthcare was effectively managed for residents. Medication practices generally protected residents. Consideration had been shown for residents’ privacy and dignity. EVIDENCE: Care management documentation files were sampled for three residents. The care plan format reflected several areas of need, and were completed. It was discussed with the registered manager that they do need to have additional information, for example in relation to a residents social care/leisure activity plan. This did not identify that it there had been a change to the resident’s going out regularly to the shop for a walk, or include information on/detailed care instructions for a sore knee or arthritis. As the resident was able to sign their contract, the registered manager will now read their care plan to them and see if they are able to sign it. Newbrae Eventide Home DS0000061527.V307428.R01.S.doc Version 5.2 Page 11 Care notes were written daily, sometimes twice, and also at night, which is good practice. They were noted to be repetitive and to contain limited information on occasions. Where a care plan was in place in relation to a resident having a pressure sore, the care notes did not evidence that the care instructions had been carried through by staff, for example in relation to encouraging and supporting the resident to move regularly to reduce the pressure. Tissue viability assessments, nutrition assessment, moving and handling assessment, and a falls risk assessments were in place, which is good practice. Residents, including the new admissions, had been registered with a GP. A record was kept for each resident of GP and other relevant healthcare professional involvement. These indicated optical and chiropody appointments, visits by the GP and district nursing services. A district nurse spoken with confirmed appropriate communication and working in partnership from the home, who requested interventions in a timely manner appropriate to the needs of residents. Appropriate records were maintained relating to the receipt and disposal of medications. Medication Administration Recording sheets (MAR) showed no omissions. Storage was well-organised. A homely remedy policy was in place. It was noted positively that a risk assessment on a resident care plan identified why they were not able to self medicate. Not all staff identified in the Pre inspection questionnaire as responsible for administering medication were demonstrated on the staff training matrix as having had medication training. The registered manager advised that as a qualified nurse he had provided them with training and assessed their competence. There was no evidence of the content of this training available. It was discussed with the registered manager that he had handled a resident’s medication while administering it, which is inappropriate. The home’s Statement of Purpose contained information on the homes aim to respect residents’ rights, privacy and dignity. Staff spoken with and observed indicated that this was put into practice. A healthcare professional confirmed that staff always assist them to treat residents in private. The registered manager advised that a small downstairs room was now available to offer privacy to residents and their visitors. A relative spoken with also confirmed that they can see their relative in the person’s own room. Following the last inspection the registered manager had introduced a policy and procedure on care of the dying, which included reference to ensuring pain control. Additional information may be added relating to for example oral and personal care. The resident manager advised that he had provided training for staff on death and dying and had provided counselling for staff following the Newbrae Eventide Home DS0000061527.V307428.R01.S.doc Version 5.2 Page 12 death of a resident. Information in care plans sampled indicated that residents views were being sought on end of life wishes. The homes Service User Guide/Statement of Purpose did not contain any information on the homes approach to managing care at the end of life. Newbrae Eventide Home DS0000061527.V307428.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, 15 The judgement in this outcome group is adequate. This judgement has been made using available evidence including a visit to this service. The range of activities provided needs to show more clearly that they meet with individual residents needs. Residents exercise choice in some areas. Residents are provided with a nutritional diet of home-cooked food. EVIDENCE: Two of the four questionnaires returned from residents confirmed that the home provided social activities that they could take part in, while the other two advised the activities were not always suitable for them. As noted earlier in the report, care plans needed to be more specific in identifying the individual activities and areas of interests that are to be offered to each resident. The registered manager advised that following a residents meeting, a DVD player was purchased along with some films and a list kept of what was what and when. Unfortunately, the lounge does not provide ample space for all residents to sit in a chair that has a comfortable view of the television. Individual activities also took place. The registered manager advised that he obtained a football kit and a book on a particular team for a resident and they watch football matches. Another individual activity included going through a book of photographs with the resident, which the family had helped to compile. Newbrae Eventide Home DS0000061527.V307428.R01.S.doc Version 5.2 Page 14 A resident said they enjoyed reading and had books brought by the mobile library. Some residents had their own individual newspaper delivered. A member of staff was seen to offer to sit and read this to a resident. A resident indicated they enjoyed playing dominoes with the staff and other residents and also like the outside entertainers, watching television and music. Inspection of the records, observation of practice and discussion with relatives confirmed that relatives felt welcome at the home and could visit regularly. Some residents were seen to be able to choose to spend time either in their own room or in the lounge with others, as they preferred. A resident advised that the time they get up in the morning suits them. Another resident, who was physically self-caring, was still in bed at the start of the inspection as that was their choice. One residents bedroom door was locked. The registered manager confirmed that this was because the person liked their privacy. The registered manager was heard to inform residents that there was chicken for dinner and to ask if that was alright. The nutrition record showed no variance for any resident, and that residents did not exercise choice at mealtimes. The nutrition record needs to identify any specific dietary needs, including those that are liquidised or where supplements are provided. It was noted positively that the nutrition record includes breakfast, lunch, dinner and supper. The registered manager was advised that if residents are offered something to eat at suppertime as they should be, this should be recorded. The meal observed was well presented and home-cooked. Most residents indicated that they always like the food served, one indicated they usually enjoy it and another that it was lovely. Staff sat at tables with residents who needed assistance and gave them ample time and assistance to enjoy their meal. A meal was saved for a resident who said they did not feel hungry at that time. Newbrae Eventide Home DS0000061527.V307428.R01.S.doc Version 5.2 Page 15 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16, 17, 18 The judgement in this outcome group is good. This judgement has been made using available evidence including a visit to this service. The home’s procedures and staff training/knowledge protected residents. EVIDENCE: The registered manager confirmed that no complaints had been received by the home to the last inspection. The Commission for Social Care Inspection had received no complaints about the home. The home’s complaint procedure was not readily available but sheets to record complaints were. One comment card indicated no awareness of the home’s complaints procedure. However it was stated that the registered manager regularly invited that any issues should be brought to him straight away, and when this had occurred he had listened and acted fairly. The registered manager advised that two of the more able residents had voted at the last election, one being taken by their family and the other by himself. All but one member of staff had been provided with training on protection of vulnerable adults, either in-house by the registered manager or provided by Southend Borough Council. Information on the course content was also available in the home for staff. Evidence was seen of bookings for additional training. A whistleblowing policy was available and known to staff. Southend Borough Council Protection Of Vulnerable Adult Guidelines were displayed in the home. All but two staff had had training in management of behaviour that challenges, provided in-house by the registered manager. Newbrae Eventide Home DS0000061527.V307428.R01.S.doc Version 5.2 Page 16 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 23, 26 The judgement in this outcome group is adequate. This judgement has been made using available evidence including a visit to this service. Most areas provide a comfortable living environment, but some refurbishment continues to be needed. Better attention to safety issues would better protect residents. EVIDENCE: Since the last inspection, the lounge has been decorated and looks much brighter and more welcoming. A downstairs visitors room has been made available, which also provides a space for people to sit quietly on their own. The top floor bathroom has been refurbished, as has the shower room. Two bedrooms have been redecorated and one re-carpeted. Two residents spoken with confirmed they were satisfied with their room, one said it was very comfy and they liked to spend time there. At the start of the inspection it was observed that all fire doors were wedged open. This was identified to the registered manager as unacceptable and a fire risk. The home need to take appropriate action to ensure the safety of residents, while allowing residents freedom of access and movement. Newbrae Eventide Home DS0000061527.V307428.R01.S.doc Version 5.2 Page 17 The window restrictor was not working in one bedroom and the registered manager confirmed that this would be given immediate attention. It was also discussed with the registered manager that not all residents have access to a call bell from their beds. While it is accepted that not all residents will have the cognitive ability to use this effectively at all times, they still should be available. In the downstairs bathroom, the frame around the WC was rusted. Some cupboards in this room were in poor condition. A COSHH (Control of Substances Hazardous to Health) item was accessible to residents on a shelf, which could present a hazard. Only one of the resident’s bedroom doors is fitted with a lock and residents had no lockable storage facility in their room. The home was seen to be clean. Newbrae Eventide Home DS0000061527.V307428.R01.S.doc Version 5.2 Page 18 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29, 30 The judgement in this outcome group is adequate. This judgement has been made using available evidence including a visit to this service. Staffing levels are adequate to meet resident needs. Recruitment procedures needed to be more robust to safeguard residents. Induction training needs to be more clearly identified to support staff and residents. Access to training is supported for staff. EVIDENCE: Newbrae provides three staff, including a senior from 8:30am to 5pm, two staff including a senior from 5pm to 9pm and at one awake and one sleeping in member of staff at night. Information from residents and relatives indicated that this was adequate to meet residents’ needs. Discussion with staff and observation of practice at the time of the site visit also indicate this to be satisfactory. Care staff and take all the cooking and cleaning. The manager is part of the rostered care hours and does not have any supernumerary hours for management tasks. It was discussed with the registered manager that residents regularly do not have a choice as to whether personal care is given by a male or female carer. Two of the current nine staff had achieved NVQ level 2. Two staff were undertaking NVQ level 3 training. Files for two recently appointed members of staff were sampled. On one file, the application form did not detail a ten year history. The applicant brought a Newbrae Eventide Home DS0000061527.V307428.R01.S.doc Version 5.2 Page 19 reference as the relevant home had previously closed. The registered manager confirmed that he had contacted the previous owner by phone to confirm the reference. The second referee had not responded so another member of staff working at Newbrae provided a reference. The file contained a copy of the passport but no other evidence of identity. There was no evidence that a Povafirst check had been undertaken. The registered manager said that the company they use will not provide anything other than a phone call, which is unacceptable, as it does not allow the registered person to provide appropriate evidence. The CRB check was dated some two months after the person had started working at the home. On the second file sampled the persons other current employer was not contacted for a reference, although this is in care work. A reference was obtained from a care agency previous employer and also from a member of staff working currently at the home. Evidence of identity was available. No Povafirst check had been undertaken and no CRB undertaken by Newbrae as required. The registered manager advised he was unaware of the changes to the legislation that required this to occur and had accepted a CRB check from a previous employer, as it was only a few months old. Both files contained a four-day induction programme format. On the first file sampled this was not signed. The induction format did not include any reference to privacy and dignity. This member of staff had previously completed a TOPSS induction training some three and a half years ago. Both staff had previous experience of working in residential care and previous training in dementia care, protection of vulnerable adults and moving and handling. There was no evidence of current and appropriate fire training for them at Newbrae. The staff training matrix provided indicated that all other staff have had fire training, although some of these were overdue for an annual update. The matrix also indicated that the majority of staff have current training in basic food hygiene and manual handling. The matrix also shows that various staff have had access to other training such as infection control, and nutritional needs but that only three staff have had first aid training. Reference to other training has been made in relevant sections in this report. Newbrae Eventide Home DS0000061527.V307428.R01.S.doc Version 5.2 Page 20 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35, 36, 38 The judgement in this outcome group is good. This judgement has been made using available evidence including a visit to this service. The registered provider/manager demonstrates clear leadership and awareness that the service needs to continue to develop and improve. EVIDENCE: The registered manager is a qualified nurse. In the past year ago has begun and completed NVQ level 4, Registered Managers Award. The rosters demonstrated that the registered manager usually works six days a week at the home. He also confirmed that he does additional work elsewhere to retain his nursing registration. The registered manager must ensure that he allows himself some time on the roster to undertake administration and management tasks and keep up-to-date with current requirement and regulations. The registered manager stated that he was building up the home and improving it, but was aware there was room for more development. Newbrae Eventide Home DS0000061527.V307428.R01.S.doc Version 5.2 Page 21 Residents meetings have been held regularly. Over the past 11 months, the registered manager has gathered information from relatives, residents and visitors including a social worker, a paramedic and a district nurse, that looked at their view of the care provided at the home. Information gathered in this way now needs to be analysed and fed back to those who participated, with details of the action plan, which will also feed into the homes development plan. The registered manager advised that the home does not look after any money belonging to residents. Records indicated that there was an appraisal, but no supervision, in place on the files for more recently appointed staff. Another file sampled showed that the member of staff had had a supervision session in October last year and February this year, followed by an appraisal in July. This does not comply with the National Minimum Standard of six sessions per year. The pre-inspection questionnaire identified that appropriate safety inspections had taken place. Those sampled included emergency lighting and fire alarm certificates and portable appliance testing. Audits within the home showed that the fire alarm in emergency lighting we tested monthly. Checks of the water system indicated that a hot water outlet was tested monthly and then checks of the cold water system were being undertaken. The registered manager was advised to make himself aware of the requirements of the home’s legionella risk assessment. The record of fire drills shows that one of the newer members of staff has not participated, and for example a permanent member of staff has not participated in a fire drill in the last year. Newbrae Eventide Home DS0000061527.V307428.R01.S.doc Version 5.2 Page 22 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 2 3 3 2 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 2 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 3 18 3 1 X X X 2 X X 3 STAFFING Standard No Score 27 3 28 2 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 2 X N/A 2 X 2 Newbrae Eventide Home DS0000061527.V307428.R01.S.doc Version 5.2 Page 23 Are there any outstanding requirements from the last inspection? YES 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 OP1 Regulation 4 & Sch 1 Requirement The Statement of Purpose must contain all information required by Schedule 1. Timescale for action 01/11/06 2. OP4 18 The registered person must 01/12/06 ensure that all staff employed at the care home receive training appropriate for the work they are to perform. This refers to that specific to the assessed care needs of the residents/ conditions associated with older people and continuing the ongoing training plan. The person registered must set 01/11/06 out in each resident’s care plan in detail, the actions that need to be taken by care staff to ensure that all aspects of the person’s health and personal care needs are met. (Previous timescale of 01/01/05, 01/07/05 and 01/11/05 not met). The person registered must set 01/11/06 out in each resident’s care plan in detail, the actions that need to DS0000061527.V307428.R01.S.doc Version 5.2 Page 24 3. OP7 15(1) 3. OP12 16(2)m & n Newbrae Eventide Home be taken by care staff to ensure that all aspects of the person’s social care needs are identified and met. 4. OP15 17(2) Sch 4 The nutrition record must evidence that specific dietary needs are met, for example supplements or liquidised meals. The person registered must ensure that the complaints procedure is readily available to all interested parties. The person registered must ensure adequate precautions against the risk of fire. This refers to the inappropriate practice of fire doors being wedged open. The person registered must ensure that as far as possible risks to service uses are identified and eliminated. This refers to the opening upstairs window. The person registered must ensure that equipment provided at the care home is well maintained. This refers to the toilet frame in the downstairs bathroom. The person registered must demonstrate robust recruitment procedures and maintain records required by regulation for inspection. The person registered must ensure that all staff are involved in regular fire drills and practices. (Previous timescale of 01/07/05 and 25/10/05 not met). DS0000061527.V307428.R01.S.doc 01/10/06 5. OP16 22(4) 01/10/06 6. OP19 23(4) 08/08/06 7. OP19 13(4)c 08/08/06 8. OP19 23(2) 01/11/06 9. OP29 17(2) Sch 2&4 08/08/06 10. OP38 23(4)e 08/08/06 Newbrae Eventide Home Version 5.2 Page 25 11. OP38 23(2)c The person registered must ensure that he is aware of the actions required by the risk assessment for legionella and have records available to evidence appropriate actions/ checks are undertaken regularly. 08/08/06 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 OP9 OP19 Good Practice Recommendations Medication should not be directly handled during administration. A programme of maintenance and redecoration of the premises to be available. Outstanding from the last inspection. Residents should have a lockable facility within the room and doors should be fitted with appropriate and safe locks. Call bells should be within the reach of residents at all times. At least 50 of care staff should achieve a minimum of NVQ level 2. Outstanding from the last inspection. The registered manager should have some rostered supernumerary hours to attend to management and administration tasks. The person registered should continue to develop the home’s quality assurance systems and collate and act upon the outcomes of resident and relative survey/ questionnaires. Outstanding from the last inspection. 3. 4. 5. OP24 OP24 OP28 6. OP31 7. OP33 Newbrae Eventide Home DS0000061527.V307428.R01.S.doc Version 5.2 Page 26 8. OP36 Staff should be provided with formal supervision at least six times each year. Outstanding from the last inspection. Newbrae Eventide Home DS0000061527.V307428.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection South Essex Local Office Kingswood House Baxter Avenue Southend on Sea Essex SS2 6BG National Enquiry Line: 0845 015 0120 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. 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