Inspection on 25/09/08 for Newent House

This inspection was carried out on 25th September 2008.

CSCI found this care home to be providing an Good service.

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

Newent House 26/10/07

Newent House 24/08/06

Newent House 23/01/06

Newent House 22/06/05

Newent House 23/03/05

Newent House 18/06/04

Newent House 05/02/03

Similar services:

Henry Nihill House

Birchwood

The Infirmary

Orchard House Nursing Home

St Josephs Rest Home

Red Court Nursing Home

Spinney (The)

Queen Elizabeth House

Extracts from inspection reports are licensed from CQC, this page was updated on 17/12/2008.

CARE HOMES FOR OLDER PEOPLE Newent House 8 - 10 Browns Road Surbiton Surrey KT5 8SP Lead Inspector Ms Rin Saimbi Key Unannounced Inspection 25th September 2008 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 Newent House DS0000034120.V372043.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. Newent House DS0000034120.V372043.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Newent House Address 8 - 10 Browns Road Surbiton Surrey KT5 8SP 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) 020 8547 6311 020 8339 9002 rory.belfield@rbk.kingston.gov.uk Community Care Services Rory Giles Belfield Care Home 38 Category(ies) of Dementia (38), Old age, not falling within any registration, with number other category (38) of places Newent House DS0000034120.V372043.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 2. Dementia - Code DE The maximum number of service users who can be accommodated is:38 26th October 2007 Date of last inspection Brief Description of the Service: Newent House is part of a large resource centre for older people, owned and managed by the Royal Borough of Kingston Upon Thames. The centre provides residential care and a day service for older people living in the community. The residential service provides accommodation for up to 38 older people. The accommodation is arranged over three floors. There are a number of communal lounges, a conservatory, and licensed bar and dining room. Each person who uses the service has a single bedroom. There are kitchenettes on the first and second floors. Bathrooms and toilets are available on each floor. There is a well-maintained garden. A copy of the service’s Statement of Purpose and Service User Guide can be obtained on request from the Registered Manager. Fees for the home at the time of writing are £575.27 per week. Newent House DS0000034120.V372043.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 2 stars. This means people who use the service experience good quality outcomes. There have been no changes in the ownership, management or service registration of the service in the last 12 months. This was an unannounced inspection that took place on 25th September 2008, it started at 10.00 am and took approximately seven hours to complete. The inspection took the form of talking to people who use the service, and observing staff interaction with people. Records that related to people who use the service were examined and a number of them were case-tracked. There was a partial tour of the premises. Staff records and documents relating to the service were also examined. Prior to the inspection, we sent out questionnaires to people who use the service and all other relevant stakeholders. A total of thirteen from people who use the service were returned and one from a staff member. All information coming to the Commission over the last year from a variety of sources was reviewed. This included the Annual Quality Assurance Assessment (AQAA), which was completed by the home in a timely and well-considered manner. We would wish to thank the people who use the service, relatives, and all staff for their time and co-operation during the inspection process. What the service does well: This is, in general, a well run home were people who use the service have their needs met. The majority of feedback received about the home was very positive. Comments received include ‘I can’t praise the staff enough’, and ‘I am happy with this home.’ Newent House DS0000034120.V372043.R01.S.doc Version 5.2 Page 6 The home has a lively, relaxed atmosphere; there are comings and goings of friends, relatives and professionals. There is a co-ordinator who organises a variety of activities to suit most preferences; and some people within the home make use of the home’s location within walking distance to the shops. The home has a licensed bar. There are two cats who live in the home and people are clearly very fond of them; there is also a member of staff who brings in her dog from time to time. The home benefits from a reasonably stable staff team who have a range of experiences and skills. There are many training opportunities for staff, which further enhance skills and ensure that people who use the service have their needs met. From observation, the staff team in general have a warm, caring approach; there is a reasonably high number of male staff who are able to support the growing number of men who use the service. The home is well decorated and maintained to a reasonable standard; this assists in creating a homely environment. Despite of the refurbishment of the kitchen, people who use the service generally felt that the food that was on offer was good. One person stated about the food, ‘gorgeous –never found fault in the food here.’ What has improved since the last inspection? There are two main areas of improvement within the home, firstly staff supervision and secondly manual handling. At the previous inspection, staff supervision was an issue because if supervisor was not available for any length of time, no interim measures were made, resulting in some staff having had no supervision for several months. This now appears to have been rectified; the aim now is that supervision occurs on a monthly basis, with part-time workers being supervised every six weeks. Secondly with regard to manual handling, the last inspection identified two key areas. Staff needed to have regular updated training and people who use the service were not getting their manual handling risk assessments reviewed on a regular basis. Both these issues appear now to have been resolved. Newent House DS0000034120.V372043.R01.S.doc Version 5.2 Page 7 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. Newent House DS0000034120.V372043.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Newent House DS0000034120.V372043.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 3,4,5 and 6 People using the service experience good quality outcomes in this area. We have made this judgement using evidence, including a visit to the service. Information is gathered from a variety of sources including the people who use the service, family and other professionals before a decision is made regarding the suitability of the home. It is only after a trail period and then a final review meeting that a decision is made about the placement. In this way, people who use the service can feel assured that the placement is able to meet their individual needs, rather than they are being slotted into a vacancy. EVIDENCE: Newent House DS0000034120.V372043.R01.S.doc Version 5.2 Page 10 Information is gathered from a variety of sources including the people who use the service, family and other professionals before a decision is made regarding the suitability of the home. There is then a period when people who use the service have the opportunity to visit the home and live there for six weeks or longer if necessary before a final review meeting is held to consider the suitability of the placement. We had discussions with relatives of people who use the service who confirmed the process. They stated that the manager and deputy had visited the relative at the home address, and then they had come for a tea visit, followed by an overnight. The relative was positive about the experience. We case tracked four people who use the service; information was examined including all the assessment details gathered prior to admission. There was a form completed which gave all the basic information for people who use the service; this included a personal history, a care plan which was divided into tasks, information about what the person could do for themselves and what they needed help with. In general it appeared that information gathered was up to date and accurate. The home is in the process of introducing the ‘Eden alternative’ which is a toolkit of information and ideas for Person Centred Care. A decision has been made that the home will initially only complete for new people coming into the service; gradually this will be extended to everyone living in the home. This is a positive development as it will focus on the person and give them a real choice about how they live their lives. The home does have various aids and adaptations that would assist people who use the service in their daily lives; these include a lift, grab rails and specialist bathing equipment. It remains positive that within the home there is a higher than average number of male people who use the service, ten in total; they in turn are supported by a higher than average number of male staff, that is to say, ten. In discussions with the males using the service, they were pleased to have this level of support. However, of the males spoken to, all were happy to receive care from female staff as well. Women only receive care from male staff if they agree to. Within the staff team there are eight people from black minority groups; there is only one person from a black minority groups amongst the people who use the service. The home does not provide intermediate care for people who require rehabilitation although they do provide respite care for individuals. Newent House DS0000034120.V372043.R01.S.doc Version 5.2 Page 11 Newent House DS0000034120.V372043.R01.S.doc Version 5.2 Page 12 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 People using the service experience good quality outcomes in this area. We have made this judgement using evidence, including a visit to the service. The assessment process lays the foundation for the care plan. This ensures that people who use the service have their health; social and personal care needs met. In this way they can remain as independent for as long as possible. In general, the administration of medication is undertaken in a way that ensures the well being of people who use the service. Some improvements need to be made to maintain health and personal care. People who use the service have their dignity and privacy respected EVIDENCE: Care plans are part of the initial assessment undertaken by the home. The care plan was divided into tasks, each outlining what the person could do for themselves, what help was required and what the expected benefits would be. Newent House DS0000034120.V372043.R01.S.doc Version 5.2 Page 13 It appeared that in general, the person using the service and their key worker reviewed care plans every month; their initials confirmed this. On an annual basis, care plans were reviewed more formally within a statutory framework with the care manager, person using the service and their representatives. Copies of the review meetings were available for inspection. Risk assessments for people who use the service were checked; it was noted that every individual had a current risk assessment for manual handling and some for general environmental factors. Historically, the administration and handling of medication within this home has been of concern. There have been improvements in this area over the recent past. For example, during this inspection the Medication Administration Records (MAR) were viewed for a number of people within the service, all appeared up to date and accurate. However on one MAR sheet, ‘Tippex’ had been used. This practice should cease and therefore a recommendation has been made regarding this. The assistant manager informed us that senior staff undertake daily audits of medication. The home also has an external audit once every six months, the last one being completed on the 17.6.08. Medication errors are still occurring, namely medication going missing on two occasions over recent months. However these errors appear to be picked up quickly and are being recorded appropriately. All staff are appropriately trained in the administration of medication. At the previous inspection, a requirement was made that people’s allergies, particularly to medication, must be recorded appropriately on the MAR sheets. Evidence indicated that this is now occurring and therefore this requirement is withdrawn. Care records detailed that people who use the service have access to a range of health care professionals and that the home is proactive in arranging health appointments. A new system has been devised which logs in a central place who has seen a health professional and when. There was evidence of people having appointments with their General Practitioner, dentist, optician, speech and language therapist and dietician. At the previous inspection, a requirement had been made that people who use the service should have their weight monitored on a regular basis. In this way the home can monitor the nutritional well being of an individual. It was noted that people who use the service are having their weight monitored on a monthly basis. However, there appear to be huge variations in the information gathered. In one example, someone’s weight had varied from Newent House DS0000034120.V372043.R01.S.doc Version 5.2 Page 14 one month to the next from 50 kilograms, to 53 to 49. In another more extreme example the persons weight from one month to another had changed from 82 to 70 kilograms, and it appeared that this had not been followed up by the home. Therefore, it has been recommended that the home should purchase suitable weighing equipment which can give accurate readings. In addition, a requirement has been made that any significant weight loss or gain must be followed up with the appropriate health professionals in order to maintain health and well being. Staff members were observed to treat people who use the service with respect and to uphold their dignity. Positive interactions were noted throughout this inspection, one person stated ‘I can’t praise the staff enough’. Staff members were noted to knock, and wait for a response before entering bedroom’s; they were heard giving people who use the service choices and addressing them in a respectful and appropriate manner. In discussion with staff, we asked questions maintaining privacy and dignity and all were able to give an appropriate and reasoned response. However, a significant number of people who responded to the questionnaire, that is to say five out thirteen, commented that staff did not respond to them appropriately. One comment received was take there ‘was a lot of indifference’, another person stated ‘ sometimes you mention something and they go off duty’. The issues raised appear two fold, firstly that staff do not appear to care about they are being told by people who use the service; secondly, that there is a lack of communication between staff at crucial times, so that information is not being handed on. A requirement is therefore being made that all staff must be alerted to the views of people who use the service. In addition, all staff must complete refresher courses on privacy and dignity. Newent House DS0000034120.V372043.R01.S.doc Version 5.2 Page 15 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 People using the service experience good quality outcomes in this area. We have made this judgement using evidence, including a visit to the service. There is a varied activities programme that ensures that differing expectations and lifestyles are catered for. Food is an important factor in determining the quality of life within a home; people within this home are very positive about the food that is offered and use mealtimes as a social event. EVIDENCE: There is a full time activities coordinator who organises a range of social and recreational activities. The activities co-ordinator produces a weekly timetable of events which include word games, bingo and chair based exercise. He also arranges for an external people to come into the home on a weekly basis and do music and dance therapy sessions. The activities co-ordinator stated that in line with the ‘Eden alternative’, people who use the service were the ones to choose what activities took place. Newent House DS0000034120.V372043.R01.S.doc Version 5.2 Page 16 In addition, the co-ordinator arranges outings to seaside, to the local parks and recently a visit to Paris. Two responses received from the questionnaires stated that people who use the service did not know when activities were taking place in another part of the home. A number of people during the inspection also stated that they did not feel that there was enough to do. Whilst acknowledging the issues raised by people who use the service, it is difficult to see how much more could be offered by the activities co-ordinator. There are a range of activities available, which are widely advertised and discussions in the residents meetings. There is also a newsletter which advices of forthcoming events. The environment of the home allows for ample space and opportunity for people within the home to participate in activities, watch television or to sit quietly. There are separate lounges and a licensed bar. People within the home can have a daily newspaper if they wish. Throughout the day, visitors and people who use the service were observed coming and going. We were able to talk to two of the visitors and an advocate. All said that they felt welcomed by the home, and could see their relatives in private if they wished or in the communal area. A number of people who use the service go out on a regular basis, many independently, risk assessments are completed if necessary. The kitchen within the home is being totally refurbished; this has been ongoing for nine weeks and is due for completion next week. The home have tried to minimise the disruption; we spoke to a number of people who use the service who all stated that they had not been aware of the works, other than during the first week when there was a lot of noise. The bar area and some of the dining room has been used as a makeshift kitchen with microwaves and food preparation area. At lunchtimes meals-onwheels are providing the food; during the morning and evenings, hot food is provided by the adjacent day centre. Comments received during the inspection were ‘I’m well fed and well watered’ and ‘good food and good outlook’. The consensus was that the meals from meals-on-wheels had been adequate, but people were looking forward to the kitchen functioning again. On the day of the inspection, people who use the service had the choice of chicken pie or chicken curry with rice; sandwiches, salad or omelettes were also available on request. This was the main meal of the day. Evening meals tended to be a lighter meal; on the day of inspection there was pork pie and salad. Soups were also available and very popular with people who use the service. Newent House DS0000034120.V372043.R01.S.doc Version 5.2 Page 17 The home is able to cater for people who have special dietary requirements, we observed people having diabetic ice cream and liquefied meals. Meals were served in a congenial dining area, albeit the area devoted to kitchen equipment. People within the service lay the tables at lunchtime and clearly see it as an important function within their daily routine. Newent House DS0000034120.V372043.R01.S.doc Version 5.2 Page 18 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 People using the service experience good quality outcomes in this area. We have made this judgement using evidence, including a visit to the service. There is a system in place for the effective handling of complaints and people who use the service and their relatives are encouraged to raise any concerns they have. People therefore should feel that their concerns would be acted upon. Arrangements are generally in place for handling allegations and instances of abuse, people who use the service can therefore feel assured that they will be protected from harm. EVIDENCE: There are policies and procedures in place for dealing with complaints. Information is made available in the Service User Guide about how a compliant, concern or suggestion should be made, and how this will be handled. The home has a complaints log, which was examined; it showed that four complaints had been made in the last year and all appear to have been dealt with in a timely fashion. We asked a number of people who use the service and some relatives who they would talk to if they had a problem. In general, people responded with ‘I’d go to the office’, where they felt that their problem could be addressed. Newent House DS0000034120.V372043.R01.S.doc Version 5.2 Page 19 However, from the responses received from people who use the service via the questionnaires there some comments made that people did not feel listened to. One person stated ‘….its like flogging a dead horse! The staff all stick together like glue’. Another said, ‘I did ask one person to speak to but I was rebuffed today.’ We discussed this issue with the manager; he stated that there are monthly residents meetings, and a questionnaire was sent out to all people who use the service in November, and it is the first time this issue has be raised. He stated that this is not acceptable that people feel that they are not listened to and he will be working on the issue. The home adopts the Royal Borough of Kingston Council’s vulnerable adult protection procedures. Staff were given a fictional scenario, which involved adult protection, and what action they would take, all were able to give an appropriate response. At the previous inspection it was noted that the majority of staff had had vulnerable adults training during their induction period and for some staff, none since then. A requirement was made at that time the staff must receive regular training. In general, staff within the home have had regular training. It was noted however that one of the assistant managers had not received any training regarding vulnerable adults since February 2005. Given their role and the length of time since their training has taken place, the requirement remains outstanding. This issue needs to be addressed with some urgency, as a further contravention of the Regulations could lead to legal action being taken. Newent House DS0000034120.V372043.R01.S.doc Version 5.2 Page 20 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): 19,21,22,24 and 26 People using the service experience good quality outcomes in this area. We have made this judgement using evidence, including a visit to the service. The home is maintained, decorated and furnished generally, to a good standard and facilities are clean and safe. This ensures that people who use the service live in a pleasant, homely and comfortable environment. EVIDENCE: The home is generally well maintained and provides a pleasant and homely environment to those who live there. There is a well-maintained garden to the rear of the property containing a number of seating areas, and there are ramps providing access to wheelchair users. To the front of the building there is limited parking available. Newent House DS0000034120.V372043.R01.S.doc Version 5.2 Page 21 The home is over three floors, with bedrooms on the first and second floor. The ground floor has three lounges, a licensed bar, dining room, laundry room and various offices. At the time of the inspection as previously stated, the kitchen area was undergoing renovation. The process has taken nine weeks so far, with seemingly minimal disruption to people who use the service. Comments received from people who use the service seemed to focus on the first few weeks, when the builders were noisy. The bar area and some of the dining room has been used as a makeshift kitchen with microwaves and food preparation area. At lunchtimes meals-onwheels are providing the food; during the morning and evenings, hot food is provided by the adjacent day centre. It is anticipated that the works will be completed in the next week. The first and second floors have their own kitchenette areas so that people who use the service or relatives can make their own drinks or light snacks. A recommendation has been made that the kitchenette areas are included in any long term redecoration plans. This is because they are beginning to look shabby, with Formica coming off in places and cupboard doors slightly off their hinges. Lavatories and washing facilities seen were, in general, appropriate and accessible to people who use the service. There are sluice facilities on the first and second floors. A number of bedrooms were viewed; some had personal furniture, others contained personal items such as photographs, ornaments and pictures. There is a bedroom on each floor which has a tracking hoist fitted. The home was generally clean and free from offensive odours. Newent House DS0000034120.V372043.R01.S.doc Version 5.2 Page 22 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 People using the service experience good quality outcomes in this area. We have made this judgement using evidence, including a visit to the service. Staff members are provided in sufficient numbers. The procedures for the selection and recruitment of staff are reasonably robust in order to provide protection to people living in the home. There is, in general, a good staff training and development programme, this ensures that staff have the knowledge and expertise to provide a high quality care to people who use the service. EVIDENCE: Staffing levels appeared to be appropriate, and in line with the needs of current people who use the service. Staffing rotas were viewed at random and indicated that there are sufficient staff on duty. There are five carers in the home during the mornings, four and sometimes five staff on for the afternoon and evening shift, and two staff on duty during the night. As well as care staff, there were a number of other staff on duty at the time of the inspection; these included the, manager, two assistant managers, a cook, kitchen assistants, cleaners and laundry staff. Newent House DS0000034120.V372043.R01.S.doc Version 5.2 Page 23 The home has recently had a change of registration allowing it to take more people who have a diagnosis of dementia. In light of this change a recommendation has been made that the home must be mindful of staffing levels given the changing needs of their residents. Three staff files were chosen at random to see if they contained all relevant information that related to selection and recruitment. The files contained job descriptions, application forms, two references and two forms of identification. All files that were checked also had a PoVA First checks; there was evidence that enhanced Criminal Records Beaux checks (CRB) had been completed and were held centrally within the Human Resources department at Kingston Council. Training records were examined, and there was discussion with staff about the training that had been completed in the preceding year. All confirmed that they had received the minimum level of training per year, that is to say three days; in the majority of cases, the levels of training had far exceeded this. The home has a stable staff team; the manager informed us that there are currently no vacancies within the staff team. There are a number of bank staff that are used to cover any shortfalls in staffing levels caused by sickness or annual leave. Agency staff are only used on an occasional basis. Newent House DS0000034120.V372043.R01.S.doc Version 5.2 Page 24 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): 31,33,36 and 38 People using the service experience good quality outcomes in this area. We have made this judgement using evidence, including a visit to the service. There are suitable arrangements for the management of the home and there is a quality assurance system based on running the home in the best interests of people who use the service. There are, in general, good arrangements for health and safety, which promote the well being of people who use the service. EVIDENCE: The manager of the home, Mr Rory Belfield, has eleven years experience in the care profession; he is well qualified with National vocational level 4, Registered Mangers Award and M.A. in Social Science. Mr Belfield has recently become the registered manager of Newent House. Newent House DS0000034120.V372043.R01.S.doc Version 5.2 Page 25 Supervision records of staff were examined, they indicated that in general supervision was undertaken on a monthly basis; staff themselves confirmed this. A record of supervision is kept with both parties signing the document as confirmation of its contents. A previous requirement that supervision must be undertaken at the required level and that the records are available for inspection purposes, is deemed to have been met and is therefore withdrawn. Quality monitoring in the home occurs in a number of ways. There is an annual development plan for the home. There are regular monthly meetings for people who use the service. Regulation 26 visits are completed on a monthly basis and were available for inspection purposes. In addition, to the Regulation 26 visits, senior staff on a regular basis make nightly visits to the home. This is undertaken as a way of monitoring the quality of care that is provided to people who use the service at all times of the day, and is positive. A number of health and safety records were examined; gas certificate was obtained on the 13.5.08; Portable Appliance Testing was completed in July 2008; Legionella testing was conducted on the 21.4.08, fridge and freezer checks were completed daily. All fire checks appeared to be in order. Newent House DS0000034120.V372043.R01.S.doc Version 5.2 Page 26 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 3 3 3 HEALTH AND PERSONAL CARE Standard No Score 7 3 8 2 9 2 10 2 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 3 X 3 3 X 3 X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X X 3 X 3 Newent House DS0000034120.V372043.R01.S.doc Version 5.2 Page 27 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 OP8 Regulation 12(1)(a) Requirement People who use the service are having their weight monitored, any significant weight loss or weight gain must be followed up by the home, this is a way of ensuring the persons well-being All staff must receive refresher courses regarding privacy and dignity. All staff must receive vulnerable adults training on an annual basis Outstanding since the previous inspection 26/10/07 Timescale for action 25/09/08 2. 3. OP10 OP18 12(4)(a) 12(1)(a) 25/12/08 25/11/08 Newent House DS0000034120.V372043.R01.S.doc Version 5.2 Page 28 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. 3. 4 Refer to Standard OP8 OP9 OP19 OP27 Good Practice Recommendations The home should purchase new weighing scales in order to gain an accurate record of peoples weight ‘Tippex’ should not used on MAR sheets The home should give some consideration to the refurbishment of the two kitchenette areas in order to maintain a homely environment. Staffing levels should be monitored regularly given the changing needs of the people who use the service; this is to ensure that there are always an adequate number of staff on duty. Newent House DS0000034120.V372043.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection London Regional Office 4th Floor Caledonia House 223 Pentonville Road London N1 9NG 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 Newent House DS0000034120.V372043.R01.S.doc Version 5.2 Page 30 - 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. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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