Inspection on 10/11/06 for Newland House

This inspection was carried out on 10th November 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

Newland House 30/08/07

Newland House 15/12/05

Newland House 11/07/05

Newland House 11/03/05

Similar services:

St Vincents

The Cotswold Home

Newbeech House

Winton House

Rush Court

Hillyfield Rest Home

The Maypole Nursing Centre

The Briars

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

CARE HOMES FOR OLDER PEOPLE Newland House 50 Newland Witney Oxfordshire OX28 3JG Lead Inspector Delia Styles Unannounced Inspection 10th November 2006 10:40 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 Newland House DS0000062675.V314474.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. Newland House DS0000062675.V314474.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Newland House Address 50 Newland Witney Oxfordshire OX28 3JG 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) 01993 702525 01993 702530 r.l.w@btinternet.com Crispin Homes Limited Mrs Elizabeth Ann Bird Care Home 30 Category(ies) of Dementia - over 65 years of age (6), Learning registration, with number disability over 65 years of age (1), Old age, not of places falling within any other category (30), Physical disability over 65 years of age (3) Newland House DS0000062675.V314474.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The number of service users accommodated at any one time must not exceed 30. 15th December 2005 Date of last inspection Brief Description of the Service: Newland House is situated on the outskirts of Witney, which is a short walk away. The building is listed, built around 400 years ago and has been sensitively adapted so as to retain many of the original period features. The interior is of a high standard and offers a comfortable environment. There is an attractive garden to the front of the house. The home offers 24-hour care by a well trained and committed staff group, has been awarded the Investor in People Award and has won the Heart of England TEC prize for the best training of a small business. A new extension to the home was completed in March 2006 and a programme of refurbishment in the house is also being undertaken. The current fees for this home range from £650 to £750 per week; newspapers, hairdressing and chiropody are included in the fees. Newland House DS0000062675.V314474.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced key inspection and was the first inspection of the home since the opening of the new extension in March 2006. The inspector arrived at a busy time but was made welcome by the manager, proprietor and staff and talked to them and residents about their views of life at Newland House. The inspection was a thorough look at how well the service is doing. It took into account detailed information provided by the service’s owner or manager, and any information that CSCI has received about the home since the last inspection. A tour of the building was undertaken. A sample of residents’ care records and other documents about the home and its management were examined. The inspector had an enjoyable lunch with residents in the dining room. Comment cards (questionnaires) were received from nine residents, nine relatives/visitors, two GPs who provide medical care to residents and a district nurse who visits. The inspector looked at how well the service was meeting the standards set by the government and has, in this report, made judgements about the standard of the service. What the service does well: Newland House is very clean, well maintained and has a welcoming and friendly ‘feel’. Residents written comments about the home are very complimentary: ‘I am very happy to be here and I am very lucky to be here’; ‘This home is in every respect first class’; ‘I am very content here’; ‘I feel I am well looked after here’. The standard of the rooms and facilities in the new wing is very high and there is more building work in progress to improve and upgrade the original house. Outside, the gardens and grounds are very attractive and well kept. The home owner, registered manager and staff work well together with the aim of helping residents to have as much independence and individual quality of life as possible. Newland House DS0000062675.V314474.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: Improve the written records of new residents’ care assessments so that the home can show that it can meet each individual’s needs and that care staff have enough information on which to plan their care. The training programme for staff in nutritional assessment and nutritional needs of residents should be further developed to involve all care and catering staff, so that all staff can make sure that residents’ dietary needs are met. Risk assessments should be undertaken for residents who wish to keep and self-administer their own medicines, to make sure that prescribed medicines are kept securely and that residents are confident and able to continue to manage their medication safely. The home must make sure that it has received all the necessary Criminal Records Bureau (CRB) and Protection of Vulnerable Adult (PoVA) list checks on people who apply to work in the home, before they start work. The home has continued to employ staff before satisfactory checks have been received, in contravention of a requirement made about the same issue in the last inspection report. The home should review the procedure for undertaking checks on individuals who provide a service in the home, and improve the records of recruitment and vetting for new staff, to show that the home takes all reasonable measures to prevent residents being potentially exposed to avoidable risk from potential abusers. Newland House DS0000062675.V314474.R01.S.doc Version 5.2 Page 7 The ways in which residents and relatives are consulted about their views on the home could be further developed so that the home can measure how well it is meeting residents’ expectations and to make sure that the home continues to be run in the best interests of the residents. The home must notify the Commission of the death, illness or other untoward events that affect the wellbeing of residents in the home, under the terms of Regulation 37 of the Care Standards Act 2000 and Care Homes Regulations 2001. 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. Newland House DS0000062675.V314474.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 Newland House DS0000062675.V314474.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1 and 3. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People who come to live in this home have good information about it before they come so that they can make an informed decision about whether it is likely to be right for them. The personalised needs assessment undertaken by the manager means that people’s diverse needs are identified and are planned for before they move in to the home. Standard 6 is not applicable: intermediate care is not provided. EVIDENCE: The home has produced new versions of its Statement of Purpose and Service User Guide (Residents’ Guide) and is planning a new brochure. The information is clearly written and accessible. Residents’ comment cards indicated that they had had enough information about the home before they came here to live and that they had a contract setting out the terms and conditions of residence. Newland House DS0000062675.V314474.R01.S.doc Version 5.2 Page 10 A resident told the inspector about how s/he had visited the home several times before deciding that this was the right home for them and had not regretted their decision. The inspector looked at the assessment information for three residents who had recently been admitted and were within their ‘trial period’ of three months stay. The written information was brief, though the registered manager who had undertaken the initial meetings and assessment of these residents together with their families, evidently has a good understanding of their individual circumstances and care needs. The inspector considers that there should be more written information provided so that care staff have enough detail upon which to base their care plans. For example, one person had been assessed as being of particular risk of falls before their admission, but the care home did not provide a risk assessment or evaluation of this resident’s risk or any preventative action to be considered by staff in order to reduce the person’s risk of falls and/or injury in the home. One GP expressed concern that, since the new extension had been built, the home may have admitted residents whose needs could not be met by the home. The proprietor and registered manager felt that this comment related to one specific person whose needs could not be met and whose full medical and care needs had not been shared with them before s/he was admitted. Newland House DS0000062675.V314474.R01.S.doc Version 5.2 Page 11 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 and 10 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The health needs of residents are well met with evidence of good multi-disciplinary working taking place on a regular basis. The staff have a good understanding of residents’ care needs. The medication system in the home is safe and well managed overall, although risk assessment for those residents who wish to keep and control their own medicines should be developed. EVIDENCE: The inspector examined a small sample of residents’ care plans. Overall, these showed that residents’ care needs had been assessed and the appropriate actions to be taken by staff to meet residents’ needs had been listed. Care plans are reviewed monthly. Since the last inspection the home has started to use an approved nutritional assessment tool – Malnutrition Universal Score Tool (MUST) – to assess and monitor residents’ risk of malnourishment and to list the actions staff should take to help residents to improve their nutrition. One senior care staff member has attended the training in this assessment and monitoring method and there was a separate file to describe the actions to be taken by care staff to address Newland House DS0000062675.V314474.R01.S.doc Version 5.2 Page 12 the nutritional care needs of residents assessed as ‘at risk’ because of their dietary intake. One relative/visitor’s comment card expressed concern that the home’s staff were not specifically trained in the nutritional care needs of older people, and do not have the specific skills to encourage residents with poor appetites and/or who require pureed or soft diets, to have an adequate diet. The inspector recommends that all care and catering staff have additional training in the MUST assessment method and nutritional needs of older people so that all the staff team are aware of, and can contribute in, helping all residents to have a well balanced and nutritional diet. Comment cards from GPs and a district nurse showed that professional carers have a high opinion of the home’s staff ability to provide a good standard of care for residents. Residents’ comment cards were unanimous in their opinion that they always receive the medical support they need. A local high street chemist supplies residents’ prescribed medication in individual cassette boxes for each resident. The home’s system for the storage, administration, recording and disposal of unused/unwanted medication is satisfactory. Four residents keep their own medication in their room in a lockable cupboard or drawer. The home does not have a risk assessment in place so that they can check that residents remain able to safely store and manage their own medicines in the home. The inspector recommends that a suitable risk assessment procedure is developed and that a list of any medications ‘self-administered’ by residents is maintained in the home’s Medications Administration Record (MAR) lists. A senior carer confirmed that any medication requiring cool storage is kept in a separate container in the kitchen fridge; ideally, this should be in a lockable container that can only be opened by carers authorised to handle medicines in the home. Newland House DS0000062675.V314474.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 and 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. There is a good range of activities within the home and community so that residents have the opportunities to participate in interesting hobbies and entertainments that suit them. Mealtimes are an enjoyable social occasion. EVIDENCE: The home has a dedicated room for activities and hobbies and residents’ artwork was on display on the walls. Residents’ comment cards indicated that the majority find that there is a range of activities to take part in, in the home, as well as trips out into the town. Art classes, music therapy and musical entertainments and slide shows are regular activities. On the afternoon of the inspection several residents enjoyed a ‘music and movement’ session. The mobile library service is also appreciated. There are regular Communion services held in the home and clergy from residents’ individual churches and denominations visit residents. Newland House DS0000062675.V314474.R01.S.doc Version 5.2 Page 14 The inspector joined residents for lunch and chose an excellent home made mushroom soup and sandwiches. Residents had the choice of prawn cocktail or soup starters, fish bites and chips, peas and grilled tomato as a main course, and a choice of hot and cold desserts. A choice of orange and apple fruit juice was offered with the meal. Residents said that the food was very good; six out of eight people who completed comment cards said that they always like the meals at the home and two that this was ‘usually’ so. Most residents come to the dining room for lunch but can choose to remain in their room if they prefer. Newland House DS0000062675.V314474.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 and 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home has a satisfactory complaints system with evidence that residents feel that their views are listened to and acted upon. EVIDENCE: The home’s complaints policy is on display in the entrance hall and is included in the homes’ written information. There is a ‘suggestions’ box for residents and visitors to use. Residents’ and relatives’ comment cards showed that they feel confident about discussing any concerns with staff and know how to make a formal complaint should they need to. No complainant has contacted the Commission with information concerning a complaint made to the service since the last inspection. The registered manager confirmed that she has not received any complaints. All new staff have access to the Oxfordshire Multi-Agency Guidelines for the Protection of all Vulnerable Adults document and receive training in adult safeguarding. Newland House DS0000062675.V314474.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 and 26 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. There is an ongoing programme of refurbishment and improvement to the accommodation and facilities in the home, resulting in a very high quality of equipment, fixtures and fittings and décor so that residents live in a comfortable and attractive environment. EVIDENCE: The new extension to the home – The Windrush Wing – was opened in March 2006. It has been completed to a very high standard. The garden borders, lawns and pond with a fountain and fencing have been restored since completion of the building work, and new lighting was being installed in the car park on the day of inspection to improve the lighting for visitors. Newland House DS0000062675.V314474.R01.S.doc Version 5.2 Page 17 A programme of refurbishment, internal building work and redecoration is underway. Several rooms are having en-suite facilities added and are being reconfigured to provide larger and more accessible rooms for residents. A stair lift is planned for a small flight of steps in a corridor, to improve access for the residents. The kitchen will have additional storage and work space added. Residents’ rooms are well decorated and furnished and supplied with flat screen TVs and built in wardrobes. All rooms are individualised with the residents’ own pictures and ornaments. The standard of cleanliness was excellent throughout. Newland House DS0000062675.V314474.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 and 30 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. The staff team work well together and with the residents, with the aim of improving residents’ quality of life. There is an established programme of training for staff so that there is a good match of qualified staff offering consistency of care to residents. However, the standard of vetting practices for new staff has not improved, with required checks not being carried out despite a requirement having been made at the last inspection about this. The procedure for undertaking checks on individuals who are employed in, and provide a service in, the home and records of the recruitment policies and procedures must be improved to show that the home takes all reasonable measures to prevent residents being potentially exposed to avoidable risk from potential abusers. EVIDENCE: The inspector looked at the current staff rota and checked this against the number of staff on duty. The rotas show that the home consistently has a senior carer and three care staff on duty from 7am to pm, a senior carer and two care staff from 2pm to 10 pm and two care staff overnight. Newland House DS0000062675.V314474.R01.S.doc Version 5.2 Page 19 Care staff and the registered manager said that staff work co-operatively together to cover any additional shifts, so that they do not use agency staff; this benefits residents because they are always cared for by staff who know them and the standard of care that is required. Residents’ comment cards showed that five of the nine respondents felt that there are ‘always’ staff available when needed, and four that this is ‘usually’ the case. Only one of the nine relatives/visitors felt that there are too few staff. The inspector looked at a sample of two staff members’ files employed since the last inspection of the home. The pre-inspection information provided by the registered manager did not indicate that a satisfactory Criminal Records Bureau (CRB) or Protection of Vulnerable Adults (PoVAFirst) checks had been obtained for these staff before they started their employment in the home. Checks on the day of inspection showed that this information had only been received between 4 and 8 weeks after they started work in the home. The home must ensure that they have received all the necessary CRB disclosures and references and that these are satisfactory before a candidate is offered a post. Recruitment and vetting practices are part of the employer’s responsibility for safeguarding residents from abuse and neglect. This was a requirement made at the last inspection in December 2005. The registered manager stated that, as a small home, all new staff are fully supervised by another carer until their CRB checks have been returned, and that there has been considerable delay in receiving the CRB checks in some cases. Since this inspection the manager has confirmed to the inspector that PoVAFirst checks are now obtained before employing new staff and that they are fully supervised until the full CRB disclosure is available. The inspector made other recommendations about improving the home’s recruitment process, record keeping and documents needed on staff personnel files - for example, a recent photograph of each staff member, and a brief record of interview questions and responses - to show that the home practices a robust and thorough procedure when recruiting new staff. Good practice guidelines for staff recruitment are described in a CSCI publication – ‘Safe and Sound?’ (June 2006) – and the registered manager was informed about how to obtain a copy of this for information. Each care staff member has a training folder and record of induction and further training that they undertake. Staff spoken to confirmed that there is a good programme of training in place and that they appreciate that much of this takes place ‘in-house’ led by outside training staff. Newland House DS0000062675.V314474.R01.S.doc Version 5.2 Page 20 At present the number of care staff who have a National Vocational Qualification (NVQ) at Level 2 is below the 50 recommended by the Commission. Nine of the 24 care staff have NVQ Level 2 or above. This is in part because of qualified staff leaving, and in availability of external assessors, the manager explained. However, the home is committed to training and more staff are currently undertaking NVQ courses. Newland House DS0000062675.V314474.R01.S.doc Version 5.2 Page 21 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, 37 and 38 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home is well managed. The manager is supported well by the senior staff in providing clear leadership throughout the home, with all staff demonstrating an awareness of their roles and responsibilities. Residents and relatives value the availability of the manager and senior staff to discuss any queries. More formal systems for consulting with residents and their relatives about their views on the home and standards should be further developed. The home must notify the commission of any events affecting the safety and welfare of residents. Newland House DS0000062675.V314474.R01.S.doc Version 5.2 Page 22 EVIDENCE: The registered manager has an ‘open door’ management style and is readily available to residents, their families and staff. This creates a friendly, supportive ‘family’ feel in the home: one relative wrote that the home has a ’very friendly atmosphere. I am always made welcome’. The manager sits in on staff handover report meetings and so is kept up to date with each resident’s care for the day. A deputy manager has been appointed to support the registered manager in her role. Residents’ and relatives’ comment cards received prior to the inspection show that people feel involved in decisions about their care and that staff and the registered manager are seen as approachable and open to suggestions and knowledgeable about care issues. Staff and residents are almost all from the same racial and ethnic background, but from conversation with the manager and staff and observation of staff and residents’ interactions during the inspection, the inspector considers that this service would be able to provide a service to meet the needs of individuals of various religious, racial or cultural backgrounds. The home has just started to develop questionnaires for residents and relatives to complete as part of a formal quality assurance programme so that the managers will be able to continue to develop the service in response to residents’ preferences and suggestions. The inspector recommends that the outcome of any surveys are shared with residents and their families, and that questionnaires/surveys could also be sent to other service providers and users, such as visiting professionals and therapists. The home does not manage any resident’s money – relatives or legal representatives do this on behalf of residents who are unable to do this independently. The homes fees include most services such as hairdressing, chiropody and newspapers. Any additional costs, for example for dry cleaning personal laundry, are invoiced to the resident or their representative separately. Training records for staff showed that they receive mandatory training in fire safety, moving and handling, first aid, food hygiene and infection control. The home has not notified the Commission of deaths, serious illness or any ‘untoward events’ affecting residents as required under Regulation 37 of the Care Homes Act 2000 and Regulations 2001. Although records are kept in the home, the registered provider and registered manager said that they were unaware of the requirement to inform the Commission and would ensure that notifications were submitted in future. A requirement is made in this respect. Newland House DS0000062675.V314474.R01.S.doc Version 5.2 Page 23 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 3 X 2 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 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 3 17 X 18 3 4 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 1 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 2 X 3 X 2 3 Newland House DS0000062675.V314474.R01.S.doc Version 5.2 Page 24 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 OP29 Regulation 19(4)(b) Requirement It is a requirement that the home must have received all necessary CRB disclosures and references before a potential employee is offered work in the home. Where a PoVA First check is required, this must have been applied for and the new member of staff fully supervised by another carer until the full disclosure is available. It is a requirement that the registered person give notice to the Commission without delay of any occurrence listed under this Regulation. Timescale for action 04/12/06 2. OP37 37 04/12/06 Newland House DS0000062675.V314474.R01.S.doc Version 5.2 Page 25 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. Refer to Standard OP3 Good Practice Recommendations It is recommended that the registered manager should improve the detail of written assessment information for care staff to refer to and which staff can plan residents’ initial care when they come into the home. Assessment of potential/known risks affecting new residents’ care should be included. Staff training in the use of the nutritional screening tool (MUST) should be extended to all care and catering staff and any nutritional care plans cross referenced to, or incorporated in, the resident’s care plan, so that all staff are aware of, and record, the specific actions to be taken for those residents assessed as ‘at risk’. It is recommended that any medication kept in the food fridge should be kept in a lockable, lidded container within the fridge, and that consideration should be given to obtaining a separate medication fridge. Assessment of residents able to self-administer medication should be documented and the home’s medication policies should include risk assessment for those residents who are able to take responsibility for their own medicines. 4. OP29 The registered person should improve the home’s recruitment procedures and ensure that the staff personnel records contain all the required and relevant information listed in Schedule 2 of the Care Homes Regulations. Good recruitment practice as outlined in the CSCI document ‘Safe and Sound?’ - June 2006 - should be followed. The home should continue to develop an effective quality assurance and monitoring system, based on seeking the views of service users, in order to measure success in meeting the aims, objectives and statement of purpose of the home. 2. OP8 3. OP9 5. OP33 Newland House DS0000062675.V314474.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Oxford Office Burgner House 4630 Kingsgate Oxford Business Park South Cowley, Oxford OX4 2SU 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. Extracts may not be used or reproduced without the express permission of CSCI Newland House DS0000062675.V314474.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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