Inspection on 30/08/07 for Newland House

This inspection was carried out on 30th August 2007.

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

Other inspections for this house

Newland House 10/11/06

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 Elaine Green Unannounced Inspection 30th August 2007 12:00 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 Newland House DS0000062675.V346537.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.V346537.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.V346537.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. 10th November 2006 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 home offers 24-hour care. 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 £600 to £750 per week; newspapers, alcohol served at meal times, hairdressing and chiropody are all included in the fees. Newland House DS0000062675.V346537.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. As part of the Unannounced Inspection of Newland House a site visit took place to the home. This took place over 6 hours on the 30th August. The Inspector joined three residents in the lounge after their midday meal, had a tour of the building, and had discussions with the manager and 5 members of the staff team whose comments will be reflected within the report. A range of records and documentation relating to the running of the home were also examined and included some of the home’s policies, procedures & guidelines, daily records, residents’ care plans, medication records and records pertaining to health and safety. In addition to the site visit the Commission for Social Care Inspection (CSCI) sent the home an Annual Quality Assurance Assessment to complete. This document provides the CSCI with statistical information related to the management and staffing of the home and gives the home the opportunity to state the things they feel they do well. Some of the information supplied by the Registered Manager in the Annual Quality Assurance Assessment document is referred to within this report. Resident surveys were sent to Newland House in order for the CSCI to gain the views of residents in relation to the services provided at the home. A total of 15 completed forms were returned to the Inspector. The comments and information gained from these surveys will be included in this report. What the service does well: Newland House is equipped to be able to provide any prospective resident with the majority of information they would need to know in order for them to make an informed decision about whether or not to stay there. They have an informative and up to date website and will print off information for those prospective residents who do not have access to a computer. No resident would be admitted to the home unless the home could meet their needs. Chiropody, hairdressing, activities and the alcohol served with meals are included within the fees. Staff support residents appropriately and treat them with dignity and respect e.g. by knocking on their bedroom doors before entering, using their preferred term of address and by supporting them to make choices in their daily living such as what to wear and what activities to participate in. Records confirm that residents of Newland House lead active lives and participate in a range of activities during the day, in the evening at weekends some, with staff support, participate in activities within the community. The food served is homemade, well presented and of good quality. The staffing Newland House DS0000062675.V346537.R01.S.doc Version 5.2 Page 6 ratios are high ensuring that residents have the staff support they require. All staff complete a skills for care induction and are given the opportunity to obtain a National Vocational Qualification in Care at Level 2 or above. The atmosphere in the home is relaxed and informal. It is clean, hygienic well maintained. The equipment provided at the home helps support residents to promote their independence and it is serviced on a regular basis. Comments included on the completed surveys returned to the Inspector by residents include: ‘I visited the home before taking up residence. I was able to choose my room.’ ‘I sleep very well. There is nowhere I would rather be.’ ‘Treatment and care – first class!’ ‘The meals at Newland House are delicious.’ ‘They really are kind, helpful and caring here, there is lots of laughter and it is homely.’ ‘The staff are kind and helpful.’ Staff spoke highly of the manager and said they found him approachable. Staff also said they felt they worked well together and made a good team. What has improved since the last inspection? What they could do better: The home must implement a Statement of Purpose and this must be accessible to prospective and existing residents. The information contained in pre-admission assessments should be more robust and the assessment methods or tools used should be stated. Residents care plans must provide staff with all the guidance they need in order to support residents safely and appropriately at all times. Appropriate healthcare Newland House DS0000062675.V346537.R01.S.doc Version 5.2 Page 7 referrals must be made so that people with specific needs can be appropriately assessed and individual guidelines can be written. Residents or their representatives must sign their assessments and care plans. In order to minimise the risk of medication errors occurring and to protect the health, safety and welfare of the residents in the home the manager must ensure that the procedures adopted by the home in relation to the checking in, storage and administration of medication and that the associated risk assessments are robust. A referral for a Pharmacist to undertake a Random Inspection of the home has been made. The home must ensure that their recruitment procedures are robust and that the staff personnel records contain all the required information and documentation. The ‘In house’ induction completed by new staff must be in sufficient depth and detail to ensure that they have the knowledge they require to work safely in the home. All staff must receive formal, documented supervision at least 6 times a year. In order to ensure that the providers are aware of the home’s performance and to make sure that they identify and address their own shortfalls the provider must make arrangements for monthly unannounced visits to be made to the home in line with Regulation 26 of the Care Homes Regulations. It is recommended that the home extends its quality assurance system to include all stakeholders and that the results are published. 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. Newland House DS0000062675.V346537.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.V346537.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): 1&3. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Prospective residents are provided with the information they require in order to make an informed decision about whether or not to move into the home however, the information provided in respect of charges for rooms is not transparent. EVIDENCE: Albeit this home does not have a brochure it does have its own website which is updated whenever changes occur. It is comprehensive and informative and updated weekly for the menu and monthly for the activities programme. Relevant text and pictures are added as available. If people have no access to the internet the home would download a copy for them and would do the same for Inspection Reports. Prospective residents and their families are invited to spend a day at the home prior to making a decision to enter the home for a Newland House DS0000062675.V346537.R01.S.doc Version 5.2 Page 10 trial period. Residents are informed on the website and in the Residents Guide of the situation regarding pets, furniture, ornaments, pictures, etc. The Inspector examined a copy of the home’s Service User Guide which provides residents with information about living in the home and specifies the range of basic fees made for the residents rooms. However, information in relation to fees is not included on the website. In addition to this on the day of the site visit the manager was unable to produce a copy of the home’s Statement of Purpose so some of the information that is required to be provided to prospective residents and that is not included on the web site was not available. Of the 15 surveys returned to the Inspector from residents all of them stated that they had had enough information about the home so that they could decide if it was the right place for them. One resident commented ‘I visited the home before taking up residence. I was able to choose my room.’ And another stated that it was investigated fully by their son. The information on the home’s Annual Quality Assurance Assessment states that all residents are able, should they wish, to see all the information which the Home keeps in their reference. They have reviewed, changed and formalised their resident pre-admission assessment form and process to ensure that they obtain as far as possible accurate information as to the prospective residents physical and mental state. On admission the preassessment form becomes the basis of the Residents Care Plan. This was a recommendation at the last Inspection and although they have made some progress towards achieving this, the information contained on these assessments still needs to be more robust. Assessment forms should include all potential and known risks, indicate how the assessor has gained the infomation and which assessment tools (if any) have been used. All preadmission assessment forms must be completed in conjunction with the prospective resident who must sign the assessment to show their agreement. Newland House DS0000062675.V346537.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. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9&10. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Albeit that residents’ health care needs are met care plans do not provide staff with the guidance they require in order for them to safely support service users at all times. The procedures adopted by the home in relation to the administration of medication are unsafe and have the potential to place residents at risk. EVIDENCE: On the day of the site visit the Inspector examined care plans of four residents. The manager explained that the information on the pre-admission assessment forms is used as the basis for writing individuals’ care plans. None of the care plans examined had been signed by the resident or their representative and although they had been signed by a member of staff there was no indication of their designation. In addition feedback from one relative stated that although they were aware that care plans existed they had never Newland House DS0000062675.V346537.R01.S.doc Version 5.2 Page 12 seen one. Care plans specify the individuals’ preferred term of address but do not contain a recent photograph of the individual. Some of the information contained on the care plans is informative e.g. whether individuals prefers a bath, whether self caring etc however, other important information was missing. For example, two of the residents whose care plans were examined have specific health care needs (epilepsy and diabetes) and yet there were no guidelines in place for staff to follow in relation to supporting them with these specific needs. In addition to this individuals’ falls risk assessments are not always reviewed following a fall and the relevant care plans are not always amended. In one care plan a member of staff had indicated that a hosit was to be used for transfers however, elsewhere in the care plan it stated that this person could mobilise themselves. In addition to this there was no risk assessment in place associated with the hoist being used to move this person and no evidence that a referral had been made to the appropriate health care professional for a moving and handling assessment to be carried out. A recommendation made at the last inspection in relation to extending staff training in the use of the nutritional screening tool (MUST) to all care and catering staff has not been met. Currently only one member of staff is able to carry out these assessments, however, the cook does have access to them. The Inspector spoke with a visiting District Nurse who confirmed that staff always call her for advice and/or make referrals when needed. She stated that she keeps records at the home in relation to all the individuals she visits and that she is very happy with the standard of care given. She also stated that she visits residents in their own rooms. On the day of the site visit the Inspector identified shortfalls in the systems used by the home for the checking in, storage, record keeping, auditing and administration of medication. Risk assesments had not been completed for all residents in relation to them storing, administering or assisting to administer their own medication. Due to the number and nature of the shortfalls identified and the potential risk to the residents of the home a referral has been made for a Pharmacist Inspector from the Commission for Social Care Inspection to visit the home and undertake a Pharmacy Inspection. Staff were observed treating residents with dignity and respect. They knock on residents doors before entering, refer to them by their prefered term of address and speak to them in a dignified and respectful manner. Of the 15 resident surveys returned to the Inspector 13 of them stated that they always receive the care and support they need and 2 stated they usually do. Comments included. ‘They really are kind, helpful and caring here.’ and ‘Treatment and care – first class!’ Newland House DS0000062675.V346537.R01.S.doc Version 5.2 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14&15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The people who live at this home are supported to live the lifestyle they choose and to maintain contact with their family and friends. Wholesome, nutritious and appetising food is provided at times to suit the people who live there. EVIDENCE: The daily records examined on the day of the site visit indicate that the residents lead the lifestyles that they choose to and that many of the residents of the home are very active. The manager explained that they try their best to provide the residents with activities that they enjoy. They are in the process of recruiting a new activity organiser who it is hoped will join the home in the near future. There is an activities room that is used for arts and crafts and the walls of the room are decorated with residents’ artwork. Some of the residents at the home enjoy going out and are supported to maintain links with the community. Staff stated that they have had some successful trips out recently to local pubs and have also organised other day trips out in the summer. Newland House DS0000062675.V346537.R01.S.doc Version 5.2 Page 14 A visiting relative confirmed to the Inspector that she is always welcomed into the home and that residents are supported in maintaining contact with their family and friends. A notice board lists all the activities that are planned for the month as well as the dates that the chiropodist and hairdresser would be visiting the home, these services are provided free of charge to all residents. The list also includes residents’ birthdays and the staff stated that they always provide a birthday cake and try to make the day special for the individual. Of the 15 completed resident surveys returned to the Inspector 9 people stated that there were always activities arranged in the home that they could take part in, 3 stated there usually were and 3 that there sometimes were. Comments from residents included ’I prefer the comfort of the armchair in my own room and watching television.’ and ‘I am happy to be quiet’. On the day of the site visit there was a menu on the wall in the dining room specifying the three-course midday meal. Although no choice was specified the manager explained that the cook speaks with residents in the morning to establish whether or not they would like an alternative. The cook also has access to residents’ nutritional assessments. It was pleasing to note that a good selection of cold drinks was available including red and white wine, sherry, fresh orange juice etc. Meals are served from a heated trolley and the food served on the day of the site visit was homemade, well presented and nutritious. Of the 15 completed residents surveys returned to the Inspector 11 people stated that they always like the meals and 4 stated they usually do. Comments from residents about the meals included ‘I love them.’ ‘The meals at Newland House are delicious.’ ‘Always good and care taken about my allergies.’ Staff interacted with residents during the meal and wore hairnets and aprons when serving food. Staff stated that none of the residents in the home required a soft textured diet but some do need occasional assistance to cut food up and assistance is given where required or when requested. Visitors are welcome to eat with residents and the ‘Activities‘ room doubles up at meal times as an additional dining room so that residents who do have guests can have some privacy. This room was used on the day of the site visit and a visiting relative said that they appreciated having this facility. Some residents prefer to eat in their own rooms and their food was taken to them on a tray. One person chose to eat in the ‘Bistro’ area, which is a pleasant area on the ground floor that looks out over the garden. Newland House DS0000062675.V346537.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. JUDGEMENT – we looked at outcomes for the following standard(s): 16&18. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home’s policies and procedures in relation to complaints and adult protection ensure that residents’ complaints are taken seriously and that they are protected form potential abuse. EVIDENCE: The Inspector had a discussion with the manger on the day of the site visit in relation to the arrangements in the home for residents to make a complaint. The manager explained that staff address any day-to-day ‘grumbles’ immediately. These ‘grumbles’ are usually sorted out on the day to everyone’s satisfaction. If this is not possible the home does have a formal complaints procedure and this is included in the service users’ guide so all residents have a copy. There have been no complaints made since the last Inspection. Of the 15 completed resident surveys returned to the Inspector 14 people stated that they knew who to speak to if they were not happy and 1 usually did, 12 people knew how to make a complaint 2 stated they would usually know and one person that they would never know how to. The home has a copy of the local adult protection guidance that includes information for staff in relation to who to contact should they want to raise an adult protection alert. Staff are also provided with training in adult protection. Newland House DS0000062675.V346537.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. JUDGEMENT – we looked at outcomes for the following standard(s): 19,20,21,23&26. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is clean, hygienic, homely and well maintained. Service users own rooms promote their independence and suit their needs and lifestyles. EVIDENCE: The Inspector had a tour of the home on the day of the site visit. All areas of the home were decorated and furnished to a high standard and were clean and hygienic. The lounges and the dining room have all been completely redecorated and refurnished. All residents’ rooms are en-suite and there are an additional 2 communal bathrooms both of which have a fully adapted bath. The grounds of the home are well maintained and are accessible by level access, there are plans in the future by the provider to further improve the garden areas including better access. Staff are employed to undertake the routine cleaning, gardening and maintenance. Newland House DS0000062675.V346537.R01.S.doc Version 5.2 Page 17 Of the 15 completed surveys returned to the Inspector by residents everyone stated that the home was always fresh and clean. Comments included ‘The flowers are always fresh.’ ‘I sleep very well. There is nowhere I would rather be.’ and ‘They really are kind, helpful and caring here, there is lots of laughter and it is homely.’ Newland House DS0000062675.V346537.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. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29&30. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Albeit the home provides sufficient numbers of appropriately trained staff to meet the needs of the residents at all times the ‘in house induction’ and recruitment practices adopted by the home are unsafe and do not promote residents health and safety or protect them from potential abuse. EVIDENCE: An examination of the staff rota, discussions with a visitor, residents and staff confirmed that there are sufficient numbers of staff on duty at all times. Monthly rotas of staff are produced in advance and are available to staff at all times. The daily staffing rota is displayed beside the staff work station in the downstairs hallway so that residents and visitors are aware of who is on duty. Following the refurbishment in 2006 the occupancy of Newland House has increased. The manager has routinely monitored staffing levels in all areas and staff have been increased steadily over the period. More staff are on duty at meal times and in the morning as demand dictates. Housekeeping and Catering staff are employed in sufficient numbers, including weekends. At the last inspection recommendations were made in relation to staff personnel files containing all the required information e.g. work history, Newland House DS0000062675.V346537.R01.S.doc Version 5.2 Page 19 references, proof of identity etc. This recommendation has not been met and shortfalls were again identified. One employee had only one reference when 2 are required. Another employees’ references were received after they were employed. Work histories were incomplete and none of the staff files had 2 acceptable forms of identity one of which should be photographic. There was evidence that some employees had completed the Skills for Care Induction, however the ‘In house’ Induction is completed in one day indicating that this is neither robust nor comprehensive. The manager must ensure that the ‘In house’ induction covers each subject in enough depth for the new staff member to be able to work competently and confidently in this home and that each item is not ‘signed off’ by the staff member and the manager until this has been achieved. Handovers take place from the care staff at each shift change which is 3 times a day. Staff receive an update on each resident including any medication changes, a summary of their general well being, appetite, any visitors including visits made by the District Nurse, GP etc. The Inspector sat in on a handover and can confirm that they are comprehensive and informative. There is always a senior on duty and manager or deputy on call. Comments from a visiting relative in relation to the staff include; ‘I have nothing but praise for the staff’ ‘The care my father got was just stunning’ ‘I’ve never heard a cross word ever.’ ‘Staff are second to none, very very, kind. They don’t talk down to anyone.’ Of the 15 completed resident surveys returned to the Inspector, 12 people stated that staff were always available when they needed them and 3 said there usually were, all the residents but one said that staff listen and act on what the resident says. Comments include ‘They really are kind, helpful and caring here.’ and ‘The staff are kind and helpful.’ Newland House DS0000062675.V346537.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. JUDGEMENT – we looked at outcomes for the following standard(s): 31,33,35&38. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Albeit this home is managed in the best interest of the people who live there by person qualified to do so, residents’ health and safety are not always protected and promoted. EVIDENCE: The Registered Manager of Newland House manages this home well and has the relevant qualifications and experience to do so. She is an ex NHS Senior Nursing Officer, has worked in the care of the elderly sector since 1985 and has been in post as manager since 1993. On the day of the site visit she stated that she is due to retire in February 2008 and that the current Deputy Manager will then take over as the Acting Manager. The Deputy Manager also Newland House DS0000062675.V346537.R01.S.doc Version 5.2 Page 21 has the relevant qualifications and experience needed to manage the home. She holds a National Vocational Qulification (NVQ) Level 4, Registered Managers Award and NVQ’s in Care Levels 1, 2 & 3. She has worked at Newland House since 1996 and has been taking over some specific management roles in advance of her appointment. The manager assured the Inspector that an application for the Deputy Manager to become the Registered Manager of the home will be made in due course. Four staff members supervision records were examined none of which had received the required formal documented supervision a minimum of 6 times a year or were on track to do so. The manager also confirmed that she does not receive formal supervision. A range of records and documentation in relation to health and safety was examined. Maintenance Contracts have been instituted for the laundry equipment, some of the kitchen equipment, gas boilers and central heating, fire detection, emergency lighting, portable electrical equipment safety, disposal of clinical waste and gardening. The home has appropriate insurance cover in place and a recent Environmental Health Check produced no recommendations. A fire detection system has been installed throughout that will detect and report a fire within metres and a ‘state of the art’ sprinkler system has been installed in the new Windrush Wing. Fire extinguishers were serviced in June 07, the fire alarms are tested weekly, a person qualified to do so has completed a fire risk assessment and the fire evacuation procedures are on display in the hallway. All the old gas boilers have been replaced in the last twelve months. The temperatures of water from hot water outlets are tested on a regular basis, however, water from at least 3 hot water outlets was recorded as being high for the last 3 months and no action has been taken to address this. Water from hot water outlets must be regulated at 43 degrees. Currently individual risk assessments are not completed for residents in respect of their safe access to all areas of the home. The manager must ensure that these are completed and that any restrictions to access are recorded in their care plan. Other shortfalls in relation to protecting and promoting residents health and safety have been highlighted elsewhere in the report e.g. care planning, medication procedures, recruitment and induction of new staff. The provider must make arrangements for monthly unannounced visits to be made to the home in compliance with Regulation 26 of the Care Homes Regulations. A copy of the report must be provided to the manager and kept in the home. The home has introduced a quality assurance system whereby they ask residents to complete a questionnaire each month. The Manager states that the results of the Questionnaire are a very useful tool and form the agenda for a formal monthly meeting between Management and Directors. It is recommended that in addition to this the results of such survey are consolidated and an annual report published and made available to all concerned and that a quality assurance system is introduced that includes all Newland House DS0000062675.V346537.R01.S.doc Version 5.2 Page 22 stakeholders. Regulations. This is in compliance with Regulation 24 of the Care Homes Newland House does not handle any monies on behalf of Residents, nor is anyone on the staff appointed as an agent for any residents finances. Newland House DS0000062675.V346537.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 1 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 3 3 3 X 3 X x 3 STAFFING Standard No Score 27 3 28 3 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 2 X 2 Newland House DS0000062675.V346537.R01.S.doc Version 5.2 Page 24 Are there any outstanding requirements from the last inspection? NO 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. Standard 1. OP1 Regulation 4(1) 5(1)(2) Schedule 1 Timescale for action In order to ensure transparency 30/11/07 the home must implement a Statement of Purpose, which specifies all the information as listed in the relevant regulations and schedule. This must be accessible and available at all times. In order to ensure that residents 30/10/07 of the home are supported safely and to protect their health safety and welfare, the manager must ensure that pre-admission assessments are robust. They must be completed in consultation with the prospective resident or their representative who must sign to show their agreement. The assessors’ designation and the assessment tools used should also be specified. In order to ensure that residents 30/10/07 of the home are supported safely and to protect their health safety and welfare, the manager must ensure that residents care plans are based on robust assessments and provide staff with all the guidance they need in order to support residents safely and DS0000062675.V346537.R01.S.doc Version 5.2 Page 25 Requirement 2. OP3 12(1)(2)(3) 13(1)(b)(4) (b)(C)(5) 14(1)(a)(c) 15(1)(2) 3. OP7 12(1)(2)(3) 13(1)(b)(4) (b)(c)(5) 14(1)(a)(c) (2)(a)(b) 15(1)(2) Schedule 3 Newland House 4. OP9 5. OP29 appropriately at all times. Appropriate health care referrals must be made so that people with specific needs such as a diagnosis of epilepsy, diabetes or those whose mobility has deteriorated can be appropriately assessed and individual guidelines can be written. All care plans must be kept up to date and amended when changes occur. A recent photograph must be included. 12(1)(2)(3) In order to minimise the risk of 30/10/07 13(1)(a)(b) medication errors occurring and to (2)(4)(a)(b) protect the health, safety and welfare of the residents in the home the manager must ensure that the procedures adopted by the home in relation to the checking in, storage and administration of medication and that the associated risk assessments are robust. These procedures must be followed at all times and medication records must be completed accurately. A referral for a Pharmacist to undertake a Random Inspection of the home has been made. 17(2)(3)(a) In order to protect residents from 30/10/07 (b) potential abuse the registered 19(1)(a)(b) person must ensure that the (c)(4)(a)(b) home’s recruitment procedures (c)(5)(d) are robust and that the staff Schedule 2 personnel records contain all the Schedule 4 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. Two forms of identity must be provided one of which should include a photograph. Two written references must be obtained and checked prior to staff being employed to work in the home and complete work DS0000062675.V346537.R01.S.doc Version 5.2 Page 26 Newland House 6. OP30 6. OP36 7. OP33 8. OP38 histories must be obtained. In order to protect service users health and safety the manager must ensure that staff are confident and competent to work in the home. All staff must complete an ‘In house’ induction over the first 6 weeks of employment.’ This must be in sufficient depth and detail to ensure that staff have the knowledge they require to work safely in the home. 13(6) In order to ensure that staff 8(1)(a)(b)(c training needs are identified and )(2)(a) that staff receive appropriate support all staff including the manager must receive formal documented supervision a minimum of six times a year. 26(1)(3)(4) In order to ensure that the (a)(b)(c)(5) providers are aware of the home’s performance and to make sure that they identify and address their own shortfalls the provider must make arrangements for monthly unannounced visits to be made to the home. A copy of the report must be provided to the manager and kept in the home. A copy of the first three months reports must be sent to the CSCI. 12(1)(a) In order to protect residents 13(4)(a)(b) health and safety and reduce the (c) risk of scalding the temperature 14(1)(2) from hot water outlets should be 23(1)(a)(2) regulated at 43C. Risk (c)(d)(j)(k)( assessments must be completed 4)(a)(b)(c)( in respect of residents’ safe d) access to all areas of the home and grounds. Any restrictions to access must be recorded in the care plan. 12(1) 13(5)(6) 18(1)(c)(2) (a)(b) 30/11/07 30/11/07 30/10/07 30/10/07 Newland House DS0000062675.V346537.R01.S.doc Version 5.2 Page 27 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 OP8 Good Practice Recommendations 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’. The results of the residents’ surveys used as part of the home’s Quality Assurance should be published and made available to all concerned. It should also be expanded to include all stakeholders. 2. OP33 Newland House DS0000062675.V346537.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Oxford Office 4630 Kingsgate Oxford Business Park South Cowley Oxford OX4 2SU 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 Newland House DS0000062675.V346537.R01.S.doc Version 5.2 Page 29 - 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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