Inspection on 15/02/07 for Newlyn Court

This inspection was carried out on 15th February 2007.

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

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Newlyn Court 16/10/06

Newlyn Court 06/03/06

Newlyn Court 04/10/05

Newlyn Court 27/07/04

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

CARE HOMES FOR OLDER PEOPLE Newlyn Court Merstone Close Bilston Wolverhampton West Midlands WV14 OLR Lead Inspector Keith Salmon Key Unannounced Inspection 15th February 2007 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 Newlyn Court DS0000017189.V328879.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. Newlyn Court DS0000017189.V328879.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Newlyn Court Address Merstone Close Bilston Wolverhampton West Midlands WV14 OLR 01902 408111 01902 408333 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) Newlyn Court Limited Miss Angela Bentley Care Home 72 Category(ies) of Dementia (72), Mental disorder, excluding registration, with number learning disability or dementia (72) of places Newlyn Court DS0000017189.V328879.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. From age 55 years No number division between categories Date of last inspection 16th October 2006 Brief Description of the Service: Newlyn Court is a privately owned, purpose built Care Home registered to provide personal and nursing care for a maximum of 72 persons experiencing dementia or mental health problems. Accommodation is provided over two floors, accessed by a passenger lift, and comprises mostly single bedrooms, with en-suite facilities, plus a number of shared bedrooms. Communal facilities comprise five lounge areas, three dining rooms, a hairdressing salon, and a sensory therapy room. At the time of this Inspection fees for care ranged from a minimum of £378 per week up-to a maximum of £480 per week. Newlyn Court DS0000017189.V328879.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This ‘Key’ Unannounced Inspection commenced at 10.00am, concluded at 2.00pm and was conducted by Mr Keith Salmon. Present throughout the Inspection, on behalf of the Home, were Miss Angela Bentley, Registered Manager, and the Proprietor, Mr Phillip White. The main objective of this Inspection was to review all of the ‘Key’ Standards, as set out on the National Minimum Standards for Care Homes for Older People, and to determine progress made by the Home in meeting ‘Requirements’ arising from the previous Inspection held on 16 October, 2006. This Report is a product of observations made during a tour of the Home, a review of care related documentation, staff duty rotas and staff files, plus a range of other documents/records reflecting the general operation of the Home. The Inspector also held 1:1 and group discussions with the Registered Manager, the Proprietor, 4 Residents, 3 Visitors, and several members of Staff. What the service does well: What has improved since the last inspection? A total of sixteen ‘Requirements’ arose as a result of the previous Inspection, held in October 2006, with two relating to issues identified at an earlier Inspection. Through evidence reviewed the Inspector was able to establish the Home had satisfactorily addressed fourteen of the ‘Requirements’. The general management of the Home is better organised and making more efficient use of its resources. Renewed commitment to Staff training, Staff supervision and Staff involvement has created a more safe and satisfying environment. With the appointment of a new Administrative Assistant, the Home’s records, particularly those relating to Staff files, have shown a distinct improvement. Newlyn Court DS0000017189.V328879.R01.S.doc Version 5.2 Page 6 In summary, the Management and Staff of the Home have worked determinedly, and effectively, during the 4 months, which have elapsed since the previous Inspection, in order to remedy these concerns. 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. Newlyn Court DS0000017189.V328879.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Newlyn Court DS0000017189.V328879.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 3. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Processes to ensure appropriate, and thorough, care needs assessment are effectively applied prior to admission, thus enabling the Manager to make an informed decision regarding the Home’s capability in meeting the individual care needs of prospective Residents. EVIDENCE: ‘Case Tracking’ which involved a full review of four Residents’ Care Plans/Files, i.e. those relating to the two most recently admitted Residents, plus two selected at random was conducted. This review demonstrated the Registered Manager personally assesses the care needs of all potential Residents, prior to making a decision as to whether the Home can successfully meet those needs, and before accepting the prospective Resident for admission to the Home. Newlyn Court DS0000017189.V328879.R01.S.doc Version 5.2 Page 9 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 good. This judgement has been made using available evidence including a visit to this service. The model of Care Plan utilised by the Home is of a comprehensive design, easy to follow and utilised well by Staff as a central part of meeting the Residents’ assessed care needs. Care is delivered considerately and effectively. The storage, administration, and disposal of medicines are in accordance with accepted good practice. EVIDENCE: As a component part of the ‘Case Tracking’ exercise the Inspector found Care Plans presented as:Easy to follow and understand. Showed evidence of regular review and current entries. Showed involvement of SU/Relative/Advocate. Showed evidence of ‘Risk Assessment’ with development of specific care planning where relevant. Newlyn Court DS0000017189.V328879.R01.S.doc Version 5.2 Page 10 A Review was undertaken of the policies/procedures relating to the management/administration of medicines, i.e. records relating to the supply, storage and disposal of medicines, including records of ambient and Medicine Room temperatures, together with records of the administration of medicines, all of which demonstrated the Home’s management/administration of medicines is in accordance with accepted good practice. Newlyn Court DS0000017189.V328879.R01.S.doc Version 5.2 Page 11 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 excellent. This judgement has been made using available evidence including a visit to this service. Leisure opportunities are provided consistent with Residents’ capabilities. The Home facilitates achievement of desired lifestyle through Residents conducting the pattern of their day, where possible, as they wish, including contact with family and friends, and continuation of religious practices. There is a daily choice of attractive and nutritious meals. EVIDENCE: The Home has a full and varied programme of activities, planned and organised, with enthusiasm and imagination, by a full-time Activities Coordinator. The current programme of activities available to Residents was displayed on a board in the entrance hall, and, in addition, all Residents have an ‘Activity Assessment Sheet’, identifying activities of most benefit within the Resident’s individual capabilities. Any activities undertaken are recorded in a ‘Personal Activity Diary’ on a monthly basis. The Inspector considers this to be of particular importance in respect of the client group cared for by Newlyn Court, and is praiseworthy in its enabling of continuity of care and easy access to activity information for visitors and other interested outside parties. Newlyn Court DS0000017189.V328879.R01.S.doc Version 5.2 Page 12 Evidence gathered from ‘Activity Diaries’, and photographic displays, confirmed group activities, including pub lunches, music & movement, craft activities, reminiscence sessions, arts and crafts (e.g. painting, candle work, clay work, ‘mental exercises’, visiting entertainers). The ‘Entertainments’ white board displayed in the entrance lobby offered an average of three organised sessions per week, during February, and included a fashion sale, visits by outside singers/entertainers on five separate occasions, a church service brought into the Home by members of a local church, arts and crafts sessions, and a pub lunch at the ‘Merry Boys’ public house. The Home also organises outings to such places as the Safari Park and Walsall lights. These trips involve two types of outing, i.e. the first for Residents who are capable of leaving the bus, with the second aimed at Residents who stay in the bus, due to their need for continued direct supervision. In addition to group activities, there is an emphasis on 1:1 activities such as nail care, reminiscence, and shopping trips – sometimes accompanied by Relatives and friends. It is usual practice for Residents to spend their day based on the ground floor, enjoying access to the corridors and communal areas, providing a facility important in the ‘management’ of the client group cared for by the Home. Discussions held with a group of three male visitors, all of whom were visiting their Wives, provided a strong consensus that quality of care is good and Residents’ needs are met. One visitor was particularly complimentary as to the specialist nature of the care provided for his Wife. In addition, they were all very satisfied with the range, quality, and choice of food offered to their Relatives. It was evident from menus observed the Home endeavours to cater for individual preferences/dislikes, including preferences of Residents from ethnic minorities. Newlyn Court DS0000017189.V328879.R01.S.doc Version 5.2 Page 13 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 interests of Residents are protected through ready access, for Residents or their Representatives, to information relating to advocacy services and the Home’s Complaints Procedure. Staff recognise they have a role in protecting Residents from abuse and are confident they would be able to carry out that role. Documentation of ‘incidents’ relating to/involving Residents is satisfactorily completed. EVIDENCE: A clear and concise Complaints Procedure, which includes reference to the Commission for Social Care Inspection as the regulatory body, together with contact details, is displayed in the main hallway. In addition, information on how to raise a complaint is included in the Service User Guide. The Home maintains a record of complaints, which was observed to be current. Examination of ‘Accidents/Incidents’ Records demonstrated nothing of particular concern for the Inspector. Residents who were able, and the 3 Visitors spoken with, stated they would have no hesitation in raising matters if they had any concerns, and were confident these would be dealt with promptly. Policies relating to protection of Residents from abuse were observed to be in place and readily accessible, including ‘Whistle Blowing’, ‘Abuse Awareness’ and ‘Adult Protection’. Staff training files indicated that Staff had received training in respect of these Policies. Newlyn Court DS0000017189.V328879.R01.S.doc Version 5.2 Page 14 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, 25, and 26. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The Home provides a safe environment with comfortable and homely bedrooms. The garden provision is well thought through being of a design, which addresses the needs of the client group. Specialist equipment, consistent with meeting the assessed care needs of Service Users and the demands of tasks carried out by Care Staff is available, and appropriately serviced and maintained. EVIDENCE: At the previous Inspection, it was noted the provision of the ‘secure’ garden had been disrupted during the building of an 8-bed extension. A ‘Requirement’ was issued to the effect, i.e. ‘The Home is to re-establish the ‘secure garden’ when work on the new extension is completed’. It was observed the extension is close to completion and work on re-landscaping the gardens to the rear and side is well advanced. Paths have been re-laid, and new borders created, Newlyn Court DS0000017189.V328879.R01.S.doc Version 5.2 Page 15 which have been slightly raised to afford a clear view of them from the new lounge extension – to be known as the ‘Garden Room’. All that remains for this section of garden to be returned to ‘secure’ status is the erection of a small section of fencing/gate immediately adjacent to the new extension. It is expected this ‘Requirement’ should be fully met during the coming weeks. Given the completion of other related works were ‘on target’ the Inspector is confident this final aspect will be satisfactorily completed during the weeks immediately following this Inspection. Two further ‘Requirements’ issued under this ‘Outcome’ Area necessitated immediate steps be taken to eradicate persistently offensive odours, and, as a linked ‘Requirement’, the Home was to review related Policies and Procedures to ensure immediate and effective response to continence ‘accidents’. At this Inspection it was evidenced the Proprietor, Manager and Staff have responded positively and effectively with the replacement of most of the ground floor carpets, introduction of a readily available ‘spillage’ kit, together with formal Staff training in its use, and consistent application of the ‘quick response’ policy by Staff. These two ‘Requirements’ are now fully met. The main corridors of the Home previously presented a very gloomy environment due to absence of natural light and the use of dark colours in decoration. Ground floor corridors have now been repainted in lighter colours, and new carpets, again of a lighter colour, have been laid. This latter change, coupled with the response to the cleaning up of ‘accidents’, has effected the most noticeable of improvements in that the smell of stale urine has been totally eradicated. The final component in the carpet replacement programme is programmed for the end of February when the carpet in the ‘Windsor Lounge’ will be replaced once the opening into the ‘Garden Lounge extension is finalised (involving the removal and replacement of existing windows and exit doors). The new 8-bed extension is also well advanced and should be completed, fully commissioned and brought into use, by the end of March. Bedrooms visited presented as clean and satisfactorily decorated, with evidence of some Residents having been encouraged, and enabled, to ‘personalise’ their own bedrooms. With the redecoration/refurbishment work now complete the general ambience of the Home has been hugely improved, presenting a much more pleasant environment for Residents, Visitors and Staff. The Home is to commended for its efforts in this ‘Outcome’ Area of care. Newlyn Court DS0000017189.V328879.R01.S.doc Version 5.2 Page 16 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 good. This judgement has been made using available evidence including a visit to this service. Staff numbers and skill-mix listed on the staff rota are sufficient to meet the assessed care needs of current Residents. Recruitment and employment practices are consistent with the safeguarding of Residents. The commitment of the Home to providing training for Care Staff is good. EVIDENCE: The current staffing rota, and those from the immediately preceding weeks, were examined. Staffing numbers and skill-mix enable a service provision, which meets the care needs of the Service Users. At the previous Inspection the management of pre-employment checks on prospective staff were found not to be in accordance with the Regulations, and, therefore, a related ‘Requirement’ was issued, i.e. ‘The Home must obtain full and satisfactory information, in respect of new Staff applicants, prior to them commencing employment. Since that time a review has been undertaken by the Proprietor and Manager looking into the arrangements for support of the Manager with administrative aspects of her role, e.g. application/appointment records, including the processing of POVA and CRB checks. The Inspector examined three sets of Newlyn Court DS0000017189.V328879.R01.S.doc Version 5.2 Page 17 Staff Records, including those of the two most recently appointed Employees, plus one chosen at random, and all were found to be well-organised, easy to follow and contained all the required elements. Overall, all staffing records have benefited from the above review process. The manner in which general organisation, clarity of presentation, and application to ensure accurate and comprehensive records of staff, are now maintained is a compliment to the newly appointed holder of this administrative support post. Therefore, the ‘Requirement’ relating to the gathering of information on prospective staff to ensure Residents’ safety and protection from abuse is fully met. A further ‘Requirement’, relating to aspects of Staff Records, was the need for them to record that Staff have participated in fire drills. These records now demonstrate Staff are subject to a thorough, and relevant, orientation/ induction programme, which is followed by comprehensive ‘foundation’ training, e.g. ‘fire safety’ including formal fire drills, ‘manual handling and lifting’, ‘first aid’, ‘simple infection control’. Therefore, the ‘Requirement’ relating to the recording of fire drills is met. With regard to the target attainment level for 50 of Care Staff to have attained NVQ Level 2 the Home has yet to meet this goal. Currently the proportion of Care Staff, who have attained NVQ Level 2, or higher, is marginally below 40 . However, evidence was observed, and confirmed verbally by Staff, that a number of Care Staff are currently taking the appropriate Course (18 in total) and successful completion in Spring/early Summer, 2007, of only five of these Staff would boost numbers above the target. Newlyn Court DS0000017189.V328879.R01.S.doc Version 5.2 Page 18 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, 32, 33, 35, 36, 38. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Operationally, the Home is very well organised, with the central purpose being ‘the best interests of Residents’. Residents’ personal financial interests are safeguarded. Staff are subject to effective support, with regular ‘supervision by the Manager, and appeared involved and happy in their work. The Home is a safe place for the Residents to live. EVIDENCE: Previously performance outcomes for this group of Standards has been rated ‘Poor’, in accordance with the application of the ‘Key Lines of Regulatory Assessment (KLORA), with more weaknesses than strengths. Newlyn Court DS0000017189.V328879.R01.S.doc Version 5.2 Page 19 This assessment resulted in 10 ‘Requirements’ being issued under this ‘Outcome’ Area, as follows:The monitoring and evaluation of service quality. Systems for the management of Residents’ personal. Establishment of staff meetings. Staff involvement in risk assessment and control. Records relating to staff fire drills. The testing of portable electrical equipment. The testing of hot water outlets accessible to Residents. The care of substances hazardous to health (COSSH). At the time of the previous Inspection the Registered Manager acknowledged there were aspects of the management process, which required improvement. Evidence forthcoming at this Inspection displayed positive steps have been taken to rectify these shortfalls, as follows:Regular sampling of the views of Service Users and Visitors to the Home has now commenced. Evidence of this was seen in returned questionnaires and summary/analysis documentation, together with confirmation from Visitors of their involvement in this process. Implementation of a newly devised and more structured approach to the management of monies relating to small personal expenditure by Residents, e.g. hairdressing, trips, toiletries, personal clothing. In essence, the Home pays ‘up-front’ for such expenditure. Having agreed a maximum figure of expenditure with the ‘paying agent’, e.g. the Relative, when this amount is reached, or at the end of each month (whichever is sooner), the Home provides the ‘paying agent’, with confirmation of expenditure and payment is made to the Home. This unusual approach was established following full consultation with interested parties, and copies of the letter circulated by Home, advising of this new system, were observed. Relatives confirmed to the Inspector they were very satisfied with the arrangement and it worked well. The Inspector also reviewed evidence of regular internal, and external, audit of related documentation. The holding of formal monthly Staff Meetings involving all Staff, plus separate meetings of various sub-groups, i.e. Nurses (Day Staff and Night Staff), Care Staff, Domestic Staff, Kitchen Staff. Minutes are being maintained and Staff confirmed they valued the meetings, appreciated having the platform from which to make a contribution, and enjoyed taking an active part in proceedings. The minutes, and comments by Staff, also provided evidence these meetings had been successfully utilised as a forum to address the ‘Requirement’ relating to Staff awareness and involvement in ‘Risk Assessment’ processes. The related ‘Requirement’ is considered met. Newlyn Court DS0000017189.V328879.R01.S.doc Version 5.2 Page 20 Implementation of a clearer, more structured, approach to Staff supervision and appraisal. Evidence of this was seen in a planning matrix, records in individual Staff Files and comments from Staff members. The Home now formally records in Staff Personal Files when Staff have received fire safety training, and participated in Fire Drills. Professional advice was sought from the Health and safety Executive as to the requirements for the checking of small, electrical appliances. Evidence was seen of the electrician having implemented a full check of all ‘Class 1’ appliances with test certificates having been attached to each appliance giving the date of test, approval status and the date for the next bi-annual check. Maintenance Supervisor tests all hot water outlets on a monthly basis as The Home has acquired a digital temperature probe with which the part of an audit of a ‘whole home’ audit. The log relating to this was reviewed and seen to be up to date. It is noted that to ensure continuing progress with redecoration/refurbishment progress, as well as completion of ‘regular’ maintenance, the Maintenance Staff complement has been doubled. Evidence was seen confirming ‘risk assessment’ has been completed on all chemicals used in the Home. Health and Safety Policies/Procedures, and the application of related practices were seen to be satisfactory. Through a process of observation, discussion with the Manager, Proprietor, Staff and Visitors, and a review of documentation, it was clear the Home has worked hard to meet the ‘Requirements’ cited within this ‘Outcome’ Area. The general management of the Home is now well organised, making more efficient use of its resources, and effective in providing a safer and more satisfying environment in which to live and work. Newlyn Court DS0000017189.V328879.R01.S.doc Version 5.2 Page 21 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 2 X X X X 3 3 STAFFING Standard No Score 27 3 28 2 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 3 x 3 3 x 3 Newlyn Court DS0000017189.V328879.R01.S.doc Version 5.2 Page 22 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 OP20 Regulation 23. (2)(a) Requirement The Responsible Person must ensure that a ‘secure garden’ is re-established. The Registered Manager must ensure 50 of the Care Staff have attained NVQ Level 2 or above. Timescale for action 31/03/07 2. OP28 18. (1)(a) 30/04/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Newlyn Court DS0000017189.V328879.R01.S.doc Version 5.2 Page 23 Commission for Social Care Inspection Shrewsbury Local Office 1st Floor, Chapter House South Abbey Lawn Abbey Foregate SHREWSBURY SY2 5DE 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 Newlyn Court DS0000017189.V328879.R01.S.doc Version 5.2 Page 24 - 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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