Inspection on 16/10/06 for Newlyn Court

This inspection was carried out on 16th October 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

Newlyn Court 15/02/07

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 16th October 2006 09:30 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.V297384.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.V297384.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.V297384.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 6th March 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.V297384.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 09.30am, concluded at 2.30pm (a total of 5.0 hours) and was conducted by Mr Keith Salmon and Mrs Debbie Sharman. Present throughout the Inspection, on behalf of the Home, was Miss Angela Bentley, Registered Manager, later joined by 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 6 March, 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 Inspectors also held 1:1 and group discussions with the Registered Manager, the Proprietor, 4 Residents, 8 Visitors, and several members of Staff. What the service does well: What has improved since the last inspection? What they could do better: Newlyn Court DS0000017189.V297384.R01.S.doc Version 5.2 Page 6 Several areas for improvement were identified. These being: The need to alleviate omissions in recruitment checks prior to the employment of new staff. The need to improve staff supervision and appraisal practices; to hold, and minute, regular staff meetings. The need to develop/implement a tool to gain the views, where possible, of Residents and/or their Representatives in respect of the quality of service provided. This would assist the home in assessing, and improving its performance. The need to establish and implement a more rapid and effective response to continence ‘accidents’ so as to reduce the strong malodours, within some areas of the Home, which are proving unpleasant for Service Users and Visitors, and present an infection control risk. To re-establish the ‘secure garden’ area - disrupted by the extension currently being built. To review the Home’s systems for ensuring all of the Standards and Regulations relating to the ‘Management and Administration’ outcome group are fully met. 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.V297384.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.V297384.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’ involving the review of 10 Residents’ Care Plans/Files, (i.e. those relating to the four most recently admitted Residents, plus 6 selected at random), demonstrated all potential Residents have their care needs assessed by the Registered Manager prior to taking up residence. Newlyn Court DS0000017189.V297384.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 and utilised well by Staff as a central part of meeting the Residents’ assessed care needs, which are 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 the Care Plans reviewed presented as: Being easy to follow and understand Showing evidence of regular review and current entries Newlyn Court DS0000017189.V297384.R01.S.doc Version 5.2 Page 10 Showing involvement of SU/Relative/Advocate Showing evidence of ‘Risk Assessment’ with development of specific care planning where relevant 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. This showed the Home’s management/administration of medicines is now in accordance with accepted good practice. Therefore, the ‘Requirement’ issued at the previous Inspection, under National Minimum Standard 0P9, has been fully met. Newlyn Court DS0000017189.V297384.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 good. 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 programme, outlining current activities offered to Residents, was displayed on a board in the entrance hall. In addition, all Residents have an ‘Activity Assessment Sheet’, identifying activities of most benefit within the Resident’s individual capabilities, with activities undertaken recorded in a ‘personal Activity Diary’, minimally on a monthly basis. The Inspectors Newlyn Court DS0000017189.V297384.R01.S.doc Version 5.2 Page 12 consider this to be of particular importance for the client group cared for by Newlyn Court. Group activities include pub lunches, music & movement, craft activities, reminiscence sessions, arts and crafts (e.g. painting, candle work, clay work, ‘mental exercises’, visiting entertainers). The Home also organises outings to a Safari Park, which, in fact, involves 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 the need for continuing direct supervision. There was also evidence within Care Plans, and from photographic displays, of visits to the ‘Walsall Lights.’ 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. Usually, all Residents spend their day based on the ground floor, and enjoy ‘free-range’ of the ground floor area. This provides a facility, which is of importance in the ‘management’ of the client group cared for by the Home. Discussions held with two groups of visitors (a total of eight persons of varying ages covering several generations) provided a strong consensus that quality of care is good and Residents’ needs are met. An area in which they would all like to see an improvement is in better access to the garden. It was noted the previous garden provision has been disrupted during work to build a new 8-bed extension. Access to ‘secure’ outside space is an important adjunct to the care of the client group, and, therefore, it will be a ‘Requirement’ of this Inspection (issued under OP20, Regulation 23) that a ‘secure garden’ area be reestablished. Two Residents, with whom the Inspector was able to have discussions, stated that the range, quality and choice of food was very good, and the Home tries to cater for their individual preferences/dislikes. Relatives, who attend the Home on a frequent basis, confirmed this to be so. Newlyn Court DS0000017189.V297384.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 adequate. This judgement has been made using available evidence including a visit to this service. The interests of Residents are protected with access to information relating to advocacy services, and the Home’s Complaints Procedure, being readily available for those Residents sufficiently capable of comprehension. Staff showed awareness of their role in protecting Residents from abuse. However, there may be potential threats to the safety of Residents arising from omissions in recruitment practice. EVIDENCE: Complaints Procedure details are included in the Service User Guide and are displayed prominently for the benefit of all interested parties. There are policies and procedures in place intended to provide protection for vulnerable people. Staff receive ‘Adult Protection’ training at induction, and through on-going staff training, confirmation of which was forthcoming through 1:1 discussions with Staff, and from Staff Records. However, there are concerns regarding potential threats to the safety of Residents, arising from omissions in the Home’s recruitment practices. Newlyn Court DS0000017189.V297384.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): 19,20,21,22, 25,26. Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. The Home generally provides a safe environment with comfortable and homely bedrooms. However, the communal rooms do not provide a pleasant environment due to unpleasant and persistent odours. There may also be a linked infection control risk. The current garden provision is unsatisfactory. 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 three ‘Requirements’ were cited under Standards covering Environment. These being: - Newlyn Court DS0000017189.V297384.R01.S.doc Version 5.2 Page 15 OP21 “Bathing facilities must be available and accessible to residents at all times.” “The provision for storage of aids and equipment must be reviewed.” “All offensive odours as identified must be eliminated.” OP22 OP26 The ‘Requirements’ relating to OP21 and OP22 are, in some ways linked, in that, there was a need to find additional space for the storage of equipment, which was blocking corridors and fire escape routes, and there was a first floor bathroom which was little used by Residents. The Proprietor informed the Inspectors there had been NCSC/CSCI agreement, some 1-2 years previously, that the bathroom could be taken out of use, and this room used as storage for equipment, e.g. hoists, wheelchairs etc. Although no written evidence of this could be produced for the Inspectors, it was observed the necessary changes in relation to fire safety have been completed, i.e. smoke alarm installed, door seals installed. Given that there is remaining bathroom provision on the first floor, and virtually all the Residents spend their time on the ground floor, from rising until retiring in the evening, the removal of this bathroom from use as a bathing facility does not seem to have a deleterious effect on care provision. Therefore, the Inspectors consider ‘Requirements’ OP21 and OP22 are no longer relevant and are to be removed. Bedrooms visited presented as clean and satisfactorily decorated, with evidence of some Residents having been encouraged, and enabled, to ‘personalise’ their own bedrooms. However, the corridors present a rather ‘gloomy’ and worn appearance. Most strikingly, as with other communal areas, there is a strong and persistent smell of urine. The Proprietor informed the Inspectors the process of redecorating the ground floor corridors, and communal rooms, has commenced. Re-painting is being undertaken in sections, followed immediately by re-carpeting throughout. Interestingly, bedrooms visited, including some where the Resident has continence problems, had no such smells. This suggests the management of continence problems of individual Residents is addressed effectively. Conversely, what is not well managed is the urgency of response by the Home in dealing with cleaning following incidents of ‘inappropriate voiding’. One group of Visitors recounted to the Inspector an occasion on which a Resident voided urine onto the carpet in the ‘Visiting Lounge’. They immediately alerted the Staff, but no one came to deal with cleaning up “for more than an hour.” Therefore, it will be a ‘Requirement’ of this Inspection that immediate steps must be taken to eradicate persistently offensive odours, and, as a further Newlyn Court DS0000017189.V297384.R01.S.doc Version 5.2 Page 16 ‘Requirement’, the Home is to review related Policies and Procedures to ensure response to such incidents is immediate and cleaning procedures are effective. Finally, the Responsible Person is ‘Required’ to submit to the CSCI a redecoration and re-carpeting programme giving target dates for completion of works. Newlyn Court DS0000017189.V297384.R01.S.doc Version 5.2 Page 17 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 poor. This judgement has been made using available evidence including a visit to this service. Performance across these standards is mixed, ranging from ‘good’ for staff training and staffing levels, to ‘poor’ in respect of recruitment practice – i.e. numbers on duty, and skill-mix, seem able to generally meet the assessed care needs of current Residents, but poor due to the seriousness of risk posed to Service Users by omissions in recruitment practice. The latter issue sufficiently serious to reduce the overall risk rating for this group of standards to ‘poor.’ EVIDENCE: The current staffing rota, plus those from the immediately preceding weeks, were examined and compared with staff numbers on duty at the time of the Inspection. These demonstrated staffing numbers and skill-mix enable a service provision, which meets the care needs of the Service Users. There is a well-organised rolling programme of training, which addresses induction, foundation, and further training. The Manager is aware of forthcoming changes to the national induction programme for newly appointed staff and will be adjusting the programme to ensure compliance. Newlyn Court DS0000017189.V297384.R01.S.doc Version 5.2 Page 18 Whilst the Home has not yet met national targets for the numbers of Staff qualified to NVQ Level 2 (or higher), the required 50 proportion will be exceeded when the group currently undertaking training successfully completes the course. The Home has pro-actively responded to the need to increase the numbers of Staff qualified to this national minimum level. The training record of a staff member was reviewed, in addition to discussion with a staff member with particular emphasis on the provision of training opportunities. The Home is meeting its obligation to provide a minimum of three days training per year. Discussion with a member of Staff also demonstrated a good understanding of Service User needs and the principles of privacy and dignity, with practical examples given of how this is promoted during day-to-day activity with Service Users. However, greater attention to detail is required at the pre-employment stage to ensure Service Users are protected. Records demonstrated a staff member commenced employment three weeks prior to receipt of a satisfactory Criminal Records Bureau Check with no evidence of a POVA check having been carried out, and without the circumstances being the subject of a documented risk assessment. A second reference was unacceptably brief, and had not been pursued for further clarification, and no identification was held on file. This is regarded as poor practice and is unjustifiable, particularly given the Home is not experiencing staffing level pressures. Newlyn Court DS0000017189.V297384.R01.S.doc Version 5.2 Page 19 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): 31,32,33,34,35,36,38 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. Performance outcomes for this group of Standards is rated ‘poor’ as there are more weaknesses than strengths. Overall, the impression gained is one of managerial strengths being vested more in the ‘clinical’ aspects of care, and day-to-day management of Staff, rather than ‘non-clinical’ operational management and general administration. The Manager is aware there are managerial aspects of the service, which require improvement, and it is considered the potential exists to meet those aims. Newlyn Court DS0000017189.V297384.R01.S.doc Version 5.2 Page 20 EVIDENCE: The Registered Manager, who has completed national qualifications required for this role, has also undertaken some periodic up-date training with more planned. Discussion showed she is aware of areas requiring her input in order for the Home to develop and meet the National Minimum Standard. Discussions with Staff and Relatives evidenced general satisfaction, with the Manager being approachable and the team happy, supportive, and communicative. For example, in conversation a member of Staff said…. “I really enjoy it here. Everyone is approachable and things are always done correctly.” The staff member further stated she would be happy for a relative of hers to live at the Home. However, currently there are no strategies for enabling Staff, Service Users and Stakeholders to influence the way the service is delivered – e.g. no Quality Assurance systems to assist the Home in assessing and improving its own performance; no evidenced staff meetings since 2004; no supervisions or performance appraisals of staff to ensure staff are best meeting Service Users’ needs. As identified above (Environmental Standards) there is a strong, and persistent, smell of urine throughout the communal areas of the Home. In addition to being unpleasant this presents an infection control risk. It is clear to the Inspectors this situation arises from the lack of an effective policy and procedure to deal with this problem. There is also an evident lack of delineation of role responsibility, which must be clarified within the Policy/Procedure. The Inspectors found that practices relating to the management of Resident’s personal monies are not being managed in accordance with the Regulations. Service Users personal monies, including cash given to the Home (e.g. by Relatives) for use by Service Users, are being pooled in the Home’s Business Account. Expenditure is by way of the Proprietor writing cheques for hair appointments, chiropody appointments, and trips etc. This system does not protect Service Users, or the Proprietor, and does not guarantee Service Users access to small amounts of cash, at all times, for incidentals. Records were available to account for financial activity, and indicate monies paid in and out with, a recorded balance held for each Service User. However, whilst the nature of expenditure appeared acceptable from the records made available, they could not be verified against receipts. Newlyn Court DS0000017189.V297384.R01.S.doc Version 5.2 Page 21 Supervision is not formally provided for Staff and there is no evidence of staff meetings being held since 2004. Through discussion with a staff member it appears one staff meeting may have been held in last 6 months although an agenda and minutes were not available, and the staff member was unclear about this. Some risk assessments are in place. However, discussion with a staff member she/he that she/he did not understand the fundamentals of ‘risk assessment’ and its application in ensure a safe environment for Residents. Data sheets are available for hazardous products used in the Home. However, information within the data sheets has not been used to measure and control the level of risk posed by individual products in the Home environment. Most maintenance records inspected were unsatisfactory, including those that directly impact upon risk to Service Users, e.g. water temperature checks, maintenance of bedrooms and compliance with all significant Fire Service requirements. Specifically, with regard to water temperatures - these are not being reliably tested as they are being tested with a hand, rather than with a temperature gauge and, therefore, are not being recorded. The Home’s Maintenance Man has carried out an audit of bedrooms and a large number of actions have been highlighted as required to ensure good maintenance and repair. The Manager and Proprietor confirmed the Maintenance Man has an on-going programme aimed at achieving this. Some requirements, arising from a Fire Safety visit in May 2006, have not been implemented, and the Proprietor remains in discussion with the Fire Service in relation to issues raised. It is not clear from records which Staff have taken part in fire drills. Electric safety tests on portable appliances are not being carried out following the Proprietor’s understanding of changes in regulations. This requires further clarification. Certification is available to demonstrate the Home’s hard wiring has been checked, but this is due for imminent renewal. A ‘Gas Landlord Certificate’ was not in place as the Proprietor was not aware this was required, although servicing of appliances had been carried out. This was rectified on the day of the Inspection and a Certificate was provided. Food Safety Management is good with no requirements arising from the visit, of the Environmental Health Officer, which was carried out on the same day as this Inspection. This good practice reduces the risk to Service Users from food borne illness. Newlyn Court DS0000017189.V297384.R01.S.doc Version 5.2 Page 22 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 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 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 2 2 3 3 X X 2 1 STAFFING Standard No Score 27 3 28 2 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 2 2 2 2 X 1 Newlyn Court DS0000017189.V297384.R01.S.doc Version 5.2 Page 23 Are there any outstanding requirements from the last inspection? YES STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP20 Regulation 23. – (2)(a) 23. – (2)(d) Requirement The Responsible Person must ensure that a ‘secure garden’ is re-established. The Responsible Person must provide to CSCI a works programme (with target dates), for the completion of redecoration and re-carpeting of the communal areas. Timescale for action 31/01/07 2. OP26 30/11/06 3. OP26 23. (2)(b)(d) 13. - (3) 23. (2)(b)(d) 13. – (3) The Registered Manager must 15/12/06 ensure that persistently offensive odours are eliminated and the situation maintained. The Registered Manager must review Policies and Procedures relating to the management of continence ‘accidents’ and ensure that response to such incidents is immediate, and that cleaning procedures are effective. The Registered Manager must ensure 50 of the Care Staff have attained NVQ Level 2 or above. DS0000017189.V297384.R01.S.doc 4. OP26 30/11/06 5. OP28 18. – (1)(a) 31/12/06 Newlyn Court Version 5.2 Page 24 6. OP18 OP29 19. – (1) The Registered Manager must ensure the protection of Residents from abuse by obtaining full and satisfactory information, in respect of applicants, prior to them commencing employment. The Registered Manager in conjunction, with the Responsible Person, must review the management of Service Users’ finances ensuring compliance with Regulation 20. The Responsible Person must ensure independent audit of all Service Users’ personal monies and accounts managed by the Home. Evidence of this must be provided to CSCI. The Responsible Person must establish and maintain a system for evaluating the quality of the services provided at the Care Home, and must include provision for consultation with Service Users and their Representatives. The Registered Manager must implement regular and evidenced staff meetings, formal supervision of staff and staff performance appraisals. The Registered Manager must ensure COSHH assessments based upon data sheet information are carried out for individual hazardous chemicals. The Registered Manager must establish systems for regularly, and reliably, testing hot water outlets to eliminate risks to Residents. DS0000017189.V297384.R01.S.doc 30/11/06 7. OP35 20. – (1)(3) 30/11/06 8. OP35 20. – (1)(3) 30/11/06 9. OP33 24. – 15/12/06 10. OP36 21. - 30/11/06 11. OP38 13. – (4) 30/11/06 12. OP38 13. – (4)(a)(c) 30/11/06 Newlyn Court Version 5.2 Page 25 13. OP38 23. – (4)(d)(e) 14. OP38 13. – (4) 15. OP38 13. – (4) 16. OP38 13. – (4) The Registered Manager must and maintain records showing the names of staff, who participate in fire drills and the date of the said drill. The Registered Manager must seek advice from the Environmental Health Department as to action required in relation to the testing of portable electric appliances and this must be confirmed in writing to CSCI. The Registered Manager must ensure Staff understand their responsibilities in relation to risk assessment and risk control within the Home. The Responsible Person must review the Home’s systems to ensure all of the Standards and Regulations relating to the ‘Management and Administration’ outcome group are fully met. 30/11/06 15/12/06 30/11/06 30/11/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Newlyn Court DS0000017189.V297384.R01.S.doc Version 5.2 Page 26 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.V297384.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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