Inspection on 04/10/05 for Newlyn Court

This inspection was carried out on 4th October 2005.

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 16/10/06

Newlyn Court 06/03/06

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 Ros Dennis Unannounced Inspection 4th October 2005 11:00 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.V258124.R01.S.doc Version 5.0 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.V258124.R01.S.doc Version 5.0 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.V258124.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. From age 55 years No number division between categories Date of last inspection 25th February 2005 Brief Description of the Service: Newlyn Court is a privately owned, purposely built care home that provides accommodation, personal and nursing care to older people with mental health problems. The home is registered to provide care for 72 people. The home has five sitting areas, separate dining rooms, a hairdressing salon and a sensory therapy room. A lift provides access between floors and wheelchair access is available throughout the home. Newlyn Court DS0000017189.V258124.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection was conducted by two inspectors and lasted for approximately 6 hours. The last full inspection of the home was undertaken in July 2004 and the CSCI pharmacist inspector conducted an inspection of medication practices in February 2005. The inspection included observing activity within the home, a tour of the premises, looking at residents care records, speaking with staff, relatives and observation of documents. The managers and staff on duty were welcoming and offered their fullest co-operation throughout the inspection. Due to the nature of resident’s mental illness the inspectors were unable to ascertain resident’s views of the service and care received. However observation confirmed that the residents appeared well cared for and staff attentive in meeting resident’s needs. A number of relatives visited the home during the inspection and those spoken with were highly complimentary regarding the service provided, level of care, staff, managers and the meals. What the service does well: What has improved since the last inspection? The home has met most of the requirements regarding medication practices that were identified by the CSCI pharmacist inspector in February 2005. The service user guide has been reviewed and contracts that have been drawn up between residents and the home ensure that residents and/or their representatives are aware of terms and conditions of occupancy. Newlyn Court DS0000017189.V258124.R01.S.doc Version 5.0 Page 6 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. Newlyn Court DS0000017189.V258124.R01.S.doc Version 5.0 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.V258124.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 2 and 4. Standard 6 is not applicable to this home. Staff individually and collectively have the skills and experience to deliver the care required by residents. EVIDENCE: The home has devised written contracts for residents and or their representatives to sign, these contracts were observed to be clear and easy to read and provide information such as the overall care and services within the home that are covered by the fees. Through observation of staff working with residents, observation of care plans and staff training documents, the home demonstrates that it meets the needs of the current residents. Discussions with staff confirmed a good understanding of the needs of the people accommodated. Newlyn Court DS0000017189.V258124.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8 and 9. Care plans and risk assessments were generally well written and provide staff with information to meet resident’s needs. To ensure that resident’s safety is not compromised risk assessments regarding the use of bed rails must be also be completed. The systems for the administration of medication are satisfactory which ensure resident’s medication needs are met. EVIDENCE: Four residents care files were examined in detail and contained a range of care plans that had been reviewed on regular basis. Each care plan was individualised and written in way that indicates that staff are aware of the residents needs. Risk assessments for moving and handling, pressure sore risk and nutrition were also present and reviewed regularly. Separate records are kept detailing personal hygiene care and these were noted to be up to date and corresponded with the care plan. To maintain consistency residents are allocated a designated key worker, however one visitor was not aware that their relative has a key worker Newlyn Court DS0000017189.V258124.R01.S.doc Version 5.0 Page 10 allocated to oversee care. The manager is advised to devise a system to ensure that individuals are made aware of the resident’s key worker. The resident’s GP visits on a regular basis and was observed to visit during the inspection to review the medical and health care needs of several residents. Further evidence contained on files demonstrates that residents mental health needs are kept under close review. In one care plan it was documented that the resident is at high risk of falling out of bed and although permission for the use of bed rails had been obtained from the resident’s representatives, a risk assessment had not been undertaken. During a tour of the premises several residents were observed to have bed rails in place but did not have documented risk assessments in place. This led to an immediate requirement notification being made for bed rail risk assessments to be completed for all residents assessed as needing bed rails. Discussion with the manager, observation of the treatment room and medication administration charts demonstrates that the home has acted on meeting most of the requirements made as a result of the CSCI pharmacist inspector visit in February 2005. The requirements not met are regarding monitoring the temperature of the treatment room, auditing of medication charts by the manager and amending the medication policy which the manager reports is in progress. On the day of this inspection the temperature of the treatment room was recorded at 27°C, which exceeds the required 25°C. A file within the nurse’s office provided confirmation that the manager had discussed issues raised by the pharmacist inspector with staff. Newlyn Court DS0000017189.V258124.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13 and 15. Daily routines are flexible with residents being offered a choice of varied activities. The home promotes an open visiting policy and residents are provided with well-balanced and wholesome meals. EVIDENCE: Discussions held and observations made evident that residents are provided with opportunities for stimulation through leisure and recreational activities in and outside of the home. The home employs an Activity Co-ordinator between 9am-4pm Monday to Friday. The Activity Co-ordinator has been in post for 2.5 years and discussions held with her indicate that she is very committed to her work. She discussed her role and responsibilities with the inspector and gave a demonstration of the sensory stimulation activities provided to the residents in the designated sensory room. The room is well equipped with a projector, soft lighting, bubble tubes, music and mood lights. The room is also used for residents wishing to listen to story tapes, watch films or listen to music. During the inspection female residents were offered nail manicures. Other activities provided include producing art & craft items to sell, reminiscence work, gardening, table top games (cards, dominoes etc) singing, hand massage, aromatherapy, foot-spa, painting and stencilling, music and movement. Newlyn Court DS0000017189.V258124.R01.S.doc Version 5.0 Page 12 A programme of external entertainment was seen displayed on notice boards and the home has photographs and numerous albums of the various trips out that people have accessed. These include shopping trips, visits to the safari park, pantomimes and trips to ‘The Albrighton Moat Project”. A trip to see the lights in Walsall has also been arranged. It was reported that the community library and church minister regularly visit the home and a hairdresser visits on a weekly basis. A ‘Friends of Newlyn Court’ group assist with activities, hold meetings and a newsletter is regularly published. Each resident has an activity diary, however the Activity Co-ordinator currently records entries on a retrospective basis once every three months. Discussions held with her indicate that she would prefer to record activities on a more regular basis but does not want this to compromise her time with residents. The manager is advised to devise a system so that resident’s attendance/nonattendance at activities can be recorded on at least a weekly basis. Although the home provides a good range of activities observations made during the inspection indicate residents could be provided with greater opportunities to engage in activities early in an afternoon, this could be explored further with the possibility of appointment of an assistant activity person and/or the care staff providing additional stimulating activities as required. The home operates an ‘open door policy’ and visitors are welcome to visit the home at all reasonable times. A number of relatives visited the home during the inspection and those spoken with were highly complementary regarding the service provided, level of care, staff, managers and the meals. Observations made evidence that staff have formed positive relationships with the residents and their visitors. Links with the local community are developed and well maintained. Residents are provided with a well balanced diet with any special dietary requirements catered for. The menus seen and meal served during the inspection looked appealing well presented. Good stocks of fresh fruit and vegetables were readily available, in addition to homemade cakes. Residents are offered three meals a day with drinks and snacks available and records are maintained of resident’s diet/fluid intake and their weight. The manager was advised to ensure that the residents are provided with a choice of drinks as people in the morning were presented with tea with no alternative offered or sugar provided. Staff were observed to be attentive, offering assistance with feeding as required. Visitors spoken with reported that their relatives are provided with very good meals. Newlyn Court DS0000017189.V258124.R01.S.doc Version 5.0 Page 13 Newlyn Court DS0000017189.V258124.R01.S.doc Version 5.0 Page 14 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16. The home does have a complaints procedure although further consideration is needed regarding the location of the procedure to ensure it is visible to all. EVIDENCE: The service user guide at reception contains a summary of the complaints procedure that meets the standard. However not all visitors spoken with during the inspection had a clear understanding of the homes complaints procedure and it was discussed with the manager that an additional copy made available on a notice board might address this. The complaints procedure that was available in the main office was observed not to meet the standard and this was pointed out to the manager for amendments to be made. The complaints log shows that the manager maintains an accurate log of any complaints or minor concerns received. CSCI has recently received three complaints, which includes two anonymous complaints. Two of the complaints detail concerns regarding the conduct of some staff, although this was not found to be the case during the inspection it was brought to the attention of the manager for investigation. Newlyn Court DS0000017189.V258124.R01.S.doc Version 5.0 Page 15 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 21, 22, 23, 24, 25 and 26. The standard of the environment is good providing residents with a comfortable place to live. Inappropriate use of bathrooms as storage means that service users do not have access to sufficient and suitable facilities. EVIDENCE: Newlyn Court is a purpose built property located in a residential area of Bilston, Wolverhampton. The home is generally well maintained and provides comfortable accommodation over two floors with passenger lifts to aid accessibility. Communal areas are spacious and are located on the ground floor within five lounges and separate dining areas. One of the lounges is a designated smoking area and there is also a separate room available for supervised sensory activities undertaken by the Activities Co-ordinator. Residents have access to all shared areas within the home. Furniture and furnishings throughout the home are generally of a good standard, domestic in style and Newlyn Court DS0000017189.V258124.R01.S.doc Version 5.0 Page 16 suitable to meet the needs of the individuals accommodated although a number of seat cushions in some of the lounges were seen to be missing. It was reported that en-suite facilities are provided in all but one of the bedrooms. The home provides five bathrooms and three shower rooms over two floors. One of these bathrooms is currently being used for the purpose of storing incontinence products, which has been previously agreed with the Commission and the fire officer. Numerous walking frames, wheelchairs and cushions were found stored in a further bathroom and a bathroom located on the ground floor was out of use due to a problem with the mixer taps; the maintenance person stated that the replacement parts were on order. One staff member reported that residents accommodated on the ground floor currently had to use the bathing facilities on the first floor, therefore bathrooms used for storage purposes appear to be having an impact on the provision of bathing facilities currently available to residents which is not acceptable. The home has limited provision for the storage of aids and equipment. A strong damp odour was detected in the shower rooms. There is no natural ventilation to these rooms and the current extractor fans require replacing with more effective fans sufficient to improve the atmosphere. The floor covering in the shower room on the ground floor was heavily soiled, the plasterwork requires attention and the toilet roll holder was found broken. Adaptations and disability equipment was seen around the home and two passenger lifts are provided to aid accessibility over the two floors. Grab rails, two hoists, assisted baths and call systems are also provided throughout. A requirement was made at the previous inspection for the carpet on the first floor corridor in the original part of the building to be replaced due to an offensive odour. Discussions held with the managers and the maintenance person evidenced that this carpet had not been replaced as it was considered that the offensive odour was due to a number of bedrooms leading off the corridor being the source of the problem and therefore the corridor carpet was cleaned and a number of bedroom carpets replaced. During a tour of the environment a strong offensive odour was detected on the same corridor and a number of bedrooms on the first floor. A mild odour was also present just past the reception area of the home. The managers and maintenance person confirmed that rooms are regularly steam cleaned in an attempt to eliminate odours. Although vinyl flooring and linoleum are not normally an acceptable equivalent to carpeting in resident’s rooms, where the needs of the resident indicate, equivalent flooring would be suitable. Once the room is vacated, it is the expectation that carpeting be provided/offered to the incoming resident. Screening is provided in double rooms. The bedrooms that were seen during an environmental tour of the home were generally well equipped and comfortably furnished and many were found personalised with the layout appropriate to individual needs. Some rooms Newlyn Court DS0000017189.V258124.R01.S.doc Version 5.0 Page 17 appeared ‘tired’ and in need of redecoration and not all rooms provide the furnishings as required by National Minimum Standard 24.2 (seating for two people, table to sit at etc) however, it had been previously agreed that where this requirement is not met arrangements for such provision are assessed, discussed and agreed with each residents, or an appropriate advocate (E.G. Friends of Newlyn Court), and documented. It was not assessed at this inspection whether limited height adjustable beds impacts on staff involved in the moving and handling residents. A requirement was made at the previous inspection for the extractor fan in the designated smoking lounge to be replaced to improve the atmosphere within the room. The findings of this inspection evidence that this requirement has been achieved. All bedrooms on the ground floor were found locked. It was reported that rooms are locked to ensure the residents do not enter into other peoples bedrooms during the day however if a resident wants to gain entry to their own room this would be enabled by a member of staff. A sign was seen on one bedroom door located on the first floor stating ‘please lock my door at night ’and a risk assessment was present in this persons care file to confirm this. The home communicates effectively with CSCI and the local infection control team during outbreaks of infectious illness and the manager also attends regular meetings with the local infection control team to keep up to date with current developments regarding infection control. The home has systems in place to spread the control of infection and all but one of the domestic staff spoken with had undertaken a training course in infection control. Laundry facilities are appropriately sited with hand washing facilities available and floor and wall finishes readily cleanable. The home provides three washers and three dryers. One of the dryers was found to be broken however it was stated that the parts had been ordered. It is recommended that COSHH data sheets be stored with the products to ensure that staff have the relevant information available on domestic trolleys. The home’s infection control policy and procedures were not reviewed on this occasion. The Environmental Health Officer has recently visited the home and it was reported that the home has complied with the two recommendations made. Following a visit by the fire service recently the Fire Officer requested that the home provide written confirmation that staff have received training in fire procedures, discussion with the manager and observation of documents confirmed that training has been undertaken but the manager has not yet provided this confirmation to the fire officer. Newlyn Court DS0000017189.V258124.R01.S.doc Version 5.0 Page 18 The grounds are well established and accessible to residents however some areas need attention. A programme of routine maintenance and renewal of the fabric and decoration of the premises was not available for inspection. Newlyn Court DS0000017189.V258124.R01.S.doc Version 5.0 Page 19 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 30. The home ensures that staff receive training that equips them with the skills to meet the needs of residents. EVIDENCE: The home provides an induction programme that meets the required level. Observation of training records demonstrates that staff receive training in core and specialist topics including dementia care, infection control and moving and handling. Staff spoke positively regarding training opportunities within the home. Newlyn Court DS0000017189.V258124.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32 and 38. The manager leads the staff team with confidence from which residents and their families benefit. The home has systems in place to protect residents from harm however by not adhering to current guidance regarding the safe use of bed rails the health, safety and welfare of residents is not fully promoted. EVIDENCE: Discussions with visitors to the home during the inspection were highly complementary regarding the service provided, level of care, staff and managers. Staff were observed to communicate effectively and appropriately with residents and visitors. Staff confirmed that they feel well supported by the manager and that good training opportunities exist within the home. Newlyn Court DS0000017189.V258124.R01.S.doc Version 5.0 Page 21 The maintenance person reported that he undertakes monthly checks on bedrooms, toilets, bathrooms, lighting, call bells and water temperatures and records examined confirmed this. During the tour of the premises the environment and equipment appeared well maintained, however a number of bed rails were found to be loose and not fitted in accordance with current guidance. One bed was found fitted with bed rails that did not match and not all beds fitted with overlay type pressure air mattresses had been fitted with the appropriate bed rails. The maintenance person is responsible for fitting bedrails however he appeared unaware of the correct fittings. Discussions were held with the maintenance person, the manager and home manager. An immediate requirement was served at the end of the inspection and the managers were required to take immediate action in order to safeguard residents. The use of bed rails can pose significant risks for people with dementia and although some risk assessments had been undertaken to support the safe use of bed rails, the assessments required further development based on guidelines provided by the Health and Safety Executive and the Medical Devices Agency 2001 guidance. The daily notes on a resident case tracked indicate that there was a ‘near miss’ incident with the resident and the use of bedrails, however the risk assessment for the safe use of these had not been reviewed or updated following this incident. Observation of the accident book demonstrates that it complies with current legislation however that manager was advised to ensure that staff complete entries in accordance with the guidance given within the book. Staff training records show that staff have received training in fire safety and other safe working practice topics, the manager acknowledged that the training file that provides an overview of training undertaken by staff needs some updating. Newlyn Court DS0000017189.V258124.R01.S.doc Version 5.0 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 3 X 3 X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 2 9 2 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 X 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 X 2 3 2 2 3 3 3 2 STAFFING Standard No Score 27 X 28 X 29 X 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X 3 X X X X X 2 Newlyn Court DS0000017189.V258124.R01.S.doc Version 5.0 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 OP8 Regulation 13 (4) (c) Requirement Risk assessments to support the safe use of bed rails must be developed based on guidelines provided by HSE and the Medical Device Agency (MHRA) and be regularly reviewed. The medication policies and procedures document must be updated and amended to include the issues identified by the pharmacist inspector (Previous date of the 31/05/05 not met). The Manager must regularly audit the medication to ensure the integrity of the MAR charts is maintained. (Compliance not met -previous immediate requirement) It must be ensured that all medication is stored in accordance with the manufacturers requirements i.e not above 25 °C (Previous date of 31/05/05 not met). The registered person must update and develop the homes complaints policy and procedure. (Slight amendment still requiredprevious date of 12/09/04 not DS0000017189.V258124.R01.S.doc Timescale for action Immediate 2 OP9 13 (2) 01/01/06 3 OP9 13 (2) 01/01/06 4 OP9 13 (2) 01/01/06 5 OP16 22(4) 01/01/06 Newlyn Court Version 5.0 Page 24 6 OP19 23 (4)(e) 7 OP19 23 (2)(d) 16 (2)(j) 8 9 OP21 OP21 23 (2)(j) 23(p) 10 OP21 12(1)(a)b 23 (2)(d) 11 12 OP22 OP26 23(l) 23 (2)(b) 13 (3) 13(4)(c) 13 OP38 met). The registered person must comply with the request of the Fire Officer to confirm to him in writing that fire safety training has been undertaken. A programme of routine maintenance and renewal of the fabric and decoration of the premises must be produced, implemented and records kept. Bathing facilities must be available and accessible to residents at all times. The current extractor fans in the shower rooms must be replaced with more effective fans sufficient to improve the atmosphere. The floor covering in the shower room on the ground floor must be cleaned/replaced, the plasterwork attended to and a new toilet roll holder and waste bins provided. The provision for storage of aids and equipment must be reviewed. All offensive odours as identified must be eliminated and the replacement of carpets included in the programme of renewal. Staff who are responsible for selecting, fitting and checking bed rails must receive appropriate training and bed rail assemblies should be included on a planned maintenance schedule. 01/12/05 01/02/06 01/01/06 01/02/06 01/01/06 01/01/06 01/01/06 01/12/05 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. Newlyn Court DS0000017189.V258124.R01.S.doc Version 5.0 Page 25 No. 1 2 3 4 5 6 7 Refer to Standard OP7 OP12 OP12 OP15 OP16 OP26 OP38 Good Practice Recommendations The manager is advised to inform relatives that residents are allocated an individual key worker. It is recommended that an assistant Activity Co-ordinator be provided. It is recommended that activities undertaken by residents be documented at least weekly. It is recommended that an alternative choice of drinks be provided to residents at all times. The home is advised to consider alternative places for location of the complaints procedure. It is recommended that COSHH data sheets be stored with the products to ensure that staff have the relevant information available on domestic trolleys. The manager is advised to ensure that staff complete entries in accordance with the guidance in the accident book. Newlyn Court DS0000017189.V258124.R01.S.doc Version 5.0 Page 26 Commission for Social Care Inspection Wolverhampton Area Office 2nd Floor St. Davids Court Union Street Wolverhampton WV1 3JE National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Newlyn Court DS0000017189.V258124.R01.S.doc Version 5.0 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. 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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