CARE HOMES FOR OLDER PEOPLE
Newlyn Court Merstone Close Bilston Wolverhampton West Midlands WV14 OLR Lead Inspector
Mike Moloney Unannounced Inspection 6th March 2006 10:30 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.V285812.R01.S.doc Version 5.1 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.V285812.R01.S.doc Version 5.1 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.V285812.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION
Conditions of registration: 1. 2. From age 55 years No number division between categories Date of last inspection 4th October 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.V285812.R01.S.doc Version 5.1 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This inspection was unannounced and took place over three hours during the late morning and early afternoon. Information was gained from documentation made available by the home, by discussions with the proprietor, the manager, the staff, visitors and service users as well as by looking around the building. Inspection work undertaken by CSCI is proportionate in relation to how a home has performed in the past. As this home has a history of providing a good service for people this inspection was brief and focused only on a small number of “key” areas of work. What the service does well: What has improved since the last inspection?
Since the last inspection a risk assessment and maintenance programme has been put into place specifically around the use of bedrails so as to improve the safety of those service users who need to use them. A general maintenance and improvement programme has also been drawn up and this includes such things as redecorating and re-carpeting various areas to maintain and improve the environment within the home. Progress has been made on the outstanding issues relating to the storage and handling of the service users medication and most have been dealt with. Some of the clutter that has made it necessary to stop using one of the bathrooms has been removed and the proprietor has plans to complete this task in the near future but, unfortunately, until that task is complete that particular bathroom will not be available for the use as such. However, the floors in the bathrooms have benefited from the use of a new floor cleaning machine but unfortunately it has not been so successful with the carpets which still give of offensive odours in some parts of the home.
Newlyn Court DS0000017189.V285812.R01.S.doc Version 5.1 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.V285812.R01.S.doc Version 5.1 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.V285812.R01.S.doc Version 5.1 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): 3 Residents are only admitted after the home has assessed that it can meet their needs. EVIDENCE: The records of a number of new residents were looked at and these were seen to contain all of the information that is required to make up a full care plan from them. Talking with the manager established that she visits prospective residents as part of the admissions procedure so as to ensure their compatibility with the other people living at the home. Newlyn Court DS0000017189.V285812.R01.S.doc Version 5.1 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): 8, 9 and 10 The health care needs of the service users are met in a manner that respects their privacy and dignity. EVIDENCE: This section must be read in conjunction with the report of the visit on 4th October 2006. A number of the residents records contained risk assessments for the use of bed rails for those individuals. Talking with the registered manager and the proprietor confirmed these were carried out by the proprietor and that he has received training on how to do so. The home has a medication room that is fully equipped with secure storage for the medication held and administered by the home. The refrigerator used to store the medications was found to be equipped with an appropriate type of thermometer. Readings of the internal temperature were kept ensuring that those medications that must be kept cool are stored appropriately. A range of other records were seen relating to the issue and disposal of medication and these were seen to be accurately maintained. The home are still investigating ways in which they can maintain the temperature of the room in general at an acceptable level.
Newlyn Court DS0000017189.V285812.R01.S.doc Version 5.1 Page 10 A range of policies and procedures relating to the maintenance of the privacy and dignity of the service users were seen to be available in the staff office and care staff were observed treating the service users in a polite, friendly and dignified manner. Newlyn Court DS0000017189.V285812.R01.S.doc Version 5.1 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): 14 Service users are helped to exercise choice and control over their lives. EVIDENCE: Talking with a number of relatives of residents and reading the visitors book showed that the service users are able to receive visitors on a regular basis. The home does help the residents to access cash and auditable records are kept of their involvement. The home also has a policy which encourages residents to bring personal possessions with them when they move in. Newlyn Court DS0000017189.V285812.R01.S.doc Version 5.1 Page 12 Complaints and Protection
The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 The home has appropriate policies and procedures for the protection of the vulnerable adults who live there. EVIDENCE: The home has a complaints procedure that contains all of the elements required by law although the records showed and the manager confirmed that no complaints had been received since the last inspection. Talking with the manager also established that she has a good working knowledge of the local policies and procedures for the protection of vulnerable adults. Newlyn Court DS0000017189.V285812.R01.S.doc Version 5.1 Page 13 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, 21, 22 and 26 Although this home is large it has a homely feel to it with a variety of facilities being available to the service users. Work towards making appropriate storage for the equipment has started as have the efforts towards combating the offensive odours that have been observed in the past. EVIDENCE: This section should be read in conjunction with the report of the visit carried out on 4th October 2005. The proprietor has now produced a maintenance schedule that out-lines the major work that is planned for the building. He is considering installing further storage for wheelchairs and walking frames, some of which are still being stored in one of the bathrooms. Progress has clearly been made on this issue but it is still a problem. The floors in the bathrooms and shower rooms were all seen to be in good and clean condition and the manager confirmed that a steam cleaner is now used on a regular basis on these and other floors. However, the cleaner has been less successful on the carpeted areas with
Newlyn Court DS0000017189.V285812.R01.S.doc Version 5.1 Page 14 there being some unpleasant odours in some parts of the home although some of the visitors reported that there had been some improvement on this issue. The extractor fans in the shower rooms were found to be working effectively. Newlyn Court DS0000017189.V285812.R01.S.doc Version 5.1 Page 15 Staffing
The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28 and 29 Appropriate numbers of staff are employed at the home and, although the training programme has yet to meet the NVQ target set out in the National Minimum Standards, the training programme, alongside a robust recruitment process ensures that the service users needs are being met by a competent and caring staff team. EVIDENCE: Observation on the day, talking with service users’ relatives and looking at the rotas and other records established that staff are deployed in appropriate numbers to meet the needs of the people currently living at the home. Although the home has yet to achieve the target of 50 of the care staff obtaining NVQ2 or above there is an assessment process in place designed to ensure that this will happen in the near future. Looking at the personnel records of some of the recently recruited staff established that the appropriate pre-employment checks had been made on them and that records of the interview process were being kept. All of the necessary records were found to be in place except for the clear and recent photographs of the individual employees that are required as part of the checking of their identity. Newlyn Court DS0000017189.V285812.R01.S.doc Version 5.1 Page 16 Management and Administration
The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33 and 35 The home has a qualified manager who is supported by an experienced management team who endeavour to safeguard the service users physically, socially as well as financially. EVIDENCE: During discussions with the manager she confirmed that she is a qualified nurse who has also completed the Registered Managers Award and these are the qualifications that are required under the National Minimum Standards for someone who is running an establishment such as this. She is ably supported by a staff team that includes administrative staff who were able to show how the service users are supported by the home to maintain their personal cash with carefully kept records.
Newlyn Court DS0000017189.V285812.R01.S.doc Version 5.1 Page 17 The manager also confirmed that the proprietor works within the home on a daily basis therefore he does not have to ensure that monthly inspections of the home are carried out as outlined within the Care Homes Regulations 2001. She also stated that the home has a relatives group that meets on a monthly basis which helps to provide feedback to the management about the views of the residents and their families. Newlyn Court DS0000017189.V285812.R01.S.doc Version 5.1 Page 18 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 x HEALTH AND PERSONAL CARE Standard No Score 7 x 8 3 9 2 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 x 13 x 14 3 15 x COMPLAINTS AND PROTECTION Standard No Score 16 3 17 x 18 3 3 x 2 2 x x x 2 STAFFING Standard No Score 27 3 28 2 29 2 30 x MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 x 3 x 3 x x x Newlyn Court DS0000017189.V285812.R01.S.doc Version 5.1 Page 19 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 OP9 Regulation 13 (2) 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). 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. Timescale for action 01/01/06 2. OP21 23 (2)(j) 01/01/06 3. OP22 23(l) 01/01/06 4. 5 6 OP26 OP28 OP29 23 (2)(b)13 (3) 18(1)a 17(2) 01/01/06 50 of the care staff must 30/09/06 achieve NVQ2 or above Clear and recent photographs of 30/06/06 individual staff must be kept with their employment records. Newlyn Court DS0000017189.V285812.R01.S.doc Version 5.1 Page 20 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.V285812.R01.S.doc Version 5.1 Page 21 Commission for Social Care Inspection Shrewsbury Local Office 1st Floor, Chapter House South Abbey Lawn Abbey Foregate SHREWSBURY SY2 5DE National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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