Inspection on 10/11/06 for Newstead House

This inspection was carried out on 10th November 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. These are things the inspector asked to be changed, but found they had not done. The inspector also made 8 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Newstead House 26/01/06

Newstead House 05/10/05

Newstead House 15/03/05

Newstead House 22/04/04

Similar services:

Ashlong House

Norbury Crescent (30)

Henry Nihill House

Birchwood

Edenvale

Wadham Avenue

Chatsworth Care - Dawson House

The Infirmary

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

CARE HOME ADULTS 18-65 Newstead House Trooper Drive Harold Hill Romford Essex RM3 9DE Lead Inspector Diane Roberts Key Unannounced Inspection 10th November 2006 09:00 Newstead House DS0000027866.V318783.R01.S.doc Version 5.2 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 Newstead House DS0000027866.V318783.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 Adults 18-65. 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. Newstead House DS0000027866.V318783.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Newstead House Address Trooper Drive Harold Hill Romford Essex RM3 9DE 01708 381363 01708 381 347 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) Servite Houses Mr Michael Davies Care Home 34 Category(ies) of Learning disability (28), Old age, not falling registration, with number within any other category (1), Physical disability of places (2) Newstead House DS0000027866.V318783.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 8th August 2006 Brief Description of the Service: Newstead House is a large purpose build home owned by Servite Houses which is a not for profit organisation. The home was originally predominately caring for older people however during the past few years this has changed to adults with learning disabilities. The building is large but attention to furnishings has made the interior a less institutional and more homely environment. Having been built with older people in mind it is fully wheelchair accessible. From discussion with staff, service users and management it would appear that the service has experienced major changes during the past five years with the focus now being much more geared to younger adults and a more user led model of care. The home has a statement of purpose and service user guide available to prospective residents before admission to the home. The home currently charges £530.20 per week. Additional charges are made for chiropody, hairdressing, newspapers, private car hire, cinema etc. Amounts may vary depending on resident choice and ability. Newstead House DS0000027866.V318783.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection took place over six and a half hours and was carried out as part of the annual inspection programme for this home. The registered manager was available throughout the inspection. The inspection focused upon all of the key standards. A partial tour of the premises was undertaken. Evidence was also taken from the Pre Inspection Questionnaire completed by the home and submitted to the CSCI. The home now comes under Servite’s - Supporting People section. The home is not ‘supporting people’ in the short term as they still view themselves as a care home. However, they are clearly trying to optimise the skills the people have that live in the home and maximise any potential. If it would be possible to help someone move to supported living accommodation, with a care package, then they would work towards this with the resident. At the current time they are concentrating on getting the individual units to self cater to move away from the care home approach. Three residents and four staff were spoken to during the inspection and ten relatives completed feedback sheets. All these comments were taken into account when writing the report. Identified in the agenda are three items that are repeated from the last report. These items must be attended to, as non-compliance will result in the CSCI giving consideration to legal action. What the service does well: What has improved since the last inspection? Since the last inspection improvements have been made with regard to the storage of medications. Reporting of incidents and accidents to the CSCI has improved. Newstead House DS0000027866.V318783.R01.S.doc Version 5.2 Page 6 Risk assessments in the care plans have been put in place and the new care planning system is developing well. What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Newstead House DS0000027866.V318783.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Newstead House DS0000027866.V318783.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1 and 2. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Prospective residents have good information about the home in order to make an informed choice. All residents are fully assessed prior to admission, to ensure that their needs will be met. EVIDENCE: The home has a statement of purpose and service users guide in place. These have not been updated since the last inspection. On inspection these documents meet the required standards and are appropriate to the resident group. Minor updates are needed to the statement of purpose in relation to change of personnel. The home has not had any new admissions for approximately 2 years. An assessment procedure is in place and it was possible to review an assessment completed in 2006 for a potential resident who ultimately did not come to the home. A daily living and needs assessment form is completed and this is linked to the new care planning system. This covers personal care and gives detail on the abilities and strengths of the individual. Newstead House DS0000027866.V318783.R01.S.doc Version 5.2 Page 9 Communication is recorded in detail and mobility and personal safety/ risk assessment are also assessed. Behavioural issues are assessed and there is mental health section, which also shows input from the Community Learning Disability Team. The assessment tool is comprehensive and covers all the required subject areas. The assessment seen was completed well and was supplemented by care management documents from the referring social services department. Newstead House DS0000027866.V318783.R01.S.doc Version 5.2 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 and 9. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home has a good care planning system in place that is developing positively. Residents are assisted to make decisions about their lives, as they are able. Residents are supported to take risks as part of their independent lifestyle. EVIDENCE: The manager has introduced a new care planning system into the home and approximately 70 of residents are on the new records. Care plans were reviewed from residents with differing levels of dependency. The care plans were seen to be person centred and gave a good level of information on the individual, their personal choices and abilities. Objectives were in place with regard to the care input planned. Newstead House DS0000027866.V318783.R01.S.doc Version 5.2 Page 11 There was some evidence of resident involvement and this was good, as it related to personal choice and rights. Resident involvement was not seen to extend to actual input to the full care planning process and whilst this can be difficult to evidence, it is felt that the home could work on this area more. Care plans were seen to be comprehensive and outlined resident’s social, mental health, physical needs and objectives. Records showed that these are generally kept under review. A care plan/goal monitoring form is in place and these were seen to contain valuable and objective information. Records, within the care planning system, evidence that residents are able to make decisions regarding their lives. This was seen to include, for example, choices on how they spend their time and if they wish to be alone. Care plans contained a good level of information on residents’ personal preferences and are written with the resident’s rights and choices in mind. From records and discussion, residents are encouraged, as their abilities allow, to make their own decisions – this is also supported by a good advocacy service that works within the home. This service visits the residents at the home weekly, independent from the management of the home. Records from these working groups were seen, which showed that they cover a range of subjects including the change of focus of the home, legal rights and choices. They also encourage residents to give their views on the home. From discussion with residents, they confirmed that they have choice with regard to how they spent their time both in and out of the home and in relation to their living spaces. The company acts, as appointee for 11 residents where there is limited family support. Two residents are able to manage their own finances. Where the management team on behalf of residents holds monies, records were checked and found to be in good order. Two people sign for transactions and receipts are available. An interest making service user account is held by head office and interest is assigned to each resident as appropriate and the home receives statements of this. As part of the care planning system, risk assessments are in place and cover a wide range of subjects. It is clear that residents are able to undertake community and home activities that contain a level of risk and that may help them achieve greater levels of independence. Management systems were seen to be in place that would reduce the risk. Accessing the community risk assessment were seen to be in place and were appropriate for the individual. Any restrictions were explained in detail and reviews were evident. Newstead House DS0000027866.V318783.R01.S.doc Version 5.2 Page 12 Newstead House DS0000027866.V318783.R01.S.doc Version 5.2 Page 13 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15, 16 and 17. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are able to take part in age, peer and culturally appropriate activities. Residents take part in the local community. Residents have appropriate personal relationships. Residents are respected by staff. Residents receive a varied diet and mealtimes. EVIDENCE: Records evidence that residents at the home are taking part in a wide range of social activities. Care plans detail residents preferences with regard to Newstead House DS0000027866.V318783.R01.S.doc Version 5.2 Page 14 social activities and in some cases the residents themselves have outlined what they enjoy doing. Residents have taken holidays abroad with either family members or local churches and organisations. The advocacy group who visits residents at the home encourages them to support registered charities, hold fund raising events and visit the projects abroad that they are supporting. From records it is clear that staff at the home are willing, in their own time, to escort residents on trips out and on weekends away. A few residents are able to attend college and undertake courses in numeracy, computer skills and literacy. One resident has just completed a horticulture related course via a local trust. Residents enjoy eating out, going for weekends away, shopping, the cinema and recently some went to the West End to see a musical and hired a stretch limousine. Records show that activities are both group and individual, often with the support of a key worker. Activities also include the development of skills in relation to daily living tasks in the home setting. Residents spoken to were happy to discuss social events in the home and what they enjoyed doing during the day. Relationships with families and friends are encouraged and individual care plans outline the resident’s key relationship. Relatives who commented felt very welcomed into the home and that they had privacy with their relative should they so wish. Residents are encouraged and supported to have keys to their rooms and take responsibility for their belongings therein. Many of the residents take part in housekeeping in relation to their rooms and laundry etc. Post is delivered unopened to each unit and the staff help the individual resident with their post, as they are able. Social drinking is accepted at the home and would be available at parties and events, such as watching football matches etc. Residents spoken to say that they liked living at the home and could choose what they wanted to do during the day. From observation during the day, residents were seen making choices about where they spent their time. Interaction between residents and staff was seen and heard to be friendly and respectful. The home is split into five units and residents tend to take meals either within their unit, with friends in other units or out in the community. When events take place, the large communal lounge may be used. At the current time the main kitchen prepare the meals and delivers them on a hot trolley to each unit. The manager is trying to work away from this and make each unit independent, catering for themselves. No specialist diets are currently being catered for in the home and residents give feedback on the food provided and their wishes at residents meetings, the minutes of which were available for inspection. Residents spoken to, and from records, are positive about the food but also enjoy eating out, which many do on a regular Newstead House DS0000027866.V318783.R01.S.doc Version 5.2 Page 15 basis. It was observed that mealtimes are flexible and allow for residents to go out of the home and come back and have a late lunch. Unit 5 is currently self-catering and alterations have been made to the kitchen area to accommodate this. Residents from the units are also spending time in small groups in the homes larger practice kitchen with a key member of staff to develop their skills in this area. Development of skills also includes shopping for food items. Residents on the units have varying levels of ability and this is reflected in the development work they are undertaking at the current time and in risk assessments on individual’s care plans. The management team at the home are trying to give residents more choice and autonomy with this approach and hope that all of the units will be selfcatering by the end of the financial year. When reviewing care plans there was a good level of detail on food preferences and any dietary needs, for example in relation to weight loss. It was unfortunate to note that weight monitoring was seen to be inconsistent and this was discussed with the manager. Newstead House DS0000027866.V318783.R01.S.doc Version 5.2 Page 16 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 and 20. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents receive personal care and support in a sensitive and respectful way. Resident’s physical and emotional health needs are met. The home has satisfactory systems in place for the safe handling of medicines. EVIDENCE: From discussion, observation and records, it is clear that residents have choice regarding their care in relation to personal hygiene and routines of the day. Where able, some residents have expressed preferences in their own care plans. Records show that residents have access to all the standard healthcare services and visit the local GP surgery as appropriate. Records also show that where required, specialist referrals have been made and that the home has links with the local Community Learning Disability Team. Newstead House DS0000027866.V318783.R01.S.doc Version 5.2 Page 17 Care plans outline care needs in relation to both physical and emotional wellbeing and detailed records are in place, which give a good overview of the current situation and the level of staff input required. The home now has a dedicated room for the storage of medication and the temperatures were within the required zone. Records show that the fridge temperatures are monitored daily. The home has reference books and resources on medications. The home uses an MDS system via a local chemist. Records of checking in medication and returns are in place. MAR sheets on the unit were checked and found to be in good order. Some residents in the home self medicate and systems are in place to monitor this in relation to resident need. An individual approach is used. Medication reviews are carried out either with specialist teams or with the general practitioner. Staff often prompt reviews via specialist staff. Medication seen on the units checked was minimal. At the current time, records submitted show that six staff have received training in this subject, which, from records, show that there is a small shortfall in those who require training. Records submitted show that further training is planned for 2006/2007, so this should have been addressed by the end of March 2007. Newstead House DS0000027866.V318783.R01.S.doc Version 5.2 Page 18 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home has systems in place, which ensure that residents’ views are listened to and acted upon. The home has systems in place, which help to ensure to ensure that residents are protected from abuse but these are not supported by staff training. EVIDENCE: The home has a clear and appropriate complaints procedure in place. The manager records all level of complaints, which is good practice. Many of the 16 complaints recorded over the last year are minor and from records show they were addressed quickly. Whilst the manager has a system for recording complaints, this was discussed, as evidence for the outcomes and the closing out date was not always available. It should also be recorded if a letter has been sent and a copy made available. From records and minutes of residents meetings, there are plenty of forums whereby residents can raise their views and discuss any concerns as well as on an individual basis. Not all relatives who commented were aware of the complaints procedure for the home or how to access the last CSCI inspection report. The home has an up to date policy and procedures in place for the protection of vulnerable adults. This includes local Havering guidance. There have been no recent incidents. Staff training records show a significant shortfall with Newstead House DS0000027866.V318783.R01.S.doc Version 5.2 Page 19 regard to staff training on this subject, although a session is planned before the end of March 2007. Records show that only 3 staff at the home has up to date training on this subject. This needs to be addressed. Newstead House DS0000027866.V318783.R01.S.doc Version 5.2 Page 20 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24 and 30. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents live in a comfortable, homely environment although some areas do need work. The home is clean. EVIDENCE: A partial tour of the building was undertaken. Where there was agreement, the inspector was able to see residents’ rooms. The home is split up into five units. Each has a small kitchen area, lounge, bathroom etc. and in addition to this there is a large communal area and practice kitchen. There is a homely atmosphere and units are individually decorated with input from residents with regard to choice of colour and furniture. Residents spoken to confirmed this. It was noted that 2 carpets need replacement in the lounge dining areas of 2 units and this should be completed as a priority. The home does have a Newstead House DS0000027866.V318783.R01.S.doc Version 5.2 Page 21 carpet cleaner but the carpets are in a poor state. The décor throughout the home was generally satisfactory, although some areas are marked and worn and possibly due for redecoration during 2007. Records show that residents stated in May 2006 that they felt that some of the lounges needed redecoration. General maintenance throughout the home was seen to be good. The home has a maintenance man who works 18.5 hours a week and in the summer does the garden as well. The home has a large rear garden with a patio and this is mainly laid to lawn with a shrub border and some small trees. It is nicely enclosed and affords the residents some privacy. The home was seen to be clean and no odours were noted. The home has a fire safety risk assessment in place. Maintenance certificates were seen for the fire alarm, emergency lighting and fire extinguishers. The fire risk assessment states that staff will be trained in fire safety every six months. Staff training records show that this is not being achieved with the last training being offered in 2005, so no staff have up to date fire safety training. This must be addressed. Newstead House DS0000027866.V318783.R01.S.doc Version 5.2 Page 22 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34 and 35. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Staff in the home are competent but statutory training needs to improve. The home needs to improve its staff files in order to evidence that they have a robust recruitment procedure that protects residents. Staff are appropriately supervised. EVIDENCE: From the records submitted, the home has a stable staff team and uses their own bank staff to supplement shifts. The home is not using any agency staff at the current time. The home has 75 of its care staff qualified to NVQ level 2 and above and records submitted state that more staff are signed up to this qualification. In addition to this the majority of the staff have attended training in learning disabilities and mental health in 2006 and 14 staff have completed LDAF training. Training on Autism is planned in the near future. The manager has completed the Registered Managers Award. Newstead House DS0000027866.V318783.R01.S.doc Version 5.2 Page 23 Training records show that there are shortfalls in relation to statutory training and the manager needs to address this, especially with a stable staff team. Only 4 staff have a first aid certificate to cover the home. More training is planned. Shortfalls relate to fire safety, manual handling, food hygiene and POVA. Lack of attention to this part of the staff training can affect competency at the home. A staff induction programme is in place and staff confirmed completion of a 4-week induction. At the current time the induction is not linked to Skills for Care and the management team should consider this. Records in relation to the completion of induction programmes were seen to be inconsistent on staff files whilst others held good evidence of the full induction and probationary period. The home has recruitment polices and procedures in place. Three staff files were checked at random. At times the home is waiting for application documents to be sent from head office and therefore the required documents are not available. A file checklist system may help in addressing any delays that may occur and ensure documents are available for inspection. Two files did not contain CRB’s because of this and only evidence was subsequently supplied for one person after the inspection day. One file did not have an application form and interview records were not available. References were seen to be in place along with identification papers. One file did not show the current immigration status of the person and whether they were actually allowed to work in the United Kingdom. This must be addressed. The home needs to tighten up on its staff files in order to evidence that they do have robust recruitment procedures. This was also shortfall noted at the last inspection. Staff files were inspected in relation to staff supervision and good records were seen to show that this takes place on a regular basis. Staff spoken to felt well supported in the home and felt that the management team were approachable. Staff spoken to were keen to complete training offered and felt that the approach to residents was positive and optimised their abilities and gave them choice. Staff said they enjoyed doing NVQ training as this enhanced the work they were doing. Newstead House DS0000027866.V318783.R01.S.doc Version 5.2 Page 24 Newstead House DS0000027866.V318783.R01.S.doc Version 5.2 Page 25 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. 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 are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 and 42. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The management of the home is stable. The quality assurance systems in the home need to be developed further. Whilst the health and safety or residents and staff is promoted, shortfalls were noted which need addressing. EVIDENCE: The manager has worked at the home for many years and has the registered managers award. Staff speak positively of him and think that the management of the home is generally good. Records show that he has undertaken periodic training. Newstead House DS0000027866.V318783.R01.S.doc Version 5.2 Page 26 The home has used a Laing and Busisson quality survey in the past, which was last completed in 2005. The home also uses the People First advocacy service as well, which seeks the views of residents in the home on the services they receive, records of this are a little limited and do not cover all aspects of the home. Minutes of residents meetings also give good feedback from residents but there is not collation of responses or action plans put in place. The manager needs to develop the homes internal quality assurance systems and formulate a more formal way of recording and analysing feedback or results. From discussion with the manager, there is a reliance on feedback from the CSCI comment cards as part of the homes quality assurance programme. This demonstrates that there needs to be a more proactive approach. Relatives who commented felt that their family members were happy and settled at the home. The also felt that the standards of care were good and that the staff were nice and helpful. The home has a health and safety policy and associated procedures in place. Every weekend each unit has a health and safety check and records of this were available for inspection. This is seen to be a good system and identifies any work to be carried out and the manager or deputy follow this up. References have been made to the statutory training of staff in previous sections. Food hygiene training needs to be provided to more staff as the home moves over towards independent catering on each unit. A sample of maintenance/safety certificates were inspected. It was noted that the home does not have an up to date safety certificate for the electrical wiring of the home and in addition to this Portable Appliance Testing has also not been carried out. It was also noted that the gas safety certificate for the home was also out of date. These were highlighted to the manager. Newstead House DS0000027866.V318783.R01.S.doc Version 5.2 Page 27 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 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 3 2 3 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 2 23 2 ENVIRONMENT Standard No Score 24 2 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 2 33 X 34 2 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 x 3 X 2 X X 2 X Newstead House DS0000027866.V318783.R01.S.doc Version 5.2 Page 28 yes Are there any outstanding requirements from the last inspection? 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 YA6 Regulation 15 Requirement The registered person must, where possible, involve the resident in the care planning process and keep all care plans under review. The registered person must promote the health and wellbeing of residents in relation to weight monitoring. The home must ensure that when complaints have been investigated, the outcomes are recorded and that all the information relating to the complaint is available. This is partially a repeat requirement. The registered person must ensure that all parts of the home are kept in a good state of repair and decoration. In relation to décor and carpet replacement. The registered person must have evidence of adequate checks, for staff working at the home – in relation to CRB’s, immigration status etc. This is a second repeat requirement and must be addressed. The staff must receive adequate DS0000027866.V318783.R01.S.doc Timescale for action 31/01/07 2. YA17 12 91) 31/01/07 3. YA22 22 31/01/07 4. YA24 23 31/01/07 5. YA34 18,19 31/01/07 6. YA35 18 and 31/01/07 Page 29 Newstead House Version 5.2 23. 7. YA39 24 and 35 8. YA42 13 and 23 training to be competent and confident to carry out the tasks expected of them. This relates to all statutory training, including adult protection. This is a repeat requirement. The registered person must further develop the quality assurance programme for the home. The registered person must ensure the health and safety of residents. This relates to safety certification for the electrical wiring of the home, portable appliance testing and gas safety. Manager advised on the day of the inspection. 31/01/07 31/12/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. 3 Refer to Standard YA32 YA34 YA34 Good Practice Recommendations The registered person should consider the staff induction programme being linked to Skills for Care. The registered person should give consideration to using a checklist system, in order to improve staff files. The registered person should maintain interview records and show that they have explored and gaps in employment. Newstead House DS0000027866.V318783.R01.S.doc Version 5.2 Page 30 Commission for Social Care Inspection Ilford Area Office Ferguson House 113 Cranbrook Road Ilford IG1 4PU 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 Newstead House DS0000027866.V318783.R01.S.doc Version 5.2 Page 31 - 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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