Inspection on 08/09/07 for New Court Place

This inspection was carried out on 8th September 2007.

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 no outstanding requirements from the previous inspection report, but made 7 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

New Court Place 28/07/09

New Court Place 05/08/08

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

CARE HOME ADULTS 18-65 New Court Place 99 Whitehouse Avenue Borehamwood Hertfordshire WD6 1HB Lead Inspector Claire Farrier Unannounced Inspection 8 & 10 September 2007 10:45 th th New Court Place DS0000070238.V350752.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 New Court Place DS0000070238.V350752.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. New Court Place DS0000070238.V350752.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service New Court Place Address 99 Whitehouse Avenue Borehamwood Hertfordshire WD6 1HB 020 8238 6990 020 8238 6991 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) www.grooms-shaftesbury.org.uk Grooms-Shaftesbury Manager post vacant Care Home 24 Category(ies) of Physical disability (24) registration, with number of places New Court Place DS0000070238.V350752.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. This home may accommodate 24 people with a physical disability who require nursing care. This home may accommodate 12 people with a physical disability who require personal care. 29th July and 9th August 2006 Date of last inspection Brief Description of the Service: New Court Place is a care home with nursing, providing accommodation and care for 24 adults between the ages of 18 and 65 years of age who have physical disabilities. It is owned by Grooms-Shaftesbury, which is a voluntary organisation. New Court Place is a three storey purpose built building. It is located in a quiet residential area of Borehamwood, about a quarter of a mile from the town. The home has been built and fitted out to high specifications that exceed those required by National Minimum Standards. The accommodation is arranged in three units on the ground and first floor that are designed to resemble an indoor street, and each resident has a large self-contained studio, with a kitchenette and ensuite shower room. The home has a patio garden accessed from the ground floor dining room. The home is fully accessible for the people who live there. The Statement of Purpose and Service Users Guide provide information about the home for referring professionals and prospective clients. Information on the fees charged was not available on this occasion. New Court Place DS0000070238.V350752.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. We spent one day at New Court Place, and the people who live there and work there did not know that we were coming. The focus of the inspection was to assess all the key standards. Some additional standards were also assessed. We talked to as many of the people who live in the home as we were able to. We also talked to some of the staff. When we were in the home we looked at the records, care plans and staff files, and we made a tour of the premises. We made a second visit to the home a few days later so that we could talk to the manager about what we had seen during the inspection. John Grooms has merged with Shaftesbury to create a new company, GroomsShaftesbury. This was the first inspection since the new company has managed the home. What the service does well: What has improved since the last inspection? Due to an administrative error the last inspection report was not sent to the home, and the home did not have the opportunity of addressing the requirements made in that report. The manager has ensured that training records and staff records are up to date. The care plans are now fully computerised, and the people who we spoke to said that they were fully involved in writing their care plans. New Court Place DS0000070238.V350752.R01.S.doc Version 5.2 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. The summary of this inspection report can be made available in other formats on request. New Court Place DS0000070238.V350752.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 New Court Place DS0000070238.V350752.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): 2 and 3 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The assessment and admission procedure provides good information for the staff so that they can meet the needs of the people who live in the home. EVIDENCE: The care plans and assessments are stored and maintained on computer. The computer records and paper files of two residents were seen. All contained good information, so that the staff are able to provide a good quality of care and meet each person’s needs. Comprehensive assessments are carried out before each person is admitted to the home, and the care plans are written to address their assessed needs (see Individual Needs and Choices). All the residents who were spoken to said that the staff are competent to meet their needs. One person said that she is treated very well here, and the staff know what she likes, for example her own routine when she goes to bed at night. The home has a stable staff team with access to appropriate training. The staff spoken to confirmed that they have sufficient information from the care plans and from training, to meet the needs of the people who live in the home. New Court Place DS0000070238.V350752.R01.S.doc Version 5.2 Page 9 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, 8 and 9 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The care plans are person centred and provide the staff with appropriate information to enable them to meet people’s individual needs. EVIDENCE: The care plans are maintained by computer, and the care staff and nursing staff are able to add the details of the care provided each day and to update them as required. We looked at the care plans of two people, and the evidence of care provided for them was tracked through their records. The care plans provide sufficient information on all aspects of each person’s care to enable the staff to meet their needs. They are arranged in modules, for example for personal care, behaviour, eating and drinking. Each module has details of the activity, any problem, the caring goal, and the actions needed. Everyone has a moving and handling assessment. There are appropriate risk assessments that provide procedures and safeguards to enable people to take part in the choice of activities safely. New Court Place DS0000070238.V350752.R01.S.doc Version 5.2 Page 10 As the care plans are computerised the residents do not have easy access to them. It was reported that the staff try to go through each person’s care plan with them, but most people find it difficult. However we spoke to one person who had recently moved into the home. This person said that they were involved in writing their care plan. Another person said that they can see their care plan when they want to, and they were involved in writing it. Following a recent strategy meeting, Hertfordshire Adult Care Services reviewed the care of two people whom they fund. Both people expressed a high level of satisfaction with the care. But there were also comments by one person that the staff did take for granted her level of independence and choice over the way her care could be managed. The residents spoken to said that regular residents meetings take place, and they are involved in decision making. The manager has asked their views about the format of the residents meetings. In the last inspection report it was reported that contact had been established with an advocacy organisation and an introductory visit was planned. There is no evidence that this has happened, and there is no information available to residents concerning independent advocacy. The manager is establishing a clear role for key working, with the emphasis on the key worker being the voice of the individual; and most residents have involved families. However there may be situations where individual residents may benefit from an independent advocate, and this service is currently not available to them. New Court Place DS0000070238.V350752.R01.S.doc Version 5.2 Page 11 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, 14, 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. The people who live in the home are supported to live full and active lifestyles. EVIDENCE: The activity room is well resourced with equipment, computers and Internet links. There is a planned programme of activities, which supports the educational and leisure interests of service users. Activities are organised across the seven-day week. The activities schedules include college courses, IT, pony trapping, wheelchair dancing, crafts and music. Several residents used the computers for Internet access and playing games during the inspection. During the morning of this inspection a group of people took part in a karaoke session. New Court Place has it’s own wheelchair accessible transport to take individual service users or groups to events. However it was reported that the activities organiser frequently uses the transport to take individual residents for hospital appointments, which takes resources and time away from providing activities in the home or leisure outings. New Court Place DS0000070238.V350752.R01.S.doc Version 5.2 Page 12 The residents pay for their activities and for their holidays. Most have one or two holidays a year, at Winged Fellowship holiday centres for people with physical disabilities. However this is not suitable for everyone, especially for those with nursing needs. Some residents have also arranged their own holidays, with support from their families. Residents who do not wish to go away are being encouraged to have a “holiday at home” and to arrange their choice of outings and activities during their holiday week. Meals are served in a cafeteria style area with adjustable seating and table heights to accommodate a range of needs and equipment. Residents are able to choose from a varied menu with a wide range of options. The chef cooks fresh food every day, and the menu choices include two roast dinners each week. There are at least two options for lunch each day, and a large range of snack type meals every evening. The residents who were spoken to said that the food is generally good, and they like the amount of choice that they have. There is a kitchenette in each resident’s room, and they are able to make their own drinks and snacks if they wish to. There is a hot drinks machine and a water cooler at wheelchair height in the dining room. Lunch was observed. It was a sociable occasion, and the staff gave appropriate and sensitive assistance to those who needed help. New Court Place DS0000070238.V350752.R01.S.doc Version 5.2 Page 13 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 adequate. This judgement has been made using available evidence including a visit to this service. The people who live in the home are confident that they will receive a good quality of personal care and healthcare. Poor record keeping and monitoring of medication means that there is a risk that people may not receive the medication that is prescribed for them. EVIDENCE: The care plans provide appropriate details of each person’s health needs, including pressure care concerns and monitoring of epilepsy. No one currently has a pressure sore, and no one is being monitored for poor nutrition. The residents have a preferred plan of care, which sets out how they wish to receive their personal care. The night staff assist those residents to get up who need to be up early because they are going to college. The staff work in teams allocated to specific residents, taking account of gender and cultural needs. Two people said that the staff provide care according to their wishes. One person raised some concerns about their care during the last year that resulted in a safeguarding investigation led by Hertfordshire Adult Care Services. (See Concerns, Complaints and Protection.) John Grooms carried out New Court Place DS0000070238.V350752.R01.S.doc Version 5.2 Page 14 an investigation of the concerns and audited the care that was provided. They identified that there had been issues with limited choice especially around bathing needs, and on some occasions staff had forgotten to offer baths. There are three baths suitable for a range of needs. Everyone is now given a choice each day of whether they would like a bath, a shower, a wash or nothing, and the choice is recorded in their care plan. The people who are able are encouraged to look after their own medication. The home has generally good procedures for storing and administering medication. However several errors were observed on this occasion. One person had a prescription for Diazepam, but there was no supply in the home, and no protocol for when it should be administered. There was no protocol for when another PRN (when required) medication, Loratidine, should be administered. A tube and a tub of Flamazine cream were stored in the fridge, but they do not need to be refrigerated. There was no MAR (medication administration record) chart for Flamazine. It was reported that it was no longer required, but it had not been returned to the pharmacist. Another medication, Daktakort, was no longer needed, but was still recorded on the MAR chart. Controlled medication is stored appropriately and recorded in the controlled drugs register. But it was not clear when one the dosage of one medication, MST, had changed. Several medications, including MST, had been handwritten onto a blank MAR chart with the wrong date. The result of this is that medications that were administered on the day of the inspection, 08/09/11, were recorded as administered on 04/09/07. New Court Place DS0000070238.V350752.R01.S.doc Version 5.2 Page 15 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 good. This judgement has been made using available evidence including a visit to this service. The people who live in the home are confident that their concerns are listened to, and that they are safeguarded from the risks of abuse. EVIDENCE: The people who we spoke to during the inspection said that they are able to make any concerns known. One person said that they can talk to their key worker. The home has a clearly written complaints procedure. Complaints are recorded in a notebook, which records each complaint and the action taken. No complaints have been recorded since the last inspection. The home has adequate policies concerning safeguarding vulnerable adults and whistle blowing. Training on safeguarding and the prevention of abuse is currently being revised following an investigation into concerns raised by one of the residents. Allegations were made against five members of staff for poor practice in care provision and moving and handling. The allegations resulted in an investigation lead by Hertfordshire Adult Care Services. There were no concerns about three of the staff, other concerns were addressed with supervision, and one had a disciplinary hearing that resulted in further training. John Grooms also identified that there had been issues with limited choice especially around bathing needs, and on some occasions staff had forgotten to offer baths. The procedures for ensuring that everyone can express their choice of the care they receive have been changed as a result. (See Personal and Healthcare Support.) New Court Place DS0000070238.V350752.R01.S.doc Version 5.2 Page 16 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, 25, 29 and 30 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. The people who live in the home enjoy a high standard of accommodation that has been designed to promote independence and exceeds the minimum standards. However the practice of holding fire doors open may cause a risk to residents in case of fire. EVIDENCE: New Court Place was purpose built by John Grooms as a care home for people with physical disbilities. The rooms are designed as studio style flats, each with a bedsitting room, a kitchenette and an en suite shower room with WC. Many of the fittings can be adjusted to suit individual needs. Each person has equipment that suits there needs, including hoists and environmental aids. The rooms reflect individual tastes and interests. The doors to the residents’ rooms lead off wide corridors that are planned to resemble streets. Wide doors, corridors and lifts mean that people who have to spend some time in bed can still access the communal areas. All areas of the home are wheelchair accessible. The large recreation and dining area on the ground floor is a New Court Place DS0000070238.V350752.R01.S.doc Version 5.2 Page 17 sociable space, and the cafeteria style dining area enables service users have access to drinks and snacks. The home appeared to be clean and well maintained, and appropriate policies and procedures are in place for the maintenance of hygiene and control of infection. However some health and safety issues need to be addressed. Some cleaning chemicals were not stored securely (see Conduct and Management of the Home). The staff do not follow the home’s procedures for taking precautions against the risk of fire. The door of the staff room on the first floor was held open with a chair on the first day of this inspection. The chair was removed when this was pointed out, but on the second day of the inspection the door was again held open with a chair. If fire doors need to be held open, they must be fitted with a suitable self-closing device. The doors in the laundry room are fitted with self closing devices, but the door between the laundry room and the ironing room was held open with a wedge, and the door between the ironing room and the landing was held open with a sewing box. New Court Place DS0000070238.V350752.R01.S.doc Version 5.2 Page 18 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, 33, 34 and 35 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The people who live in the home are supported by a stable staff team who have the experience and training to understand and meet their needs. EVIDENCE: The people who live in the home are supported by a stable team of nurses, care workers and activity staff. The staff rotas indicate that two registered nurses and seven care assistants work in the morning with one registered nurse and seven care assistants in the afternoon. One registered nurse and three care assistants work at night. On the first day of the inspection the staff team was reduced by one care worker because seven people were away on holiday. The manager is supernumerary. There is little change in the staff team, and only one nurse has been employed since the last inspection. All the staff who we spoke to said that said that the training and support provided for them is very good. John Grooms training programme is continuing until Shaftesbury procedures are fully implemented. An audit has been completed to make sure that all mandatory health and safety training is up to date. Following the concerns described in Concerns, Complaints and Protection New Court Place DS0000070238.V350752.R01.S.doc Version 5.2 Page 19 training has been implemented to minimise the risk of institutionalisation and address the lack of professional boundaries in some areas. The manager is qualified to train staff in first aid, infection control and management of epilepsy; the deputy manager is a qualified moving and handling trainer; and the chef is qualified to provide food hygiene training. Several other nurses have specific expertise, for example in multiple sclerosis and epilepsy, and they are able to provide information and training for the other staff. At the last inspection it was reported that 49 of the care staff have NVQ level 2 qualification. Seven more staff are currently working towards the qualification, and two are ready to start the course. There is an expectation that all care staff will undertake NVQ qualifications. Two of the eight support workers have a qualification at NVQ2 or above, and four are working towards it. We checked the staff files of two members of staff. They contained sufficient information to show that they are fit to work in the home. New Court Place DS0000070238.V350752.R01.S.doc Version 5.2 Page 20 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, 41 and 42 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The health and safety and confidentiality of the people who live in the home may be at risk due to poor practice in some areas of record keeping and maintaining a safe environment. EVIDENCE: The manager is a qualified nurse. She previously worked at the Chalfont Centre for Epilepsy, and she is a qualified trainer for first aid, infection control and management of epilepsy. She has applied to CSCI for registration. Since the last inspection John Grooms merged with Shaftesbury, and the new company is named Grooms-Shaftesbury. The policies and procedures of both companies are currently being reviewed, and the company intend to complete the development of all new joint policies and procedures by the end of March 2008. New Court Place DS0000070238.V350752.R01.S.doc Version 5.2 Page 21 There is no evidence of a formal system for quality assurance in the home. However it was reported that the John Grooms Quality Assurance Coordinator carriers out regular audits of the home’s procedures, and questionnaires have been sent to the people who live in the home and to their families. A report of the quality assurance process should be produced, that shows how people’s views are taken into account for the development of services in the home. A representative of John Grooms has made regular monitoring visits to the home, and the reports of the visits include the views and opinions of people who live in the home. The home generally maintains appropriate records for the health and safety of the residents and staff in the home. In some cases staff do not always follow the home’s policies and procedures. We noticed two health and safety concerns during the inspection. 1. Several fire doors were held open by artificial means. (See Environment.) 2. Several COSHH (Control of Substances Hazardous to Health) controlled items, including hand sanitizer and urine/odour neutraliser, were seen on the work surface in the utility room on the first floor. A spray container of cleaner and a container of Tesco Sterilising Solution were seen in unlocked cupboards in the utility room. These were potentially accessible for the residents, and were therefore a health and safety hazard. There was no COSHH (Control of Substances Hazardous to Health) risk assessment for the Tesco Sterilising Solution. The home’s procedure for fire drills states that there should be a minimum of one fire drill every three months. The record of each fire drill should include the names of staff who attend. There was no record of a recent fire drill, and no evidence that all staff have taken part in a fire drill within the last 12 months. Some records are not stored securely. Files with details of the residents’ finances are stored on open shelves in the main office, and the door to the office was open throughout this inspection. In the office there were also a trolley containing care plan files. These care plans were out of date, but they contained personal information about the people who live in the home. New Court Place DS0000070238.V350752.R01.S.doc Version 5.2 Page 22 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for 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 X 2 3 3 3 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 2 25 4 26 X 27 X 28 X 29 3 30 3 STAFFING Standard No Score 31 X 32 3 33 3 34 3 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 2 3 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 2 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 X 3 X 2 X 2 2 X New Court Place DS0000070238.V350752.R01.S.doc Version 5.2 Page 23 Are there any outstanding requirements from the last inspection? N/A 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(2)(a) Requirement Measures must be put in place to ensure that care plans are provided in a format that each person can access and understand. Measures must be put in place to ensure that medication is audited effectively, and that any errors in medication are noted and rectified without delay. The registered person must ensure that fire doors are kept closed unless an automatic door closer is fitted. The registered person must produce a report of the results of the consultation with residents and their families. The report must be supplied to the Commission, and made available for the residents in order to provide feedback for their input. All personal information must be stored securely in order to protect the confidentiality and privacy of the people who live in the home. All substances that may be hazardous to health must be stored securely at all times. DS0000070238.V350752.R01.S.doc Timescale for action 10/02/08 2. YA20 13(2) 10/01/08 3. YA24 23(4)(a) 10/01/08 4. YA39 24(2) 10/02/08 5. YA41 17(1)(b) 10/01/08 6. YA42 13(4)(a) 10/01/08 New Court Place Version 5.2 Page 24 7. YA42 23(4)(e) The registered person must ensure that every member of staff, including the night staff, take part in at least one fire drill a year. 10/02/08 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. Refer to Standard YA7 Good Practice Recommendations It is recommended that an external advocacy service should be identified in order to provide independent advocacy for residents in situations where this may be appropriate. The holidays arranged by New court Place for the residents are not suitable for all, particularly those with nursing needs. It is recommended that a range of alternative holiday venues should be explored, in order to give every resident the opportunity of taking a holiday away from the home. 2. YA14 New Court Place DS0000070238.V350752.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection Hertfordshire Area Team CPC1 Capital Park Fulbourn Cambridge CB21 5XE 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 New Court Place DS0000070238.V350752.R01.S.doc Version 5.2 Page 26 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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