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Inspection on 15/05/06 for Newhaven

Also see our care home review for Newhaven for more information

This inspection was carried out on 15th May 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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

What follows are excerpts from this inspection report. For more information read the full report on the next tab.

What the care home does well

Service users are very positive about the care and support provided at Newhaven. They describe it as a friendly place and enjoy good relationships with all staff groups. A service user said `staff can`t do enough for you`. Two services users confirmed staff had a gentle approach. A service user confirmed they were very happy at Newhaven `you can`t fault it the staff are very good` and `you can do what you like when you like`. This person said `the staff were very understanding, take you as you are and treat you accordingly`. Another person when asked if they got on with staff said` I would say so`. A thorough admission process takes place to ensure the needs of service users can be met. Service users are positive about the standard and choice of meals provided.

What has improved since the last inspection?

The improvement in the medication records reported at the last inspection has been maintained. The standard of cleanliness and management of odours associated with incontinence has improved and no problems were identified at this inspection. An additional member of staff is now being provided at night to reflect the needs of service users and the lay out of the building. There has been a big push to update the mandatory training for staff and provide additional training related to care practices.

What the care home could do better:

More work is required to ensure that accurate records of changes in a person`s health or condition and the response by staff are recorded in the care records. A further requirement has been made. A programme of social care and activities needs to be put in place to provide residents with a more stimulating environment. The management team need to ensure that any issues raised by service users are fully investigated to ensure their views are heard and safe practice are maintained. Health & safety issues related to the storage of medication, safe use of a sharps box and recording of the drug refrigerator temperatures were identified and requirements have been made. The fabric of the home is showing signs of age and wear. This is recognised by the company who plan to build a new home on an identified site in Stevenage. Building work is expected to start in the spring/early summer of 2007. In the mean time there are areas that need to be addressed to maintain good standards for service users. The manager needs to review the arrangements for staff to receive regular supervision. Health & safety issues were identified in relation to the use of mobility equipment and recording of fire alarm checks. A high number of requirements have been made as a result of this inspection. Quantum Care need to ensure that their own auditing systems are identifying and addressing these issues in a proactive way.

CARE HOMES FOR OLDER PEOPLE Newhaven Drakes Drive Stevenage Hertfordshire SG2 OEY Lead Inspector Mrs Sheila Knopp Unannounced Inspection 15th May 2006 10:10 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 Newhaven DS0000019481.V294318.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. Newhaven DS0000019481.V294318.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Newhaven Address Drakes Drive Stevenage Hertfordshire SG2 OEY 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) 01438 354811 014 38 758223 www.quantumcare.co.uk Quantum Care Limited Kerry Ann Stevenson Care Home 42 Category(ies) of Dementia - over 65 years of age (42), Old age, registration, with number not falling within any other category (42), of places Physical disability over 65 years of age (42) Newhaven DS0000019481.V294318.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 22nd November 2005 Brief Description of the Service: Newhaven was purpose built about 30 years ago in a residential area of Stevenage and provides accommodation on three floors for up to forty-two service users over sixty-five years of age who may also have dementia or a physical disability. Service users occupy single rooms in group living units. Each unit has an open plan lounge/dining area and kitchenette. Bathrooms and toilets are conveniently situated throughout the home and are fitted with appropriate aids. There is a large activities room on the ground floor, where the kitchen, laundry and administration areas are also located. The garden to the rear of the home is not overlooked and provides outdoor space where service users can spend their time. Inspection report can be obtained on request from the home. The current fees range from £430 - £490 per week based on an assessment of needs (correct on 15.5.06). Newhaven DS0000019481.V294318.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This report is based on an unannounced visit to the home by two inspectors who spent a total of 11 hours 50 minutes hours in the home. The report includes information provided by residents (18), visitors (1) and staff (8). Six care plans were reviewed in detail following discussions with the residents and staff. Information received about the home since the last inspection in November 2005 has also been reviewed. What the service does well: What has improved since the last inspection? The improvement in the medication records reported at the last inspection has been maintained. The standard of cleanliness and management of odours associated with incontinence has improved and no problems were identified at this inspection. An additional member of staff is now being provided at night to reflect the needs of service users and the lay out of the building. There has been a big push to update the mandatory training for staff and provide additional training related to care practices. Newhaven DS0000019481.V294318.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. Newhaven DS0000019481.V294318.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 Newhaven DS0000019481.V294318.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 – standard 6 does not apply to this service Quality in this outcome area is assessed as good. This judgement has been made using available evidence including a visit to this service. A member of the management team meets with prospective service users and gathers information from health & social care professionals to make sure the home can meet their needs. EVIDENCE: A service user who has recently moved into the home confirmed that they had been visited before their admission and provided with information about Newhaven. The case records confirmed a full assessment had been carried out and information from other agencies involved with the service user had been considered before offering a place. The service user had felt welcomed and confirmed that they were very satisfied with the support being provided by staff. Newhaven DS0000019481.V294318.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): 7, 8, 9 & 10 Quality in this outcome area is assessed as poor. This judgement has been made using available evidence including a visit to this service. Service users had received a good standard of personal care and were positive about the support being provided by staff. The records confirm that service users have access to community health services. The care records indicate that service users are involved in agreeing how they wish to be supported and the follow up reviews that take place. Some improvements are required in care plans to ensure specific information relating to individual needs is recorded and any changes reflected in these plans. The systems for administering medication to service users has improved since the last inspection. However new requirements have been made regarding the potentially unsafe use of a blood glucose monitoring machine, the safety of a sharps disposal box and the storage facilities in the treatment room which could result in unsafe practices. Newhaven DS0000019481.V294318.R01.S.doc Version 5.1 Page 10 Staff adopt an individual approach to each service user, which respects their privacy and dignity. However they do need to be sensitive to the needs of service users when leaving windows open. A high proportion of the female service users do not wear tights or stockings and this needs to be reviewed to ensure that this is by choice. This issue was also the subject of 2 complaints received by the manager. EVIDENCE: All the service users observed had been assisted achieve a good standard of personal care. No issues were identified at this inspection in relation to the management of continence. Staff have received recent training from the continence advisor with further sessions planned. Four service users in summer clothing had been left sitting in a cold room where staff had left the windows open. This has also been the subject of an earlier complaint made to the manager. Service users confirmed that staff used their preferred names. Good humoured conversations between service users and staff were heard but staff confirmed their awareness of adopting different approaches to individuals. Each service user has a plan of daily care setting out their preferences. The records examined had been reviewed monthly but changes in the care required were not always updated on the plan of care. Information on one care plan regarding the condition and management of pressure sores was sparse. Pressure relieving equipment had been provided by the community nurses. Staff reported they did not always get feed back on the progress of the treatments carried out by the community nurses. Staff are monitoring service users identified at risk of falls and have access to a local falls prevention service. The records provided an inconsistent picture of how the nutritional needs of residents were being monitored. Not all service users had been weighed on admission. The action taken to respond to changes in weight had not been recorded. The fluid monitoring chart for a resident demonstrated that staff were not recording the fluids taken at the time they were given and on days when the records indicated an inadequate intake there was no indication that this had been reviewed. A requirement regarding the standard of record keeping was made following the last inspection. Service users in their rooms had access to drinks. Newhaven DS0000019481.V294318.R01.S.doc Version 5.1 Page 11 Those in the lounges were given regular drinks but these were not left along side them so they could help themselves. The good practice of providing fruit and snacks for residents with dementia to pick up as they wish, seen in other Quantum Care homes was not in evidence here. The fruit in the kitchenettes was old and discoloured. The systems for ordering, recording and administering medication to service users was reviewed. Monitoring visits are made by the dispensing pharmacists who provides a report to the management team. Quantum Care have recently updated their medicine policy and a copy and training pack was available. Records were available for the competency assessments carried out on staff before they are able to give out medication. Daily audits of the administration records and stock levels are carried out by a member of the management team. Staff request GP’s to carry out regular reviews of medication. The administration records checked were well kept and reconciled with the stock levels of medication held. Based on this information it was assessed that a requirement from the last inspection had been met. However further requirements have been made: • The records required to ensure medicines are stored at the correct temperatures were not available for the refrigerator. • A sharps box provided for the use of the Community Nurses was being used without a lid. • From discussions with staff it did not appear that service users had their own blood glucose monitoring machines in line with Health Protection Agency guidance (MDA/2004/044) to prevent the spread of infection. • Staff had allowed supplies from the community nurses to accumulate reducing working space and restricting access to the sink provided for hand washing and the sharps box. • There is a lack of cupboard space in the treatment room resulting in medication to be returned to the pharmacist or being stored outside the medication trolleys while a service user is in hospital being kept on the floor. The manager may wish to consider alternative arrangements for storing the community nurses equipment and records. Newhaven DS0000019481.V294318.R01.S.doc Version 5.1 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, & 15 Quality in this outcome area is assessed as adequate. This judgement has been made using available evidence including a visit to this service. None of the residents spoken with raised concerns about not having enough to do. However the home does not currently have an activities organiser and the focus of the care staff is completing the physical care tasks required of them. No one in the home is taking a lead on organising and circulating a programme of activities or demonstrating that the well being of service users with dementia is being promoted. Service users confirmed they were able to make choices about their daily lives within the home. One person said ‘you can do what you want when you like’. Another person described arrangements for her husband to have lunch with her to mark a special occasion. Service users are provided with a varied and nutritious diet. EVIDENCE: Brief descriptions of interest and leisure activities are recorded on each person’s care plan and pen pictures have been provided by some relatives to provide greater insight into the lives and experiences of those with dementia. Newhaven DS0000019481.V294318.R01.S.doc Version 5.1 Page 13 The daily reports do not give much information about how service users spend their day. Those able to occupy themselves spoke of passing the day by reading and watching TV. The manager is currently advertising for an activities organiser. In the meantime is was suggested that additional care staff are identified on the rota to provide something each day and that the care staff on each unit are asked to put a programme of activities together for short periods during the day. The manager may wish to consider increasing the amount of external entertainers brought in as a supplement while a fuller programme is developed. Some service users go to a monthly tea dance in a local community centre. One of the inspectors spoke with a visiting minister who holds services for those who wish to attend and also provides individual support. Service users are able to have a key to their door and bring in personal possessions and furnishings to personalise their rooms. The menu’s are regularly reviewed and nutritionally assessed by Quantum Care. Service users expressed a high level of satisfaction with the meals they are served and are provided with a choice of hot and cold options. Those requiring soft and pureed diets are catered for. The main meal served on the day of inspection was found to be plentiful, hot and tasty. The manager was asked to look into providing diabetic puddings to match those served to other service users in addition to fruit and yoghurts. Newhaven DS0000019481.V294318.R01.S.doc Version 5.1 Page 14 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 & 18 Quality in this outcome area is assessed as poor. This judgement has been made using available evidence including a visit to this service. While there are policies and procedures in place to support service users and relatives who wish to raise concerns it was identified that the manager had not responded appropriately to a service user who raised concerns about the alleged behaviour of a staff member. EVIDENCE: A log of concerns and complaints received by the home is maintained and has been updated to meet a requirement from the last inspection. This record did not give cause for concern in relation to the number or range of complaints received. One did relate to staff leaving windows open and this was also identified, as a problem at this inspection so needs re-enforcing with staff. It was identified from the care records of a service user that an incident that had made the service user feel vulnerable and threatened had not been reported under the Hertfordshire Vulnerable Adult Procedure or formally investigated under the home’s own complaint procedure. The manager has been advised to make a referral and update the Commission on the outcome of discussions with social services and any investigation carried out. The manager must ensure that the joint working policy administered by the County Council is followed in all instances. In response to a requirement made following the last inspection abuse awareness training has taken place. Newhaven DS0000019481.V294318.R01.S.doc Version 5.1 Page 15 Service users confirmed they had been able to vote in recent elections. Where individuals lack capacity to make decisions staff have access to social workers the service users representative and advocacy service. Newhaven DS0000019481.V294318.R01.S.doc Version 5.1 Page 16 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 & 26 Quality in this outcome area is assessed as poor. This judgement has been made using available evidence including a visit to this service. Quantum Care need to ensure that the standard of decoration and furnishings continue to provide service users with comfortable well-maintained surrounds until a date is set for the transfer to new accommodation. Currently areas of the home look very tired and worn with damaged furniture and fittings. The current housekeeping team provide residents with a fresh, clean environment in which to live. To prevent the spread of infection staff need access to liquid soap and disposable hand towels in all areas where personal care is carried out. EVIDENCE: The building is showing its age in the gradual deterioration in many areas. The kitchen fittings in some units are damaged with doors missing and cracked work surfaces. The surfaces on some wooden furniture have come off making it unsightly. Newhaven DS0000019481.V294318.R01.S.doc Version 5.1 Page 17 The bathrooms and the bathing equipment are showing signs of wear. Some new dining and lounge chairs have been provided but more are needed. The manager reported some bedrooms have been decorated. The flooring in the laundry has been replaced. The safety systems are maintained with regular checks on window restrictors and hot water temperatures. Low surface temperature radiators are in place. No issues were identified on the day of inspection. A new housekeeping team has been recruited and the home was found to be fresh and clean on this occasion. This has addressed problems identified at the last inspection. The service users were very positive about the support they receive from the housekeeping staff and their involvement with them. In line with current infection control procedures liquid soap and disposable paper towels need to be available to staff in all rooms where personal care is carried out. None of the bedrooms seen had this facility. Storage boxes have now been provided in the bathrooms to address an issue identified at the last inspection. Newhaven DS0000019481.V294318.R01.S.doc Version 5.1 Page 18 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, 29 & 30 Quality in this outcome area is assessed as good. This judgement has been made using available evidence including a visit to this service. Staff are provided in sufficient numbers to meet the physical needs of the service users in a timely manner. There has been an agreed increase in the number of staff at night to respond to the needs of the service users and lay out of the building. There has been a real thrust by the management team since the last inspection to provide updated training for staff to ensure thy have the knowledge and skills to care for service users safely. Standard 28 is not fully met as the number of care workers with qualifications at NVQ level 2 or above has not been achieved. A requirement has not been made as there is a programme in place with 19 staff working towards this award. The recruitment and induction procedures in place protect service users by ensuring suitable staff are employed and given the required training to do their jobs. EVIDENCE: The rotas indicate that consistent levels of staff are provided during the day. The manager has been reviewing the dependency of service users to ensure their needs can continue to be met within the home’s staffing levels. Newhaven DS0000019481.V294318.R01.S.doc Version 5.1 Page 19 Where possible four staff are provided at night and recruitment is taking place for another night care worker. The files of 4 newly recruited staff were reviewed. Suitable references and criminal records bureau checks had been obtained to assist with protecting residents. New staff were able to provide details of their induction and the records confirmed the mandatory training and company induction days they attended. The Quantum Care induction process leads to a B-Tech qualification, which enables the individual to move on to NVQ training. To reflect the specialist dementia care category the home is registered for the company need to ensure courses above the basic level are made available to staff. Newhaven DS0000019481.V294318.R01.S.doc Version 5.1 Page 20 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35, 36 & 38 Quality in this outcome area is assessed as adequate. This judgement has been made using available evidence including a visit to this service. The registered manager has the required experience and qualifications to carry out their role. However the management team is relatively new and while the requirements from the last inspection were largely met this inspection has highlighted further areas for improvement, which may require additional support from the company. The management team need training in staff supervision to fulfil this role. Quantum Care has a quality assurance system in place, which includes seeking the views of service users, relatives and stakeholders to improve the service provided. Service users are able to deposit money for safekeeping. Newhaven DS0000019481.V294318.R01.S.doc Version 5.1 Page 21 Standard 38 was not fully met because there were gaps in the fire alarm test records. To prevent accidents staff also need to check the rubber protectors on Zimmer frames and not use wheelchairs unless they are in full working order. EVIDENCE: Regular visits are made to the home by senior managers within Quantum Care and monthly reports provided to the manager and Commission. While a number of requirements referred to in this report have been picked up there are areas that have not been identified and this needs to be reviewed to support the service users and management team. The records of resident and staff meetings confirmed their views are sought on the running of the home. Relatives and service users are invited to an annual forum held in the home to feedback the outcome of the quality monitoring questionnaires. A programme of mandatory training has now been introduced to address the shortfalls identified at the last inspection. Details of the training programme and individual staff files together with staff interviews confirmed the good progress that has been made. The system for enabling service users to have access to their personal money was checked and found to be in order. A company audit is also carried out. Staff are not receiving the planned 6 supervision sessions a year detailed under standard 36 to enable their working practices to be reviewed. In some cases this is due to long term sickness within the management team and not all opportunities for supervision are being recorded. The supervisors have not received training in this aspect of their work. The health & safety systems were reviewed. Up to date records for electrical, gas, water safety, window restrictors, fire equipment and emergency lighting checks were in place. Records of regular fire drills are maintained. Gaps in the recording of fire alarm checks had occurred while the designated person was on leave. The rubber protectors on a service users Zimmer frame had worn through. When staff were alerted to the fact that a wheelchair footplate had swung out and was not going to get the service user safely through the door they replied that the wheelchair was broken. The incidence of accidents are recorded and monitored. Newhaven DS0000019481.V294318.R01.S.doc Version 5.1 Page 22 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 x x 3 x x N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 1 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 x 18 1 2 x x x x x x 2 STAFFING Standard No Score 27 3 28 2 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 x 3 x 3 2 x 2 Newhaven DS0000019481.V294318.R01.S.doc Version 5.1 Page 23 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 OP7 Regulation 15(1)&(2) Requirement Care plans must be audited and updated to reflect the changing needs of service users. Brought forward from 22/11/05 Details of the outcome of treatment and action required by staff in relation to the prevention and management of pressure sores must be recorded in the care plan and reviewed on a continuing basis. Weigh service users on admission and then at intervals based on an assessment of risk. Record the action taken in response to weight loss/gain. Ensure staff maintain accurate records of fluid intake, where these are required, and record the action taken when an adequate intake is not achieved Record and maintain records of the drug refrigerator temperatures. Ensure medication is stored off the floor in locked cupboards. Diabetic service users must have their own blood glucose DS0000019481.V294318.R01.S.doc Timescale for action 30/06/06 2. OP8 15(1)&(2) 30/06/06 3. OP8 15(1)&(2) 30/06/06 4. OP8 12(1) 30/06/06 5. 6. 7. OP9 OP9 OP9 13(2) 13(2) 13(3)&(4) (c) 30/06/06 30/06/06 15/05/06 Newhaven Version 5.1 Page 24 8. OP12 16(2)(m) &(n) 9. 10. OP18 OP19 13(6) 23(2)(b)& (d) 11. OP26 13(3) 12. 13. OP38 OP38 13 (4) 23(4) monitoring machines where required. Consult service users about their social interests and plan a programme of activities, which meets their needs and reflects the needs of those with dementia. Identify staff to carry this out and circulate a programme to service users. All allegations of abuse must be referred under the Hertfordshire Vulnerable Adult procedure. The fabric of the building, decoration and furnishings must be maintained in good order. Damaged and worn furniture and kitchen units must be repaired or replaced Provide staff with liquid soap and disposable hand towels in all areas where personal care is carried out. Ensure equipment used for mobility is regularly checked and in working order Maintain weekly fire alarm test records and identify someone to do the tests when the designated person is on leave. 30/06/06 15/05/06 30/09/06 31/07/06 30/06/06 15/05/06 Newhaven DS0000019481.V294318.R01.S.doc Version 5.1 Page 25 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 OP36 Good Practice Recommendations Supervision training is recommended to support the management team fulfil this role. Newhaven DS0000019481.V294318.R01.S.doc Version 5.1 Page 26 Commission for Social Care Inspection Hertfordshire Area Office Mercury House 1 Broadwater Road Welwyn Garden City Hertfordshire AL7 3BQ National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Newhaven DS0000019481.V294318.R01.S.doc Version 5.1 Page 27 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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