Inspection on 17/10/07 for Newhaven

This inspection was carried out on 17th October 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 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 12 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Newhaven 03/09/08

Newhaven 29/11/06

Newhaven 07/03/06

Newhaven 25/05/05

Newhaven 20/12/04

Newhaven 01/07/04

Similar services:

Larch Avenue

Alderson Road 12

Cranworth Close Registered Care Home

Pennine Camphill

Muston Road (70)

Grayling

The Cornerstone

John Street Nursing Home

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

CARE HOME ADULTS 18-65 Newhaven Church Lane Boroughbridge North Yorkshire YO51 9BA Lead Inspector Dawn Navesey Key Unannounced Inspection 17th October 2007 09:50 Newhaven DS0000007873.V353279.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 Newhaven DS0000007873.V353279.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. Newhaven DS0000007873.V353279.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Newhaven Address Church Lane Boroughbridge North Yorkshire YO51 9BA 01423 325053 F/P01423 325053 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.st-annes.org.uk St Anne`s Community Services vacant post Care Home 5 Category(ies) of Learning disability (5) registration, with number of places Newhaven DS0000007873.V353279.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. Registered for 5 Service Users with Learning Disabilities some or all of whom may also have Physical Disabilities 29th November 2006 Date of last inspection Brief Description of the Service: Newhaven is a care home registered by St Annes Community Services to provide personal care and accommodation for up to five people with learning disabilities some or all of who may also have physical disabilities. The home consists of a two storey detached property located on a quiet road in the town of Boroughbridge, which offers a wide range of public amenities including shops, churches and pubs. Each of the five bedrooms is for single accommodation, none of which has en-suite facilities. The home has a garden to the rear and hard standing for parking to the front. There is ramped access. Current information about services provided at Newhaven in the form of a statement of purpose, service user guide and the most recent inspection report published by the Commission for Social Care Inspection are available by contacting the home. Information provided by the service manager on 25 October 2007 indicated that the current weekly fee for the home is £1119.52. Additional costs include toiletries, hairdressing and transport costs. Newhaven DS0000007873.V353279.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The Commission for Social Care Inspection (CSCI) inspects homes at a frequency determined by how the home has been risk assessed. The inspection process has now become a cycle of activity rather than a series of one-off events. Information is gathered from a variety of sources, one being a site visit. More information about the inspection process can be found on our website www.csci.org.uk This visit was unannounced and was carried out by one inspector who was at the home from 9.50am to 6pm on the 17 October 2007. The purpose of the inspection was to make sure the home was operating and being managed for the benefit and well being of the people living there. And also to monitor progress on the requirements and recommendations made at the last inspection. Before the inspection evidence about the home was reviewed. This included looking at any reported incidents, accidents and complaints. This information was used to plan the visit. An AQAA (Annual Quality Assurance Assessment) was completed by the home before the visit to provide additional information. Survey forms were sent out to people living at the home, their relatives and health and social care professionals. None of these have been returned at the time of writing this report. During the visit a number of documents and records were looked at and some areas of the home used by the people living there were visited. Some time was spent with the people who live at the home, talking to them and interacting with them. Time was also spent talking to staff and the deputy manager. Feedback at the end of the visit was given to the deputy manager. I would like to thank everyone who contributed to the inspection process and to the home for their hospitality What the service does well: Staff have good knowledge of the needs of the people who use the service. They have got to know them well and are aware of their likes and dislikes and how they communicate any unhappiness. In a compliment received by the home a relative said, “The staff have provided excellent care for my relative”. Staff work hard to make sure that people who use the service have regular and varied activity. This does however depend on staffing levels. Newhaven DS0000007873.V353279.R01.S.doc Version 5.2 Page 6 People who use the service are encouraged to keep in contact with family and friends. In a compliment received by the home, a relative said, “The house is a pleasure to visit, I’m made to feel welcome and my thoughts and opinions on my relatives care are valued”. Staff interact well with people who use the service. They are kind and make sure dignity is respected What has improved since the last inspection? What they could do better: The Statement of Purpose must be reviewed to make sure the information is current. This will help people to make decisions on whether the home will meet their needs. Pre-admission assessments must be carried out before people move into the home. This will make sure the home can meet the person’s needs. People who use the service must have a detailed and up to date care plan, which includes their specific health needs. This will make sure they receive person centred, safe support that meets their needs properly. All identified risks for people who use the service must have a detailed, up to date action plan in place in order to minimise or prevent the risk. Newhaven DS0000007873.V353279.R01.S.doc Version 5.2 Page 7 The organisation must check the staffing levels to make sure there are enough staff to provide a safe level of supervision, stimulation and support at all times. One staff member said, “When we only have two staff on duty we cannot go out with people”. Guidelines for ‘as and when’ required medication must clearly state the circumstances in which the medication is required. This will make sure practice is safe. The temperature of the home must be kept at a level that is warm and comfortable for people who use the service. Records such as staff records, care plans, risk assessments and those to do with health and safety or maintenance must be kept up to date. This will ensure the best interests of the people who use the service are safeguarded. The food eaten by people who use the service, who are nutritionally at risk should be recorded more accurately. This will make sure that their nutritional needs are met. Systems should be put in place to make sure foodstuffs are not consumed when past their use by date to avoid any risk of food poisoning. Storage facilities in the home should be looked at to make sure people who use the service have access to all communal areas. 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. Newhaven DS0000007873.V353279.R01.S.doc Version 5.2 Page 8 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 Newhaven DS0000007873.V353279.R01.S.doc Version 5.2 Page 9 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 People who use the service experience poor quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. People who may use the service or their representatives do not have the information needed to choose a home that will meet their needs. The lack of pre-admission assessments could lead to the needs of the people who use the service not being properly met. EVIDENCE: The Statement of Purpose and Service User Guide are documents that give information on what the home can provide. The people who use the service have their own copy of the Service User Guide and the Statement of Purpose is available on request. The file containing the Statement of Purpose is disorganised and the information is out of date. This means that anyone considering using the service would not have the right information about the home. There has been one new admission to the home since the last inspection. In the AQAA, the manager said that all new admissions are planned in advance following a community care assessment. She also said that the home has their own assessment to assess the needs of anyone thinking of using the service. However, there was no evidence of any pre-admission assessment for the person who had most recently moved in. It was unclear how the person’s Newhaven DS0000007873.V353279.R01.S.doc Version 5.2 Page 10 needs had been assessed and how the manager could be sure that the home could meet this person’s needs. Staff said they had relied on information that came with the person from their previous placement. This information was not up to date and could have led to the person’s needs being overlooked and the person being placed at risk. Newhaven DS0000007873.V353279.R01.S.doc Version 5.2 Page 11 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 People who use the service experience adequate quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Staff are, in the main, aware of the individual needs of people who use the service. The lack of detail in some care plans and risk management plans could however, lead to the needs of the people who use the service not being properly met. EVIDENCE: Some people who use the service have support plans that have been developed from the assessment of their needs. Some of the plans gave clear, detailed instruction on how needs are met. However, some care plans need more explanation and more detailed and specific information for staff to make sure that important care needs are not overlooked. For example, people who need support with personal hygiene have plans that say, “assist” or “encourage” but do not say how this is done. Another person needs support with a visual impairment. Staff are advised to “guide” this person but again the care plan does not say how this should be done. Many of the care plans Newhaven DS0000007873.V353279.R01.S.doc Version 5.2 Page 12 are not signed by the person completing them and are not dated so it is unclear as to which information is current. Staff said they had received some basic training on care planning from the manager. Staff also said that care plans were always agreed and then signed off by the manager. There was no evidence to suggest this had been done. A person who has been living in the home for seven months has no up to date care plans. All care plans in place refer to the previous home this person was living at. It is clear that the person’s needs have changed since that time and the care plan information is no longer relevant. Staff confirmed this to be the case and said they were “learning as they went along” with this person. This situation could lead to important care needs being missed. Risks to people who use the service have been identified and assessed. Some of the risk assessment information is up to date and reviewed. However some are out of date, containing old information. This is particularly relevant to the person mentioned above. Risk assessments have been reviewed as current for this person, when it is very clear they are no longer relevant as they refer to the person’s previous home. Some risks have not been assessed for people who use the service. For example, one person is using bed rails on their bed. There is nothing in place to say why these are needed. Staff said they were being used because they were “there”; the bed rails are attached to the bed. There was no evidence to suggest they were needed. The use of the rails could lead to injury for this person if they are not needed or could be an unnecessary limitation on this person’s freedom and choice. Some of the information and risk management plans are vague and do not give enough detail. This again, could lead to important needs being missed. The personal files of the people who use the service are disorganised and confusing. There is lots of old out of date information mixed in with current information. It is recommended that some old information be archived so that the information is more easily available. Staff said they had at times found them confusing and difficult to work with. One said, “They really need slimming down”. The deputy manager said it was something he and the manager had planned to get done. Despite these gaps in care planning and risk assessment documents, the current staff have a good knowledge of the needs of the people who use the service. Many of them have worked at the home for a number of years. They were able to accurately describe the care they give and talk about the detail of how people like to be supported in their daily routines. People who use the service look well presented and well cared for. In a compliment received by the home a relative said, “The staff have provided excellent care for my relative”. Staff are currently gathering information to plan review meetings for people who use the service. Some staff said they did not feel confident or supported Newhaven DS0000007873.V353279.R01.S.doc Version 5.2 Page 13 by the manager with this. It was clear from looking at some of the priority lists that had been prepared that they did not link with any assessment for the person using the service. Some people had experienced some person centred planning in the past. Actions from this did not seem to have been followed up. For example, it had been recorded that a person who uses the service would like to go horse riding. It was not clear if this had ever happened for the person. People who use the service were offered choices throughout the day, around what to do or what to eat. Most do not use verbal communication so are observed for their body language and facial expressions in response to questions and choices. Staff also rely on their knowledge of the people who use the service and what their usual responses are. One person uses signed communication. Most staff seemed to be aware of the signs this person uses. It would be good practice to have this information in the person’s care plan so that all staff could become familiar with the signs and increase communication and choice for this person. Staff said they involve the family of people who use the service in drawing up care plans and gaining information on likes and dislikes. Again, there was no evidence of this in the care plans. It would be good practice to show how this has been done. Newhaven DS0000007873.V353279.R01.S.doc Version 5.2 Page 14 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): 11, 12, 13, 14, 15, 16 and 17 People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. People who use the service are supported to make choices about their lifestyle and supported to develop their life skills. In the main, appropriate activities are arranged and a good, healthy and varied diet is offered. EVIDENCE: People who use the service have a variety of activities that they are involved in within their local community. This includes day centres, clubs, shopping, meals out, going out to the pub and going to shows. Staff have recently introduced themed evenings such as a ladies pamper night or a men’s night out to the pub. This recognises the different needs of the people who use the service. Staff have also introduced themed food nights and have been introducing people who live at the home to a wide variety of food from different cultures. During the visit, one person went out for a walk into the local shopping area and others went out shopping in the afternoon in the Newhaven DS0000007873.V353279.R01.S.doc Version 5.2 Page 15 home’s transport. In the AQAA, the manager said that they have identified that some people would benefit from some increased activity at weekends. The deputy manager said that no plans had been made as yet, as to how this was going to be done. On looking through the daily records for people who use the service, it appeared that advice in care plans was not always being followed. One person had a leisure care plan that said he enjoyed one to one time and shopping. The daily notes did not have anything recorded about this type of activity. The deputy manager said he felt that this was an error in recording activity rather than the fact it may not have happened. Other people had gaps in daily notes that would lead to thinking they have not been out or involved in any activity for a number of days at a time. Staff said this would not happen and that regular activity is given to all people who use the service. Staff also said that their ability to get people out and about in the community is reliant on there being enough staff. One said, “When we only have two staff on duty we cannot go out with people”. The manager must review staffing levels to make sure the leisure and recreational needs of people who use the service are being met. People who use the service are supported to keep in touch with family and friends. Some people who use the service have regular visitors to the home. Others are supported to keep in touch by making phone calls or sending letters and postcards. In a compliment received by the home, a relative said, “The house is a pleasure to visit, I’m made to feel welcome and my thoughts and opinions on my relatives care are valued”. Staff said they are aware of the importance of assisting people who use the service to be as independent as they can be. They gave examples of what they do to encourage and allow people to develop their independence skills. A relative commented, “My relative continues to improve, they are cheerful, happy and content”. Staff’s interactions with people who use the service were good. The home has a lively atmosphere and staff were chatty and jovial. The people who use the service seem to all get on well. Staff said that they had a wide range of interests and they try to make sure that all needs are met. One person who uses the service smiled and laughed when asked if they enjoyed the company of others using the service. Staff said this was a positive response. The menus and choices of food in the home are good. The food is varied and healthy, while making sure that people who use the service get their preferred choices. Some people who use the service are nutritionally at risk due to their fluctuations in appetite. Staff said they make sure that extra snacks are offered at these times and their food is enriched to make it more nutritious for them. This is not always accurately documented in people’s daily notes and could lead to nutritional needs being missed. People who use the service were Newhaven DS0000007873.V353279.R01.S.doc Version 5.2 Page 16 supported with any assistance they needed at meal times. This was done with discretion and respect for the person. Some foodstuffs in the fridge were found to be past their use by date. Other food items had been opened but the date this happened had not been noted so it was difficult to know if these foods were still in date. This practice puts people who use the service at risk. Newhaven DS0000007873.V353279.R01.S.doc Version 5.2 Page 17 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, 20 and 21 People who use the service experience adequate quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. The lack of some written documentation could lead to personal and health care support needs being overlooked. EVIDENCE: Staff have a good awareness of the personal care, and likes and dislikes of the people who use the service. Staff were seen to support people with their personal care needs in private and with dignity. However, as mentioned in the Individual Needs and Choices section of this report, there is a lack of detail and clear instructions on how to deliver care in the care plans. A person who is using pressure-relieving equipment has no plans in place for prevention of pressure sores. A person who has epilepsy has a care plan in place for the epilepsy management. However, this has not been reviewed for some time. Some staff gave more detail than is in the care plan as to how the epilepsy is managed. The current care plan is out of date or not detailed enough to make sure this person is supported properly. It is not clear if all staff would act in the same way when supporting this person. Newhaven DS0000007873.V353279.R01.S.doc Version 5.2 Page 18 The support plans have details of any health professionals that people who use the service see. These include, GP, occupational therapist, dentist, specialist nurse, and optician. Records are kept of any health appointments and their outcome. In the AQAA, the manager said that they are planning to ensure all people who use the service have their last wishes and funeral plans documented. This had started for some people. Staff have received training in some of the specialist health needs of people who use the service. In the AQAA, the manager said that they access community learning disability services for specialised help in mental health needs, physical disabilities, speech and diet. The home uses a monitored dosage pre-packed system for medicines. All staff take responsibility for the administration of medication and have been trained to do so. There are good ordering and checking systems in place, with a clear audit trail for any unused medication returned to the pharmacy. The medication administration records (MAR) were checked and showed some errors in administration. The MAR sheets had not been signed for medication that had been given. The deputy manager was made aware of this and said he would investigate the errors. Some people receive medication ‘as and when required’. There are guidelines in place for staff to follow in the event of anyone needing this medication. However, the guidelines do not describe behaviours in detail. It is unclear when medication should be given. The guidance states that medication is to be given for “severe agitation”. It did not clearly describe what this meant and could lead to medication being given when not needed depending on staff’s interpretation of the guidance. Newhaven DS0000007873.V353279.R01.S.doc Version 5.2 Page 19 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 People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. People who use the service and their relatives have their views listened to, taken seriously and acted upon. There are good systems in place to protect people from abuse. EVIDENCE: The home has a complaints procedure which is part of the Service User Guide. It is an easy read complaints procedure, making it more accessible. Due to the complex needs of the people who use the service, staff said many of them would find it difficult to access this formal procedure. In answer to this, staff have developed a list of indicators of unhappiness for each person who uses the service. This is good practice and means that when any of the indicators are displayed, staff investigate to see what the problem may be for people. It is not clear if the complaints procedure is distributed to relatives or representatives of people who use the service. On the day of the visit the complaints procedure could not be located. As the procedure is not displayed, it would be good practice to distribute it so that everyone is aware of how to complain. Staff have received training on safeguarding adults. They were able to say what action they would take if they suspected abuse or had an allegation of abuse made to them. They were also able to describe the different types of abuse. They knew where the policy on adult protection was kept and could Newhaven DS0000007873.V353279.R01.S.doc Version 5.2 Page 20 refer to it. In the AQAA, the manager said that refresher training in safeguarding adults is now available to all staff. One staff member said, “I am due for an update next month”. Good records are kept of the finances of people who use the service and their monies are kept safe. Proper handovers of the monies takes place at each shift change and the manager regularly checks the finance records and receipts. Newhaven DS0000007873.V353279.R01.S.doc Version 5.2 Page 21 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, 29 and 30 People who use the service experience adequate quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. The home, in the main, offers an attractive, homely, clean and safe environment for people who use the service but is not always warm enough. EVIDENCE: The home is fairly well maintained and a number of areas have been redecorated since the last inspection. It is clean and tidy and looks homely. There is a new gas fire in the lounge and new seating. The central heating boiler has been repaired. On the day of the visit, some parts of the home appeared a little cold at times. Staff said they thought the heating needed to be turned up as the weather had turned a bit colder. They said they would make sure this happened. One staff said that there had been some discussion with the maintenance department about whether the current central heating boiler had the capacity for the Newhaven DS0000007873.V353279.R01.S.doc Version 5.2 Page 22 number of radiators in the home. The deputy manager said he would make sure this situation was monitored. One of the upstairs bedrooms felt particularly cold. Staff said they use a portable heater in the colder months to warm this room up before the person goes to bed. It would be good practice to monitor the temperature in this room to make sure it is kept warm enough at all times. There is a risk assessment in place for the use of the portable heater to make sure this is safe. The bedrooms of the people who use the service are well maintained and show their individual interests and personality. Some minor decoration and minor repairs to plasterwork are waiting to be done. One person has just had a new carpet. One of the people who use the service nodded, said, “Yes” and gave a big smile, in answer to whether they liked their room. There is a sensory room at the home. At the time of the visit, this was being used to store old pieces of furniture and the mobile hoists. Staff said it was possible for people who use the service to use this room and that they would move the stored equipment out whenever anyone wanted to use it. The sensory room space was identified as somewhere that should be available to someone who uses the service when they display behaviour that challenges others. It is clear that it would take some organisation to make this room immediately available. The manager should consider other ways of storing equipment. The upstairs bathroom in the home is looking in need of redecoration and the bathroom suite, whilst functional, is looking a little tired and worn. Some pieces do not match and the side of the bath is coming away. The downstairs bathroom has an assisted bath and hoist available for those who need it. The home has an attractive, large enclosed garden. Clinical waste is properly managed and staff wear protective clothing when attending to the personal care needs of people who use the service. Staff have received training in infection control and were able to say what infection control measures are in place. Newhaven DS0000007873.V353279.R01.S.doc Version 5.2 Page 23 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, 35 and 36 People who use the service experience adequate quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Staff are trained and skilled, however they are not always in sufficient numbers to support the people who use the service properly. EVIDENCE: There are staff on duty throughout the day and night. Staff said there should be three staff on the morning shift and three staff on the afternoon shift. At night there is one member of staff on waking night duty and one staff sleeping in. An on-call manager supports them. The manager is on the rota as part of these numbers. They do not have any supernumerary time to attend to their management role. At the time of the visit, the home was short staffed, with people on sick leave and vacant posts. This has meant that on many occasions, the daytime staffing levels have been two staff not three on shift. Staff said they could meet the needs of the people who use the service on these numbers but they could not find as much time for activities and outings. Some people who use the service, need the support of two staff for moving and handling and their personal care needs. At these times, other people who use the service are left Newhaven DS0000007873.V353279.R01.S.doc Version 5.2 Page 24 without supervision. Staffing levels must be reviewed to make sure there are enough staff to provide a safe level of supervision and a good level of activity and stimulation. The organisation’s recruitment records have been inspected by the CSCI’s Provider Relationship Manager at the organisations head office. This showed that recruitment is properly managed by the organisation. Interviews are held; references and CRB (Criminal Record Bureau) checks are obtained before staff start work and checks are made to make sure staff are eligible for work. The home should keep a proforma of this staff information. This gives details confirming that recruitment is properly managed by the organisation. The service manager signs this to show it has been checked against the original records. However, this could only be found on one member of staff’s records in this home. Staff’s files were disorganised and this also made it difficult to find information. Staff said their training is mostly up to date now and refresher courses have been given or are booked. Records are kept of staff’s training but these had not been kept up to date by the manager, so it was difficult to assess who had completed what training and when. In the AQAA, the manager said that staff’s training was up to date. Almost half of the staff team have achieved an NVQ (National Vocational Qualification) in care at level 2 or above. Some more staff are now due to start this too. Staff spoke highly of their training and said they felt they did a better job because of it. Comments included, “It helps in knowing how to best meet the needs of the service users”, “It gives you more insight to give better care” and “Makes you think more about encouraging people to be more independent”. Staff gave mixed comments on the effectiveness of teamwork within the home. Some staff said they felt they had a good team. Another said, “It has been rocky of late, we don’t feel supported by the manager”. Another said, “I have felt demoralised by the lack of support from the manager”. These comments referred to the manager having had some periods of absence from the home and it was at these times staff felt unsupported. Staff said they had been given the job of preparing a review meeting but had not received any support to do this. They said they had not been able to have time with the manager due to her absence from the home. Staff should be supervised in order to help them carry out their role properly. Records showed that staff have, in the main, received regular supervision meetings and regular staff meetings have taken place. Newhaven DS0000007873.V353279.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, 38, 39, 41 and 42 People who use the service experience adequate quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. The home is adequately managed. The interests of the people who use the service are seen as important to the manager and staff and are safeguarded most of the time. EVIDENCE: The home has an experienced manager who has now started the Registered Managers Award. She is a registered nurse for people with a learning disability. She has not yet applied to the CSCI to be the registered manager of the service. It is an offence for a person to manage a home when they are not registered and she has now been in post as home manager for over six months. A manager’s application must be submitted as soon as possible. Newhaven DS0000007873.V353279.R01.S.doc Version 5.2 Page 26 As mentioned in the Staffing section of this report, staff have been feeling that the home has lacked leadership due to the periods of absence of the manager from the service. One staff said, “It feels like we are missing a manager”. The deputy manager has been in post for five months and is currently in charge on a day-to-day basis. He said he is supported by the other managers in the organisation and the service manager. He said he had welcomed this support. The service manager visits the home on a monthly basis to carry out visits. This involves talking to people who use the service and staff about the home. A report of these visits is made showing details of any action to be taken to improve the service. In addition to this, the organisation sends out annual satisfaction questionnaires, as part of its quality assurance programme. This also includes people who use the service, relatives and staff. The results of these were not available in the home though. As mentioned in the Individual Needs and Choices and Personal and Healthcare Support sections of this report, care plans and risk assessment records must improve. The plans did not show evidence of how the manager checks them to make sure they are of a good standard and give staff detailed and specific instruction on care and support needs. Staff carry out daily, weekly or monthly health and safety checks around the home such as fire alarms, emergency lighting and water temperatures. Staff have now completed fire training and two staff are trained to deliver this. Environmental risk assessments are completed but had not been reviewed for over a year. Some of the records on maintenance had not been maintained well. It was difficult to see if jobs and repairs had been completed. Staff said the organisation had been short staffed in the maintenance department. Certificates to show that safety tests had been carried out on the home’s gas and electrical wiring were available in the home. Some information to do with health and safety was difficult to find at first, as some of the files were bulky, with lots of old information in them. Accident and incident records were well recorded. Fridge and freezer temperatures are now being recorded twice daily to make sure that food is stored at the correct temperature. However, as mentioned in the Lifestyle section of this report, systems need to be put in place to make sure out of date foodstuffs are not consumed. The home has a comprehensive range of policies and procedures in place to ensure health and safety. Staff said they could always find any information they needed in these policies. Newhaven DS0000007873.V353279.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 2 2 1 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 3 23 3 ENVIRONMENT Standard No Score 24 2 25 X 26 X 27 X 28 X 29 3 30 3 STAFFING Standard No Score 31 X 32 3 33 2 34 2 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 X 2 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 2 15 3 16 3 17 2 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 2 2 X 2 2 3 X 2 2 X Newhaven DS0000007873.V353279.R01.S.doc Version 5.2 Page 28 Are there any outstanding requirements from the last inspection? Yes. STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. 2. Standard YA1 YA2 Regulation 4(1) 14(1) Requirement The Statement of Purpose must be reviewed to make sure the information is current. Pre-admission assessments must be carried out before people move into the home. Timescale for action 30/11/07 30/12/07 3. YA6 YA19 15(1) This will make sure the home can meet the person’s needs. People who use the service must 30/01/08 have an up to date detailed care plan, including health care needs. This will ensure that they receive person centred support that meets their needs. The previous timescale of 15/01/07 has not been met in full. All identified risks for people who use the service must have a detailed up to date action plan in place in order to minimise or prevent the risk. The previous timescale of 15/01/07 has not been met in full. The organisation must review the staffing levels to make sure DS0000007873.V353279.R01.S.doc 4. YA9 13(4) 30/01/08 5. YA14 YA33 18 30/11/07 Newhaven Version 5.2 Page 29 6. YA20 13(2) there are enough staff to provide a safe level of supervision, stimulation and support at all times. Guidelines for as and when required medication must clearly state the circumstances in which the medication is required. 30/11/07 7. YA24 8. YA37 This will make sure practice is safe. 23(2) The temperature of the home must be maintained at a level that is warm and comfortable for people who use the service. CSA The manager must make Section 11 application to be registered with the CSCI. This will make sure the home has a person who is responsible for the day to day running and is also accountable to the CSCI. Records such as staff records, care plans, risk assessments and those to do with health and safety or maintenance must be kept up to date. This will ensure the best interests of the people who use the service are safeguarded. 18/10/07 31/12/07 9. YA41 YA42 17(1) 12(1) 30/01/08 Newhaven DS0000007873.V353279.R01.S.doc Version 5.2 Page 30 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 YA17 Good Practice Recommendations The food intake of people who use the service, who are nutritionally at risk should be recorded more accurately. This will make sure that their nutritional needs are met. Storage facilities in the home should be reviewed to make sure people who use the service have access to all communal areas. Systems should be put in place to make sure foodstuffs are not consumed when past their use by date to avoid any risk of food poisoning. 2. 3. YA24 YA42 Newhaven DS0000007873.V353279.R01.S.doc Version 5.2 Page 31 Commission for Social Care Inspection Aire House Town Street Rodley Leeds LS13 1HP 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 Newhaven DS0000007873.V353279.R01.S.doc Version 5.2 Page 32 - 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. 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