Inspection on 29/11/06 for Newhaven

This inspection was carried out on 29th November 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found no outstanding requirements from the previous inspection report, but made 9 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Newhaven 03/09/08

Newhaven 17/10/07

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 Mrs Maggie Coxon Key Unannounced Inspection 29th November 2006 09:30 Newhaven DS0000007873.V321962.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.V321962.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.V321962.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Newhaven Address Church Lane Boroughbridge North Yorkshire YO51 9BA 01423 325053 01423 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) St Anne’s Community Services Mrs Anne Marie Black Care Home 5 Category(ies) of Learning disability (5) registration, with number of places Newhaven DS0000007873.V321962.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 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 service users with learning disabilities some or all of who may also have physical disabilities. The home consists of a two storey detached property home 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 acting manager on 15th November 2006 indicated that the current weekly fee for the home is £1,101.22. Additional costs include toiletries, hairdressing and transport costs. Newhaven DS0000007873.V321962.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This is what was used to write this report: • • • • • Information about the home kept by the Commission for Social Care Inspection. Information asked for before the visit, this is called a pre-inspection questionnaire. Comments from the relatives of two of the service users. Comments from the service users’ care manager. A visit to the home that they didn’t know was going to happen. This lasted for seven hours and included talking to and observing staff interaction with all four people currently living in the home. Discussions about how the home is run were also held with care staff and with the acting manager and deputy manager. All areas of the home were seen and records that the home has to keep were checked. Service users’ medication was also checked to make sure that it was being properly looked after for them. People living in the home were unable to express a preference as to how they wished to be known but the manager said he thought the term service user would be best. What the service does well: Service users and staff get to know each other very well and staff are kind and friendly so service users can be confident that they will get good help. Service users can have lots of contact with friends and family and see them at any time. Staff also spend a lot of time talking to them. This means that they can have company whenever they like. Service users see their GP, dentist, optician and chiropodist whenever they need to. This means that they can stay as healthy as possible. Service users have a good choice of food and drinks at mealtimes. This ensures that they have a varied diet of their choosing and can enjoy their meals. Service users are asked to say what care they need and how they would like this to be given, this gives them the chance to have a say in planning services for themselves in the future. Newhaven DS0000007873.V321962.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? 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. Newhaven DS0000007873.V321962.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 Newhaven DS0000007873.V321962.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1,2 and 4. Quality in this outcome area is good. Information about the service provided is available to anyone who wants it. A detailed needs assessment process ensures that all the needs of service users are identified and planned for before they move into the home. This judgement has been made using available evidence including a visit to the service. EVIDENCE: The home has a detailed statement of purpose and service user guide, which are both produced in a user-friendly format and a copy of the service user guide is provided to each service user. A detailed assessment had been taken on each of the service users before they moved in. No admissions have been made since the last key inspection but it is the home’s policy that any prospective service user has introductory visits to the home and moves in on a trial basis before the placement is made permanent. Newhaven DS0000007873.V321962.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 and 9. Quality in this outcome area is adequate. Service users make a number of decisions and choices on a daily basis but information about how service users should be helped needs to be checked and updated so that they can be confident that they are getting the best support. This judgement has been made using available evidence including a visit to the service. EVIDENCE: Case tracking showed that service users’ individual personal plans have not been reviewed or updated for some time. Information available however identified that staff are expected to meet the needs of the individual service user in a way that promotes their wellbeing. Daily records, discussions with relatives, care manager and staff and observations made during the visit confirmed this to be the case. Newhaven DS0000007873.V321962.R01.S.doc Version 5.2 Page 10 Person centred planning meetings have been held for each service user in which they have had a say in the plan for changes to services needed and individuals’ wishes and agreed outcomes have been recorded. Daily records showed that service users are able to make choices and decisions in their daily lives and observations at the visit confirmed this. Records showed that service users can take reasonable risks subject to a personal risk assessment although these had not been reviewed or updated for some time. Newhaven DS0000007873.V321962.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): 12,13,15 16 and 17. Quality in this outcome area is good. The range of activities enjoyed by service users is varied and individually tailored. They are supported to develop and maintain personal relationships. Meals are nutritious and offer a varied diet with special diets being catered for. This judgement has been made using available evidence including a visit to the service. EVIDENCE: Service users have a variety of activities that they participate in within their local community and all of them have had a holiday or short break of their choice. Service users are allowed personal space when they want it. Newhaven DS0000007873.V321962.R01.S.doc Version 5.2 Page 12 Service users are well supported to develop and maintain personal relationships with family and friends and one of them had just been to meet their sister in London. Relatives said they are kept well informed about their relative’s wellbeing. Staff select the main meals based on what they know the service users like. Service users choose what they want for breakfast and lunchtime during the visit was very relaxed and informal with individuals being helped in an unobtrusive manner. Liquid refreshments were also offered on a regular basis. Staff explained that meals are varied and nutritious with a healthy diet being encouraged for all service users. Newhaven DS0000007873.V321962.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 good. Service users are able to stay as healthy as they can by being helped to attend regular health appointments and by being helped to take their medication. They are also well supported when having their personal care needs met. This judgement has been made using available evidence including a visit to the service. EVIDENCE: Staff were seen to provide all support, including that concerning personal care needs, in a way that promoted the service users’ privacy and dignity. Case tracking identified that each service user is registered with a GP. They attend regular appointments with various health care professionals, opticians, chiropodists and dentists. Service users’ health records are well kept. The Newhaven DS0000007873.V321962.R01.S.doc Version 5.2 Page 14 relative of one service user said that staff have offered to support family members to visit their relative in hospital if he is admitted. All of the service users have their medication administered by staff. This is well recorded and all medication is securely stored. All of the care staff have undertaken appropriate medication training. Staff have had specialist training in administering certain medication to one of the service users in an easier way making the process better for the service user concerned. Newhaven DS0000007873.V321962.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. Systems are in place for dealing with concerns or complaints and for ensuring the protection of service users although better staff training could better protect individuals. This judgement has been made using available evidence including a visit to the service. EVIDENCE: A comprehensive complaints procedure is followed and is made available to residents in easy read and pictorial form. Where service users are unable to verbalize concerns staff observe behaviours and body language to identify any dissatisfaction. There have been no complaints since the last inspection. There is also an adult protection procedure in operation and all staff have some adult protection training during their induction although they have not had refresher training. There is an adult protection investigation being undertaken at present by the organization in agreement with the Local Authority adult protection team, this is being well managed. Service users’ monies are checked weekly by staff to make sure no mistakes have been made with them, the acting manager agreed to introduce a system of daily checks so that any mistakes can be spotted and rectified sooner. A Newhaven DS0000007873.V321962.R01.S.doc Version 5.2 Page 16 check of the service users’ personal monies against records kept showed that they were all correct and well accounted for. The deputy manager explained that no physical restraint is used on any of the service users. Newhaven DS0000007873.V321962.R01.S.doc Version 5.2 Page 17 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): 24,25,28,29 and 30. Quality in this outcome area is adequate. Whilst the home is clean and tidy there are areas that require redecoration and the heating system is faulty and needs replacing to ensure that service users can be warm and safe. This judgement has been made using available evidence including a visit to the service. EVIDENCE: The home is generally well maintained although some communal areas are now in need of redecoration, these include the lounge/dining area and the landing area on the first floor. The deputy manager explained that the sensory room has been redecorated and refurbished, that new furniture has been ordered for the lounge and that Newhaven DS0000007873.V321962.R01.S.doc Version 5.2 Page 18 one service user’s bedroom is to have a new carpet laid. Service users’ bedrooms are decorated and furnished to their personal taste. Bathrooms are well equipped and there are appropriate aids and adaptations fitted throughout the home. The home was clean and tidy throughout. It was also warm although there are problems with the heating system. The gas fire in lounge has been condemned and the central heating system is not working effectively. The heating is currently being supplemented through the use of portable electric heaters. Whilst the deputy manager had risk assessed the use of these with regard to service users knocking them over, the risks to individuals of being harmed through direct contact with the heaters or through tripping over trailing cables had not been assessed. Newhaven DS0000007873.V321962.R01.S.doc Version 5.2 Page 19 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. Quality in this outcome area is adequate. The home is adequately staffed. Many of the staff however are not trained well enough however to give service users confidence that they are getting the best support possible. This judgement has been made using available evidence including a visit to the service. EVIDENCE: Sufficient staff were on duty at the time of the visit and staff rosters indicate that the home is adequately staffed at all times. The acting manager explained that the home 66 hrs short of day staff at present these hours are being recruited to and confirmed that there would be no times when there would be less than 2 staff on duty. St Anne’s Community services have good recruitment procedures. They make appropriate personnel checks before employing someone. Newhaven DS0000007873.V321962.R01.S.doc Version 5.2 Page 20 The acting manager explained that all staff have undertaken medication training and most have undertaken infection control training. A third of care staff have completed NVQ training. Newly recruited staff undertake the learning disability award framework induction and foundation training. All staff have had basic training in adult protection, moving and handling, food hygiene and first aid. They have not however had training to keep their skills in these areas up to date. The acting manager has given every staff member an appraisal since he has been in post and the deputy manager has been giving all staff formal supervision on a regular basis. Newhaven DS0000007873.V321962.R01.S.doc Version 5.2 Page 21 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37,39 and 42. Quality in this outcome area is adequate. The home is adequately managed even though the registered manager is currently not in post. Whilst several health and safety issues require attention, the managers are aware of these and have a plan to address them thus ensuring the safety and well being of service users. This judgement has been made using available evidence including a visit to the service. EVIDENCE: The registered manager of the home is currently on temporary leave and the deputy manager has been managing the service in her absence. An acting manager has recently been appointed on a part time basis to provide additional support until the registered manager’s return to work. One relative commented that the recent changes in management have made communication channels less clear but that the quality of service for the service users has not been adversely affected.37 Newhaven DS0000007873.V321962.R01.S.doc Version 5.2 Page 22 The service manager undertakes monthly quality audits of home. Service users’ views have been ascertained through person centred planning meetings and through observations. The views of relatives have also been surveyed and a mini plan has been developed for the home. The acting manager and deputy manager said they plan to survey health and social care professionals. Feedback from the service users’ care manager said that the home is being well managed by the acting manager and the deputy manager.39 Health and safety issues requiring action were noted as follows: • • The boiler room was unlocked at the time of the visit. The company that fitted it has condemned the gas fire in the lounge and the central heating radiators are not working effectively. The heating is currently being supplemented through the use of portable electric heaters. Whilst the deputy manager had risk assessed the use of these with regard to service users knocking them over, the risks to individuals of being harmed through direct contact with the heaters or through tripping over trailing cables has not been assessed. The fire risk assessment for the home has not been reviewed for some time. Whilst the fire safety system is generally being checked on a weekly basis, these were sometimes being missed. Fire safety training was overdue for all staff and the newest recruit had not had any substantial fire training. Hot food temperature checks were sporadic and inconsistently recorded. All hot water outlets are being tested monthly, full immersions outlets should ideally be tested weekly. Whilst a system is in place for checking and recording hot water storage temperatures records showed that the hot water is being stored at less than 60°C. The acting manager explained that some of the garden flagstones are uneven and present a risk to service users. • • • • • • The acting manager has delegated duties to care staff to have responsibility for different areas including health and safety. He and the deputy manager said that they would check all health and safety systems and ensure that appropriate procedures are followed forthwith. Any accidents are well recorded. Newhaven DS0000007873.V321962.R01.S.doc Version 5.2 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 3 2 3 3 X 4 3 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 2 ENVIRONMENT Standard No Score 24 2 25 3 26 X 27 X 28 2 29 3 30 3 STAFFING Standard No Score 31 X 32 2 33 3 34 3 35 1 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 X 1 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 3 X 2 X X 1 X Newhaven DS0000007873.V321962.R01.S.doc Version 5.2 Page 24 No. 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 2 3 Standard YA6 YA9 YA24 Regulation 15 (2) 17 23(2) Requirement Service users’ care plans must be regularly reviewed and updated as required. Service users’ risk assessments must be regularly reviewed and updated as required. The condemned gas fire in lounge must be replaced and the central heating system be repaired or replaced. The use of portable electric heaters must be risk assessed fully in relation to the service users including for risks of burns and trips. All staff must be provided with mandatory refresher training. All staff must be provided with fire safety training at regular intervals. Action must be taken to ensure that stored hot water is held at a temperature of 60 °C or greater. Any uneven flagstones in the garden must be relaid. Timescale for action 15/01/07 15/01/07 29/01/07 4 YA24 YA42 13(4) 29/12/06 5 6 7 8 YA35 YA42 YA42 YA42 13(4) 23(4) 13(4) 23(2) 26/02/07 22/12/06 22/01/07 26/02/07 Newhaven DS0000007873.V321962.R01.S.doc Version 5.2 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. 2. 3. 4. Refer to Standard YA23 YA24 YA32 YA42 Good Practice Recommendations All staff should be given adult protection adult protection refresher training. The lounge/dining area and the landing area on the first floor should be redecorated. A minimum of 50 of care staff should be trained to NVQ level 2 or above. The fire risk assessment for the home should be reviewed and updated as necessary. The fire system should be tested every week. All hot meats should be temperature tested before service. Hot water temperatures at full immersion outlets should be tested weekly. Newhaven DS0000007873.V321962.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection York Area Office Unit 4 Triune Court Monks Cross York YO32 9GZ 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.V321962.R01.S.doc Version 5.2 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. 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