Inspection on 03/09/08 for Newhaven

This inspection was carried out on 3rd September 2008.

CSCI found this care home to be providing an Adequate service.

The inspector found no outstanding requirements from the previous inspection report, but made 3 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Newhaven 17/10/07

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 27/11/2008.

CARE HOME ADULTS 18-65 Newhaven Church Lane Boroughbridge North Yorkshire YO51 9BA Lead Inspector Carol Haj-Najafi Key Unannounced Inspection 3rd September 2008 09:30 Newhaven DS0000007873.V370801.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.V370801.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.V370801.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 jennifer.hanrahan@st-annes.org.uk www.st-annes.org.uk St Anne’s Community Services 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) Mrs Jane Louise Robinson Care Home 5 Category(ies) of Learning disability (5) registration, with number of places Newhaven DS0000007873.V370801.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 17th October 2007 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 whom 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. On the 8 September 2008 the service manager told us the current weekly fee for the home is £1,144.38. Additional costs include toiletries, hairdressing and transport costs. Newhaven DS0000007873.V370801.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 1 star. This means the people who use this service experience adequate quality outcomes. The Commission for Social Care (CSCI) inspects care homes to make sure the home is operating for the benefit and well being of the people who live there. More information about the inspection process can be found on our website www.csci.org.uk We have reviewed our practice when making requirements, to improve national consistency. Some requirements from previous inspection reports may have been deleted or carried forward into this report as recommendations – but only when it is considered that people who use services are not being put at significant risk of harm. In future, if a requirement is repeated, it is likely that enforcement action will be taken. The last key inspection was carried out in October 2007. Before this unannounced visit we reviewed the information we had about the home which included an annual quality assurance assessment (AQAA) that the manager completed. We used this information to help us decide what we should do during our inspection visit. People who live at the home have limited communication and cannot tell us if they are satisfied with the service they receive. Surveys were sent out to staff and health care professionals. Nine surveys were returned. Comments from the surveys have been included in the report. One inspector was at the home for one day from 09.30am to 4.15pm. During the visit we looked around the home and talked to staff. We observed how staff interacted with people who live at the home and looked at care plans, risk assessments, daily records and staff records. Feedback was given to two staff at the end of the visit. What the service does well: An experienced staff team work with the people who live at the home. They talked about using different approaches with people to make sure people’s individual needs are met. One staff member said, “We always try to offer choice to people.” Staff have good knowledge about the people who live at the home. Newhaven DS0000007873.V370801.R01.S.doc Version 5.2 Page 6 Good systems are in place to make sure people’s health and personal care needs are met. We received positive feedback from two healthcare professionals. One person said, “ The care service responds to individuals who have problems or are experiencing difficulties appropriately.” Another person said, “Excellent calm attitude with users.” Staff are well trained. One staff said, “We get plenty of training.” Another staff said, “We are always made aware of what training is available.” What has improved since the last inspection? What they could do better: The personal profiles are very good but there are some gaps in how people’s needs should be met. More information should be added to make sure people’s needs are properly identified. Person centred plans should be updated to make sure people’s wishes and aspirations are recognised. Listening devices are sometimes used to alert staff if people have an epileptic seizure. The use of the monitors should be identified through a proper assessment process. This will make sure people are safe and their privacy is taken into account. People who live at the home should have more stimulation and opportunities to go out. Staff should be able to spend more quality time with people. This will make sure people have a fulfilling and interesting lifestyle. One staff member said, “We want to make their life more interesting because at the moment they do not have a very interesting life.” The use of the home’s vehicle should be monitored more closely to make sure people are getting fair access to the vehicle and value for money. Some areas of the home should be decorated to provide people with more pleasant surroundings. Daily records do not always contain enough information to get a full picture of what people have been doing. One person attends a day centre up to five days Newhaven DS0000007873.V370801.R01.S.doc Version 5.2 Page 7 a week. Staff could not confirm when they attended during August. Daily records did not contain information when they attended. This will make sure people’s lifestyle can be properly monitored especially when people who use the service cannot tell you what they have been doing and if they are happy with the service they receive. The home should have clearer guidance on how long food can be saved after it has been cooked. This will make sure food is safe to eat. The manager has introduced some good systems to improve the service. However more management systems should be introduced to monitor the quality of the service. This will make sure the home is achieving its aims and objectives. 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.V370801.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.V370801.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): 2 People who use the service experience good quality outcomes in this area. Systems are in place to make sure people’s needs are properly assessed before they move into the home. We have made this judgement using a range of evidence, including a visit to the service. EVIDENCE: At the last inspection we identified that the home could improve their pre admission assessment process. Following the inspection we received an action plan from the home that told us ‘the procedure will be reviewed to ensure future admissions will be effective’. The same people have lived at the home since the last inspection so the home has not had an opportunity to put their new procedure into practice. In the AQAA the manager said, “The Service Users have care packages in place and these are reviewed by Social Services to ensure that Newhaven is meeting their needs on an individual basis and remains an appropriate placement for them.” Newhaven DS0000007873.V370801.R01.S.doc Version 5.2 Page 10 At the last inspection we also identified that the Statement of Purpose was out of date so anyone considering using the service would not have the right information about the home. We looked at a Statement of Purpose update sheet which confirmed it was last updated in July 2008. Newhaven DS0000007873.V370801.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 & 9 People who use the service experience good quality outcomes in this area. In the main, people’s needs are identified and met although some gaps in the care planning process could result in some care needs and aspirations being overlooked. We have made this judgement using a range of evidence, including a visit to the service. EVIDENCE: Much of the day was spent in the lounge observing the care being given to people. This included how staff interact with people at the home. Staff were polite and chatted to people throughout the day. Everything was done at a relaxed pace. In the AQAA the manager said, “Staff are experienced and have been employed at Newhaven for a number of years; they are all experienced in individual’s needs and the importance of individual choice. Choice is always Newhaven DS0000007873.V370801.R01.S.doc Version 5.2 Page 12 offered and all staff are aware of non-verbal cues to look for when identifying a response to choices offered.” We talked to four staff. They had good knowledge about the people who live at the home. They talked about using different approaches with people to make sure their individual needs are met. One staff member said, “We always try to offer choice to people.” We looked at three people’s care plans and assessments. New personal profiles have been introduced. These contained some very good information about each person and how their needs should be met. The care that staff described, for each person, was the same as the care that was written in the personal profiles. For example one staff member talked about supporting one person with a specific routine and this was recorded in their personal profile. The personal profiles are very good but there are some gaps in how people’s needs should be met. For example staff described how they support one person to get in the bath but this information was not recorded. Daily records identified that one person had been shouting, screaming and had ‘kicked out’ but their personal profile and care plans did not contain any information about this. Staff said the personal profiles are replacing the existing plans but they are still learning how to do the profiles and ‘will be building on them’. A list of ‘indicators’ of how people are feeling has also been introduced. These identify when people are happy or unhappy. These help everyone to understand how the person is feeling. The files we looked at did not contain up to date information about people’s goals or aspirations. Person centred plans were completed in 2006; one plan was completed when the person lived elsewhere. Each file had a lot of information, some of which is duplicated and some which is not current. Staff were asked if they could find specific pieces of information but struggled to locate them because of the amount of information in each file. Risks to people who use the service have been identified, assessed and regularly reviewed. There is information to help staff manage and minimise risks. For example, one person’s file identified how the risk of injury is minimised when they are having their haircut. When we looked around the home we noticed listening devices (baby monitors) in two bedrooms. Staff explained these were used to alert staff if people had an epileptic seizure. The devices were on during the day even when people were not in their room. We looked at risk assessments but these did not contain any information about using the devices. Newhaven DS0000007873.V370801.R01.S.doc Version 5.2 Page 13 The use of listening devices must be properly assessed and there should be specific guidance for when they are used. This will protect people’s privacy. Newhaven DS0000007873.V370801.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): 12, 13, 14, 15, 16 & 17 People who use the service experience adequate quality outcomes in this area. People are given opportunities to take part in different activities but they also have periods with very little stimulation. More regular activity would give people a fuller and more stimulating lifestyle. We have made this judgement using a range of evidence, including a visit to the service. EVIDENCE: People go to various organised activities during the week. Some go to day centres; others have organised group and one to one activity programmes. One person attends a group activity for older people one afternoon a week. Another person has one to one staffing and attends various activities in the community one day a week. Newhaven DS0000007873.V370801.R01.S.doc Version 5.2 Page 15 When asked what the home does well, one staff member said, “Giving service users the right to their own independence in the community.” However concerns were raised that people did not get enough stimulation or opportunities to go out. We spoke to four staff and received seven staff surveys. Several staff raised concerns that people who live at the home did not have enough ‘quality time with staff’. Staff felt they were spending too much time cleaning and this was having an impact on people’s lifestyles. They said, in the main, people who live at the home cannot assist with daily living tasks. We looked at the cleaning rota which had daily and weekly tasks. The list was extensive. For example it said the fridge should be emptied and cleaned every day; upstairs windows cleaned every Saturday and office paintwork cleaned every Sunday. We looked at daily records. These did not always contain enough information to get a full picture of what people had been doing. One person attends a day centre up to five days a week. Staff could not confirm when s/he attended during August. Daily records did not contain information when s/he attended; the transport records were unclear who had travelled; a diary completed by the day service was not always filled in. Some days a daily record was not completed. There should be sufficient information to monitor people’s quality of lifestyle especially when people who use the service cannot tell you what they have been doing and if they are happy with the service they receive. Activities in the community take place but these are limited. Staff said people enjoy visiting the town centre, which is within walking distance but it is not always possible to get people out. We looked at the transport records. The vehicle that is used by four people had only been out thirteen times during August. These were predominantly to take people to day centres or food shopping. There was very little evidence to show what people do when they are at home. Staff said, people sit for long periods because staff are doing other tasks. Staff devise a weekly menu, which is based on people’s preferences. They also record each meal that people eat. The menus were varied and nutritious. Newhaven DS0000007873.V370801.R01.S.doc Version 5.2 Page 16 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 & 20 People who use the service experience good quality outcomes in this area. People’s health and personal care needs are well met. We have made this judgement using a range of evidence, including a visit to the service. EVIDENCE: Staff said the home is good at meeting people’s personal and healthcare needs. People have good daily support with their personal care. Care plans had good information about how personal care needs should be met although as stated in the previous section some areas should be expanded. Daily records showed us that staff are vigilant and look for changes in wellbeing. For example, staff noted that one person had slight reddening to the skin, this was closely monitored and staff asked for healthcare advice as soon as they thought it was becoming sore. We received positive feedback from two healthcare professionals. One person said, “ The care service responds to individuals who have problems or are Newhaven DS0000007873.V370801.R01.S.doc Version 5.2 Page 17 experiencing difficulties appropriately.” Another person said, “Excellent calm attitude with users.” We looked at information that showed us people’s health is properly monitored. Health care action plan have recently been introduced; these identify people’s healthcare needs. These have recently been introduced. Weight is monitored and healthcare appointments are clearly recorded. We looked at medication systems. Medication is well organised and, generally, systems are in place to make sure the right medication has been administered. This includes identifying which staff is responsible for administering medication on each shift. Clear guidance is available that identifies when people should receive ‘as and when required’ (PRN) medication. When the pharmacy delivers the medication a member of the night staff team writes out the medication administration records (MAR). They do not sign the records and there is no evidence to show it has been checked. Printed MAR charts are not essential but they are better than handwritten charts. This is because there is less risk of error. If a handwritten MAR is the only available option, there must be a robust system to check that the MAR is correct before it is used. Following the inspection the manager confirmed they had arranged with the pharmacy to provide printed medication administration records. Newhaven DS0000007873.V370801.R01.S.doc Version 5.2 Page 18 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22 & 23 People who use the service experience good quality outcomes in this area. Systems are in place to make sure people are safeguarded. Transport costs are not properly monitored, which could result in people paying for services they do not receive. We have made this judgement using a range of evidence, including a visit to the service. EVIDENCE: Staff said the home had not received any complaints since the last inspection and no complaints were recorded in the complaints record. In the AQAA the manager said, “Staff attend St Anne’s training on Safeguarding Vulnerable Adults and are aware of whistle blowing, and the ‘Tell us what you think’ reporting. They are all aware of signs and symptoms to watch for and would not hesitate in reporting mal practices.” Staff 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. We looked at the records for the home’s vehicle. The mileage for each journey was recorded but it was not possible to establish who travelled in the vehicle. According to the transport records the vehicle was only used thirteen times Newhaven DS0000007873.V370801.R01.S.doc Version 5.2 Page 19 during August. Four people who use the vehicle each pay £56 a month towards the cost. The use of the vehicle should be monitored more closely to make sure people are getting fair access to the vehicle and value for money. Newhaven DS0000007873.V370801.R01.S.doc Version 5.2 Page 20 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24 & 30 People who use the service experience adequate quality outcomes in this area. People live in a clean and homely environment. Some areas are shabby so people do not always have pleasant surroundings. We have made this judgement using a range of evidence, including a visit to the service. EVIDENCE: The home is clean and tidy and looks homely. The bedrooms of the people who use the service are generally well maintained and show their individual interests and personality. There is an attractive, large enclosed garden. The downstairs bathroom has an assisted bath and hoist available for those who need it. At the last inspection we identified that some areas of the home needed decorating. That was also identified at this inspection. Some areas are Newhaven DS0000007873.V370801.R01.S.doc Version 5.2 Page 21 decorated satisfactorily; other areas paintwork and plasterwork is damaged and wallpaper is torn. In the two upstairs bedrooms, the velux windows did not have suitable blinds. One blind was torn and the other had fastenings that had stretched so it did not cover the window properly. The last report stated ‘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’. This has still not been addressed. We looked at maintenance checks that had been carried out by staff at the home. These identified that work had been outstanding for a long period of time. For example, they recorded that wallpaper was coming off on the stairs and it need decorating in October 2007. The stairs still needed decorating. At the last inspection we identified that the home was cold at times. Staff said this problem has been resolved and the temperature of the house is satisfactory. Clinical waste is properly managed and staff wear protective clothing when attending to the personal care needs of people who live at the home. Newhaven DS0000007873.V370801.R01.S.doc Version 5.2 Page 22 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 33, 34 & 35 People who use the service experience adequate quality outcomes in this area. Staff are trained and skilled, however they are not always allocated enough time to support the people who live at the home properly. We have made this judgement using a range of evidence, including a visit to the service. EVIDENCE: Staff said they work well together and communication is good. One staff said, “Everybody takes responsibility and we do things together.” Another staff said, “We are a good staff team.” As stated in the lifestyle section, several people raised concerns about staffing levels. Staff thought the people who live at the home had their basic needs well met, for example personal care, but thought people’s quality of life could improve if they had more quality time with staff. One staff member said, “we want to make their life more interesting because at the moment they do not have a very interesting life.” Another staff member said the home is ‘often short staffed’ and they have to use agency staff which ‘is sometimes difficult’. Newhaven DS0000007873.V370801.R01.S.doc Version 5.2 Page 23 Staff said the people who live at the home are ‘very dependant’ and making sure their personal care needs are met ‘takes up a lot of time’. Staff also said they spend time transporting some people to day services. Most people who live at the home require support from two staff for moving and handling. One staff member said they thought a domestic should be employed to work at the home, which would ‘free up time to work with people’. We looked at the staff rota. The week of the inspection, three staff worked during each day but for four out of seven evenings only two staff were on the rota to work. Staff told us they are given training which is relevant to their role, it helps them understand and meet the individual needs of the people who live at the home, and keeps them up to date with new ways of working. One staff said, “We get plenty of training.” Another staff said, “We are always made aware of what training is available.” In the AQAA, the manager told us all staff employed within the service hold or are working towards National Vocational Qualification, Level 2 or above. The manager also told us, staff have completed relevant training and satisfactory pre-employment checks have been carried out before staff start working at the home. We did not have access to the training or pre-employment records because only the manager can access these and she was not present at the inspection. Newhaven DS0000007873.V370801.R01.S.doc Version 5.2 Page 24 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 & 42 People who use the service experience adequate quality outcomes in this area. The manager has introduced some good systems to improve the service. However the home is still not fully achieving its aims and objectives because people’s needs are not being fully met. We have made this judgement using a range of evidence, including a visit to the service. EVIDENCE: The registered manager is on maternity leave, so a temporary manager is managing the home. The temporary manager also manages another registered service. Staff said the current management arrangements are satisfactory and the manager is managing the home well. One person said, “She will listen to what people have to say and will let us know what needs updating.” A deputy Newhaven DS0000007873.V370801.R01.S.doc Version 5.2 Page 25 manager has been appointed and should be starting working at the home shortly. Staff said the recent introduction of health action plans, personal profiles and the list of indicators of how people are feeling has been good because it has helped identify people’s needs. There have been management changes at the home in the last few months. Some staff said this had been difficult and at times they have not felt supported. One person said when they wanted guidance they ‘have not been able to get in touch with the person’ they wanted to speak to. St Anne’s ‘management advice line’ was displayed in the office. At least once a month a representative of the organisation should visit the home to make sure it is being properly managed. These are called Regulation 26 visits. Staff said the area manager visits regularly and looks around the home and asks people if they are okay. Staff could not locate the reports for any of the visits during 2008. We should be able to look at these so we can check the quality of the service is being properly monitored. Accidents and incidents are well recorded. Daily notes identify when accident/incident forms have been filled in. As stated in the lifestyle section of the report, sometimes staff do not record enough information about what people have done during the day. This also applies to describing people’s behaviour in daily records. For example, staff wrote ‘agitated’ or ‘severe agitation’ to describe behaviour but did not describe what those behaviours were. It is very important to record enough information to monitor people’s welfare and measure their quality of life. We also identified that people should have a fuller and more stimulating lifestyle, and staffing levels and allocation of tasks needs to be addressed, to make sure people’s needs are properly met. The management team should introduce strategies to make sure the home achieves its aims and objectives. The manager tells us about important events that happen at the home. Since the last inspection we have received notifications when significant events have occurred. On the day of the inspection, some people were having lasagne for lunch and others were having party food. The party food had been cooked the day before and the lasagne had been cooked two days before. The home should have clear guidance on how long food can be saved after it has been cooked. This will make sure food is safe to eat. Newhaven DS0000007873.V370801.R01.S.doc Version 5.2 Page 26 In the AQAA the manager told us, relevant policies and procedures are in place and equipment has been serviced or tested as recommended by the manufacturer or regulatory body. We checked when some of the equipment was serviced and this corresponded with what had been written in the AQAA. Newhaven DS0000007873.V370801.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 X 2 3 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 2 ENVIRONMENT Standard No Score 24 2 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 2 34 3 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 X 3 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 3 3 X 3 2 3 X 2 2 X Newhaven DS0000007873.V370801.R01.S.doc Version 5.2 Page 28 Are there any outstanding requirements from the last inspection? No 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 YA14 YA33 2 YA41 12 (1) (a) 17(1) (a) Regulation 18 (1) (a) Requirement Staff must be given sufficient time to spend with people who live at the home. This will make sure people’s needs are met. Sufficient information must be recorded about people who live at the home. This will make sure their quality of life and welfare can be properly monitored. Timescale for action 30/10/08 30/10/08 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard YA6 Good Practice Recommendations The care planning process should continue to be developed to make sure people’s care needs and aspirations are properly identified. This will make sure peoples are needs and wishes are met. Listening devices should only be used to minimise the risk of harm if it has been identified through a comprehensive risk assessment process. This will make sure people are safe and their privacy has been taken into account. DS0000007873.V370801.R01.S.doc Version 5.2 Page 29 2. YA9 Newhaven 3 4 5 6 7 YA23 YA24 YA38 YA39 YA42 Use of the home’s vehicle should be carefully monitored to make sure people who pay for the vehicle are getting fair access and value for money. The home should be decorated and maintained to a reasonable standard. This will make sure people live in a pleasant environment. Management systems should continue to be developed to make sure the home achieves it’s aims and objectives. Regulation 26 visits reports should be made available in the home. This will help make sure the quality of the home is properly monitored There should be clear guidance on how long food can be saved after it has been cooked. This will make sure food is safe to eat. Newhaven DS0000007873.V370801.R01.S.doc Version 5.2 Page 30 Commission for Social Care Inspection North Eastern Region St Nicholas Building St Nicholas Street Newcastle Upon Tyne NE1 1NB 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.V370801.R01.S.doc Version 5.2 Page 31 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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