Inspection on 06/03/06 for Newhaven

This inspection was carried out on 6th March 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 there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Newhaven 08/01/07

Newhaven 22/08/05

Newhaven 09/02/05

Newhaven 17/08/04

Newhaven 24/02/04

Similar services:

Clover House

Parkside

Park Lodge

Mere Hall View

St Bonaventures

Hudson Road

Whitewalls

Home Farm

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

CARE HOMES FOR OLDER PEOPLE Newhaven 5 Sunningdale Road Wallasey Wirral CH45 OLU Lead Inspector Inger Moynihan Unannounced Inspection 6th March 2006 09:00 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Newhaven DS0000018915.V285677.R01.S.doc Version 5.1 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Newhaven DS0000018915.V285677.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Newhaven Address 5 Sunningdale Road Wallasey Wirral CH45 OLU 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) 0151 639 6420 Mr Danny So Mrs Lynda So Mr Danny So Care Home 16 Category(ies) of Learning disability over 65 years of age (16) registration, with number of places Newhaven DS0000018915.V285677.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. Only five adults with a learning disability and eleven elderly people with a learning disability may be accommodated within the maximum number of sixteen. One named adult with a learning disability under the age of 65 years (six weeks respite care) within the maximum number of sixteen. 22nd August 2005 2. Date of last inspection Brief Description of the Service: Newhaven is registered to provide care for 16 elderly people with a learning disability. The home consists of two adjacent semi-detached houses in a quiet residential area of New Brighton. The home is close to a bus route which gives easy access to local shops, the seafront and other community facilities. Accommodation is provided in six single and five shared rooms. Six bedrooms have en suite facilities. Communal areas consist of a lounge/dining room and a small lounge at the side of the main living area. The home has a large back garden which has fixed garden furniture and is reached via a patio door. Newhaven DS0000018915.V285677.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection took place over six hours and was the second statutory unannounced inspection for 2005/2006. A tour of the premises took place and staff and service users records were inspected. Three staff were spoken to and observations were made on the service user group. What the service does well: What has improved since the last inspection? What they could do better: The assessment process needs to be developed as it is not possible to understand the meaning of some documentation. This could result in aspects of service users care needs being missed. Service users care needs are met in a variety of ways. However, because the assessment documentation was soemtimes unclear, it was not possible to establish whether the service users care needs are being fully met. Improvements need to be made to the care plans to ensure service users care needs are being met in accordance with their particular requirements. Newhaven DS0000018915.V285677.R01.S.doc Version 5.1 Page 6 There is evidence of service users health care needs being met, however it was not possible to establish whether these care needs are being addressed appropriately as the assessments and care plans are not up to date. Improvements need to be made to the medication administration procedures to ensure service users safety and welfare. Arrangements will be made for the CSCI pharmacist to visit the home in order to carry out an audit of this aspect of care provision. A range of social activities are provided to ensure service users interest and mental stimulation. However, improvements do need to be made to this aspect of care provision to prevent service users from becoming bored. All staff have completed some degree of training in relation to the protection of vulnerable adults from abuse. However, the necessary supporting documentation is not in place which could lead to issues of abuse not being dealt with appropriately. The standard of the decor is mixed with some parts of the home being maintained to a good standard and other parts being in need of further attention. The home does not therefore present as a homely and comfortable environment throughout. There is a shortfall in the care and domestic staffing hours provided. Staff are provided with relevant training although this aspect of care provision does need to be developed to ensure service users specific care requirements are met. The Registered Manager has allocated the responsibility of the day to day control of the home to a senior member of staff. This creates some inconsistency in the management of the service as this member of staff does not yet wish to become registered with the CSCI. Concerns were raised during the inspection that improvements are only made to the standard of care when legal requirements are made through the regulatory process. Also that the Registered Manager and the senior member are not pro-active in addressing the improvement agenda. This issue will also be addressed with the Registered Providers outside of the inspection process. Most service users are supported with the management of their finances and systems are in place to demonstrate any transactions made on their behalf. Improvements need to be made to the systems in place to ensure they can be easily audited. Staff are supervised informally to ensure they are supported in their role. A system of formal supervision is not in place for the purpose of staff development. Newhaven DS0000018915.V285677.R01.S.doc Version 5.1 Page 7 The health, safety and welfare of the service users is promoted throughout the home. However, some improvements still need to be made to ensure service users safety and welfare. Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Newhaven DS0000018915.V285677.R01.S.doc Version 5.1 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Newhaven DS0000018915.V285677.R01.S.doc Version 5.1 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 3 and 4 The assessment process needs to be developed as it is not possible to understand the meaning of some documentation. This could result in aspects of service users care needs being missed. Service users care needs are met in a variety of ways. However, because the assessment documentation is soemtimes unclear, it was not entirely possible to establish whether the service users care needs are being fully met. EVIDENCE: A range of assessments and risk assessments have been completed to ensure staff are aware of service users different care requirements. The issues addressed are relevant to service users care needs. While the risk assessments identify the level of risk presented, there is no explanation as to the meaning of the outcome of the assessment. The assessment and risk assessment process needs to be developed in order to identify a clear outcome in relation to the service uses care needs. If the outcome of a risk assessment is not clearly identified, then important aspects Newhaven DS0000018915.V285677.R01.S.doc Version 5.1 Page 10 of service users care needs may be missed and they may be left vulnerable to the risk of harm. Service users physical and emotional care needs are met through regular contact with relevant health care professionals and a range of social activities are provided. Staff are provided with relevant training, although more specialist training does need to be provided to reflect the service users specific care requirements. None of the service users living as at Newhaven have any specific care needs in relation to their social, cultural or religious preferences. Newhaven DS0000018915.V285677.R01.S.doc Version 5.1 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8 and 9 Improvements need to be made to the care planning process to ensure service users care needs are met in accordance with their particular requirements. There is evidence of service users health care needs being met, however it was not entirely possible to establish whether these care needs are being addressed appropriately as the assessments and care plans are not up to date. Improvements need to be made to the medication administration procedures. EVIDENCE: A documented plan of care is in place for each of the service users to ensure the staff can provide the appropriate package of care. The care plans cover a range of issues relevant to the care of the service users and guidance is in place on how the care should be provided. A record is kept of service users welfare on a regular basis and there is evidence of service users health care needs being addressed and monitored. Newhaven DS0000018915.V285677.R01.S.doc Version 5.1 Page 12 The following issues of concern were raised in relation to the documentation examined: • • • The care plans had not been reviewed since July 2005 therefore did not present a current picture of the service uses care needs. The diary sheets staff keep to monitor service users welfare were not regularly maintained and in one instance gaps of about seven days appeared. An incident of challenging behaviour in the form of violence against another service user had been recorded in one care plan but not the other. As a consequence of this there was no documented evidence to indicate staff had monitored this situation. A management plan was in place for service users who present with challenging behaviour, however, this had not been reviewed and gave guidance that was no longer relevant. A management plan had not been drawn up for a service user who presented with challenging behaviour in the form of screaming and shouting. • • These issues were discussed during the inspection and guidance was given with regard to the way in which care plans should be maintained. It was agreed that the specific issues identified would be updated immediately. Reviewing a service users care plan is a crucial part of the care planning process and demonstrates the decision making with regard to any changes being made. Without this, important aspects of a service users care needs may be missed and both the service users and the staff may be left vulnerable to the risk of harm. This is particularly important when challenging behaviour is presented in the form of violence and aggression. In the light of this it was agreed that all care plans would be reviewed by 31 March 2006. There is documented evidence to indicate that service users care needs are met. Regular contacts is maintained with a range of health care professionals such as the service users Community Psychiatric Nurse, Chiropodist, Optician and GP. Assessments are carried out in relation to tissue viability for the prevention of pressure sores and nutritional screening. However in light of the fact that the care plans are not up to date, it was not entirely possible to establish the accuracy of the information recorded. A part of the inspection process included sending out questionnaires to a range of health care professionals in order to obtain their comments on the standard of care provided. The comments made were positive including the clients care is to a high standard and the home is well organised and the care in relation to diabetes is excellent. The medication administration record sheets are well maintained and all staff who administer medication have been provided with training. A record of the Newhaven DS0000018915.V285677.R01.S.doc Version 5.1 Page 13 medication to be returned to the supplying pharmacist was in place and safe storage facilities are provided. The following issues of concern were raised: • • • • • • The general guidance about the way medication should be administered on the basis of as and when required was out of date. Specific guidance in relation to when medication should be administered on the basis of as and when required had not been documented. The guidance in relation to the use of homely remedies was out of date (2003). Medication was being kept in an unlabelled bottle. A list of the medication to be returned to the supplying pharmacist had not been kept. The drug fridge was not locked. For service users welfare and good health, the Registered Persons are required to ensure up to date guidance is available for staff reference on when medication should be administered on the basis of as and when required. The guidance in relation to the use of homely remedies must be reviewed along with a list being maintained of any medication to be returned to the supplying pharmacist. As a matter of good practice the fridge storing service users medication must always be kept locked. As a matter of routine, prescribed creams are always kept in the fridge. The Registered Persons should seek confirmation from the supplying pharmacist that this is the appropriate storage facility. As a result of these concerns arrangements will be made for the CSCI Pharmacist Inspector to visit the home in order to carry out an audit of the medication procedures in place. Newhaven DS0000018915.V285677.R01.S.doc Version 5.1 Page 14 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13 and 15 A range of social activities are provided to ensure service users interest and mental stimulation. However, improvements do need to be made to this aspect of care provision. Service users maintain contact with their family and friends who can visit at any time, however private facilities are not available to all service users. A varied menu is in place to ensure service users interest and good health. EVIDENCE: A range of leisure activities are provided. These include board games, art and craft, listening to music and the TV. Staff are available to take the service users to the shops or for a walk in the local area. Some service users join the activities provided at the sister home Newhaven Care. Some service users attend an evening social club and others attend day centres. While it is acknowledged that this aspect of care provision has certainly improved over the past year, further improvements still need to be made to ensure service users interest and stimulation. Information was given in respect of this issue. Service users friends and family may visit the home at any time although private facilities are not available to service users who share a bedroom. Newhaven DS0000018915.V285677.R01.S.doc Version 5.1 Page 15 A varied menu is in place to ensure service users good health and interest. Diets based around a service users medical needs are catered for appropriately and staff have received guidance from a relevant health care professional in this aspect of care provision. Regular hot and cold drinks and snacks are available through the day. Service users nutritional care needs are assessed and supporting guidance is in place on how to address specific care requirements. As stated earlier in the report, because the care plans are not up to date, it was not entirely possible to establish the accuracy of this information. Newhaven DS0000018915.V285677.R01.S.doc Version 5.1 Page 16 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 A documented complaint procedure is in place to ensure service users and staff views are listened to and acted upon appropriately. All staff have received some degree of training in relation to the protection of vulnerable adults from abuse. However the necessary supporting documentation is not in place which could lead to issues of abuse not being dealt with appropriately. EVIDENCE: The CSCI has not received any complaints about the standard of care provided at Newhaven and no complaints have been made directly to the home. A documented complaint procedure is in place. Most staff have completed formal training on the protection of vulnerable adults from abuse. The remaining staff have been provided with informal inhouse training in this aspect of care provision although arrangements have been made to them to attend a further training course on 22/3/06. A copy of the Wirral adult protection procedure is not in place which means that issues of abuse may not be investigated and dealt with appropriately. This issue was discussed with the senior member of staff conducting the inspection and advice was given as to how to obtain this information. Newhaven DS0000018915.V285677.R01.S.doc Version 5.1 Page 17 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19 and 26 The standard of the decor is mixed with some parts of the home being maintained to a good standard and other parts being in need of further attention. The home does not therefore, present as a homely and comfortable environment throughout. The home is clean and tidy throughout. EVIDENCE: The standard of the decoration throughout the home is mixed. Some areas are decorated in a way that provides a homely environment and other parts primarily the bedrooms, en suites and bathrooms are in need of further attention. The following issues were raised in relation to the standard of the facilities: • • • • The casing around the water pipes in en suite facilities need painting. Bedroom doors need varnishing. The tiles in the bathroom on the first floor had become black. The carpeting in one bedroom was rucked and could present as a tripping hazard. DS0000018915.V285677.R01.S.doc Version 5.1 Page 18 Newhaven • • • • • Window frame surrounds need painting. The carpet in the dining room was badly stained and needs to be replaced. Towels were frayed. Plastic mattress covers were used on beds. An old commode and ladders were being stored in the garden. For service users comfort and welfare the Registered Persons are required to address these issues. Some of the bedrooms were very cold and it came to light that the heating in one half of the building was turned off during the day. The Registered Persons are advised to ensure an ambient temperature is provided in all parts of the home to ensure service users are not restricted to staying in the lounge. Newhaven DS0000018915.V285677.R01.S.doc Version 5.1 Page 19 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27 and 30 There is a shortfall in the care and domestic staffing hours provided. Staff are provided with relevant training although this aspect of care provision does need to be developed to ensure service users specific care requirements are met. EVIDENCE: A copy of the staff rota was submitted for inspection. This indicated there was a small shortfall in the care staffing hours and a large shortfall in the domestic staffing hours. The Registered Persons are required to address this issue. Staff records indicate that a range of appropriate training is provided to support the staff in their role. This training has included first aid, personal safety, food hygiene and moving and handling. Staff have also completed formal induction training. Specialist training in relation to service users particular care requirements, which include Parkinsons disease, Alzheimers disease and manic depression, has not been provided although information and guidance has been given by appropriate health care professionals. While it is acknowledged that this information will be useful to support staff in their role, this aspect of care provision needs to be developed to ensure the service users receive the care they require in the way that is needed. Although further training has been arranged, the homes training plan for the forthcoming year was not available. It was agreed this would be faxed to the CSCI following the inspection. Newhaven DS0000018915.V285677.R01.S.doc Version 5.1 Page 20 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 35, 36, and 38 The Registered Manager has allocated the responsibility of the day to day control of the home to a senior member of staff. This creates some inconsistency in the management of the service as this member of staff does not yet wish to become registered with the CSCI. Most service users are supported with the management of their finances and systems are in place to demonstrate transactions made on their behalf. Improvements need to be made to the systems in place to ensure they can be easily audited. Staff are supervised on an informal basis to ensure they are supported in their role. A system of formal supervision for the purpose of staff development, is not in place. The health, safety and welfare of the service users is promoted throughout the home. However, some improvements still need to be made to ensure service users safety and welfare. Newhaven DS0000018915.V285677.R01.S.doc Version 5.1 Page 21 EVIDENCE: Although Mr So is currently the Registered Manager of the service, he has delegated the responsibility of the day to day control of the home to a senior member of staff. The senior member of staff confirmed that while she is happy to continue with this responsibility, she did not wish to make an application to the CSCI to become registered for this position until she has completed National Vocational Qualification level 4. The completion of this qualification will take about 15 months. Newhaven care home is registered with the CSCI and consequently must have a Registered Manager in place. If the current manager does not wish to continue with his responsibilities then another person must be proposed for this position. This issue will also be addressed with the Registered Providers outside the inspection process, however in the interim the Registered Persons must write and inform the CSCI of the action being taken to address this matter. The management of the home appears to be open and inclusive of staff. However concerns were raised about how improvements to the service only take place through the inspection process and there is no evidence of the Registered Manager being pro-active in developing and improving the standard of care provided. In the light of this, the Registered Persons are required to ensure the home is managed in a way that complies with the Care Homes Regulations 2001 and promotes and makes proper provision for the health and welfare of the service users. Service users are supported to manage their finances. A record is in place of the date service users receive their weekly pension allowance and any financial transactions made on their behalf; receipts are maintained for some transactions. Two service users take responsibility for their own money although the Registered Manager does assist them with the cashing of their pension. The Registered Manager takes responsibility for all financial matters relating to the service users with the exception of the daily transactions, this responsibility is held by the senior member of staff. The documentation in place was examined and the actual money for two service users was checked; this money was in good order. To further improve the system in place, the Registered Persons must introduce an auditing system whereby a check is carried out on all records and money held. These checks should be countersigned by another senior member of staff who is made clear of the purpose of this exercise and their responsibilities in relation to it. The Registered Persons must also ensure a receipt is obtained for all financial transactions. Where this is not possible, a receipt with an allocated number should be issued by the home. Newhaven DS0000018915.V285677.R01.S.doc Version 5.1 Page 22 The fire log book indicated that regular fire safety checks are carried out with the whole fire system being serviced annually (March 2005). The emergency call points are tested weekly although the last test carried out was 3/2/06. The emergency lighting is also tested weekly, however this was last tested on 16/2/06. All staff are provided with regular fire safety training when a fire drill is carried out; this was conducted on 2/2/06. To ensure both staff and service users safety, the Registered Persons are required to address these issue as a matter of priority. It was agreed these tests were updated immediately. A range of equipment is provided to support the service users with their care requirements. All of this equipment is provided and maintained by the Wirral Social Services. Staff monitor the condition of this equipment on a daily basis to ensure service users welfare. Water temperatures are monitored and recorded to ensure they are within safe limits. Bed rails are provided for a number of service users. Although the use of this equipment was subject to a risk assessment carried out by a district nurse, the documentation was not available for inspection. To ensure service users ongoing safety, the Registered Persons are required to ensure an up to date risk assessment is carried out in relation to the ongoing use of bedrails for each of the service users. For service users safety, hourly checks are carried out each night on service uses who use bed rails. The senior member of staff conducting the inspection said she was aware of the potential dangers involved in using bed rails and confirmed staff had been updated on this information. A record of any accidents that occur is recorded in the homes accident book. This documentation held basic information in relation to the action taken in respect of the follow-up care provided. The accident book held at the home was out of date and the Registered Providers must ensure the appropriate documentation is available for the purpose of recording all accidents in accordance with current legislation. Advice was given with regard to how to obtain this documentation from the Health and Safety Executive. The radiator in the quiet room was very hot and may present as a danger to service users. In the light of this a risk assessment must be undertaken with regard to ensuring service users safety in this area. Systems are in place to ensure staff are supported within their role and to ensure good communication within the home. The senior member of staff conducting the inspection and the Registered Manager are always available for advice and support. The senior member of staff conducting the inspection was not familiar with the system of formal supervision. It was agreed that for the Newhaven DS0000018915.V285677.R01.S.doc Version 5.1 Page 23 purpose of staff development and the further improvement of the service, the Registered Persons would introduce this system into the home. Newhaven DS0000018915.V285677.R01.S.doc Version 5.1 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 x x 2 2 x x HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 2 10 x 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 x 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 x 18 2 2 x x x x x x 3 STAFFING Standard No Score 27 2 28 x 29 x 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 x x x 2 2 x 2 Newhaven DS0000018915.V285677.R01.S.doc Version 5.1 Page 25 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 Standard OP3 Regulation 14 Requirement The Registered Persons are required to ensure all risk assessments are kept up to date and there is clear meaning to their outcome. The Registered Persons are required to ensure all care plans are reviewed. The care plans must be kept up to date and reflect service users current care needs. The Registered Persons are required to ensure a management plan is in place for any service user who presents with challenging behaviour. The Registered Persons are required to ensure staff are provided with general guidance in relation to when medication is given on the basis of as and when required. The Registered Persons are required to ensure specific guidance is in place in relation to when service users are given medication on the basis of as and when required. The Registered Persons are DS0000018915.V285677.R01.S.doc Timescale for action 31/03/06 2 OP7 15 31/03/06 3 OP7 15 31/03/06 4 OP9 13 31/03/06 5 OP9 13 31/03/06 6 OP9 13 31/03/06 Page 26 Newhaven Version 5.1 7 OP9 13 8 OP9 13 9 10 OP9 OP12 13 16 11 OP18 13 12 OP19 23 13 14 OP19 OP19 23 23 15 OP19 23 16 17 18 OP19 OP19 OP19 23 23 23 required to ensure a homely remedies policy is in place. The Registered Persons are required to ensure surplus medication is stored appropriately and not in un labelled bottles. The Registered Persons are required to ensure a record is maintained of any medication to be returned to the supplying pharmacist. The Registered Persons are required to ensure the drug fridge is kept locked. The Registered Persons are required to ensure a broader range of social activities are provided. The Registered Persons are required to ensure the necessary documentation is in place in relation to the investigation of any incidents of abuse. The Registered Persons are required to ensure the water pipes that have become blackened are made good. The Registered Persons are required to ensure bedroom doors are varnished. The Registered Persons are required to make good the grouting that has become blackened in the bathrooms. The Registered Persons are required to ensure the rucked carpet in one of the bedrooms is made safe. The Registered Persons are required to ensure window frame surrounds are painted. The Registered Persons are required to ensure items stored in the garden are removed. The Registered Persons are required to ensure the badly DS0000018915.V285677.R01.S.doc 31/03/06 31/03/06 31/03/06 08/05/06 31/03/06 03/06/06 03/06/06 03/06/06 03/06/06 03/06/06 03/06/06 03/06/06 Newhaven Version 5.1 Page 27 19 20 21 OP19 OP19 OP19 16 16 16 22 OP27 18 23 OP27 18 24 OP30 18 25 OP31 12 26 OP35 13 27 OP36 18 28 29 OP38 OP38 23 13 stained carpet in the dining room is replaced. The Registered Persons are required to ensure frayed towels are disposed of. The Registered Persons are required to ensure suitable bedding is provided. The Registered Persons are required to ensure an ambient temperature is maintained in all parts of the building. The Registered Persons are required to ensure the minimum domestic staffing hours are provided at all times. The Registered Persons are required to ensure the minimum care staffing hours are provided at all times. The Registered Persons are required to ensure specialist training is provided which reflects service users specific care requirements. In this instance a programme of training for the forthcoming year is to be submitted to the CSCI. The Registered Persons are required to write to the CSCI and inform it of the action being taken with regard to be management of the home. The Registered Persons are required to ensure a system is introduced whereby service users financial records can be easily audited. The Registered Persons are required to ensure a system of formal supervision is introduced to the home. The Registered Persons are required to ensure regular fire safety checks are carried out. The Registered Persons are required to ensure a risk DS0000018915.V285677.R01.S.doc 03/06/06 03/06/06 03/06/06 03/06/06 03/06/06 08/05/06 08/05/06 31/03/06 08/06/06 31/03/06 31/03/06 Newhaven Version 5.1 Page 28 30 OP38 13 assessment is carried out in relation to the use of bed rails. The Registered Persons are required to ensure appropriate documentation is in place for the recording of all accidents. 08/05/06 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 OP38 Good Practice Recommendations It is recommended that, for service users safety and welfare, the Registered Persons keep up to date with the information provided on the Medical Devices Agency Website and the Health and Safety Executive Website. Newhaven DS0000018915.V285677.R01.S.doc Version 5.1 Page 29 Commission for Social Care Inspection Liverpool Satellite Office 3rd Floor Campbell Square 10 Duke Street Liverpool L1 5AS National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Newhaven DS0000018915.V285677.R01.S.doc Version 5.1 Page 30 - 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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