Inspection on 08/01/07 for Newhaven

This inspection was carried out on 8th January 2007.

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

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Newhaven 06/03/06

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 Key Unannounced Inspection 8th, 9th and 17th January 2007 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.V317135.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 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.V317135.R01.S.doc Version 5.2 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/Person (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.V317135.R01.S.doc Version 5.2 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. 27th June 2006 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.V317135.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. Information about Newhaven was obtained through discussion with the Registered Manager and members of the staff team. Policies, procedures and supporting documentation was looked at along with a selection of service users’ case files. Service users and staff were spoken to during the visit for the purpose of obtaining their views on the standard of the service. A part of the inspection process includes sending questionnaires to service users carers and health care professionals in order to obtain their views on the standard of the service provided. Comments made in these questionnaires are included in the report and contribute to the basis of any judgments made. Fees: 345.00 per week What the service does well: What has improved since the last inspection? Improvements have been made to the administrative systems, catering arrangements, physical environment and documentation kept in relation to service users care needs. All of this improves the overall service provision. Newhaven DS0000018915.V317135.R01.S.doc Version 5.2 Page 6 What they could do better: Improvements need to be made to the assessment process to ensure service users full care needs are clearly identified before they spend time at the home. Improvements need to be made to the care planning process to ensure staff know how to look after the service users in accordance with their individual care needs and to ensure service users health and welfare is properly monitored. Although improvements have been made to the medication administration procedures, further work still needs to be undertaken to ensure all records are accurately maintained. A broader range of social activities need to be provided to ensure service users interest and mental stimulation. Systems are in place to ensure service users are protected from harm and abuse, although it was acknowledged that the Registered Manager/Person needs to familiarise himself on these procedures. Improvements need to be made to the complaint procedure to ensure service users and their representatives know how to make a complaint. Further improvements still need to be made to the physical environment. Some improvements need to be made to the recruitment procedure to ensure suitably qualified and competent staff are employed. Further improvements need to be made to the overall management of the home to ensure an improved service provision Improvements need to be made to the systems in place to ensure service users health, safety and welfare is promoted. Please contact the provider for advice of actions taken in response to this Newhaven DS0000018915.V317135.R01.S.doc Version 5.2 Page 7 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 DS0000018915.V317135.R01.S.doc Version 5.2 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.V317135.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 3 and 6 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Improvements need to be made to the assessment process to ensure service users care needs are clearly identified before they spend time at the home. EVIDENCE: A range of assessments and risk assessments have been completed to ensure staff are aware of service users different care requirements. Some improvements need to be made to this documentation to ensure staff have all the information they need on how to look after the service users properly and ensure they are kept safe from harm. This issue was addressed during the visits. Overall improvements had been made to the way information is stored and it is now easier to establish service users different care needs. Newhaven DS0000018915.V317135.R01.S.doc Version 5.2 Page 10 Service users communication needs have been assessed and in one instance a health care professional had been consulted. It was acknowledged that this aspect of the assessment process needs to be developed further given the communication difficulties some service users experience. The assessment documentation addressed some issues relating to equality and diversity such disability, sex and age. To ensure a more holistic approach is taken to service users care needs, this aspect of care provision needs to be developed further to include issues such as race, religion, gender and sexuality. Arrangements had been made for one service user to visit the home on a trial basis with a view to them moving into the home permanently. While staff had recorded basic information in relation to their daily welfare, this did not reflect the service users care needs as outlined by the Deputy Manager and did not give sufficient detail to demonstrate how the staff were supporting this individual service user. While offering a service user a trial visit is considered good practice, a full assessment of their care needs must be carried out prior to the visit starting. It is only by doing this can the staff know how to look after the service user in accordance with their particular care needs and ensure they are kept safe from harm. Intermediate care is not provided at this home. Newhaven DS0000018915.V317135.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 7 8 and 9 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Improvements need to be made to the care planning process to ensure staff know how to look after the service users in accordance with their individual care needs and to ensure their health and welfare is properly monitored. Although improvements have been made to the medication administration procedures, further work needs to be undertaken to ensure all records are accurately maintained. EVIDENCE: A selection of service users case files were looked at during the visit. Since the last inspection improvements have been made to the overall documentation and it was easier to track individual aspects of service users care needs. The care plans indicated that staff monitor service users general welfare on a daily basis and relevant health care professionals are consulted as required. Management plans are now in place for any service user who presents with challenging behaviour. The case files looked at demonstrated that service users health care needs had been addressed and that regular Newhaven DS0000018915.V317135.R01.S.doc Version 5.2 Page 12 health care checks had been carried out. Staff spoken to during the visit confirmed they had access to service users case files. The following issues arose that require further attention. • While a documented plan of the care provided to each service user had been compiled, some aspects of the documentation needed to be developed further in order to give a full picture of each service users care needs. Some information was not signed or dated. There was no evidence of service user involvement of the care planning. One of the care plans had not been reviewed when a service user had become seriously ill. While day staff had recorded details of the service users general welfare, minimal information had been recorded by the night staff. • • • It is vitally important that service users care plans are reviewed and kept up to date at all times. It is only by doing this will staff have all of the information they need on how to look after the service users properly. Not having this information available could lead to aspects of service users care needs being missed and them being left vulnerable to the risk of harm. While it is acknowledged that the responsibility for the daily care of the service users has been delegated to the Deputy Manager, the Registered Manager/Provider must be pro active in monitoring all aspect of care provision to ensure service users safety and welfare. It is acknowledged that this aspect of care provision is included in the forthcoming years training programme. The service users spoken to during the visit said they liked living at the home and said the staff are very good and help them with everyday things. Staff take responsibility for the administration of service users medication to ensure their safety and welfare. The records inspected were accurately maintained and appropriate storage facilities were in place. Staff who administer medication confirmed they have been provided with training in this aspect of care provision. Guidance was available for staff in relation to the administration of homely remedies. General information was in place in relation to medication given on the basis of as and when required along with specific guidance relating to individual service users. The following issues arose that require further attention. • • An official medication administration record sheet had not been completed for the administered of one service users medication. This information had been recorded on a separate sheet of A4 paper. An error on a medication administration record sheet had not been discussed with the supplying pharmacist for some months, rather staff had changed this information by re writing the directions by hand. DS0000018915.V317135.R01.S.doc Version 5.2 Page 13 Newhaven • Supporting documentation had not been recorded on how staff must test service users blood sugar levels. To ensure service users safety and welfare, accurate records must be maintained at all times. Supporting guidance must also be provided to staff about any medical procedures they have been instructed to carry out. Newhaven DS0000018915.V317135.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12 13 14 and 15 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Service users friends and relatives can visit the home at any time to ensure they can maintain friendships and family contact. Service users are encouraged to make their own decisions in order to maintain their independence. A broader range of social activities need to be provided to ensure service users interest and mental stimulation. EVIDENCE: A range of social activities are provided for the service users to ensure their mental stimulation and to prevent them from becoming bored. Staff spoken to confirmed service users can join in with these activities if they wish. Service users are sometimes taken out shopping or for a drive around the Wirral using the homes own mini bus. Arrangements have been made for an outside entertainer to come into the home each month. A number of service users attend day centres and social clubs. On the day of the visit the staff were playing bingo with one service user. Newhaven DS0000018915.V317135.R01.S.doc Version 5.2 Page 15 It was recognised that improvements still need to be made to this aspect of care provision to ensure more meaningful activities are provided and to ensure service users do not become bored. This issue has been raised at past inspections and only small improvements have been made since this time. In the light of the service users having specialist care needs, specific training must be provided to staff on how to develop this area of care provision. The Registered Manager/Person acknowledged the benefits of service users being taken on holiday and agreed to look into this issue and keep the CSCI updated of the progress being made. Relatives and friends may visit the home at any time which ensures service users can maintain friendships and family relationships. Staff support service users to exercise choice and control in their lives in order that they can maintain as much independence as possible. Service users have personalise their rooms with their own belongings in order to make them more homely. The service users spoken to during the visit confirmed they could spend time in their rooms when they wanted and the routines in the home were flexible. Improvements have been made to the catering arrangements. A new menu has been introduced to ensure service users good health and interest and diets based around a service users medical needs are catered for. Service users nutritional care needs are assessed and supporting guidance is in place on how to address specific care requirements. The food stores were well stocked with dry and frozen food. Fresh meat and vegetables are now purchased and more home-made meals are provided. Staff spoken to during the visit confirmed that great improvements had been made to this aspect of care provision. The service users spoken to during the visit said they enjoyed their meals and always had plenty to eat and drink. Newhaven DS0000018915.V317135.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 19 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Systems are in place to ensure service users are protected from harm and abuse although the Registered Manager/Person acknowledged he needed to familiarise himself with the adult protection procedures. Improvements need to be made to the complaint procedure to ensure service users and their representatives know how to make a complaint. 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. Staff spoken to demonstrated they knew what action to take in the event of them receiving a complaint. A complaint policy and procedure is in place. Some changes need to be made to the procedure to ensure service users and their carers are clear on the procedure they should follow in the event of them wanting to make a complaint. This will also ensure they know their concerns and views will be listened to and acted upon appropriately. The service users spoken to during the visit said they would speak to a member of staff if they were unhappy about the care they received. This aspect of care provision must be developed to ensure service users are aware of the different agencies and people they can contact if they are unhappy about the care they receive. Systems are in place to ensure service users are safeguarded from abuse and neglect. A copy of the Wirral Adult Protection Procedure and supporting information is in place which staff can refer to when necessary. The staff Newhaven DS0000018915.V317135.R01.S.doc Version 5.2 Page 17 spoken to during the visit demonstrated a basic understanding of this issue and were clear on the action they should take in the event of them suspecting or knowing an incident of abuse had occurred. The Registered Manager/Person acknowledged he needed to familiarise himself on this procedure to ensure any allegations of abuse are managed in line with the Wirral Adult Protection Procedures. All but one member of staff has completed training in this aspect of care provision and arrangements have been made for this training to be provided in the near future. This aspect of care provision is included in the homes forthcoming training programme. Staff and service users should be given the telephone number of the organisation Acton on Elder Abuse so they know who to contact if they wish to raise an anonymous concern about the care provided that the home. Newhaven DS0000018915.V317135.R01.S.doc Version 5.2 Page 18 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. JUDGEMENT – we looked at outcomes for the following standard(s): 19 and 26 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Although improvements have been made to the overall environment and the home is now a much more comfortable place to live, further work still needs to be carried out to ensure all parts of the home are maintained to an good standard. EVIDENCE: Since the last inspection improvements have been made to the overall environment and the home now appears much brighter and more homely. The outside of the home, both back and front, has now been repaved. The area at the back is ramped so provides a safe environment for service users who experience difficulty with their mobility. Plans are being made for hand rails to be fitted and garden furniture to be provided so that service users can enjoy the garden when the weather is good. Inside the home a new wooden laminate floor has been fitted throughout the ground floor and these areas Newhaven DS0000018915.V317135.R01.S.doc Version 5.2 Page 19 have also been redecorated. The home is awaiting delivery of new dining furniture and lounge chairs. Improvement work has been carried out in some of the bedrooms and en-suites although further work still remains outstanding in some rooms. All metal framed beds have been replaced and new head boards have been ordered. Plans are being made for a new walk in shower and bathroom to be fitted. On the day of the visit the home was clean and tidy and pleasantly warm. Systems are in place to control the spread of infection and staff confirmed they have completed training in relation to this aspect of care provision. This aspect of care provision is also included in the forthcoming years training programme. Newhaven DS0000018915.V317135.R01.S.doc Version 5.2 Page 20 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. JUDGEMENT – we looked at outcomes for the following standard(s): 27 28 29 and 30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. There are sufficient staff on duty to care for the service users, however further training need to be provided to ensure an improved quality of the service. Some improvements need to be made to the recruitment procedure to ensure suitably qualified and competent staff are employed. EVIDENCE: There are currently 11 service users living at the home. The staff rota indicated there is a minimum of two staff on duty throughout the day and night. This is in addition to the Registered Manager/Person and a full time administrator. There is a domestic on duty each morning from Monday to Friday. The staff spoken to during the visit confirmed there were sufficient staff on duty to carry out their work. One of the service users spoken to during the visit confirmed the staff were always available. A concern was raised in relation to the Deputy Manager not having taken a day off in three weeks. This situation could lead to them becoming tired and not being able to care for the service users properly. The Registered Manager/Person outlined this was an unusual occurrence and that normally this member of staff has 2 days off each week. Domestic staffing levels are provided to ensure the home is kept clean and tidy. Newhaven DS0000018915.V317135.R01.S.doc Version 5.2 Page 21 Two staff are qualified to National Vocational Qualification (NVQ) level 2 and a further two staff are in the process of working towards this award. One member of staff is qualified to level 3 and the Deputy Manager is in the process of working towards level 4. This is in line with good practice and ensures they are up-to-date on current care practices. Although the Registered Manager/Person has completed ongoing training, he has still not completed NVQ 4 which is the recognised award for a manager of a care home. The Registered Manager/Person must ensure he continues with his own training and development by completing NVQ 4 and other training which will demonstrate he has the ongoing experience and skills necessary for managing and improving the home. A selection of staff files were looked out during the visit. Most of the necessary information was in place although there was no documentation in place to demonstrate that a Criminal Records Bureau check had been carried out on one staff member. This issue was clarified during the visit although it did highlight the staff files need to be more organised in order to demonstrate that appropriate checks have been carried out on all staff members. The application forms used in the recruitment procedure needs to be developed further to ensure that prospective staff full employment history is obtained; this issue was addressed during the visit. Records must also be held in relation to obtaining a statement by the person as to their mental and physical health. A programme of staff training is now in place. This training covers a range of issues relevant to the care of the service users and the management of the home. It is planned that at all staff will complete this training programme over the forthcoming year. In the past most of the training provided at the home has been through work books. While it is acknowledge this training is useful, in the light of the home accommodating service users with complex needs and the Registered Manager/Provider still experiencing problems with regard to the overall management of the home, training from external sources must also be provided to ensure the home is run in line with current good practice and is focused on service users care needs. This issue has been raised at past inspections and has still not been addressed. Again the Registered Manager/Person is advised to consult with the British Institute of Learning Disability or other relevant agencies with regard to this aspect of care provision. Newhaven DS0000018915.V317135.R01.S.doc Version 5.2 Page 22 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. JUDGEMENT – we looked at outcomes for the following standard(s): 31 33 35 36 and 38 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Further improvements need to be made to the overall management of the home to ensure an improved service provision. Improvements need to be made to the way service users financial records are maintained to ensure they are protected from abuse. Improvements need to be made to the systems in place to ensure service users health, safety and welfare is promoted. EVIDENCE: During past visits concerns have been raised about the lack of management presence and poor management systems within the home. These past visits have resulted in large amounts of requirements being made and improvements Newhaven DS0000018915.V317135.R01.S.doc Version 5.2 Page 23 only coming about because of this regulatory input. Since this time changes have been made to the way the home is run and while Mr So continues to take responsibility for the overall management of the home, he has delegated the key responsibility for the direct care of the service users to the Deputy Manager. He has also employed an administrator for the purpose of improving the administrative systems and supporting documentation. While it is acknowledged that these changes have resulted in improvements to different aspects of care provision, the CSCI remains concerned that Mr So is not a pro active in the management of the home and changes are still only made following regulatory input. In the light of this, a quality assurance system must be set up for the purpose of ongoing monitoring and continuous improvement to the overall management of the service. The Registered Manager/Person must be pro active in this area and ensure the service is focused on how service users are being looked after and the quality of the care they receive. During the visit a quality assurance check list was established. Although this was appropriate for the running of the home, this must be developed further to include all aspects of the National Minimum Standards for Older People. It should also involve seeking out the views of the service users, staff and relevant health care professionals on the standard of the care provided. The staff spoken to during the visit said they felt well supported in their role and confirmed the Registered Manager and Deputy Manager were always available for support and advice. A selection of service users financial records were looked at during the visit. All balances, receipts and transactions were accurately maintained. Some changes need to be made to the way the information is recorded so that it can be easily audited. In this instance service users users weekly pension payments must be logged according to when financial transactions take place. This will also ensure these records correspond accurately with service users savings books. A system of checks must also be introduced for the purpose of ensuring service users are protected from abuse. Documentation was in place to demonstrate that regular safety checks had been carried out around the building which included the electrical wiring, fire safety equipment and the gas installation. Regular fire safety checks had been carried out. All accidents were recorded appropriately and staff had been provided with training in relation to promoting safe working practices within the home. The following issues arose that require further attention: • • It was reported that the small electrical appliances had been tested, however, there was no documentation in place to demonstrate when this had been done. This issue was addressed during the visit. Water temperatures had been monitored weekly. While new documentation had been set up the purpose of collating more detailed DS0000018915.V317135.R01.S.doc Version 5.2 Page 24 Newhaven • • • • • information, the records for November and December 2006 were not available. Although some action had been being taken to prevent the risk of legionella, the Registered Manager/Person had not taken up-to-date advice on how this issue should be addressed. This issue was addressed during the visit. The whole fire alarm had not been serviced. This issue was addressed at during the visit. Although a record was in place in relation to the tests made on fire call points around the home, the system was ineffective for ensuring all points were tested over a given period of time. Although a policy statement was in place in relation to the use of bed rails, risk assessment had still not been completed. This issue was addressed during the visit. A lock had not been fitted to the tank cupboard in one of the bedrooms. This cupboard is usually hidden by a wardrobe but this had been moved because a new boiler had been fitted. This issue was addressed during the visit. To ensure staff and service user safety the Registered Manager/Person must ensure all of these issues are addressed as a matter of priority. Newhaven DS0000018915.V317135.R01.S.doc Version 5.2 Page 25 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 x x n/a HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 3 10 x 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 x 18 2 2 x x x x x x 3 STAFFING Standard No Score 27 2 28 3 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 x 2 x 2 3 x 2 Newhaven DS0000018915.V317135.R01.S.doc Version 5.2 Page 26 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 Manager/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 Person is required to ensure service users holistic care needs are assessed which should include all issues relating to equality and diversity. The Registered Person is required to ensure an accurate and up to date care plan is in place for each service user. The care plans must to ensure issues of equality and diversity are explicitly addressed. (Previous timescale of 05/07/06 not met). The Registered Person is required to ensure accurate records are maintained for the administration of service users medication. The Registered Person is required to ensure staff are provided with written guidance on any medical procedures they have been instructed to carry out. The Registered Person is required to ensure a broader range of social activities are provided so that service users do not become bored (Previous DS0000018915.V317135.R01.S.doc Timescale for action 30/04/07 2 OP7 15 30/04/07 3 OP9 13 30/04/07 4 OP9 13 30/04/07 5 OP16 16 30/04/07 Newhaven Version 5.2 Page 27 6 OP16 22 7 OP13 13 8 OP23 23 9 OP28 10 and 18 10 OP29 18 11 OP30 18 12 OP31 12 timescale of 08/07/06 not met). The Registered Person is required to change the complaint procedure to ensure service users and their carers know how to make a complaint. They must also be informed of the different agencies and people they can contact if they are unhappy about the care they receive. The Registered Person is required to ensure he his up-todate with the Wirral adult protection procedures so that any allegations of abuse are managed correctly. The Registered Person is required to ensure the outstanding refurbishment work is carried out in order to provide service users with a more comfortable and pleasant environment in which to live. The Registered Person is required to ensure his ongoing development by completing appropriate training in relation to the running of the home. The Registered Person must also complete National Vocational Qualification level 4. The Registered Person is required to ensure all of the necessary information is held in staff files in order to demonstrate that suitable staff are employed at the home. The Registered Person is required to ensure specialist training in relation to service users particular care requirements is provided. The Registered Person is required to ensure the home is managed in a way that makes proper provision for the health and welfare of the service users. DS0000018915.V317135.R01.S.doc 30/04/07 30/04/07 30/04/07 17/01/08 30/04/07 30/04/07 30/04/07 Newhaven Version 5.2 Page 28 13 OP33 24 14 OP35 17 15 OP35 17 16 OP38 13 The Registered Person is required to establish and maintain a system for reviewing and improving the quality of care provided. (Previous timescale of 31/08/06 not met). The Registered Person is required to ensure changes are made to the way information relating to service users finances is changed to ensure it can be easily audited. The Registered Person is required to ensure a system of checks is introduced for service users financial records. The Registered Person is required to ensure all fire call points are tested over a given period of time. 30/04/07 30/04/07 09/01/07 09/01/07 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 Refer to Standard OP38 OP18 Good Practice Recommendations It is recommended that the Registered Person keeps a clear and detailed record of the water temperature checks. It is recommended that at the Registered Person gives all staff and service users or their representatives the telephone number of the organisation Acton on Elder Abuse so they know who to contact if they wish to raise an anonymous concern about the care provided. Newhaven DS0000018915.V317135.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection Liverpool Satellite Office 3rd Floor Campbell Square 10 Duke Street Liverpool L1 5AS 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. 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