Inspection on 23/01/07 for Newhaven Care

This inspection was carried out on 23rd January 2007.

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

The inspector found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 11 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Newhaven Care 05/06/06

Newhaven Care 08/03/06

Newhaven Care 01/08/05

Newhaven Care 15/02/05

Newhaven Care 05/05/04

Newhaven Care 17/11/03

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 HOME ADULTS 18-65 Newhaven Care 20 Penkett Road Wallasey Wirral CH45 7QN Lead Inspector Inger Moynihan Key Unannounced Inspection 23rd and 25th January 2007 10.30 Newhaven Care DS0000018916.V317136.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 Care DS0000018916.V317136.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 Care DS0000018916.V317136.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Newhaven Care Address 20 Penkett Road Wallasey Wirral CH45 7QN 0151 630 5584 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) Mr Danny So Mrs Lynda So Catherine Higginson Care Home 14 Category(ies) of Learning disability (14) registration, with number of places Newhaven Care DS0000018916.V317136.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 5th June 2006 Brief Description of the Service: 20 Penkett Road is a care home registered with the Commission for Social Care Inspection to provide accommodation for 14 service users who have a learning disability. The home is situated in a residential area of Wallasey, Wirral. The home is close to local amenities and the sea front is a short drive away. The home is a large detached property that has been adapted over the years to meet the needs of service users. There are parking facilities to the front of the house and a garden to the rear that is accessible to service users. Accommodation is mainly provided in double rooms. There is a large conservatory/dining area that is also used for other activities. Newhaven Care DS0000018916.V317136.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. Information about Newhaven Care 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. Observations were also made on the service user group. 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: An assessment of service users care needs is carried out before they move into the home on a permanent basis. Service users are supported to make decisions and take responsible risks as part of living an independent lifestyle. The service users spoken to during the visit spoke well of the staff team saying they were very kind and friendly. Staff support service users to continue with their education and training so they have opportunities for personal development. Service users are encouraged to be a part of the local community through the use of health care and social facilities. Service users have opportunity to maintain family links and friendships. The daily routines in the home are flexible which means service users can exercise choice in their daily activities. Service users receive personal support in the way they prefer. Efficient medication administration procedures are in place to ensure service users good health. The home has a complaint procedure to ensure service users views are listened to and acted upon appropriately. Systems are in place to ensure service users money is managed correctly and they are protected from abuse. Newhaven Care DS0000018916.V317136.R01.S.doc Version 5.2 Page 6 For the most part the standard of the decor is good providing service users with an attractive and homely place to live. The home is run for the benefit of the service users and there are sufficient staff on duty to care for the service users properly. Systems are in place to ensure the premises are kept clean, hygienic and free from offensive odours. Informal supervision is provided on a regular basis and a system of staff appraisal is in place for the purpose of staff development and ensuring service users are cared for appropriately. What has improved since the last inspection? What they could do better: Care plans are not always updated to reflect service users specific care needs. Although a management plan had been implemented for the purpose of helping staff to manage service users challenging behaviour with low level staff interventions, staff have not completed training in this aspect of care nor was there written guidance for staff reference. Staff should be provided with specialist training to ensure service users are cared for in accordance with current good practice and to improve service provision. Some improvements need to be made to the recruitment procedure to ensure suitably qualified and competent staff are employed. The health, safety and welfare of the service users is promoted, although some improvements need to be made in some areas of care provision. Newhaven Care DS0000018916.V317136.R01.S.doc Version 5.2 Page 7 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 Care DS0000018916.V317136.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 Care DS0000018916.V317136.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 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. An assessment are of service users care needs is carried out before they move into the home on a permanent basis. EVIDENCE: The care plan of the service user most recently admitted into the home was looked at during the visit. The Registered Manager had carried out an assessment of this service users care needs which included consulting with relevant health care professionals, day centre staff and family members. A record of this information was in place and a trial visits took place prior to them moving into the home permanently. All of this ensures the placement is suitable and the staff have the necessary information on how to look after the service user in accordance with their particular care needs. The issue of equality and diversity was discussed with the Registered Manager and it was agreed that while some issues were addressed, not all details such as service users race, religion and sexuality had been addressed. The Registered Manager stated that she was not aware that any service users had specific care requirements in relation to these issues but agreed to ensure this Newhaven Care DS0000018916.V317136.R01.S.doc Version 5.2 Page 10 issue was looked at in more detail when all care packages were next reviewed in February 2007. Newhaven Care DS0000018916.V317136.R01.S.doc Version 5.2 Page 11 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6 7 and 9 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Care plans are not always updated to reflect service users specific care needs. Service users are supported to make decisions and take responsible risks as part of living an independent lifestyle. 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 with regard to how the care should be provided. A record is kept of service users welfare and there is evidence of service users health care needs being addressed and monitored. Regular contact is made with a range of health care professionals to ensure service users welfare. Newhaven Care DS0000018916.V317136.R01.S.doc Version 5.2 Page 12 Most of the care plans have been reviewed and updated to ensure staff have the correct information on how to look after the service users in accordance with their current care needs. In one instance the plan of care had not been updated to reflect that a service user had become unwell. While there was evidence to demonstrate the service users welfare had been monitored and additional care interventions had been provided, the Registered Manager must ensure all supporting documentation is reviewed and updated. This issue was addressed during the visit. As indicated earlier in the report, the issue of equality and diversity must be explicitly addressed in service users care plans to ensure service users specific care needs are met in relation to their religion, gender, age, religion and sexuality. Management plans have been implemented for the purpose of helping staff to manage service users challenging behaviour with low level staff interventions being used. Staff have not completed training in this aspect of care and details of how staff should manage such situations had not been recorded. To ensure this aspect of care provision is being managed in accordance with current good practice, a record of any interventions carried out must be kept and staff must be provided staff with appropriate training. The Registered Person must seek further advice with regard to this training from the British Institute of Learning Disability and ensure the training provided is accredited with this organisation. During discussion staff demonstrated a basic understanding of how to ensure service users safety but at the same time encourage service users to make decisions for themselves in order to maintain an independent lifestyle. The service users spoken to during the visit spoke well of the staff team saying they were very kind and friendly. Newhaven Care DS0000018916.V317136.R01.S.doc Version 5.2 Page 13 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12 13 15 16 and 17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Staff support service users to continue with their education and training so they have opportunities for personal development. Service users are supported to be a part of the local community and have opportunity to maintain family links and friendships. The daily routines in the home are flexible which means service users can exercise choice in their daily activities. EVIDENCE: Although none of the service users are in paid employment, staff do support service users to attend college and training provided by local day centers. Newhaven Care DS0000018916.V317136.R01.S.doc Version 5.2 Page 14 Service users are supported to participate in the local community for their social and health care needs. Service users do not generally use public transport as the home has a minibus which staff use for day trips out etc. Staff spend time with service users on a one-to-one basis outside of the home which the Registered Manager recognised was important for service users own development. A range of social activities are provided both inside and out of the home. Service users attend day centres and social clubs and trips out are also organised. The Registered Manager explained that social activities are often focused around music and art and craft. Plans have been made to introduce and improve the range of social activities provided. The Registered Manager has planned a project with service users around healthy eating and good health care. She has undertaken training in relation to health action planning and has asked family members for information around service users past experiences and future aspirations. She has carried out research on the Internet and has sought further information from the British Institute of Learning Disability. All of this is in line with good practice and further improves the quality of life for the service users living at the home. During discussion, the Registered Manager acknowledged the benefits of service users being taken on holiday and agreed to look into this issue for the forthcoming year. The routines in the home are flexible which means service users can exercise choice in their daily activities. Restrictions are only placed on service users for their safety and welfare. Service users privacy is respected and staff were seen interacting with the service users and not exclusively with each other. Although service users can choose to be alone or in company, some bedrooms are double occupancy and there is no this is private visitors room in the home. Newhaven Care DS0000018916.V317136.R01.S.doc Version 5.2 Page 15 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18 19 and 20 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users receive personal support in the way they prefer and systems are in place to ensure service users good health. Efficient medication administration procedures are in place to ensure service users good health. EVIDENCE: There is documented evidence to show that service users care needs are met. Regular contact is maintained with a range of health care professionals such as the service users Community Psychiatric Nurse, Chiropodist, Optician and GP. Efficient systems are in place for the safekeeping and handling of service users’ medication and only trained staff are allowed to administer medication. A policy and procedure in relation to the administration, safe handling and recording of medication is available for staff reference; this documentation has been checked by the supplying pharmacist for its accuracy. To further safeguard the service users welfare, arrangements have been made for the Newhaven Care DS0000018916.V317136.R01.S.doc Version 5.2 Page 16 supplying pharmacist to carry out a regular audit of the medication procedures. Guidance is in place to demonstrate when medication should be given on the basis of as and when required and the homely remedies policy is currently being updated. One of the service users spoken to during the visit confirmed they receive their medication as prescribed. Two carers questionnaires were returned to the CSCI. They both indicated they were always made welcome at the home. They confirmed they are informed of important matters affecting their relative and are consulted on aspects of their care. Both questionnaires indicated they were aware of the homes complaint procedures but they had no complaints to make. One questionnaire indicated they found the Registered Manager and staff team to be very helpful and very good with their brothers care. Another indicated they found the Registered Manager very helpful. Newhaven Care DS0000018916.V317136.R01.S.doc Version 5.2 Page 17 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home has a complaint procedure to ensure service users views are listened to and acted upon appropriately. Improvements need to be made to the way service users financial records are maintained to ensure they are protected from abuse. EVIDENCE: The CSCI has received one concern about the way the home is being managed, this concern has been raised with the Registered Provider and is currently being looked into. This issue was also discussed with the Registered Manager during the visit. Staff spoken to during the visit demonstrated they knew what action to take in the event of them receiving a complaint. A complaint procedure is in place, however this needs to be developed to ensure service users and 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. Changes need to be made to the way complaint investigation information is stored to ensure the complainants privacy is respected. This aspect of care provision also needs to 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. Newhaven Care DS0000018916.V317136.R01.S.doc Version 5.2 Page 18 Systems are in place to ensure service users are safeguarded from abuse and neglect. A copy of the Wirral Adult Protection Procedures are in place along with supporting information which staff can refer to when necessary. The staff 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. Not all of the staff have received training in relation to this issue although dates have been set for this training to be provided within the next two months. Although this issue is included in the initial in-house induction training programme, the Registered Manager agreed this needs to be explicitly addressed rather than being incorporated into other aspects of care provision. Yearly training updates have been planned and this issue is also discussed during meetings and with staff on an individual basis. A selection of service users financial records were looked at during the visit. All balances, receipts and transactions were accurately maintained. An auditing system was set up during the visit. 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 the financial transaction takes place. This will ensure these records correspond accurately with service users savings books. This issue was addressed during the visit. Newhaven Care DS0000018916.V317136.R01.S.doc Version 5.2 Page 19 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 and 30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. For the most part the standard of the decor is good providing service users with an attractive and homely place to live. Systems are in place to ensure the premises are kept clean, hygienic and free from offensive odours. EVIDENCE: Newhaven Care DS0000018916.V317136.R01.S.doc Version 5.2 Page 20 The premises are comfortably furnished with good light levels throughout. The premises are in keeping with the local community. The home has a planned programme of maintenance and redecoration. Many of the bedrooms are double occupancy with some having en-suite facilities. Service users have personalise their rooms with their own belongings which reflects their personal interests and hobbies. Improvements have been made to the overall standard of the building. A new wood laminate floor has been fitted in the lounge and dining room and all metal frame beds have been removed. General repairs have been undertaken around the home and badly worn towels and plastic tablecloths are no longer used. The back of the home has been paved. Plans are being made for extra garden furniture and pot plants to be provided. The home is awaiting delivery of new dining tables and headboards. The following issues arose that require attention. • • • • • • The conservatory roof needed cleaning bedroom doors were scratched and need to be re varnished. This issue was addressed during the visit. en suites would benefit from having water pipes boxed in the bathroom on the mezzanine floor requires redecoration. This was partly addressed during the visit. a new toilet seat needs to be provided in the toilet on the mezzanine floor a number of toilets had become very black and require cleaning or replacement. 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 included in the forthcoming years training programme. Newhaven Care DS0000018916.V317136.R01.S.doc Version 5.2 Page 21 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 and 35 Quality in this outcome area adequate. This judgement has been made using available evidence including a visit to this service. Service users are supported by experienced staff, although further training needs to be provided to ensure service users are cared for in accordance with current good practice. There are sufficient staff on duty to ensure the service users are cared for. Some improvements need to be made to the staff recruitment procedure to ensure suitably qualified and competent staff are employed. Staff are supervised informally for the purpose of them developing within their role and improving the service provision. EVIDENCE: The Registered Manager demonstrated she was aware of her responsibilities with regard to the management of the home, supervision of staff and the care of service users. Through discussion she demonstrated her commitment to Newhaven Care DS0000018916.V317136.R01.S.doc Version 5.2 Page 22 supporting the staff within their role and demonstrated an open and positive style of management. Staff spoken to confirmed the Registered Manager was always available for advice and support when necessary. Most of the staff have worked at the home for many years so are familiar with the service users specific care needs and can communicate with the service users easily. The staff demonstrated a commitment to caring for the service users properly and ensuring their needs were fully met. The staff rota indicated there is a minimum of three staff on duty each day with this reducing to two staff in the evening. A domestic is on duty for three mornings each week. The staff turnover is low and agency staff are not used. A selection of staff files were looked out during the visit. All of the necessary information was in place and appropriate checks had been carried out on all staff to ensure they are suitable to work with vulnerable adults. All staff are given a copy of the General Social Care Councils Code of Conduct which sets out the standards expected of persons employing and working within the social care sector. The Registered Manager reported that she does not keep a record of the information gathered during the recruitment and selection procedure and issue of equality and diversity are not explicitly addressed. It would be considered good practice to ensure detailed notes are kept of any interview carried out with prospective staff members. Also that the issue of equality and diversity are explicitly addressed to ensure to the Registered Manager has an understanding of the applicants views on this aspect care provision. During past inspections concerns have been raised about the lack of training provided to the staff team as this had resulted in institutional practices and there being a lack of focus in the overall management of the home. Since this time improvements have been made to the way staff are supported and a programme of training has now been set up for the forthcoming year. This training is suitable for the running of the home and the care of vulnerable people. In light of the home accommodating service users with a learning disability and them having specific care requirements, the Registered Person must also provide training from external sources to ensure staff have the necessary skills and experience to care for the service users in line with current good practice. This issue has been raised at past inspections and has still not been addressed. Again the Registered Person is advised to consult with the British Institute of Learning Disability or other relevant agencies with regard to this aspect of care provision. All staff have either completed training to the National Vocational Qualification standards or are in the process of completing this training. This is in line with good practice and ensures they are up-to-date on current care practices. The Newhaven Care DS0000018916.V317136.R01.S.doc Version 5.2 Page 23 staff spoken to during the inspection said they enjoyed their work and felt well supported in their role. The Registered Manager spoke well of the staff team and said they were all committed to ensuring the service users are well cared for. Newhaven Care DS0000018916.V317136.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 39 40 and 42 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home is run for the benefit of the service users. Systems have been set up to ensure the ongoing improvement of the standard of care provided. Policies are procedures have been reviewed to ensure service users rights and best interests are safeguarded. The health, safety and welfare of the service users is promoted, although some improvements do need to be made in some areas of care provision. EVIDENCE: Newhaven Care DS0000018916.V317136.R01.S.doc Version 5.2 Page 25 There are clear lines of management and accountability within the home which is run for service users best interest. Mrs Catherine Higginson, the Registered Manager is qualified to National Vocational Qualification level 4 which is the recognised qualification for a manager of a residential care service. The staff spoken to during the visit spoke highly of Mrs Higginson saying she was always available for support and advice. The Registered Manager has undertaken training for her own development and the improvement of the service provision. Although a formal quality assurance system is not in place, systems have been set up to ensure the ongoing monitoring and continual improvement of the standards of care provided at the home. Through discussion the Registered Manager demonstrated her commitment to ensure the service was focused on the needs and future aspirations of the service users. Staff are supervised regularly and administrative systems are checked. Regular informal meetings take place with staff for the purpose of finding new ways of working and developing the service. The Registered Manager agreed to develop the quality assurance systems within the home by seeking out service user, carers, health care professionals and staff views on this standard of the service provision. Seven health care Professional comment cards were returned to the CSCI. They all indicated staff communicate clearly and work in partnership with them. They confirmed staff understand service users care needs and that specialist advice is incorporated into the service users care plan. All of the comment cards indicated the service users medication was appropriately managed and they had no complaints to raise about the home. All of the comment cards indicated the health care professionals were satisfied with the overall care provided within the home. One health care professional raised a concern about staffs lack of knowledge around service users benefits and the systems in place to accommodate new service users. This issue will be addressed directly with the person raising the concern and with the Registered Provider. The policies and procedures were not examined during the visit, although the Registered Manager reported that all of this information had been reviewed. Documentation was in place to demonstrate that regular safety checks had been carried out around the building. Staff have been provided with training in relation to promoting safe working practices within the home and further training is planned for the forthcoming year. The Registered Manager has put in place new health and safety guidance. A number of issues arose that require further attention. Newhaven Care DS0000018916.V317136.R01.S.doc Version 5.2 Page 26 • • • • • • It was reported that the small electrical appliances had been tested, although there was no documentation in place to demonstrate when this had been done. This issue was being addressed during the visit. Although the temperature of the water around the building had been checked, insufficient information had been collated to monitor this appropriately. Although some action had been being taken to prevent the risk of legionella, the up-to-date advice on how this issue should be addressed had not been taken up. This issue was being addressed during the visit. The whole fire alarm had not been serviced. This issue was being addressed during the visit. The fire call point on the emergency fire escape had not been tested. More detailed information needs to be recorded in the accident book. To ensure staff and service user safety the Registered Person must ensure all of these issues are addressed as a matter of priority. Newhaven Care DS0000018916.V317136.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 2 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 2 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 x 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 x 15 3 16 3 17 x PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 x 3 x 2 x x 2 x Newhaven Care DS0000018916.V317136.R01.S.doc Version 5.2 Page 28 yes Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard YA2 Regulation 14 Requirement The Registered Person is required to ensure that issues of equality and diversity are explicitly addressed in the assessment process (previous timescale of 31/07/06 not met). The Registered Person is required to ensure that issues of equality and diversity are explicitly addressed in the care planning process The Registered Person is required to provide staff with training in relation to issues of equality and diversity (previous timescale of 31/07/06 not met). The Registered Person is required to ensure staff are provided with training in relation to the management of challenging behaviour (previous timescale of 31/07/06 not met). The Registered Person is required to ensure information held in relation to complaint investigations is stored appropriately. The Registered Person is DS0000018916.V317136.R01.S.doc Timescale for action 30/04/07 2 YA6 15 28/02/07 3 YA6 18 30/04/07 4 YA6 18 30/04/07 5 YA22 22 30/04/07 6 YA22 22 30/04/07 Page 29 Newhaven Care Version 5.2 7 YA24 23 8 YA34 12 9 YA35 18 10 11 YA42 YA42 13 13 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 all of the outstanding items with regard to the maintenance of the building are addressed. The Registered Person is required to ensure a record is kept of any information collated during the staff recruitment procedures. Also that issues of equality and diversity are explicitly addressed during the interview process. The Registered Person is required to ensure specialist training in relation to service users particular care requirement is provided. The Registered Person is required to ensure all fire call points are tested. The Registered Person is required to ensure a detailed record is made of all accidents in the home. 30/04/07 30/04/07 30/04/07 30/04/07 23/01/07 Newhaven Care DS0000018916.V317136.R01.S.doc Version 5.2 Page 30 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 Refer to Standard YA42 Good Practice Recommendations The Registered Person is required to ensure a clear and detailed record is kept of the water temperature checks. Newhaven Care DS0000018916.V317136.R01.S.doc Version 5.2 Page 31 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. Extracts may not be used or reproduced without the express permission of CSCI Newhaven Care DS0000018916.V317136.R01.S.doc Version 5.2 Page 32 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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