Inspection on 05/06/06 for Newhaven Care

This inspection was carried out on 5th June 2006.

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

The inspector found no outstanding requirements from the previous inspection report, but made 10 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Newhaven Care 23/01/07

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 5th June 2006 08:30 Newhaven Care DS0000018916.V291211.R01.S.doc Version 5.1 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.V291211.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 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.V291211.R01.S.doc Version 5.1 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 Mrs Lynda So Care Home 14 Category(ies) of Learning disability (14) registration, with number of places Newhaven Care DS0000018916.V291211.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 8th March 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.V291211.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This Unannounced inspection took place over five hours and was conducted with the newly registered manager Mrs Catherine Higginson. Information about the service was obtained through a pre-inspection questionnaire and discussions with the staff team. Service users case files and supporting documentation was examined and a tour of the home took place. What the service does well: A range of risk assessments have been carried out to minimise the risk of harm to staff and service users. Staff support service users to become part of and participate in the local community in accordance with their assessed needs. Service users have opportunity to maintain family links and friendships inside and outside the home. The daily routines in the home are flexible which means service users can exercise choice in their daily routines. Service users receive personal support in the way they prefer. Efficient systems are in place to ensure service users good health. 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. Systems are in place to ensure the premises are kept clean, hygienic and free from offensive odours. There are clear lines of management and accountability within the home which is run for service users best interest. Service users are supported by experienced staff. Newhaven Care DS0000018916.V291211.R01.S.doc Version 5.1 Page 6 There are sufficient numbers of staff on duty at any time to ensure the service users are well cared for. Formal 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. Service users benefits from a well run home. The health safety and welfare of the service users is promoted. What has improved since the last inspection? What they could do better: The Statement of Purpose and Service User Guide need to be streamlined so prospective service users have the information they need to help them make a decision on whether to move into Newhaven Care on a permanent basis. Service users are only admitted into the home on the basis of a full assessment, which ensures staff can provide the appropriate package of care. However, issues of equality and diversity need to be explicitly addressed in the assessment process. In some instances more detailed information needs to be kept in relation to the review process to demonstrate the decision making behind changes made to care plans. Service users health, personal and social care needs are set out in an man individual plan of care. However, issues of equality and diversity need to be explicitly addressed in the care planning process. Systems are in place to ensure service users are safeguarded from abuse and harm. However improvements need to be made to the record keeping in relation to service users financial records. Newhaven Care DS0000018916.V291211.R01.S.doc Version 5.1 Page 7 For the most part the standard of the decor is good providing service users with an attractive and homely place to live. However, some improvements still need to be made. Staff are provided with a range of appropriate training to ensure they know how to care for the service users properly, however, the registered manager does recognise that this aspect of care does need to be developed further. Service users are supported by experienced staff, although further training does need to be provided to ensure service users are well cared for. Service users benefits from a well run home, although some improvements still need to be made to ensure service users receive an improved standard of care. Improvements need to be made to the policies and procedures to ensure the staff have the necessary information to refer to when caring for the service users. 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 Care DS0000018916.V291211.R01.S.doc Version 5.1 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.V291211.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1 and 2 The quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The Statement of Purpose and Service User Guide need to be streamlined to ensure prospective service users have the information they need to help them make a decision on whether to move into Newhaven Care on a permanent basis. Service users are only admitted into the home on the basis of a full assessment, which ensures staff can provide the appropriate package of care. Issues of equality and diversity need to be explicitly addressed in the assessment process. EVIDENCE: A Statement of Purpose and Service User Guide is in place to ensure prospective service users have the information they need to assist them make a decision about whether to move into Newhaven Care on a permanent basis. At the last inspection it was identified that this documentation needed to be streamlined. The registered manager is in the process of completing this work. A range of documentation is in place to indicate that a comprehensive assessment of service users care needs has taken place to ensure staff know how to look after the service users properly. Information about service users care needs is also obtained from relevant health care professionals to ensure Newhaven Care DS0000018916.V291211.R01.S.doc Version 5.1 Page 10 the staff have all the information they need to provide an appropriate package of care. The staff spoken to during the inspection confirmed they had access to all of the assessment documentation to ensure they know how to look after the service users 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, disability, gender, age, 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 some of these issues but agreed to ensure this issue was looked at in more detail . In the light of this, the registered persons are required to ensure the assessment documentation is updated to ensure service user specific care requirements in relation to their race, religion, disability, gender, age, and sexuality are explicitly addressed. Newhaven Care DS0000018916.V291211.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6, and 9 The quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Service users health, personal and social care needs are set out in an individual plan of care. Issues of equality and diversity need to be explicitly addressed in the care planning process. A range of risk assessments have been carried out to minimise the risk of harm to staff and service users. 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 are 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. The registered manager and two senior members of staff have recently completed training in relation to health action plans. This will further contribute to ensuring the staff Newhaven Care DS0000018916.V291211.R01.S.doc Version 5.1 Page 12 know how to look after service users in accordance with their particular care requirements. Although the care plans had recently been reviewed, the outcome and process followed during the review had not always been recorded in sufficient detail. Although it was recognised that some reviews held all the required information the registered persons must ensure all the necessary information is recorded in relation to the review process in order to demonstrate the basis of any decision making that formulates any changes made to a care plan. 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, disability, gender, age, religion and sexuality. This issue was discussed with the registered manager who agreed to ensure the matter was addressed. Management plans had been implemented for the purpose of helping staff to manage service users challenging behaviour. Some staff have completed basic training in relation to the management of aggressive behaviour. The manager is in the process of addressing this issue to ensure all staff have completed training in relation to the challenging behaviours presented by the service user group. The registered persons should 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. This will ensure the practices are in line with current good practice and are safe to both service users and staff. The registered persons The registered manager confirmed that arrangements had been made for all staff to undertake training in relation to the management of challenging behaviour although she did acknowledge that the staff group were very experienced and have known the service users for many years, so are clear about how to support the service users in this aspect of care provision. Service users are encouraged to take responsible risks as part of living an independent lifestyle although risk assessments have been completed to ensure their safety. An up to date risk assessment have been completed in relation to the use of a bedrail. This information secured the service users safety in relation to this piece of equipment. Although a policy was in place in relation to this aspect of Newhaven Care DS0000018916.V291211.R01.S.doc Version 5.1 Page 13 service provision, more detailed information needs to be recorded to ensure staff are clear about the potential dangers of using bed rails and staffs responsibilities with regard to the care of the person using this piece of equipment. This policy was updated within two days of the inspection. Newhaven Care DS0000018916.V291211.R01.S.doc Version 5.1 Page 14 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 13, 15 and 16 The quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Staff support service users to become part of and participate in the local community in accordance with their assessed needs. Service users have opportunity to maintain family links and friendships inside and outside the home. The daily routines in the home are flexible which means service users can exercise choice in their daily routines. EVIDENCE: At the last two inspections Staff assist service users to become part of and participate in the local community by way of the use of leisure and health care facilities. The home has its own transport which means the service users can go out and enjoy a more interesting life style. A range of social activities are provided and the registered manager has plans to convert the garage into an activity centre. The home does not have any set routines with regard to social Newhaven Care DS0000018916.V291211.R01.S.doc Version 5.1 Page 15 activities and the staff are determined by the service users needs on the day. Staff are available to spend time with the service users in groups or on an individual basis. More recently service users have been to the baths and to the promenade and shopping. Although it is acknowledged that social activities take place, during inspection it appeared that staff had minimal interaction with the service users who was sitting in the lounge watching. While it is clear that the registered manager is aware of service users specialist social care needs, the registered persons must ensure that staff are also trained on the importance of providing specialist social activities to people with a learning disability. The home should look to provide social activities that are both relaxing and stimulating. Staff support service users to maintain friendships with their family and friends both inside and outside the home. The routines in the home are flexible which means service users can exercise choice in their daily routines. Restrictions are only placed on service users for their safety and welfare. Not all of the service users have their own bedroom so there are limitations on when they can be alone or in company. There is no separate visitors room and the lounge and dining room are not separate. concerns were raised about the use of plastic crockery. At this time it was agreed that this would only be used if it was identified that the use of ceramic crockery would present as a danger. At this inspection plastic cups were being used at lunchtime. This issue was discussed with the registered manager who agreed that plastic cups should not routinely be used but only used where a risk of harm was identified. Under these circumstances a member of staff should be allocated to supervise and support the service user during mealtimes and a blanket rule of all service users having to use plastic cups must not be implemented. This practices is institutional and does not respect service users dignity. In the light of this the registered persons are required to carry out the appropriate risk assessment in relation to a service user using plastic cups and implement a strategy whereby they are supported during mealtimes. Newhaven Care DS0000018916.V291211.R01.S.doc Version 5.1 Page 16 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 and 20 The 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. Efficient systems are in place to ensure service users good health. Efficient medication administration procedures are in place to ensure service users good health. EVIDENCE: Service users have access to a range of health care professionals and are supported to attend health care appointments as required. There is documented evidence to show 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. The staff spoken to confirmed they are aware of how to ensure service users privacy and dignity when providing personal care. This aspect of care provision is incorporated into the induction training when staff are first employed at the home. Service users particular care requirements are also outlined in their care plan and further training in relation to this aspect of care Newhaven Care DS0000018916.V291211.R01.S.doc Version 5.1 Page 17 is being planned for the forthcoming year. Policies and procedures in relation to this aspect of care provision are available staff reference. Efficient systems are in place for the safekeeping and handling of service users’ medication and only trained staff are allowed to administer medication. Staff spoken to who had not completed this training confirmed they never administered 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 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. Newhaven Care DS0000018916.V291211.R01.S.doc Version 5.1 Page 18 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23 The quality in this outcome area is adequate. 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. Systems are in place to ensure service users are safeguarded from abuse and harm. However improvements need to be made to the record keeping in relation to service users financial records. EVIDENCE: The CSCI has not received any complaints about the standard of care provided at Newhaven Care and no complaints have been made directly to the home. A documented complaints procedure is in place. The staff spoken to demonstrated they are aware of the action they should take in the event of them receiving a complaint about the standards of care provided. All staff have completed training in relation to the protection of vulnerable adults from abuse and a copy of the Wirral adult protection procedure is available for staff reference. The staff spoken to were aware of the action they should take in the event of an incident in abuse taking place. The registered manager has recently compiled an information booklet for all staff in relation to this aspect of care provision to ensure they are clear on their responsibilities with regard to protecting vulnerable adults from abuse. A selection of service users financial records were inspected. These records were not accurately maintained although after further inspection, it became apparent that the actual amount of money held did correspond to that in the Newhaven Care DS0000018916.V291211.R01.S.doc Version 5.1 Page 19 records. These records were also cross-referenced with service users savings accounts; all of this information was accurately maintained. Issues raised included receipts had not been logged properly and financial transactions made on behalf of service users had not been recorded. Also service users weekly pension had not been entered into these records. An auditing system had not yet been implemented. This issue was discussed with the registered manager who agreed to ensure all at the records were updated within two days of the inspection. To ensure service users protection in relation to staff handling their money, the registered persons are required to ensure detailed and accurate records are maintained at all times. An auditing system must also be introduced to ensure the accuracy of these records. The registered manager confirmed that all records had been updated within two days of the inspection. Since the last inspection a serious concern has been raised about the way one of the registered providers manages service users finances. An investigation of this concern was conducted through the Wirral adult protection procedures and it has been concluded that service users finances are appropriately maintained. Newhaven Care DS0000018916.V291211.R01.S.doc Version 5.1 Page 20 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24 and 30 The 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. However, some improvements still need to be made to ensure a more homely environment is provided. Systems are in place to ensure the premises are kept clean, hygienic and free from offensive odours. EVIDENCE: Newhaven Care DS0000018916.V291211.R01.S.doc Version 5.1 Page 21 The premises are comfortably furnished. The light levels throughout the home are good and the home is pleasantly decorated. 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. The following issues were noted as requiring attention: • • • • • • • • The radiator cover in the lounge was broken curtains have not been fitted to the bathrooms on the upper floors the conservatory roof was badly blackened towels were frayed metal framed beds were being used the carpet in the dining room was badly stained the patio area was untidy and dirty plastic tablecloths were being used It is anticipated that all of these issues will be addressed by the end of July this year. In the light of this the registered persons are required to send a copy of the maintenance programme to the CSCI. This should include timescales for the completion of this work. To date the lounge/dining area and conservatory have been redecorated and plans are being made for a new floor covering to be fitted. The back garden is in the process of being totally cleared with plans being made for a new patio area to be built. New chairs have been ordered to the dining room. A new blind will be fitted to the window in the dining room which overlooks the fire escape. All of this work will significantly enhance the comfort of the home and will enable the service users to enjoy the back garden while the weather is fine. Systems are in place to prevent the spread of infection. A system is also in place to ensure all equipment being used in the home is in good working order. The domestic staff spoken to during the inspection confirmed she had sufficient equipment to carry out a work and that arrangements had been made that her to complete training in relation to infection control within the near future. Newhaven Care DS0000018916.V291211.R01.S.doc Version 5.1 Page 22 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 32, 33, 35 and 36 The quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. There are clear lines of management and accountability within the home which is run for service users best interest. Service users are supported by experienced staff, although further training does need to be provided to ensure service users are for in accordance with current good practice. There are sufficient numbers of staff on duty at any time to ensure the service users are well cared for. Staff are provided with a range of appropriate training to ensure they know how to care for the service users properly, however, the registered manager does recognise that this aspect of care does need to be developed further. Formal 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. Newhaven Care DS0000018916.V291211.R01.S.doc Version 5.1 Page 23 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 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. 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 the staff are up-to-date on current care practices. The staff spoken to during the inspection said they enjoyed their work and felt they worked well as a team. The registered manager spoke well of the staff team and said they were all committed to ensuring the service users are well looked after. The staff rota submitted during the inspection indicated there were sufficient staff on duty to care for the service users in accordance with their preferred needs. There have been a few changes to the staff group which is a positive aspect of the home as this ensures consistency in the care provided to the service users. Staff ensure specialist services are provided to ensure service users receive the specific care they need. The registered manager reported that she does not hold regular staff meetings and as she finds individual discussion with staff more useful. She stated that because the staff group is small, the communication within the home is good. Staff records indicated that most of the necessary checks had been carried out to ensure the staff are suitable to work with vulnerable adults. The only outstanding item is staff birth certificates. The registered persons are required to address this issue to further ensure service user safety. The registered manager is currently looking to streamline all of the staff files although it must be noted that significant improvements have been made to this documentation since last inspection. Since the last inspection the registered manager has undertaken a lot of work to develop staff training. She has been in contact with a local training agency and a relevant health care professional from Ashton House Hospital. It was agreed that a copy of the forthcoming years training plan would be submitted to the CSCI. While it is acknowledged that staff have undertaken appropriate training, the registered persons should look to specialist training in relation to service users who have learning disability. The registered persons should specifically refer to the British Institute of Learning Disability for specialist training and current good practice in this area. Newhaven Care DS0000018916.V291211.R01.S.doc Version 5.1 Page 24 The issue of equality and diversity was discussed with the registered manager. She acknowledged that while a policy was in place in relation to equal opportunities this does need to be developed to reflect current legislation and good practice. The registered manager agreed to begin to raise the issue of equality and diversity such as race, religion, age, gender, sexuality, and disability through staff supervision and general discussion to ensure staff are up-to-date on current legislation and good practice. Formal supervision is provided on a regular basis. This gives staff an opportunity to discuss any issues or concerns they may have and to discuss their development within their role. A system of staff appraisal is also in place to ensure staff are fulfilling their responsibilities with regard to the care of vulnerable adults. Discussion with staff during the inspection confirmed they enjoyed their work and are well supported in their role. Newhaven Care DS0000018916.V291211.R01.S.doc Version 5.1 Page 25 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39, 40 and 42 The quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Service users benefits from a well run home, although some improvements still need to be made to further improve the service provision. Although no formal quality assurance system is in place, systems have been set up to ensure the ongoing improvement of the standard of care provided. Improvements need to be made to the policies and procedures to ensure the service users rights and best interests are safeguarded. The health safety and welfare of the service users is promoted. Newhaven Care DS0000018916.V291211.R01.S.doc Version 5.1 Page 26 EVIDENCE: There are clear lines of management and accountability within the home which is run for service users best interest. Mrs Catherine Higginson, who has recently been registered with the CSCI is qualified to NVQ level 4 which is the recognised qualification for a manager of a residential care service. The staff spoken to during the inspection spoke well of Mrs Higginson saying she was always available for advice and support when necessary. Mrs Higginson has worked very hard to improve all aspects of the service provision to ensure the service users are well cared for and have a good quality of life. She recognises that further work still needs to be carried out and has made plans to address these issues. Although a formal quality assurance system is not in place procedures have been set up to ensure a good standard of care is provided at the home and that further improvements are always made where necessary. This includes the registered manager carrying out spot checks to ensure staff are providing the necessary care and reviewing all care plans and other documentation. The home also has a book to record visitors comments. The relative of one service user had commented I always find the staff very helpful and they always answer my questions. They are very caring. The registered manager is in the process of organising training for herself around this aspect of care provision. Arrangements have been made for the supplying pharmacist to carry out an audit of the medication procedures to ensure they are in line with good practice. The registered manager keeps regular contact with the staff from the day centres service users attend and relevant health care professionals. At the last inspection the policies and procedures were examined. It was acknowledged that while a lot of the information was relevant, some of it was old and out of date. At this time it was agreed that all of this information needed to be streamlined to ensure easy access for staff. At this inspection the registered manager agreed to ensure this work was completed within the agreed timescale. Safe working practices are promoted throughout the home. Policies and procedures relating to this aspect of care provision are available for staff reference although as stated above some improvements do need to be made to this aspect of care provision. Staff have completed training in health and safety and further training is being planned the forthcoming year. Regular safety checks are carried out on all equipment at the home. Newhaven Care DS0000018916.V291211.R01.S.doc Version 5.1 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 2 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 3 23 2 ENVIRONMENT Standard No Score 24 2 25 x 26 x 27 x 28 x 29 x 30 3 STAFFING Standard No Score 31 3 32 2 33 2 34 x 35 2 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 x x 3 x LIFESTYLES Standard No Score 11 x 12 x 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 2 x 2 2 x 3 x Newhaven Care DS0000018916.V291211.R01.S.doc Version 5.1 Page 28 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 YA4 Regulation 4&5 Requirement The registered persons are required to ensure the statement of purpose and the service user guide is streamlined and available for inspection at all times. (Previous timescale of 31/05/06 not met) The registered persons are required to ensure that issues of equality and diversity are explicitly addressed in the assessment process. The registered persons are required to ensure that issues of equality and diversity are explicitly addressed in the assessment process. The registered persons are required to ensure detailed records are kept of care plan reviews. The registered persons are required to ensure service users dignity is respected. In this instance that plastic crockery is not used unless it has been identified through a risk assessment that this is appropriate. (Previous timescale of 08/06/06 not met) DS0000018916.V291211.R01.S.doc Timescale for action 31/07/06 2 YA2 14 31/07/06 3 YA6 15 31/07/06 4 YA6 15 31/07/06 5 YA17 12 31/07/06 Newhaven Care Version 5.1 Page 29 6 YA23 13 7 YA24 23 8 YA34 7 9 YA35 18 10 YA40 18 The registered persons are required to ensure service users financial records are accurately maintained and that an auditing system is introduced into the home. The registered persons are required to submit a copy of the maintenance programme to be CSCI. This should include all of the items highlighted in this report. The registered persons are required to ensure a copy of staffs birth certificate is held on file. The registered persons are required to submit a copy of the forthcoming years training programme. Particular attention must be paid to providing staff with training in relation is issues of equality and diversity and the management of challenging behaviour. The registered persons are required to ensure that policies and procedures are reviewed to reflect current good practice and service users current care requirements. 08/07/06 31/07/06 31/07/06 31/07/06 31/07/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Newhaven Care DS0000018916.V291211.R01.S.doc Version 5.1 Page 30 Commission for Social Care Inspection Liverpool Local 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 Care DS0000018916.V291211.R01.S.doc Version 5.1 Page 31 - 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. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!