Inspection on 08/03/06 for Newhaven Care

This inspection was carried out on 8th March 2006.

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

The inspector found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 23 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 05/06/06

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 Unannounced Inspection 8th March 2006 09:00 Newhaven Care DS0000018916.V285679.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.V285679.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.V285679.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.V285679.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 1st August 2005 Brief Description of the Service: 17 Penkett Road is a care home registered with the Commission for Social Care Inspection to provide accommodation for 16 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. Accommodation is mainly provided in double rooms. There is a large conservatory/dining area that is also used for other activities. There are parking facilities to the front of the house and a garden to the rear that is accessible to service users. Newhaven Care DS0000018916.V285679.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection took place over 6 hours and was the second statutory unannounced inspection for 2005/2006. A tour of the premises took place and staff and service users records were inspected. Three staff were spoken to and observations were made on the service user group. What the service does well: Staff understood the importance of ensuring service users confidentiality. New menus are in the process of being drawn up to ensure service users interest and good health. The menus provided have improved and more fresh vegetables and fruit are now provided. Service users physical and emotional health care needs are met through the support of relevant health care professionals. A complaint procedure is in place to ensure service users views are listened to and acted upon. The standard of the environment is good providing service users with an attractive and homely place to live. The standard of hygiene is good which ensures a comfortable and safe environment. All of the necessary security checks are carried out to ensure prospective staff are safe to work with vulnerable adults. Staff role. are appropriately supervised to ensure they are supported within their Systems are in place to ensure service users are safeguarded from abuse and harm and staff demonstrated an understanding of how they would deal with this issue within the home. What has improved since the last inspection? Since the last inspection improvements have been made to the admission procedures, the storage of medication, staff training, the condition of the Newhaven Care DS0000018916.V285679.R01.S.doc Version 5.1 Page 6 building and the service users safety in relation to the use of bed rails. All of this further improves the overall standard of care provided at the service. What they could do better: The Statement of Purpose and Service User Guide needs 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. The sytems in place for the assessment of service users care requirements need to be developed as it is not possible to understand the meaning of some documentation. This could result in aspects of service users care needs being missed. Service users care needs are met in a variety of ways. However, because the assessment documentation was soemtimes unclear, it was not entirely possible to establish whether the service users care needs are being fully met. Service users personal development is addressed through the care planning process. A range of leisure activities are provided, however, this aspect of care provision needs to be developed to ensure a stimulating environment is provided. Improvements need to be made to the care planning process to ensure service users care needs are met in accordance with their particular requirements. A range of risk assessments have been carried out to ensure service users safety. However, some improvements need to be made to this documentation to ensure there is a clear meaning to the outcome. To ensure service users welfare, improvements need to be made to the medication administration policies and procedures. Systems are in place to ensure service users are safeguarded from abuse and harm. However, improvements need to be made to the supporting documentation. Staff are provided with a range of appropriate training to ensure the service users are cared for in accordance with good practice. However specialist training in relation to service users specific care requirements is not always provided. The health safety and welfare of the service users is promoted, however, some improvements need to be made to ensure service users further welfare. Newhaven Care DS0000018916.V285679.R01.S.doc Version 5.1 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. Newhaven Care DS0000018916.V285679.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.V285679.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, 2, 3 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. The service users assessment document needs to be further develped as it was not easy to understand the numerical outcome. Service users care needs are met in a variety of ways. However, because the assessment documentation was soemtimes unclear, it is not possible to establish whether the service users care needs are being fully met. 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 in to Newhaven Care on a permanent basis. This information does however need to be streamlined to ensure it contains all the required information. A pre-admission assessment document has now been compiled and a range of documentation is in place for the purpose of assessing service users care requirements in more detail. This documentation covers a range of relevant issues to ensure the staff know how to provide the appropriate package of care. A range of risk assessments have also been completed to ensure staff Newhaven Care DS0000018916.V285679.R01.S.doc Version 5.1 Page 10 are aware of service users safety. Although the level of risk is identified in the risk assessments, there is no explanation as to the meaning of the numerical outcome. Also a lot of information had not been signed or dated and some of the documentation was repetitive. In the light of this, the assessment and risk assessment process needs to be streamlined and developed in order to identify a clear outcome. If the outcome is not identified, this could lead to aspects of the service users care needs being missed and them being left vulnerable to the risk of harm. The Acting Manager demonstrated a commitment to ensure these issues were addressed immediately. There is documented evidence to indicate that service users care needs are met. Regular contacts is maintained with a range of health care professionals such as the service users Community Psychiatric Nurse, Chiropodist, Optician and GP. However in light of the fact that the care plans are not up to date, it was not entirely possible to establish the accuracy of the information recorded. Newhaven Care DS0000018916.V285679.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, 9 and 10 Improvements need to be made to the care planning process to ensure service users care needs are met in accordance with their particular requirements. A range of risk assessments have been carried out. Some improvements need to be made to the supporting documentation to ensure there is a clear understanding of the outcome of the assessment completed. Staff understood the importance of ensuring service users confidentiality. EVIDENCE: A documented plan of care is in place for each of the service users in order 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. Although the care plans had recently been reviewed, not all of the issues highlighted in the care plan had been addressed. Also there was no information recorded to explain the basis of any decision making. Newhaven Care DS0000018916.V285679.R01.S.doc Version 5.1 Page 12 A management plan had been implemented for the purpose of helping staff to manage service users challenging behaviour. This management plan had been drawn up in conjunction with the service users Psychiatrist. The Acting Manager confirmed that not all staff have been provided with training on the management of challenging behaviour. To ensure service user and staff safety, the management plans need to be developed further to give more detailed information on the exact interventions required in the event of challenging behaviour being displayed. Training must also be provided to all staff in relation to 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. Some improvements need to be made to these documents to ensure there is a clear understanding of the outcome of the assessment completed. Guidance and advice was given in relation to this area of care provision. Information held in relation to service users care needs is stored securely and staff respect service users confidentiality in relation to this aspect of care provision. Newhaven Care DS0000018916.V285679.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 11, 14 and 17 Service users personal development is addressed through the care planning process. A range of leisure activities are provided, however, this aspect of care provision does need to be developed to ensure a stimulating environment is provided. New menus are in the process of being drawn up to ensure service users interest and good health. EVIDENCE: A range of leisure activities are provided and a member of staff is allocated to take on this area of care provision. The activities provided include swimming, videos, puzzles, trips to the local shops and pub lunches. Some service users attend evening social clubs and others attend day centres. It was acknowledged that this aspect of care provision has improved over the past year, however, all of the staff spoken to during the inspection agreed that further improvements still need to be made to ensure service users interest and stimulation. Newhaven Care DS0000018916.V285679.R01.S.doc Version 5.1 Page 14 The Acting Manager is in the process of drawing up new menus and confirmed that more fresh fruit and vegetables are now provided. The Acting Manager confirmed that plastic crockery was now only being used for a couple of service users, although she could not account for why this was the case. This issue was discussed with the Acting Manager who agreed that plastic crockery is institutional and childlike. In the light of this the Registered Providers must ensure appropriate crockery is provided for all service users unless a risk of harm has been identified. The Acting Manager agreed with these comments and confirmed that ceramic crockery would be used for all service users. Newhaven Care DS0000018916.V285679.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19 and 20 Service users physical and emotional health care needs are met. To ensure service users welfare, improvements need to be made to the medication administration policies and procedures. EVIDENCE: Service users have access to a range of health care professionals and are supported to attend health care appointment 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. A medication administration procedure is in place and safe storage facilities are provided. The key to the medication cabinet is now step kept securely. A homely remedies policies in place. It is recommended that the signature of the service users GP is obtained for this policy. The homes supplying pharmacist recently carried out an audit of the medication administration policies and procedures; the Acting Manager reported that no issues of concern were raised. All staff who administer medication have been provided with training. Staff are trained to give rectal diazepam. This training was provided by a Community Psychiatric Nurse from Ashton House in November 2005. Although Newhaven Care DS0000018916.V285679.R01.S.doc Version 5.1 Page 16 this is in line with good practice, specific documented guidance was not available for staff reference and the circumstances under which this medication should be given to individual service users had not been recorded. To ensure service users safety and well being, the Registered Providers are required to ensure documented guidance is available for staff reference. General information about service users medication was available for staff reference. The Registered Persons are advised to also obtain copies of the information leaflets that accompany specific medications. This information should be easily available for staff reference. Newhaven Care DS0000018916.V285679.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23 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 supporting documentation. 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 (March 2005. A copy of the Wirral adult protection procedure is also available for staff reference, however the most current information was not available for staff reference. Advice and guidance was given in relation to how this information could be obtained. A whistle blowing policy is in place along with other relevant information. The staff spoken to were aware of the action they should take in the event of an incident in abuse taking place. However there was no in-house adult protection procedure in place for staff reference. To ensure service users protection and to ensure the appropriate procedures are followed in relation to an incident of abuse occurring, the Registered Persons are required to ensure a detailed procedure is in place for staff reference. Newhaven Care DS0000018916.V285679.R01.S.doc Version 5.1 Page 18 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 standard of the environment within the home is good providing service users with an attractive and homely place to live. The standard of hygiene is good which ensures a comfortable and safe environment. EVIDENCE: Newhaven Care DS0000018916.V285679.R01.S.doc Version 5.1 Page 19 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 maintenance and renewal programme for the fabric and redecoration of the premises. 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 For service users comfort and safety the Registered Persons are required to address these issues. At the back of the home is a small patio area and large garden. This area is not particularly attractive and it was reported that plans are being made for the garden to be made more attractive in order to encourage the service users to make use of this area. This issue has been addressed at the last three inspections and to date no improvement has been made. To ensure service users are given the choice and opportunity to enjoy the garden when the weather is good, the Registered Persons are required to improve this aspect of service provision. 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. Newhaven Care DS0000018916.V285679.R01.S.doc Version 5.1 Page 20 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): 34, 35, 36 All of the necessary security checks are carried out to ensure prospective staff are safe to work with vulnerable adults. Staff are provided with a range of appropriate training to ensure the service users are cared for in accordance with good practice. However specialist training in relation to service users specific care requirements is not always provided. Staff role. are appropriately supervised to ensure they are supported within their EVIDENCE: All of the necessary security checks are carried out to ensure prospective staff are safe to work with vulnerable adults. All staff have complete formal and inhouse induction training to ensure they know how to look after the service users in accordance with their particular needs. The in-house induction training programme needs to be developed to include all aspects of service users protection and safety. The Acting Manager reported that staff have completed a range of appropriate training to ensure the service users are cared for in accordance with good practice. This training has included personal safety, moving and handling, medication administration, aggression management, and the protection of Newhaven Care DS0000018916.V285679.R01.S.doc Version 5.1 Page 21 vulnerable adults from abuse. Specialist training in relation to service users specific care needs has been provided although this aspect of care provision does need to be developed further. Most of the staff have completed training in line with the National Vocational Qualification standards and more staff are starting this training within the near future. The Acting Manager is proactive in seeking out training for the staff team although a training programme for the forthcoming year has not been established. In the light of this the Registered Persons are required to carry out a training audit which reflects service users care needs and staffs training requirements. A copy of this programme of training must be submitted to the CSCI in order to demonstrate that suitably qualified and competent staff are employed at the home. The staff spoken to during the inspection said they enjoyed their work and felt well supported in their role. They confirmed they worked well as the team. They spoke highly of the Acting Manager and confirmed she was always available for support and advice. This is a positive aspect of the home and goes some way to ensuring the service users receive a consistent level of care. Staff are supervised informally. The Acting Manager also carries out formal supervision and has introduced a system of appraisal for staff development. Newhaven Care DS0000018916.V285679.R01.S.doc Version 5.1 Page 22 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, 40 and 42 Although the Acting Manager is deemed competent and experienced to run the service for its stated purpose, improvements need to be made to some aspects of the service provision. 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, however, some improvements need to be made to ensure service users further welfare. EVIDENCE: The Acting Manager has completed National Vocational Qualification level 3 and 4 which is the recognised qualification for a manager of a residential care service. The Acting Manager identified her own training needs and agreed to ensure they were addressed within the near future. During the inspection, a concern was raised that improvements are only made through the regulatory process and that the Registered Providers and to some Newhaven Care DS0000018916.V285679.R01.S.doc Version 5.1 Page 23 degree the Acting Manager, are not pro active in improving the overall standard of the service. Advice was given with regard to how improvements could be made and the Acting Manager demonstrated a commitment to ensure the further improvement of the standard of care provided. In the light of this, the Registered Persons are required to ensure the home is managed in a way that complies with the Care Homes Regulations 2001 and promotes and makes proper provision for the health and welfare of the service users. A file containing a wide range of policies and procedures is in place. While a lot of the information was relevant, the Acting Manager agreed that some of it appeared old and may be out of date. The information held needs to be streamlined to ensure staff can easily access information to support them within their role. The policies and procedures file held information relating to the use of restraint. The information in place gave staff guidance on the different types of restraint that can be used and how the use of restraint should be documented. This policy also made reference to a matron being employed in the home when this is not the case. The Acting Manager was not aware this information was in place and confirmed that restraint is not used to manage any challenging behaviour presented by the service users. Given that restraint is never used in the home, it is potentially dangerous to give staff guidance that may lead them to manage and support service users in a way that may cause more harm. This issue was addressed at the last inspection and an assurance was given by the Registered Persons that the matter had been addressed. In the light of this the Registered Persons are again required to ensure staff are given appropriate guidance in relation to the management of service users challenging behaviour. Radiators were noted to be very hot is some of the bedrooms. To ensure service users safety, a risk assessment must be undertaken to highlight any potential dangers. Action must then be taken to address any issues raised. A record of any accidents that have occurred are recorded in the home s accident book. This documentation held basic information in relation to the action taken in respect of the follow-up care provided. The accident book held at the home was out of date and the Registered Providers must ensure the appropriate documentation is available for the purpose of recording all accidents in accordance with current legislation. Advice was given with regard to how to obtain this documentation. Newhaven Care DS0000018916.V285679.R01.S.doc Version 5.1 Page 24 The Fire logbook indicated that regular fire safety checks are carried out and that the whole fire alarm system is serviced on an annual basis. All staff receive regular fire safety briefings. The Registered Persons are required to ensure the emergency call bells are tested weekly as stated by the Merseyside Fire Department. Most staff have received training in relation to health and safety, moving and handling and risk assessment. The Registered Persons are required to ensure this training is provided for all staff to ensure the safety of both staff and service users. Bed rails are used for one service user. A risk assessment was carried out by a relevant health care professional to ensure the service users safety and welfare. The Acting Manager demonstrated she was aware of the potential dangers of using bed rails, however this information had not been documented for staff reference. It was agreed this issue would be addressed immediately. The Registered Providers are required to ensure service users safety by providing staff with training in relation to this aspect of care provision. Newhaven Care DS0000018916.V285679.R01.S.doc Version 5.1 Page 25 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 2 4 x 5 x INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 2 ENVIRONMENT Standard No Score 24 2 25 x 26 x 27 x 28 x 29 x 30 3 STAFFING Standard No Score 31 x 32 x 33 x 34 3 35 2 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 x x 2 3 LIFESTYLES Standard No Score 11 2 12 x 13 x 14 2 15 x 16 x 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score x 3 2 x 2 x x 2 x 2 x Newhaven Care DS0000018916.V285679.R01.S.doc Version 5.1 Page 26 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 YA4 Regulation 4,5 Requirement The Registered Persons are required to ensure the Statement of Purpose and the Service User Guide includes all of the required information. The Registered Persons are required to ensure the assessment process is developed to ensure a clear outcome. The Registered Persons are required to ensure all aspects of the service users care plans are included in the review process. The Registered Persons are required to ensure management plans give clear guidelines with regard to how staff should manage service users challenging behaviours. The Registered Persons are required to ensure the risk assessments are developed to ensure a clear outcome. The Registered Persons are required develop the leisure activities provided. The Registered Persons required to ensure service users dignity is respected. In this instance that plastic crockery is not used DS0000018916.V285679.R01.S.doc Timescale for action 31/05/06 2 YA2 14 14/07/06 3 YA6 15 14/07/06 4 YA9 14 14/07/06 5 YA9 14 14/07/06 6 7 YA14 YA17 16 12 08/06/06 08/06/06 Newhaven Care Version 5.1 Page 27 8 YA20 13, 15 9 YA23 13 10 11 12 13 14 YA24 YA24 YA24 YA24 YA34 23 16 23 16 18 15 YA35 18 16 YA40 17 unless it has been identified through a risk assessment that this is appropriate. The Registered Persons are required to ensure documented guidance is available for staff reference in relation to the appropriate use of rectal diazepam. The Registered Persons are required to ensure staff are fully aware of the action they should take in the event of an incident of abuse occurring and that all the necessary supporting documentation is available for staff reference. The Registered Persons required to ensure the garden is kept in a good state of repair. The Registered Persons are required to ensure the radiator cover in the lounge is repaired. The Registered Persons are required to fit curtains in the top floor bathrooms. The Registered Persons required to ensure the conservatory roof is cleaned. The Registered Persons are required to ensure the staff induction training is developed to include issues relating to service users protection and safety. The Registered Persons required to ensure staff are provided with specialist training in relation to service users specific care requirements. In this instance that a training programme for the forthcoming year is submitted to the CSCI office. The Registered Persons are required to ensure the policies and procedures are reviewed to reflect current good practice and service users current care requirements. DS0000018916.V285679.R01.S.doc 08/05/06 08/05/06 01/01/07 08/06/06 08/06/06 08/07/06 08/07/06 08/05/06 08/07/06 Newhaven Care Version 5.1 Page 28 17 YA42 13,17 18 YA42 18 19 YA42 13,16 20 YA42 13 21 YA42 18 22 YA42 23 23 YA42 13 The Registered Persons are required to ensure staff are supported in their role by way of appropriate policies and procedures. In this instance that inappropriate information relating to the use of restraint is not given to staff. The Registered Persons are required to ensure all staff are provided with training in relation to the management of challenging behaviour. In this instance a proposal as to when this training will be provided should be submitted to the CSCI. The Registered Persons are required to ensure service users safety. In this instance a risk assessment must be carried out on the radiators in the bedrooms. The Registered Persons are required to ensure the most current accident book is used for the recording of all accidents in the home. The Registered Persons are required to ensure staff are provided with training in relation to health and safety. In this instance the Registered Providers must submit a proposal to the CSCI as to when this will be provided. The Registered Persons are required to ensure the appropriate checks are carried out on all fire safety equipment. The Registered Persons are required to ensure documented guidance is in place in relation to the risks associated with the use of bed rails. 08/03/06 08/06/06 08/03/06 08/06/06 08/06/06 08/03/06 08/03/06 Newhaven Care DS0000018916.V285679.R01.S.doc Version 5.1 Page 29 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 YA20 Good Practice Recommendations It is recommended that the Registered Persons obtain copies of the information leaflets supplied with individual medications. Newhaven Care DS0000018916.V285679.R01.S.doc Version 5.1 Page 30 Commission for Social Care Inspection Liverpool Satellite Office 3rd Floor Campbell Square 10 Duke Street Liverpool L1 5AS National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Newhaven Care DS0000018916.V285679.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. 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