Inspection on 20/12/07 for Newhaven Community Care Ltd (Phoenix House)

This inspection was carried out on 20th December 2007.

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

The inspector found no outstanding requirements from the previous inspection report, but made 11 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Newhaven Community Care Ltd... 29/04/09

Newhaven Community Care Ltd... 19/06/08

Similar services:

Coopers Mill Ltd

Bramley Avenue (73)

Paradise Lodge

Grangewood

Upaya Ananda

Newton Court (1-2)

Kings Lane (32)

Pemdale

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

CARE HOME ADULTS 18-65 Newhaven Community Care Ltd (Phoenix House) 124 Crowstone Road Westcliff on Sea Essex SS0 8LQ Lead Inspector Michelle Love Unannounced Inspection 20th December 2007 09:00 Newhaven Community Care Ltd (Phoenix House) DS0000070048.V353688.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 Community Care Ltd (Phoenix House) DS0000070048.V353688.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 Community Care Ltd (Phoenix House) DS0000070048.V353688.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Newhaven Community Care Ltd (Phoenix House) Address 124 Crowstone Road Westcliff on Sea Essex SS0 8LQ 01702 337057 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) sharondbales@hotmail.com Newhaven Community Care Ltd Vacant Post Care Home 6 Category(ies) of Learning disability (6) registration, with number of places Newhaven Community Care Ltd (Phoenix House) DS0000070048.V353688.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category of service only: Care home only - Code PC to service users of the following gender: Either whose primary needs on admission to the home are within the following categories: 2. Learning disability - Code LD - maximum number of places 6. The maximum number of service users who can be accommodated is: 6 N/A Date of last inspection Brief Description of the Service: Phoenix House is a care home providing personal care and accommodation for up to six residents who have a learning disability. The home is a three storey detached house situated in a residential area and is close to all local amenities. There are six bedrooms for residents within the home and it has a large lounge overlooking the rear garden and an adjacent dining area. Additionally there are two other lounge areas for residents use. The home has a rear garden which residents are able to access. Two mini buses are available to transport the residents to their activities and to college. The weekly fees charged to residents is currently £1853.00. Additional, charges incurred by residents relate to chiropody, transport, holidays, personal toiletries, hairdressing and some leisure pursuits. There is a Statement of Purpose and Service Users Guide readily available within the home. Newhaven Community Care Ltd (Phoenix House) DS0000070048.V353688.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was the registered provider’s first unannounced key inspection since being registered. The visit took place over an eight-hour period. Prior to this inspection, the registered provider had submitted an Annual Quality Assurance Assessment, detailing what they do well, what could be done better and what needs improving. As part of the process a number of records relating to residents, care staff and the general running of the home were examined. Additionally a full tour of the premises was undertaken, members of staff were spoken with and their comments are used throughout the main text of the report. Following the inspection surveys were forwarded to relatives and healthcare professionals to seek their views. It is disappointing that no relatives’ surveys were received and only one healthcare professional provided a response. The manager and other members of the staff team assisted the inspector. Feedback on the inspection findings was given throughout the day and summarised at the end of the day. The opportunity for discussion and/or clarification was given. What the service does well: What has improved since the last inspection? This is not relevant as this is the first inspection for Phoenix House since it was first registered. Newhaven Community Care Ltd (Phoenix House) DS0000070048.V353688.R01.S.doc Version 5.2 Page 6 What they could do better: 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 Community Care Ltd (Phoenix House) DS0000070048.V353688.R01.S.doc Version 5.2 Page 7 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 Community Care Ltd (Phoenix House) DS0000070048.V353688.R01.S.doc Version 5.2 Page 8 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 good. This judgement has been made using available evidence including a visit to this service. Prospective residents have their needs assessed prior to moving into the care home, so as to ensure that staff working within the care home are able to meet their needs and provide the appropriate care. EVIDENCE: The file of one newly admitted resident was inspected and evidence indicated that the management of the home completed a pre admission assessment prior to admission, so as to ensure that they are able to meet the prospective resident’s needs. Additional information was provided by the resident’s previous placement and placing authority. Following discussion with the manager a clear rationale was presented to the inspector, as to why the resident did not have a transition/trial visit to the home, prior to admission. Records indicated that the manager and operations manager visited the resident within their previous placement as part of the assessment process. The Annual Quality Assurance Assessment details that as part of this process, photographs of the home and their intended bedroom/bathroom/communal areas were also provided to enable the resident to see what was available/on offer. The Commission recognises that it is normal procedure for prospective residents and their representatives to visit the care home prior to admission. Newhaven Community Care Ltd (Phoenix House) DS0000070048.V353688.R01.S.doc Version 5.2 Page 9 There was no evidence to indicate that the management of the home had confirmed in writing to the resident and/or their representative that they could meet the resident’s needs. Information was recorded that a review was undertaken four months after their admission and that the resident had settled into the home environment at Phoenix House. The review included the resident, their next of kin, healthcare professional and care manager. Newhaven Community Care Ltd (Phoenix House) DS0000070048.V353688.R01.S.doc Version 5.2 Page 10 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. Shortfalls in care planning means that residents may not always receive the desired outcomes or a proactive approach to their care management. EVIDENCE: Care records were examined and were comprehensive, informative and made reference to the individual’s health, social, emotional and physical care needs. However, further development of the care planning process needs to be undertaken by the management of the home to ensure that support plans record in detail, information pertaining to staff’s interventions, covering all areas of assessed need and explicit guidelines for dealing proactively with individual’s inappropriate and/or challenging behaviour. For example the care plan made reference to diversions being created by staff, to prevent the resident displaying self-injurious behaviours. No precise information was recorded detailing the type of self-injurious behaviour exhibited and there were no guidelines within the care plan document depicting what diversions were required by staff to support individuals. Newhaven Community Care Ltd (Phoenix House) DS0000070048.V353688.R01.S.doc Version 5.2 Page 11 Information relating to the latter was recorded but this was only recorded as part of the risk assessment process. The manager was advised that it could prove useful to have this information located within the actual plan of care. Care plans also made reference to residents using makaton and pictures as a way of communicating their needs. The care plan did not specifically include the makaton signs/pictures favoured and/or frequently used by the individual. The manager was advised that this may prove useful as a way for support staff/agency staff to engage with residents and for residents to feel confident and secure that staff have the ability to engage with them. During the morning of the inspection only one member of care staff and the manager were observed to interact positively with all three residents. Rapport between staff and residents was observed to be inconsistent and intermittent, however staff in the afternoon were observed to have a very good relationship with residents and interaction was observed to be much more positive. This resulted in residents being more vocal and expressing more non-verbal signs of communication with individual members of staff. The Annual Quality Assurance Assessment detailed that it is hoped that more communication aids will be purchased and used within the home and for a member of staff to become a communication co-ordinator within the care home. Where restrictions are imposed on individual residents’ choice and freedom, further work is required to ensure that there is clear information depicting agreement between the home and the resident and that where appropriate other interested parties have also been consulted e.g. resident’s family and/or placing authority. It was positive to note that the care plan made reference to restraint, however consideration must also be given to ensuring that this is comprehensive and includes aspects relating to their personal care and to any self-injurious behaviour. Information should also be documented to indicate to staff what to do should strategies not prove successful. Challenging behaviour records evidenced that there have been occasions when physical restraint has been used by staff with residents. No records were available in some cases detailing the actual type of restraint used or the length of time restraint was imposed on the person. One record seen, also indicated that a member of staff was unclear as to certain methods of physical intervention required so as to support the resident and provide safe and positive outcomes. This records must be reviewed to ensure that all staff working at the home are aware of individual’s care needs and how these are to be met. Another record also indicated that resident’s `toys` are taken away from them periodically as a means of punishment. This is not documented as a strategy to be adopted by staff and there is no rationale as to why this is undertaken or the benefit this has, if any, and there was no evidence, this had been agreed by the resident’s representative/placing authority and/or healthcare professional. This type of approach can be seen as institutional. Newhaven Community Care Ltd (Phoenix House) DS0000070048.V353688.R01.S.doc Version 5.2 Page 12 Risk assessments were comprehensive and completed for the majority of assessed risk areas for individuals. However, shortfalls were identified as not all aspects of risk were highlighted e.g. choking, weight to be monitored regularly/weight loss and other challenging behaviour. Daily care records were completed daily and most records were observed to be detailed and informative, however there were occasions when records were basic and did not provide sufficient evidence of how the resident had spent their day. Newhaven Community Care Ltd (Phoenix House) DS0000070048.V353688.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. Residents have their social care needs met giving them a good quality of life. Meals provided to residents are of a satisfactory quality and promote a healthy diet and wellbeing for people at the home. EVIDENCE: An activity board is available within the office detailing activities undertaken by all three residents at the home. The manager advised the inspector that formal day care activities have proved difficult and elusive for residents, however this is still being explored and it is hoped for early 2008, that this will be achieved. The activity board evidenced residents participation in swimming, going to the gym, adult education classes, shopping, attendance at the Mencap Sports Club on a Saturday, walks, kids kingdom, train rides and other community based activities. Consideration should be given to devising a pictorial activity board, so that residents are able to make an informed choice as to the activities planned/available and to give them more autonomy. Newhaven Community Care Ltd (Phoenix House) DS0000070048.V353688.R01.S.doc Version 5.2 Page 14 The Annual Quality Assurance Assessment details that the staff and management of the home are continuing to forge links within the local community and to seek more formal day care opportunities for residents. Records indicate that residents are enabled and actively encouraged to maintain relationships with family members and friends, and the home operate an `open visiting` policy, whereby they can see family and friends at any reasonable time. The manager has devised a pictorial menu book so that residents are able to make an informed choice as to their personal preferences for food/drinks. This was seen as very positive and a way of enabling residents to make choices. The manager advised that the menu is devised on a weekly basis and residents are actively encouraged to be part of the decision making process. Nutritional records for residents were observed to be appropriate and offered residents a varied choice, including a cooked breakfast at weekends. Newhaven Community Care Ltd (Phoenix House) DS0000070048.V353688.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. Whilst the management of resident’s healthcare is good and their needs are met, which provides them with good outcomes, shortfalls were identified in relation to the management of medication for some people, which could adversely affect their wellbeing. EVIDENCE: Records showed that resident’s healthcare needs are met and that they have access to a range of healthcare professionals and services as and when required e.g. GP, Consultant Psychiatry, Dentist, Optician, Continence Nurse etc. Records were observed to be well maintained, and organised and included outcomes of any visit. It was disappointing that one resident missed a healthcare appointment and was charged for non-attendance. The rationale as to why the appointment was missed was not recorded. The manager was advised to ensure, that wherever possible healthcare appointments, are not missed so that residents have their healthcare needs met. The Annual Quality Assurance Assessment details that the care service does well in supporting residents with their personal care in line with their personal preferences and needs. Newhaven Community Care Ltd (Phoenix House) DS0000070048.V353688.R01.S.doc Version 5.2 Page 16 As part of this site visit, medication practices and records were checked. Medication at the home is managed, in the main, through the use of a monitored dosage system (blister pack). In general records were well maintained and managed. The Medication Administration Record (MAR) for one person indicated that they regularly refused one of their medications. On most occasions on the reverse of the MAR sheet there was an explanation detailing the reason for refusal/behaviour exhibited, however there were instances when no clarification was recorded. The manager was advised that as part of good practice procedures information should be recorded so that any common trends/patterns could be observed and discussed with a healthcare professional. A list of those staff deemed competent to administer medication was not devised. The manager was advised this, needs to be reviewed and implemented depicting the name of the staff member and including their initial and signature. On inspection of staff training records, these showed that all but one person has up to date medication training. This must be reviewed to ensure that all staff who administer medication have the necessary skills/up to date training to ensure positive outcomes for resident’s. On evidence of senior staff meeting minutes, this detailed that there have been occasions when medication has been out of stock for residents. This concurs with information provided from a healthcare professional to the Commission for Social Care Inspection whereby one person’s medication was not available for 3 days. The manager was advised that no Regulation 37 Notifications had been forwarded to the Commission for Social Care Inspection detailing when this occurred and evidence of proactive action taken by the management of the home to rectify the deficit. Newhaven Community Care Ltd (Phoenix House) DS0000070048.V353688.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 poor. This judgement has been made using available evidence including a visit to this service. Whilst complaint management is adequate, residents are not safeguarded or protected from possible abuse and there is a lack of understanding and awareness by the management team to deal proactively with this area and to ensure resident’s wellbeing. EVIDENCE: Phoenix House has a complaints policy and procedure in place. This needs to be amended to reflect the Commission for Social Care Inspection and not the previous registration authority. The management team’s complaint file indicated that one complaint had been made since the home opened. Further development is required to ensure that information recorded includes the specific nature of the complaint, the investigation process, action taken and outcome. Additionally there was no evidence that the management of the home had formally written to the complainant advising of the above and/or that the complainant was satisfied with the outcome. One relative’s quality assurance questionnaire detailed that they were unaware of the complaint policy and procedure within the home. The management of the home was observed to have a safeguarding policy and procedure, however this was observed to have been devised 5 years previously. No local policy and procedure was available within the home. The manager was advised that this document requires reviewing and updating so as to contain up to date information. Discussion took place with the manager in relation to information, which had been passed to the Commission for Social Newhaven Community Care Ltd (Phoenix House) DS0000070048.V353688.R01.S.doc Version 5.2 Page 18 Care Inspection pertaining to an alleged safeguarding issue. It is clear from these discussions that the manager/registered provider failed to adopt and instigate appropriate safeguarding measures in line with local policies and procedures and that an internal investigation was conducted by the manager, which did not cover all of the issues or safeguard residents’ safety and wellbeing. At the inspection the manager confirmed that she was unaware of local policies and procedures relating to safeguarding and that she was unaware as to whether or not the registered provider had been made aware of the alleged issues. Staff spoken with confirmed that they would report to the manager any areas of concern/suspected safeguarding issue, however not all were aware as to the location of the safeguarding policy and procedure. The staff training plan indicated that not all members of staff had received training relating to safeguarding, yet the Annual Quality Assurance Assessment detailed that all staff had received training. The Commission recognises that this document was compiled in August 2007 and that some members of staff have since left the home’s employment. Newhaven Community Care Ltd (Phoenix House) DS0000070048.V353688.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 good. This judgement has been made using available evidence including a visit to this service. The residents’ benefit from a well maintained home that meet their needs. EVIDENCE: As part of this inspection a tour of the premises was undertaken. The home was observed to be well maintained and decorated to a high standard, creating a very modern, light and bright living space for residents. The home has one large lounge and 2 smaller lounge areas for residents use. Resident’s bedrooms were observed to be personalised and individualised to suit their individual needs. Residents were unable to give a view as to whether or not they liked their bedroom, as a result of their communication difficulties, however residents were observed to access their bedrooms freely. A random sample of safety and maintenance certificates showed that equipment and services in the home were kept in good order. The home has a fire safety risk assessment in place and all other fire safety records were seen to be in order. Newhaven Community Care Ltd (Phoenix House) DS0000070048.V353688.R01.S.doc Version 5.2 Page 20 Training records showed that not all members of staff had received training relating to fire safety, health and safety and infection control. Newhaven Community Care Ltd (Phoenix House) DS0000070048.V353688.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, 34, 35 and 36 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The level of staffing, on occasions, restricts the ability of the service to deliver person centred care and to ensure that residents needs, can be met and that they are safe. Shortfalls in staff training mean that some staff are not able to meet the needs of the residents living at the home. EVIDENCE: The manager advised that staffing levels at the home should be 3 staff between 07.45 a.m. and 14.45 p.m., 3 staff between 14.30 p.m. and 21.45 p.m. and 2 waking night staff between 21.30 p.m. and 08.00 a.m. each day. In addition to the above, an extra member of staff is deployed between 09.30 a.m. and 14.30 p.m. each day for activities. Each of the residents is contracted to have between 21-33 hours each week for 1-1 staffing and two residents are contracted to have between 14-21 hours each week for 2-1 staffing (accessing community activities). On inspection of four weeks staff rosters, it was evident that staffing levels as detailed above had not always been maintained. The outcome is this could have a detrimental affect on actual care delivery and resident’s wellbeing. The Newhaven Community Care Ltd (Phoenix House) DS0000070048.V353688.R01.S.doc Version 5.2 Page 22 Commission for Social Care Inspection has received no regulation 37 notifications detailing the reduction in staffing levels and measures undertaken by staff to deploy staff to the care home to meet residents needs. Additionally the staff rosters do not always make it clear as to who is providing 1-1 support for individual residents and the full names of agency/bank staff are not always recorded on the roster. The rosters also evidence that on occasions some staff are undertaking 14 hour shifts and some staff are completing a late shift followed by a waking night shift or a waking night shift followed by an early shift (total 18.5 hours). The latter is not seen as good practice and potentially places both staff and residents at risk. The manager/registered provider must ensure that staff, are competent to undertake their role. One healthcare professional advised following the inspection that they have found it difficult to work within this service, as there have been many staff changes. This person also felt that staff did not always show an awareness of the needs of the client group and most recommendations were not communicated or actioned and they feel that they are “having to start from scratch”. The healthcare professional raised concern that they did not always feel that some staff had the skill, competency or confidence to deal with current residents and that some staff seemed “out of there depth” with one resident. A random sample of staff files, were inspected for those staff newly appointed since the last key inspection. The majority of records as required by regulation were available, however gaps were noted in relation to no recent photograph for one person, no health declaration for two people, no confirmation for one person as to whether or not they are able to remain in the UK indefinitely, full employment history not fully explored for one person, inductions for some people not in line with Skills for Care and little/no evidence of training in core areas e.g. safeguarding, food hygiene, health and safety etc. for three people. The staff rosters evidenced that agency staff had been utilised at the care home on a regular basis and that two members of staff from the existing staff team are also employed by an external agency in addition to being employed at Phoenix House. It was disappointing that not all agency staff used at the care home had a record of induction or a profile from the agency confirming that all necessary checks as required by regulation had been undertaken and received. This is unsatisfactory and does not safeguard residents from potential abuse. A copy of the homes training plan was provided for the inspector. Evidence indicated that there are gaps in individuals training relating to manual handling, infection control, food hygiene, first aid, epilepsy, makaton and fire safety. Additional consideration needs to be made to ensure that staff, receive training relating to inclusive communication, autism and those conditions associated with adults who have a learning disability. One member of staff Newhaven Community Care Ltd (Phoenix House) DS0000070048.V353688.R01.S.doc Version 5.2 Page 23 advised that since they were recruited they have received no training. The training plan submitted to the inspector confirms this. One healthcare professional advised the inspector that they have suggested providing autism training to the staff team and to attend staff meetings, but have yet to hear back from the management of the home. Training records indicate that 3 staff had attained NVQ Level 2 and 2 staff had attained NVQ Level 3. The Annual Quality Assurance Assessment detailed that “those staff members who do not currently have a NVQ qualification are willing to work towards one”. Of those staff files inspected, staff had received supervision. The manager was advised that the National Minimum Standards recommends that staff receive formal supervision six times yearly. Staff spoken with confirmed that supervisions had taken place, but not as frequently as originally agreed. Newhaven Community Care Ltd (Phoenix House) DS0000070048.V353688.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 and 42 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Whilst aspects of the management of the home are sound, there remain areas of concern that adversely affect the wellbeing of residents. EVIDENCE: The manager has been at the care home since it opened in July 2007, however she has only managed the home officially since September 2007 and is due to leave on 28th December 2007. When questioned the manager advised the inspector that her working experience has primarily been with those people living in housing schemes. Her role has been to oversee these schemes and to provide day-to-day support as required. The training plan evidences that she has attained NVQ Level 4 in Care and has undertaken a variety of other courses relating to manual handling, food hygiene, safeguarding, medication administration etc. Newhaven Community Care Ltd (Phoenix House) DS0000070048.V353688.R01.S.doc Version 5.2 Page 25 Although there are some areas as highlighted within the main text of the report which are good and evidence proactive management, there are some areas which require further development and these refer to care planning, medication administration and practices, management of safeguarding issues and staff training. Of those staff spoken with, the majority of the comments relating to the manager were observed to be positive, “she’s very nice” and “it’s a shame she’s leaving”. A quality assurance audit, to seek the views of relatives and staff pertaining to the service/facilities provided at Phoenix House, has been completed. The majority of comments by staff were seen to be positive, however one survey recorded that they were not satisfied with the management of the home, as they did not feel sufficiently supported on occasions. It is disappointing that an independent advocate has not been utilised to assist the management of the home with seeking the views of residents and other interested parties e.g. social/healthcare professionals have not been included in the quality assurance process. Only one relative survey was available and apart from one issue were generally satisfied with the services/care provided for their member of family. There is clear evidence to indicate that staff/residents meetings are being conducted on a regular basis. Further development is required to evidence proactive action taken by the management team to address identified issues highlighted at staff/senior meetings. Staff spoken with confirmed these had taken place and were a useful means of gathering information and discussing issues. The home holds monies on behalf of residents and records were seen to be well maintained with appropriate receipts readily available to evidence monies received and expenditure. There is a health and safety policy within the home. Resident’s records pertaining to accident/incident records were seen to be completed in sufficient detail. Newhaven Community Care Ltd (Phoenix House) DS0000070048.V353688.R01.S.doc Version 5.2 Page 26 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 3 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 1 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 2 33 X 34 2 35 2 36 2 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 DS0000070048.V353688.R01.S.doc 2 2 X 2 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 2 17 X Score PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 X 2 2 X 2 X X 3 X Version 5.2 Page 27 Newhaven Community Care Ltd (Phoenix House) Are there any outstanding requirements from the last inspection? N/A 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 YA6 Regulation 15 Requirement Timescale for action 20/12/07 2. YA9 3. YA21 4. YA22 Ensure each resident has a detailed and comprehensive plan of care, which clearly identifies their care needs so that staff are able to deliver appropriate care. 13(4) Ensure that risk assessments are devised for all areas of assessed risk. This will ensure that risks are minimised and residents’ wellbeing are safeguarded. 12(1)(a)(b) Ensure that residents receive and 37 their prescribed medication at all times and that any shortfalls are notified to CSCI. This will ensure residents safety and wellbeing and provide evidence of actions taken to address any deficit. 22 Ensure that any record of complaint includes information relating to the specific nature of the complaint, investigation, action and outcome. This will ensure that there is a clear audit trail evidencing complaint management. 20/12/07 20/12/07 20/12/07 Newhaven Community Care Ltd (Phoenix House) DS0000070048.V353688.R01.S.doc Version 5.2 Page 28 5. YA23 13(6) 6. 7. YA23 YA32 17(1)(a) 18(1)(a) 8. YA34 19 9. YA35 18(1)(c) and (i) 10. YA36 18(2) 11. YA39 24 Ensure that all staff working at the care home know how to prevent residents from being harmed or placed at risk of abuse so as to ensure residents safety and wellbeing. Maintain a detailed record of any physical restraint used on a resident. Ensure there are sufficient staff on duty to meet the needs of residents so as to promote their wellbeing and positive outcomes. Robust recruitment procedures must be adopted to ensure residents are safeguarded from abuse. Ensure that all members of staff receive training appropriate to the work they are to perform so as to deliver appropriate care to individual residents and meet their needs. Ensure that all staff working at the care home are appropriately supervised so that they feel supported. Ensure that the views of all interested parties are sought and the outcomes from surveys available. 20/12/07 20/12/07 20/12/07 20/12/07 01/04/08 01/03/08 01/06/08 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. Refer to Standard YA6 YA14 Good Practice Recommendations Ensure that daily care records reflect how residents spend their day and evidence staff interventions. Consider devising a larger print/pictorial activity board for residents so that they can make an informed choice. DS0000070048.V353688.R01.S.doc Version 5.2 Page 29 Newhaven Community Care Ltd (Phoenix House) 3. 4. 5. 6. YA21 YA22 YA23 YA32 Devise a list of those staff deemed competent to administer medication to residents. This should include their name, initial and signature. Amend the complaints policy and procedure to reflect that the Commission for Social Care Inspection no longer investigate complaints. Obtain a copy of local safeguarding policies and procedures. 50 of staff to attain an NVQ qualification. Newhaven Community Care Ltd (Phoenix House) DS0000070048.V353688.R01.S.doc Version 5.2 Page 30 Commission for Social Care Inspection Eastern Region Eastern Regional Contact Team CPC1, Capital Park Fulbourn Cambridge CB21 5XE 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 Community Care Ltd (Phoenix House) DS0000070048.V353688.R01.S.doc Version 5.2 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. 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