Inspection on 30/01/07 for Newholme

This inspection was carried out on 30th January 2007.

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

The inspector found no outstanding requirements from the previous inspection report, but made 4 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Newholme 19/01/09

Newholme 23/02/06

Newholme 28/07/05

Newholme 08/03/05

Newholme 20/07/04

Similar services:

2 Perhaver Park

The Vicarage

St George`s

5 Seafield Road

Credence House

Radfords

Honeybourne House

32 Beaumont Way

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

CARE HOME ADULTS 18-65 Newholme Bushy Cross Lane Ruishton Taunton Somerset TA3 5JT Lead Inspector David Kidner Unannounced Inspection 30th January 2007 09:45 Newholme DS0000036050.V324552.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 Newholme DS0000036050.V324552.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. Newholme DS0000036050.V324552.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Newholme Address Bushy Cross Lane Ruishton Taunton Somerset TA3 5JT 01823 442298 01823 444338 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) Somerset County Council (LD Services) Mr Kenneth `John` Salter Care Home 8 Category(ies) of Learning disability (8) registration, with number of places Newholme DS0000036050.V324552.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. Registered for up to 8 persons in category LD who may have a concurrent physical disability Date of last inspection 23/02/06 Brief Description of the Service: Newholme is a spacious bungalow type domestic dwelling located in the village of Ruishton approximately 4miles from Taunton. There are eight single occupancy bedrooms; two bedrooms have full en-suite facilities. There are two large well-equipped assisted bathrooms. The home is arranged as two separate living areas, with each area having its own kitchen / dining room, lounge and bathroom. However, service users are able to choose where to spend their day, and have access to all communal areas within the home. Newholme is registered with the Commission for Social Care Inspection (CSCI) to provide care for up to eight service users who have a learning disability. Service users admitted to the home may also have a concurrent physical disability. The Registered Manager is Mr John Salter and the Responsible Individual is Mr David Dick. The home is owned by Somerset Social Services. Newholme DS0000036050.V324552.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. One Inspector conducted this Key Unannounced Inspection over one day (7.5hrs). The Inspector viewed records in relation to care and support plans, risk assessments, health and safety, staff training records, the management of medicines, spoke to a number of care staff and toured the premises. On the day of the inspection eight service users were living at the home. The Registered Manager was available at the beginning of the inspection. However, the Deputy Manager was available in the afternoon. The Inspector met all the service users who live at Newholme. It was difficult to seek the views of the service users due to their individual needs. However, the Inspector is able to use Somerset Total Communication. The Inspector sat in the lounge, kitchen and dining areas and observed staff interactions with service users. It was noted that staff were interacting well with service users and were offering choices in day-to-day living. Staff conducted themselves in a very professional manner. As part of the Inspection process the Inspector sent Relative/Visitors comment cards to all relatives. Seven comment cards were returned. All comment cards confirmed that the home make relative’s welcome and that they are satisfied with the overall care provided at Newholme. Written comments included very positive comments in relation to the care team and their dedication and attention. Comment cards were also sent to the GP, health care professionals and social workers. One comment was received from social workers. Both GPs and one health care professional replied. Comments included: “ excellent care” another comment made was “high standard of care”. Comments also stated that they were satisfied with the overall care provided. At present there are no service users residing at the home who are from black and ethnic minority cultures. The service has policies and procedure in relation to equality and diversity matters. The Inspector would like to thank the service users and the care team for making the Inspector welcome at the home and their contribution in the inspection process. As a result of this inspection the home had four requirements and four recommendations. Newholme DS0000036050.V324552.R01.S.doc Version 5.2 Page 6 What the service does well: What has improved since the last inspection? What they could do better: The Registered Manager must review the staffing levels at the home to ensure that at all times suitably qualified, competent and experienced persons are working at the home. The CSCI request a copy of the review. It is strongly recommended that the Registered Manager should audit the amount of activities that individual service users access outside of the home environment. The Registered Manager must ensure that the home records the administration of all medicines in the home, including variable doses. A Homely Remedies Policy must also be developed. Newholme DS0000036050.V324552.R01.S.doc Version 5.2 Page 7 The Complaints procedure must include the telephone number of the Commission for Social Care Inspection. The home must make arrangements to enable staff to inform the registered person and the CSCI of the views as to the conduct of the care home. 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. Newholme DS0000036050.V324552.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Newholme DS0000036050.V324552.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1 Key Standard 2 was not fully assessed, as there have not been any new admissions to the home since February 2005. However, the home have detailed admission protocols. Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Newholme has a detailed dated Statement of Purpose and Service User Guide EVIDENCE: Newholme has a detailed dated Statement of Purpose and Service User Guide that provide details of the services and facilities available. It is presented in an accessible format. The fee is based on individual assessed needs. Newholme DS0000036050.V324552.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): 679 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. The home has developed detailed care and support plans that are regularly updated and reviewed. The care team offers service users as mush choice as possible in many aspects of daily living. Detailed records are maintained in relation to service user’s finances. EVIDENCE: The Inspector reviewed three care and support plans. All were very comprehensive and contained detailed information regarding each person’s individual care and support needs. Some service users have high support needs in relation to eating and drinking. The care and support plans contained detailed guidelines on how these needs must be met. Guidelines relating to Newholme DS0000036050.V324552.R01.S.doc Version 5.2 Page 11 this had also been updated and reviewed. It was noted that each plan had been formally reviewed with action points to identify areas to address. The care and support plans are reviewed monthly by the key worker group. ‘My Day’ diaries are kept for each individual service user. This details how service users have spent their day and the individual care and support that has been given. The home has an information pack for night staff, providing details of individual service users’ night care needs, including sleeping positions, epilepsy guidelines and emergency procedure. Service users are supported to make choices regarding their daily lives. The Inspector noted that staff was offering service users choices in how to spend their day and choices in food and drink. It was very apparent that the care team are very aware of the service users likes and dislikes. Members of the care team stated that they use photos of food/meals to offer choices. The home also employs a cook and the cook advised the Inspector that they involve the service users in the planning and choosing of meals as much as possible. One service user has an advocate. The home has detailed risk assessments relating to individual service users. The Inspector viewed a number of these assessments. Risk assessments covered areas such as moving and handling, travelling in the homes vehicle, hot water, trips, cooking and accessing the kitchen. It was noted that they had all been recently reviewed. The Inspector was advised that the format of the risk assessments is under review. None of the service users are able to manage their finances. The relatives of two service users manage their relative’s finances. Records are maintained of all financial transactions involving service user’s monies. The finance records are audited weekly by the administrator for the home and annually by an auditor from County Hall. Newholme DS0000036050.V324552.R01.S.doc Version 5.2 Page 12 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): 11 12 13 14 15 16 17 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Service users are supported to take part in activities and entertainments within the home and local community. However, it appears that at times service users are not accessing the local community as much as the care team wish to provide. The home has a very good relationship with relatives/carers. The service meets the complex dietary needs of individual service users. EVIDENCE: Service users are supported to participate in a wide range of activities. A ‘My Day’ plan is developed for each service user. This document records all activities that are offered and the time spent engaged in that activity. This is used as part of the homes quality audit and this information is forwarded to Newholme DS0000036050.V324552.R01.S.doc Version 5.2 Page 13 senior managers within social services. The activities currently provided include: story time, aromatherapy, light room, swimming, hydrotherapy, cooking and music. Service users access a variety of leisure and entertainment venues. Three service users attend the local college. A musician and Reiki Therapist visit the home on alternate weeks. At the time of the inspection some staff that the Inspector spoke to stated that in their opinion some service users are not accessing the local community and local facilities as much as they should be, and stated that in their opinion there are not always enough staff on duty to facilitate this. Staff commented that the service users have very complex needs and due to staffing levels it is not always possible to ensure that all service users have the opportunity to leave the home on a regular basis. At the time of the inspection the home was experiencing a staffing shortage. This meant that some service users did not go to college. The issue relating to adequate staffing levels is identified under ‘Staffing’ in this report. However, it is strongly recommended that the Registered Manager review the frequency of activities and leisure opportunities that individual service users are accessing out of the home. Service users are provided with a holiday away from the home each year, or a series of day trips, dependent upon their individual needs. The Registered Manager and the care team advised the Inspector that the home has a very good relationship with the relatives of the service users. Relatives are involved in the planning of care provision as much as possible. Relatives and friends are invited and encouraged to visit the home. As part of the inspection process the Inspector sent Relative/Cares comment cards to all of the relatives. Seven comment cards were returned. This was very pleasing. All comments confirmed that the relatives are made welcome at the home and are satisfied with the overall care provided. Written comments included very positive comments in relation to the care team and their dedication and attention. Service users have unrestricted access to all areas of the home. All bedrooms have appropriate locks fitted. The Inspector noted that staff were communicating with service users in a caring and supportive manner. Some service users chose to be alone and not partake in joint activities. The home does not have a set menu. Care staff prepare breakfast and lunch. The main meal of the day is the evening meal. The home employs a cook to provide evening meals. The cook and care team use photographs to offer service users a choice of menu and are aware of individual service users dietary needs and preferences. Two service users have PEG feeds. Staff confirmed that they have received appropriate training from the District Nursing Team, and there are clear guidelines for each individual’s care. The Newholme DS0000036050.V324552.R01.S.doc Version 5.2 Page 14 Inspector was able to view documentation in relation to this. A dietician visits the service users and reviews their eating and drinking regime with staff. At present there are no service users that need to have food prepared and served to meet their individual cultural and religious requirements. Due to the complex needs of some service users individual records are kept of all meals and drinks. Newholme DS0000036050.V324552.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 20 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Personal care is conducted in a sensitive and respectful manner. Service users have access to a variety of healthcare professionals. Medicines are well managed but some areas need addressing. EVIDENCE: Service users are provided with assistance to undertake personal care tasks as required. Risk assessments have been conducted in relation to transfers and moving and handling where needed. Personal care is carried out in private at all times. The care team support service users in accessing a variety of health care professionals by attending the GP surgery or the dentist, and ensure that specialist advice is sought as required. At the time of the inspection the physiotherapist visited the home. Care and support plans included details of epilepsy and nutritional guidelines. There was evidence that the speech and Newholme DS0000036050.V324552.R01.S.doc Version 5.2 Page 16 language therapy services and psychology services have been involved as needed. The Registered Manager stated that all service users have recently had eating and drinking assessments. Food and fluid charts are completed as required. Service users weight is measured regularly and recorded in the care plan. However, some records viewed did not confirm that some service users had attended some follow up appointments for the dentist and chiropodist. This was bought to the attention of the Deputy Manager at the time of the inspection and was being investigated at the time of the inspection. As part of the inspection process the inspector sent comment cards to the GP’s and health and social care professionals involved with the home. Five comment cards were returned. Two from GP’s, two from care managers and one from a healthcare professional. All comments were extremely positive and very complimentary of the services provided at the home. Comments included: “ excellent care” another comment made was “high standard of care”. Staff have been provided with appropriate training to meet the health needs of the service users This has included training on the administration of enemas, PEG feeds and the administration of Midazalam. The inspector viewed the arrangements for the management of medicines. All medications are stored securely. Medication Administration Records (MAR) include a photograph of the service user. A record is maintained of all medications received and leaving the home, including the reason for medications being returned to the pharmacy. On examination of the MAR sheets it was noted that two staff signatures sign for the administration of medicines. The times of administration are highlighted on the MAR sheet. On some MAR sheets it was not easy to establish at what times medicines were signed for as signatures entered into other boxes on the MAR sheets. It is recommended that how care staff signs the MAR sheet be given further consideration. It was also noted that some variable doses had not been recorded and on two occasions it was unclear if medicines had been given as prescribed. At the time of the inspection the Inspector was not able to view the homes Homely Remedy Policy and ascertain the agreed homely medicines for each service user. These matters were bought to the attention of two staff members including the Deputy Manager and must be addressed. Newholme DS0000036050.V324552.R01.S.doc Version 5.2 Page 17 Newholme DS0000036050.V324552.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 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 detailed complaints procedure but needs to include the telephone number of the CSCI. The home does not have a whistleblowing Policy to protect vulnerable adults. EVIDENCE: Somerset Social Services have a complaints procedure that includes details of external agencies that may be contacted, including CSCI. However, it was noted that the telephone number was not included. This must be addressed. Somerset Social Services Department have also produced a video providing details of how to make a complaint. The comment cards received from relatives/carers confirmed that they were aware of the homes complaints procedure and have never had to make a complaint. There have been no complaints received by CSCI. There are appropriate policies relating to the Protection of Vulnerable Adults. At the time of the inspection the Inspector was not able to locate the homes Whistleblowing Policy amongst the policies and procedures, nor the homes document ‘Raising concerns at work’ that is usually located in Guidelines File. The Deputy Manager was also not able to locate the above policies and guidelines. The home must ensure that the home has a Whisleblowing Policy and that staff are able to inform the registered person and the CSCI of the Newholme DS0000036050.V324552.R01.S.doc Version 5.2 Page 19 views of the conduct of the care home. However, some staff spoken to demonstrated how they would raise issues of concern. The home does not use physical intervention. As previously stated none of the service users are able to manage their finances. The service has policies and procedures in relation to the management of service users finances. The relatives of two service users manage their relative’s finances. Records are maintained of all financial transactions involving service user’s monies. The finance records are audited weekly by the administrator for the home and annually by an auditor from County Hall. At the time of the inspection the Inspector did not view the financial records. Newholme DS0000036050.V324552.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 24 25 26 27 28 29 30 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Newholme is decorated and furnished to a high standard. It provides comfortable accommodation. It is clean and hygienic. Bedrooms reflect individual needs, preferences and lifestyle. Staff are commended for promoting individuality. The home has very good bathing, showering and toilet facilities. There are good facilities to assist service users in their mobility and promoting independence. EVIDENCE: The Inspector viewed all areas of the home. Newholme is spacious and furnished to a high standard. The premises are comfortable, bright and were free of offensive odours. It has a homely environment but this would be further Newholme DS0000036050.V324552.R01.S.doc Version 5.2 Page 21 enhanced if staff memos/information were not displayed in some communal areas. Some information also contained service users personal information. This was bought to the attention of the Registered Manager at the time of the inspection and it is recommended that this be reviewed. The main hallways would benefit from redecoration to further promote the homeliness of the home. The Inspector viewed all service users bedrooms. Each bedroom reflected the individual needs of the service users. Rooms were very tastefully decorated and furnished and were very individualised. There were many personal possessions and photographs of family members. Some bedrooms had televisions fitted to wall brackets so service users could watch television in bed and at the correct angle for viewing. Some rooms has varies types of lighting fitted to promote stimulation and mood. Staff have paid attention to detail and are commended. Overhead tracking is installed in some bedroom areas to assist in moving and handling. All rooms have wash hand basins with hand washing facilities for staff when completing intimate personal care. Two bedrooms have full en-suite facilities. The home has two large assisted bathrooms that have very good facilities including overhead tracking, hoists, electronic baths that have Jacuzzi facilities. These areas were very clean and hygienic. The toilets are accessible and meet the needs of the service users with mobility difficulties. Newholme has accessible patio and garden space. Kitchen and laundry facilities are domestic in style. Staff have a dedicated sleep-in facility and separate shower facilities. The home has appropriate environmental adaptations to meet the needs of the service users. At the time of the inspection all areas of the home were clean and hygienic. Care staff completes all domestic activities. The home has a spacious laundry that appears well managed. Newholme DS0000036050.V324552.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 32 33 34 35 Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. The home encourages and supports staff to obtain formal qualifications. It appears that there may not be adequate staff on duty at all times to meet the holistic needs of the service users. The service has a comprehensive training and development plan. EVIDENCE: Staff are encouraged to achieve formal qualifications. The Registered Manager confirmed that 50 of the staff employed has obtained the NVQ 2 qualification or it’s equivalent. Two further staff are undertaking NVQ qualification, one at level 2 the other at level 3. The home meets the standard in relation to 50 of the workforce achieving an NVQ2 or above. Care staff have received appropriate training in relation to meeting specific care needs of some individual service users. This includes moving and handling, use of Midazalam, administration of enemas and PEG feeding. Newholme DS0000036050.V324552.R01.S.doc Version 5.2 Page 23 Duty rotas were viewed and they identified the number of staff on duty. Staffing levels are maintained at four care staff throughout the day until 8pm. There is one waking and one sleeping–in member of staff at night. The Registered Manager is supernumerary to the staff team. Agency/relief staff have not been used. A cook is employed who cooks the evening meal The staff group work within four teams, with each being lead by a senior member of staff. Each team acts as co-ordinator for two service users and takes lead responsibility for certain areas of practice within the home. The Inspector spent a considerable amount of time talking to staff in private and in small groups about staffing levels at the home and observing care practices. Care staff were very professional, however, vocal in the fact that in their opinion there are not adequate staff on duty to meet the complex support needs of the service users. All service users have very high support needs. Two service users require PEG feeding that also entails an individual approach in relation to eating and drinking and the administration of medicines. Another service user is registered blind and all other service users need total care and support in meeting personal care needs and assistance with eating and drinking. As previously stated, care staff also feel that they do not have enough staff on duty to provide a variety of activities on a regular basis out of the home. Staff appeared very committed but tired and felt that they are only meeting personal care needs. This coupled with staff completing all domestic tasks and preparing breakfast and lunch may be putting a strain on the care team. Some care staff made reference to guidance that service users might be got out of bed early of a morning to ease the pressure on staff of a morning. This practice must cease if this is the case. There was not substantial evidence to support this at this inspection. Therefore, the Registered Manager must review the staffing levels at the home to ensure that at all times suitably qualified, competent and experienced persons are working at the home. The CSCI request a copy of the review. Two staff recruitment files were examined and both were found to contain the documentation required under Schedule 2 of the Care Home Regulations 2001. The service has a very comprehensive staff Learning and Staff Development Programme and a specific programme aimed at learning disabilities services. Both programmes offer a variety of courses and training opportunities. The Registered Manager stated that all staff has an individual training plan and portfolio. This was a requirement at the last two inspections. This has now been met. Records viewed indicted that the Registered manager completes an audit of staff training and ensures that refresher training is provided. The Registered Newholme DS0000036050.V324552.R01.S.doc Version 5.2 Page 24 Manager stated that staff have been identified to access training in infection control. From records viewed and discussion with some care staff, it was not clear if staff have received training in the protection of vulnerable adults. This should be reviewed and provided if needed. Newholme DS0000036050.V324552.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 37 39 42 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. The Registered Manager is an experienced Manager. The home has good records in relation to health and safety. EVIDENCE: The Registered Manager, Mr John Salter is a registered nurse in learning disabilities. He has been the Registered Manager at Newholme for three years and has been working with people who have learning disabilities for many years. Mr Salter has undertaken a Certificate in Management Studies and access appropriate training including refresher training when needed. Newholme DS0000036050.V324552.R01.S.doc Version 5.2 Page 26 The service has varies methods of quality assurance. However, it is recommended that the home seek the views of other interested stakeholders as identified in Standard 39.7 of the National Minimum Standards. The Inspector viewed a number of records in relation to health and safety. Electrical Hardwiring: The Registered Manager stated that this certificate is date 03.02.06. The certificate was not seen at the time of the inspection. Gas Safety: The Registered Manager stated that this certificate is date 04.08.06. The certificate was not seen at the time of the inspection. Portable Appliance Testing: This was undertaken in March 2006. Visual checks are completed on a monthly basis. Hot water temperatures: Records are kept of all hot water outlets. Records viewed indicted that hot water temperatures are within the safety levels identified by the Health and Safety Executive. Legionella: A certificate for this is dated 07/03/06. Hoists: The Inspector viewed all records relating to the six-monthly checks on the hoists used in the home. All hoists were last serviced on the 02/01/07. The Arjo bath was serviced on 09/01/07. Fridge, freezer and food temperatures: Daily records are kept of fridge and freezer temperatures. Fire Safety: An annual service on the fire system and emergency lighting was conducted on 21.12.06. Weekly fire point checks are conducted and weekly checks are maintained on the emergency lighting. The weekly check was conducted at the time of the inspection. The fire extinguishers and blanket were last serviced on 07/02/06. The sprinklers were tested on the 12/01/07. All staff have received regular fire training. The Registered Manager has a programme to ensure that all staff receive fire drills. COSSH: Records are well maintained all products stored safe and secure. Accidents/Incidents: The home keeps records of all accidents and incidents and these are audited on a monthly basis. Monthly visual checks are undertaken all moving and handling equipment. Newholme DS0000036050.V324552.R01.S.doc Version 5.2 Page 27 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 3 2 X 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 2 23 2 ENVIRONMENT Standard No Score 24 3 25 3 26 4 27 3 28 3 29 3 30 3 STAFFING Standard No Score 31 X 32 3 33 2 34 3 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 X LIFESTYLES Standard No Score 11 3 12 3 13 2 14 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 X 3 X 2 X X 3 X Newholme DS0000036050.V324552.R01.S.doc Version 5.2 Page 28 NO 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 YA20 Regulation 13 (2) Requirement The Registered Manager must ensure that the home records the administration of all medicines in the home including variable doses. A Homely Remedies Policy must also be developed. The Complaints procedure must include the telephone number of the Commission for Social Care Inspection. The home must make arrangements to enable staff to inform the registered person and the CSCI of the views as to the conduct of the care home. Having regard for the size of the care home and the number and needs of the service users, the Registered Manager must review the staffing levels at the home to ensure that at all times suitably qualified, competent and experienced persons are working at the home. The CSCI request a copy of the review. Timescale for action 19/02/07 2 YA22 22 (7) (a) 28/02/07 3 YA23 21 (2) 28/02/07 4 YA33 18 (1) (a) 19/03/07 Newholme DS0000036050.V324552.R01.S.doc Version 5.2 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 2 3 4 Refer to Standard YA13 YA24 YA35 YA39 Good Practice Recommendations It is strongly recommended that the Registered Manager should audit the amount of activities that individual service users access outside of the home environment. The Registered Manager should review the practice of staff memos/information and service user information being displayed in some communal areas. It was not clear if staff have received training in the protection of vulnerable adults. The Registered manager should review this and such training be accessed. The Registered Manager should seek the views of other interested stakeholders as part of the home’s quality assurance. Newholme DS0000036050.V324552.R01.S.doc Version 5.2 Page 30 Commission for Social Care Inspection Somerset Records Management Unit Ground Floor Riverside Chambers Castle Street Taunton TA1 4AL National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. 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