Inspection on 24/11/05 for 22-25 Trevean Gardens

This inspection was carried out on 24th November 2005.

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 3 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

22-25 Trevean Gardens 10/02/09

22-25 Trevean Gardens 21/03/07

22-25 Trevean Gardens 04/05/05

22-25 Trevean Gardens 01/11/04

22-25 Trevean Gardens 04/05/04

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 08/07/2008.

CARE HOME ADULTS 18-65 Trevean Gardens 22 Trevean Gardens Alverton Terrace Penzance Cornwall TR18 4JD Lead Inspector Ian Wright Announced Inspection 24th November 2005 14:15 Trevean Gardens DS0000008904.V250113.R01.S.doc Version 5.0 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 Trevean Gardens DS0000008904.V250113.R01.S.doc Version 5.0 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. Trevean Gardens DS0000008904.V250113.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Trevean Gardens Address 22 Trevean Gardens Alverton Terrace Penzance Cornwall TR18 4JD 01736 361369 01208 77760 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) Royal Mencap (Housing & Support Services) Mrs Hilary Sarah Jane Reynolds Care Home 11 Category(ies) of Learning disability (11) registration, with number of places Trevean Gardens DS0000008904.V250113.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 4th May 2005 Brief Description of the Service: Trevean Gardens provides care for up to eleven service users with a learning disability. The home consists of two interconnecting houses, and two selfcontained flats, in a terrace of properties. The houses each provide accommodation for four service users each and the flats currently accommodate a single person and a married couple. The scheme is within walking distance of Penzance town centre, and its services and facilities. Service users pursue varied day activity programmes. The houses and flats have their own sitting rooms, kitchens, bathrooms and single bedrooms. The staff support and encourage the service users to be active and independent, and to be involved in the local community. The registered provider of the scheme is Mencap and is managed by Mrs Hilary Reynolds. Trevean Gardens DS0000008904.V250113.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection took place over five and three quarter hours. The inspection was carried out on an announced basis. The inspector was able to speak to the majority of service users, the registered manager and some of the staff members on duty. The inspection primarily took place in one of the houses. The inspector examined care and service records, and inspected the building. What the service does well: What has improved since the last inspection? What they could do better: Although medication training seems satisfactory, there is limited documentary evidence all staff have completed this. The registered manager said all staff have completed the training, but evidence must be improved. Failure to provide satisfactory medication training could put service users at risk. The registered persons must ensure there is a satisfactory system regarding the prevention of Legionella. Failure to do so could put the health and safety of service users at risk. The registered provider’s policy regarding death and dying must be expanded to include issues regarding illness and aging. This is currently in draft form. Trevean Gardens DS0000008904.V250113.R01.S.doc Version 5.0 Page 6 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. Trevean Gardens DS0000008904.V250113.R01.S.doc Version 5.0 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 Trevean Gardens DS0000008904.V250113.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 2, 4 The registered persons have a suitable assessment policy and procedure. Service users are able to visit the home before formal admission is arranged. EVIDENCE: The registered provider has a satisfactory pre admission assessment procedure. There have been no recent admissions although there is currently one vacancy. Assessments for service users regarding this vacancy are comprehensive. The registered manager said prospective service users are able to visit before admission is arranged. This would include overnight stays as applicable. Trevean Gardens DS0000008904.V250113.R01.S.doc Version 5.0 Page 9 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, 10 Appropriate policies and procedures, and documentation are in place regarding care planning and risk assessment. Documentation is stored confidentially. EVIDENCE: A copy of a care plan is contained in each service user’s file. These are reviewed regularly. Service users said they are encouraged to take appropriate risks. Suitable risk assessments are maintained on each service user’s file, and these are reviewed appropriately. All information is stored confidentially in the offices of the service. Trevean Gardens DS0000008904.V250113.R01.S.doc Version 5.0 Page 10 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, 17 Opportunities for service users to develop their skills and abilities are excellent. Food, and support provided at mealtimes, is to a good standard. EVIDENCE: The registered manager said the scheme has recently been reorganised: • One house focuses on improving independent living skills but it is accepted service users abilities to live independently are more limited. • One house is for service users where care plans focus on increasing skills so people may move on if they wish. • The flats enable service users to live independently e.g. prepare their meals and receive only outreach support from staff. The flats however offer the security of remaining in a registered care home environment. Mencap also offers a domiciliary care service where service users can move into their own homes, but receive outreach support. This is managed separately to Trevean Gardens. Service users spoke positively about the changes, and said the changes enabled them to develop their skills and self-confidence. The inspector felt the Trevean Gardens DS0000008904.V250113.R01.S.doc Version 5.0 Page 11 changes had been well thought through. If there are further developments the registered persons must consult the Commission. Service users receive appropriate levels of support to assist them to prepare meals. The registered manager said this varies according to individual skill levels. The registered manager and service users said service users are involved in choosing what they wish to eat and in purchasing food. The registered manager said service users receive appropriate support to have a healthy balanced diet. The registered manager said service users receive support to do this from the dietician where this is necessary. Appropriate records are kept of food eaten. The inspector did not sample food on this occasion, but meals prepared looked varied and appetising. Trevean Gardens DS0000008904.V250113.R01.S.doc Version 5.0 Page 12 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 20, 21 Service users receive personal care in a manner, which respects their privacy and dignity. Medication is managed appropriately although evidence of medication training must be improved. EVIDENCE: Service users said they were happy with how personal care and support is provided. The inspector observed staff working with service users in an appropriate manner. Care interventions are appropriately documented in care plans. The medication was inspected in one of the houses. The registered provider has a suitable policy regarding the storage and handling of medication. An appropriate medication system is in operation, storage is appropriate and satisfactory records are maintained. Staff receive training regarding the handling of medication as part of their induction and foundation training. Despite the training pack looking comprehensive, there is limited documentation to evidence staff have received this training. The registered persons must improve evidence that staff have received this training e.g. issue a certificate or maintain completed workbooks for individual staff on the premises for inspection. The registered manager said all staff will also receive training regarding the handling of medication from the pharmacist shortly. Trevean Gardens DS0000008904.V250113.R01.S.doc Version 5.0 Page 13 A previous requirement has been issued regarding expanding the registered providers death and dying policy to include issues regarding illness and ageing. This is currently in draft form. The policy must now be finalised, as the requirement has been outstanding for at least one year. Trevean Gardens DS0000008904.V250113.R01.S.doc Version 5.0 Page 14 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): 23 The registered persons have a satisfactory approach to protect service users from abuse, neglect and self-harm. EVIDENCE: The inspector observed an appropriate adult protection policy is in place. The registered manager said staff are informed of the policy as part of their induction and they complete a learning pack called ‘Respect and Protect’ as part of their foundation training. Staff are also able to attend training organised by social services if spaces are available. Staff receive a Criminal Record Bureau / Protection of Vulnerable Adults check when they commence employment. The registered manager said one member of staff has not yet received their disclosure from the Criminal Records Bureau. The registered manager said the member of staff has received a ‘POVA First’ check. She said the matter is being chased and the person is currently supervised appropriately according to guidelines issued by the Commission /CRB. Trevean Gardens DS0000008904.V250113.R01.S.doc Version 5.0 Page 15 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, 30 The registered persons provide satisfactory facilities for service users accommodated in the home. The home was clean and hygienic on the day of the inspection. EVIDENCE: The inspector inspected the building. Since the last inspection Trevean Gardens has been completely redecorated, and decorations are vastly improved. The buildings are homely and comfortable. Service users are involved in choosing the colour schemes. All parts of the service were clean and hygienic on the day of the inspection. Some of the carpets look like they will need replacement in the next 2-3 years. The registered provider should allow for this in its business / financial plan. Trevean Gardens DS0000008904.V250113.R01.S.doc Version 5.0 Page 16 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31 The registered persons provide appropriate staffing levels to meet service users needs. EVIDENCE: Satisfactory staff rotas were observed. Rotas are maintained appropriately with two staff always on duty during the waking day, with two staff sleeping in. The inspector discussed staffing levels and deployment with the registered manager. Service users in one of the houses, and in the flats spend time without staff support. Risk assessments have been completed regarding this issue, and service users appear to have well developed skills. Service users in the service are never left alone, and staff are always available in the ‘higher needs’ house. A sleep in member of staff is always within each of the houses between 23:00 and 07:30. Staffing deployment is kept under review. If there are any further changes to staffing levels and deployment these must be negotiated with the Commission for Social Care Inspection. Trevean Gardens DS0000008904.V250113.R01.S.doc Version 5.0 Page 17 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): 39, 42 The registered persons have a well-developed quality assurance system. Health and safety standards are generally satisfactory, although appropriate precautions must be taken regarding the prevention of Legionella. EVIDENCE: The registered manager discussed a comprehensive quality assurance system with the inspector. This included consulting various stakeholders (service users, staff and external professionals) regarding the service. The registered manager said a subsequent team development day was held to look at some of the issues raised. A service development plan was written. This is to an excellent standard, is thorough and comprehensive. It is clear that this was not just a ‘paper exercise’ and has led to considerable developments in the scheme. For example there has been a reorganisation of how support within the scheme is structured and the positive developments are outlined earlier in the report. Trevean Gardens DS0000008904.V250113.R01.S.doc Version 5.0 Page 18 Health and safety checks are carried out appropriately by staff, and where appropriate by qualified external contractors. These include checks on fire, electrical and gas appliances. Health and safety risk assessments are generally appropriate. However a risk assessment must be developed regarding the prevention of Legionella. The registered persons should liaise with the housing association and environmental health department regarding this issue. Appropriate measures must be taken regarding the prevention of Legionella and documentary evidence maintained regarding necessary checks. Trevean Gardens DS0000008904.V250113.R01.S.doc Version 5.0 Page 19 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score x 3 x 3 x Standard No 22 23 Score x 3 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 3 x x 3 3 Standard No 24 25 26 27 28 29 30 STAFFING Score 3 x x x x x 3 LIFESTYLES Standard No Score 11 4 12 x 13 x 14 x 15 x 16 x 17 Standard No 31 32 33 34 35 36 Score 3 x x x x x CONDUCT AND MANAGEMENT OF THE HOME 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Trevean Gardens Score 3 x 2 2 Standard No 37 38 39 40 41 42 43 Score x x 4 x x 3 x DS0000008904.V250113.R01.S.doc Version 5.0 Page 20 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 YA20 Regulation 13, 18 Requirement Staff must receive training regarding the administration of medication. The registered persons must be able to evidence this. (Timescale of 31.8.05 not met. 2nd Notification.) The registered provider is required to expand its death and dying policy to cover the care of service users who are aging, with reference to the national minimum standard (Timescale of 31.1.05 not met 2nd Notification) Appropriate measures must be taken regarding the prevention of Legionella and documentary evidence must be maintained regarding necessary checks. Timescale for action 28/02/06 2 YA21 12 01/01/06 3 YA42 13, 23 28/02/06 Trevean Gardens DS0000008904.V250113.R01.S.doc Version 5.0 Page 21 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 YA30YA24 Good Practice Recommendations Some of the carpets look like they will need replacement in the next 2-3 years. The registered provider should allow for this in its business / financial plan. Trevean Gardens DS0000008904.V250113.R01.S.doc Version 5.0 Page 22 Commission for Social Care Inspection St Austell Office John Keay House Tregonissey Road St Austell Cornwall PL25 4AD 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. 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