Inspection on 04/05/05 for 22-25 Trevean Gardens

This inspection was carried out on 4th May 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. 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 but made no statutory requirements on the home.

Other inspections for this house

22-25 Trevean Gardens 10/02/09

22-25 Trevean Gardens 21/03/07

22-25 Trevean Gardens 24/11/05

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 Unannounced 4 May 2005 1600 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 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 Stationary 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 D52-D04 S8904 Trevean Gardens V215894 040505 Stage 4.doc Version 1.30 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 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 Society Mrs Hilary Sarah Jane Reynolds Care Home 11 Category(ies) of Learning Disability (11) registration, with number of places Trevean Gardens D52-D04 S8904 Trevean Gardens V215894 040505 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 1st November 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 man and a married couple. The home 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 D52-D04 S8904 Trevean Gardens V215894 040505 Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection took place over five and a quarter hours. The inspection was carried out on an unannounced basis. The inspector was able to speak to the majority of service users, and the staff members on duty. The inspector examined the medication system, staff and care records, and inspected the building. What the service does well: What has improved since the last inspection? What they could do better: Although Mencap appears to have a suitable approach to induction and training for staff, the registered manager must ensure staff have received all of the training necessary for people to do their jobs and can evidence this (e.g. moving and handling, food hygiene, first aid, medication, NVQ 2 in care). Mencap must also be able to evidence staff have completed induction training when they start their jobs. Trevean Gardens D52-D04 S8904 Trevean Gardens V215894 040505 Stage 4.doc Version 1.30 Page 6 Some redecoration is required as parts of the interior of the home are beginning to look shabby. This work should be completed by professional contractors so the burden does not fall on staff and service users. Some fixtures and fittings e.g. towel rails need to be fixed to the wall. 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 D52-D04 S8904 Trevean Gardens V215894 040505 Stage 4.doc Version 1.30 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 Standards Statutory Requirements Identified During the Inspection Trevean Gardens D52-D04 S8904 Trevean Gardens V215894 040505 Stage 4.doc Version 1.30 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 standard(s) 3 The registered persons satisfactorily demonstrate the staff team have appropriate skills and knowledge to work with service users in order to meet their needs. EVIDENCE: There was evidence service users have appropriate support from staff with personal care. Discussion with staff and staff files evidence that they have appropriate skills and knowledge to work with the service user group. However evidence of training received by staff needs to be improved as outlined in NMS 35. Trevean Gardens D52-D04 S8904 Trevean Gardens V215894 040505 Stage 4.doc Version 1.30 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 standard(s) 6, 7, 9, 10 The registered persons appropriately support service users so their care and support needs are met. Service users are supported to make decisions about their lives and take appropriate risks. EVIDENCE: All service users have a comprehensive care plan in their individual files. Service users have a review meeting at least once a year where goals are set to assist their development. External professionals and relatives are invited where this is appropriate. Service users stated they are consulted about decisions regarding their lives. Copies of risk assessments are contained in individual files which are reviewed regularly. Written documentation is stored in locked files, and there is an office where confidential discussions can take place. The organisation of the service enables service users to maximise their skills (e.g. cook independently) and move on to more independent living (i.e. flats within the service.) Trevean Gardens D52-D04 S8904 Trevean Gardens V215894 040505 Stage 4.doc Version 1.30 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 standard(s) 11-16 Service users receive appropriate support to participate in the home and wider community. Staff work with service users in a respectful manner and encourage service users to be as independent as possible. EVIDENCE: The staff team were observed to work within the ethos of encouraging service users to live as independently as possible. Service users said they were involved in a range of domestic tasks such as cooking. The home has two move on flats to enable service users to move on from the care home to live more independently. Service users the inspector spoke to said they had benefited from this opportunity. Service users all stated they had a wide range of opportunities to participate in the community such as attending college, supported work placements and leisure opportunities. One service user said he did not think he had been registered to vote in the general election, and staff were asked to clarify this issue, and ensure all service users were on the electoral roll. Trevean Gardens D52-D04 S8904 Trevean Gardens V215894 040505 Stage 4.doc Version 1.30 Page 11 Service users said they were able to have visitors at any time, and staff stated service users were in regular contact with their families and friends. Daily routines are flexible and tailored to individual needs for example people prepare meals when they wish, and can go to bed when they wish. All service users have a lock on their bedroom doors, and receive their own mail unopened. Staff were observed to work with service users in a supportive and respectful manner. Trevean Gardens D52-D04 S8904 Trevean Gardens V215894 040505 Stage 4.doc Version 1.30 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 standard(s) 18,19,20 Service users personal and health care needs are met appropriately. The medication system is managed to a satisfactory standard, however training in this area needs to be improved /evidenced. EVIDENCE: Service users said staff provide personal care in an appropriate manner, and their privacy and dignity is respected. Service users said they could get up and go to bed when they wished. Service users choose their own clothes and appeared to be supported appropriately with personal care. Staff said healthcare services were responsive to service users care needs, and various health care appointments are arranged appropriately (e.g. dentist and optician). Medication systems in both houses are managed appropriately. Records for the receipt, administration and disposal of medication are kept appropriately. However there is insufficient evidence staff have received appropriate training regarding the administration of medication (e.g. from a pharmacist). Staff work with service users who are aging appropriately. Service users who are aging are encouraged to maintain their skills and participate in the community. However the rights of those who are getting older and wish to live Trevean Gardens D52-D04 S8904 Trevean Gardens V215894 040505 Stage 4.doc Version 1.30 Page 13 a more sedate lifestyle are respected. However the previous requirement to expand the organisational policy regarding this issue is still outstanding and has been renotified. Trevean Gardens D52-D04 S8904 Trevean Gardens V215894 040505 Stage 4.doc Version 1.30 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 standard(s) 22 Mencap has a suitable complaints procedure and there is evidence service users use this, and complaints are responded to appropriately. EVIDENCE: The registered manager has received three complaints from service users which were settled appropriately. Several service users said they had received a copy of Mencap’s complaints procedure, which is also supplied on a cassette tape and includes pre-paid postcards to be sent to the organisations office. This assists greatly service users who may lack literacy skills. Trevean Gardens D52-D04 S8904 Trevean Gardens V215894 040505 Stage 4.doc Version 1.30 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 standard(s) 24-30 Facilities offer a range of options for service users, e.g. adjacent move on flats. This enables service users to develop their skills and move on to live more independently. Several rooms in the home require redecoration. EVIDENCE: The care home offers a flexible environment to meet service user needs; e.g. a staffed care home, and two move on flats next door where service users receive outreach support. Some of the rooms e.g. kitchens and bathrooms are on the small side, although there is little that can be done to improve this situation. An immediate requirement was made regarding a broken loft hatch which could have been a health and safety hazard to staff and service users. This has since been fixed. One bedroom has excellent facilities for a physically disabled service user e.g. hoist, en suite bathroom. Some of the other bedrooms are on the small side although service users have made these as homely as possible. Some of the communal rooms, hallways and bedrooms need to be redecorated, and this work should be done by professional decorators rather than the burden being placed on staff and service users. Trevean Gardens D52-D04 S8904 Trevean Gardens V215894 040505 Stage 4.doc Version 1.30 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 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31-36 The registered provider has appropriate recruitment and supervision procedures, and these are well managed by the registered manager. Appropriate induction and training policies are in place, although evidence staff are receiving induction and training must be improved. EVIDENCE: Staff the inspector spoke to appear to be clear regarding their roles and responsibilities. Each role has an appropriate job description and there is appropriate evidence of a satisfactory recruitment process in operation. Satisfactory information is obtained for the recruitment of individual staff (e.g. two references, proof of identity, and a Criminal Bureau check.) Staff spoken to appear to be professional in their approach, knowledgeable, and have appropriate experience. Satisfactory staff rotas are maintained, with two staff are always on duty during the waking day, with two staff sleeping in. Mencap has an appropriate induction and training programme, however evidence staff have completed induction, NVQ 2 and training required by regulation must be improved (e.g. certificates of induction and training should be in individual files.) Day to day supervision, and one to one supervision sessions are managed to a good standard. Trevean Gardens D52-D04 S8904 Trevean Gardens V215894 040505 Stage 4.doc Version 1.30 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 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 38, 41, 42 Management of the home is to a good standard with opportunities for staff to be included in day to day decision making. Records regarding service users, health and safety and the management of the home are to a good standard. Health and safety precautions are satisfactory. EVIDENCE: Staff the inspector spoke to said management were supportive, and involved them in making day to day decisions regarding the running of the home. There is evidence of regular staff meetings, and individual formal one to one supervision. Records regarding the management of the home, and records regarding individual service users are maintained to a satisfactory standard. Satisfactory health and safety measures are in place to ensure the protection of staff and service users (e.g. checks on fire prevention equipment, electrical appliances.) A requirement has been made elsewhere regarding improving Trevean Gardens D52-D04 S8904 Trevean Gardens V215894 040505 Stage 4.doc Version 1.30 Page 18 health and safety training. An immediate requirement was made to fix the loft hatch, and appropriate action has been taken regarding this since the inspection. Trevean Gardens D52-D04 S8904 Trevean Gardens V215894 040505 Stage 4.doc Version 1.30 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 x 3 x x Standard No 22 23 ENVIRONMENT Score 3 x INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 3 3 x 3 3 Score Standard No 24 25 26 27 28 29 30 STAFFING Score 2 3 3 3 3 3 3 Standard No 11 12 13 14 15 16 17 3 3 3 3 3 3 3 Standard No 31 32 33 34 35 36 Score 3 2 3 3 2 3 CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Trevean Gardens Score 3 3 2 x Standard No 37 38 39 40 41 42 43 Score x 3 x x 3 3 x D52-D04 S8904 Trevean Gardens V215894 040505 Stage 4.doc Version 1.30 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 24 Regulation 16,23 Requirement Timescale for action 1.1.06 2. 20 13, 18 3. 32, 35, 42 18 4. 21 12 The registered provider arrange for internal redecorations to be arranged. This should be completed by professional decorators so the burden does not fall on service users and staff. Staff must receive training 31.8.05 regarding the administration of medication, and must be able to evidence this (e.g. from a pharmacist) Staff must receive satisfactory 31.8.05 induction and training as required by regulation (e.g. NVQ 2, first aid, infection control, moving and handling, food handling). The registered manager must be able to provide satisfactory evidence staff have completed an NVQ 2, induction and training (e.g. copies of certifcates on personnel files). The registered provider is 1.1.06 required to expand the homes 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.) Version 1.30 Trevean Gardens D52-D04 S8904 Trevean Gardens V215894 040505 Stage 4.doc 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 Good Practice Recommendations Trevean Gardens D52-D04 S8904 Trevean Gardens V215894 040505 Stage 4.doc Version 1.30 Page 22 Commission for Social Care Inspection 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. Extracts may not be used or reproduced without the express permission of CSCI Trevean Gardens D52-D04 S8904 Trevean Gardens V215894 040505 Stage 4.doc Version 1.30 Page 23 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!