This inspection was carried out on 12th December 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 4 statutory requirements (actions the home must comply with) as a result of this inspection.
CARE HOME ADULTS 18-65
5 Trinity Street Old Hill Cradley Heath West Midlands B64 6HT Lead Inspector
Mr Jon Potts Unannounced Inspection 12th December 2005 13:50p 5 Trinity Street DS0000004854.V272852.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 5 Trinity Street DS0000004854.V272852.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. 5 Trinity Street DS0000004854.V272852.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION
Name of service 5 Trinity Street Address Old Hill Cradley Heath West Midlands B64 6HT 01384 823048 NONE 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) info@Inshoresupportltd.com Inshore Support Mr Adam Webb, Mr Ian Forrest-Jones Tracey Lake Care Home 3 Category(ies) of Learning disability (3) registration, with number of places 5 Trinity Street DS0000004854.V272852.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION
Conditions of registration: Date of last inspection 19/7/05 Brief Description of the Service: 5 Trinity Street provides long term care to 3 adults with a learning disability who are of mixed gender. The house is sited near the centre of Old Hill in an established residential area that affords easy access by foot to a range of local facilities, including public transport. Staff also have access to a car for transporting the residents between venues. The house is a terraced property that has been adapted for its current use and consists of two living rooms, a kitchen/diner and three single bedrooms as well as bathroom and toilets. The main stated aim of the home is to provide a service that reflects the expectations of the residents: identifying and fulfilling their individual needs by means that are valued by society; this in order to develop and support individual and personal experiences and characteristics which are culturally valued and maintained. There is a staff group that consists of a manager, senior support and support workers. There are waking staff available 24 hours per day. The manager is responsible to a service manager and directors of Inshore support who have a number of homes of similar size and purpose. 5 Trinity Street DS0000004854.V272852.R01.S.doc Version 5.0 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This unannounced inspection was carried out between 1.50pm and 3.30pm and involved the registered manager. The inspector met and spoke to two residents during the course of the inspection. Information/evidence was drawn from some limited case tracking, staff files, and sight of documents, policies and procedures. What the service does well: What has improved since the last inspection? What they could do better:
There is still a need for the ratio of staff with NVQ level 2, 3 or 4 to increase so that there is 50 with this qualification. The manager also needs to complete additional training so that she has the necessary management input at NVQ level 4. The working history of prospective staff also needs to be checked to ensure that there are no gaps in this record, and if there is some explanation of why. The staff have commenced documenting when one resident refuses his meals and the alternatives offered although this practice needs to be improved so that it is consistent. The introduction of personal care planning was discussed with the manager, this an area which the manager should develop further. 5 Trinity Street DS0000004854.V272852.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. 5 Trinity Street DS0000004854.V272852.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 5 Trinity Street DS0000004854.V272852.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 Resident’s needs are reviewed through multidisciplinary meetings on an ongoing basis. EVIDENCE: No residents have been admitted to the home since the last inspection at which point copies of social work assessments were seen for all the residents. A requirement raised at the time of the last inspection was that there must be documented evidence of multidisciplinary reviews for residents. Evidence of this was seen at the time of this inspection for the one resident who case file was examined. 5 Trinity Street DS0000004854.V272852.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 Residents assessed, changing needs and personal goals are reflected in their individual plan and supporting documentation. EVIDENCE: The changing needs of the one resident’s care that was tracked were seen to have been reviewed with the involvement of a multidisciplinary team, the notes from the last review reflecting the residents changing needs. The review provided a clear base line from which the staff could review the residents care plan. The risk assessments for this resident had been revised since the last inspection and showed areas where there were limitations, these now more clearly detailed than at the time of the previous inspection. The use of personal care planning was discussed, this an area that the manager should develop with the residents so as to enhance the service user focus of the plans. This development of such an approach is to be encouraged. 5 Trinity Street DS0000004854.V272852.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): 17 Residents have access to a varied diet in keeping with their individual choices. EVIDENCE: The records of foods taken by the residents indicate that they have access to appropriate and well balanced diets. Resident’s food likes and dislikes were clearly recorded in their case files. The home does not have a set menu and it was agreed that this was appropriate as meals taken are very much based on resident’s choices on a day-to day basis. One of the resident’s was documented as occasionally refusing meals and whilst staff are now documenting when meals are offered and refused on some occasions this practice was seen not to be consistent. 5 Trinity Street DS0000004854.V272852.R01.S.doc Version 5.0 Page 11 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): 20 Residents are being encouraged to have involvement with the administration of their medication as appropriate and are protected by the home’s policies and procedures. EVIDENCE: The home was seen to have a policy on medication; this recently revised with expansion to cover the action staff should take if medication was given in error. The homes systems for the administration of medication were judged to be acceptable with very clear directions seen in respect of the handling of ‘as required’ medication. Medication when received at the home is now better documented on the Medical Administration Records. Information in care plans as to the administration of medication has been expanded, this seen to be very detailed. Staff have undertaken training in the safe handling of medication, this an accredited training package. Discussion with the manager indicated that the residents were being encouraged by staff to ask questions about their medication and to have some involvement in its administration, this with the full support of staff. 5 Trinity Street DS0000004854.V272852.R01.S.doc Version 5.0 Page 12 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): These outcomes were not fully assessed at the time of this inspection EVIDENCE: These outcomes were not fully assessed at the time of this inspection 5 Trinity Street DS0000004854.V272852.R01.S.doc Version 5.0 Page 13 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 Residents live in a comfortable, well-maintained and homely environment that overall meets with their lifestyles and expectations. EVIDENCE: The home is sited in a suitable position and presents as a well-maintained and homely environment in keeping with the provision of ‘normal’ domestic style living. There is no indication that the house is anything other than a domestic home, this ensuring that it blends into the immediate community. The home has a redecoration and refurbishment programme identifying works for the next twelve months. The bedroom doors are currently only lockable on the outside, although the home has completed risk assessments in respect of residents not having keys to their bedrooms. Overall the home is suitable for the needs and lifestyle of the residents with ample communal space available. 5 Trinity Street DS0000004854.V272852.R01.S.doc Version 5.0 Page 14 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): 32,34,35 Residents are, with one exception, supported and protected by the home’s recruitment policy and procedures. The home has identified how staff skills and knowledge will be developed through its training provision. Continuation of the homes current training plan will increase the qualification and competence of staff. EVIDENCE: The home was seen to have a training plan that clearly identified training staff held, what was booked and what was needed. The majority of staff had received training in the majority of mandatory health and safety areas. There are currently 3 staff that have completed NVQ level two although there are three currently undertaking NVQ 2/3 or 4. When these staff have completed their qualification the home will have in excess of the 50 ratio required assuming there is minimal staff turnover. The staff files for one member of staff employed since the last inspection was checked in respect of recruitment practices, these evidencing that these were satisfactory with all necessary recruitment checks in place with the exception of a unqualified gap in their employment history. Any employment of staff without disclosure has only occurred following risk assessment, receipt of all other recruitment checks (except that detailed above) including POVA 1st and discussion with the CSCI.
5 Trinity Street DS0000004854.V272852.R01.S.doc Version 5.0 Page 15 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): The resident’s benefit from a well run home. EVIDENCE: The manager has successfully completed the registration process since the time of the last inspection and was deemed competent to run 5 Trinity Street Street. She has completed an NVQ level 4 in care; this subject to verification but needs to complete the additional management units to meet the expected standards. Based on the outcomes of this and the previous inspection the home is judged to be well run. Systems for the support of the manager by the company were seen to be in place. 5 Trinity Street DS0000004854.V272852.R01.S.doc Version 5.0 Page 16 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 X X Standard No 22 23 Score X X ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 3 X X X X Standard No 24 25 26 27 28 29 30
STAFFING Score 4 X X X X X X LIFESTYLES Standard No Score 11 X 12 X 13 X 14 X 15 X 16 X 17 Standard No 31 32 33 34 35 36 Score X 2 X 2 3 X CONDUCT AND MANAGEMENT OF THE HOME 2 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21
5 Trinity Street Score X X 3 X Standard No 37 38 39 40 41 42 43 Score 2 X X X X X X DS0000004854.V272852.R01.S.doc Version 5.0 Page 17 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 YA17 Regulation 16 Requirement Staff must consistently record when meals are offered, and the times they are offered, when a resident is refusing meals. There must be at least 50 of the staff team qualified in NVQ level 2 or three by the identified date. This is a repeated requirement that should have been met by the 30.11.05. To ensure that any gaps in prospective employees working history is fully explored. The manager must complete her NVQ level 4 in management (Registered managers award) Timescale for action 15/01/06 2 YA32 18 31/03/06 3 4 YA34 YA37 19 10, 18 15/01/06 31/05/06 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 YA6 Good Practice Recommendations To look to develop personal care planning as a tool for
DS0000004854.V272852.R01.S.doc Version 5.0 Page 18 5 Trinity Street involvement of residents in life and care planning. 5 Trinity Street DS0000004854.V272852.R01.S.doc Version 5.0 Page 19 Commission for Social Care Inspection Halesowen Record Management Unit Mucklow Office Park, West Point, Ground Floor Mucklow Hill Halesowen West Midlands B62 8DA National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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