Inspection on 31/01/06 for Templecroft

This inspection was carried out on 31st January 2006.

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 but made no statutory requirements on the home.

Other inspections for this house

Templecroft 15/01/08

Templecroft 19/10/06

Templecroft 09/08/05

Templecroft 18/11/04

Templecroft 19/05/04

Templecroft 06/01/04

Similar services:

Snydale Care Home

Abbey The

Hawkhills

Larchfield Manor

Beeches The - North Yorkshire County Council

The Grove Waltham

Carentan House

Ravensworth Lodge

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

CARE HOMES FOR OLDER PEOPLE Templecroft 42 Scartho Road Grimsby North East Lincs DN33 2AD Lead Inspector Beverley Hill Unannounced Inspection 31st January 2006 09:30 X10015.doc Version 1.40 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 Templecroft DS0000002894.V281116.R01.S.doc Version 5.1 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 Older People. 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. Templecroft DS0000002894.V281116.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Templecroft Address 42 Scartho Road Grimsby North East Lincs DN33 2AD 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) 01472 752684 01472 7500143 Dryband One Limited Mrs Ann Elizabeth Martin Care Home 40 Category(ies) of Old age, not falling within any other category registration, with number (40) of places Templecroft DS0000002894.V281116.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 9th August 2005 Brief Description of the Service: Templecroft Care Home is situated in the town of Grimsby on a regular bus route and within walking distance of the main shopping areas. The home provides accommodation and care for up to forty people over the age of sixtyfive and in no other category. District nurses provide any element of nursing care that may be required. There are two floors with a passenger lift and stair access. There are three lounge areas and a large dining room with individual tables set out. Patio doors open from the dining room onto a paved courtyard that has a raised pond and an area for tables and chairs. The home has seven shared bedrooms and twenty-six single rooms, eight of which have en-suite facilities. The home has two bathrooms with parker baths, a shower room for more able service users and an unassisted bathroom that is rarely used. All these rooms have toilets in them. The home has further single toilets throughout, near the lounge and dining areas. There is a good-sized car park at the front of the building. The environment is homely, clean and well presented. There are four or five care staff on duty throughout the day as well as the registered manager and three waking night staff. The home also has a good complement of domestic, laundry, cooks and kitchen assistants. Templecroft DS0000002894.V281116.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection was unannounced and took place over one day. The Inspector spoke to the manager and three care staff that were on duty at the time of the inspection. Throughout the day the Inspector spoke to nine people who lived at Templecroft and two relatives and received feedback cards from a further three relatives. The inspector looked at a range of paperwork in relation to staff recruitment, staff supervision and training, service users finances, care plans, risk assessments, medication management, the servicing of equipment, fire prevention management and policies and procedures. The Inspector also checked that people who lived in the home had the opportunity to suggest changes and were listened to. The Inspector completed a partial tour of the building and checked that all the things that needed to be done from the last inspection had been done. What the service does well: The home continues to be very clean and tidy and homely in appearance. People spoken to liked their home and thought the domestic staff worked very hard. The management and staff team have developed positive relationships with service users and relatives. People spoken to and feedback comments received were very complimentary about the care provided and the approach of the staff. Everyone spoken to stated that visitors were made to feel very welcome, could come at any time and were offered refreshments. Staff felt the morale was good and they worked together well as a team. Although not assessed at this inspection, service users informed the inspector that the meals provided continued to be good. Service users stated that staff promoted their privacy and dignity by knocking on doors before entering and generally helping them in a considerate way. The proprietors were closely involved with the home and visited on a regular basis to support the staff team and to oversee the running of the home. Templecroft DS0000002894.V281116.R01.S.doc Version 5.1 Page 6 What has improved since the last inspection? What they could do better: Documentation regarding the care provided to people could be improved further so that staff members are aware from shift to shift of issues they have to observe. When service users are admitted when the manager is on holiday senior care staff could write the care plan instead of waiting for the manager to return. This would ensure that staff members have written information about how to meet the service users needs rather than relying on verbal exchanges. Some areas of managing medication could be improved. Although service users personal allowances were managed well the manager needed to ensure that receipts were issued to the visitor depositing money into the service users account or alternatively ensure that the visitor signed the log. Templecroft DS0000002894.V281116.R01.S.doc Version 5.1 Page 7 The manager needed to stick to the supervision plan to ensure staff received six formal supervision sessions per year. 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. Templecroft DS0000002894.V281116.R01.S.doc Version 5.1 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Templecroft DS0000002894.V281116.R01.S.doc Version 5.1 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 4 The home demonstrated its capacity to meet the current needs of service users admitted to the home. EVIDENCE: The home completed assessments of need prior to admission and obtained assessments completed by care management. This enabled them to develop a care plan to meet the needs. The home had sufficient equipment within the home to meet a range of needs and specialist equipment was obtained via district nursing services as required. The home had a training plan in place that covered mandatory and service specific training and staff members were prepared to participate. There was a good skill mix of staff and they knew the needs of service users well. Templecroft DS0000002894.V281116.R01.S.doc Version 5.1 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 9 and 10 The home provided an environment where service users health and personal care needs were met but the lack of a care plan for one service user and inconsistent recording of care potentially placed them at risk of care being missed. EVIDENCE: Although there had been some improvements in recording the care provided to service users this was not consistent in all the care files examined. For example one care file had daily record entries of ‘fine today’ and ‘no problems’ and another did not follow through important issues highlighted on one shift to the next. In one care file examined the service user did not have a care plan. They had been admitted for respite two weeks previous and as the manager had been on holiday a care plan had not been produced. Staff members were working from an assessment completed by a senior carer. Staff members need to be able to complete care plans in the absence of the manager. Generally medication was managed effectively and was signed on administration. There were a few areas to address including the storing and recording of Temazepam medication as a controlled drug for good practice and ensuring that those service users admitted for respite consistently have their Templecroft DS0000002894.V281116.R01.S.doc Version 5.1 Page 11 medication signed into the home. One specific type of eye drops needed to be stored in the fridge as per manufacturers instructions and care was needed when staff transcribed medication onto the medication administration record sheet to ensure full instructions. Service users spoken to stated that their health and care needs were met and described how care was delivered in a respectful way. These were some of the comments made to the inspector about staff respecting privacy and dignity. ‘I feel they do (respect privacy and dignity), they knock on doors and you can talk to them privately’ ‘staff know me well, I like to keep smart and they help me to keep smart. They make sure I have shirts and ties to wear’, ‘oh yes they respect privacy, they knock on doors and are pretty good all round’. Staff reported respecting privacy and dignity by ensuring that they knocked on doors before entering, ensuring that they knew service users needs and therefore how much assistance they required and making sure personal care tasks were carried out sensitively. They confirmed that all shared rooms had privacy screens and mail was delivered unopened to people unless there were special instructions from family members. One relative who visits frequently told the inspector they had witnessed staff knocking on doors and that ‘from the kitchen staff right through, the attitude is very good’. Templecroft DS0000002894.V281116.R01.S.doc Version 5.1 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 13 and 14 The home maintained community links, encouraged service users to keep in contact with their families and promoted choice and independence. EVIDENCE: Service users spoken to stated that their visitors were made to feel welcome and could visit at any time. This was confirmed in discussions with relatives visiting during the inspection. One feedback card stated, ‘I am 100 satisfied as to the care the staff give my wife, I have no complaints regarding every member of staff. They treat me with courtesy at all times’. Service users can see their relatives in private and one relative advised they usually used the dining room when it was quiet. Some service users had installed their own telephones and the home had phones for people to use in private to remain in touch with families. Care plans reflected the need to maintain contact with relatives. Links were maintained with the wider community via local clergy, visiting entertainers and the mobile library. One person informed the inspector that the manager was taking them shopping the next day for more clothes. Two service users continue to use a local church hall for bingo to which staff take them and collect them after the event. One service user stated they would like to go for Templecroft DS0000002894.V281116.R01.S.doc Version 5.1 Page 13 a pint occasionally and watch a game of pool. This was discussed with the manager to try and arrange. There was evidence that service users were able to make choices about aspects of their lives within the home. Routines were flexible with no set times for visiting or rising and retiring and the inspector saw evidence of service users entering the dining room for breakfast up until 10am. Service users and staff explained that some people chose to lie-in and kitchen staff provided staggered breakfasts as required. Care plans reflected the need to encourage choice and independence and one service user managed their own medication. Bedrooms were personalised, as people were encouraged to bring in their own small items of furniture and ornaments. Templecroft DS0000002894.V281116.R01.S.doc Version 5.1 Page 14 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 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 The home protects service users from abuse by training staff, good recruitment and adherence to policies and procedures. EVIDENCE: The home had policies and procedures that linked to the multi agency policies and procedures regarding protecting vulnerable adults from abuse and staff were aware of what to do if they suspected abuse had occurred. Staff had received training and there was evidence that issues had been discussed in staff meetings. The homes recruitment practices ensured that references and criminal records bureau checks were in place prior to employment of staff. Templecroft DS0000002894.V281116.R01.S.doc Version 5.1 Page 15 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19 and 26 The home provided a clean, safe and well-maintained environment for service users. EVIDENCE: This standard was assessed fully at the last inspection but since then the proprietor has started the process of covering radiators in the communal seating areas. Four had been covered and the manager confirmed a further three covers had been made and were ready for installation. Privacy locks had been installed to every door and the driveway had been resurfaced. The proprietor was proactive in responding to requirements and ensuring that the home had a safe and well-maintained environment. General day-to-day maintenance issues were completed as they occurred. The home was suitable for its intended purpose. The communal areas and bedrooms examined were spotlessly clean and free from any odours. The staff members work hard to maintain standards. Templecroft DS0000002894.V281116.R01.S.doc Version 5.1 Page 16 Templecroft DS0000002894.V281116.R01.S.doc Version 5.1 Page 17 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 28 and 30 Service users were cared for by trained and competent staff. EVIDENCE: The manager and staff demonstrated a commitment to training and when those progressing through NVQ 2 and 3 complete the courses the home will have 57 of staff trained to NVQ level 2 or above. A range of internal training, external facilitators and distance learning techniques were used in staff training. The home had a training plan that included mandatory and service specific training. Mandatory training was on a rolling programme to ensure updates took place and individual logs were maintained. All staff other than new staff members had completed mandatory and adult protection training and specific courses had been arranged for them. Senior care staff had completed an accredited medication course and six staff had completed a dementia awareness course with an external facilitator. The company had five homes and had access to moving and handling trainers. Training was organised with staff from each of the homes. Service specific training included a range of videos and questionnaires the company had purchased covering the conditions affecting older people. Relevant staff had also participated in other courses such as, diabetes management, optical awareness, Parkinson’s disease, arthritis, aggression management, stress in the workplace and nutrition in care homes. Templecroft DS0000002894.V281116.R01.S.doc Version 5.1 Page 18 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. 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 and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 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, 35 and 38 An experienced manager promotes the general safety, wellbeing and finances of service users and progress has been made in the area of staff supervision, which means that care practices are monitored. EVIDENCE: The registered manager had worked in the home for twenty years, sixteen of those as the manager. They were progressing through the Registered Managers Award and had four units left to complete. The manager was proactive in ensuring the home was a safe environment for service users and staff, although according to records, the home was overdue a fire drill, which the manager was to address next week. Maintenance records were examined and fire systems and equipment checked regularly. The quality assurance system was not assessed at this inspection but the manager confirmed that they were continuing through the process and results Templecroft DS0000002894.V281116.R01.S.doc Version 5.1 Page 19 of surveys would be published to service users and visitors and a copy forwarded to CSCI. The home managed service users personal allowance when requested although this mainly tended to be for hairdressing and chiropody. For good practice receipts could be issued to visitors depositing money into service users accounts or signatures obtained on the individual record. Since the last inspection progress had been made with formal staff supervision and a plan had been produced for the following year. The manager needs to continue with the plan to ensure that care staff members receive a minimum of six supervision sessions per year. Templecroft DS0000002894.V281116.R01.S.doc Version 5.1 Page 20 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People 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 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 x x x 3 x x HEALTH AND PERSONAL CARE Standard No Score 7 2 8 x 9 2 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 x 13 3 14 3 15 x COMPLAINTS AND PROTECTION Standard No Score 16 x 17 x 18 3 3 x x x x x x 4 STAFFING Standard No Score 27 x 28 2 29 x 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 x x x 3 2 x 3 Templecroft DS0000002894.V281116.R01.S.doc Version 5.1 Page 21 Are there any outstanding requirements from the last inspection? YES 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 OP7 Regulation 12(1)(a) Requirement The registered person must ensure that daily records are clear about the care provided and follow through to the next shift (previous timescale of 09/08/05 not met) The registered person must ensure that senior care staff members are able to complete care plans for service users admitted during the manager’s absence. The registered person must ensure that the service user identified at risk of pressure sores has a risk assessment completed with steps to minimise the risks, which is signed by the service user or their representative. The care plan to reflect the risk. The registered person must ensure that respite medication is signed into the home, transcribing medication onto the MAR is thorough, Temazepam is stored and recorded as a controlled drug and one particular type of eye drops are DS0000002894.V281116.R01.S.doc Timescale for action 31/03/06 2 OP7 15 31/01/06 3. OP7 15 31/03/06 4. OP9 13(2) 31/01/06 Templecroft Version 5.1 Page 22 5. OP33 24 6. OP36 18(2) stored in the fridge. The registered person must 31/03/06 continue the quality assurance programme, publish results of surveys and forward a copy to the CSCI The registered person must 31/03/06 ensure that the supervision plan is implemented to ensure all care staff receives a minimum of six formal supervision sessions per year. 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 OP15 OP28 OP31 OP35 Good Practice Recommendations The registered person should ensure that daily/weekly menus are available for service users to see. The home should continue to work towards 50 of staff trained to NVQ Level 2. The manager should continue to work towards their Registered Managers Award. The manager should ensure receipts are given to people deposited money into the home or obtain their signature on the financial record. Templecroft DS0000002894.V281116.R01.S.doc Version 5.1 Page 23 Commission for Social Care Inspection Hessle Area Office First Floor 3 Hesslewood Country Office Park Ferriby Road Hessle HU13 0QF 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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