Inspection on 12/10/05 for Three Trees

This inspection was carried out on 12th October 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 no outstanding requirements from the previous inspection report, but made 10 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Three Trees 16/02/09

Three Trees 25/01/07

Three Trees 28/02/06

Three Trees 15/02/05

Three Trees 14/09/04

Similar services:

Larch Avenue

Alderson Road 12

Cranworth Close Registered Care Home

The Cornerstone

John Street Nursing Home

Pennine Camphill

Muston Road (70)

Grayling

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

CARE HOME ADULTS 18-65 Three Trees 24 St Johns Avenue Bridlington East Yorkshire YO16 4NG Lead Inspector Sarah Sadler Unannounced Inspection 12th October 2005 09:30 Three Trees DS0000019764.V258471.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 Three Trees DS0000019764.V258471.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. Three Trees DS0000019764.V258471.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Three Trees Address 24 St Johns Avenue Bridlington East Yorkshire YO16 4NG 01262 601626 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) Mr Barrie Stephen Gosland Mrs Christine Alma Gosland Mrs Christine Alma Gosland Care Home 21 Category(ies) of Learning disability (21) registration, with number of places Three Trees DS0000019764.V258471.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 1st March 2005 Brief Description of the Service: Three Trees is a three storey building in the seaside town of Bridlington. The home is registered to offer care to twenty-one residents, male and female, who have a learning disability. The home is generally well maintained within the building and outside. Bedrooms are individually decorated to reflect the style and tastes of the individual. Residents have access to all communal areas and can spend time with others in the lounge and dining room or take time to be alone in their bedrooms. The home has its own transport for taking residents to day centres or on outings in the surrounding countryside and has good access to the local bus service and railway station. Residents have access to a range of educational, social and leisure activities through day centres, work experience and different clubs and forums. Three Trees DS0000019764.V258471.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection was undertaken over one day by one inspector. The inspection was part of the annual inspection programme from April 1st 2005 to March 31st 2006. During the inspection a tour of the premises was undertaken, residents, and members of staff were spoken to. A large amount of time was spent with residents, observing their everyday life. Some time was spent reading resident and other records within the home. What the service does well: What has improved since the last inspection? What they could do better: An immediate requirement was issued to the home regarding a broken window and must be addressed as per the requirements. Three Trees DS0000019764.V258471.R01.S.doc Version 5.0 Page 6 There are some risk assessments to support residents in their everyday lives; these require further clarification and details. The risk assessments for safe working practices require development. 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. Three Trees DS0000019764.V258471.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 Three Trees DS0000019764.V258471.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 Residents are assessed prior to admission to ensure that the home can meet their needs. EVIDENCE: Individual assessments have been undertaken for residents. The assessments includes; personal hygiene, personal appearance, general daily life needs, social and leisure needs, road safety needs, and a general risk assessment for the resident. These have been used in the development of individual care plans. Three Trees DS0000019764.V258471.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): 6,7,8,9 Residents have individual plans of care, which are used to assist them to make choices in their everyday lives. Residents are generally supported in taking risk through the assessment process. EVIDENCE: Residents’ files included individual care plans, which identify the individual support required by the resident. The care plan includes some basic risk assessments, of which some are detailed, however others require further development. There are daily notes kept for the support received by residents. Care is reviewed on a monthly basis by the residents’ key worker, and on annual basis by the management in the home. Annual Social Service care reviews take place with residents present. These reflected that residents’ needs are being met. Residents were observed to undertake activities that they chose to do, for example joining in an exercise class, sitting drawing or sitting in their own room. Staff interviewed reflected positively on the choices that residents make offering good examples; “ residents choose what they are going to do, whether Three Trees DS0000019764.V258471.R01.S.doc Version 5.0 Page 10 to have a lie in, what to eat, to go out and to go to the pictures. Further examples of the risks residents take in every day life were, “ to go into town, to go out on their own.” Records for residents’ meetings do not now contain details of individual residents and residents do not now attend meetings that discuss individual’s requirements. Three Trees DS0000019764.V258471.R01.S.doc Version 5.0 Page 11 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): 12,13,15,16,17 Residents are able to take part in a variety of activities both inside and outside of the home. This may include spending time with their family and relatives. Residents’ nutritional needs are met. EVIDENCE: Many of the residents were attending the local day centre at the time of the inspection. Residents’ records reflected that residents attend a variety of activities, these include; going to the local pub, board games and listening to their CD player. The staff interviewed confirmed that residents enjoy; parties, going to the local theatre, going shopping, going out for lunch, DVD nights at the home and their individual hobbies. The deputy manager confirmed that all residents are able to vote should they wish to do so, and that the staff support residents with this. Residents were observed to have access to all areas of the home and to be able to choose when to spend time with others or to be alone. Evidence of residents risk assessments regarding the holding of a key to the home or their rooms was not available. The deputy manager confirmed that these are in place. Three Trees DS0000019764.V258471.R01.S.doc Version 5.0 Page 12 Residents’ files included details of their family. Families are involved in the residents’ lives and the staff inform families of any relevant events. Residents are supported to visit and stay with families. There is a four week menu in place and residents are offered a variety of foods. Records are kept of the food provided. Staff confirmed that residents are offered choices should they not like the meal of the day. Residents were observed to be relaxed at their mealtime with staff available to support residents should this be needed. Residents confirmed that the cook is good and commented, “ … is a good cook”, “she is fantastic”, “she is a brilliant cook”, and “she does a nice buffet”. With their favourite meals being fish and sausages. Three Trees DS0000019764.V258471.R01.S.doc Version 5.0 Page 13 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): 18,19,20 Residents are able to be involved in how they are supported. Residents’ health and medication needs are met. EVIDENCE: Residents’ files included details of the support required by the residents in maintaining their personal and health care needs. Residents confirmed that they are supported with their personal hygiene, and that staff “ help do hair and make up”. Residents’ medical details are assessed upon admission and records of important events are kept which include details of GP, chiropody and other health professional appointments and visits. The details include the reason for the visit and the outcomes, for example if any treatment has been prescribed. Records reflected that residents are supported in attending medical appointments. Weekly checks are undertaken of the residents’ weights and this is recorded. However these are communal records. An exercise group has been commenced in the last month and this occurred during the inspection. Consideration was given to the differing abilities of the residents and to posture. Residents were clear about the rules for partaking in this and were happy and enjoyed themselves throughout. Three Trees DS0000019764.V258471.R01.S.doc Version 5.0 Page 14 All medicines entering and administered within the home are recorded and stored appropriately. There is a clinical waste contract held for the disposal of medicines. There are currently no controlled drugs within the home. There is a refrigerator for the storage of medicines and weekly temperature checks are kept of this. At the inspection no evidence was seen that accredited medication training has been undertaken. Copies of training certificates were forwarded to the CSCI as a response to the draft inspection report, this identified that staff have undertaken training in the ‘Care of Medicines’. However this training is not accredited. Three Trees DS0000019764.V258471.R01.S.doc Version 5.0 Page 15 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): 22,23 Residents are able to complain or raise an issue of concern and would be supported by the polices and procedures within the home in the case of an allegation of abuse. EVIDENCE: There continues to be a complaints procedure held within the home, which includes the timescales for actions and the contact details of the CSCI. The registered proprietor confirmed that there have been no complaints to the home. There is a policy in the home that addresses that any allegations of abuse will be investigated. The registered proprietor confirmed that this would be via the Local Authority procedure ‘The Protection of Vulnerable Adults’, of which a copy is kept within the home. Residents confirmed that a monthly residents’ meeting occurs where they can discuss any issues they wish. Records of these meetings are kept. There are polices to support staff and residents with the issues of physical and verbal aggression and for if a resident becomes absent from the home. The deputy manager confirmed that where necessary residents are supported with the handling of their finances and that records are kept of all transactions. Three Trees DS0000019764.V258471.R01.S.doc Version 5.0 Page 16 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 Residents on the whole live in a well maintained and comfortable home. EVIDENCE: The home was clean and tidy throughout, being comfortable, with no unpleasant aromas. Residents are able to personalise their rooms and some have recently received new wardrobes. Two rooms have had the double glazed windows replaced. One landing window was broken and had sharp edges, an immediate requirement was issued to the home to address this. In two of the bathrooms the hot water is not regulated and reached temperatures of 55.6° centigrade. The hot water outlets in residents’ rooms were found to be close to 43 ° centigrade. There continues to be a laundry area with an impermeable floor and washable walls. Residents confirmed that they are supported to “ get their washing done”. Three Trees DS0000019764.V258471.R01.S.doc Version 5.0 Page 17 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 A stable staff team that are experienced and trained supports residents. Residents are also supported by the homes recruitment and training practices. EVIDENCE: The registered proprietor confirmed that there have been no staff changes since the last inspection. He confirmed that should any new staff be employed then criminal record bureau (CRB) and the protection of vulnerable adults (POVA) checks would be completed prior to employment. The registered provider also detailed that any new staff would only be employed with the agreement that they would undertake to train to NVQ level 2. There is a recruitment policy and staff files continued to hold evidence of CRB checks. Individual staff training records are held within staff files which reflected that staff had undertaken a variety of in house training, this included; Confidentiality, Health and Safety, Fire, Grievance and Disciplinary procedures. There is a separate file that includes the certificates for training that staff have undertaken, this includes; First Aid, Food Hygiene and POVA. Staff stated that over the last year they had undertaken this training. The registered proprietor confirmed that the staff team are continuing to undertake NVQ training and that the home has not yet achieved the target of 50 of the staff team trained to NVQ level 2 or equivalent. The registered proprietor also confirmed that staff have recently commenced Learning Disability Award Framework (LDAF) style training within the home, and booklets for this were Three Trees DS0000019764.V258471.R01.S.doc Version 5.0 Page 18 available within the home. Staff confirmed that they had some knowledge of the GSCC code of conduct, but have not received individual copies of this. Three Trees DS0000019764.V258471.R01.S.doc Version 5.0 Page 19 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): 37,39,42 Residents live in a well run home. Residents are involved in the development of the home. Residents’ Health and Safety needs are on the whole met. EVIDENCE: The home continues to be run by the same manager, who has been in post for a number of years. The registered manager has completed the NVQ level 4 in management and is continuing to work to attain the NVQ level 4 in care. There is a quality assurance system in place, which seeks the views of residents, their relatives, and the staff in the home. An annual report is compiled from this information and an action plan devised. One of the residents’ questionnaires included the comment about the home, “ I like it very much”. There is a fire risk assessment and plan of the home detailing the fire exits. An officer form the Local Fire Authority visited the home in May of this year and no areas of concern were raised in the report of this visit. Three Trees DS0000019764.V258471.R01.S.doc Version 5.0 Page 20 The fire alarm system was serviced in April 2004 and a weekly check of the fire alarm and equipment is undertaken by the staff in the home. A recent service of the fire fighting equipment has been undertaken. An assessment of each resident and their response to the fire alarm, has been completed. This details, for example if the fire brigade need to be aware of an individuals responses when they attend the home. The home is registered for the safe removal of hazardous waste, has employers liability insurance and a landlords Gas Safety certificate. The electrical wiring certificate is in need of renewal and the registered proprietor confirmed that he has written to the electrician requesting an up to date check. Daily refrigerator temperature checks are undertaken and cooked food is checked to ensure it is heated to the required temperatures. One window on an upstairs landing was broken and the registered proprietor confirmed that this had only occurred recently. The registered proprietor confirmed that the glass had been glued. However as the glass had sharp edges and posed a risk to residents an immediate requirement was issued to ensure that the window was made safe within 24 hours of the inspection. The hot water in two of the bathrooms is not regulated and when tested was found to be 57° centigrade. There is not a risk assessment regarding this. Some of the radiators in the home are not guarded and no risk assessment is available for this. The registered proprietor confirmed that the recommendation for risk assessments for safe working practices continues to be ongoing. Three Trees DS0000019764.V258471.R01.S.doc Version 5.0 Page 21 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 3 3 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 3 1 3 1 X Standard No 24 25 26 27 28 29 30 STAFFING Score 1 X X X X X 3 LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 Standard No 31 32 33 34 35 36 Score X 3 X 3 2 X CONDUCT AND MANAGEMENT OF THE HOME 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Three Trees Score 3 2 1 X Standard No 37 38 39 40 41 42 43 Score 3 X 3 X X 1 X DS0000019764.V258471.R01.S.doc Version 5.0 Page 22 No Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard YA7YA9 Regulation 13 (4) & Schedule 3 13(2) Requirement The registered person must ensure that risk assessments are in place to support residents in any activities they undertake. The registered person must ensure that daily refrigerator temperature checks are taken and records kept. The registered person must ensure that staff have undertaken accredited medication training. The registered person must ensure that the windows in the home pose no risk to the health and safety of residents, staff or visitors to the home. The registered person must ensure the regular maintenance of the fire detection equipment. The registered person must ensure risk assessments are in place for the hot water in the home. The registered person must ensure that the electrical systems within the home meet the appropriate requirements. The registered person must ensure risk assessments for safe DS0000019764.V258471.R01.S.doc Timescale for action 30/11/05 2 YA20 30/10/05 3 YA20 18 30/11/05 4 YA24YA42 13 (4(a)) & 23 12/10/05 5 6 YA42 YA42 23 23 30/10/05 30/10/05 7 YA42 23 30/10/05 8 YA42 23 30/10/05 Three Trees Version 5.0 Page 23 working practices in the home. 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 YA19 YA32 YA34 YA37 Good Practice Recommendations The registered person should ensure no communal recording. The home should continue with its training programme to ensure a minimum of 50 of the care staff have achieved their NVQ 2 by 2005. The registered provider should ensure that staff are employed to and provided with copies of the GSCC code of conduct. The registered manager should obtain a National Vocational Qualification level 4 in care and management by 2005. Three Trees DS0000019764.V258471.R01.S.doc Version 5.0 Page 24 Commission for Social Care Inspection Hessle Area Office First Floor, Unit 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. Extracts may not be used or reproduced without the express permission of CSCI Three Trees DS0000019764.V258471.R01.S.doc Version 5.0 Page 25 - 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. 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