Inspection on 01/03/06 for Tracey House

This inspection was carried out on 1st March 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Excellent. 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

Tracey House 06/07/09

Tracey House 27/06/07

Tracey House 17/05/05

Tracey House 09/11/04

Tracey House 04/05/04

Similar services:

The Vicarage

Fairfields Country Rest Home

7 Hyde Road

5 Seafield Road

Queensmount

Poldhu

Trevaylor Manor

Didsbury Court Rest Home

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

CARE HOMES FOR OLDER PEOPLE Tracey House Haytor Road Bovey Tracey Newton Abbot Devon TQ13 9LE Lead Inspector Megan Walker Unannounced Inspection 1st March 2006 11:30 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 Tracey House DS0000003846.V285397.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. Tracey House DS0000003846.V285397.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Tracey House Address Haytor Road Bovey Tracey Newton Abbot Devon TQ13 9LE 01626 833281 01626 833070 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 R J Cooksey Mrs C M Cooksey, Dr J T Zakrzewski, Mrs J T Zakrzewski Care Home 24 Category(ies) of Old age, not falling within any other category registration, with number (24), Physical disability over 65 years of age of places (24) Tracey House DS0000003846.V285397.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: None Date of last inspection 17th May 2005 Brief Description of the Service: Tracey House is a privately owned registered care home for twenty-three frail, older people who may have additionally a degree of physical disability, in the categories of OP and PD(E). The owners live on site and work as part of the staff team. The ground floor has a large sun lounge, a dining room and a small elegant lounge. Four ground floor bedrooms have their own sun lounge, and six have a patio door. Altogether there are 22 bedrooms, one being large enough to accommodate a couple. All but three upstairs bedrooms can be accessed via a passenger lift or stair lift. Most bedrooms have en-suite facilities, 18 of which include a shower, and all enjoy attractive views. There are two bathrooms with hoists, one on each floor. The house is situated about a mile from the centre of Bovey Tracey and has two and a half acres of attractive grounds with far reaching views of the surrounding countryside. There are level paths around the beautiful garden, with benches and seats at many vantage points. There are flowering shrubs, fruit trees and a productive vegetable garden. The home is not registered to provide nursing care and it does not offer intermediate care. Tracey House DS0000003846.V285397.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place between 11h30 and 15h45 on Wednesday 2nd March 2006. The Registered Provider and Manager, Mrs Jo Zakrzewski, was present at the time of this inspection and part of the time was spent talking with her about the running of the home. Part of the inspection was divided between observing and talking to other staff, residents living in the home, and people attending for day care. Four people spoken to offered an opinion about the home and its provision of care, and two staff members about working in the home. Individual Care Plans and staff records were looked at, and there was a brief tour of the inside of the premises. The Commission for Social Care Inspection has introduced key standards to be inspected over each inspection year. Therefore, unless it is felt necessary by the inspector, some standards will not be inspected. To obtain a full picture of the home it is recommended that previous reports also be taken into consideration. What the service does well: What has improved since the last inspection? The Registered Providers have begun a programme of installing radiator covers and at the time of this inspection fourteen had been completed in order of priority according to individual risk assessments. Since the last inspection Mathias Foundling, Pharmacist Inspector, has spent time at the home reviewing the medication system and policies. Subsequently action to implement his advice has been taken by Mrs Zakrzewski. There are further plans to improve the current storage of medication and it is hoped that this will ease the existing practice for medication handling and administration. Tracey House DS0000003846.V285397.R01.S.doc Version 5.1 Page 6 Lockable storage for medication has been provided in all the bedrooms so that it is available should the occupant choose to self-medicate. Risk assessments have been completed for the installation of hot water valves on all the showers. At the time of this inspection the two showers awaiting fail-safe valves to be fitted were not in use and had warning notices in place prohibiting use. Mrs Zakrzewski stated that these would be fitted elsewhere if/as required according to risk and/or personal wishes of individual residents, or when the bedroom becomes vacant. A thumbnail style lock has been fitted in the Visitor’s toilet. What they could do better: 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. Tracey House DS0000003846.V285397.R01.S.doc Version 5.1 Page 7 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 Tracey House DS0000003846.V285397.R01.S.doc Version 5.1 Page 8 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): These standards were inspected at the previous inspection. EVIDENCE: Tracey House DS0000003846.V285397.R01.S.doc Version 5.1 Page 9 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): 9, 11 The home’s medication policy and procedures have improved to the benefit of residents. Residents can feel reassured that their last wishes, as far as it is practicable, will be met. EVIDENCE: Since the last inspection Mathias Foundling, Pharmacist Inspector, has spent time at the home reviewing the medication system and policies. Subsequently action to implement his advice has been taken by Mrs Zakrzewski. There are further plans to improve the current storage of medication and it is hoped that this will ease the existing practice for medication handling and administration. One resident was observed taking responsibility for her own medication. She confidently explained her understanding of what medication she was taking and why it was necessary. A fixed lockable storage cabinet holding all her medication was seen in her bedroom. Individual Care Plans inspected showed a section titled “Special Instructions in Event of Death”. There was clear documentation of the individual’s preferences including instructions about funeral directors and in one instance a “Living Will”. Mrs Zakrzewski stated that if for any reason staff could not obtain this information directly from an individual, families or a representative acting on behalf of that person (e.g. solicitor) would be consulted. Tracey House DS0000003846.V285397.R01.S.doc Version 5.1 Page 10 At the time of this inspection all the residents were white and British-born. The majority were of a Christian faith, either Catholic or Protestant although there was a small percentage of non-believers. Mrs Zakrzewski confirmed that should the home be approached by anyone of another faith or culture, all their needs including their religious and cultural needs would be taken into account at the time of pre-assessment, and that should there be anyone living at the home of another faith, prior to death, guidance would be sought to ensure that appropriate religious practice and rituals were met. Tracey House DS0000003846.V285397.R01.S.doc Version 5.1 Page 11 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): These standards were inspected at the previous inspection. EVIDENCE: Tracey House DS0000003846.V285397.R01.S.doc Version 5.1 Page 12 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): 17, 18 Residents’ legal rights are protected. Residents are protected from abuse although more training is required for all staff to ensure that they are aware of all the issues relating to adult protection. EVIDENCE: All the residents are on the electoral register. Mrs Zakrzewski confirmed that the majority choose to vote by post and are encouraged and enabled to do so at election times. Mrs Zakrzewski stated that over 50 of staff at Tracey House have received training from Teignbridge Social Services in the protection of vulnerable adults, and that the rest of the staff would attend this training course when it became available. A random selection of staff files were inspected and there was no record that these staff had attended any Adult Protection training. It was discussed during the inspection about the possibility of Mrs Zakrzewski introducing an In-House training session using the “No Secrets” documentation and video provided by the local authority to ensure that all staff had a base knowledge of adult protection issues, including abuse by neglect. Tracey House DS0000003846.V285397.R01.S.doc Version 5.1 Page 13 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, 24, 25, 26 Environmental hazards have been identified that could cause a potential risk of harm to residents and/or staff. EVIDENCE: As part of a business plan, the Registered Providers have risk assessed all the radiators in residents’ bedrooms in order to prioritise fitting radiator covers. At the time of this inspection fourteen had been completed. At the time of this inspection two radiators in the corridor near to the dining room were on and found to be hot to touch. Both were in prominent places where they could cause a potential risk to anyone tripping and falling against them, or anyone accidentally leaning against it as they waited to pass through into the dining room. Apparently at least one resident has stated that they do not want a cover on the radiator in their room. Mrs Zakrzewski agreed during this inspection that this would be formally recorded with a signature of agreement from the individual concerned on that person’s care plan. Tracey House DS0000003846.V285397.R01.S.doc Version 5.1 Page 14 Notices alerting individuals about hot water had been put on walls near every hot water outlet where a fail-safe device had not been fitted. The en-suite showers identified at the last inspection had all been risk assessed, and there are two valves remain to be fitted. Mrs Zakrzewski confirmed that these would be fitted as required according to risk assessments, and according to the home’s Action Plan of the previous inspection. During a tour of the premises a main corridor cupboard housing an electrical meter and consumer units was found unlocked. There was no signage indicting electrical hazard. Cleaning products were also found stored in this cupboard. A senior carer was informed that this cupboard must be kept locked and that it must not be used to store potentially flammable substances. This carer later confirmed that she had informed Mrs Zakrzewski about this. Also during the tour of the premises cleaning products were found on the bath side. The senior carer explained that this was for ease of use. It was explained that all chemical products must be kept in a locked cupboard although this cupboard could be in the bathroom. Locks have not been fitted to bedroom doors, or in en-suite facilities. As part of the Business Plan, Mrs Zakrzewski confirmed that locks would be fitted as rooms became vacant or if a resident requested a lock. She also stated that Tracey House was a home offering accommodation to older people who are still mentally competent and therefore would not go into someone else’s room unless invited. There was, however, no documentation on residents’ files to show if residents had been consulted about bedroom door/ensuite locks. Discussion with Mrs Zakrzewski about this prompted the possibility of a notice of consent stating personal preference and to be signed in confirmation, being given to each resident and then kept on their personal file. The lock on the Visitor’s Toilet has been changed since the last inspection so that it can be opened from the outside in the event of an emergency. The laundry procedure was discussed as at present clean laundry is removed from the tumble drier, folded and put into baskets for return to individuals simultaneously with soiled laundry being put into the washing machine. There was no apparent procedure to ensure that care staff do not change from one task to another without first taking adequate precautions to prevent crossinfection. It was agreed with Mrs Zakrzewski that she would review current practices although it is not currently practical for the clean laundry baskets to be stored elsewhere in the home. Tracey House DS0000003846.V285397.R01.S.doc Version 5.1 Page 15 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): 29, 30 The recruitment procedure is still not fully adhered to prior to appointment. Staff are trained to ensure that they are competent in doing their jobs. EVIDENCE: Inspection of staff files for staff employed since the last inspection found that one had only one reference although this person had already started working in the home. Mrs Zakrzewski was made aware of this at the time of this inspection and agreed to follow up a second reference. There was no contract of employment on this file however Mrs Zakrzewski has subsequently confirmed in writing to the Commission that the home’s current practice is to issue a contract after the probationary period when a decision has been made to offer permanent employment. All the staff files seen had CRB checks recorded. A random selection of staff files was inspected as well as discussion with Mrs Zakrzewski and a Senior Carer, Sharon Brown, about staff training. All completed training (including dates) was seen recorded on personal staff files. There was also a separate file holding certificates of training by members of staff. Ms Brown explained that in some instances only certain staff who express a particular interest and/or as part of an staff member’s Personal Development, will attend a course, for example, “Bereavement & Loss”; “Parkinson’s”; ”Falls Awareness”. The member(s) of staff use the staff meeting to feedback to other staff about the course and what they learnt from it. All night staff and the majority of day care staff have received training in “Handling and Administration of Medication”. New staff are due to take this Tracey House DS0000003846.V285397.R01.S.doc Version 5.1 Page 16 course on 9th March 2006. The home uses “Boots” The Chemist’s Medication Handling course as well as distance learning courses if they are available. Mrs Zakrzewski and the home’s cook, Kate Reece, at the time of this inspection were awaiting confirmation of a “Safer Food, Better Business” training session. All staff received Fire Safety training on 7th February 2006. For a number of reasons Mrs Zakrzewski is planning to hold this again as an In-house training session in the near future. Since the previous training session Ms Brown explained that all staff have been issued with a plan of the home that indicates all the fire extinguishers, glass breakpoints and fire exits. The home ‘s fire zones were seen to have been colour coded on a board next to the fire zone board. Ms brown explained that this was to enable staff “at a glance” to recognise and match residents’ rooms and zones. Other training seen on files included “Management of Continence”, “Safe Swallowing and Feeding”, “Manual Handling”, Hoist training, Food Hygiene and Hearing Aid training. Supervision records on individual staff files included a Training and Personal Development section. Some staff have received training in the protection of vulnerable adults and Mrs Zakrzewski confirmed that other staff would be attending a course with Teignbridge Social Services as soon as this became available. Tracey House DS0000003846.V285397.R01.S.doc Version 5.1 Page 17 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): 34, 36 The accounting and financial procedures of the home ensure that residents live in a well maintained and comfortable home. All staff are appropriately supervised. EVIDENCE: Mr George Zakrzewski has principle responsibility for the administration and accountancy of the home. Conversations with staff showed that they are kept aware by the home’s management team of any business plans and proposals for their implementation. It was evident from a tour of the premises that the home is well maintained and that issues such as a worn carpet are dealt with promptly to prevent further wear and tear, and potential accidents. The home has a valid insurance certificate including public liability cover. Inspection of a selection of staff files showed that all staff receive regular staff supervision and Mrs Zakrzewski confirmed that this is at least six times per Tracey House DS0000003846.V285397.R01.S.doc Version 5.1 Page 18 year, including an annual appraisal for all staff. Files seen also had supervision notes as a record of formal interview style supervision sessions. Alternate supervision sessions were recorded as a practical period when staff were supervised completing a particular task. There was a section for Personal Development and Training Needs, with a detailed record of any training completed by the individual documented on their personal file. Mrs Zakrzewski explained that although she doesn’t receive direct supervision or have mentor, she does maintain contact with other homeowners. She confirmed that this has been supportive in helping her to understand the Care Standards Act and meeting the National Minimum Standards. Mrs Zakrzewski also stated that she is a Christian and that this helps her in her work because she has the support of fellow Christians and their prayers. Tracey House DS0000003846.V285397.R01.S.doc Version 5.1 Page 19 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 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 X 8 X 9 3 10 X 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 X 14 X 15 X COMPLAINTS AND PROTECTION Standard No Score 16 X 17 3 18 3 2 X X X X 2 2 3 STAFFING Standard No Score 27 X 28 X 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X X X 3 X 4 X X Tracey House DS0000003846.V285397.R01.S.doc Version 5.1 Page 20 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 OP24 Regulation 12 Requirement Timescale for action 2. OP29 17 The Registered Provider must obtain locks for bedroom doors and en- suite facilities that are suitable for use by residents, and accessible by staff in emergencies. These locks must be fitted on the request of the occupant, or when a room is vacated and before it becomes 30/11/06 occupied again. Risk assessments and evidence of consultation with individual residents about having a lock fitted on their bedroom and/or en-suite doors must be kept on individual residents’ files if locks are not fitted. This requirement is outstanding from the previous inspection and the timescale extended. Staff records must include all documents required by Schedule 4 of the regulations. This requirement is 31/05/06 outstanding from the previous inspection and the timescale extended. Tracey House DS0000003846.V285397.R01.S.doc Version 5.1 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 OP19 Good Practice Recommendations The Registered Provider should continue as planned to ensure that all hot water outlets are fitted with fail-safe devices that prevent the hot water from coming out at above 43 degrees C. or risk assessments kept on individual residents’ files support a valve not being fitted, or the valve is fitted when the room becomes vacant. The Registered Provider should continue as planned to ensure that all radiators are covered or replaced with low surface temperature radiators, within a risk management framework. 2 OP25 Tracey House DS0000003846.V285397.R01.S.doc Version 5.1 Page 22 Commission for Social Care Inspection Ashburton Office Unit D1 Linhay Business Park Ashburton TQ13 7UP 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 Tracey House DS0000003846.V285397.R01.S.doc Version 5.1 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!