Inspection on 17/05/05 for Tracey House

This inspection was carried out on 17th May 2005.

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 01/03/06

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 TQ13 9LE Lead Inspector Stella Lindsay Announced 17 May 2005 th The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for 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 D54-D07 S3846 Tracey House V216057 170505 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Tracey House Address Haytor Road Bovey Tracey Newton Abbot Devon TQ13 9LE 01626 833281 01626 833070 cozak@btconnect.com Mr & Mrs Cooksey Dr & Mrs Zakrzewski Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Care Home 23 Category(ies) of OP, (23) registration, with number PD(E) (23) of places Tracey House D54-D07 S3846 Tracey House V216057 170505 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 9th November 2004 Brief Description of the Service: Tracey House is a privately owned registered care Home for twenty-three elderly frail residents 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 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 ground floor has a large sunny 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 accomodate a couple. All but three upstairs bedrooms can be accessed via a passenger lift or stair lift. Most bedrooms have ensuite facilities, 18 of which include a shower, and all enjoy attractive views. There are two bathrooms with hoists, one on each floor. Tracey House D54-D07 S3846 Tracey House V216057 170505 Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection took place between 10am and 5.30pm on a Tuesday in May 2005. It included a tour of the premises, an examination of care records, staff files, health and safety records, and the medication system. The pharmacy Inspector visited on 26th May 2005. As well as discussion with one of the Registered Providers, the inspector spoke with eleven residents and two staff, and thanks all for their time. Seven residents and one relative returned comment cards to the Commission for Social Care Inspection, and their contributions are represented in the report. What the service does well: What has improved since the last inspection? Residents were delighted with the new gardening club. They appreciate the effort made by staff to make it work. Eight showers have been replaced, to include thermostatic controls which will avoid any risk of a resident being scalded. Tracey House D54-D07 S3846 Tracey House V216057 170505 Stage 4.doc Version 1.30 Page 6 The Registered Manager considers that staff are recognising and responding to individual requests more, and this was seen to be happening during the inspection. The management are commended for encouraging this. 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 D54-D07 S3846 Tracey House V216057 170505 Stage 4.doc Version 1.30 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 Standards Statutory Requirements Identified During the Inspection Tracey House D54-D07 S3846 Tracey House V216057 170505 Stage 4.doc Version 1.30 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 standard(s) 1,3, &5 Tracey House has produced a good range of information to ensure that potential new residents can make an informed decision about admission to the home. Admissions are carefully considered, to ensure that care needs can be met. EVIDENCE: Tracey House provides a Statement of Purpose which provides all the information required by this standard, clearly written, with colour photographs. Testimonials from residents and relatives are included. A sample contract of residence is given. An Admissions Book is kept, with the application forms from potential residents, often long before they actually need residential care. Individuals and families visit, and some have been known to the home through village and Church connections. Usually people have attended for day care or stayed for one or more respite periods before deciding to move in. Emergency admissions are unlikely, because of the interest in any vacancy by people already known to the service. Tracey House D54-D07 S3846 Tracey House V216057 170505 Stage 4.doc Version 1.30 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 standard(s) 7,8,9,10 Very high standards of personal care are maintained. Health care is obtained promptly when needed. The system for handling, administering and security of some medicines was inadequate. EVIDENCE: Residents confirmed that staff are ‘pretty quick to come and help’, and that they check frequently at night if anyone is ill. Residents who responded to the home’s own questionnaire all said that they considered their care to be ‘excellent’. All residents have care plans, which they have signed, showing their agreement. They are drawn up on admission from the assessment that has been made of the person’s needs, covering medical history, any communication problems, and personal care needed. They are up-dated each month by a senior member of the team. There are records of health care attention, including efforts by management to speed up treatment, and help residents get treatment to which they are entitled. Records by care staff are not made every day, but when there is something to be recorded. This is appropriate, as some residents at Tracey House remain independent. Client Handling Assessment forms are completed, residents’ property is listed, Tracey House D54-D07 S3846 Tracey House V216057 170505 Stage 4.doc Version 1.30 Page 10 and recreational activity risk assessments are completed where necessary. The Pharmacist Inspector found named medicine pots prepared in advance, and administration pre-signed on the Medication Administration Record (MAR) chart. Another member of staff administered the medicines from the preprepared named pots to the residents at a later date or time. The Managers were informed that secondary dispensing is unacceptable, and posed a potential risk of harm to residents. The Managers were informed that medication must never be removed from the original container supplied by the pharmacist until the time of administration. The best way of administering medicines to a resident is directly from the dispensed container and transferred to a medicine pot as a way of hygienically handing it to the resident, one at a time. The person administering the medicine must sign the MAR chart immediately after the medicine has been given. The written policy did not have details of the supplying pharmacy, out-of – hours pharmacy, GPs, ordering of prescriptions, or safe procedures for handling and administering medicines. A cupboard containing pre-prepared named pots and other medicines was not secure. Several medicines were found out of date in the cupboard. Tracey House D54-D07 S3846 Tracey House V216057 170505 Stage 4.doc Version 1.30 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 standard(s) 12,13,14,15 There is a very good range of activities on offer, and residents’ enthusiasms are encouraged. The meals are very good, with an emphasis on fresh fruit and vegetables. EVIDENCE: Assistance is given to residents to get up and go to bed when they want. Laundry is delivered the following morning, as night staff sort and iron clothes. Some residents like to help with laying tables or sewing on name tapes. Residents and staff were pleased to talk about the range of activities that are enjoyed. People are delighted with the Gardening Club that has just started. Old favourites are the Exercise Club and the Video Club. A sewing group has been started to bring together the work of all the knitters. A music evening is held weekly, after supper. ‘Songs of Praise’ is taped, so that people can watch it after supper. On Fridays, all who wish to go are given a lift into Bovey Tracey, and make their own way around the town, and all meet up for a coffee and a lift home. Some residents are able to go for walks unaccompanied. One said it is important to them to have the afternoons to themselves, and that at Tracey house they can ‘live as we want to live’. Communion services are provided by local Churches, with sometimes more than half the residents attending. One of the Registered Providers leads a monthly prayer group. Tracey House is not specifically a faith-based Home, but residents felt comfortable in talking about their faith and their Church Tracey House D54-D07 S3846 Tracey House V216057 170505 Stage 4.doc Version 1.30 Page 12 connections. Residents said that they could look at the Menu board in the dining room, and ask for something different. On the day of the inspection gammon with parsley sauce was served for lunch, and was very well received. One resident had a vegetarian alternative. Roast potatoes and three vegetables were served – including broccoli from the garden. Residents said that there is always plenty of fresh fruit and vegetables, and a fruit salad is available every day. Comments that were not complimentary came from two residents who felt there were too many vegetable dishes. The cook came to the dining room to serve the desserts, and to gather feedback from the residents. Residents commented on the quality and variety of the meals. Residents who have any difficulty with eating are given their meals in the privacy of the small lounge, to maintain their dignity and the comfort of others. Tracey House D54-D07 S3846 Tracey House V216057 170505 Stage 4.doc Version 1.30 Page 13 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 standard(s) 16 Tracey House has a satisfactory complaints procedure, and evidence that residents feel their views are listened to and acted upon. EVIDENCE: The Complaints Procedure is distributed with the Statement of Purpose. Residents said that they are always taken seriously, and any problems sorted out quickly. The Registered Provider has produced forms for recording formal complaints, but has not received any. The Commission for Social Care Inspection has not received any complaints about Tracey House. Some residents spoken to did not know about a complaints procedure, but were not bothered, because they felt they could ask for anything. Tracey House D54-D07 S3846 Tracey House V216057 170505 Stage 4.doc Version 1.30 Page 14 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 standard(s) 19,20,21,22,23,24,25,26 Tracey House is well suited for accommodating physically frail people. Some environmental requirements are still outstanding, causing a potential risk of harm to residents, and the Registered Providers are working towards meeting them. EVIDENCE: There is easy access around the house, with a shaft lift reaching part of the upper floor, and a stair lift reaching the other section. Three bedrooms are reached by a separate flight of stairs. There are several external doors with slight lips but no step, from the lounges and residents’ own bedrooms, encouraging people to get out into the garden. The garden paths are paved, making them smooth but not slippery. The large lounge is divided into three sections by pillars and furniture, to give choice of seating areas, while being available for large gatherings or entertainments. It has windows in every direction. The small lounge was described by the people sitting in it as ‘a lovely little lounge – homely’. There are two bathrooms, both with hoists. Eighteen of the bedrooms have an Tracey House D54-D07 S3846 Tracey House V216057 170505 Stage 4.doc Version 1.30 Page 15 en suite shower, while another has a shower room adjacent. One communal toilet had a bolt which could not be opened by staff in an emergency. Call bells have been fitted in en suite toilets according to risk assessment. The bedrooms range in size from 10.1sq.metres to 25.9sq.metres. Some have their own sun lounge while all have pleasant views. The Registered Providers will entirely furnish the room or clear it to make space for the residents’ own belongings, giving the occupant choice over what they bring. Locks for bedroom doors, suited to the occupant and accessible by staff in an emergency are still required, to enhance privacy and security. The Registered Providers have fitted thermostatic valves to both the baths and all the showers which are in use, to avoid risk of scalding. Still required are covers for radiators, to prevent risk of harm to residents. The laundry is a busy area. The Registered Providers need to revise their procedures to ensure no possibility of contamination between clean and soiled laundry. The home was very clean and sweet-smelling throughout. Tracey House D54-D07 S3846 Tracey House V216057 170505 Stage 4.doc Version 1.30 Page 16 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27,28,29 There are sufficient staff to meet the individual needs of residents, and they are competent and caring. There is a sound procedure for recruiting staff, but it was found not to be fully implemented. EVIDENCE: A rota is kept, which shows that three care staff are employed in the mornings, except Sunday, two in the afternoons, and one at night. The work of the Registered Providers, who live on-site, combines to make this an effective workforce. They are sometimes included as part of the workforce on the rota. One or two cleaners are also on duty each weekday. Young people aged 15/16 are employed to help at tea-time. Residents said they enjoy having the young people working in the home. Of the 17 care staff employed, seven have achieved NVQ 2 and/or 3 or equivalent, and two more are working towards this. This is good progress, and working towards the 50 required by this standard. There is a sound recruitment procedure. References are CRB clearances are requested. Staff files were examined, and one was found to be missing references and proof of identity. Staff records must be complete, to maximise the protection of residents. Tracey House D54-D07 S3846 Tracey House V216057 170505 Stage 4.doc Version 1.30 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31,32,33,38 The management of this home is very effective in maintaining an excellent service, and in supporting the staff and enabling them to contribute to the development of the home. EVIDENCE: All four owners contribute to the running of the home, and are competent and experienced, with a variety of qualifications. One is a State Registered Nurse. The main manager of care is a qualified physiotherapist. She has the City & Guilds Advanced Care Management certificate and has completed two units of the Registered Managers’ Award. The ‘Investors in People’ award was first gained in April 2000, and has been reviewed and recognition maintained in November 2004. This confirms the continuing development of the systems in the home for communication, training, and enabling staff to come forward with suggestions for improving practices throughout the home. Staff said they were pleased with the support and encouragement they get from managers. Tracey House D54-D07 S3846 Tracey House V216057 170505 Stage 4.doc Version 1.30 Page 18 Feedback has been gathered from residents and their relatives. One resident said that any comment they had made had been carefully listened to. Safe systems of work are in place, and where environmental requirements have been made, a timetable to meet them has been produced. Tracey House D54-D07 S3846 Tracey House V216057 170505 Stage 4.doc Version 1.30 Page 19 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score 4 x x x x x HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 x 14 x 15 x COMPLAINTS AND PROTECTION 3 4 3 2 4 2 2 2 STAFFING Standard No Score 27 3 28 3 29 2 30 x MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x x 3 4 4 x x x x 3 Tracey House D54-D07 S3846 Tracey House V216057 170505 Stage 4.doc Version 1.30 Page 20 Yes Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP19 Regulation 13 Requirement The Registered Provider must ensure that all showers are fitted with fail safe devices that prevent the hot water from coming out at above 43 degrees C. (previous date set at 30/10/04) The Registered Provider must obtain a set of locks for bedroom doors which are suitable for use by residents, and accessible by staff in emergencies, and fit the lock on the request of the occupant, or when a room is vacated. The Registered Provider must ensure that all radiators are covered or replaced with low surface temperature radiators, within a risk management framework. The Registered Providers must review the medication policy to ensure it is applicable to this home, and covers the procedures required. Medication must be directly administered from the original dispensed labelled container, and the MAR chart must be signed immediately after administration. Timescale for action 30/03/06 2. OP24 12 30/03/06 3. OP25 13 31/10/05 4. OP9 13.2 04/07/05 5. OP9 13.2 17.1(a) Schedule 3 28/06/05 Tracey House D54-D07 S3846 Tracey House V216057 170505 Stage 4.doc Version 1.30 Page 21 6. OP9 13.2 7. 8. 9. OP9 OP26 OP29 13.2 13 17 The Registered Providers must order the prescriptions from the surgery, referenced back to the original repeat prescription, and keep a copy or reference to the original prescription on the premises. Lockable storage must be provided for all medicines. All toilets used by residents must have locks which are accessible by staff in an emergency. Staff records must include all documents required by Schedule 4 of the regulations. 04/07/05 28/06/05 31/10/05 31/10/05 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. Refer to Standard OP9 OP26 Good Practice Recommendations The Home should obtain Patient Information leaflets to be kept in one file for the provision of up-to -date information on medicines. The Registered Provider should produce a procedure for the laundry to ensure that no contamination occurs between clean and soiled laundry. Tracey House D54-D07 S3846 Tracey House V216057 170505 Stage 4.doc Version 1.30 Page 22 Commission for Social Care Inspection 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. 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