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Inspection on 19/09/07 for Tracey Vale Residential Home

Also see our care home review for Tracey Vale Residential Home for more information

This inspection was carried out on 19th September 2007.

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.

What follows are excerpts from this inspection report. For more information read the full report on the next tab.

What the care home does well

What has improved since the last inspection?

What the care home could do better:

CARE HOMES FOR OLDER PEOPLE Tracey Vale Residential Home Brimley Vale Bovey Tracey Newton Abbot Devon TQ13 9DA Lead Inspector Graham Thomas Unannounced Inspection 19th September 2007 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 Tracey Vale Residential Home DS0000032549.V347025.R01.S.doc Version 5.2 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 Vale Residential Home DS0000032549.V347025.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Tracey Vale Residential Home Address Brimley Vale Bovey Tracey Newton Abbot Devon TQ13 9DA 01626 833066 01626 833567 tony.rooks@devon.gov.uk http/www.devon.gov.uk/adoption.htm Devon County Council 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) Anthony James Rooke (Not now working in this home) Care Home 35 Category(ies) of Dementia - over 65 years of age (10), Mental registration, with number Disorder, excluding learning disability or of places dementia - over 65 years of age (10), Old age, not falling within any other category (35), Physical disability (6), Physical disability over 65 years of age (6) Tracey Vale Residential Home DS0000032549.V347025.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. Service Users who require adaptations or equipment such as hoists or wheelchairs, or who require care from more than one care assistant, shall be accommodated in rooms 7, 10, 18, 21 & 22 only. Service Users in the PD category must be over 55 years of age. Date of last inspection 5th September 2006 Brief Description of the Service: Tracey Vale Residential Home is owned and managed by Devon County Council and is registered to accommodate people who fall into the registration categories of Old Age, Dementia (over 65 years of age), Mental Disorder, excluding learning disability (over 65 years of age) and Physical Disability (over 55 years of age). The home provides long-term, short term and respite and has a re-enabling unit that provides intermediate care for a maximum of six people. The home is situated in a quiet residential area in Brimley, which is on the outskirts of Bovey Tracey. Some local facilities, including a shop, are within a short walking distance and town centre is approximately half a mile away. Information about the service is available in a Statement of Purpose and a Service Users Guide. Tracey Vale Residential Home DS0000032549.V347025.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. Before the inspection we sent an Annual Quality Assurance Assessment (AQAA) form which the manager completed and returned. This is the service’s own self-assessment. We visited the home on 19th and 20th September and spoke individually with five people living in the home and others in small groups. Four staff were interviewed including an Assistant Manager. We also spoke with a visiting Community Nurse and a relative. A number of records were examined including eight care plans, five staff files and other documents concerning the running of the home. After the Inspection we wrote to Devon County Council’s Responsible Individual about the radiators and heating in the home. What the service does well: What has improved since the last inspection? What they could do better: • Records about individual residents are not complete or well maintained. This means that some important needs may not be met. • The activities programme needs to be improved, particularly for people who are less able. • More staff need to be trained in safeguarding vulnerable people from abuse. Tracey Vale Residential Home DS0000032549.V347025.R01.S.doc Version 5.2 Page 6 • The home is not sufficiently warm and people have no control over heating in their own rooms. • Better arrangements are needed to make sure that good standards of cleanliness are maintained in the home. • Some parts of the home require redecorating and re-furnishing. • People should be offered keys to their rooms and have lockable storage to keep their possessions safe. • There is not yet a registered manager. This is a legal requirement. • Some serious accidents are not reported to the Commission. This is a legal requirement. It is important so that any patterns can be monitored and appropriate action taken. 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. The summary of this inspection report can be made available in other formats on request. Tracey Vale Residential Home DS0000032549.V347025.R01.S.doc Version 5.2 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 Vale Residential Home DS0000032549.V347025.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 1, 3 and 6 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. New residents can be confident that the ability of the home to meet their needs will be considered before admission. The Re-enablement Unit provides a valuable service to people who need help to regain their independence. EVIDENCE: The service users’ guide states that the first four to six weeks following a longterm admission will be on a trial basis so this gives both the service user and the home the opportunity to ensure that the service is suitable before making a long-term commitment. In addition to offering long-term care Tracey Vale offers short-term and respite care and has a self contained ‘Enablement Unit’ which provides intermediate care for up to six people. Tracey Vale Residential Home DS0000032549.V347025.R01.S.doc Version 5.2 Page 9 In the self-assessment that the manager returned to us, she stated that before any admission the team discusses the referral notes and professional reports. This allows them to assess the person’s needs and whether the home can meet them. She referred to a planned admission process for those on longer stays at the home. It was stated that there was a comprehensive service users’ guide and plans based on the individual needs of the person. Links with the local hospital and related professionals were said to ensure continuity for people receiving intermediate care. It was confirmed during this visit that there was a service users’ guide providing information to people moving into the service. However, not everyone who had recently moved in had received a copy. One such person told us that on arrival staff had spent time telling him about the service. However, there was no written information to which he could refer as a reminder or to answer queries. This was also confirmed by a visiting relative. An inspection of assessments and care plans for people using the intermediate service provided evidence of input from an Occupational Therapist and a Physiotherapist. Tracey Vale Residential Home DS0000032549.V347025.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 7, 8, 9 and 10 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. People living at Tracey Vale receive a generally satisfactory standard of health and personal care. However, recording practice is currently poor and may place people at risk. EVIDENCE: The assistant manager with whom we spoke stated that there was an ongoing exercise to improve the structure and content of individual files and care plans. This included all information being integrated into single, individual files and staff being encouraged to use these as a point of reference. At the time of this inspection visit individual information was held in various locations and was sometimes duplicated. Examination of recording in the files demonstrated that these were not yet being used by staff as a working document. Some plans were not signed by the individuals concerned or their representatives. Recording in the files generally was inconsistent and piecemeal. Some files lacked the basic details required by regulation such as a photograph and details of the person’s GP. Tracey Vale Residential Home DS0000032549.V347025.R01.S.doc Version 5.2 Page 11 We examined eight individual files. These files contained clear contracts and service agreements concerning, for example, laundry arrangements. Four files contained no plan, though there were assessments that had been regularly reviewed. The risk assessments in four plans had not been completed and there was incomplete information about risks in another two. Information was held in the files about individual interests and activities though this was not consistently completed. Some files contained health records concerning, for example, weight and fluid monitoring and records of visits from health professionals. However, these did not always correspond with records made in the daily notes. For instance, in one file, the daily notes showed that a District Nurse had visited the person. There was no record of this in the medical visits section of the file. The daily notes in another file referred to a potentially serious physical symptom which required a professional referral. Poor recording made it very difficult for us to follow what had happened about this. We asked the assistant manager for further information. After investigating the issue, she confirmed that it had not been followed up and no referral had been made. Fortunately, there had been no adverse outcome for the person. We discussed health monitoring with a visiting Community Nurse. She stated that in her experience the home had always reported any issues promptly and complied with any prescribed or recommended treatments. People with whom we spoke felt that their healthcare needs were met and that they could see a doctor when needed. One person mentioned recent routine and specialist healthcare appointments which she had been supported to attend. We observed that people appeared clean, well groomed and cared for. People with whom we spoke stated that they were generally satisfied with the personal care and support they received and spoke well of the staff. However, several people mentioned the home’s continued reliance on agency staff. They pointed to inconsistencies and omissions in their personal support which might have resulted from this. One example given was an evening drink which was promised but never arrived. We examined the home’s system for administering medicines. There have been significant improvements in this area since the last key inspection. All medicines were securely stored. There was separate refrigerated storage for those medicines that needed to be kept cool. Additional security was in place for controlled drugs. Risk assessments had been completed for those people who were administering their own medicines. Records concerning medicines administered by staff were sampled. These were found to be up to date and in good order. Some minor recording issues were discussed with the senior carer. We observed medicines being administered at Tracey Vale Residential Home DS0000032549.V347025.R01.S.doc Version 5.2 Page 12 lunch time. This was carried out in accordance with current good practice guidance. Each person has a single bedroom and all of the bedroom and bathroom doors are lockable. This enables personal care and care provided by healthcare professionals to be carried out in private. During the inspection visit staff were seen to be treating residents with respect and using their preferred forms of address. Tracey Vale Residential Home DS0000032549.V347025.R01.S.doc Version 5.2 Page 13 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 12 to 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People living at Tracey Vale are encouraged to maintain their independence and helped to keep in touch with those close to them. The range of activities could be improved, particularly for those who are less independent. EVIDENCE: We discussed social activities with people living in the home and with staff. We also examined records concerning activities. Our discussions confirmed that there various activities were taking place. One person referred to a skittles match and occasional trips to places such as a local garden centre and castle. A staff member spoke of organising a group trip to a nearby steam railway. Television is provided in the lounges and some of the residents have their own televisions. However, the range of daily activities was limited, particularly for those with cognitive impairments such as dementia. The assistant manager agreed that this needed to be extended. Daily routines appeared to be sufficiently flexible to accommodate individual needs and expectations. For example, breakfast is served at any time during an extended period. This can be taken in the dining room or in individual rooms according to individual choice. During the inspection visit, people were Tracey Vale Residential Home DS0000032549.V347025.R01.S.doc Version 5.2 Page 14 spending time in their own rooms or in the homes lounges pursuing their own interests or socialising. The home’s service users’ guide contains information on the visiting arrangements. People living at Tracey Vale confirmed that visitors are welcome at any time and that they may offer them refreshments and/or a meal if they choose to do so. A payphone is available in a small private lounge so that the people living in the home can make or receive calls in comfort and privacy. Some people also have their own individual phones. People were being encouraged to maintain their autonomy in such matters as managing their own medication. Most people who needed help to manage their personal finances were helped by their families. An employee of the County Council does act as appointee when required. Small sums of personal spending money are held in a joint account for some of the residents. Records of individual transactions are recorded and individual interest is calculated and accredited to individual residents. We examined mealtime arrangements and discussed these with people living in the home and the kitchen staff. We also examined menus and observed a lunch-time meal. People were generally satisfied with the food supplied and confirmed that choices were offered regularly. One person confirmed that her particular dietary requirements were accommodated by the home. Menus showed a varied and wholesome diet. Inspection of the kitchen and food stores showed a plentiful supply of fresh, frozen and other ingredients. We observed a lunchtime meal taken in one of the home’s dining rooms. This was taken in a friendly and convivial atmosphere. Staff offered assistance where this was required. Tracey Vale Residential Home DS0000032549.V347025.R01.S.doc Version 5.2 Page 15 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 16 and 18 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. People living at Tracey Vale can feel confident that staff will listen to and act upon what they say. However, the high proportion of staff not trained in safeguarding vulnerable people from abuse may pose some potential risk to people living in the home. EVIDENCE: The home uses Devon County Council’s corporate complaints procedure. Details of this are described in the service users’ guide. This had not been received by one person who had recently moved in, or their relative. Three complaints had been received , one of which was upheld. A record was seen which indicated that complaints were being dealt with in accordance with the policy. People with whom we spoke felt that staff listened to them and generally acted upon what they said. Meetings are held for people living at the home at which they can discuss any concerns. Minutes of a recent meeting were seen during the inspection visit. There were robust procedures in place concerning safeguarding vulnerable people from abuse. Staff with whom we spoke were clear about the action they might take in the event of suspected or actual abuse. Thirteen of the twenty six staff had received training in safeguarding vulnerable people. This remains the same proportion as identified at the last inspection. Tracey Vale Residential Home DS0000032549.V347025.R01.S.doc Version 5.2 Page 16 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 19, 24, 25 and 26. Quality in this outcome area is poor This judgement has been made using available evidence including a visit to this service. The home is not sufficiently warm for people who live there. Some areas of the home appear unacceptably shabby and in need of refurbishment. The cleaning arrangements at the time of the visit were not sufficient to ensure the comfort and health of people living in the home. EVIDENCE: Tracey Vale was purpose built in the 1960s. Accommodation is arranged over two floors. Stairways and a shaft lift provide access between the floors. On the first floor there are eighteen individual rooms, two lounges, a kitchenette and dining area. There are also four toilets, an assisted bath a staff room and a sluice room. On the ground floor there are a further seventeen individual rooms. These are divided so that there is separate accommodation for people receiving intermediate care. This includes its own dining and lounge space. Tracey Vale Residential Home DS0000032549.V347025.R01.S.doc Version 5.2 Page 17 The kitchen and food stores are sited on the ground floor. Next to the kitchen there is a dining area and small conservatory. This is in addition to a further lounge area and a small telephone lounge. There are four toilets on this floor as well as assisted bathing facilities, a shower room, laundry and staff offices. Some individual rooms are small though this is compensated by abundant communal space. Individual rooms were sufficiently comfortable and homely and contained wash hand basins. Fresh towels had been supplied. Portable call bells were provided in each room. Those living at the home for a longer period had personalised their rooms with numerous possessions, family photographs and ornaments. Windows were restricted and the hot water temperature at hand basins was regulated to prevent scalds. Two people told us that they had never had keys to their rooms and were unaware that they could have one. Not all the rooms had lockable storage. One person expressed concern about the security of personal possessions. Three people living at the home and a visitor remarked that the home was cold. Minutes of a residents’ meeting also showed that this issue had been raised. Radiators in individual rooms could not be individually controlled. Requirements concerning the individual control of radiators have been made repeatedly since 2005. Following the inspection visit, we wrote to Devon County Council’s Responsible Individual to find out the Council’s intention regarding this matter. We were assured that this had been made a priority and that a contractor had been commissioned to conduct the necessary work. Lounge areas were homely and comfortably furnished. However, many areas of the home were in need of redecoration and refurbishment. This was particularly evident in corridors where the décor was shabby. Some individual rooms had recently been redecorated. One was in the process of redecoration during the visit. The kitchenette on the first floor was in poor condition. Laminate had broken away from the edges of work surfaces and a door was missing from a lower cupboard. The floor in the adjacent dining area was due for replacement. Carpet in the corridor outside the ground floor kitchen was very grubby. Dining furniture in the home was of an institutional rather than homely nature. In the information provided by the home before the visit, it was stated that there were plans to address these issues. Various aids and adaptations were seen around the home. These included, for example, toilet frames and raised seats, mobile hoists and walking frames. At the time of this inspection visit the home had recently lost the services of two cleaning staff. The assistant manager stated that recruitment of new cleaning staff had been problematic. Care staff were covering this work at the time of the visit. As a consequence some areas such as toilets were found not to be sufficiently clean and hygienic throughout the inspection visit. Bins in various individual rooms were also in need of emptying. Tracey Vale Residential Home DS0000032549.V347025.R01.S.doc Version 5.2 Page 18 The large laundry room had cleanable walls and washable floors. There were sluicing facilities, two washing machines and two tumble dryers. The washing machines had programmes for foul or infected laundry. Tracey Vale Residential Home DS0000032549.V347025.R01.S.doc Version 5.2 Page 19 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 27 to 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People living at Tracey Vale are well protected by the home’s recruitment practices. There are sufficient trained and qualified staff to meet individual needs. However, reliance on agency staff does sometimes adversely affect the continuity of care. EVIDENCE: Discussion with the manager and examination of the rotas confirmed that between 7:45am and 10:00pm there are usually six staff on duty. In addition the home had two cooks and a maintenance person for 30 hours per week. Although there was funding for two domestic staff there were none at the time of this visit. The manager stated that there had been some difficulty in replacing these staff. During the visit, people living at Tracey Vale appeared clean, well groomed and mostly satisfied with the service they were receiving. This suggested that the levels of care staffing were adequate. In conversation, people commented positively on the staff and stated that they were helpful and supportive. However, several people mentioned the home’s continued reliance on agency staff and found the continual changes in staff unsettling. Examination of the staff files and interviews with staff confirmed that the recruitment procedure includes the necessary checks to ensure the safety of Tracey Vale Residential Home DS0000032549.V347025.R01.S.doc Version 5.2 Page 20 people living in the home. These included taking up references, confirming the person’s employment history and criminal records checks. More recently recruited staff were able to confirm that there was a structured induction process and training. Of the 26 care staff, 18 have a National Vocational Qualification in care at level 2 or above. Records and discussion with staff confirmed that structured induction training was in place. Other training was discussed with the assistant manager. It was evident from staff records and this discussion that there were gaps in staff training in areas relevant to people’s needs. In particular, gaps were identified with regard to dementia, incontinence and safeguarding vulnerable adults. However, a structured system had been put in place to identify these shortfalls so that they could be addressed. Tracey Vale Residential Home DS0000032549.V347025.R01.S.doc Version 5.2 Page 21 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 31, 33, 35, 37 and 38. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. People living at Tracey Vale can feel confident that the new management team is working towards positive improvements in the home. However, urgent attention is needed in some areas of management, such as record keeping, to ensure the health, safety and welfare of people living there. EVIDENCE: Since the last key inspection, the registered manager has moved to another of the local authority’s homes. He has been replaced by a manager registered for a different home who has many years experience of managing a similar home successfully. This manager is supported a co-manager and assistant manager who are also experienced. Correspondence from the Authority’s Assistant Tracey Vale Residential Home DS0000032549.V347025.R01.S.doc Version 5.2 Page 22 Director also confirmed that an external resources manager is supporting the home to implement an action plan to address shortfalls in the service. The present manager has yet to be registered with the Commission. It is an important legal requirement that the manager is registered with the Commission so that their legal obligations can be enforced should this prove necessary. At the time of this visit, the manager was on a phased return to work following an extended period of illness. She was not present during the visit as she was taking annual leave. The home was therefore in the control of co-manager and assistant manager. This inspection provided evidence that action was in progress on a number of fronts to improve the service. Shortfalls in the system for managing the use medicines had been addressed. Changes were being introduced in the system of care planning and recording. A structured approach to meeting staff training needs was in place. A new corporate quality monitoring system was being implemented in the home. This included questionnaires for people using the service which had been summarised in August 2007. There are also regular residents’ meetings which are recorded. For most people living at Tracey Vale, families or legal representatives provide assistance in managing their financial affairs. The home does hold small amounts of personal spending money for residents. Detailed records were available of the amounts held. Policies, procedures and other records were seen concerning health and safety checks in the home. These included, for example, records of recent checks on hot water safety valves and fire equipment safety checks. Workplace risk assessments had been carried out and general risk assessments were seen for issues such as the use of transport, moving and handling and slips, trips and falls. Staff files provided evidence of regular training in health and safety topics. Numerous records were examined during the inspection visit. Some records, such as those concerning health and safety, were detailed, up to date and in good order. Records concerning medication had improved. Individual planning and risk assessments contained serious shortfalls. Homes are required by regulation to report to us any incidents which seriously affect the welfare of people living in them. This is so that the Commission can monitor patterns of such incidents. Some incidents at Tracey Vale had gone unreported. For example, one person had been admitted to hospital following a fall. Recording in some areas. Tracey Vale Residential Home DS0000032549.V347025.R01.S.doc Version 5.2 Page 23 Tracey Vale Residential Home DS0000032549.V347025.R01.S.doc Version 5.2 Page 24 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 2 X 3 X X 3 HEALTH AND PERSONAL CARE Standard No Score 7 1 8 2 9 3 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 X X X X 2 1 2 STAFFING Standard No Score 27 3 28 3 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 3 X 3 2 2 3 Tracey Vale Residential Home DS0000032549.V347025.R01.S.doc Version 5.2 Page 25 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 15(1) & 17(1)(3) Requirement The initial service user assessments must be built upon and individual risk assessments should be carried out to enable the home to formulate detailed care plans of how the individual residents needs should be met by the staff. Previous timescale of 05/11/06 not met Health care needs must be recorded in such a way as to ensure that any urgent referrals are followed up and monitored. More opportunities must be provided to enable the service users to engage in social, occupational and recreational activities if they wish to do so. Previous timescales of 31/3/06 and 5/12/06 not met. Particular attention must be paid to the recreational needs of people with cognitive impairments. The Registered Person must ensure that all staff receive training in safeguarding DS0000032549.V347025.R01.S.doc Timescale for action 01/12/07 2 OP7 12(1)(b) 18/10/07 3 OP12 16(2)(m) and (n) 31/01/08 4 OP18 13(6) 30/04/08 Tracey Vale Residential Home Version 5.2 Page 26 5 OP25 23(2)(p) 6 OP25 23(2)(p) 7 OP26 23(2)(d) 8 OP31 s.11 Care Standards Act 2000 37 9 OP37 vulnerable people from abuse. Arrangements must either be made to have individual thermostatic controls fitted to the radiators or to replace the existing radiators with radiators that can be individually controlled. Previous timescales of 30/4/05, 20/12/05, 31/3/06 and 5/12/06 not met. The home must be kept sufficiently warm to meet the individual needs of people living there. The Registered person must ensure that appropriate measures are in place to maintain sufficient standards of cleanliness and hygiene throughout the home at all times. The Registered Person must ensure that the manager of the home is registered with the Commission. The Registered person must ensure that all deaths, illnesses and other events adverse to the welfare of people living in the home are reported to the Commission without delay. 01/06/08 31/10/07 31/10/07 01/02/08 31/10/07 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 OP19 OP24 Good Practice Recommendations Plans to improve décor and furnishings in the home should be implemented. The registered person should ensure that all people living DS0000032549.V347025.R01.S.doc Version 5.2 Page 27 Tracey Vale Residential Home 3 OP24 in the home are offered a key to their room unless otherwise indicated by a risk assessment. All service users should have lockable storage available in their individual rooms. Tracey Vale Residential Home DS0000032549.V347025.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Ashburton Office Unit D1 Linhay Business Park Ashburton TQ13 7UP National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 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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