Inspection on 26/10/05 for Trafalgar House

This inspection was carried out on 26th October 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 4 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Trafalgar House 24/10/06

Trafalgar House 10/05/05

Trafalgar House 07/12/04

Trafalgar House 07/06/04

Similar services:

Thorndene

Insight - Eastchurch

Southfields

Magenta

Seabourne House

33 St John`s Church Road

Dovedale Court

Lyncol House

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

CARE HOME ADULTS 18-65 Trafalgar House 9 Sutherland Avenue Bexhill-on-sea East Sussex TN39 3LT Lead Inspector James Houston Unannounced Inspection 26th October 2005 08:10 Trafalgar House DS0000021273.V259965.R01.S.doc Version 5.0 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Trafalgar House DS0000021273.V259965.R01.S.doc Version 5.0 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Trafalgar House DS0000021273.V259965.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Trafalgar House Address 9 Sutherland Avenue Bexhill-on-sea East Sussex TN39 3LT 01424 222911 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) Care Management Group Limited Mr Kevin Mark Dyer Care Home 7 Category(ies) of Learning disability (7) registration, with number of places Trafalgar House DS0000021273.V259965.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. That the home is registered to accommodate up to seven (7) service users. That the service users are aged between 18 and 65 years upon their admission. That the category of service users admitted have a learning disability, not falling within any other category. 10th May 2005 Date of last inspection Brief Description of the Service: Trafalgar House provides social and residential care for seven adults with learning disabilities, who may present with challenging behaviour. It is one of a large number of around 80 specialist homes, owned by the Care Management Group (CMG), providing services to adults within this category. The home is a detached three-storey property with a small garden, situated in a quiet residential area of the town of Bexhill-on-Sea. The shopping centre and railway station are within easy walking distance. Service users accommodation is on three floors, having sufficient bathroom, shower and toilet facilities. There is office accommodation for the manager and staff. Trafalgar House DS0000021273.V259965.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place during the morning and early afternoon of the twenty-sixth of October 2005. At this time there were six residents living in the home. Prior to this inspection inspector read records held by the Commission for Social Care Inspection and prepared those standards to be inspected. During the inspection the inspector spoke to five residents and two staff members and the acting manager. A tour was made of the whole premises and a range of records including three care plans and policies and procedures was read. After the inspection relatives of two residents were spoken with. What the service does well: What has improved since the last inspection? 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. Trafalgar House DS0000021273.V259965.R01.S.doc Version 5.0 Page 6 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Trafalgar House DS0000021273.V259965.R01.S.doc Version 5.0 Page 7 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1,2,3 and 4. The home’s documents give full information to those considering living in the home and those advising them. The home meets the needs of those living there. Visiting arrangements for prospective residents are appropriate. EVIDENCE: The home has a statement of purpose and service users’ guide that were inspected. Necessary minor modifications were made during the inspection. The acting manager confirmed that he is fully involved in the assessment of any prospective residents. From discussion with residents, their relatives and staff and the home’s manager it is clear that staff individually and collectively have the skills and experience to meet the needs of the current resident group. Observation confirmed that staff are able to communicate with residents. The acting manager said that prospective residents visit the home prior to admission in order to meet the staff and the home’s residents. He said that the home does not take emergency admissions. Trafalgar House DS0000021273.V259965.R01.S.doc Version 5.0 Page 8 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6 and 9. Comprehensive care plans are kept and regularly reviewed. EVIDENCE: Good care plans are drawn up. Staff said that they read them and are familiar with them. Relatives said that they had been involved in giving background information and that they are invited to reviews. Records inspected showed that daily reports are written. Those read were well written and informative, up to date and signed. The home has a key worker system, and key workers’ reports were found to be written monthly and to be up to date. Risk assessments are drawn up and those inspected were found to be reviewed regularly. Staff said that they are familiar with them and give guidance to residents as needed. The home has a suitable policy setting out the action to be taken by staff in the event of resident going missing. Trafalgar House DS0000021273.V259965.R01.S.doc Version 5.0 Page 9 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 13,14, 15 and 17. Residents have the opportunity to engage in appropriate leisure activities. Visitors are made welcome. Meals and mealtimes promote the well being of residents. EVIDENCE: Staff said that the staff group as a whole is knowledgeable about local resources and specialist organisations and the inspection bore this out. The acting manager said that relationships with the local community are good. Residents do not go out alone, but with staff they use public transport or go out in the home’s people carrier. Staff said that residents do not go out in large groups and observation confirmed this. Residents are on the electoral roll, but did not vote in this year’s election. Staff said that there are enough of them to enable valued activities for residents to happen during the evening and weekends. Residents are able to undertake a variety of pursuits inside the home such as playing pool and games, and outside the home pursuits such as going shopping and to the library. Residents confirmed that they had been on at least one holiday this year and that they had enjoyed them. Trafalgar House DS0000021273.V259965.R01.S.doc Version 5.0 Page 10 Residents said that their visitors are made welcome and relatives said that they are well received if they visit the home. Staff confirmed that they give hospitality to visitors. Residents said that they like the meals served, and records inspected showed that an up to date and detailed record of meals served is kept, with a clear record of alternatives given. Staff confirmed that residents choose where they eat. Residents help with food purchasing and meal preparation as far as is possible. Staff said that no residents currently need assistance with eating. Trafalgar House DS0000021273.V259965.R01.S.doc Version 5.0 Page 11 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19 Residents’ healthcare needs are met. EVIDENCE: Records inspected showed that careful attention is paid to the meeting the full range of residents’ healthcare needs. Residents and their relatives said that they were satisfied with this aspect. Residents said that staff usually accompanies them on visits to their GP and that the staff member usually comes in with them and that they are happy with this. The home uses a wide range of services from the local community team for learning disability. Trafalgar House DS0000021273.V259965.R01.S.doc Version 5.0 Page 12 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22. The home has suitable systems for dealing with complaints. EVIDENCE: The home has a suitable complaints policy available to residents. Minor necessary modifications to it were made during the inspection. Residents said that they feel able to raise matters with staff, and relatives said that they are aware of the procedures. No complaints have been made to the Commission for Social Care Inspection since the last inspection concerning the running of the home. The home’s complaints log was inspected and advice was given concerning the advisability of including one resolved issue in the log as well as in the records of the relevant resident. Trafalgar House DS0000021273.V259965.R01.S.doc Version 5.0 Page 13 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24,26,2728 and 30. The home offers a high standard of accommodation for its residents and is suitable for its stated purpose. EVIDENCE: The acting manager said that since the last inspection much work has been done in improving the fittings and furniture in residents’ rooms and a tour of inspection confirmed this. The large gardens are now to a satisfactory standard. Staff confirmed that there is a system for recording maintenance items needing attention. The provider has their own maintenance team and staff from it were working on site throughout the inspection. The fire officer visited recently and items raised are being addressed. Residents are all provided with single rooms and these were found to be suitably personalised. Rooms are lockable, but residents said they do not use the keys. On the first floor the home has one bathroom with a toilet, and two other toilets for the use of six residents. The newer seventh room on the second floor has its own en suite bathroom. Trafalgar House DS0000021273.V259965.R01.S.doc Version 5.0 Page 14 The home has two spacious lounges and a large dining room for residents. They are well furnished. Office and staff accommodation is of a very good standard. The home has a small laundry that is suitable for the needs of the establishment. Residents said that they help in the laundering of their clothes. The home has infection control policies of which staff said that they were aware. The home was clean and tidy throughout. Trafalgar House DS0000021273.V259965.R01.S.doc Version 5.0 Page 15 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31,32,34 and 36. Staff understand their roles. Staff are competent but qualification levels need attention. Recruitment systems protect residents. Attention to staff supervision frequency and staff appraisals is needed EVIDENCE: Staff confirmed that they had been given a job description appropriate to their role. Discussion with staff and reading of records showed that staff get to know and develop a relationship with the residents they support. Staff said that they are familiar with the General Social Care Council Code of Conduct. Staff were seen to be accessible to and approachable by residents. Residents and relatives said that staff are helpful. Staff were motivated and committed. Relatives, staff and the acting manager said that there had been a lot of staff turnover in the last year. This was said to have meant staff working overtime and some use of agency staff. The acting manager said that the home is now fully staffed. The acting manager said that one staff member currently has NVQ level 2 in care. No staff are currently doing it. Eight staff are ready to start. The requirement made at the previous inspection has been restated. The recruitment files of three recently appointed staff were inspected and were found to contain the required information. Staff said that they had been issued with terms and conditions of employment. Trafalgar House DS0000021273.V259965.R01.S.doc Version 5.0 Page 16 The acting manager said that staff receive supervision but not at the recommended frequency and that annual appraisals need to be reinstated. He said that he and his seniors have received training in supervision. Trafalgar House DS0000021273.V259965.R01.S.doc Version 5.0 Page 17 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37,38,39,42 and 43. An application from the provider is needed in respect of a registered manager. Residents benefit from the ethos and management approach of the home. Quality assurance mechanisms need further development. Wedging open fire doors compromises safety. Management systems are good. EVIDENCE: The acting manager has considerable relevant experience. He undertakes relevant periodic training to update his knowledge and skills. He is intending to undertake the Registered Manager’s Award in the near future. No application has been made to date by the provider in respect of a registered manager for the home. The home has regular minuted staff meetings and residents meetings. These minutes were made available to the inspector. Residents, relatives and staff said that the manager is easy to approach and listens. The inspector found the atmosphere in the home open and inclusive. Trafalgar House DS0000021273.V259965.R01.S.doc Version 5.0 Page 18 The manager has commenced work which will lead to the production of an annual development plan specific to the home, based on a cycle of planning action and review, reflecting the aims and outcomes for residents. The manager noted that the timescale for a requirement, made at the last inspection, of 1 November 2005 would not be met, and a new timescale has been set. Several fire doors were found to be wedged open. Consideration should be given to the installation of devices, where permitted, which allow fire doors held open to close in the event of the fire alarm sounding. The home has a range of support systems provided by the home’s provider. The home’s administrator was present during the inspection. Adequate insurance cover is in place and a current certificate was on display. The provider undertakes regular monthly visits, and records inspected confirmed this. Staff said that they are clear about the roles of internal and external management. Trafalgar House DS0000021273.V259965.R01.S.doc Version 5.0 Page 19 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score 3 3 3 3 X Standard No 22 23 Score 3 X ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 3 X X 3 3 Standard No 24 25 26 27 28 29 30 STAFFING Score 3 X X 3 3 X 3 LIFESTYLES Standard No Score 11 X 12 X 13 3 14 3 15 3 16 X 17 Standard No 31 32 33 34 35 36 Score 3 2 X 3 X 2 CONDUCT AND MANAGEMENT OF THE HOME 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Trafalgar House Score X 3 X 3 Standard No 37 38 39 40 41 42 43 Score 2 3 2 X X 2 3 DS0000021273.V259965.R01.S.doc Version 5.0 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 YA32 Regulation 18(1) Timescale for action That 50 of (duty) care staff are 01/01/06 qualified to NVQ level 2, or above. (Previous timescale of 01.01.06 had not expired). That a manager is registered for 01/07/06 the home, who has the appropriate experience and qualification (Previous timescale of 01/07/06 had not expired). That the manager produces an 01/03/06 annual development plan specific to the home, based on a cycle of planning-action-review, reflecting the aims and outcomes for service users. (Previous timescale of 01.11.05. had not expired). Fire doors should not be wedged 01/12/05 open. Requirement 2. YA37 9(2)(b) 3. YA39 24(1) 4. YA42 23(4)(a) RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Trafalgar House DS0000021273.V259965.R01.S.doc Version 5.0 Page 21 1. 2. 36 36 Provide formal recorded supervision for staff at least six times per year. Provide annual appraisals for staff. Trafalgar House DS0000021273.V259965.R01.S.doc Version 5.0 Page 22 Commission for Social Care Inspection East Sussex Area Office Ivy House 3 Ivy Terrace Eastbourne East Sussex BN21 4QT 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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