Inspection on 17/05/05 for Tramways Corner

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 Good. 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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Tramways Corner 15/09/09

Tramways Corner 21/10/08

Tramways Corner 13/05/08

Tramways Corner 08/08/07

Tramways Corner 19/07/06

Tramways Corner 03/11/05

Tramways Corner 25/01/05

Tramways Corner 11/08/04

Similar services:

2 Perhaver Park

The Vicarage

St George`s

5 Seafield Road

Credence House

Radfords

Honeybourne House

32 Beaumont Way

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

CARE HOME ADULTS 18-65 Tramways Corner 39 Trebarwith Crescent Newquay Cornwall TR7 1DX Lead Inspector Elaine Bruce Announced 17 May 2005 09:30 a.m. 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 Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationary 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. Tramways Corner D52-D04 S9094 Tramways Corner V215692 170505 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Tramways Corner Address 39 Trebarwith Crescent Newquay Cornwall TR7 1DX 01637 872049 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) Mrs Catherine Fogarty Mrs Mary V Musselwhite Care Home 8 Category(ies) of Learning disability (8) registration, with number of places Tramways Corner D52-D04 S9094 Tramways Corner V215692 170505 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: Service users to include up to 8 adults with a learning disability (LD) of whom 1 may also have a physical disability. Date of last inspection 25th January 2005 & 8th February 2005 Brief Description of the Service: Tramways Corner is an end terrace property very close to the town centre of Newquay. Behind the property there is parking for two cars. Additional car parking is available in a near by pay at the metre car park. There is a courtyard to the back of the house accessed through the kitchen. In the courtyard there is seating, pots of plants and a barbecue. Accommodation is provided on three floors (there is no stair lift facility) to upstairs bedrooms. On the ground floor there is a large lounge/diner and a kitchen that also has dining space. The laundry is domestic in type but is separate to the kitchen. Tramways Corner D52-D04 S9094 Tramways Corner V215692 170505 Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection took place on the 17th May 2005 over three hours and was carried out as an announced inspection. A tour of the premises (to include some of the service users bedrooms) took place and one service user and one staff member were spoken to. The rest of the service users were at their day care resources. The inspection concentrated on paperwork and statutory requirements which had been outstanding from the inspection of the 8th February 2005. What the service does well: What has improved since the last inspection? What they could do better: Tramways Corner D52-D04 S9094 Tramways Corner V215692 170505 Stage 4.doc Version 1.30 Page 6 Tramways is a small home which has struggled with meeting the requirements of The Care Standards Act (2000). For example it is recognised that staff resources have been limited to allow policies and procedures to be developed. The home has struggled unnecessarily at times as it would appear that they have been unable to prioritise the requirements of legislation. 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. Tramways Corner D52-D04 S9094 Tramways Corner V215692 170505 Stage 4.doc Version 1.30 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Standards Statutory Requirements Identified During the Inspection Tramways Corner D52-D04 S9094 Tramways Corner V215692 170505 Stage 4.doc Version 1.30 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users’ know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 1 and 2 The home’s statement of purpose and service user guide documentation provide prospective service users with details of what the home provides helping an informed decision about admission to the home. All service users are assessed prior to admission to the home to ensure that the home will be able to meet their care needs. EVIDENCE: The statement of purpose document and the service user guide are available in the home and have been issued to each service user and their representative. The documentation has recently been updated to include information on a new staff member. Most of the service users have lived at the home for a considerable period of time. Assessments are undertaken by the registered provider or an appropriate member of staff prior to a new service user admission to the home. The placement is initially agreed on a first month trial basis. The registered provider emphasised the importance of a successful placement for the existing service users as well as the new person coming to the home. Tramways Corner D52-D04 S9094 Tramways Corner V215692 170505 Stage 4.doc Version 1.30 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate, in all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 6,7,9 The service user’s personal and social care needs are being met by the staff team. Further financial arrangements are necessary to ensure that the service users are protected. EVIDENCE: Each service user has in place a detailed care plan that is supplemented by daily records. All the staff are involved in the daily recording and evidence of care plan reviews are in place. Risk assessments are in place for each service user. Each risk assessment identifies risks and hazards and the action taken to reduce risk. Service users are encouraged to manage their own financial affairs. A detailed discussion took place with the registered provider on the good practice recommendation to set up bank accounts for the service users separate to the present system which is related to the business account. Tramways Corner D52-D04 S9094 Tramways Corner V215692 170505 Stage 4.doc Version 1.30 Page 10 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 standard(s) 15 and 17 Service users are encouraged to have social relationships with family and friends. The meals provided in the home are satisfactory with healthy eating encouraged. EVIDENCE: Family and friends can visit the home at any reasonable time during the day and the evening. This information is documented in the statement of purpose. Daily records evidence when the service users have had visitors. Service users can receive their visitors in private: in their room or in the lounge. Service users can also telephone their family and friends or visit them at any time. Some of the service users go home at the week-end. The more able service users are allowed to go out unaccompanied, although it is expected that they say exactly where they are going and when they will return. The home has in place a visitor’s book that all visitors to the home are asked to sign. The home encourages a healthy eating programme. Daily records evidence dietary needs/requirements and information is also included in care planning documentation. Records are in place of meals that the service users have Tramways Corner D52-D04 S9094 Tramways Corner V215692 170505 Stage 4.doc Version 1.30 Page 11 eaten at the home. Recent changes to the menu have taken place which have apparently been successful to both the service users and the staff cooking the meals. All staff have responsibility for meals preparation and basic food hygiene certificate training is to be updated. The recommendations from the District Council Environmental Health Officer inspection (27/01/05) have been addressed. Tramways Corner D52-D04 S9094 Tramways Corner V215692 170505 Stage 4.doc Version 1.30 Page 12 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 standard(s) 19 and 20 The service user’s health care needs are met by the staff and multidisciplinary health care staff as required. Medication procedures require updating to ensure safe practice at all times. EVIDENCE: All the service users are registered with a general practitioner. Health care services such as Chiropody, Dentistry and Ophthalmology are all available in Newquay. Service users are helped to their appointments by the staff. Community nursing support is available in the home when required although there are no service users in receipt of this service at this time. All recording of any accidents is taking place as required. There is a policy and procedure available in the home that requires expanding to include information on controlled medication for example. Medication training has commenced for all staff. Medication administration records were found to be completed appropriately on the day of the inspection. Tramways Corner D52-D04 S9094 Tramways Corner V215692 170505 Stage 4.doc Version 1.30 Page 13 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 standard(s) 22 and 23 The home has a satisfactory complaints procedure provided to the service users in the service user guide. Staff are due to receive adult protection training to provide them with the knowledge and understanding of adult protection issues to protect service users from abuse. EVIDENCE: The home has a complaints policy and procedure in place that includes information to guide the service users should they wish to complain. This documentation has been provided in the service user guide. An adult protection and whistle blowing policy and procedure is in place. Each staff member is provided with this documentation in their staff handbook. One staff member is due to attend adult protection training (from the local social services department) and there are plans for other staff to receive this training. Tramways Corner D52-D04 S9094 Tramways Corner V215692 170505 Stage 4.doc Version 1.30 Page 14 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 standard(s) 24,25,26,27,28,29 and 30 The standard of the environment within Tramways is satisfactory providing the service users with a homely and comfortable environment. EVIDENCE: Tramways is a small home that is homely with comfortable communal accommodation. The communal lounge has recently been decorated. External maintenance has recently taken place to include for example a new roof. The home is not suitable for wheel chairs as bedrooms are accessed by stairs with no stair lift or shaft lift facility. Bedrooms are available on the first and second floor. Each bedroom is individual and has been personalised. Six bedrooms are single with one double bedroom. Furniture and soft furnishings are satisfactory. Two bedrooms have recently been decorated. Shared toilets and bathing facilities are available on each floor of the home. The home was found to be clean on the day of the inspection with all staff having responsibility for cleaning duties. Infection control policies and Tramways Corner D52-D04 S9094 Tramways Corner V215692 170505 Stage 4.doc Version 1.30 Page 15 procedures are in place to guide staff and more information is to be accessed on COSHH requirements. Regular maintenance testing of the premises is taking place to include for example gas safety, hard wiring testing, testing of portable appliances. A County Council Fire Officer inspection took place on the 5th April 2005 all was found to be satisfactory from this visit. Tramways Corner D52-D04 S9094 Tramways Corner V215692 170505 Stage 4.doc Version 1.30 Page 16 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 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31,32,33,34,35 and 36 Staffing levels include times when there is only one staff member on the premises. This information must be clearly included in the statement of purpose document. Staff training is being updated to ensure that the staff can meet the needs of the service users. EVIDENCE: Each staff member has been provided with a staff information pack to include important information such as a job description and a contract of employment. Important policies and procedures are also included in this pack. The General Social Care Council good practice guidance documentation is at the home. Staff training has commenced in areas such as medication with plans for an evolving training programme to include statutory training and good practice training to take place. Encouragement is being given by the registered provider to undertake NVQ training. It is recommended that the induction training that new staff members receive is expanded to meet the requirements of The National Minimum Standards. Tramways Corner D52-D04 S9094 Tramways Corner V215692 170505 Stage 4.doc Version 1.30 Page 17 There are times when one staff member is on duty in the home and it is recommended that this information be included in the statement of purpose document. At night there is one sleeping in member of staff. Prior to staff members being employed two written references are taken and a criminal records bureau check. In addition a completed application form and health care declaration is requested. There has been one new staff member employed since the last inspection. Staff supervision has commenced and a discussion took place with the registered provider on the content and recording of supervision. Tramways Corner D52-D04 S9094 Tramways Corner V215692 170505 Stage 4.doc Version 1.30 Page 18 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 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 37,39 and 40 The certificate of registration for the home at this time is still incorrect. When this is addressed a judgement will be made on the leadership of the home. EVIDENCE: The registered provider and her daughter have responsibility for running the home and at this time the daughter is not on the certificate of registration. This situation will hopefully be addressed soon once a satisfactory criminal records bureau check has been received by the CSCI. Since the last inspection the daughter of the registered provider has commenced the Registered Managers Award which has been to the benefit of the service users and the home. Policies and procedures have been developed since the last inspection on quality assurance. A good pictoral questionnaire for the service users feedback Tramways Corner D52-D04 S9094 Tramways Corner V215692 170505 Stage 4.doc Version 1.30 Page 19 on the running of the home is ready to be commissioned and a questionnaire is also ready which would be suitable for receiving feed back from visitors/professionals to the home. All policies and procedures have now been reviewed and developed as required by legislation. Tramways Corner D52-D04 S9094 Tramways Corner V215692 170505 Stage 4.doc Version 1.30 Page 20 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 x x x Standard No 22 23 ENVIRONMENT Score 3 2 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 3 2 x 3 x Score Standard No 24 25 26 27 28 29 30 STAFFING Score 3 3 3 3 3 3 3 Standard No 11 12 13 14 15 16 17 x x x x 3 x 3 Standard No 31 32 33 34 35 36 Score 3 2 2 3 2 2 CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Tramways Corner Score x 3 2 x Standard No 37 38 39 40 41 42 43 Score 2 x 3 3 x x x D52-D04 S9094 Tramways Corner V215692 170505 Stage 4.doc Version 1.30 Page 21 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 Regulation Requirement Timescale for action RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. 3. 4. 5. Refer to Standard 7 20 23 33 35 Good Practice Recommendations For bank accounts to be set up for individuals who have not got this facility at this time. To update the medication policy and procedure. For all staff to receive adult protection training. to add information in the statement of purpose that there are times when one staff member only is on duty. To expand the induction training to new staff members. Tramways Corner D52-D04 S9094 Tramways Corner V215692 170505 Stage 4.doc Version 1.30 Page 22 Commission for Social Care Inspection John Keay House Tregonissey Road St Austell, Cornwall PL25 4AD 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 Tramways Corner D52-D04 S9094 Tramways Corner V215692 170505 Stage 4.doc Version 1.30 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. 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