Inspection on 12/07/06 for Tredegar Care Home

This inspection was carried out on 12th July 2006.

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

Tredegar Care Home 16/02/06

Tredegar Care Home 27/09/05

Tredegar Care Home 26/11/04

Tredegar Care Home 30/06/04

Similar services:

Springfield House

The Shelley

Sutton Lodge Nursing Home

St Helier`s Residential Hotel

St Joseph`s

Ridgemount

Wingham Court

Old Hastings House

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

CARE HOMES FOR OLDER PEOPLE Tredegar 13 Upper Avenue Eastbourne East Sussex BN21 3UY Lead Inspector Liz Daniels Key Unannounced Inspection 12th July 2006 10:00 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 Tredegar DS0000014069.V290868.R01.S.doc Version 5.1 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Tredegar DS0000014069.V290868.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Tredegar Address 13 Upper Avenue Eastbourne East Sussex BN21 3UY 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) 01323-412808 01323-731119 New Century Care (Eastbourne) Limited Sandra Barnes Care Home 26 Category(ies) of Old age, not falling within any other category registration, with number (26) of places Tredegar DS0000014069.V290868.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. Service users should be aged 65 and over on admission. A maximum of 26 service users may be accommodated at any one time. 16th February 2006 Date of last inspection Brief Description of the Service: Tredegar is a detached property, which has been converted and adapted as a care home in Eastbourne. It is owned by New Century Care Ltd and provides nursing and personal care for up to 26 residents of an older age. Tredegar is arranged over three floors with a shaft lift providing access to all floors. There are five double bedrooms, two of which have en-suite facilities and sixteen single rooms, nine with en-suites. The home has hoists and bath hoists, and there are grab rails and disability aids in the bathrooms and toilets. Two lounges and a dining room provide communal space and there is access to a garden with a seating area. At the front of the home, there is a parking area for several cars. The home is situated within walking distance of the main town, mainline railway station and main bus routes. The seafront and a large park area are approximately a mile away. Prospective residents or their representatives are welcomed to view the premises, discuss their needs with the Registered Manager and to spend time with the staff and residents. Weekly fees as at 12/05/06, range from £500 - £750. The fees do not include hairdressing, chiropody, residents’ telephone calls and any sundries such as newspapers: these are charged as extras. Information about the service is available on the organisation’s website (New Century Care) and from the home’s manager. Tredegar DS0000014069.V290868.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This key inspection was unannounced. It included a visit to the home by an Inspector, which began at 10am and lasted for eight and a half hours and a further visit the following day lasting three hours. The Deputy Manager facilitated the majority of the visit as the Registered Manager was off site on the first day, but she was then at the home the following day. Four staff met with the Inspector and the visit also provided the opportunity to meet with several residents in the lounge and to talk in more detail with five of them in the dining room and in the privacy of their own rooms. Four relatives spoke with the Inspector during the site visit. The Inspector was also able to tour the premises before examining records that included resident’s files, medication records, staff files, training records, the accident log and the complaints log. Evidence contributing to the inspection has also been gathered from previous inspections, surveys circulated to residents and their relatives (of which seven were returned to the Inspector) and from data provided by the Registered Manager. All of the key standards and those where concerns had been raised at the last inspection, were inspected. What the service does well: What has improved since the last inspection? The Requirement from the last inspection has been met, as staff now sign the MAR charts when medication has been administered, ensuring residents receive the correct medication at the correct time. The staff at Tredegar have all had training in the management of pressure areas and wound care, whereby residents’ skin integrity is protected wherever possible. The deputy manager has become the designated person within the home who takes a lead in monitoring tissue viability. Similarly the trained nurses have received in house training in medications but they and the carers are currently undertaking a distance-learning course about medications, to ensure residents are protected by the home’s practise. Tredegar DS0000014069.V290868.R01.S.doc Version 5.1 Page 6 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. Tredegar DS0000014069.V290868.R01.S.doc Version 5.1 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Tredegar DS0000014069.V290868.R01.S.doc Version 5.1 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 3 and 6 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. Good information is available about the service provided at Tredegar, and a thorough assessment of prospective residents takes place, ensuring a resident’s individual needs can be met. EVIDENCE: Every bedroom at Tredegar has a copy of the Resident’s Guide and a copy is given to prospective residents when they visit, or is sent out following an enquiry to the home. The copy shown to the Inspector was comprehensive but it needed to be updated to reflect the change from the National Care Standards Commission (NCSC) to the Commission (CSCI) and the current management structure of the home. The Manager confirmed that New Century Care could provide a copy in varying formats to suit individual need, on request. A copy of the most recent CSCI inspection report is not included nor is resident feedback. However these are both on display in the main hallway and the organisation’s website also has a link that enables access to view the Commission’s inspection reports for the home. Tredegar DS0000014069.V290868.R01.S.doc Version 5.1 Page 9 Previous inspections have found that following an enquiry, it is usual practice for prospective residents and their relatives to be invited to visit Tredegar and spend time with the manager and staff, view the available rooms and discuss the home’s suitability. If they then wish to pursue an admission, the manager or her deputy undertakes an assessment in their own home, or if they are in hospital, they visit them there. Where possible, information is gathered from the prospective resident’s Care Manager, or from nursing and medical staff if the person is in hospital, although their written assessment is rarely available. A pro-forma is also completed and if the home is suitable, a letter is sent to the person, or their relatives, to confirm that the home can meet their assessed needs. Once funding has been agreed, if it is needed, they are then admitted for a trial period. One relative who met with the Inspector, could recall the manager coming to see his relative in hospital and chatting about her needs, prior to her admission six weeks previously. He had visited the home on her behalf and was shown her room, as it was the only one available at the time. He felt he had ‘had good information about the home’ and that it is ‘pretty good really’. Four resident’s files were viewed during the visit. All had comprehensive preadmission assessments in place although they had not all been signed and dated. Two of the files also contained a further initial assessment that had been completed three days after admission. The information gathered had then been used to underpin a care plan for each resident. Tredegar does not provide Intermediate Care although residents are admitted for planned respite care or, very occasionally, for emergency respite. Tredegar DS0000014069.V290868.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. Comprehensive care plans enable residents to have individualised care and good practise ensures residents are cared for with respect and dignity. However medication recording should be improved to ensure residents are protected. EVIDENCE: The care files for four residents were reviewed. All had care plans and risk assessments to reflect the individual needs of the resident. All had been reviewed monthly and there was evidence that they had been updated. A ‘Daily Record’ is completed for each resident, recording any significant events: any changes in care are also passed on verbally in the handover between each shift. The condition of residents’ skin is assessed and monitored: any pressure areas are recorded and if a sore develops the treatment and outcome is documented. The deputy manager confirmed that all the nurses have been trained in the prevention and treatment of pressure areas (tissue viability) and that she is the designated person within the home who monitors and advises about wound management. Advice is also sought from a tissue viability nurse specialist within the organisation. However there is no protocol in place to Tredegar DS0000014069.V290868.R01.S.doc Version 5.1 Page 11 meet the National Institute for Clinical Excellence (NICE) guidelines for pressure area care: these recommend that any person who develops a Stage 2 pressure sore is referred to a nurse specialist, enabling the resident to have expert advice and an individualised plan of treatment. Alternatively residents are referred back to the GP and a district nurse is asked to visit. There are various types of pressure relieving mattresses and cushions, including air, overlay and alternating pressure mattresses, to support the management of pressure areas at Tredegar. Resident’s dependency is also assessed and the risk of falling is identified. The home has electric hoists, (last serviced in March 06) and there is a wheel-in shower and hoist-assisted baths for those with reduced mobility. Grab rails are fitted in the toilets and raised seats are available; there are also adjustable beds. Each resident has a continence assessment as part of their admission and if necessary they are seen by the continence nurse specialist. Nutritional screening is also undertaken and resident’s weights are monitored. The chiropodist visits the home every 6 weeks or more frequently if needed and arrangements are made for residents to see a dentist or optician as needed. Where possible residents remain registered with their own GP or they register with a GP of their choice. No current residents wish to self-medicate. A resident’s medication is discussed at their pre-admission assessment and the Manager assesses whether it is appropriate for them to self medicate if they wish to do so, recording it as a Risk Assessment. If they are assessed as safe, the resident and where possible their next of kin, will sign a consent form with the Registered Manager, which is then kept in the resident’s file. All rooms have a lockable space where the resident can keep a month’s supply of medication and the staff then monitor the Medication Administration Record (MAR chart) and check that the medication is being taken. The medications for the remainder of the residents are stored in a clinical room, with some stock in a wall cupboard, but most in a medicine trolley. The majority of medication is dispensed in blister packs. Previous inspections have found good practice in place for the storage and disposal of medication but some administration had not been signed for appropriately, at the last inspection. The MAR charts were therefore reviewed at this visit. Medication that had been administered had been signed for correctly and medication that had not been given had been identified on the MAR chart. However the reason for not giving had not been recorded. The name of residents with their photo, accompanies their MAR chart: some resident’s photos were not included. The trained nurses at the home administer medications; they have all had in-house training with the Boots pharmacist and they and the carers are currently undertaking a distance-learning course with Bromley College. Carers assist in the administration of medication although they are not involved in the administration of Controlled Drugs (CDs). A Boots pharmacist audits medications in the home annually. Tredegar DS0000014069.V290868.R01.S.doc Version 5.1 Page 12 Staff who met with the Inspector confirmed that they aim to support residents by providing personal and nursing care where needed, but at the same time they endeavour to maintain privacy and dignity, showing respect when residents are undergoing examinations or personal care. All residents seen were appropriately dressed for where they were. Screens are provided for those residents in double rooms and during the visit, staff were observed to be attentive and courteous. Tredegar DS0000014069.V290868.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. The recreational pursuits that are available must be circulated to all residents in the home, to ensure that their social, cultural, religious and recreational interests and needs are met. EVIDENCE: There is a large lounge at Tredegar where residents can meet together, watch television or spend time with their visitors. There is also a smaller lounge, which can be used as a quiet room where residents can read, or families can meet together. Videos and various games are available, as well as a selection of books. There is an ‘Activity Co-ordinator’ in post, who organises an activities programme and publicises the week ahead in the main hall of the home. The deputy manager explained that other ‘ad-hoc’ events are also arranged, dependant on the weather and staff availability. These are publicised verbally on the day and residents invited to join in. As well as group events the co-ordinator spends time with each resident, supporting them individually by chatting with them or providing activities such as foot spas and hand massages. The Inspector viewed a record of activities that had been arranged, which included a variety of individual and group activities, such as flower arranging, sewing, reading, a dog visiting and beanbag throwing. A hairdresser also visits the home every week. Arrangements are made if Tredegar DS0000014069.V290868.R01.S.doc Version 5.1 Page 14 residents wish to receive communion or attend church services and the home currently celebrates the Christian festivals. There are several nurses and carers employed from overseas and although there have not been celebrations for other festivals the deputy manager explained that the nurses and residents chat about their different cultural backgrounds. The deputy is therefore confident that the home could meet the needs of residents with varying social and cultural needs. Social and emotional needs are identified in the care plans and a life history and record of choice of lifestyle are made. The staff who spoke with the Inspector felt the residents are encouraged to maintain any hobbies they may have, if possible. One resident said ‘I never get bored; there is always something to do’. Another said their room was nice and ‘it’s nice to see outside but I can’t get out’. Similarly a relative commented that ‘some activities are arranged but no outings are organised’ so there is not a lot for their relative to do. Of the service user surveys returned to the Inspector prior to the visit, 57 of the respondents said there are ‘usually’ activities for them to take part in, 29 said ‘sometimes’ and 14 did not respond. The value of providing more structured activities and circulating the plan to those residents, who spend more time in their room, was discussed and agreed. Some of the residents manage their own financial affairs but in general relatives or solicitors act on their behalf. Some residents choose to keep money in their room in a lockable cupboard or drawer, whilst others prefer that their money is held in the home’s safe. It is separated out and accounted for individually. If staff are asked to shop for a resident, receipts are obtained. The home does not act as the appointee for any resident. Previous inspections have found the food provided at Tredegar is varied and enjoyed by the residents. Meals can be eaten in the dining room, the main lounge or alternatively in resident’s own rooms if they prefer. The menu seen by the Inspector was nutritious and varied and runs over a four-week period. Two choices of meal are available for lunch, one of which is meat free and there are generally sandwiches, or something on toast, for supper. The menu is displayed in the hallway but the aim is to put a copy on each dining table. The cook who met with the Inspector explained that she meets the residents each day when serving the afternoon teas: she therefore has regular feedback about the meals provided and has the opportunity to learn particular likes and dislikes. The Manager informs her about any new residents and particular dietary needs and these are recorded on a board in the kitchen. The value of circulating the menu throughout the home each week was discussed and agreed, as this would benefit those residents who spend most of their time in their room and cannot access the menus currently displayed. One resident who met with the Inspector described the food as ‘good’, whilst another commented that ‘it was a nice lunch today’. However a relative thought ‘the meals are not very good’ and continued that their relative ‘doesn’t Tredegar DS0000014069.V290868.R01.S.doc Version 5.1 Page 15 eat much of it’. In the surveys returned, 29 responded that they always like the food and 71 said ‘usually’. The kitchen and storage areas were viewed. Fresh fruit and vegetables were evident and food was appropriately stored in the fridges and freezers. Some residents also have small fridges in their rooms to enable them to keep cold drinks or particular choices of fresh food. Tredegar DS0000014069.V290868.R01.S.doc Version 5.1 Page 16 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. The home has a satisfactory complaints procedure and residents are confident that their views are listened to and acted upon. Safe measures are in place to ensure residents are protected from abuse. EVIDENCE: The home’s complaints procedure is displayed in the main hall and in the resident’s guide. There is a policy within the home that clearly identifies timescales for any concerns or complaints to be investigated and a response to be given. The outcome of any investigation is fed back to the complainant. The residents and relatives who spoke with the Inspector during the site visit and the service user surveys received, all expressed confidence in the Management Team; 71 of them responded that they ‘always’ know who to speak to if not happy. One relative explained that they had had reason to make a complaint to the home but confirmed that the situation had been thoroughly investigated and appropriate action taken to achieve a satisfactory outcome. The Commission has not received any complaints about the service since the last inspection. The complaints log contained several entries where residents and relatives have raised concerns this year: the investigation undertaken and the outcome reached were clearly recorded. Adult Protection policies and procedures continue to be in place and Criminal Record Bureau (CRB) Disclosures are applied for as part of the recruitment process. A copy of the East Sussex multi agency guidelines is available in the home: the home works to the organisations policy for the management of Tredegar DS0000014069.V290868.R01.S.doc Version 5.1 Page 17 adult abuse, which clearly identifies Social Services as the lead agency. There is also a policy in place for whistle blowing. Previous inspections have found that the organisation considers ‘Adult Abuse’ as mandatory training. Of the four staff files reviewed, one staff member had had training in March 06, but there was no evidence that the other three staff had been trained in Adult Abuse. However all staff receive induction training which includes a basic introduction into the symptoms of abuse and the action to take. The staff that met with the Inspector demonstrated an understanding of what is abusive and they were also able to outline the appropriate action to be taken to protect an individual’s interests. Tredegar DS0000014069.V290868.R01.S.doc Version 5.1 Page 18 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19 and 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. Tredegar provides a safe well-maintained home for residents to live that is clean, pleasant and hygienic. EVIDENCE: Tredegar is a detached property situated in a residential part of Eastbourne and within easy access of the shops and the railway station. There is a spacious lounge where activities are held and where residents can relax or chat together, as well as a second smaller lounge and a dining room. Accommodation is arranged over 3 floors and each floor can be accessed by a shaft lift. All radiators are guarded and emergency lighting is provided throughout the home. Thermostatic controls are fitted to the water outlets in bathrooms and en-suite facilities. The maintenance staff check the outlets each month and record the temperature of the water. Magnetic door guards have been fitted to the fire doors throughout the building that need to be held open and to most of the bedroom doors, enabling residents to choose to have their door open. The home is comfortably furnished and resident’s rooms are Tredegar DS0000014069.V290868.R01.S.doc Version 5.1 Page 19 individualised with their personal possessions and in some cases small items of their own furniture. Each room is lockable and residents are offered their own key if appropriate. The fire alarm is activated monthly and the staff on duty treat it as a fire drill. There are also incidental fire drills. Attendance is recorded and all the fire points are checked. It is unclear from the attendance lists how frequently night and day staff have attended over the last year. The value of developing a matrix to enable monitoring that all staff attend the required number of fire drills, was raised and agreed. 57 of the respondents in the service user survey answered that the Home is ‘always’ fresh and clean and 43 said ‘usually’. Policies are in place for managing infected linen and it is washed separately to other laundry. There is also a sluice room, containing a disinfector. The laundry room is situated whereby infected or soiled linen is not carried through areas where food is prepared or stored. The room has an impermeable floor and the wall finish allows easy cleaning. There are two washing machines with a 95°C wash and a sluice facility. Tredegar DS0000014069.V290868.R01.S.doc Version 5.1 Page 20 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30 Quality in this outcome area is adequate. This judgement has been made using evidence including a visit to the service. Some areas of recruitment need improving to ensure residents are protected by the procedures in place and the staff must be updated in their training to ensure that residents are in safe hands at all times. EVIDENCE: Tredegar has a registered nurse on duty for the full 24-hour period. Four carers support him or her during the morning, three in the afternoon and evening and two at night. The Manager works some shifts as the nurse in charge and some shifts as an extra, enabling her to provide staff support and to complete administrative work. These numbers appear adequate for the number of residents that the home is registered for. Agency staff are very rarely used as the organisation has its own ‘bank’ of staff to provide temporary cover. Catering and cleaning staff, maintenance and gardening staff are also employed. Of the fourteen care staff, nine have or are currently studying for the National Vocational Qualification (NVQ) level 2. It is the home’s policy that any new care staff are recruited with a view to them undertaking the ‘Skills for Care’ Induction and Foundation, leading into the NVQ level 2 if they do not already have it. Four staff files were inspected during the site visit. All had CRB disclosures, two references and a completed application form containing all the appropriate Tredegar DS0000014069.V290868.R01.S.doc Version 5.1 Page 21 information. One carer’s CRB had been received three months after her start of employment this year although a ‘Protection of Vulnerable Adults First’ (POVA First) check had been received before starting employment with the organisation. A POVA First check is applied for, for all new recruits, enabling staff to be employed to work under supervision until the full CRB disclosure is received. Copies of identification such as a passport were in two of the files, two of the four files had a photo and all files had a copy of the contract with terms and conditions of employment. An annual training programme is in place for both the trained nurses and the care staff. The mandatory training including fire training, ‘Moving and Handling’ and ‘First Aid’ are scheduled, although not all staff are up to date with these. There is also specialist training specific for the needs of the residents currently at Tredegar. All training is held in work time whereby staff have a minimum of three paid training years per year. Tredegar DS0000014069.V290868.R01.S.doc Version 5.1 Page 22 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 and 38 Quality in this outcome area is good. This judgement has been made using evidence including a visit to the service. Tredegar is well managed whereby the residents are kept safe and there are good quality assurance processes in place to ensure that the home is run in the best interests of residents. EVIDENCE: The Manager at Tredegar is a registered nurse with considerable experience in caring for the elderly and she has attained her Registered Manager’s Award (RMA). A deputy manager supports her in leading a team of carers and ancillary staff and it is anticipated she will be undertaking her NVQ level 4 later this year. An Area Manager for the organisation visits the home at least once a week. One member of staff commented that ‘the Manager is very approachable’ and ‘we can raise issues anytime’. Another confirmed that they ‘have confidence in the management team’. Tredegar DS0000014069.V290868.R01.S.doc Version 5.1 Page 23 The home undertakes annual service user surveys as part of its quality assurance. These are analysed and the results publicised within the home. A copy of the feedback and an analysis of the results are available in the main hall of the home for perusal. The analysis is also fed-back to staff at staff meetings and any areas for improvement are discussed. The organisation has an Annual Development Plan for the home and it has been found at past inspections that this changes, dependant on current issues and the needs of the residents. The Manager confirmed that this ethos continues. As has been found at previous inspections, some of the residents manage their own financial affairs but in general relatives or solicitors act on their behalf. The organisation’s Head Office holds individual accounts for some residents and their personal allowance is then sent out from that account, to the home. A balance of their account is held on computer. The resident then has a choice how their money is spent. Some residents have money brought into the home by relatives: residents can then either keep it in their room or it is held in the office safe and separate balance books with receipts are maintained. These were not examined in detail at this visit as previous inspections have always found them to be well maintained. Prior to the site visit the Manager returned data to be considered as part of the inspection. Training sessions that are scheduled for this year were included. However not all staff have had their annual fire training as the arranged sessions with the fire officer were cancelled as the fire officer was unable to attend. Similarly some staff had not had their mandatory annual training in ‘Moving and Handling’ although training sessions for this are scheduled for this year. Some have not been trained in First Aid or Food Hygiene: these sessions are not currently scheduled on the home’s training programme. Maintenance records were not explored in full at this inspection as the data previously provided by the Manager suggests that all checks are maintained. The Accident Log for the home was viewed: slips, trips and falls have been recorded and appropriate action taken. The deputy manager explained that all the accidents are reviewed and any trends and the action needed to reduce that trend identified. Tredegar DS0000014069.V290868.R01.S.doc Version 5.1 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 3 X 3 X X N/A 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 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 2 Tredegar DS0000014069.V290868.R01.S.doc Version 5.1 Page 25 Are there any outstanding requirements from the last inspection? No 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 OP8 Regulation 12 (1) 13 (1) Schedule 3 (3)(n) 2. 3. OP29 OP38 Schedule 2 (1) 18 (c)(i) Requirement Timescale for action 30/09/06 A protocol, that meets the NICE guidelines by ensuring residents are referred to a tissue viability nurse specialist if they develop a Stage 2 pressure sore, must be in place. Proof of identification and a 12/07/06 photo of each staff member must be held on file. Staff must have their mandatory 30/09/06 training updates in Fire and First Aid. Staff must be trained in Food Hygiene. Tredegar DS0000014069.V290868.R01.S.doc Version 5.1 Page 26 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 OP12 Good Practice Recommendations The reasons why medications are not administered should be clarified on the MAR charts. Residents should be made aware in advance, of the facilities and activities available to them, enabling them time to make a choice about their involvement. Tredegar DS0000014069.V290868.R01.S.doc Version 5.1 Page 27 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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