Inspection on 16/02/06 for Tredegar Care Home

This inspection was carried out on 16th February 2006.

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 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 12/07/06

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 Unannounced Inspection 16th February 2006 13:45 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.V282209.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.V282209.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.V282209.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. 27th September 2005 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. It is 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. Tredegar is arranged over three floors with a shaft lift providing access to all floors. There are two communal lounges, a dining room and access to a garden with a seating area. Tredegar DS0000014069.V282209.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place over a period of just over five hours, between 1.45pm and 7pm. It was facilitated by the Registered Manager and the Inspector was also able to meet with the Area Manager from New Century Care, who ‘oversees’ Tredegar, and two other members of staff. The focus of the inspection was to review those core standards and a sample of other standards not assessed at the last inspection and to explore the progress made with the Requirements in place. The inspection also provided the opportunity to meet several residents and a relative informally, chat with 2 residents in the privacy of their own room and to inspect some key records and documentation. This report should be read in conjunction with the report from the last inspection this year, on 27th September 2005. What the service does well: What has improved since the last inspection? The door guards to allow internal fire doors to be open, but close if the fire alarm is activated, have been adjusted and are now working effectively. This meets the Requirement from the last Inspection. Tredegar DS0000014069.V282209.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.V282209.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.V282209.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): 6 Tredegar is not designated as a service providing intermediate care. EVIDENCE: Tredegar offers respite care and also short-term rehabilitation following hospitalisation, or a significant event that requires a period of recovery. No rooms are reserved so any short-term support is dependent on there being rooms available. However, it does not provide intermediate care. Tredegar DS0000014069.V282209.R01.S.doc Version 5.1 Page 9 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 9 Some good practise is in place for the administration, storage and disposal of medication. However, the MAR sheets must be filled in correctly to reflect whether medication has been administered and if not, why not. EVIDENCE: Currently there are no residents at Tredegar who self-medicate. However a policy is in place for the administration of medication, updated in October 2005 and this includes a procedure for enabling residents who wish, to be responsible for his or her own medication. Their medication is kept in the locked drawer in their room. The Home orders one months supply for them: the staff monitor that it is being taken and maintain a record on the MAR sheet. The medication for the remaining residents is kept in the ‘Drug Room’. The majority is dispensed in blister packs, providing one months supply (the NOMAD system). There are also trays in the drug trolley named for each resident to enable medication not in the NOMADS to be separated for each individual. The name and telephone number of each resident’s GP, any allergy the resident may have and a photo of them, accompany their MAR sheet. A specimen signature for each of the nurses administering medication is also held. The MAR charts were examined: not all had been signed correctly. The Tredegar DS0000014069.V282209.R01.S.doc Version 5.1 Page 10 NOMADS were also checked: some medication had not been given although the MAR chart had been signed, with no code to explain why the medication had not been administered. A record of medication for disposal is maintained and signed by two staff: the Home then uses a Waste Management Company for disposal. The nursing staff administer medication and the second checker is a carer. Three senior carers have also been trained to administer ‘Over the Counter’ medication such as simple analgesia. Those staff who have completed their NVQ explore medication as part of that but in addition all staff undertake ‘safe handling of medicines’ training and are mentored by an NVQ assessor. The training is aimed at care staff but the Home considers it a good update for all staff. Carers are observed as checkers before being assessed as competent. Tredegar DS0000014069.V282209.R01.S.doc Version 5.1 Page 11 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 14 Residents at Tredegar are helped to exercise personal autonomy and choice. Their rooms appear homely and have been personalised with their own furniture and possessions. EVIDENCE: The philosophy at Tredegar is that residents should be as independent as they are able for as long as possible. During the inspection they were choosing to spend time either in the lounge or their rooms. The Inspector viewed two bedrooms on this occasion and found them to be personalised with the resident’s own possessions and furniture. Two residents who met with the Inspector said they are happy at the Home. One resident said that although there are some group activities organised, he would enjoy some more entertainment as he finds the time often passes slowly. When a new resident arrives the staff complete a questionnaire with them to identify their usual timetable, and any particular likes and dislikes. The Activity Organiser also takes a life history from the resident and identifies if there are any particular activities they enjoy. A Care Plan is subsequently developed which reflects their individual health needs, but specific emotional and social needs are not included. The Manager explained that these would usually be passed on informally and verbally at handover. A service user profile is also being introduced which specifies particular nutritional needs and any likes and dislikes so the cook is aware of individuals’ preferences. Tredegar DS0000014069.V282209.R01.S.doc Version 5.1 Page 12 Residents or their relatives take responsibility for their finances wherever possible and the Home does not act as the appointee for any resident. The residents’ key workers inform relatives if they notice a resident requires more toiletries etc; or residents can pay money which the Manager holds in the safe so that items can be bought for them as they request. Advocacy services are publicised enabling any residents to access them if they wish or need someone to speak on their behalf. Tredegar DS0000014069.V282209.R01.S.doc Version 5.1 Page 13 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18 The flowchart that has been added to the Home’s procedure for the Protection of Vulnerable Adults ensures the policy is comprehensive and the reader will contact all the appropriate personnel and agencies. A good programme of training in Adult Abuse is in place for all staff. EVIDENCE: There is a policy in place for the Protection of Vulnerable Adults, which explains the definitions of abuse and the action to take. Social Services are not identified as the lead agency for any investigation. However during the inspection the Manager discussed a flowchart, which leads the reader to contact Social Services if concerned about the possibility of abuse and also gives the contact details for the Commission. This was added to the current policy and the Manager confirmed that it would be included in future training. All staff had training in adult abuse, the year before last and approximately half last year. The Organisation has now agreed that it should be mandatory as annual training for all staff. A notice on the board confirmed that the next session had been arranged for 22nd February. The two staff who met with the Inspector were clear how to respond if they suspected Adult Abuse and both are attending the training in February. The Manager is aware that in the event of a member of staff being unsuitable to work with vulnerable adults, they must be referred for inclusion on the POVA register. Some of the residents handle their own financial affairs, or relatives are appointed to act on their behalf. The Home keeps clear records of all financial transactions which residents can have access to if they wish. Tredegar DS0000014069.V282209.R01.S.doc Version 5.1 Page 14 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 21 and 26 Tredegar has sufficient and suitable lavatories for the number of residents that can be accommodated and there are plenty of baths and showers to provide wash facilities. Good practice is in place to ensure the Home is clean and to minimise the risk of infection. The door guards have been adjusted and are now working effectively. This meets the Requirement from the last Inspection. EVIDENCE: A full tour of the Home was not undertaken at this inspection but the Inspector was able to see residents as they relaxed in the lounge and to chat with two residents and a relative who was visiting. There are ten rooms with en-suite facilities across the three floors and on the top floor a shower and toilet shared between two bedrooms. There are toilets near to the lounge and dining room on the ground floor and seven bathrooms across the three floors. There are also three showers suitable for wheelchair users. During the inspection, all areas seen were clean and free from odour. There is a policy in place, last reviewed in October 2005, that identifies the cause and risk of spread of infection, the need for notification to the Commission, the need for protective clothing, how to manage spillages and how to undertake Tredegar DS0000014069.V282209.R01.S.doc Version 5.1 Page 15 ‘Barrier nursing’. Protective clothing is provided for use in the kitchen and bathrooms. Any spillages are cleaned with disinfectant and the individual wears an apron and gloves. If a resident has an infection, staff wear aprons and gloves whilst caring for them. These are then disposed of into yellow bags in the room. Very soiled linen is placed in red bags then into yellow bags, notifying the laundry staff that it is contaminated and needs to be washed separately. There is a laundry room situated on the ground floor that has a non-slip cleanable floor and is an appropriate environment. Its position allows soiled linen to be brought down in the lift and taken there without needing to be carried through areas where food is stored or intruding on residents. There are two washing machines which both provide a hot wash at 95C. Both also have a sluice facility. There is also a tumble dryer. Staff are trained in the risk of infection and how to control its spread. During the last inspection, some doors were propped open as the magnetic door guards, despite being checked monthly, were ineffective. This was discussed at this inspection. The Manager confirmed that a new guard has been fitted to one of the two corridor doors that had been knocked and had been broken. The second guard is on order. The footplates on the bedroom door guards that were faulty have all been re-set. These were seen by the Inspector and were all working. The monthly checks continue and staff are aware that doors must not be propped open but that the guards may need to be adjusted. Tredegar DS0000014069.V282209.R01.S.doc Version 5.1 Page 16 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission 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): 30 All new staff receive an induction into the Home and the Organisation is committed to providing a good programme of staff training. EVIDENCE: New staff have orientation on their first day and are given an overview of fire procedures, how the call bell system works, how to use the care plans, Moving & Handling, Health & Safety and Confidentiality. They then undertake an induction programme, generally within 6 weeks of starting. A record of their learning is kept and once each area has been completed, signed off by both the staff member and their assessor (usually the Manager or Deputy Manager). Records show that training is offered to all staff and that they receive at least 3 days training per year. Much of the training is arranged within the Organisation but if a resident has a particular need the Area Manager confirmed that the they will source training: they will then either invite the trainer to come to Tredegar or seconde one member of staff externally who will then cascade the training to other staff ‘in house’. All carers who are recruited are expected to study for their NVQ level 2 and within the last 3-4 months, it has been made mandatory that staff undertake the Foundation for NVQ level 2 once they have been in post at least 6 weeks. Tredegar DS0000014069.V282209.R01.S.doc Version 5.1 Page 17 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 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): 33 and 35 Effective quality monitoring systems based on seeking the views of residents and their relatives are in place. There are good financial arrangements to ensure resident’s money is handled appropriately. EVIDENCE: The views of the residents are actively sought informally as there is an ‘Open Door’ policy within the Home, enabling staff, residents and their relatives to meet with the Manager or Deputy and express their views. There are resident, staff and family meetings held 4 times/year. Generally there is a fair attendance at them but complaints or concerns are rarely raised. A general questionnaire is sent out approximately once/year. The results are analysed and made public; a copy is also displayed in the main entrance of the Home. The Inspector viewed the findings from the last questionnaire: overall the feedback about the care and the staff was very positive. Different monthly quality assurance audits are also undertaken. The Organisation has an Annual Development Plan. The Area Manager explained that specific negative Tredegar DS0000014069.V282209.R01.S.doc Version 5.1 Page 18 comments from the resident survey would either be managed individually through the complaints process or if they were of a more general nature would be built into the Annual Development Plan. The Area Manager audits the Home annually and there are monthly visits as required by Regulation 26. Some of the residents handle their own financial affairs, or solicitors are appointed to act on their behalf. The Home’s Management Team does not act as the appointee for any of the resident’s financial affairs, nor does the Organisation. Residents or their appointee are invoiced monthly. The fees and any sundry items or services not included in the fees, are separated out on the invoice. The Home also holds personal monies for sundries and services, for those residents who prefer. Any money brought in is held in the safe and separate balance books are maintained. The Inspector examined the records held by the Home, for personal monies. Policies and Procedures for managing resident’s money are in place. Tredegar DS0000014069.V282209.R01.S.doc Version 5.1 Page 19 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X X X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 X 8 X 9 2 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 X 14 2 15 X COMPLAINTS AND PROTECTION Standard No Score 16 X 17 X 18 3 X X 3 X X X X 3 STAFFING Standard No Score 27 X 28 X 29 X 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X X 3 X 3 X X X Tredegar DS0000014069.V282209.R01.S.doc Version 5.1 Page 20 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 OP9 Regulation 13(2) 17 1a,3a Sch3.3i Requirement MAR sheets must be filled in correctly to reflect whether medication has been administered and if not, why not. Timescale for action 31/03/06 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. Refer to Standard 14 Good Practice Recommendations The emotional and social needs of residents should be included in the Care Plan to ensure all staff are aware of individual care needs. Tredegar DS0000014069.V282209.R01.S.doc Version 5.1 Page 21 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. Extracts may not be used or reproduced without the express permission of CSCI Tredegar DS0000014069.V282209.R01.S.doc Version 5.1 Page 22 - 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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