Inspection on 27/09/05 for Tredegar Care Home

This inspection was carried out on 27th September 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

Tredegar Care Home 12/07/06

Tredegar Care Home 16/02/06

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 27th September 2005 10:30 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Tredegar DS0000014069.V250718.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 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.V250718.R01.S.doc Version 5.0 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.V250718.R01.S.doc Version 5.0 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. 26th November 2004 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.V250718.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 over a period of nearly seven hours, beginning at 10.30am and finishing at 5.15pm. The Inspector met with the Deputy Manager initially and later during the Inspection, with the Registered Manager, another Manager from New Century Care and four other members of staff. The Inspector also had a tour of the building, and met with three residents and a relative before inspecting documentation and a range of key records. 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. Tredegar DS0000014069.V250718.R01.S.doc Version 5.0 Page 6 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.V250718.R01.S.doc Version 5.0 Page 7 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 5 Tredegar provides comprehensive information for prospective residents, enabling an informed choice about the suitability of the Home. Relatives and prospective residents are involved as far as possible in decisions about admission. A good assessment process is in place. EVIDENCE: Tredegar has a current Statement of Purpose and Resident’s Guide. Following an enquiry to the Home, prospective residents or their relatives are invited to look round and see which rooms are available. Once there is confirmation that the admission is desired, the Manager or Deputy Manager undertakes an assessment, either in the prospective resident’s home or in hospital. For individuals referred through Care Management arrangements, information from Social Services and/or Health is usually gathered verbally and informs the assessment process. An assessment pro-forma is completed and the information then put into the computer whereby a Care Plan can be generated based on that assessment. A letter is then sent to confirm the Home can meet the resident’s assessed needs before the resident moves in, initially on a trial basis. Emergency and unplanned admissions are avoided. The three residents Tredegar DS0000014069.V250718.R01.S.doc Version 5.0 Page 8 and a relative who met with the Inspector all felt they had been involved in their admission and are pleased with the Home. Tredegar DS0000014069.V250718.R01.S.doc Version 5.0 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): 7, 8 and 10 The Care Plans reflect the health, personal and social care needs of the residents and by being regularly reviewed, remain contemporary. Good practice in including residents or their relatives in their Care Plans is evident. Health care needs appear to be met well. Residents feel their privacy is upheld. EVIDENCE: Tredegar provides 24 hour nursing care if required and all the residents have a care plan which reflects their current health and personal care. Four care plans were viewed and the Inspector met with three of those residents and the relative of the other. The information from the pre-admission assessment is used to generate an initial care plan that is then shared and developed with the resident or a relative and signed by them. The Care Plans seen all included a copy of the Health and/or Social Services assessments. A risk assessment for falls, a nutritional assessment, a dependency assessment and an assessment of tissue viability are evident. All are reviewed monthly. Any broken areas of skin are recorded in the care plan and reviewed until resolved. Pressure mattresses are used when required and the monthly weighing of residents at risk of weight loss is prescribed and undertaken. The Home enables the residents to have access to the external health professionals they Tredegar DS0000014069.V250718.R01.S.doc Version 5.0 Page 10 need and staff accompany them to health appointments. Staff are committed to promoting privacy and respect for residents. Tredegar DS0000014069.V250718.R01.S.doc Version 5.0 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): 12, 13 and 15 The routines of daily living are varied and flexible, dependent on the individual choices of the residents. Relatives and visitors are welcome and included. The menus are varied and nutritious and specific dietary requests and needs are accommodated. EVIDENCE: There is an activity programme, organised by the activity co-ordinator at Tredegar, which is publicised on a calendar in the main entrance. Ad hoc recreation is also organised. On the day of Inspection, two entertainers were visiting and nine residents were joining in with the music and singing. There is a library of books, which are changed monthly, and ‘talking books’ are delivered for two residents with visual impairment. During the inspection, the Inspector found residents choosing to spend time in their room, or in the lounge. The rooms are furnished and personalised with resident’s own possessions. Visitors are welcome at any time and can meet their relative or friend in private in their room, or in the quiet lounge upstairs. The Home’s policy on maintaining the involvement of relatives, friends and representatives with their residents, is reflected in the Resident’s guide. The Inspector met with the chef and inspected the Home’s food preparation area. Two alternatives for lunch were being cooked, and a soft diet had also been prepared. All looked attractive and appetising. There is a 4-week menu and the residents are asked the day before what they would like. There is the Tredegar DS0000014069.V250718.R01.S.doc Version 5.0 Page 12 choice of both a cooked breakfast and a cooked supper. Meals can be taken in the Dining Room or residents can choose to eat in their rooms. All the residents who met with the Inspector praised the food as varied and tasty. A feeding programme for those residents with poor dietary intake, is completed before meals are served, ensuring time is given to all residents’ nutritional needs. Tredegar DS0000014069.V250718.R01.S.doc Version 5.0 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): 16 There is a complaints policy in the Home, which staff are aware of and the policy and contact details are publicised for residents. Staff and residents have confidence that concerns will be followed through. EVIDENCE: One complaint has been forwarded to the Commission since the last Inspection. The Home has discussed this fully with the staff and brought in changes in practise to address the concerns raised. There is a complaints procedure that identifies the timeframes for managing the complaint and the people who need to be involved. All complaints and the action taken are recorded and the outcomes fed back to the complainant. The details of how to contact the Commission, should the complainant wish to, are publicised in the Resident’s Guide. All the residents and relative seen demonstrated an excellent rapport with the staff and said they could talk to the Nurse in charge for the shift if they had any concerns and have confidence that their complaint will be listened to and acted upon. All the staff that met with the Inspector knew how to manage any complaints and had confidence that they would be acted upon by the Management Team. Tredegar DS0000014069.V250718.R01.S.doc Version 5.0 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): 19, 24 and 25 In general the Home is well maintained. However, some of the magnetic door guards do not work satisfactorily, increasing the risk of doors being propped open. There should be Risk Assessments for areas where radiators are unguarded. EVIDENCE: Tredegar provides comfortable, well-decorated accommodation over three floors, with a shaft lift enabling access for those with reduced mobility. There is a lounge and dining room on the ground floor, a first floor lounge provides a quiet area for relaxing with visitors, or reading, and a small sitting area on the second floor has tea and coffee making facilities for visitors to use. The bedrooms are comfortably furnished and each has a lockable storage space and telephone point. Curtain screens provide privacy for those residents who share a double room. A range of equipment and aids are installed to provide support and promote independence. Adjustable beds are provided for those residents needing nursing care. Any significant maintenance is built into the Home’s Annual Development Plan. Although the magnetic door guards are checked monthly, some were not supporting the doors to keep them open during the Tredegar DS0000014069.V250718.R01.S.doc Version 5.0 Page 15 Inspection. Some of the radiators in areas accessed by residents are not guarded. However the Manager has contacted the Inspector after the Inspection to confirm that they are ‘low surface heat’ radiators, which considerably reduce the risk of residents being burned in the event of an accident. Thermostatic controls are on all water outlets to provide water close to 43C. Tredegar DS0000014069.V250718.R01.S.doc Version 5.0 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): 27, 28 and 29 A team of care staff is employed to meet the health needs of clients and an appropriate skill mix is in place throughout the 24-hour period. Correct recruitment procedures are in place and new staff are appropriately supported and supervised. EVIDENCE: Registered Nurses lead each shift supported by care staff. There is a staff rota in place to cover the 24-hour period. 4 carers are rostered with a trained nurse during the day, 3 carers with a nurse for the afternoon and evenings and 2 carers with a nurse for the night shift. The Manager usually works Monday to Friday and is supported by the Deputy Manager. The Manager has just completed her Registered Managers Award (RMA). Kitchen, domestic, laundry and maintenance staff are also employed. Currently over 50 of carers are undertaking or have completed their NVQ level 2: part of the employment agreement for new staff is that they must undertake it. Once an educational audit has been undertaken in October, the Home hopes to support trained nurses from overseas to work as care staff whilst they complete their adaptation programme. This will be in conjunction with Brighton University. Three staff files were reviewed. All contained references received prior to appointment. Recruitment checks had been applied for. Staff are appointed once a POVA first check is received and then supervised until there is CRB clearance. Records indicate that new staff undertake induction training and that there is comprehensive training in place for all staff. Staff meetings are held monthly and used as an opportunity for practise discussion and information sharing. All members of staff are included. Tredegar DS0000014069.V250718.R01.S.doc Version 5.0 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): 31, 36 and 38 The Home is well managed and care staff are appropriately supervised. Training and maintenance checks are in place whereby the health, safety and welfare of residents and staff are promoted and protected. EVIDENCE: The Deputy Manager initially facilitated the Inspection as the Manager was on Annual Leave. However, she came in to meet with the Inspector. The Inspector found that staff and residents demonstrate the Management Team support each other in managing the Home in a positive and motivated way. The Registered Manager is a first level nurse with experience in caring for older people in the care home setting. She has recently completed her Registered Managers Award (RMA). Both staff and residents stated that the Manager is approachable and they find her helpful and supportive. Staff confirmed that they have sessions of supervision and records show these are generally every 1-2 months. The sessions are used, as an opportunity to discuss individual progress and identify any training needs. Staff have had their mandatory Tredegar DS0000014069.V250718.R01.S.doc Version 5.0 Page 18 training in Moving & Handling and in Fire Procedures, but the last training in First Aid is recorded as being in 2003. Documentation for safety checks were viewed and found to be in order. The Fire Alarm system and Emergency Lighting were last serviced in June 2005 and the last test was on 9th September 2005. The Fire Extinguishers were last serviced in November 2004 and the last monthly check ‘in house’ was on 5th September 2005. The last organised Fire Drill was on 3rd August 2005 during the day and the last night drill was on 1st August 2005. Equipment seen during the Inspection has all been serviced this year. Tredegar DS0000014069.V250718.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 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 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 x 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 x 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 x 18 x 2 x x x x 3 3 x STAFFING Standard No Score 27 3 28 3 29 3 30 x MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 x x x x 3 x 3 Tredegar DS0000014069.V250718.R01.S.doc Version 5.0 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. 2 Standard OP19 Regulation 23 (4)(a)(c) Requirement The Home must ensure the magnetic door releases are maintained to protect residents in the event of a fire. Timescale for action 30/11/05 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 Tredegar DS0000014069.V250718.R01.S.doc Version 5.0 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.V250718.R01.S.doc Version 5.0 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. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!