Inspection on 10/09/09 for Trefula House

This inspection was carried out on 10th September 2009.

CQC found this care home to be providing an Adequate service.

The inspector found no outstanding requirements from the previous inspection report, but made 3 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Trefula House 20/09/07

Trefula House 17/08/06

Trefula House 01/12/05

Trefula House 15/06/05

Trefula House 11/01/05

Trefula House 08/07/04

Trefula House 23/03/04

Similar services:

The Vicarage

Fairfields Country Rest Home

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5 Seafield Road

Poldhu

Queensmount

Trevaylor Manor

Didsbury Court Rest Home

Extracts from inspection reports are licensed from CQC, this page was updated on 26/11/2009.

Inspecting for better lives Key inspection report Care homes for older people Name: Address: Trefula House St Day Redruth Cornwall TR16 5ET     The quality rating for this care home is:   one star adequate service A quality rating is our assessment of how well a care home, agency or scheme is meeting the needs of the people who use it. We give a quality rating following a full assessment of the service. We call this a ‘key’ inspection. Lead inspector: Diana Penrose     Date: 1 0 0 9 2 0 0 9 This is a report of an inspection where we looked at how well this care home is meeting the needs of people who use it. There is a summary of what we think this service does well, what they have improved on and, where it applies, what they need to do better. We use the national minimum standards to describe the outcomes that people should experience. National minimum standards are written by the Department of Health for each type of care service. After the summary there is more detail about our findings. The following table explains what you will see under each outcome area. Outcome area (for example Choice of home) These are the outcomes that people staying in care homes should experience. that people have said are important to them: They reflect the things This box tells you the outcomes that we will always inspect against when we do a key inspection. This box tells you any additional outcomes that we may inspect against when we do a key inspection. This is what people staying in this care home experience: Judgement: This box tells you our opinion of what we have looked at in this outcome area. We will say whether it is excellent, good, adequate or poor. Evidence: This box describes the information we used to come to our judgement. Copies of the National Minimum Standards – Care Homes for Older People can be found at www.dh.gov.uk or bought from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop 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 Our duty to regulate social care services is set out in the Care Standards Act 2000. Care Homes for Older People Page 2 of 34 Reader Information Document Purpose Author Audience Further copies from Copyright Inspection report CSCI General public 0870 240 7535 (telephone order line) Copyright © (2009) Commission for Social Care Inspection (CSCI). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CSCI copyright, with the title and date of publication of the document specified. www.cqc.org.uk Internet address Care Homes for Older People Page 3 of 34 Information about the care home Name of care home: Address: Trefula House St Day Redruth Cornwall TR16 5ET 01209820215 01209822499 admin@trecaregroup.co.uk Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): Type of registration: Number of places registered: Trecare Group Limited care home 34 Conditions of registration: Category(ies) : Number of places (if applicable): Under 65 dementia mental disorder, excluding learning disability or dementia old age, not falling within any other category physical disability Additional conditions: Date of last inspection Brief description of the care home Trefula Nursing Home is situated on the outskirts of the village of St Day, near Redruth. It is in a quiet secluded area and has extensive views of the surrounding countryside. The home provides nursing and personal care for up to thirty-four elderly people, there is a Registered Nurse on duty at all times. The homes registration allows for people with a physical disability, dementia or mental disorder. The home was first registered in 1992 and comprises of a two-storey house with an extension to the rear. Care Homes for Older People Page 4 of 34 Over 65 12 12 22 0 0 0 0 6 Brief description of the care home Accommodation is provided in two distinct areas. There are toilet and bathing facilities. Some bedrooms have en suite facilities. Meals are prepared in a comparatively small kitchen on the ground floor and served in the dining rooms or lounges. Residents can choose to eat in their individual bedrooms if preferred. The home has extensive gardens that are well maintained. Access for residents is restricted in certain areas for safety reasons. There is a large car park at the front of the home. There is a flexible visiting policy and residents can see their visitors in private. Information about the home is available in the form of a residents guide, which can be supplied to enquirers on request. A copy of most recent inspection report is available in the home. Current fees range from 394 to 1383 pounds per week this information was supplied during the inspection. Additional charges are made in respect of private healthcare provision, hairdressing and personal items such as newspapers, confectionary and toiletries. Care Homes for Older People Page 5 of 34 Summary This is an overview of what we found during the inspection. The quality rating for this care home is: Our judgement for each outcome: one star adequate service Choice of home Health and personal care Daily life and social activities Complaints and protection Environment Staffing Management and administration peterchart Poor Adequate Good Excellent How we did our inspection: An Inspector visited Trefula Nursing Home on the 10 September 2009 and spent eight hours at the home. An expert by experience, employed by the Care Quality Commission, accompanied the Inspector for four hours. She spent her time talking with people using the service and staff, she also observed life in the home and toured the premises. This was a key inspection and an unannounced visit. The purpose of the inspection was to ensure that peoples needs are properly met, in accordance with good care practices and the laws regulating care homes. The focus was on ensuring that residents placements in the home result in good outcomes for them. All of the key standards were inspected. On the day of inspection 32 people were living in the home. The methods used to Care Homes for Older People Page 6 of 34 undertake the inspection were to meet with people using the service, the registered provider, relatives and staff to gain their views on the services offered by the home. The manager was on annual leave on the day of this inspection. Records, policies and procedures were examined and the inspector toured the building. The manager had returned an Annual Quality Assurance Assessment which was used to inform this inspection. We received completed surveys from three residents, six staff and three healthcare professionals which were also used to inform this inspection. This report summarises our findings. What the care home does well: What has improved since the last inspection? Refurbishment has continued to improve the home, several bedrooms have been redecorated and flooring has been replaced. New windows were being installed during this inspection and we were told there has been a new boiler installed. Commodes have been replaced where necessary. An outside agency has been employed to interview all staff and obtain an impartial view on the training provided by the Company and any additional training that staff would like to undertake. There is now a person within the Trecare group that is responsible for overseeing staff training. Several forms and documents have been improved / produced. Two activities coordinators have been employed. Care Homes for Older People Page 8 of 34 What they could do better: If you want to know what action the person responsible for this care home is taking following this report, you can contact them using the details set out on page 4. The report of this inspection is available from our website www.cqc.org.uk. You can get printed copies from enquiries@cqc.org.uk or by telephoning our order line –0870 240 7535. Care Homes for Older People Page 9 of 34 Details of our 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) Outstanding statutory requirements Requirements and recommendations from this inspection Care Homes for Older People Page 10 of 34 Choice of home These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People are confident that the care home can support them. This is because there is an accurate assessment of their needs that they, or people close to them, have been involved in. This tells the home all about them and the support they need. People who stay at the home only for intermediate care, have a clear assessment that includes a plan on what they hope for and want to achieve when they return home. People can decide whether the care home can meet their support and accommodation needs. This is because they, or people close to them, have been able to visit the home and have got full, clear, accurate and up to date information about the home. If they decide to stay in the home they know about their rights and responsibilities because there is an easy to understand contract or statement of terms and conditions between them and the care home that includes how much they will pay and what the home provides for the money. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. There is information available for prospective residents and enquirers which is in the process of being updated. We saw no written evidence to show that peoples needs have been assessed by a suitably qualified member of staff to assure that the home can meet their individual needs, other than some Information gathered from external healthcare professionals. Evidence: We were shown a draft copy of a new statement of purpose which required further input from the manager before it was to be implemented. The registered provider told us that they intend to have a copy in each residents room for the resident and their family to refer to. We looked at the care files of three people admitted to the home since June 2009 and one admitted in December 2008. The two recent files held assessment documentation from external agencies and hospital discharge information. We saw no pre-admission Care Homes for Older People Page 11 of 34 Evidence: assessments undertaken by staff at the home in any of the files. Since this inspection the manager has told us that one file did not have an assessment as she had disposed of it but she said the others were in the files. A nurse showed us a copy of a blank assessment form that she said was the format in use. She told us that the completed assessments used to be held in matrons office. A member of staff looked in the office to see if assessments were filed there but none could be found. We were shown a new form that is to be implemented for recording the pre-assessment information, it allows for more information regarding mental health needs to be recorded. Staff told us that the manager usually undertakes the pre admission assessments herself but sometimes one of the Registered Mental Nurses does them. The manager told us that she often takes someone with her. Care Homes for Older People Page 12 of 34 Health and personal care These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People’s health, personal and social care needs are met. The home has a plan of care that the person, or someone close to them, has been involved in making. If they take medicine, they manage it themselves if they can. If they cannot manage their medicine, the care home supports them with it, in a safe way. People’s right to privacy is respected and the support they get from staff is given in a way that maintains their dignity. If people are approaching the end of their life, the care home will respect their choices and help them feel comfortable and secure. They, and people close to them, are reassured that their death will be handled with sensitivity, dignity and respect, and take account of their spiritual and cultural wishes. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Individual care plans are generated for each resident that inform and direct staff on the care to be provided, when they are completed correctly. There is a medicines system in place; an updated policy, specific care planning and extra attention in some areas will provide a safer system and provide more protection for people using the service. We saw that residents privacy was appreciated but there was little interaction or conversation between staff and residents to ascertain that they are respected as individuals.. Evidence: We looked at four care files and the care plan documentation was in the same format as the last inspection. The forms cover health, social and personal care needs. They were available to staff but the nurses seemed to access them more than the care staff. They were divided into relevant sections and nurses told us that when they are completed correctly they are very detailed and direct staff in the care to be provided. The care plans we saw had varying levels of detail written on them and they were not very person centred. There was evidence that reviews take place and that the plans are updated but we saw no multi disciplinary review documentation. The daily records Care Homes for Older People Page 13 of 34 Evidence: we saw refer to the care plans and notes are kept to a minimum. We were told that the nurses make notes every day and care staff only write in the records if there is something specific to record. They have a separate daily living profile that they complete each day and we saw these in the care files. The Annual Quality Assurance Assessment (AQAA) states that the manager intends to make the care plans more person centred and to adopt the Liverpool Care Pathway for end of life care. Risk assessments we saw included Waterlow scoring, nutrition, moving and handling, falls and Barthel scoring. There were no risk assessments for people who require the use of bed rails or any other restraint. The registered manager was going to address this following the last inspection. We were shown a new risk assessment form that is to be introduced soon for this purpose it included space for residents or their representative to consent to the use of bed rails. We were told that work on the Gold Standard Framework (GSF), for end of life care, has recommenced and that some training has taken place. The records show that doctors and other healthcare professionals visit residents when required. One of the nurses we talked to said she is a moving and handling trainer and regular training takes place in the home. She said the home has sufficient equipment for moving and handling. We were told there is also suitable pressure relieving equipment, some of which is hired and some owned by the Company. Nurses told us they have a good relationship with the doctors surgeries and other specialist healthcare professionals. Completed nutritional screening forms were seen as part of the admission assessment and there is some evidence of reviews. A nurse told us that most people are weighed monthly and that new weighing equipment was due to arrive soon which would enable all residents to be weighed more accurately. It was difficult to gain the views of people using the service as many could not communicate with us. Care seemed to be task orientated rather than individualised and there appeared to be no structure or organisation for the care staff, many of whom were new to the role. Three surveys were received from people using the service and the people felt their needs were met. People we talked to said they have little choice on what they do each day but staff are caring. One person said she did not want to be in a home but said that she was treated OK. We saw that staff did not interact well with people using the service there was little conversation or motivation. One resident had a wet blouse with what looked like cornflakes down her front and no one had done anything about it. Care Homes for Older People Page 14 of 34 Evidence: We were shown a medicines policy that required updating to state the actual process used in the home. An up to date copy of the guidelines set by the Royal Pharmaceutical Society was seen. Medicine reference books and patient information leaflets (PIL) were seen. A monitored dosage system of medication was seen in use and there was appropriate storage in three areas of the home. Controlled drugs were held in one area of the home in an appropriate cupboard. It was noted that money was held in this cupboard; the separate storage provision for money was discussed with a member of staff. Two medicines fridges were seen; the records of temperature monitoring were shown to us and showed that monitoring is not regular. Staff said the temperature of the rooms that store medicines is not monitored. We did not check the temperature on this occasion but it was above the recommended limit at the last inspection; monitoring is recommended to ensure the stability of medicines is maintained. We were told that no residents administer their own medicines. Records were examined for the receipt, administration and disposal of medicines in two areas. They were generally satisfactory but we noted that medicines that are refused or dropped on the floor are not recorded in the disposal records. We saw that handwritten instructions on the medication administration charts were not witnessed with two staff signatures, although some were signed by a doctor which is good practice. Photographs of each resident were seen with their medication administration charts. We were told that there are no diabetics prescribed insulin injections at the moment. Blood sugar monitoring takes place and we were told that people do not have an individual machine. We were told this will be addressed. We were told that no specific care plans are in place for people prescribed to have medicines administered, when required, or any directions on how to make an assessment if this medicine is required. We were however shown a suitable format that will soon be implemented. We were told that the nurses administer all medicines in the home and keep themselves up to date. Level 1 medicines training for care staff has not yet been formalised and included in the induction process. Staff said they respected peoples privacy and dignity but this could not be confirmed by people using the service. We saw that most people in their rooms had their doors open but we could not evidence whether people wished to have their doors open or not. Two carers were observed operating a hoist to move a resident from a wheel chair to an arm chair, this procedure was carried out in an unorganised way and Care Homes for Older People Page 15 of 34 Evidence: although the resident was safely put into a chair there was no conversation or words of reassurance. This is not a dignified procedure for anyone to experience; a few kind words and some reassurance would have shown some consideration for the resident. Staff were seen assisting residents with their lunchtime meal but there was very little conversation or encouragement. Care Homes for Older People Page 16 of 34 Daily life and social activities These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: Each person is treated as an individual and the care home is responsive to his or her race, culture, religion, age, disability, gender and sexual orientation. They are part of their local community. The care home supports people to follow personal interests and activities. People are able to keep in touch with family, friends and representatives. They are as independent as they can be, lead their chosen lifestyle and have the opportunity to make the most of their abilities. People have nutritious and attractive meals and snacks, at a time and place to suit them. There are no additional outcomes. This is what people staying in this care home experience: Judgement: People using this service experience poor quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. There is no activities programme or regular activities taking place, entertainers do not visit very often and staff interaction with people is poor and does not motivate them in any way. It is not evident that people using the service live a life of their preference or that there are many choices available to them. Evidence: We were told that a full time activities coordinator has been employed and that very soon another member of staff will be assisting her. The coordinator told us she had been on sick leave for six weeks and had only recently returned to work. She said there is no programme but she spends the day divided between the different areas of the home and she talked about some of the activities she provides for residents. One resident told us she gets very lonely in the home and someone to talk to would be nice. We saw no activities taking place during this inspection. There was music playing in one lounge in the morning, other than that the television was on all day. No one seemed to be watching it. One person said he did not know what the programme was and he could not hear it but it was something to do just looking at it. In the afternoon a carer was seen looking at a magazine with a resident and another walking around the corridor with a resident; their interaction was good. Care Homes for Older People Page 17 of 34 Evidence: When we arrived at 09.20 two women were asleep in one lounge with the television on, throughout the day people were seen sleeping in both lounges and in their rooms. Staff of all grades were seen in the lounges but most were not communicating or motivating residents to converse or interact with them in any way. There was no sense of fun or any enjoyment of any kind between staff and residents. We observed several people employed as carers but it seemed as if their job was to stand around talking to each other, just looking at the residents. The expert by experience did not observe any kind interaction between carers and residents during this inspection. There are several new inexperienced care staff employed and it may be relevant for them to have training in communication. The manager told us following this inspection that staff had told her they felt uncomfortable and unsure how to react as for many it was their first experience of an inspection. We were shown the format for life history books that are being compiled with residents and their families. We saw records maintained by the activities coordinator, these showed a date but no year and were not signed. The records gave a list of attendees with some information on whether or not sessions were enjoyed. Individual records were also seen in the care files which gave more detail as to emotional responses and what people gained from the sessions. A diary also contained some activity records in the secure unit, a nurse said this helps staff see what has taken place during the day. There appeared to be a great deal of duplication. The records show that activities do not take place on a regular basis and care staff do not record any interaction they have with residents. We were told that entertainers have not visited the home for some time and that the annual fete was cancelled due to the weather; it will now take place at Christmas. Staff said that families visit and bring in their pet dogs and young children which residents love to see. They said that activities include skittles, parachute games with music, netball, baking and making cards for Christmas. We were also told that a vicar visits if residents request it but no one goes out to church. We were told that none of the residents go out socially they only leave the home if they have a hospital appointment to attend. We were told that two people in particular are taken for walks in the garden but this was not evident during this inspection. The garden has been neglected and the enclosed garden accessed from the secure unit has not been developed into a sensory area which was the plan two years ago. The AQAA states that they hope to develop personalised social and leisure plans using information from the life history books and to provide regular outings. Invite more (and different) entertainers to the home and investigate other specialist activities, for example music therapy. Staff are to train in aromatherapy and massage. They state Care Homes for Older People Page 18 of 34 Evidence: they will be organising a separate Christmas fayre and raffle as well as organising a larger summer fete. We were told there is a very large sum of money in the residents fund and staff are putting forward ideas as to how to utilise this money. We saw a visitors record that showed that family and friends visit. There were visitors in the home during this inspection. One man said he can visit his wife when he likes, there are no restrictions. People using the service were not able to express their views very well or tell us very much about choices available to them. One woman said she does as she likes another said she does not have a choice of when she wants to get up or go to bed, the night staff get her out of bed between 5.30 and 6.00am to wash and dress her before the day staff come on duty and she goes to bed around 7pm. She was not happy about this routine but did not like to complain. There were choices available on the menu; most people had the roast dinner on the day of this inspection. Residents had their own possessions in their rooms, some were much more personalised than others. The registered provider said that some people had chosen the colours for the decoration of their rooms. The menu we saw was handwritten, it was varied and nutritional. There was a choice of two hot meals at lunchtime and at teatime. The cook told us that people have a cooked breakfast if they ask for it. He also told us that fresh vegetables are on offer and that fruit is available with the afternoon tea. He said that cakes are homemade and cakes are made for residents birthdays. Staff told us that drinks and snacks are available on request. Plenty of water and fruit squash was seen available for residents. The lunchtime meal was served in the dining room, lounges or individual bedrooms. We noted that very few people went to the dining room and that the dining tables in the secure unit were not being used. A nurse told us they tend to get used at breakfast and teatime more than at lunchtime. Several people had lunch in their rooms, some were seen being assisted but others were seen asleep with their lunch left on the table beside them. Staff told us the food is good and two residents told us they enjoy the food provided. The three surveys returned told us that people always enjoy the food. Some people were given asistance with their meal but as mentioned previously there was little conversation observed or words of encouragement. Care Homes for Older People Page 19 of 34 Complaints and protection These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: If people have concerns with their care, they or people close to them know how to complain. Any concern is looked into and action taken to put things right. The care home safeguards people from abuse and neglect and takes action to follow up any allegations. People’s legal rights are protected, including being able to vote in elections. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. There are suitable policies in place for complaints and adult protection but there is no system in place to show that complaints are investigated or acted upon. Not all staff have received training in respect of adult protection to ensure that people using the service are safeguarded, but we were assured that this is being arranged. Evidence: We were told that the complaints policy was same throughout the group of homes and this was seen to be suitable at the last inspection. There was no method seen in the home for recording complaints, the action taken and the outcome. We were shown some details of concerns raised that were held in residents files or staff files. There was little evidence that these were investigated, by whom or what the outcome was. The AQAA states that there is clear documentation and complaints are followed up promptly as per procedures and a complaints file is maintained. Thank you letters and cards were seen in the file but were not dated. Concerns have been raised to the Commission since the last inspection, they mainly concern an individual resident although some issues could affect other residents. The concerns have included the lack of stimulation and activities, lack of individual choice, lack of staff interaction, their attitude and lack of respect for residents, and the TV on but no one watching it. Also Call bells being left out of reach and staff drinking tea while bells are not answered. Some of these concerns have been upheld during this inspection. Care Homes for Older People Page 20 of 34 Evidence: We saw the whistleblowing policy that refers to the No Secrets document and an adult protection policy. There is also a copy of the Local Authority inter agency procedures and alerters guide in the home. The training records were seen and show that several staff have not attended adult protection training, the general manager told us that this has been identified and is in hand, most of the staff are new recruits. The training will take place in house provided by staff from the Department of Adult Social Care, it will include training on the Mental Capacity Act and Deprivation of Liberties. There has been one safeguarding referral regarding an employment agency member of staff and a resident, the case has been closed. There is a secure facility for the storage of money in the home. Care Homes for Older People Page 21 of 34 Environment These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People stay in a safe and well-maintained home that is homely, clean, pleasant and hygienic. People stay in a home that has enough space and facilities for them to lead the life they choose and to meet their needs. The home makes sure they have the right specialist equipment that encourages and promotes their independence. Their room feels like their own, it is comfortable and they feel safe when they use it. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home is comfortable and well maintained but there are offensive odours in some areas which is unpleasant. The bathing facilities require upgrading to ensure that suitable aids and adaptations are provided for people with dementia or a mental disorder and consider moving and handling safety. The grounds are accessible but do not provide a pleasant safe place for people to sit or walk about. Evidence: The inspector and the expert by experience toured the building separately. The home was reasonably clean and warm with comfortable furniture but there were several parts of the home that smelt of urine, including the lounges. The building appeared to be well maintained and new windows were being installed during this inspection. We observed the bathing facilities to be very clinical and only two of the five were in use. We were told that the bathing facilities in the secure unit had been reviewed but nothing has changed. One bath has very high sides and is unsuitable therefore the room is used for the storage of equipment. The other bathroom is poorly designed, with confined space for staff assisting residents onto the bath hoist but is still in use. The provision of a wet room was discussed with the registered providers in October 2005 and we were told during this inspection that this is still planned for the secure unit. The registered provider told us about plans to remove three unused toilets to provide storage space. The sink taps in the rooms that we saw were not suitable for Care Homes for Older People Page 22 of 34 Evidence: people with arthritis and in one bathroom the hot tap was running; this could have been the result of a resident not having the ability to turn it off. Residents care plans in the secure unit are now securely held in locked cabinets. The laundry was seen and we saw two washers and two driers. There are three sluices with washer disinfectors in the home. We saw that hand-washing facilities were appropriate and alcohol hand cleansing gel was in use. We saw disposable gloves and aprons around the home for staff use. The grounds have been neglected and there were fallen leaves making it unsafe for elderly people to walk around. The enclosed garden off the lounge in the secure unit which could be accessed by people using the service has not been converted into a sensory garden with seating and attractive flowerbeds as planned at the last inspection two years ago. The registered provider told us this is still the plan for this area but not a priority at the moment. Staff told us that not many people go out in the grounds and those that do are escorted by staff. We were told that a new boiler had been installed; there were bouts of noise throughout this inspection which we were told were coming from the boiler or the pipes, apparently this has always been a problem. The AQAA told us that one bathroom has been refurbished and a new wet room has been provided on the first floor. New commodes have been purchased and there is a rolling programme to replace the beds and mattresses in the home. The AQAA also told us that future plans include the ongoing purchasing of new furniture and refurbishment of building. The provision of a wet room, new office, drugs storage and treatment area on the ground floor. Also improved equipment storage areas and relocation of the laundry. The providers would like to develop the dementa wing to include a further 5 or 6 bedrooms. Care Homes for Older People Page 23 of 34 Staffing These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have safe and appropriate support as there are enough competent staff on duty at all times. They have confidence in the staff at the home because checks have been done to make sure that they are suitable to care for them. Their needs are met and they are cared for by staff who get the relevant training and support from their managers. There are no additional outcomes. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Staffing levels appear to be sufficient but the skill mix of staff needs to be addressed to ensure that peoples needs can be fully met. The Company are striving to provide training for staff and a needs analysis has taken place to ensure that training will benefit the needs of the home; this will include increasing the number of staff with NVQ qualifications, currently at 45 . Recruitment procedures are not robust and do not offer protection to people using the service. Evidence: We were told there were no staff vacancies at the moment. From examining the staff files and talking to staff it was evident that several new care staff had been employed over the past three months. Several of the new carers have not worked in a care setting before and the nurses said they needed to ensure they were well supervised which was difficult sometimes. Nurses said they required training in dementia and mental disorders, which had already been identified. There are only two Registered Mental Nurses employed and the general nurses have to work in all areas of the home, they have not had their competencies assessed for working with people who have mental health problems. Work needs to be done to ensure that the skill mix of staff is suitable to meet the needs of people using the service at all times. We were told that on average there are two nurses with 5 or 6 care staff on duty during the daytime and one nurse with 5 or 6 care staff overnight. In addition during Care Homes for Older People Page 24 of 34 Evidence: the day there are generally 3 housekeepers, 1 cook, 1 kitchen assistant, 1 laundry worker, 1 maintenance person and 1 or 2 activity coordinators. The duty rota was confusing, it would be beneficial to record staff qualifications against their name to identify NVQ levels for example. Staff told us the numbers of staff on duty were sufficient and this appeared to be so; some staff appeared to have time on their hands to chat amongst themselves. People who could tell us said the staff are kind and residents surveys told us there are usually enough staff available to meet peoples needs. One person told us she has to wait quite a while sometimes for her call bell to be answered. Three staff surveys told us that communication is a problem and needs to be improved. The AQAA told us that 45 of care staff have an NVQ either at level 2 or 3 and copies of NVQ certificates are kept on file. We were told that 19 care staff have shown an interest in commencing NVQ training and we were shown a list of the names put forward. Six staff files were inspected, five were for new recruits. Not all of the records required by legislation were held. Only three files held a photograph of the employee and only two a job description. Two did not have any evidence of induction but we were told the paperwork was probably with the employee. The dates of employment were missing from four files but a member of staff told us the dates for two of these from the duty rota. None of the files held terms and conditions of employment. Each person had a POVA check and three a full CRB check. One person had commenced work prior to the POVA check being obtained. There was no evidence of the supervision arrangements for staff commencing prior to the full CRB disclosure being obtained. Some staff had commenced work without two satisfactory references, only three people had the required two references. We were told that the recruitment documentation is dealt with at the administration office, which is at another home. The manager must ensure that the relevant documents are on file in the home prior to people starting work and that appropriate supervision arrangements are in place. We were shown an employee handbook, the GSCC code of conduct, an initial induction sheet and an induction booklet. We were told that these documents and the policies for dealing with aggression, physical intervention, challenging behaviour and the Mental Capacity Act are given to all new employees. We were told that moving and handling training takes place within the first week of employment and that other mandatory training takes place as soon as possible. We saw some completed induction booklets that had been signed by a person supervising the employee. Care Homes for Older People Page 25 of 34 Evidence: We were shown a training matrix, the master copy is held on a computer at the administration office. It showed that statutory training takes place however there are some gaps on the record. POVA training was not up to date and the General Manager discussed this after the inspection. Other areas of training such as dementia, Mental Capacity Act and Deprivation of Liberties also had large gaps in the records. We were told that new training supplier, that is part of the local regeneration scheme, is to be utilised and someone from the company had already interviewed all of the staff and undertaken a training needs analysis. A member of Trecare staff is working across the group of homes and is responsible for co-ordinating staff training. She was helping us with this inspection and was enthusiastic in her role. She told us she had only been at Trefula for three weeks but she was aware of most of the systems in place and where to find documentation and so on. Staff told us they had been interviewed about training and were looking forward to attending various courses, these included dementia, POVA, literacy and numeracy skills and NVQ training. The AQAA told us that the manager intends to continue through the group to develop greater depth in the in-house training which will afford the flexibility to deliver quality training specific to the home. Ensure that regular supervision and annual appraisals are maintained and recorded and review staff contracts and ensure that job descriptions are available for all staff Care Homes for Older People Page 26 of 34 Management and administration These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have confidence in the care home because it is led and managed appropriately. People control their own money and choose how they spend it. If they or someone close to them cannot manage their money, it is managed by the care home in their best interests. The environment is safe for people and staff because appropriate health and safety practices are carried out. People get the right support from the care home because the manager runs it appropriately with an open approach that makes them feel valued and respected. The people staying at the home are safeguarded because it follows clear financial and accounting procedures, keeps records appropriately and ensures their staff understand the way things should be done. They get the right care because the staff are supervised and supported by their managers. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. There is a new manager in post who intends register with the Care Quality Commission. She has been developing systems in the home but must ensure that recruitment, staffing and the admission of new residents complies with legislation and safeguards people using the service. There are systems in the home for dealing with residents money and health and safety that aim to protect people from harm. Evidence: There is no registered manager at the moment although the present manager told us she has sent her registration application form to the Care Quality Commission. She is a Registered Nurse in Learning Disabilities and has commenced the Leadership and Management Award for Care Services. She was on annual leave during this inspection and a Registered General Nurse was in charge of the home. Most staff told us they felt supported by the manager and that she works well with the residents. A few people said she has upset some staff but there was no further explanation. One person said she is very abrupt and another said she does not have Care Homes for Older People Page 27 of 34 Evidence: much to do with her. Survey comments include The present manager is efficient and caring, She acts on issues as soon as possible, The manager is unapproachable and can be quite blunt and rude to staff at times and I dont feel appreciated at Trefula. We were told that the manager has been approached about admitting younger residents and some details were on a board. This was discussed with the manager after this inspection and she must be mindful to admit people within the registration categories and apply for a variation if necessary. Recruitment procedures have not been robust as stated in the previous section of this report and the manager is aware that this is a breach of regulations. She must ensure that as well as sufficient staff the skill mix and competency of staff must be appropriate to meet the individual needs of people using the service. Staff and residents said the Registered Provider and the General Manager visit the home, they walk around the building and they chat with them. The registered provider completes a report each month as detailed under regulation 26 of the care homes regulations 2001. We were told that the bi-annual quality assurance surveys have recently been sent out to relatives. We saw some that had been returned and they were mostly positive. We were told they will be collated and a report written when more have been received. Staff told us they have regular staff meetings and we saw an agenda on a notice board and minutes in a file. The minutes showed that staff can air their views and that issues get addressed, they also showed that the manager has voiced her appreciation of the staff. We were told that a residents committee is being set up by the staff to organise events and fundraising. The manager also intends to talk to all residents regularly to get their opinions of the home. We were told that an external consultant undertakes health and safety audits and that accidents in the home are also audited. The manager has completed an Annual Quality Assurance Assessment (AQAA) for the Commission and returned it within the specified timescale. We were told that the policy for the management of residents money is the same as the other homes in the group and is under review. Money is held in a residents account dealt with by the administration office staff. We were told that petty cash is held in the safe to purchase items for people and the receipts are sent to the administration office where an administrator deals with the residents account and Care Homes for Older People Page 28 of 34 Evidence: invoices relatives for purchases as necessary. We were told that if anyone has a negative balance in the account it is reimbursed by the Company and then the relatives are invoiced. Electronic records are maintained of all transactions and the accounts are printed each month for the resident or their representative and we saw examples of these. Receipts are kept for purchases and for money received on behalf of residents. Two members of staff have access to the safe when the manager is absent from the home. External consultants have been employed to assist with health and safety management and they also supply training on a rolling programme. This system appears to have improved staff attendance. They have undertaken a full health and safety audit with an action plan and they have written policies for the home, a fire risk assessment and developed a hazard analysis and critical control point (HACCP) system. Moving and handling training is undertaken with a member of staff who said she has completed the train the trainers course. The AQAA told us that the service and equipment checks are up to date and the maintenance and fire records were seen and up to date. There were no accident records in the file we were shown from February to July 2009. 5 accidents were recorded for August and 2 for September. The Environmental Health Officer visited during this inspection and the report was good, there were some cleaning and maintenance issues. The records show that kitchen staff have undertaken food hygiene training and the cook we spoke to said he had achieved the food hygiene foundation certificate. The cook said that visitors no longer enter the kitchen to make drinks but staff do despite the fact that they have their own facility on the second floor of the building. Care Homes for Older People Page 29 of 34 Are there any outstanding requirements from the last inspection? Yes £ No R Outstanding statutory requirements These are requirements that were set at the previous inspection, but have still not been met. They say what the registered person had to do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. No. Standard Regulation Requirement Timescale for action Care Homes for Older People Page 30 of 34 Requirements and recommendations from this inspection: Immediate requirements: These are immediate requirements that were set on the day we visited this care home. The registered person had to meet these within 48 hours. No. Standard Regulation Requirement Timescale for action Statutory requirements These requirements set out what the registered person must do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The registered person(s) must do this within the timescales we have set. No. Standard Regulation Requirement Timescale for action 1 3 14 The needs of prospective 30/11/2009 residents must be fully assessed prior to their admission to the home To ensure that the home can fully meet all of their individual needs Appropriate bathing facilities 11/01/2010 must be provided, that are suitable for elderly people including those requiring assistance. This will ensure peoples health and welfare is provided for and moving and handling risks are kept to a minimum 2 21 12 3 29 19 Staff must not commence 19/10/2009 work prior to two satisfactory references and a POVA first check being received. Appropriate supervision arrangements must be in place until a Care Homes for Older People Page 31 of 34 Statutory requirements These requirements set out what the registered person must do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The registered person(s) must do this within the timescales we have set. No. Standard Regulation Requirement Timescale for action satisfactory CRB disclosure has been received. This will ensure a more robust recruitment procedure for the safeguarding of vulnerable people. Recommendations These recommendations are taken from the best practice described in the National Minimum Standards and the registered person(s) should consider them as a way of improving their service. No Refer to Standard Good Practice Recommendations 1 2 3 7 8 12 Care plans should always contain sufficient detail to inform and direct staff on the care to be provided. People should receive appropriate individualised care taking into consideration their wishes and feelings Suitable activities, entertainment and staff interaction should be provided for people using the service with suitable records maintained for each person. To ensure people are stimulated and have opportunities to socialise People using the service should be encouraged to choose how they spend their time and have routines that suit them and their individual lives. Complaints should be recorded and detail the issues, actions taken and outcomes. All staff should receive appropriate trainig on the safeguarding of vulnerable adults regularly and on induction to the home The gardens should be kept tidy and safe and the enclosed garden should be made suitable for people with dementia to enjoy some time outside. Further efforts should be made to eliminate offensive odours around the home The registered persons should undertake a review of the 4 14 5 6 16 18 7 19 8 9 26 27 Care Homes for Older People Page 32 of 34 Recommendations These recommendations are taken from the best practice described in the National Minimum Standards and the registered person(s) should consider them as a way of improving their service. No Refer to Standard Good Practice Recommendations skill mix of staff to ensure that there are always suitably trained and experienced staff on duty to meet the changing needs of residents. Care Homes for Older People Page 33 of 34 Helpline: Telephone: 03000 616161 or Textphone: or Email: enquiries@cqc.org.uk Web: www.cqc.org.uk We want people to be able to access this information. If you would like a summary in a different format or language please contact our helpline or go to our website. Copyright © (2009) Commission for Social Care Inspection (CSCI). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CSCI copyright, with the title and date of publication of the document specified. 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