CARE HOMES FOR OLDER PEOPLE
Trefula House St Day Redruth Cornwall TR16 5ET Lead Inspector
Diana Penrose Unannounced Inspection 20th September 2007 09:25 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 Trefula House DS0000009152.V345192.R01.S.doc Version 5.2 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. Trefula House DS0000009152.V345192.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION
Name of service Trefula House Address St Day Redruth Cornwall TR16 5ET 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) 01209 820215 01209 822499 Issuemarket Limited Miss Pamela May Davey Care Home 34 Category(ies) of Dementia - over 65 years of age (12), Mental registration, with number Disorder, excluding learning disability or of places dementia - over 65 years of age (12), Old age, not falling within any other category (22), Physical disability (6) Trefula House DS0000009152.V345192.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION
Conditions of registration: Date of last inspection 17/08/06 Brief Description of the Service: 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 home’s 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. Accommodation is provided in two distinct areas. There are adequate 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 £550.00 to £800.00 per week; the registered manager supplied this information. Additional charges are made in respect of private healthcare provision, hairdressing and personal items such as newspapers, confectionary and toiletries. Trefula House DS0000009152.V345192.R01.S.doc Version 5.2 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. A CSCI Regulation Inspector visited Trefula Nursing Home on the 20 September 2007 and spent eight and three quarter hours at the home. A CSCI Pharmacy Inspector also spent five and three quarter hours at the home, inspecting all aspects of the medication system. The home has returned their Annual Quality Assurance Assessment document to the Commission for Social Care Inspection, and this along with the inspection record for the home has been used as evidence to support this inspection. 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 twenty-six people were living in the home. The methods used to undertake the inspection were to meet with the people using the service, the registered manager and staff to gain their views on the services offered by the home. Records, policies and procedures were examined and the inspector toured the building. This report summarises the findings of this inspection. The registered manager has not yet complied with the one requirement set at the last inspection but has been working towards it. Residents expressed satisfaction with the care and services provided at the home and are treated with kindness and respect. Overall the home is providing a good quality of care to the residents placed there. What the service does well:
The home provides a warm, clean, homely environment that is well-maintained and safe for residents, staff and visitors. Refurbishment is ongoing and the people using the service are involved with the choice of colours for their rooms and the communal areas. The laundry facilities are good and appropriate precautions are in place for infection control. The grounds are tidy and a portion has been enclosed for resident’s safety. Care provided is to a high standard and residents are only admitted following a full assessment to ensure the home can meet their needs. Prospective residents and their family are encouraged to visit the home prior to making any decision to move in. Residents have an individual detailed care plan and Trefula House DS0000009152.V345192.R01.S.doc Version 5.2 Page 6 relevant risk assessments are undertaken. The plans are reviewed every month with the resident or their representative when possible. All residents are registered with a doctor and health professionals visit when needed. Some of the nurses in the home specialise in certain subjects and act as links with external specialists. The home has appropriate equipment for moving and handling purposes and the prevention of pressure sores. Residents say their care needs are met and they are very happy living in the home. They say the staff are kind and caring and they all work well together. Visitors are very welcome and residents talked about their visitors; some said they are able to go out with their family and friends when they wish. There are suitable systems for dealing with complaints and abuse. Staff and residents said they could approach the manager if they had a problem. There is a robust recruitment policy and the documents required by law are held in the home. There are sufficient numbers of staff on duty and the skill mix is suitable for the people currently accommodated. Both residents and staff said there are enough staff to ensure that needs are met. Staff were observed to interact well with residents in a very kind, relaxed manner. Care practices observed were appropriate and safe. All new care staff are enrolled onto the NVQ level 2 course, in care, if they do not already have the qualification. At present 61 of care staff have achieved at least NVQ level 2, some have achieved level 3. There are posters advertising training sessions in the home and staff said they receive appropriate training. Statutory training is provided in the home and most of it is implemented by an external agency. The home is well managed and there are suitable systems in place for quality assurance monitoring. Resident’s financial interests are safeguarded by the home’s system for dealing with their money. What has improved since the last inspection?
Refurbishment has continued to improve the home, with the whole of the main building being re-painted. Three double bedrooms in the original building have been converted into single rooms with en-suite facilities that include wet room type showers. The extension at the back (zone 5) has been made into a safe unit for people with dementia or a mental disorder. The lounge has been extended to include a dining area with access to an enclosed part of the garden. The registered manager said that there are plans to improve the garden and include a sensory area. There is s rolling programme for the replacement of bed tables and commodes following an audit of the environment.
Trefula House DS0000009152.V345192.R01.S.doc Version 5.2 Page 7 Only one Registered Mental Nurse is employed which limits the number of people that can be admitted with dementia or a mental disorder. However all staff have attended or will soon attend training in respect of dementia which will improve their competency. Nurses and care staff spoke positively about the new unit and the new challenges they are confronted with. The registered manager said that activities for the people using the service are more structured and there are some staff that are keen to be involved with the organisation and provision of activities. An exercise class now takes place once a week. What they could do better:
All residents requiring the use of bed rails or any other type of restraint such as bucket chairs must be fully risk assessed and consent obtained from the resident’s relatives or representative. The registered manager has details on where to access information regarding the use of bed rails. Attention needs to be made to the storage of medicines to ensure they are stored within the temperature range specified by the manufacturer. To enable an audit of administration of medicines to people in the home the receipt, and administration of all medicines must be recorded. Social interests and hobbies are recorded in the resident’s records but there appears to have been no evaluation of these records or any survey to ascertain what activities the residents would actually like. There are some records of the activities that take place but there is no one responsible for co-ordinating the activities or ensuring that records are up to date. The registered manager has been trying to recruit a co-ordinator for several months; maybe this task would be better delegated to one or two staff in the home with some time each week allocated for this. It is important that all staff receive adult protection training as a priority. Some staff have attended external courses and the registered manager has a training pack but the training sessions have not yet been arranged. The bathing facilities require reviewing to ensure that suitable aids and adaptations are provided for people who are old, infirm or physically disabled including those with dementia or a mental disorder. The facilities should ensure that moving and handling of residents can be carried out safely. Storage issues must be addressed as equipment is kept in bathrooms. Confidential documents such as care plans must be stored securely and confidentially. The facilities for making drinks in the main kitchen are utilised by all staff and visitors to the home. This needs to be changed for health and safety reasons. Staff should use the facilities in the staff room for making drinks and separate arrangements need to be made for visitors. Trefula House DS0000009152.V345192.R01.S.doc Version 5.2 Page 8 The maintenance man will check with the fire authority to ensure that he is following the correct procedures for checking the emergency lighting. 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. The summary of this inspection report can be made available in other formats on request. Trefula House DS0000009152.V345192.R01.S.doc Version 5.2 Page 9 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 Trefula House DS0000009152.V345192.R01.S.doc Version 5.2 Page 10 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. JUDGEMENT – we looked at outcomes for the following standard(s): 3 (6 is N/A) Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are only admitted to the home following an assessment of their needs to ensure the home can provide appropriate care. EVIDENCE: Evidence was provided in the form of records and discussion with the registered manager and staff. The registered manager said that she, or another nurse, visits prospective residents whenever possible to assess their needs prior to admission. A specific form is used to record the assessment, which is comprehensive and those inspected were completed appropriately. Relevant information from other healthcare professionals for example, Adult Social Care, GP’s and hospital staff, was seen. One of the nurses went out to undertake two assessments during the inspection. She discussed the needs of the prospective residents with the registered manager and telephone conversations took place with the hospital staff and social worker. Later in the day one of the prospective resident’s
Trefula House DS0000009152.V345192.R01.S.doc Version 5.2 Page 11 visited the home with her family. They met some of the residents and staff in the home. Trefula House DS0000009152.V345192.R01.S.doc Version 5.2 Page 12 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. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Individual care plans are generated for each resident that inform and direct the staff in their care provision, care must be taken to ensure these are kept up to date and that all relevant risks are assessed fully. The people using the service have access to health care services as necessary to ensure their assessed needs are met. There are systems and policies in place for dealing with resident’s medicines; extra attention in some areas will ensure a safer system. Systems are in place to ensure that residents are respected and their privacy is upheld at all times. EVIDENCE: Evidence was provided in the form of documentation, records, observation, talking with the people using the service, staff and registered manager. Each person using the service has a written care plan that includes health, social and personal care needs. The plans are divided into relevant sections and they are very detailed to direct staff in the care to be provided. Some of the plans had been signed by the resident or their representative. Plans
Trefula House DS0000009152.V345192.R01.S.doc Version 5.2 Page 13 inspected had been signed as reviewed monthly, nurses said they are responsible for certain resident’s care plans and try to ensure they are up to date. Risk assessments include Waterlow scoring, nutrition, moving and handling, falls and Barthel scoring. There must be a detailed written risk assessment for people who require the use of bed rails or any other restraint. The registered manager has details on where to access information regarding this and said this would be addressed. She said that bumpers are used on all bed rails when the residents are in bed. Some relatives have signed to consent for the use of bed rails. The daily records refer to the care plan and notes are kept to a minimum. Both nurses and care staff record in the care documentation. Records show that doctors and other healthcare professionals visit residents when required. The home has sufficient equipment for moving and handling and training takes place. The home has some pressure relieving equipment, some hired and some supplied by community nurses. The tissue viability nurse specialist visits the home to audit dressings and give advice regularly. Some of the nurses in the home specialise in certain subjects and act as links with external specialists. The registered manager has stated in the AQAA document that more feedback and information from these nurses would be useful. Nutritional screening takes place on admission and needs are reviewed regularly. Residents are weighed regularly according to their individual requirements and records are kept. The home has started to be involved in the gold standard framework for palliative care, which should enhance the care given when a person reaches the end stages of their life. The arrangements for ensuring privacy and dignity are specified in the statement of purpose. People using the service said that staff respect their privacy and dignity and this was observed to be so during the inspection. Suitable screening is provided in shared rooms and residents are addressed by their preferred name, this is recorded in their care plan. We found that there were some gaps in the recording of the receipt of medicines into the home meaning that it was not possible to fully audit the records of administration of medicines in the home. For one service user prescribed a night time sedative the record indicated that medicines had been offered but not needed on days after the medicine was recorded as out of stock although there was no record of a receipt of this medicine. We observed the nurse on duty administering the medicines in a caring and considerate manner, explaining what each medicine was and asking the people if they wished to take it. We did however observe that the record of administration was often signed before the actual administration had taken place. We found that the temperature of the medicines storage area was above that recommended by the manufacturers of the medicines, however medicines requiring refrigeration were stored appropriately although only the current Trefula House DS0000009152.V345192.R01.S.doc Version 5.2 Page 14 temperature is recorded. We also found a discrepancy in the recording of controlled drugs and this was corrected at the time of the inspection. Trefula House DS0000009152.V345192.R01.S.doc Version 5.2 Page 15 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home provides some activities, entertainment and trips out; the registered manager hopes to improve this to offer a lifestyle that meets individual residents needs more fully. Links with family, friends and the community are good and allow residents the opportunity to socialise. Residents are helped to maintain control over their lives and staff respect their individual preferences and choice. Dietary needs of residents are well catered for with a varied selection of food available that aims to meet their taste and preference. EVIDENCE: Evidence was provided in the form of documentation, records, observation, talking with the people using the service, staff and registered manager. The registered manager has been actively trying to recruit an activities coordinator. At present the care staff provide activities for residents as staffing levels allow. The registered manager said there are a few staff that are keen to help with activities and they tend to be responsible for organising planned sessions. People using the service spoke about a trip to Tehidy Park recently and a planned trip to Newquay aquarium in November. People using the service and staff said the summer fete was a success and there were photographs in the entrance hall. One resident said, “the fete was lovely and
Trefula House DS0000009152.V345192.R01.S.doc Version 5.2 Page 16 the weather was good, we had a lovely time”. Activities includes games manicures, one to one chats and going out around the garden. A person comes in to provide exercise sessions and entertainers come in from time to time. Some residents said there could be more to do but there are a lot of people who are unable to join in. The televisions were on in all three lounges but very few people were watching them. Social interests and hobbies are recorded in the resident’s records but there appears to have been no evaluation of these records or any survey to ascertain what activities the residents would actually like. There are some records of the activities that take place. There is a record of visitors to the home. Residents said they could receive visitors in private and at any time. They also said they go out with their family and friends when they wish. One resident had been out during the inspection. Residents who can express their views said they do as they like each day within reason. They said they are given choices in respect of food, clothes to wear, daily routines and so on. They also said they are addressed by their preferred name. One resident said she goes out with friends at any time she likes. All residents have their own possessions in their rooms. Staff said they try to ensure that Trefula is home and that residents can choose their routines and how to spend their time. They said there are no restrictions on the time for going to bed or getting up in the mornings. The registered manager said that residents can choose the colours for the decoration of their rooms and the communal areas have been decorated in colours chosen by the residents. The registered manager said that resident’s that are able are encouraged to air their views and express their preferences via resident’s meetings and annual quality assurance surveys. Each person has a nutritional needs assessment and their food likes and dislikes are recorded. There is a varied menu with fresh vegetables and fruit available each day. The menu is under review and new dishes are being tried at the moment. One of the cooks is researching the options of providing a wider selection of soft/pureed meals. Homemade cakes were seen in the kitchen ready for afternoon tea. There was a supply of fruit in the kitchen and fresh vegetables were served with the lunchtime meal. Staff said that drinks and snacks are available on request. Plenty of water and fruit squash is provided for all residents. Meals are served in the dining rooms, lounges or individual bedrooms. The dining tables have tablecloths and fresh flowers are on each table, there is special cutlery, plates and plate guards available for those who need them. Everyone spoken with said the food is very good and everyone appeared to enjoy the lunchtime meal. A number of residents require assistance with their meals and staff did this in a sensitive manner that was unhurried. Residents said they have a cake Trefula House DS0000009152.V345192.R01.S.doc Version 5.2 Page 17 made for them on their birthday and there are special celebrations at Christmas and Easter, and so on. Trefula House DS0000009152.V345192.R01.S.doc Version 5.2 Page 18 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. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home has a satisfactory complaints procedure that ensures complaints are listened to and acted upon. Arrangements are in place for the protection of residents safeguarding them from harm or abuse however staff training in this area needs to be addressed. EVIDENCE: Evidence was provided in the form of documentation and discussion with the registered manager. There is a suitable complaints policy in the home and a method for recording complaints, the action taken and the outcome. There have been no complaints since the last inspection. Thank you letters and cards are kept and displayed on notice boards. The home has an adult protection policy that includes the Local Authority inter agency procedures, alerters guide and a draft copy of the national framework for safeguarding adults. A flow chart is included for staff to reference easily. There is a secure facility for the storage of money in the home. The Registered Manager said it continues to be difficult getting staff onto the external adult protection training days but some staff have attended. The registered manager has a training pack for use in the home but has not been able to implement the training as yet. She said she may have to consider an external agency to provide the training. Some staff spoken with had attended the training but others had not. It is important that all staff receive this training as a priority.
Trefula House DS0000009152.V345192.R01.S.doc Version 5.2 Page 19 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. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 21, 22 and 26 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home and grounds are well maintained providing a safe environment for residents, staff and visitors. The bathing facilities require reviewing to ensure that suitable aids and adaptations are provided for people with dementia or a mental disorder. The facilities should ensure that moving and handling of residents can be carried out safely. Storage issues must be addressed and confidential documents must be stored securely. The home is well furbished, clean and free from offensive odours making it a pleasant place to live in. EVIDENCE: Evidence was provided in the form of a tour of the building, records, talking with the people using the service, maintenance man, staff and registered manager. The home is clean, warm, comfortable and well maintained. There has been further re-decoration and refurbishment since the last inspection. Three double
Trefula House DS0000009152.V345192.R01.S.doc Version 5.2 Page 20 rooms have been converted into singles with en suite facilities in the original part of the building. Hospital style beds are provided as required and screening is provided in double rooms. Residents spoken with are very happy with their accommodation and surroundings. Commodes and bed tables are being replaced on a rolling programme. The home is now registered to admit people with dementia or a mental disorder; these people are accommodated in the rear extension, zone five. The lounge in this area has been extended to become a lounge/diner, which is an improvement. The bathing facilities must be reviewed in to ensure that appropriate amenities are available for people who are old, infirm or physically disabled including those with special needs due to dementia or a mental disorder. One bath in zone five has very high sides and has been deemed by staff to be unsuitable therefore the room is used for storage of equipment. The other bathroom is poorly designed, with confined space for staff assisting residents onto the bath hoist. The provision of a wet room was discussed with the registered providers in October 2005 and would be very beneficial for the residents accommodated. There is a table and chairs at the end of the corridor for staff to use for completing their paperwork. Resident’s care plans are held on this table and not stored confidentially. A secure facility must be provided. A nurses station / office has previously been discussed with the registered providers. Storage facilities in the home must be reviewed, as equipment is currently stored in bathrooms, there is no storage space provided in zone five. There is a secure garden accessible to the people using the service. The registered manager said there are plans to re-design the garden and provide a sensory garden. Trefula House DS0000009152.V345192.R01.S.doc Version 5.2 Page 21 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. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Staffing levels meet the needs of residents and staff morale appears to be good. Residents are in safe hands and benefit from the 61 of care staff that have achieved an NVQ qualification. Recruitment procedures are robust and offer protection to the residents. The home provides appropriate training for staff to help them be more competent in their roles. EVIDENCE: Evidence was provided in the form of documentation, records, observation, talking with the people using the service, staff and registered manager. The registered manager said the skill mix of staff has improved and the staff team works well. Retention of staff has improved which means that agency staff have not been required for some time. The rota shows sufficient numbers of staff on duty and both staff and residents said the numbers are sufficient. There are usually two nurses on duty during the day and one at night. There are on average 5 care staff in the mornings, 4 in the afternoons and 2 at night. Staff said they work well as a team and staff are considerate to one another’s needs. For example, one nurse said her colleague stayed on late so that she could complete a training course, another offered to take the on-call duty for Matron so she could have a night off. Residents said that staff are very kind and caring. Staff were observed to interact well with residents, in a very kind, friendly manner. They took time to stop and talk to residents.
Trefula House DS0000009152.V345192.R01.S.doc Version 5.2 Page 22 61 of care staff have an NVQ either at level 2 or 3 and copies of NVQ certificates are kept on file. All new care staff are enrolled on the NVQ level 2 course if they have not already achieved the qualification. The home has a robust recruitment policy and the registered manager said she ensures that appropriate checks are made prior to employing new staff. Three personnel files were inspected and contained the documents required by law, records were held of CRB disclosure numbers and the dates applied for and received. The registered manager has been told by one of the Company directors to destroy CRB disclosures held in the home. Disclosures must be held until a CSCI inspector has checked that the CRB / POVA process has been carried out appropriately. An equal opportunities monitoring form is in use and there is an equal opportunities policy. There is one overseas worker at the moment but she was not on duty during the inspection. Staff and residents said she is a valued member of the team. New employees sign for the receipt of various documents and policies, these include the GSCC code of conduct, the employee handbook and the homes emergency procedure manual. There are specific induction programmes for staff in each area. Care staff are enrolled onto the NVQ level 2 course, in care, following induction, if they do not already have the qualification. Each member of staff has an individual training plan and a training record card, there is also a matrix held electronically. There are basic training records of care instruction for care staff that are very useful. Training is identified through the appraisal and supervision system, staff meetings, general conversation and observation. Staff say the training provision is good and the manager allows staff to be flexible with the duty rota to enable them to attend. All staff spoken with had attended or were soon to attend dementia training. One of the nurses had just attended study days to become the link nurse for tissue viability. Another nurse was implementing the gold standard framework for palliative care and was sending information to resident’s relatives and representatives during the inspection. Trefula House DS0000009152.V345192.R01.S.doc Version 5.2 Page 23 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. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 and 38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The Registered Manager is a person of good character and fit to run the home. The home is run in the best interest of the residents and they benefit from the Quality Assurance systems in place. There is a suitable system in the home for dealing with residents’ money that ensures that the residents’ financial interests are safeguarded. Appropriate training and safety checks are undertaken to ensure the health safety and welfare of residents and staff. EVIDENCE: Evidence was provided in the form of documentation, records, observation, talking with the people using the service, staff and registered manager. The registered manager is competent and experienced to run the home. She is a qualified mental nurse and has achieved the Registered Managers’ Award.
Trefula House DS0000009152.V345192.R01.S.doc Version 5.2 Page 24 She keeps herself up to date on current issues by reading relevant magazines, using the internet and attending appropriate training. Recent training includes a diabetes update and she is booked to attend training on the mental capacity act. All staff spoken with said they feel supported by the manager and that she operates an open door policy. One member of staff said, “the manager respects our family commitments”. Another said, “She is the best manager I have ever worked for”. People using the service said the home is well managed and the manager sees them every day. Staff and residents said the directors of the company visit the home, they walk around the building and they talk to them. The registered manager said she could be more supported in her role by the directors of the Company in respect of administration, for example. Quality assurance surveys are sent to relatives to complete with or on behalf of residents every six months and participation appears to be good. The results are held in a file and the registered manager said that they are collated and action taken if needed. Regular meetings take place with residents and all grades of staff, minutes are maintained. One of the directors visits the home each month to inspect and report as detailed under regulation 26 of the care homes regulations 2001. An external consultant undertakes health and safety audits. The registered manager has undertaken environmental audits and equipment has been replaced as a result of the audits. The registered manager also audits accidents each month and care plans from time to time. There is a suitable policy for the management of resident’s money. The registered manager holds money for all residents. Resident’s money is held in a non-interest bank account separate to the business account. Available money is stored securely in a safe in the form of petty cash and receipts are kept for all money removed from the safe. Appropriate electronic records are maintained of all transactions, the accounts are printed every three months for the resident or their representative. Receipts are kept for purchases and for money received on behalf of residents; all receipts are signed by whoever is involved in the transaction. There is a book to record purchases from the trolley shop and these are transferred to the individual residents records. There is a system for staff to follow when the registered manager is not in the home. The registered providers endeavour to ensure that working systems are safe. An external agency has been employed to assist with health and safety management and they also supply training on a rolling programme. This system has improved staff attendance. Statutory training was taking place during this inspection and included fire, health and safety, infection control and food hygiene. One of the consultants involved in the training sessions said that the agency has a responsibility for fire safety, health and safety and food safety in the home. They have undertaken a full health and safety audit with an action plan; the next audit is due soon. They have written policies for the home, a fire risk assessment and developed a hazard analysis and critical control point (HACCP) system for the home. Moving and handling training is
Trefula House DS0000009152.V345192.R01.S.doc Version 5.2 Page 25 undertaken with a member of staff who has completed the train the trainer’s course. Suitable systems are in place for infection control. All necessary service and equipment checks are undertaken as appropriate. Accidents are few and are recorded and reported appropriately. COSHH data sheets are available to staff. The maintenance man is responsible for the fire log records; he said he would check with the fire authority with regard to the correct procedures for checking the emergency lighting. The cooks have all achieved the food hygiene foundation certificate. The cook remains concerned about the number of people entering the kitchen, mainly to access the drinks machine. He said he has been advised by the EHO to address this with the management. Staff have their own facility in the staff room for making hot drinks, they do not need to use the facilities in the kitchen. Staff should not enter the kitchen unless absolutely necessary and with the authorisation of the cook. The kitchen is very small and excess people in this space pose a risk to health and safety. The use of kitchen equipment by noncatering staff could create an infection control risk. Visitors should not utilise the home’s kitchen facilities, they should ask a member of staff if no separate facility is provided. Trefula House DS0000009152.V345192.R01.S.doc Version 5.2 Page 26 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 3 X X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X 2 2 X X X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 3 Trefula House DS0000009152.V345192.R01.S.doc Version 5.2 Page 27 Are there any outstanding requirements from the last inspection? Yes 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) Requirement Timescale for action 20/02/08 2 OP9 13(2) 3 OP12 16(2) (m) (n) All medicines must be stored within the temperature range as specified by the manufacturer to ensure that their potency is maintained so meaning that people are administered effective medicines To enable an audit of 20/12/07 administration of medicines to people in the home the receipt, and administration of all medicines must be recorded. The registered person shall 10/01/08 having regard to the size of the care home and the number and needs of service users— (m) consult service users about their social interests, and make arrangements to enable them to engage in local, social and community activities and to visit, or maintain contact or communicate with, their families and friends; (n) consult service users about the programme of activities arranged by or on behalf of the care home, and provide facilities for recreation including, having regard to the needs of service
DS0000009152.V345192.R01.S.doc Version 5.2 Trefula House Page 28 users, activities in relation to recreation, fitness and training. For example: • suitable leisure and recreational activities must be provided for residents Re-notified 4 OP18 13 (6) The registered person shall make 10/01/08 arrangements, by training staff or by other measures, to prevent service users being harmed or suffering abuse or being placed at risk of harm or abuse. For example: • all staff must receive adult protection training 5 OP21 OP22 23 (2) (l) (n) The registered provider must 10/01/08 ensure the care home is suitable for achieving the aims and objectives set out in the statement of purpose. The registered person shall having regard to the number and needs of the service users ensure that— (l) suitable provision is made for storage for the purposes of the care home; n) suitable adaptations are made, and such support, equipment and facilities, including passenger lifts, as may be required are provided, for service users who are old, infirm or physically disabled; For example: • suitable storage space must be provided for equipment such as wheelchairs an hoists • storage of confidential documents must be secure • specialist-bathing facilities such as a ‘Parker’ type bath
Trefula House DS0000009152.V345192.R01.S.doc Version 5.2 Page 29 or wet room to be provided depending on a review and risk assessment of the facilities 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 OP9 Good Practice Recommendations It is recommended that the home develop an audit system to monitor the administration of medicine in the home. It is also recommended that the home ensure that when peoples condition and preferences change, and their need for medicine alters this should be recorded within the service user plan. • Staff should not enter the kitchen unless absolutely necessary and with the authorisation of the cook, they should use the facilities in the staff room for making drinks. • It is strongly recommended that visitors have a separate facility for making drinks they should not utilise the kitchen. 2 OP38 Trefula House DS0000009152.V345192.R01.S.doc Version 5.2 Page 30 Commission for Social Care Inspection Ashburton Office Unit D1 Linhay Business Park Ashburton TQ13 7UP National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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