Inspection on 28/06/07 for Trefusis

This inspection was carried out on 28th June 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found no outstanding requirements from the previous inspection report, but made 1 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Trefusis 22/06/06

Trefusis 19/10/05

Trefusis 04/04/05

Trefusis 07/10/04

Trefusis 22/04/04

Similar services:

2 Perhaver Park

The Vicarage

St George`s

5 Seafield Road

Credence House

Radfords

Honeybourne House

32 Beaumont Way

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

CARE HOME ADULTS 18-65 Trefusis 38 Trefusis Road Redruth Cornwall TR15 2JH Lead Inspector Lynda Kirtland Unannounced Inspection 28th June 2007 09:30 Trefusis DS0000009120.V340467.R01.S.doc Version 5.2 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 Trefusis DS0000009120.V340467.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 Adults 18-65. 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. Trefusis DS0000009120.V340467.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Trefusis Address 38 Trefusis Road Redruth Cornwall TR15 2JH 01209 219333 01326 371099 mail@dcact.org 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) Spectrum Ms Janet Elizabeth Hurley Care Home 3 Category(ies) of Learning disability (3) registration, with number of places Trefusis DS0000009120.V340467.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 22nd June 2006 Brief Description of the Service: Trefusis is a care home providing accommodation and personal care for up to 3 adults with a learning disability. The home is run by Spectrum, an organisation that provides specialist care in small units to adults who have autistic spectrum conditions. The aim is to provide service users with a homely environment in a local community setting and to enable them to live as normal a life as is possible. Spectrum employs a manager and team of staff to provide care and support for the service users living in the home. Senior managers from outside of the home are available to provide additional specialist input as and when it is required. The house is a detached, two-storey building set in its own grounds. Access is suitable for the three service users living there. The home is situated within easy reach of the town of Redruth with good access to transport and all the facilities of the town. The home has transport and drivers. Service users are provided with individual furnished bedrooms and a shared bathroom. The home has a combined kitchen and dining room, separate office and two lounges, one of which doubles as a staff sleeping in facility. The home has a spacious garden that is well maintained. There is a lockable office on the first floor of the building. Fees range from £1111.00 - £1869.00 per week. Additional charges are made to service users for hairdressing, certain activities outside of the home such as bowling and swimming and personal items. Trefusis DS0000009120.V340467.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an annual key inspection, which took place on 28 June 2007 and was unannounced. It lasted for approximately six hours. Information about the home received by the Commission since the previous inspection was taken into account when planning the inspection. The purpose of the inspection was to ensure that residents (service users’) needs are appropriately met in the home, with particular regard for ensuring good outcomes for them. This involved interviews with residents, observation of their daily life and care provided. There was an inspection of the home’s premises and of written documents concerning the care and protection of the residents and the ongoing management of the home. Staff were interviewed and observed in relation to their care practices and there was a discussion with the home’s manager. The principle method used was case tracking. This involves examining the care notes and documents for a select number of residents and following this through with interviews with them and staff working with them. This provides a useful, in-depth insight as to how residents’ needs are being met in the home. At this inspection, two residents were case tracked. What the service does well: Residents are familiar with the services that Trefusis provide as they have lived at the home for some time. In addition there is a written and pictorial Service users Guide which a resident and staff member produced that explains what the home provides. Residents have detailed written care plans, which set out how the home will meet their personal, health and social care needs, including needs relating to their individual backgrounds and culture, age, sex, religion, individual abilities and sexual orientation. Residents confirmed they and their relatives are invited to regular reviews so that their care plans can be agreed with them and updated. They are encouraged to make important decisions about their lives, such as what activities to take part in during the week and how to spend their free time so that they develop their confidence and independence. Any risks are carefully managed, to minimise restrictions on residents and enable them to take part in activities that develop their skills and enhance the quality of their likes. Residents explained that they take part in a wide range of activities in the community, which vary according to their individual interests for example attendance at college, voluntary work in the community. Staff support is provided as needed. Activities are age and culturally appropriate for them. Residents attend a variety of social activities within Spectrum and visit pubs Trefusis DS0000009120.V340467.R01.S.doc Version 5.2 Page 6 and cafes with staff, in the community. Residents confirmed they are supported and encouraged to maintain contact with their families so that they maintain and develop valued relationships outside of the home. Residents confirmed they take part in planning, shopping and preparing meals with staff support so that they enjoy their meals, eat healthily and develop their independent living skills. Residents are encouraged to independently attend to their personal care and take pride in their appearance. Staff provide low-key support and prompts, where necessary. They are helped to access a range of NHS healthcare providers, such as doctors, opticians and community nurses so that they maintain good general health and receive any specialist services they need. Their medicines are safely stored in the home and staff have clear written guidance so that they are protected from medication errors. Residents are able to make their views known and are taken seriously, especially if they wish to complain about any aspect of their care. They said that they are safe and well cared for in the home and there is a commitment among the staff team to ensure their welfare and protection from abuse. There are very sound formal systems in place to protect them, including written guidance for staff, and training. The home provides residents with ordinary, domestic accommodation in the community so that they can develop their skills and independence in a noninstitutionalised setting. It is well situated so that they can access local community facilities easily and essential maintenance tasks are carried out promptly to ensure it is kept safe for them. It was clean and tidy throughout at the time of the unannounced inspection. There are sufficient numbers of staff with formal qualifications in care so that residents can have confidence that they are competent and they are employed in sufficient numbers to be able to work effectively with them individually. The staff team is selected fairly and on the basis that people employed to work in the home is fit and suitable to work with vulnerable adults in a care setting. All staff undergo induction training before they start to work in the home and have good ongoing access to training so that residents can have faith in their skills. The home is competently and well managed for the benefit of residents. The manager is registered with the Commission as a fit and suitable person to be in charge of a care home. Residents confirmed that they are given opportunities to contribute their views about the management of the home, particularly during reviews and said that they are satisfied with the care and services the home provides. The home provides residents and staff with a safe environment to live and work in and they said that they feel safe in the home. What has improved since the last inspection? Trefusis DS0000009120.V340467.R01.S.doc Version 5.2 Page 7 The home’s manager said that she has increased the range of activities that residents are able to take part in so that they have more choice in this respect and improved quality to their lives. There have been improvements to the home’s environment since the previous inspection. The home has been redecorated; residents choose the décor for their rooms and even participated in the painting of them with staff. New carpets, kitchen equipment and fire equipment has been purchased and installed. Residents are now provided with improved information on the cost of their placements in the home, including clear, up-to-date and accurate information on how the contributions they make are calculated so that they are made fully aware of their financial rights and obligations. Spectrum have introduced Personal Development Plans. This means that residents have specific goals and aspirations to work towards in a timely fashion. Residents are encouraged to participate in this process. Written records of medicines administered to residents, are now countersigned where they are hand written, so that it is clear who has authorised any changes, where these occur. The registered manager commented that the staff team have been more stable leading to a more consistent approach in working with residents and felt this had lead to less stress for residents as there have been fewer incidents in the home. Residents commented that they like the staff that are working at the home. What they could do better: From this inspection one statutory requirement was identified. It was brought to the Commission’s attention during the inspection that the registered manager had a period of absence from the home for over 28 days, the commission had not been informed of this or the interim management arrangements in her absence. Under legislation this information must be reported to the commission so that the service can evidence that robust management systems are put in place during the registered manager absence. Recommendations to improve practice have been identified as follows: • A process for auditing PRN medication should be implemented so that the registered manager is aware of the quantity of PRN medication in stock, and can undertake audits, which will allow a monitoring of the medication. • A risk assessment of staff working alone at night at Trefusis should be undertaken to ensure that residents and staff are confident that there are safe and robust processes in place if needed. Trefusis DS0000009120.V340467.R01.S.doc Version 5.2 Page 8 Paper towels should be made available in the kitchen area to promote infection control • Care staff should be provided with more regular individual/ formal supervision, with records maintained. • Records should be kept in line with the guidance of the Data protection Act so that residents can access all documentation relating to them. All the above was discussed with the registered manager who agreed to address these points immediately. The inspector would like to thank the residents, staff and registered manager for their kind assistance during this inspection process. • 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. Trefusis DS0000009120.V340467.R01.S.doc Version 5.2 Page 9 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Trefusis DS0000009120.V340467.R01.S.doc Version 5.2 Page 10 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1,2, Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users’ needs are assessed prior to their admission so that they can be confident it will meet their health, personal and social care needs, including needs relating to their age, religion, cultural and ethnic backgrounds, abilities, gender and sexual orientation. EVIDENCE: There have been no changes to the service users group since the previous inspection and the home’s records confirm that all the residents have lived in the home for several years. From observations and talking with residents it was evident that they are settled in the home, and that they get on well with each other and with the staff. From documentation inspected it was evident that admissions are made following a full assessment and in consultation with the resident, their family or advocate, and relevant professionals. A copy of the home’s statement of purpose and Service Users Guide is placed on the individuals file. The Service user Guide is presented in pictorial as well as written form. A resident and member of staff developed a creative and informative pictorial version of the Service user Guide. Trefusis DS0000009120.V340467.R01.S.doc Version 5.2 Page 11 Service users have written statements of the terms and conditions of their placement, in suitable formats which they have signed. The information given to them has been amended to include the total cost of their placement and a detailed breakdown of how their personal contributions towards the total cost is calculated to provide them with clear information about their welfare rights. Trefusis DS0000009120.V340467.R01.S.doc Version 5.2 Page 12 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7,9 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users are aware of their care plans, which fully address their health, personal and social care needs, including needs relating to their individual and diverse backgrounds (age, religion, culture and ethnicity, abilities, gender and sexual orientation). They are able to take safely managed risks and make important decisions about their lives so that they develop their skills and independence. EVIDENCE: Residents confirmed that they are aware of and understand their care plans in discussions with them during the inspection. They said that they are invited to attend their reviews and to contribute to the process. Relatives and representatives are invited to attend. Residents care plans are detailed and address their individual health, social and personal care needs in full. Spectrum has introduced Person Centred Planning and this identifies clearly the individual’s aspirations and goals and how this will be worked toward. This also informs and directs staff in how to support the resident to achieve this goal to encourage them to fully maximise their Trefusis DS0000009120.V340467.R01.S.doc Version 5.2 Page 13 skills for independent living. New staff to the home confirmed they were able to understand the care plans and that the detail of how to assist in a particular task allowed consistency of care. The home’s manager, staff and residents provided examples of how they are enabled and encouraged to make decisions for themselves and their abilities in this respect are considered as part of the care planning process. There are formal consultation exercises held with residents each month and records are maintained of this, as well as informal discussions on a day-to-day basis. Residents are able to choose what to wear, the types of activities they would like to take part in during the day and how to spend their leisure time, for example. There are detailed, written risk assessments in place for each resident with clear risk management plans so that they can undertake a range of activities to develop their skills and independence in ways that are safe. These also detail any restrictions that are necessary to protect the resident and/ or other people. Residents have signed them to indicate their agreement. Residents manage their own finances and maintain their own records, supported by care staff to monitor their money. Records were inspected and receipts tallied with expenditures made. Trefusis DS0000009120.V340467.R01.S.doc Version 5.2 Page 14 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14,15,16,17 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Service users are able to take part in a wide range of activities in and out of the home, which are appropriate to their ages, individual needs, interests and cultural backgrounds so that they develop their skills and confidence. They are supported to maintain valued social and family relationships so that they are not isolated or institutionalised. They are informed of their rights and responsibilities so that they are aware of what is expected of them. They are provided with a wholesome and varied diet so that they enjoy their meals and stay healthy. EVIDENCE: Residents care plans and daily care records provide good evidence that their interests and abilities are fully considered in planning their daily activities, which are planned with them individually. Residents complete their own daily dairy, which evidences the range of activities, and decision-making that they take. Some activities include assisting them to access voluntary employment opportunities and college, for example. Residents said that they are satisfied Trefusis DS0000009120.V340467.R01.S.doc Version 5.2 Page 15 with the activities provided for them. At the time of the inspection residents were engaged in a variety of different and appropriate activities in and out of the home, with staff support provided as necessary. All of the residents maintain valued relationships with their families and friends, with staff support as necessary, which their daily care records confirmed. They are able to make telephone calls in private if they wish Residents are supported and encouraged to eat healthily. They undertake shopping, planning for and preparing meals with assistance from staff. Residents plan the menu for the week and go shopping with a member of staff. Nutritional needs and preferences are considered as part of the care planning process. The residents looked healthy and well nourished and were aware of the importance of eating healthily. The home has an ordinary, domestic kitchen, which they can access freely, to prepare drinks and snacks when they want them. Trefusis DS0000009120.V340467.R01.S.doc Version 5.2 Page 16 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18,19,20 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users’ personal and healthcare needs are well met so that they are able to live full and active lives in and out of the home. There are systems in place to support them with medication, it is recommended that PRN medication is audited more thoroughly to ensure medication errors do not occur. EVIDENCE: Residents individual care plans address their personal and health care needs. A resident confirmed that during a recent bout of illness that staff cared for ‘me really well’ and that she trusted staff to know if a doctor needed to be contacted or not. Documentation confirmed that there is access to a range of health professionals and that they are contacted when needed. The residents appeared to be attractively and fashionably dressed so that they can comfortably take part in community life. The home has suitable bathroom facilities so that they can attend to their personal care in private. There are satisfactory facilities for storage of medicines and records appeared to be accurate. There were a couple of gaps in the signing of medication being administered but the registered manager was aware of this and had addressed Trefusis DS0000009120.V340467.R01.S.doc Version 5.2 Page 17 it. Residents in this home are on low levels of medication. It was difficult to undertake an audit of PRN medicines, as the MAR sheets did not record the number of tablets it had received/ or was in stock and therefore a count of tablets, which were not in blister packs, was difficult to audit. It is recommended that a record of tablets in stock be clearly recorded so that the registered manager is aware of what medication she has in storage and can monitor that it is being used appropriately. Staff have attended the in house safe handling of medication course. The written procedures to guide staff on how to safely administer medicines were available. Trefusis DS0000009120.V340467.R01.S.doc Version 5.2 Page 18 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22, 23 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users are listened to and respected so that their views, concerns and complaints are taken seriously and acted upon. There are formal and informal systems in place to ensure that they are able to feel safe in the home. EVIDENCE: Residents were encouraged to speak to the inspector if they wished in private or with staff present so that they could make their views known or raise any concerns. Residents confirmed that if they had any worries or concerns that they would either talk to staff or their family about them. They felt that staff would listen to their concerns. Each resident is provided with written copies of the home’s formal complaints procedure and has formal and informal opportunities to raise any concerns with staff before they become serious complaints. They expressed satisfaction with the care and services provided to them at the home, comments such as “it’s lovely here” and “I like it here” were made. The home has written procedures to guide staff on what to do if they suspect a resident is at risk of abuse. There are records to show that staff are recruited on the basis that they are suitable to work with vulnerable adults in a care setting and appropriate checks are made. Residents are not isolated in the home, but take part in a range of activities in the local community and have relationships with people from outside of the home that they can communicate serious concerns to. Spectrum has a whistle blowing policy. The Registered Manager has attended the Multi Disciplinary Adult Protection course. Staff have attended Spectrums in house vulnerable adults training. Trefusis DS0000009120.V340467.R01.S.doc Version 5.2 Page 19 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24,30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home’s environment provides service users with an ordinary, domestic setting so that they can develop their skills and independence in a noninstitutional setting. It is safe and clean so that service users are protected from risks of cross-infection. EVIDENCE: The home is well situated so that residents can readily access local community facilities, but set in its own grounds so that they have a degree of privacy. It is an ordinary, domestic house, suitable to encourage residents to develop their skills in independent living. Residents showed the inspectors their bedrooms and said that they helped to choose the decorations and design of their rooms and were involved in the painting of their room. The rooms are decorated and furnished to a good standard and residents were happy with them. Since the previous inspection Spectrum have decorated the home to a good standard. New carpets have been purchased, new kitchen equipment has been Trefusis DS0000009120.V340467.R01.S.doc Version 5.2 Page 20 purchased and installed and lino replaced, all downstairs areas have been redecorated and fire doors have been installed. It was noted that the home was clean and tidy at the time of this inspection. Staff have attended basic food hygiene, and infection control courses, as have some residents. It is recommended that in the kitchen area paper towels are available so that infection control can be promoted further. Trefusis DS0000009120.V340467.R01.S.doc Version 5.2 Page 21 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32,33, 34, 35, 36. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Staff are employed in sufficient numbers and qualities to work with Service users. The registered manager agreed to risk assess the practice of lone working at night to ensure that service users and staff are confident that there is sufficient support during this time. Staff have access to ongoing training so that service users can have confidence in their knowledge and skills to work with them in a competent manner. Staff are recruited on the basis of fair, safe and effective recruitment and selection policies and practices so that service users can have faith that they are suitable to work in a care setting. The registered manager acknowledged that staff supervision to ensure ongoing care practice and training needs are effectively monitored and managed would recommence. EVIDENCE: Staff and residents confirmed that staff are employed in sufficient numbers to be able to work effectively with residents. There is a minimum of two staff members on duty at all times, however on the day of inspection three staff were on duty to ensure that residents could then all partake in their individual activities with sufficient staff support. Trefusis DS0000009120.V340467.R01.S.doc Version 5.2 Page 22 At night one sleeping in member of staff is on duty. This was discussed with staff and the registered manager as to the potential difficulties/ risks one member of staff being alone in the building at night may face. The registered manager, confirmed by staff, acknowledged that the current resident group do not need much support at night due to their levels of dependency. However it was acknowledged that the risks attached to one working at night need to be considered in more depth. The registered manager agreed to undertake a risk assessment in this aspect taking into account the dependency needs of the current Service users group. The registered manager stated that 50 of the staff tem have gained a NVQ at a minimum level 2, some staff are in the process of starting this course. The majority of staff has attended first aid, food hygiene and moving and handling training. Spectrum provides an annual programme of training courses, which staff confirmed they are encouraged to attend. From observations of staff interaction with residents it was evident that they communicate with residents a competent, fair, patient manner and work with them at their pace. Recently recruited staff records were inspected which demonstrated that a fair and robust recruitment process is in place. All relevant document as required by legislation had been gained before the individual commenced employment at the home. Interview records indicate that they are selected on their suitability to work in the care sector. It was noted that residents are not currently involved in the recruitment process but newly appointed staff felt that residents views were being sought during her probationary period of work. Staff training records indicates that they undergo induction training on commencing work with Spectrum and have good access to ongoing training so that they can update their knowledge and skills continuously during their employment. A staff member also confirmed this. The registered manager acknowledged that due to her recent absence at work, staff supervision has not been completed as regularly as needed and this would be addressed. Staff stated that they found supervision to be beneficial. Trefusis DS0000009120.V340467.R01.S.doc Version 5.2 Page 23 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. 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 are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37,39,40, 41,42 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is competently managed for the benefit of Service users. There are formal and informal systems in place to ensure that service users’ views are taken into account in the ongoing management of the home. The home is maintained to a good standard to ensure that it is safe for all those who live, work and visit the home. Spectrum must ensure that if the registered manager is absent for more than 28 days they inform CSCI of the interim management arrangements to ensure that the home continues to be managed in a safe manner. Record keeping of residents is detailed but they must be kept in line with the Data Protection Act. EVIDENCE: The Registered Manager is completing her NVQ 4 in care and then will commence her Registered Managers Award. She continues to ensure that her training is up to date. Residents and staff spoke highly of her skills and felt that she was approachable and listened to their ideas or concerns. From Trefusis DS0000009120.V340467.R01.S.doc Version 5.2 Page 24 observations residents communicated with the Registered Manager in a relaxed manner. It was brought to the Commissions attention that the registered manager had a period of absence from the home for 3 months. The home ensured that interim management arrangements were put in place, and this did not affect the service delivery to residents. However under legislation Spectrum must inform the Commission of any management absences if they are to last over a 28-day period. This must be carried out with any future management absences lasting more than 28 days, in all Spectrum homes in the future. Spectrum has a quality assurance process, which involves collating views of residents, their relatives, advocates, professionals and staff. This is included in the care planning process and its reviews as well as more generalised monitoring of the service. In addition the homes have a monthly monitoring process, known as regulation 26 and these reports are sent to the Commission. Residents maintain their own individual and separate dairy of events. Staff complete their own records on each individual resident of daily events, however these are all contained in one dairy. This breaches the Data protection Act, as records are combined and therefore breaching confidentiality. This was discussed with the registered manager who agreed that in future separate daily records for each resident would be kept, and then residents will be able to access these if they wish and not be privy to other residents’ personal information. The home’s environment appeared safe and there are written individual environmental risk assessments in place to minimise risks to residents staff working in the home. Records of fire safety equipment tests evacuations occur regularly. Maintenance of the home and its equipment inspections undertaken by Environmental health are all satisfactory. and and and and Trefusis DS0000009120.V340467.R01.S.doc Version 5.2 Page 25 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 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 3 2 3 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 X 28 X 29 X 30 2 STAFFING Standard No Score 31 X 32 3 33 2 34 3 35 3 36 2 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 4 17 4 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 X 3 X 3 3 2 3 X Trefusis DS0000009120.V340467.R01.S.doc Version 5.2 Page 26 Are there any outstanding requirements from the last inspection? 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 YA37 Regulation Requirement Timescale for action 30/08/07 38 The registered provider must (1)(A)(b)(2) inform the Commission if a 93)(4)(5) registered manager is to be absent form managing the home for a period of 28 days or longer. Interim management arrangements must be forwarded to the Commission in this instance. 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 YA20 Good Practice Recommendations A process for auditing PRN medication should be implemented so that the registered manager is aware of the quantity of PRN medication in stock, and can undertake audits, which will allow a monitoring of the medication. A risk assessment of staff working alone at night at Trefusis should be undertaken to ensure that Service users and staff are confident that there are safe and robust processes in place if needed. DS0000009120.V340467.R01.S.doc Version 5.2 Page 27 2 YA33 Trefusis 3 4. 5 YA30 YA36 YA41 Paper towels should be made available in the kitchen area to promote infection control Care staff should be provided with more regular individual/ formal supervision, with records maintained. Records should be kept in line with the guidance of the Data protection Act so that Service users can access all documentation relating to them. Trefusis DS0000009120.V340467.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Unit D1 Linhay Business Park Ashburton Devon 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 © 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 Trefusis DS0000009120.V340467.R01.S.doc Version 5.2 Page 29 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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