Inspection on 14/09/04 for Tregarne

Care Homes For Adults (18 – 65)Tregarne HostelNorth Street St Austell Cornwall PL25 5QEAnnounced Inspection14th September 2004 Commission for Social Care InspectionLaunched in April 2004, the Commission for Social Care Inspection (CSCI) is the single inspectorate for social care in England. The Commission combines the work formerly done by the Social Services Inspectorate (SSI), the SSI/Audit Commission Joint Review Team and the National Care Standards Commission. The role of CSCI is to: • Promote improvement in social care • Inspect all social care - for adults and children - in the public, private and voluntary sectors • Publish annual reports to Parliament on the performance of social care and on the state of the social care market • Inspect and assess ‘Value for Money’ of council social services • Hold performance statistics on social care • Publish the ‘star ratings’ for council social services • Register and inspect services against national standards • Host the Children’s Rights Director role.Inspection Methods & FindingsSECTION B of this report summarises key findings and evidence from this inspection. The following 4-point scale is used to indicate the extent to which standards have been met or not met by placing the assessed level alongside the phrase Standard met? The 4-point scale ranges from: 4 - Standard Exceeded (Commendable) 3 - Standard Met (No Shortfalls) 2 - Standard Almost Met (Minor Shortfalls) 1 - Standard Not Met (Major Shortfalls) O or blank in the Standard met? box denotes standard not assessed on this occasion. 9 in the Standard met? box denotes standard not applicable. X is used where a percentage value or numerical value is not applicable. ESTABLISHMENT INFORMATION Name of establishment Tregarne Hostel Address North Street, St Austell, Cornwall, PL25 5QE Email address Tel No: 01726 72429 Fax No:Name of registered provider(s)/company (if applicable) Cornwall County Council Name of registered manager (if applicable) Mrs Elisabeth-Anne Philp Type of registration Care Home No. of places registered (if applicable) 16Category(ies) of registration, with (number of places) Learning disability (16), Physical disability (16), Sensory impairment (16) Registration number D040000441 Date first registered 6th February 2004 Was the home registered under the Registered Homes Act 1984 as amended? Do additional conditions of registration apply ? Date of last inspectionDate of latest registration certificate 6th February 2004 YES NO 23/3/04 If Yes refer to Part CTregarne HostelPage 1 Date of inspection visit Time of inspection visit Name of inspector Name of inspector Name of inspector 1 2 314th September 2004 10:00 am Mike StokesID Code071536Name of inspector 4 Name of specialist (e.g. Interpreter/Signer) (if applicable) Name of establishment representative at the time of inspectionMrs Elisabeth-Anne PhilpTregarne HostelPage 2 CONTENTSIntroduction to Report and Inspection Inspection Visits Brief Description of the Services Provided Part A: Summary of Inspection Findings Inspector’s Summary Statutory Requirements/Good Practice Recommendations from last Inspection Conditions of Registration Statutory Requirements/ Good Practice Recommendations from this Inspection Part B: Inspection Methods & Findings National Minimum Standards for Care Homes for Adults (18 – 65) 1. Choice of Home 2. Individual Needs and Choices 3. Lifestyle 4. Personal and Healthcare support 5. Concerns, Complaints and Protection 6. Environment 7. Staffing 8. Conduct and Management of the Home Part C: Part D: D.1. D.2. D.3. Compliance with Conditions ( if applicable) Provider’s Response Provider’s Comments Action Plan Provider’s AgreementTregarne HostelPage 3 INTRODUCTION TO REPORT AND INSPECTION Every establishment that falls within the jurisdiction of the Commission for Social Care Inspection (CSCI) is subject to inspection, to establish if the establishment is meeting the National Minimum Standards relevant to that setting and the requirements of the Care Standards Act 2000 as amended. This document summarises the inspection findings of the CSCI in respect of Tregarne Hostel. The inspection findings relate to the National Minimum Standards (NMS) for Care Homes for Adults (18-65) published by the Secretary of State under the Care Standards Act 2000. The Regulations applicable to the inspected service are secondary legislation, with which a service provider must comply. Service providers are expected to comply fully with the National Minimum Standards. The National Minimum Standards will form the basis for judgements by the CSCI regarding registration, the imposition and variation of registration conditions and any enforcement action. The report follows the format of the NMS and the numbering shown in the report corresponds to that of the Standards. The report will show the following: • Inspection methods used • Key findings and evidence • Overall ratings in relation to the standards • Compliance with the Regulations • Required actions on the part of the provider • Recommended good practice • Summary of the findings • Providers response and proposed action plan to address findings This report is a public document. INSPECTION VISITS Inspections are undertaken in line with the agreed regulatory framework with additional visits as required. This is in accordance with the provisions of the Care Standards Act 2000. The following inspection methods have been used in the production of this report. The report is based on the findings of the specified inspection dates.Tregarne HostelPage 4 BRIEF DESCRIPTION OF THE SERVICES PROVIDED. Tregarne is a pleasant split level detached house located within walking distance of St Austell town centre. The home is a Social Service’s establishment that provides short stay care for up to sixteen people with a learning disability. Service users accommodation is located on the ground and first floors. Each floor is selfcontained and therefore has the ability to function independently. One floor of the home has been adapted to meet the needs of service users with a physical disability. The home has the benefit of a fully equipped sensory room and a small computer suite. The property has pleasant gardens to three sides and a parking area to the front.Tregarne HostelPage 5 PART ASUMMARY OF INSPECTION FINDINGSInspector’s Summary (This is an overview of the inspector’s findings, which includes good practice, quality issues, areas to be addressed or developed and any other concerns.) Choice of Home (Standards 1-5) The 5 standards were inspected and 4 met the required standard. A requirement is made to provide further information in the service users’ guide. The registered manager has made appropriate arrangements for other professionals and service users’ representatives to have access to information and support regarding the services and facilities at the home. Individual Needs and Choices (Standards 6-10) 5 standards were inspected and records and discussion demonstrate that these standards are being met. Lifestyle (Standards 11-17) 7 standards were inspected and met the required standard. Service users are supported to use community facilities as part of their plan for the short stay at the home. Personal Support and Healthcare (Standards 18-21) 3 standards were inspected and demonstrated that the service users receive support services as required. Concerns and Complaints (Standards 22-23) These 2 standards were inspected and the protection of vulnerable adults procedures are understood and implemented at the home. Environment (Standards 24-30) 6 standards were inspected and 5 met the required standard. A requirement is made regarding the implementation and timescale of the development plan for environmental standards at the home. Services are generally provided in a comfortable, safe and clean environment. Staffing (Standards 31-36) 4 standards were inspected and met the required standard. The registered manager is committed to providing a well trained workforce. Conduct and Management of the Home (Standards 37-43) 6 standards were inspected and met the required standard. The registered manager is involved in detailed survey procedures to complete a quality audit involving service users and representatives. The registered person is providing services to meet the needs and welfare of the service users.Tregarne HostelPage 6 Requirements from last Inspection visit fully actioned? If No please list belowYESSTATUTORY REQUIREMENTS Identified below are areas not addressed from the last inspection report which indicate a non-compliance with the Care Standards Act 2000 and accompanying Regulations. The code in “Standard” is a cross-reference to the Standards described in full in the section “Inspection Findings”. No. Regulation Standard Required actions Timescale for actionAction is being taken by the Commission for Social Care Inspection to ensure compliance in regard to the above requirements. RECOMMENDATIONS Identified below are recommendations from the last inspection that have not been implemented No. Refer to Good Practice Recommendations StandardCONDITIONS OF REGISTRATION THAT APPLY (OTHER THAN NUMBERS AND CATEGORY OF SERVICE USERS).MET (YES/NO)Tregarne HostelPage 7 STATUTORY REQUIREMENTS IDENTIFIED DURING THE INSPECTION Action Plan: The Registered Person is requested to provide the Commission with an Action Plan, which indicates how requirements are to be addressed with the time scale within which such actions will be taken. This action plan will be made available on request to the Area Office.STATUTORY REQUIREMENTS Identified below are areas addressed in the main body of the report which indicate noncompliance with the Care Standards Act 2000, and accompanying Regulations 2001, and the National Minimum Standards. The Registered Provider(s) is/are required to comply within the given time scales. The code in “Standard” is a cross-reference to the Standards described in full in the section “Inspection Findings”. No. Regulation Standard * Requirement Timescale for action The registered manager must clarify information regarding shared accommodation in the service users guide. The registered person must provide each service user with a service guide to the home in an appropriate format. The home’s premises must be suitable for its stated purpose; accessible, safe and well maintained; meets service users’ individual and collective needs in a comfortable and homely way; and have been designed with reference to relevant guidance. The ‘Responsible Individual’ must provide the Commission with written information regarding the proposals and the timescale for the implementation of development plans regarding the homes environmental standards.1.5YA130.11.04.2.23YA2430.11.04.PART BINSPECTION METHODS & FINDINGSThe following inspection methods have been used in the production of this report Direct observation Indirect observation Sampling • Pre-inspection questionnaire Tregarne Hostel YES NO YES Page 8 • Records • Care plans / Care pathways • Meals • Activities • Other enter details here ‘Tracking’ care and support Group discussion with service users Individual discussion with service users Group discussion with staff Individual discussion with staff Discussion with management Service user survey Relatives/significant others survey/feedback Visiting professionals survey / feedback Tour of premises Formal interviews Document reading Additional inspection information: Number of service users spoken to at time of inspection Number of relatives/significant others the inspectors had contact with Number of letters received in respect of the service CRB check for the responsible individual seen CRB check for the manager seen Certificate of registration was displayed at the time of the inspection Certificate of registration accurately reflected the situation in the service at the time of inspection Total No. of care staff employed (excluding managers) Total No. of staff with nursing qualifications employed Date of inspection Time of inspection Duration of inspection (hrs)YES YES NO NO NO YES NO NO NO NO YES YES YES NO YES NO NO 0 0 1 NO NO YES YES 22 X 14/9/04 10:00 5.0The following pages summarise the key findings and evidence from this inspection, together with the CSCI assessment of the extent to which the National Minimum Standards for Adults (18-65) have been met. The following scale is used to indicate the extent to which standards have been met or not met by placing the assessed level alongside the phrase Standard met? The scale ranges from: 4 - Standard Exceeded 3 - Standard Met 2 - Standard Almost Met 1 - Standard Not Met Tregarne Hostel (Commendable) (No Shortfalls) (Minor Shortfalls) (Major Shortfalls) Page 9 0 or blank in the Standard met? box denotes standard not assessed on this occasion. 9 in the Standard met? box denotes standard not applicable. “X” is used where a percentage value or numerical value is not applicable.Tregarne HostelPage 10 Choice of HomeThe intended outcomes for the following set of standards are: • • • • • Prospective service users have the information they need to make an informed choice about where to live. Prospective service users’ individual aspirations and needs are assessed. Prospective service users know that the home they 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.Standard 1 (1.1 – 1.4) The registered person produces an up to date statement of purpose setting out the aims, objectives and philosophy of the home, its services and facilities and terms and conditions; and provides each service user with a service users guide to the home. The statement of purpose should clearly set out the physical environmental standards met by the home in relation to standards 24.2, 24.9, 25.3, 25.5, 27.2, 27.4 and 28.2; and a summary of this information should appear in the service users’ guide. X X Range of fees charged From To £ £ (per week) NO Any charges for extras If yes, please state what the extras are 2 Key findings/Evidence Standard met? A statement of purpose has been completed that meets the required standard. The registered manager has stated that the service users relatives and care managers have been informed in writing that this document and inspection reports exist and are available for reading at the home. The registered manager has completed the service users guide and intends to produce the guide in an appropriate format to enhance communication with service users. A requirement is made to clarify the statement in the guide that ‘sharing may occur in emergencies’. The clarity is required regarding planned admissions and what occurs if the single rooms are occupied and double rooms for planned single occupancy at the time of an emergency referral. The registered manager states in standard 4 ‘the home could cancel regular service users’ stays to accommodate emergency admissions as necessary’. Standard 25.2 requires that all service users are offered the option of a single room and this must be complied with when organising all admission procedures.Evidence: documentation and discussion with registered manager.Tregarne HostelPage 11 Standard 2 (2.1 – 2.8) New service users are admitted only on the basis of a full assessment undertaken by people competent to do so, involving the prospective service user, using an appropriate communication method and with an independent advocate as appropriate. 3 Key findings/Evidence Standard met? All service users access the home by a care management process that involves a social care and financial assessment. The assessment is requested at the time of referral and is then discussed at a pre-admissions meeting with senior staff at Tregarne Hostel. Evidence: documentation and discussion.Standard 3 (3.1 - 3.10) The registered person can demonstrate the home’s capacity to meet the assessed needs (including specialist needs) of individuals admitted to the home. 3 Key findings/Evidence Standard met? Tregarne is providing short stay accommodation to service users with a complex range of needs, dependency levels and ages from 18 to 70 years. Standard 3.10 states that in homes providing short stays, the statement of purpose, assessment process and service user plan are designed to meet the specific needs of the people for whom the service is intended. The Local Authority and registered manager have reviewed the homes aims and a feasibility study has been completed by Cornwall Social Services to provide specific services and facilities. The current services and facilities at Tregarne are in demand and reviews indicate that assessed needs are being met. Key staff review the care plan during and after each stay for the total of 110 service users accessing short stays at the home. Evidence: records, survey and discussion with registered manager. Standard 4 (4.1 - 4.5) The registered manager invites prospective service users to visit the home on an introductory basis before making a decision to move there, and unplanned admissions are avoided wherever possible. 3 Key findings/Evidence Standard met? Introductions vary depending on individual need but all service users are encouraged to visit prior to their first stay. On the direction of senior management the home must be able to respond to emergency admissions. In order to meet this commitment the home has introduced a system where two beds per night are given a provisional status. This means the home could cancel regular service users’ stays to accommodate emergency admissions as necessary. Evidence: discussion with staff.Tregarne HostelPage 12 Standard 5 (5.1 - 5.5) The registered manager develops and agrees with each prospective service user a written and costed contract/statement of terms and conditions between the home and the service user. 3 Key findings/Evidence Standard met? The criteria of this standard were discussed with the registered manager. The social services finance section provides a copy of the contract to Tregarne. The registered manager has complied with a recommendation to include within the guide, the procedures for service users and representatives to receive terms and conditions regarding short stays at Tregarne. Evidence: discussion with registered manager.Tregarne HostelPage 13 Individual Needs and ChoicesThe intended outcomes for the following set of standards are: • • • • • 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.Standard 6 (6.1 – 6.10) The registered manager develops and agrees with each service user an individual Plan which may include treatment and rehabilitation, describing the services and facilities to be provided by the home, and how these services will meet current and changing needs and aspirations and achieve goals. 3 Key findings/Evidence Standard met? Each service user has a plan of care that is generated from the assessment received at referral and from information gained at the pre-admission meeting and previous knowledge of the service user. The registered manager stated that new processes have been developed to include every service user and updated on each visit to reflect changing needs. The home operates a key worker system to assist in this process. Evidence: documentation and discussion.Standard 7 (7.1 – 7.7) Staff respect service users’ right to make decisions, and that right is limited only through the assessment process, involving the service user, and as recorded in the individual Service User Plan. 3 Key findings/Evidence Standard met? The key worker agrees the plan of care with the service user and carers receive a copy of these agreements. Service users are involved in reviews that involve care managers, relatives and staff from Tregarne. The registered manager is currently organising a survey that will be sent to all service users and carers. Evidence: documentation and discussion.Tregarne HostelPage 14 Standard 8 (8.1 – 8.5) The registered manager ensures that service users are offered opportunities to participate in the day to day running of the home and to contribute to the development and review of policies, procedures and services. 3 Key findings/Evidence Standard met? The registered manager has complied with a recommendation to develop quality audit procedures by seeking the views of service users and representatives. The registered manager has developed a user friendly and appropriate format for consultation on all aspects of the home. Evidence: survey format and discussion.Standard 9 (9.1 – 9.4) Staff enable service users to take responsible risks, ensuring they have good information on which to base decisions, within the context of the service user’s individual Plan and of the home’s risk assessment and risk management strategies. 3 Key findings/Evidence Standard met? The assessment process and previous knowledge of service users provide information for support staff to provide for service users welfare. Individual assessments are provided regarding service users needs and these should continue to be developed at the home. Evidence: records and discussion.Standard 10 (10.1 – 10.6). Staff respect information given by service users in confidence, and handle information about service users in accordance with the home’s written policies and procedures and the Data Protection Act 1998, and in the best interests of the service user. 3 Key findings/Evidence Standard met? Staff are given appropriate instruction during LDAF and NVQ training opportunities and training in reference to Cornwall County policy and procedure. Evidence: records and discussion.Tregarne HostelPage 15 LifestyleThe intended outcomes for the following set of standards are: • • • • • • • 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.Standard 11 (11.1 – 11.4) Staff enable service users to have opportunities to maintain and develop social, emotional, communication and independent living skills. 3 Key findings/Evidence Standard met? The registered manager stated that issues arising from service users presentation or assessment are dealt with in the context of this short stay facility. The group living situation offers many opportunities to look at sharing, decision making, domestic and independent living skills. Evidence: observation and discussion.Standard 12 (12.1 – 12.6) Staff help service users to find and keep appropriate jobs, continue their education or training, and / or take part in valued and fulfilling activities. 3 Key findings/Evidence Standard met? A mini bus and people carrier are provided to assist service users to continue their regular planned educational and occupational activities during the day by attendance at social services day care centres in St. Austell and Liskeard. Evidence: records and discussion.Tregarne HostelPage 16 Standard 13 (13.1 – 13.5) Staff support service users to become part of, and participate in, the local community in accordance with assessed needs and the individual Plans. 3 Key findings/Evidence Standard met? The home provides a mini bus with a tail lift to accommodate disabled service users. A people carrier is also available to assist with the service users transport needs during the day, evenings and weekends. Support staff complete appropriate checks as approved drivers in addition to the designated drivers and passenger assistants that are provided. The ethos of the home is to assist service users to enjoy a short stay by accessing local shops, pubs, cinema, leisure centres and activities. Evidence: records and discussion.Standard 14 (14.1 – 14.6) Staff ensure that service users have access to, and choose from a range of, appropriate leisure activities. 3 Key findings/Evidence Standard met? The registered manager has complied with a recommendation to clarify proposals to provide sufficient drivers on each shift to meet the homes statement of purpose regarding service users accessing community facilities during their stay at the home. Service users can enjoy a range of in house leisure activities. The home has the advantage of a fully equipped sensory room, a small computer suite and ‘The Friends of Tregarne’ have provided for the construction of an activity room in the garden. Service users can pursue their own interests, listen to music, watch television and videos or share activities with others in the communal areas. Evidence: records and discussion.Standard 15 (15.1 – 15.5) Staff support service users to maintain family links and friendships inside and outside the home, subject to restrictions agreed in the individual Plan and Contract (subject to standards 2 and 6 if necessary). 3 Key findings/Evidence Standard met? The home is a short stay facility and therefore all service users have established on-going family or carer links. The home operates an open visiting policy. Evidence: discussion.Tregarne HostelPage 17 Standard 16 (16.1 – 16.11) The daily routines and house rules promote independence, individual choice and freedom of movement, subject to restrictions agreed in the individual Plan and Contract (subject to Standards 2 and 6 if necessary). 3 Key findings/Evidence Standard met? Service users are able to exercise control over their lives and communicate their choices according to individual skills and ability. The registered manager stated that staff respect service users’ privacy and dignity and only enter their rooms with the individuals’ permission. Daily routines allow for flexibility around a variety of issues including activities, meals and bedtimes. Evidence: discussion and records.Standard 17 (17.1 – 17.9) The registered person promotes service users’ health and wellbeing by ensuring the supply of nutritious, varied, balanced and attractively presented meals in a congenial setting and at flexible times. 3 Key findings/Evidence Standard met? There are 2 kitchen areas where the main kitchen prepares for the majority of service users and the lower floor accommodation area is available for service users to prepare meals under supervision. The home has a cook with care staff providing cover in her absence. Staff have undertaken basic food hygiene training. The home provides meals, drinks and snacks to meet individual needs that are available at all times. The home caters for a variety of diets providing diabetic, low fat and vegetarian meals. The record of food provided for service users was inspected. Evidence: observation, records and discussion.Tregarne HostelPage 18 Personal and Healthcare SupportThe intended outcomes for the following set of standards are: • • • • 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.Standard 18 (18.1 – 18.11) Staff provide sensitive and flexible personal support and nursing care to maximise service users’ privacy, dignity, independence and control over their lives. 3 Key findings/Evidence Standard met? The assessment process identifies the service users preferences and the level of support required. The majority of service users have regularly used the service and a consistency of approach can be achieved. Evidence: discussion and records.Standard 19 (19.1 – 19.5) The registered person ensures that the healthcare needs of service users are assessed and recognised and that procedures are in place to address them. No. of incidents where service users have been taken to Accident & Emergency during last 12 months No. of service users with pressure sores at the time of inspection (from information taken from care notes) 003 Key findings/Evidence Standard met? As this is a short stay facility the permanent carers retain the overall responsibility for service users physical and emotional health. Should someone become ill whilst staying at the home staff contact their carers and if necessary seek advice from the service users own GP’s. If this is not possible the home has the facility to register an individual with a local practice as a temporary resident. Some service users receive support from a district nurse or other specialist professional during their stay. Evidence: discussion and records.Tregarne HostelPage 19 Standard 20 (20.1 – 20.14) The registered manager and staff encourage and support service users to retain, administer and control their own medication, within a risk management framework, and comply with the home’s policy and procedure for the receipt, recording, storage, handling, administration and disposal of medicines. 3 Key findings/Evidence Standard met? The registered manager has provided a medication policy and procedure. The home does not maintain stocks of medication as service users bring the medicines they require for their stay and any surplus is returned home when they leave. The home does not have a visiting pharmacist but, if required, is able to contact a local chemist for advice. Service users selfmedicating are provided with a lockable space in which to store medication. The registered manager stated that arrangements are being made for staff administering medication to undertake accredited training. The community nursing service visits the home as required to assist service users that are Insulin dependent. Evidence: documentation and discussion.Standard 21 (21.1 – 21.8) The registered manager and staff deal with the ageing, illness and death of a service user with sensitivity and respect. 0 Key findings/Evidence Standard met? Not inspected.Tregarne HostelPage 20 Concerns, Complaints and ProtectionThe intended outcomes for the following set of standards are: • • Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm.Standard 22 (22.1 – 22.7) The registered person ensures that there is a clear and effective complaints procedure, which includes the stages of, and timescales for, the process and that service users know how and to whom to complain. No. of complaints made to the home during last 12 months No. of these complaints fully substantiated No. of these complaints partly substantiated No. of these complaints not substantiated No. of these complaints not yet resolved No. of complaints sent direct to CSCI Percentage of complaints responded to within 28 days 26 12 0 0 0 0 100 3 Key findings/Evidence Standard met? The homes complaints procedure and the contact number and address of the Commission have been included as part of the service users guide. The registered manager is recording the issues that have been raised by service users or carers and responding appropriately. The registered manager stated that a monthly review of comments and complaints are included in the management systems for the quality audit. Evidence: records and discussion.Tregarne HostelPage 21 Standard 23 (23.1 – 23. 6) The registered person ensures that service users are safeguarded from physical, financial or material, psychological or sexual abuse, neglect, discriminatory abuse or self harm, or inhuman or degrading treatment, through deliberate intent, negligence or ignorance, in accordance with written policy. The home has an Adult Protection procedure (including Whistle Blowing) which complies with the Public Disclosure Act 1998 and the DOH Guidance No Secrets No of staff referred for inclusion on POCA/POVA lists YES03 Key findings/Evidence Standard met? There is a comprehensive adult protection policy and procedure that is adopted within the home. Evidence: records and discussion.Tregarne HostelPage 22 EnvironmentThe intended outcomes for the following set of standards are: • • • • • • • 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.Standard 24 (24.1 – 24.13) The home’s premises are suitable for its stated purpose; accessible, safe and well maintained; meet service users’ individual and collective needs in a comfortable and homely way; and have been designed with reference to relevant guidance. 2 Key findings/Evidence Standard met? The home is a pleasant split level detached house located within walking distance of St Austell town centre. Within the home appropriate facilities are available on both levels, allowing each floor to function independently. The home does not provide a lift facility to assist service users with a physical disability to access the different floor levels. As a local authority facility, Tregarne was required to be registered as a care home in April 2002. For the purposes of the environmental standards Tregarne is a ‘ pre-existing home’ and should include the space provided for each service user in the statement of purpose. The registered manager is aware that the original purpose of the building was to accommodate more able service users and the home now has referrals for a range of complex needs and ages. The Commission made a requirement in the inspection report 9th December 2003 regarding the review of services and environmental issues. The registered manager and the inspector agree that the homes environment requires upgrading to meet standards. The Commission has not made immediate requirements for this work while a review of services and development plans regarding environmental standards has been completed. A requirement is made for the Responsible Individual to provide the Commission with written information regarding these proposals and the timescale for implementation. Evidence: tour of the premises and discussion.Tregarne HostelPage 23 Standard 25 (25.1 – 25. 11) The registered person provides each service user with a bedroom, which has useable floor space sufficient to meet individual needs and lifestyles. Total no. of single bedrooms with at least 10 sq.m usable space or additional compensatory space Pre-existing homes only (1st April 2003) – single bedrooms below 10 sq.m usable space or additional compensatory space Total no. of wheelchair users accommodated for in rooms at least 12 sq.m Total no. of wheelchair users accommodated for in rooms less than 12 sq.m Total no. of shared rooms at least 16 sq.m Total no. of shared rooms below 16 sq.m Percentage of places within single rooms: 100 80 - 99 Less than 80 Total no. of single bedrooms Number of single bedrooms with en suite Total no. of double bedrooms Number of double rooms with en suite NO YES NO 12 0 2 0 4 81 1 1 13 Key findings/Evidence Standard met? The registered manager should continue to provide the Commission with information regarding the review of services and development plans regarding the environmental standards. The implementation of this programme will be dependent on the response to the requirement made in standard 24.Evidence: tour of the premises and discussion.Tregarne HostelPage 24 Standard 26 (26.1 – 26.4) The registered person provides each service user with a bedroom that has furniture and fittings sufficient and suitable to meet individual needs and lifestyles. 3 Key findings/Evidence Standard met? The rooms do not have matching furniture, colour coordination or show signs of being personalised but this standard is met with regards to short stay accommodation. All service users rooms have been fitted with an appropriate lock to provide privacy and security as required. The inspector notes that various furniture and fittings showed signs of wear and an audit and review of this standard is recommended with a detailed upgrading and replacement programme produced. The implementation of this programme will be dependent on the response to the requirement made in standard 24. Evidence: tour of the premises and discussion. Standard 27 (27.1 – 27.6) The registered person provides service users with toilet and bathroom facilities which meet their assessed needs and offer sufficient personal privacy. 3 Key findings/Evidence Standard met? Bathing and toilet facilities are located on each floor of the home and are of sufficient number and design to meet service users needs. Evidence: tour of the home and discussion.Standard 28 (28.1 – 28.3) A range of comfortable, safe and fully accessible shared spaces is provided both for shared activities and for private use. 3 Key findings/Evidence Standard met? The home operates a no smoking policy within the building. Communal areas are comfortable and suitable for a range of activities. Internally there is an access problem for wheelchair users who wish to transfer between the ground and first floor, as the home does not have a lift. The home has pleasant gardens that include a bar-b-cue area. Evidence: observation.Tregarne HostelPage 25 Standard 29 ( 29.1 – 29.8) The registered person ensures the provision of environmental adaptations and disability equipment necessary to meet the home’s stated purpose and the individually assessed needs of all service users. 0 Key findings/Evidence Standard met? Not inspected.Standard 30 (30.1 – 30.9) The premises are kept clean, hygienic and free from offensive odours throughout and systems are in place to control the spread of infection, in accordance with relevant legislation, published professional guidance and the purpose of the home. 3 Key findings/Evidence Standard met? Social services have comprehensive infection control policies and procedures that are adopted within the home. The home was clean and free from offensive odours. The home has effective systems in place for the disposal of clinical waste. Protective clothing is available and used by staff. The laundry area is spacious and well equipped with commercial appliances. Evidence: discussion and records.Tregarne HostelPage 26 StaffingThe intended outcomes for the following set of standards are: • • • • • • 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.Standard 31 (31.1 – 31.7) The registered manager ensures that staff have clearly defined job descriptions and understand their own and other’s roles and responsibilities. 3 Key findings/Evidence Standard met? The registered manager is responsible to comply with Local Authority policy and procedure regarding recruitment, induction, training and appropriate communication through daily contact and staff meetings. Evidence: records and discussion.Standard 32 (32.1 – 32.6) Staff have the competencies and qualities required to meet service users’ needs and achieve Sector Skills Council workforce strategy targets within the required timescales. 3 Key findings/Evidence Standard met? The registered manager has an assessment regarding each of the 110 service users that are known and a combination of these service users may use the short stay accommodation at any one time. Risk assessments and needs are considered by management and senior staff for each shift. Up to 6 carers, ancillary staff, driver and additional managers hours are provided during the morning, which is considered a peak time of activity. As service users attend day care activities the staffing levels are reduced. The staffing levels are once again increased for evenings and weekend activity. Evidence: records and discussion.Tregarne HostelPage 27 Standard 33 (33.1 – 33.11) The home has an effective staff team with sufficient numbers and complementary skills to support service users’ assessed needs at all times. Staff numbers/hours relating to the needs of service users are based on guidance recommended by the Department of Health. Personal Care No. service users High needs No. service users Medium needs No. service users Low needs Total no. of hours needed No. of staff with NVQ level 2 or above No. of Trainees registered on Sector Skills Council training programme X X X X X No. of full time equivalent Staff with nursing qualification (where applicable) No. staff hours allocated No. staff hours allocated No. staff hours allocated Total Hours Provided X X X X Nursing X X XXX3 Key findings/Evidence Standard met? The home has a stable and effective staff team. The home has experienced difficulties with staff sickness resulting in the use of relief staff. The registered manager stated that the agreed staffing levels are maintained and that an increase in care hours had been achieved since the last inspection and an additional assistant manager post has been agreed. The registered manager has negotiated the introduction of 2 waking support staff to assist service users that require attention at night. The duty officer sleeping in and being on call supports this arrangement. Evidence: documentation and discussion.Tregarne HostelPage 28 Standard 34 (34.1 - 34. 8) The registered person operates a thorough recruitment procedure based on equal opportunities and ensuring the protection of service users. 3 Key findings/Evidence Standard met? Social Services have a comprehensive recruitment policy and procedure that is adopted within the home. Administration relating to the recruitment of staff is undertaken at county hall, where staff files are maintained. Records are kept at the home regarding references and a satisfactory criminal records bureau check is in place for all staff prior to being confirmed in post. All staff receive a statement of terms and conditions and posts within the home are subject to a six-month probationary period. Evidence: records and discussion.Standard 35 (35.1 - 35.8) The registered person ensures that there is a staff training and development programme which meets the Sector Skills Council workforce training targets and ensures staff fulfil the aims of the home and meet the changing needs of service users’. 0 Key findings/Evidence Standard met? Not inspected.Standard 36 (36.1 - 36.8) Staff receive the support and supervision they need to carry out their jobs. Key findings/Evidence Standard met? Not inspected.0Tregarne HostelPage 29 Conduct and Management of the HomeThe intended outcomes for the following set of standards are: • • • • • • • 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.Standard 37 (37.1 – 37.4) The registered manager is qualified, competent and experienced to run the home and meet its stated purpose, aims and objectives. Registered manager qualified to level 4 NVQ in Management and care [by 2005]. YES3 Key findings/Evidence Standard met? The registered manager has appropriate experience, an RNMH qualification and is an NVQ Assessor. The registered manager is advised to register on the RMA. Evidence: registration process.Standard 38 (38.1 – 38.6) The management approach of the home creates an open, positive and inclusive atmosphere. 0 Key findings/Evidence Standard met? Not inspected.Tregarne HostelPage 30 Standard 39 (39.1 – 39.10) Effective quality assurance and quality monitoring systems, based on seeking the views of service users, are in place to measure success in achieving the aims, objectives and statement of purpose of the home. 3 Key findings/Evidence Standard met? The registered manager has complied with the recommendation to complete effective quality monitoring systems based on the views of service users and carers. The registered manager is currently involved in a survey that has contacted all service users and their carers. The registered manager will supply the Commission with a report on completion of the survey. In addition, the registered manager has sent the Commission’s comment cards to all 110 service users and carers, to assist in this inspection process. The inspector received 24 responses from carers and 24 responses from service users that had mainly been completed by carers acting as their advocate. The overall summary is that the majority of responses are satisfied with services provided, made to feel welcome and safe. There is a marked reduction in the approval rate for staff numbers on duty and only 9 carers thought it sufficient and 8 carers have a concern in this area. The service users response again indicated a majority of general approval but 8 of 23 responses did not think suitable activities were provided and 9 of 19 responses wished to be more involved in decision making. The registered manager stated that these perceptions of services would be included in the homes survey and may indicate a need to promote clearer lines of communication with carers and service users. The inspector has provided the registered manager with the numerical details of the various responses to assist in the review of services. The factual information given to the Commission anonymously or otherwise has not been passed to the registered manager without seeking prior approval. Evidence: Survey details, comment cards from service users, carers and discussion. Standards 40 (40.1 – 40.6) The home’s written policies and procedures comply with current legislation and recognised professional standards, covering the topics set out in Appendix 2 of the National Minimum Standards for Adults (18-65). 3 Key findings/Evidence Standard met? A comprehensive policies and procedures manual is adopted within the home. The registered manager has access to senior management to provide supervision and advice. Evidence: records and discussion.Tregarne HostelPage 31 Standard 41 (41.1 – 41.3) Records required by regulation for the protection of service users and for the effective and efficient running of the business are maintained, up to date and accurate. 3 Key findings/Evidence Standard met ? The various records inspected during this inspection were appropriately maintained. Evidence: records and discussion.Standard 42 (42.1 – 42.9) The registered manager ensures so far as is reasonably practicable the health, safety and welfare of service users and staff. 3 Key findings/Evidence Standard met? Staff have access to moving and handling, fire safety, first aid and food hygiene training. The building is safely maintained, the equipment and systems are regularly tested and serviced. The home appears security conscious. The home maintains adequate records in relation to fire prevention and accident and incident reporting. The registered manager has complied with a recommendation regarding the provision of mobile phones on the transport providing assistance to service users. The registered manager should continue risk assessments regarding the need for communication between staff and the home for various health and safety issues. Evidence: records and discussion. Standard 43 (43.1 – 43.7 ) The overall management of the service (within or external to the home) ensures the effectiveness, financial viability and accountability of the home. 3 Key findings/Evidence Standard met ? The home is a Social Services establishment that has clear lines of accountability within the home and with external management. The registered manager receives monthly budget statements and supervision. Insurance cover is in place and should be at the minimum level of £5M as stated in this standard. Evidence: records and discussion.Tregarne HostelPage 32 PART C(where applicable)COMPLIANCE WITH CONDITIONSCondition CommentsComplianceCondition CommentsComplianceCondition CommentsComplianceCondition CommentsComplianceLead Inspector Second Inspector Regulation Manager DateMike Stokes Bridget Spear 2nd November 2004Signature Signature SignatureTregarne HostelPage 33 Public reports It should be noted that all CSCI inspection reports are public documents.Tregarne HostelPage 34 PART DD.1PROVIDER’S RESPONSE TO IDENTIFIED STATUTORY REQUIREMENTSRegistered Person’s comments/confirmation relating to the content and accuracy of the report for the above inspection.We would welcome comments on the content of this report relating to the Inspection conducted on 14 September 2004 and any factual inaccuracies: Please limit your comments to one side of A4 if possibleAction taken by the CSCI in response to provider comments: Tregarne Hostel Page 35 Amendments to the report were necessaryNOComments were received from the provider Provider comments/factual amendments were incorporated into the final inspection report Provider comments are available on file at the Area Office but have not been incorporated into the final inspection report. The inspector believes the report to be factually accurateNONote: In instances where there is a major difference of view between the Inspector and the Registered Provider both views will be made available on request to the Area Office. D.2 Please provide the Commission with a written Action Plan by 29 October 2004, which indicates how requirements are to be addressed and stating a clear timescale for completion. This will be kept on file and made available on request.You will also note that the Commission has identified in the inspection report good practice recommendations and it would be useful to have some indication as to whether you intend to take any action to progress these. Status of the Provider’s Action Plan at time of publication of the final inspection report: Action plan was required YESAction plan was received at the point of publicationYESAction plan covers all the statutory requirements in a timely fashion Action plan did not cover all the statutory requirements and required further discussion Provider has declined to provide an action planYESOther: enter details here Tregarne HostelPage 36 D.3PROVIDER’S AGREEMENT Registered Person’s statement of agreement/comments: Please complete the relevant section that applies.D.3.1 I KATH BROWN of Tregarne Hostel confirm that the contents of this report are a fair and accurate representation of the facts relating to the inspection conducted on the above date(s) and that I agree with the requirements made and will seek to comply with these. Print Name Signature Designation Date Or D.3.2 I of Tregarne Hostel am unable to confirm that the contents of this report are a fair and accurate representation of the facts relating to the inspection conducted on the above date(s) for the following reasons: Acting County Resources & Dev. Manager 28/10/04 KATH BROWNPrint Name Signature Designation Date Note: In instance where there is a profound difference of view between the Inspector and the Registered Provider both views will be reported. Please attach any extra pages, as applicable.Tregarne HostelPage 37 Tregarne Hostel / 14th September 2004Commission for Social Care Inspection 33 Greycoat Street London SW1P 2QF Telephone: 020 7979 2000 Fax: 020 7979 2111 National Enquiry Line: 0845 015 0120 www.csci.org.ukS0000041927.V176201.R01© This report may only be used in its entirety. 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