Inspection on 18/08/06 for Trelawne

This inspection was carried out on 18th August 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. 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 there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Trelawne 20/05/09

Trelawne 29/05/08

Trelawne 22/05/07

Trelawne 23/02/06

Trelawne 22/09/05

Trelawne 16/03/05

Trelawne 19/01/05

Trelawne 29/03/04

Similar services:

Claremont House

Oak Ridge

Sun Court Nursing Home

Ashville House

Bilney Hall

Hill Barn

Mabbs Hall Nursing Home

Henrietta House

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

CARE HOMES FOR OLDER PEOPLE Trelawne 31 Lancaster Gardens West Clacton On Sea Essex CO15 6QG Lead Inspector Neal Cranmer Key Unannounced Inspection 18th August 2006 09:30a X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Trelawne DS0000017985.V290125.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Trelawne DS0000017985.V290125.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Trelawne Address 31 Lancaster Gardens West Clacton On Sea Essex CO15 6QG 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) 01255 220259 N\A Mrs Monica Roberts Mrs Monica Roberts Care Home 13 Category(ies) of Old age, not falling within any other category registration, with number (13) of places Trelawne DS0000017985.V290125.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 23rd February 2006 Brief Description of the Service: Trewlawne Rest Home is situated in an established area of Clacton-on-Sea, known as the Gardens Area, close to the sea front, and within easy walking distance of all local amenities. The home is registered for thirteen older people. The registered person is Mrs Monica Roberts who has managed the home for a number of years. The home provides accommodation on two levels. A passenger lift is provided for access to the first floor. A number of communal areas are available. The home has a large garden area to the rear of the property. Telephone conversation with the registered manager on the 13th September 2006 indicated that the fee range for the home is between £326.00 -£380.00 per week, additional charges are made for the following: • • • Hairdressing Chiropody Toiletries. Trelawne DS0000017985.V290125.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced (key) inspection to Trewlawne, which took place on the 18th August 2006, the first inspection to the home for the year 2006/2007; the registered manager was available at the home throughout the course of the inspection. The fieldwork visit to the home took place over a two-day period, due to unforeseen interruption. The inspection included discussions with service users, the registered manager and staff. In addition to these discussions a range of documentary records and files were sampled, including pre-admission assessments, care plans and policies and procedures. A total of twenty-six of the thirty-eight standards were inspected, of which twelve were met, ten were minor shortfalls, with the remaining four being major shortfalls. Tour of the premises evidenced that the home was decorated and maintained to a high standard. What the service does well: What has improved since the last inspection? A significant number of requirements from the last inspection remain outstanding, which are referred to below. Trelawne DS0000017985.V290125.R01.S.doc Version 5.2 Page 6 What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Trelawne DS0000017985.V290125.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Trelawne DS0000017985.V290125.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 3. Quality in this outcome area is good. This judgement has been made using available evidence, including a visit to this service. Service users are not admitted to the home without first having their needs assessed. EVIDENCE: Since the previous inspection there have been three new admissions to the home. Each of the care plans sampled contained evidence of pre-admission assessments having been carried out, each of which covered the following areas: • • • • Current prescribed medication Mental Health status Social contact Physical health. The assessments were then used as the basis for the development of the service user’s plan of care. Trelawne DS0000017985.V290125.R01.S.doc Version 5.2 Page 9 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10. Quality in this outcome area is adequate. This judgement has been made using available evidence, including a visit to this service. Service users’ care plans do not adequately reflect all their personal and social care needs. Service users can expect that their healthcare needs will be catered for. The home’s medication administration practices are robust in terms of ensuring service users are protected. Practice observed on the day of the inspection shows that staff are not always conscious of service users’ rights and privacy. EVIDENCE: Care plans are based upon the assessment of needs for daily living skills and covered the following areas: • Routine upon waking DS0000017985.V290125.R01.S.doc Version 5.2 Page 10 Trelawne • • • • • Routine for retiring to bed Likes/dislikes and allergies Personal hygiene Social needs and relationships General health needs. Daily records bore little relationship to the actual plan of care, which itself did not contain any evidence of objective setting. The care plans sampled contained inconsistent evidence of review taking place. Discussion with the registered manager evidenced that service users are supported wherever possible to retain their existing General Practitioner at the point of admission, however if this is not practical then the registered manager arranges registration on their behalf. Sampling of healthcare records evidenced that the following healthcare professionals are providing input into the home: • • • • General Practitioners District Nurses Chiropodists Physiotherapists. The registered manager spoke of one service user who is currently being treated for a pressure area to their heel by a district nurse. A risk assessment was seen in respect of the service user’s skin tissue viability. The home’s medication records were sampled and found to be in order. Medication is dispensed only by staff who have undertaken training. The preinspection questionnaire submitted evidenced that three members of the staff team have yet to undertake the said training. The home does not hold any medications that are of a ‘controlled drug’ nature. During the course of the inspection a service user was heard being supported to have some blood taken by a visiting district nurse. Discussion with the registered manager confirmed that the visit had taken place in the dining room, which it was stressed was vacant at the time, with the door closed. Discussion took place around the appropriateness of this in terms of respecting the service user’s dignity. Trelawne DS0000017985.V290125.R01.S.doc Version 5.2 Page 11 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15. Quality in this outcome area is poor. This judgement has been made using available evidence, including a visit to this service. Access to a range of social interests and opportunities to take part in the local community are limited. Service users are supported to the best of their individual abilities to exercise their choice and autonomy. Service users are provided with a diet that is wholesome and nutritious, but service users are not actively encouraged to make a choice. EVIDENCE: Discussion with service users and staff indicated that activities and opportunities to partake in the local community are minimal. There is no structured activity plan for the home, and service users when asked how they spent their days responded by saying ‘sitting in front of the television’ or ‘listening to the radio’. No evidence was seen of any activities taking place on the day of the inspection. Trelawne DS0000017985.V290125.R01.S.doc Version 5.2 Page 12 Quality satisfaction questionnaires sampled made reference to the following activities, which staff indicated did sometimes took place on an ad hoc basis: • • • • • • Bingo Reminiscence Dominoes Knitting Watching television Going for walks A lack of activities at the home has been raised as a concern from previous inspections. Discussion with the manager indicated they are giving consideration to the employment of an activities co-ordinator whose role it would be to move this matter forward. None of the service users residing at the home are able to manage their own financial affairs. Discussion with the registered manager indicated that the home does not handle or manage any money on behalf of the service users. Discussion with service users indicated that they had been able to bring personal effects with them to the home when moving in. Service users spoken with indicated that the food provided by the home was generally good, although there was little in the way of choice. Meals were provided three times daily at least one of which the service user stated was cooked. The last meal provided by the home was teatime, which was stated to be at about 4:30 pm. Discussion with the service user indicated that whilst an evening drink is provided no snacks are available after teatime. The lunchtime meal was discreetly observed to be taken in a congenial setting and in an unhurried manner Trelawne DS0000017985.V290125.R01.S.doc Version 5.2 Page 13 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18. Quality in this outcome area is good. This judgement has been made using available evidence, including a visit to this service. The home’s Complaints and Adult Protection arrangements are sufficiently robust to ensure that service users are protected. EVIDENCE: The home has in place a complaints procedure which was displayed on the wall in a prominent position, and which included the contact details of the Commission for Social Care Inspection. At the time of the inspection no complaints had been received in respect of the service. The home’s adult protection arrangements are robust and include the following information: definition of abuse, legal position, types of abuse, and how they may present. Evidence was provided that all staff have now received training on adult protection Trelawne DS0000017985.V290125.R01.S.doc Version 5.2 Page 14 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 25, and 26. Quality in this outcome area is adequate. This judgement has been made using available evidence, including a visit to this service. Service users are supported in an environment that is safe and well maintained. The home was found to be very clean and pleasantly presented with no unpleasant odours. EVIDENCE: Tour of the premises evidenced that the home is fit for its stated purpose, is accessible, safe and well maintained, meeting service users’ needs in a comfortable and homely way. Those spoken with were complimentary of the homeliness and tidiness of the home. Trelawne DS0000017985.V290125.R01.S.doc Version 5.2 Page 15 The grounds of the home were found to be tidy and well kept, and were readily accessible to service users (although on the day none were seen venturing into the garden area.) The requirement from the previous inspection for all radiators to either be guarded or of the low surface temperature variety remains unmet, although the registered manager pointed out that this was scheduled to be addressed. The home’s laundry facilities are sited well away from areas where food preparation takes place, and hand washing facilities were available the floor and wall surfaces were tiled, thereby making them easy to clean. The laundry did not have a sluicing facility available. Discussion with the registered manager evidence that soiled incontinence pads are placed in yellow bags and collected by a clinical waste company on a weekly basis. Discussion with the registered manager and sampling of records evidenced that the home does not have in place any policies or procedures on infection control/dealing with spillages, although protective clothing is provided. Trelawne DS0000017985.V290125.R01.S.doc Version 5.2 Page 16 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30. Quality in this outcome area is poor. This judgement has been made using available evidence, including a visit to this service. The home’s duty rotas show that the numbers and skill mix of staff on duty are sufficient to meet the needs of service users. The home’s recruitment practice requires further development to ensure service users are protected. staff receiving a limited formal induction. EVIDENCE: Currently the home has ten service users in residence. Discussion with the registered manager confirmed that the home does not employ any carers under the age of eighteen, and all staff left in a position of being in charge of the home are all aged over twenty-one. The duty rota sampled indicated that currently the staffing levels for the home are two in the morning and two in the afternoon. In addition, the home employs a domestic and handyman four days a week. Nights are covered by one waking night staff; in addition the registered manager covers sleep-ins, living at the home in a self-contained flat The home employs seven care staff; of these one is qualified at N.V.Q level 2 in care, with another three having commenced their level 3 awards. Trelawne DS0000017985.V290125.R01.S.doc Version 5.2 Page 17 Three staff files were sampled in respect of the home’s recruitment practices. Whilst some improvement was evidenced there remained no evidence of staff receiving any formal induction. Supervision had commenced at the home but to date not all staff were receiving formal supervision. None of the files sampled contained application forms. Trelawne DS0000017985.V290125.R01.S.doc Version 5.2 Page 18 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 32, 33, 34, 35, 36, 37 and 38. Quality in this outcome area is poor. This judgement has been made using available evidence, including a visit to this service. The registered manager has previous care experience. The management ethos of the home is open and transparent. Quality assurance requires further development to ensure the views of service users are taken into account. At present service users’ tenure is not protected by an open and available business plan and the service does not take responsibility for managing service users’ personal monies. Staff supervision is not available to all staff working in the home. Policies and procedures for dealing with clinical waste are not in place. Trelawne DS0000017985.V290125.R01.S.doc Version 5.2 Page 19 EVIDENCE: The registered manager has a number of years’ experience of working in the care sector and has now commenced their N.V.Q level 4 in management, and recognises the need to also undertake the award in care. The manager provided some evidence of having undertaken periodic training, although this was minimal. Discussion with staff evidenced that the management style at the home is one of openness and transparency. The home uses questionnaires to gauge the quality of its service provision, three of which were sampled. Discussion took place with the manager about how they addressed any areas of concern that maybe highlighted, and about the need to give consideration to expanding the use of the questionnaires to a wider audience of interested stakeholders. The registered manager was referred to National Minimum Standard 33 for further guidance. The home has in place public liability insurance, although to date a business plan for the service, which provides evidence of the home’s ongoing financial viability, was unavailable for inspection. The home does not manage any monies on behalf of service users. Although evidence was provided that formal supervision is now being provided at the home, this has yet to be made available to all staff. The registered manager must ensure that all necessary policies and procedures are in place that protect individuals both living and working at the home. This relates specifically to the need to develop policies and procedures on infection control. Trelawne DS0000017985.V290125.R01.S.doc Version 5.2 Page 20 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 1 14 3 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X X 2 2 STAFFING Standard No Score 27 3 28 3 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 3 2 1 3 2 1 1 Trelawne DS0000017985.V290125.R01.S.doc Version 5.2 Page 21 Are there any outstanding requirements from the last inspection? Yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. 2. Standard OP7 OP12 OP13 Regulation 15 (2b) 16 (m) Requirement The registered person must ensure that service users’ plans of care are kept under review. The registered person must make provision to enable service users to engage and participate in social and community activities. The previous timescale set of the 30/06/06 was not met. The registered person must make sure that adequate quantities of wholesome and nutritious food are made available to service users at all reasonable times. This relates specifically to the availability of snacks. The registered person must take all reasonable precautions to ensure that the home is free from hazards. This relates specifically to the need for all radiators to be guarded. The previous timescale set of the 30/06/06 was not met. Timescale for action 31/10/06 31/10/06 3. OP15 16 (i) 31/10/06 4. OP25 13 (4a) 31/10/06 Trelawne DS0000017985.V290125.R01.S.doc Version 5.2 Page 22 5. OP29 19, Schedule 2. 6. OP30 13 (6) 18 (ci) 7. OP33 24 8. OP34 25 9. OP36 18 10. OP37 Trelawne 13 (3) The registered person must ensure that all information and documents in respect of persons working in the home are in place, as set out in Regulations 17 and 19, and Schedule 2 of the Care Homes Regulations. The previous timescales set were not met. The registered person must ensure that all staff receive the appropriate training necessary to ensure that service users are protected from the risk of harm and or abuse, and which is appropriate to the work they are to perform. This relates specifically to the need for all staff to be provided with formal induction at the point of commencing employment in the home. The registered person must ensure that a process for reviewing and keeping under review the home’s quality of service provision is developed. The previous timescale set of the 30/06/06 was not met. The registered person must ensure that a business plan is developed that is available for inspection by the Commission for Social Care Inspection. The previous timescales set of June 2005, 31/12/05 and 30/06/06 were not met. The registered person must ensure that all staff working at the care home receive appropriate supervision. The previous timescale set of June 2005, 31/12/05 and 30/06/06 were not met. The registered person must ensure that suitable arrangements are made to prevent the spread of infection. DS0000017985.V290125.R01.S.doc 30/11/06 31/10/06 30/11/06 30/11/06 31/10/06 31/10/06 Version 5.2 Page 23 OP38 OP26 This relates specifically to the need to develop policies and procedures for infection control. 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 OP31 Good Practice Recommendations It is recommended that the registered manager complete their N.V.Q level 4 in management, and enrol for the level 4 in care at the earliest convenience. Trelawne DS0000017985.V290125.R01.S.doc Version 5.2 Page 24 Commission for Social Care Inspection Colchester Local Office 1st Floor, Fairfax House Causton Road Colchester Essex CO1 1RJ National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. 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