Inspection on 22/05/07 for Trelawne

This inspection was carried out on 22nd May 2007.

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 18/08/06

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 Wolton-Harragan Key Unannounced Inspection 22nd May 2007 10:30 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.V340788.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.V340788.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.V340788.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 18th August 2006 Brief Description of the Service: Trelawne Rest Home is situated in an established area of Clacton-on-Sea, known locally as the Gardens, 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. 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.V340788.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This report follows a key inspection of Trelawne Rest Home that included an unannounced visit to the service on May 22nd 2007 as well as subsequent visits and fieldwork. The judgements made within this report are based upon evidence found on the inspection visits along with information submitted by the service and feedback from service users, staff and other parties since the previous inspection. Mrs Monica Roberts, the proprietor/manager of Trelawne, was unavailable at the first inspection visit but was present at the second visit and took an active role in the inspection process. During this inspection 27 of the 38 applicable standards were looked at; 19 of these were met, 6 were nearly met, 1 was unmet and 1 was not applicable. There are 7 statutory requirements following this inspection, 5 of which are outstanding from previous inspections. During the visits to Trelawne, people living at the home and staff were spoken with. All were positive about the home and the people living there appeared at ease and were happy to talk to the Inspector. Interactions between staff and the people living at Trelawne observed during this inspection were positive. The visit Trelawne included an environmental tour of the home, discussions with people living at the home, staff and the home manager, as well as the opportunity to look at records of how people living at Trelawne were supported and how the staff were recruited and trained. What the service does well: People living at Trelawne speak highly of the staff and of the meals offered. Trelawne continues to provide care of an intuitive nature, supporting people in an environment that is homely and well maintained. Staff at Trelawne were positive in their approach to their work and worked well together to meet the needs of those living at the home. The staff respected the needs and rights of those living at Trelawne. Trelawne DS0000017985.V340788.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? 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. The summary of this inspection report can be made available in other formats on request. Trelawne DS0000017985.V340788.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.V340788.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. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 3 & 6 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Prospective service users can expect to have the information they need to make an informed choice about where to live and to have his/her needs assessed before moving into the home. The home did not provide intermediate care. EVIDENCE: The home had a published Statement of Purpose and Service User Guide, both of which were made available to existing and prospective residents at Trelawne. The examination of care records showed that people living in the home had had their individual needs assessed prior to moving in and these assessments formed the basis of individual care plans. Discussions with the Trelawne DS0000017985.V340788.R01.S.doc Version 5.2 Page 9 proprietor/manager, staff and service users supported the evidence found in care records and indicated that these assessments gained views and insights from the individual, their families and professionals involved in the individual’s care. Trelawne DS0000017985.V340788.R01.S.doc Version 5.2 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 & 10 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. People living at the home cannot expect all their health, personal and social care needs to be set out in an individual plan of care although needs identified would be met. The home’s policies and procedures for dealing with medicines offer protection and people are treated with respect. EVIDENCE: The examination of care records and individual plans of care showed that there had been improvements to the frequency of the reviews of plans and the quality of entries in the daily records. However, there was not evidence to show that all the needs of individuals were identified with in needs assessments or that these assessments were fully reflected by the plans developed. For example, during the environmental tour of the home it was noted that one bed had bed rails in place although this was not mentioned within the person’s records and there was no risk assessment in place to Trelawne DS0000017985.V340788.R01.S.doc Version 5.2 Page 11 support this decision. Another person had apparent breathing difficulties, which was not referred to within their plan of care. Care records sampled showed that one person took responsibility for the storage and administration of their own medication and the staff of the home regularly monitored this. There were risk assessments in place to support this practice as well as policies and procedures to protect and support the individual. The homes of general policies and procedures for the storage, administration and recording of medicines were seen to be appropriate and offered sufficient protection to those living at Trelawne. The observation of interactions between staff and people living at the home provided evidence that people were treated with respect and their right to privacy was upheld. Staff were seen to knock on doors before entering private bedrooms and address those living at the home in a respectful and caring manner. Trelawne DS0000017985.V340788.R01.S.doc Version 5.2 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 & 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People who use services are able to make choices about their life style. Social, cultural and recreational activities meet individual’s expectations. EVIDENCE: The examination of records within the home showed there were activities on offer to people living at Trelawne. There was a programme displayed showing tabletop activities on a daily basis and records were maintained detailing how people had participated and whether they had appeared to enjoy the activity. Some people living at Trelawne were more independent and were able to independently pursue activities outside the home, others were supported to go to the shops or to the seafront. Discussions with staff and with people living at the home indicated that the activities offered were enjoyed and people generally felt there was ‘enough to do’. Records showed that people living at Trelawne were encouraged to make decisions about how they lived and how they spent their time. Trelawne DS0000017985.V340788.R01.S.doc Version 5.2 Page 13 The home was open to visitors at any time and people living at Trelawne stated that they had regular contact with relatives and friends. There were visitors in the home at the time of inspection and all spoke of being made to feel very welcome at Trelawne. People living at the home spoke well of the food offered at Trelawne. Records showed there was a good range of meals provided and snacks and drinks were available throughout the day. The main meal of the day was served at lunchtime and, although there was little choice offered, this was seen to be nutritionally balanced and attractively presented. Trelawne DS0000017985.V340788.R01.S.doc Version 5.2 Page 14 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16 & 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People living at the Home are able to express their concerns, and have access to a robust, effective complaints procedure, and are protected from abuse, and have their rights protected. EVIDENCE: Trelawne had a robust and accessible complaints procedure that was supported by appropriate Protection Of Vulnerable Adults protocols that were understood by staff. Service users spoken with felt safe at the home and indicated that they could raise issues of concern with the proprietors and these would be acted upon. Trelawne DS0000017985.V340788.R01.S.doc Version 5.2 Page 15 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 25 & 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The physical design and layout of the home enables people to live in a safe, well-maintained and comfortable environment, which encourages independence. EVIDENCE: The home employs a handyman and a domestic who maintain Trelawne to a good standard. All areas were well decorated, clean and free from offensive odours. The sink in one bedroom required attention, although the manager and the handyman were both aware of this and were waiting for the appropriate tradesmen to attend. Trelawne DS0000017985.V340788.R01.S.doc Version 5.2 Page 16 The home was furnished in a domestic style and met the needs of people living there in a homely fashion. The home was considered fit for its stated purpose, accessible and safe. There were adequate bathrooms and WCs and all but two bedrooms had en-suite toilets. Since the last inspection, some radiators at Trelawne had been covered to minimise surface temperatures. However, there were some in some rooms that had not been covered and, although the proprietor/manager believed these to be safe, there was no evidence of risk assessments being conducted. Individuals living at the home expressed satisfaction with their environment and were happy to allow the inspector access to their rooms. Trelawne DS0000017985.V340788.R01.S.doc Version 5.2 Page 17 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 & 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Staff in the home are trained and skilled and in sufficient numbers to support the people who use the service, in line with their terms and conditions, and to support the smooth running of the service. EVIDENCE: Discussions with the manager and the examination of records showed that staff were employed in adequate numbers to meet the needs of those living at the home. Staff files were appropriately maintained and showed the home’s recruitment practices offered protection to those living at the home by ensuring that all necessary pre-employment checks were undertaken. There was evidence of staff receiving training to develop their skills and competences although records of formal induction were poor. Discussions with those living at the home gave evidence that they felt safe at Trelawne and that the staff were able to meet their needs. Trelawne DS0000017985.V340788.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. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 34, 35, 36 & 38 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The management and administration of the home is based on openness and respect, has effective quality assurance systems developed by a qualified, competent manager. EVIDENCE: The home is managed by the proprietor who has a number of years experience in caring for the client group. She is undertaking her NVQ level 4 in management and has attended the training sessions that have recently been made available to the staff group. Discussions with staff and people living at Trelawne DS0000017985.V340788.R01.S.doc Version 5.2 Page 19 the home showed that the general ethos of the home is open and understanding and there were records of staff meetings being held. Views of those living at the home are sought through questionnaires although there was no evidence of a formal quality assurance process being undertaken. There was also no evidence of there being a business plan for the home to demonstrate its continued financial viability despite this being a requirement of the previous inspection. Records of staff supervision were poor. Although some staff had received some supervision, this was infrequent and insufficient. Although most records relating to the welfare of people living at Trelawne were in place, none of the individual records examined contained photographs as required in Schedule 2 of the Care Home Regulations 2001. There were appropriate policies and procedures in place regarding the health, welfare and safety of those living in Trelawne, staff and visitors. Electrical and gas safety checks had been conducted at appropriate intervals and the home displayed relevant Insurance and Registration Certificates. Fire procedures were displayed in prominent positions and regular checks of fire alarms and safety equipment had been undertaken. Trelawne DS0000017985.V340788.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 3 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 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X X 2 3 STAFFING Standard No Score 27 3 28 3 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 2 1 3 2 2 3 Trelawne DS0000017985.V340788.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. Standard OP7 Regulation 14(2)(b) 15(2)(b) Requirement Timescale for action 31/10/07 2. OP25 13(4)(a) 3. OP30 13 (6) & 18 (c)(i) 4. OP33 24 The registered person shall ensure the needs and aspirations of all people living at Trelawne are regularly reassessed and the individual plans reflect all needs of each person. Te registered person shall make 31/10/07 there are risk assessments conducted to assess the safety of all radiators through Trelawne and take appropriate actions to minimise the risks these present. The previous timescale of 31/10/06 was not met. The registered person must 31/10/07 ensure that all staff receive formal induction at the point of commencing employment in the home to ensure that people living at Trelawne are protected from the risk of harm and or abuse. The previous timescale of 31/10/06 was not met. The registered person shall 31/10/07 develop a formal process for assessing the quality of the service provided at Trelawne to ensure the home continues to operate in the best interests of DS0000017985.V340788.R01.S.doc Version 5.2 Trelawne Page 22 5. OP34 25 6. OP36 18 7. OP37 17(1)(a) Schedule 3 the people living there. The previous timescale of 30/11/06 was not met. The registered person shall 31/10/07 develop a business plan for Trelawne to demonstrate the continued financial viability of the home. The previous timescale of 30/11/06 was not met. The registered person shall 31/10/07 provide all care staff with formal supervision on at least 6 occasions each year to ensure staff development needs are identified and practices are updated. The previous timescale of 31/10/06 was not met. The registered person shall 31/10/07 ensure all care records for people living at the home contain up to date photographs of the individual to ensure the persons best interests can be protected. RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Trelawne DS0000017985.V340788.R01.S.doc Version 5.2 Page 23 Commission for Social Care Inspection Colchester Local Office 1st Floor, Fairfax House Causton Road Colchester Essex CO1 1RJ 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 Trelawne DS0000017985.V340788.R01.S.doc Version 5.2 Page 24 - 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. 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