Inspection on 22/09/05 for Trelawne

This inspection was carried out on 22nd September 2005.

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 18/08/06

Trelawne 23/02/06

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 Unannounced Inspection 22nd September 2005 09:30 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.V252395.R01.S.doc Version 5.0 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.V252395.R01.S.doc Version 5.0 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.V252395.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 16th March 2005 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 is available. The home has a large garden area to the rear of the property. Trelawne DS0000017985.V252395.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection that took place over one day on 22nd September 2005, lasting 5.5 hours. The inspection process included discussion with service users and the home’s registered manager. Tour of the premises included sampling of service users’ private accommodation, toilets and bathrooms, as well as communal living areas. During the course of the inspection a range of documentary evidence was sampled. On the day of the inspection twenty-two of the thirty-eight standards were inspected, of these nine were meet, seven were minor shortfalls, with the remainder being shortfalls. A significant number of these shortfalls remain outstanding from previous inspections. What the service does well: What has improved since the last inspection? Since the previous inspection a significant number of the requirements identified remain outstanding and largely unaddressed. Some rationale for this was offered on the day of the inspection, however, whilst this was acknowledged, this cannot be accepted as a valid reason for the home’s on-going failure to comply with requirements and progress its services. Trelawne DS0000017985.V252395.R01.S.doc Version 5.0 Page 6 There was little evidence presented on the day to suggest that the home has done anything significant since the previous inspection to move forward in raising its standards. 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.V252395.R01.S.doc Version 5.0 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.V252395.R01.S.doc Version 5.0 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): No outcomes were inspected in this section on this occasion. EVIDENCE: Trelawne DS0000017985.V252395.R01.S.doc Version 5.0 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): 8 and 11. Service users’ healthcare needs require further development to ensure that all service users’ skin viability is assessed. Care plan records require further development to include the wishes of service users and/or their relatives in the event of the service users’ demise. EVIDENCE: At the previous inspection it was recommended that a risk assessment of all service users’ skin tissue viability be completed. The registered manager stated that to date this has not taken place. At the previous inspection the registered manager was required to make provision for the recording in the service users’ care plans their wishes in the event of their demise. The registered manager stated that to date this requirement has not been meet. Trelawne DS0000017985.V252395.R01.S.doc Version 5.0 Page 10 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 and 15. Activities provided and made available within the home need development to ensure that they meet with service users’ social and recreational interests. Service users are supported to maintain links with family members. Service users are provided with a wholesome and varied diet in pleasant homely surroundings. EVIDENCE: Discussion with the registered manager indicated that service users go out occasionally and partake in-house in playing the piano, watching TV and doing puzzles. However, three care plans sampled did not contain any documentary evidence to show that activities were taking place. Discussion with service users indicated that activities during the day are very limited, and when asked how they spent their days, spoke of predominantly sitting listening to the radio or watching TV. One service user spoke of visiting the local shops on their own to purchase odds and ends. Discussion with service users and the registered manager evidenced that the home has an open door policy on the receiving of visitors. Service users spoke of being free to choose where they receive their visitors. Trelawne DS0000017985.V252395.R01.S.doc Version 5.0 Page 11 Meals are provided three times daily, at least one of which was seen to be cooked. Service users spoken with spoke of the meals being very nice and homely cooked. Hot and cold snacks were seen to be provided. The interval between the last meal taken and the next was seen to be no greater than twelve hours. The lunchtime meal on the day of the inspection was discreetly observed, and seen to be pleasantly presented and taken in a quiet unrushed atmosphere. Service users spoke of the meal being pleasant. Trelawne DS0000017985.V252395.R01.S.doc Version 5.0 Page 12 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. The home’s Complaint Procedure requires reviewing to ensure that it meets with regulatory requirements. The home’s Adult Protection and Whistle Blowing Policies were both deemed to meet with regulatory requirements, however staff remain in urgent need of training in adult protection matters. This training requires scheduling as a matter of extreme urgency to ensure that service users are adequately protected. EVIDENCE: The home has a complaints procedure which requires reviewing to clarify that complaints made may be referred directly to the Commission for Social Care Inspection without direct referral to the home manager first. The home maintains a log of complaints received. The home has an Adult Protection Policy and Whistle Blowing Policy, both of which were deemed to meet with regulatory requirements. At the previous two inspections the need for staff to receive training in this area was identified as an urgent requirement. Discussion with the registered manager evidenced that this requirement continued to remain outstanding. Based upon this finding an ‘Immediate Requirements Notice’ was left, requiring the home manager to present evidence to the Commission for Social Care Inspection that training in this area had been scheduled for all staff, under Regulation 13 (6) of the Care Homes Regulations, and that confirmation of the scheduling of the said training be received within seven days of the serving of the notice. Trelawne DS0000017985.V252395.R01.S.doc Version 5.0 Page 13 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, 20, 21, 22, 24, 25 and 26. The premises were seen to be in a state of good repair and were deemed to be suitable for their stated purpose. Indoor and outdoor communal spaces were safe and accessible. Toilet and washing facilities provided at the home were suitable to meet the needs of the service users. Aids and adaptations were seen to be available to enable service users to maximise their independence. Service users’ bedrooms visited were all seen to be equipped with the necessary furniture and fittings. All bedrooms were naturally ventilated and centrally heated. Radiators were all fitted with thermostatic controls; one radiator was seen to require the fitting of a radiator guard. The home on the day of the inspection was found to be very tidy and free from any unpleasant odours. Trelawne DS0000017985.V252395.R01.S.doc Version 5.0 Page 14 EVIDENCE: The location and layout of the home was suitable for its stated purpose, being tidy, safe and accessible to service users. The home employs a general handyman. The home complies with the local fire department regulations. Communal space available at the home was deemed adequate; the home has a small dining room area. Lighting in all communal rooms was domestic in nature and sufficiently light to facilitate reading. Furnishings in all communal areas were domestic in character and were deemed to be of a good quality. Toilet and washing facilities were seen to be positioned close to the lounge and dining areas. All service users’ private accommodation, bar two, has en-suite facilities. In addition, the home has two further bathrooms, one on the ground floor and one on the first floor. Aids and adaptations at the home were deemed to be adequate. There was evidence of hand grab rails in toilet and bathroom areas and the first floor bathroom had a bath chair. There is a lift to enable service users access to the first floor. Service users’ bedrooms visited were seen to be appropriately furnished and equipped; all rooms bar two were en-suite. Bedrooms were naturally ventilated and all were seen to be centrally heated, with radiators being thermostatically controlled. The radiator situated on the first floor landing was seen to require the fitting of a radiator guard to protect service users from the risk of sustaining injury. The home’s laundry room is situated well away from the kitchen area; hand washing facilities were seen to be available. On the day of the inspection the home was seen to be very clean and hygienic and free from any unpleasant odours. Trelawne DS0000017985.V252395.R01.S.doc Version 5.0 Page 15 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): 28 and 29. Staff at the home are not yet qualified at N.V.Q Level 2 or better, although two are now registered for the award. The home’s recruitment practices were sampled and found to be in significant need of further development to comply with regulatory requirements to ensure that they are robust in terms of protecting service users. EVIDENCE: As yet, none of the care team are N.V.Q Level 2 or better qualified, although the registered manager spoke of two staff being in the process of completing the award. Three staff files were sampled in terms of the home’s recruitment practices. Two of the files sampled of employees recently employed did not contain any evidence of Criminal Record checks. Significant discussion took place with the registered manager around the need to ensure that staff are not employed at the home without the necessary pre-employment checks being completed first, and evidenced in staff files. Trelawne DS0000017985.V252395.R01.S.doc Version 5.0 Page 16 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, 33, 34,36, 37 and 38. The registered manager has worked in the care setting for a number of years and is due to commence the Level 4 Managers Award, although, to date, they have not enrolled for the Award in Care. The home needs to develop a process to enable the quality of its service provision to be kept under review. The home needs to develop a business plan which includes evidence that the home remains financially viable. The home needs to put in place a mechanism to ensure that all staff receive formal supervision. The home needs to ensure that all of the records required under regulation are kept in respect of service users. Evidence was presented that suggested that the home maintains safe working practices. Trelawne DS0000017985.V252395.R01.S.doc Version 5.0 Page 17 EVIDENCE: The registered manager has run the home for a number of years and since the last inspection has commenced her N.V.Q Level 4 in management, although not care. It was pointed out to the registered manager that they will be required to also hold the qualification in care as well by December 2005. The home has a relative satisfaction questionnaire which is sent out annually. Discussion took place around the need to expand this out to include other stakeholders and about how to then analyze the returned questionnaires to inform improvements in practice. The home continues not to have a business plan, although the certificate of public liability was seen and was current. The registered manager was unable to provide any evidence of formal supervision being provided to the staff team. The home continues to need to ensure that all records required in relation to service users under Schedule 3 of the Care Homes Regulations are maintained. The following safety certificates were sampled and found to comply: • • • • • Gas safety certificate Electrical Installation certificate Environmental Health Officer’s premises inspection certificate Fire alarm/emergency lighting certificate Lift safety certificate. Trelawne DS0000017985.V252395.R01.S.doc Version 5.0 Page 18 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 x x x x HEALTH AND PERSONAL CARE Standard No Score 7 x 8 2 9 x 10 x 11 2 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 1 13 3 14 x 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 x 18 1 3 3 3 3 x 3 2 3 STAFFING Standard No Score 27 x 28 2 29 1 30 x MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 x 1 1 x 1 2 3 Trelawne DS0000017985.V252395.R01.S.doc Version 5.0 Page 19 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 OP11 Regulation 12 (3) Requirement The registered person must make provision for recording the wishes of service users and/or their relatives. (this relates specifically to the wishes of service users in the event of their demise). The previous timescale of June 2005 was not meet. The registered person must make provision to enable service users to engage and participate in social and community activities. The registered person must ensure that the home’s complaints procedure complies with regulatory requirements. The registered person must ensure that staff are provided with the necessary training appropriate to the work they are to perform, to help ensure that service users are protected from suffering abuse or harm. The registered person must take all reasonable precautions to ensure that the home is free from hazards. This relates DS0000017985.V252395.R01.S.doc Timescale for action 31/12/05 2 OP12 16 (m) 31/12/05 3 OP16 22 31/12/05 4 OP18 13 (6) 18 31/10/05 5 OP25 13 (4a) 31/12/05 Trelawne Version 5.0 Page 20 6 OP29 17,19 Schedule 2. 7 OP34 25 8 OP36 18 9 OP37 17 10 OP33 24 specifically to the need for a radiator guard to be fitted, as identified under National Minimum Standard 25. 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 timescale of June 2005 was not meet. 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 timescale set of June 2005 was not meet. The registered person must ensure that staff working at the care home receive appropriate supervision. The previous timescale set of June 2005 was not meet. The registered person must maintain in respect of each service user the records specified in Schedule 3 of the Care Homes Regulations. The previous timescale set of June 2005 was not meet. 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 of June 2005 was not meet. 31/12/05 31/12/05 31/12/05 31/12/05 31/03/06 Trelawne DS0000017985.V252395.R01.S.doc Version 5.0 Page 21 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 2 3 Refer to Standard OP31 OP28 OP8 Good Practice Recommendations It is recommended that the registered person should enrol on the N.V.Q Level 4 course in care. It is recommended that the registered person should have 50 of the staff team qualified at N.V.Q Level 2. It is recommended that a risk assessment of all service users’ tissue viability be completed Trelawne DS0000017985.V252395.R01.S.doc Version 5.0 Page 22 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. Extracts may not be used or reproduced without the express permission of CSCI Trelawne DS0000017985.V252395.R01.S.doc Version 5.0 Page 23 - 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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