Inspection on 23/02/06 for Trelawne

This inspection was carried out on 23rd February 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 18/08/06

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 Unannounced Inspection 23rd February 2006 09:03 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.V262388.R01.S.doc Version 5.1 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.V262388.R01.S.doc Version 5.1 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.V262388.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 22nd September 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 are available. The home has a large garden area to the rear of the property. Trelawne DS0000017985.V262388.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection which took place over one day in February 2006, lasting 5.00 hours. The inspection process included discussion with a number of service users and the registered manager. Tour of the premises included viewing service users’ private rooms, toilet and bathing facilities, as well as communal living areas. During the course of the inspection a range of documentary evidence was viewed. On the day of the inspection nineteen of the thirty-eight standards were inspected, of these eleven were met, four were minor shortfalls, with the remainder being major shortfalls. What the service does well: What has improved since the last inspection? The home has now started to make provision for the recording of the wishes of service users and/or their relatives in the event of the service users’ demise. The home’s complaint procedure has been developed so it now complies with regulatory requirements. All staff has now received training in adult protection. Provision has now been made for staff to be trained up to NVQ Level 2. Trelawne DS0000017985.V262388.R01.S.doc Version 5.1 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.V262388.R01.S.doc Version 5.1 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.V262388.R01.S.doc Version 5.1 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. Evidence seen of recent admissions to the home indicated that admissions are not made without first having assessed the needs of the service users. EVIDENCE: Care plans were sampled of the two most recent service users admitted to the home. Both contained copies of pre-admission needs assessments which covered the following areas: • • • • • • • • • • Personal care needs Physical well being Diet/allergies Dietary preferences Sight Hearing Communication Oral health Foot care Mobility DS0000017985.V262388.R01.S.doc Version 5.1 Page 9 Trelawne • • • • Dexterity History of falls Continence Personal safety and risk Although the assessment tool was quite comprehensive, some of the information included could be further developed to ensure it is sufficiently comprehensive to inform the development of the service user’s care plan. Trelawne DS0000017985.V262388.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 10 and 11. Service users’ health, personal and social care needs were seen to be set out in their individual plans of care. Service users’ healthcare needs were seen to be well met. Service users were seen and heard to be treated with respect and their right to privacy upheld. Service users are treated with sensitivity and respect and their wishes are recorded. EVIDENCE: Two care plans were sampled. They were seen to be based upon the assessment of need for daily living and were generally well detailed. At the previous inspection it was recommended that service users be risk assessed for their susceptibility to developing pressure sores; the two care plans sampled evidenced that this was now taking place. Trelawne DS0000017985.V262388.R01.S.doc Version 5.1 Page 11 Observation of interactions between staff and service users evidenced that service users’ privacy and dignity was upheld by staff. Discussion with the registered manager confirmed that medical examinations of service users are carried out in the privacy of service users’ own rooms. Service users were heard to be referred to respectfully by staff. At the previous inspection the registered person was requested to make provision for the recording of service users’ wishes, and/or their relatives, in the event of a service user’s demise. The home has now developed a service user plan relating to service users’ funeral arrangements, however as yet the registered person still needs to discuss these matters further with service users’ next of kin. Trelawne DS0000017985.V262388.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12 and 14. The home needs to look at ways of further developing opportunities for service users to partake in meaningful activities within the home. Service users are supported to exercise choice and control in their everyday lives, dependent on their individual needs. EVIDENCE: Discussion with the registered manager indicated that the following activities take place for service users on a daily basis: • • • • • Reading and discussing newspapers Watching television Listening to music Discussing the news Playing the piano However, currently the home is not maintaining any records to evidence how service users spend their time recreationally. Trelawne DS0000017985.V262388.R01.S.doc Version 5.1 Page 13 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 service users. Discussion with service users indicated that they were entitled and supported to bring personal possessions into the home with them when moving in. Trelawne DS0000017985.V262388.R01.S.doc Version 5.1 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 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 and adult protection arrangements are now sufficiently robust to protect service users. EVIDENCE: The home’s complaints procedure has now been reviewed to include reference to the fact that a complainant may refer their complaint to the Commission for Social Care at any stage. The home’s complaints procedure was prominently positioned on the wall. The home maintains a log for recording any complaints received. At the time of the inspection no complaints had been received by either the home or the CSCI. The home’s adult protection policy included the following information: • • • A definition of abuse Legal position Types of abuse and how they may present The policy also made reference to the following other relevant policies and procedures: • • • Complaints policy Accident policy Whistle blowing policy Trelawne DS0000017985.V262388.R01.S.doc Version 5.1 Page 15 At the previous inspection an Immediate Requirements Notice was left in respect of the need for the registered person to ensure that all staff received training in adult protection. Evidence was presented that all staff have now received focussed training which covered the following areas: • • • • • • • What is abuse Why people are abusive Types of abuse Recognising abuse Effects of abuse Abuse vs challenging behaviour How to minimise abuse. Trelawne DS0000017985.V262388.R01.S.doc Version 5.1 Page 16 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): 25. Overall the home is safe, comfortable and decorated to a high standard. However, a number of radiators in the home still require guarding to ensure that risks to service users are minimised. EVIDENCE: At the previous inspection the need was identified for all radiators to be fitted with radiator guards or to have low temperature surface. To date there remain radiators that continue to be unguarded. This, therefore, poses a potential health and safety risk to service users. Trelawne DS0000017985.V262388.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30. Service users’ needs are met sufficiently well by the number and availability of staff. The home’s recruitment practices need improving significantly to ensure that service users are adequately protected by the home’s recruitment practices. Staff training at the home has improved greatly. This needs to be maintained to ensure staff remain competent to carry out the roles they are employed to perform. EVIDENCE: Currently the home has only eight service users in residence. The home does not employ any staff 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 are two in the morning and two in the afternoon. In addition, a handyman and cleaner are employed at the home fours days a week. Nights are covered by one waking night staff. In addition, the registered manager sleeps in/is living at the home in a self-contained flat. Trelawne DS0000017985.V262388.R01.S.doc Version 5.1 Page 18 The home employs six care staff, of these one is NVQ Level 2 qualified. The registered manager provided evidence in the format of application forms that a further three staff were being put forward to commence their Level 3 award. The home does not employ any staff or trainees under the age of eighteen. Three staff files were sampled in respect of the home’s recruitment practices; a number of gaps were noted in terms of the documentary evidence required under Regulation 19, Schedule 2 of the Care Homes Regulations. The registered manager was once again reminded that they must not employ any person at the home without first having obtained a current Criminal Records Bureau check in respect of that individual or, at the very least, a POVA first check. Even then the employee must not work at the home unless under full supervision and with all other pre-employment checks having been carried out first. This requirement has been an issue for a while now and requires urgent attention to ensure that compliance is met. Since the previous inspection the following training has been undertaken at the home: • • • • Protection of Vulnerable Adults Promotion of continence, and the management of incontinence Pressure ulcer prevention Prevention and management of constipation Trelawne DS0000017985.V262388.R01.S.doc Version 5.1 Page 19 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 and 37. The registered manager has a number of years’ experience of working in the care sector, although they need to undertake periodic training to ensure they remain competent to fulfil the role. The registered person needs to develop a process for ensuring that the home is run in the best interest of the service users (this relates specifically to the need to develop a quality assurance process). The registered person needs to develop a business plan for the service which evidences the accounting and financial arrangements for the home. Although staff are receiving formal supervision, the registered person needs to ensure that the frequency meets with requirements. Some slight further work is required to ensure that the home is safeguarding the health and welfare of service users. Trelawne DS0000017985.V262388.R01.S.doc Version 5.1 Page 20 EVIDENCE: The registered manager has a number of years’ experience of working in the care sector. Although they are not qualified in either NVQ Level 4 in care or management, evidence was presented of the manager having now commenced their NVQ Level 4 in management. The registered manager is not responsible for any other registered establishment. The manager was unable to provide evidence of having undertaken any periodic training to keep themselves updated. The home continues not to have a quality assurance process by which to review, and keep under review, the quality of the home’s service provision. Significant discussion took place around how to move this matter forward and the registered manager was referred to National Minimum Standard 33 for further guidance. The home continues not to have a business plan, although the registered manager recognises this and spoke of having recently discussed this matter with their NVQ assessor. The home’s certificate of public liability assurance was displayed, although the one seen on display was not current. Discussion with the registered manager indicated that since the previous inspection formal supervision has now commenced, although the frequency is currently not in line with requirements. The manager was reminded of the need to ensure that all staff receive formal supervision at least six times yearly. Records required by regulation to be kept in the home continue to have gaps. The registered manager was referred to Regulation 17 of the Care Homes Regulations which specifies the documentary evidence required. Trelawne DS0000017985.V262388.R01.S.doc Version 5.1 Page 21 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 X HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 X 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 X 14 3 15 X COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 x X X X X X 2 X STAFFING Standard No Score 27 3 28 3 29 1 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 1 1 X 2 2 X Trelawne DS0000017985.V262388.R01.S.doc Version 5.1 Page 22 Yes Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP12 Regulation 16 (m) Requirement 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 31/12/05 was not met. The registered person must take all reasonable precautions to ensure that the home is free from hazards. This relates specifically to the need for a radiator guard to be fitted, as identified under National Minimum Standard 25. The previous timescale of the 31/12/05 was not met. Timescale for action 30/06/06 2. OP25 13 (4a) 30/06/06 3. OP29 17,19 Schedule 2. The registered person must 30/06/06 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 of June 2005 and 31/12/05 were not met. Trelawne DS0000017985.V262388.R01.S.doc Version 5.1 Page 23 4. OP33 24 5. OP34 25 The registered person must 30/06/06 ensure that a process for reviewing and keeping under review the home’s quality of service provision is developed. The previous timescale was not met. The registered person must 30/06/06 ensure that a business plan is developed that is available for inspection by the Commission for Social Care Inspection. The previous timescales of June 2005 and 31/12/05 were not met. The registered person must ensure that staff working at the care home receive appropriate supervision. The previous timescales of June 2005 and 31/12/05 were not met. 30/06/06 6. OP36 18 7. OP37 17 The registered person must 30/06/06 maintain in respect of each service user the records specified in Schedule 3 of the Care Homes Regulations. The previous timescales of June 2005 and 31/12/05 were not met. 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 person should enrol on the N.V.Q Level 4 course in care. Trelawne DS0000017985.V262388.R01.S.doc Version 5.1 Page 24 Trelawne DS0000017985.V262388.R01.S.doc Version 5.1 Page 25 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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