Inspection on 21/05/08 for Trelawney House

This inspection was carried out on 21st May 2008.

CSCI found this care home to be providing an Poor service.

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

Trelawney House 18/11/08

Trelawney House 09/07/07

Trelawney House 02/11/06

Trelawney House 06/06/06

Trelawney House 17/11/05

Trelawney House 17/05/05

Trelawney House 04/11/04

Trelawney House 14/05/04

Similar services:

Fairfields Country Rest Home

Poldhu

Queensmount

Trevaylor Manor

Didsbury Court Rest Home

Belma

Hunters Care Centre

Manor Lodge

Extracts from inspection reports are licensed from CQC, this page was updated on 28/09/2008.

CARE HOMES FOR OLDER PEOPLE Trelawney House Polladras Carleen Helston Cornwall TR13 9NT Lead Inspector Ian Wright Unannounced Inspection 21st May 2008 08:15 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 Trelawney House, Polladras DS0000053715.V364856.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. Trelawney House, Polladras DS0000053715.V364856.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Trelawney House, Polladras Address Polladras Carleen Helston Cornwall TR13 9NT 01736 763334 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) Christine Anne Gatzianidis Rigas Gatzianidis Manager post vacant Care Home 11 Category(ies) of Old age, not falling within any other category registration, with number (11) of places Trelawney House, Polladras DS0000053715.V364856.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. To include one named service user with dementia which is outside the registered category. 9th July 2007 Date of last inspection Brief Description of the Service: Trelawney Care Home is situated in Polladras, approximately five miles from the town of Helston. The registered persons provide residential care for up to eleven elderly people. Day-care is also available for people living in the community. The home is set in spacious grounds in a very pleasant rural setting. There is sufficient car parking available. Accommodation is on two floors; the first floor can be accessed by a passenger lift. There is one large lounge and a smaller television lounge. Meals are cooked in a large kitchen and served in the dining room. Trelawney provide a meals on wheels facility and supplies approximately ten meals to people in the community each day. The registered providers live adjacent to the care home and are actively involved in its day-to-day running. A team of care staff provide personal care and support. There are opportunities for socialising and visitors are encouraged. A copy of the inspection report is available from management or the Commission for Social Care Inspection. The range of fees at the time of the inspection is £ 355-£453 per week. There are additional charges e.g. for hairdressing, chiropody, trips out and newspapers etc. Trelawney House, Polladras DS0000053715.V364856.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 0 star. This means the people who use this service experience poor quality outcomes. This unannounced key inspection took place in nine hours in one day. All of key national minimum standards were inspected. The methodology used for this inspection was: • To case track five people who use the service. This included, where possible, meeting and discussing with the people who use the service their experiences, and inspecting their records. • Discussing with four staff their experiences working in the home. • Discussion with other people who use the service and their representatives. • Observing care practices. • Discussing care practices with management. • Inspecting records and the care environment. • Assessing ‘Adult Safeguarding’ (adult protection) procedures and practices in the home, as part of a CSCI national survey. Other evidence gathered since the previous inspection, such as notifications received from the home (e.g. regarding any incidents which occurred), was used to help form the judgements made in the report. What the service does well: What has improved since the last inspection? Although people said they are happy with the service, the Commission for Social Care Inspection is concerned that none of the five statutory requirements issued at the inspection in July 2007 have been fully complied with. Trelawney House, Polladras DS0000053715.V364856.R01.S.doc Version 5.2 Page 6 What they could do better: This inspection has resulted in thirteen statutory requirements. Action regarding these legal requirements is necessary within the timescales set. In summary, requirements have been made regarding: • • • • • • • • • • Providing satisfactory information regarding terms and conditions of residency when people are admitted to the service. Having satisfactory pre admission assessment processes. Improving care planning and record keeping. Improving the operation of the medication system. Developing the adult protection procedure. Ensuring the smell of urine is eradicated in some bedrooms. Improving staff training, particularly in regard to ensuring training meets regulatory standards. Improving recruitment and personnel information obtained when staff are employed. Ensuring health and safety standards are improved. An immediate requirement was issued at this inspection regarding the testing of fire equipment. Quality assurance systems so there are not shortfalls regarding the above matters. The commission will monitor the registered persons to ensure satisfactory improvements are achieved. This service will now be considered as part of the Commission’s Regional Improvement Strategy. Subsequently the registered provider’s will need to produce an Improvement Plan which must be submitted to the Commission. We will monitor this is complied with. This monitoring will include a further Key Inspection within the next six months. 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. Trelawney House, Polladras DS0000053715.V364856.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 Trelawney House, Polladras DS0000053715.V364856.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): 2, 3 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Information provided to people who use the service (e.g. regarding what service is offered, and individual assessment of need) needs improvement. This will ensure people who use the service and their representatives know appropriate assessment has been completed before people are admitted to the home, and they have satisfactory information regarding the rights and responsibilities, and what service they can expect. EVIDENCE: The registered provider has developed a statement regarding the terms and conditions of residency / contract for people who pay privately for their care. Other people who are funded by a local authority are issued with a contract from them. Individualised contracts were available for most people using the service, although these were absent from some files. It is required by law that people receive this information when they are admitted to the home. Trelawney House, Polladras DS0000053715.V364856.R01.S.doc Version 5.2 Page 9 The registered provider has an assessment policy. There was satisfactory evidence that a senior member of staff has assessed some people using the service, however assessments were absent on some people’s files. It is unclear whether the registered provider assessed them before admission was arranged. Some of the people living there said they could not remember visiting the home before admission was arranged, or somebody visiting them to assess their needs. The registered provider has obtained a copy of assessments completed by either social services and/or the National Health Service for some people, and these were inspected on several people’s files. However, third party assessments should not be considered a substitute for the registered provider to complete a pre admission assessment. The inspector was concerned about assessment processes for two people living in the home: (1) At least one person has a diagnosed mental health need. The home is only registered to provide care for the elderly with general personal care needs and people who have mental health problems or dementia at the time of admission. The person has been living at the home for over a year. The person felt they were happy with the service. The person’s representatives were also present at the time of the inspection and were also happy with the care provided. However the person’s relatives did think there should be more liaison between mental health professionals, the home and the family. This was discussed with the registered provider and a recommendation has been made. This should for example help share information and also assist in the care planning process. The person appeared very anxious and distressed. It is not clear whether this is generally the person’s state of well being, or whether meeting the inspector exacerbated the person’s anxiety state. If the former is the case there certainly needs to be more liaison with the community psychiatric nurse to provide staff with more guidance and assistance to help the person concerned. (2) One person’s needs have changed substantially. However there does not appear to have been any reassessment of the person’s needs when they returned to the home from hospital in October 2007. From the care plan it is not clear whether the person’s needs are being adequately met. Trelawney House, Polladras DS0000053715.V364856.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 who use the service and their representatives said they were happy with the care provided. However, health and personal care standards need improvement particularly in regard to care planning and the management of medication. These improvements will ensure staff have suitable guidance and records of care. People can subsequently be more assured their care needs will be met appropriately. EVIDENCE: The inspector spoke to the majority of people living in the home, and the relatives of some people who were visiting at the time of the inspection. All expressed happiness with the service delivered. People living in the home said staff did their best to meet their needs, and care was delivered in a manner which suited them. However care planning in the home is not satisfactory. Of the four people who were case tracked, two did not have a care plan, and two people’s care plans were written at least a year ago. For the two people who had a care plan there Trelawney House, Polladras DS0000053715.V364856.R01.S.doc Version 5.2 Page 11 was no evidence of review. Care plans that are available are accessible to staff, and staff complete care notes on a daily basis. One person’s needs had changed substantially since September 2007. However the person’s care plan was dated July 2007 and did not reflect the person’s current needs and how staff would meet them. People who use the service said they were satisfied with the healthcare support they received. This includes visits from GP’s, district nurses and chiropodists. Staff complete notes when the doctor or district nurse has called to see on of the people using the service. From the records inspected there did not appear to be evidence that there was input from community psychiatric nurses, dentists or opticians. If these services are not provided, it is essential that contact is made, and appropriate records are kept of these medical interventions. The registered provider has a medication policy. Medication is administered via a ‘NOMAD’ system (Dossetts filled by the pharmacist). The medication system was inspected and needs some improvement regarding the storage of medication. Some medication was kept in an unlocked drawer in the staff office. This included Co codamol tablets, paracetamol tablets (with no label for who the medication was prescribed for), Fentanyl patches (for pain relief). Some of this medication appeared to be for people who had either left the home or had passed away. This medication needs to be disposed of if no longer required for the person whom it was prescribed for. Other medication was stored securely, however the keys for the cabinet were kept in an unlocked drawer. The keys to the medication cabinet must always be kept securely, for example on the person of whoever is in charge of the home / shift. Medication records were completed to a satisfactory standard. There should however be a photograph of the person attached to their medication sheet. This will assist staff in identifying the person who they are administering medication to. Nine out of the twelve personnel files inspected, showed evidence of staff receiving training regarding medication. This is okay as long as the other three staff do not handle medication. If they do, it is essential they receive medication training i.e. from a pharmacist, before they administer any medication. People who use the service said they felt staff worked with them in a manner, which respected their privacy and dignity. People who use the service were positive about their care. People who use the service said personal care was provided to a good standard. Staff were observed working with people, in a positive manner and appeared caring and kind. Trelawney House, Polladras DS0000053715.V364856.R01.S.doc Version 5.2 Page 12 The registered provider has a satisfactory policy regarding equal opportunities. There are currently no people who use the service from ethnic minorities, although it is understood the registered provider would be happy to accommodate people who use the service from other cultures. The local population is predominantly Cornish, and from ‘White-UK’ background. Issues regarding sexuality and gender seem to be suitably addressed. Staff appeared to work with people with physical disabilities in a positive manner, for example walking at the individual’s pace. However one person used a wheel chair did not have footplates, and this should not occur so the risk of physical injury is avoided. The person was also wheeled into the lounge after the main meal and left in their wheel chair. It was not clear whether the person would have been happier and more comfortable if they were transferred to a soft chair. Trelawney House, Polladras DS0000053715.V364856.R01.S.doc Version 5.2 Page 13 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 generally good. This judgement has been made using available evidence including a visit to this service. Appropriate arrangements are in place so people who use the service can enjoy a lifestyle that meets their needs. Food provided is to a good standard so people enjoy a choice of good quality meals that meet nutritional needs. EVIDENCE: Routines were observed as flexible and appear to suit the needs of people using the service. The inspector observed staff working in an appropriate matter with people who use the service. The morning routine appeared to work in a manner which individualised the needs of people who use the service. People who use the service either spend time in the lounge or in their bedrooms. The registered provider said trips out occur and some people go to the local community centre to join in with community activities. Staff organise bingo and dominos. However on the day of the inspection no activities were organised. There was no music or TV in the main lounge. This may have been people’s choice, but there did not appear to be any opportunities for stimulation or interaction, as staff time was taken up with either house keeping or care tasks. This matter should be discussed with people living in the home. It may be appropriate to have a TV in the main lounge, the radio on, more newspapers and magazines available. It may be possible to develop activities Trelawney House, Polladras DS0000053715.V364856.R01.S.doc Version 5.2 Page 14 further for example for an hour’s session in the morning or afternoon each day. A recommendation is made regarding this. People who use the service said they could make choices and did not feel there were excessive or inappropriate restrictions placed upon them. People said they could get up and go to bed when they wished. People the inspector spoke to, said they did not feel pressurised regarding how they spent their time. Bedroom doors are not lockable. This should be the case as outlined in the national minimum standard. A suitable door lock / key (i.e. with an overriding facility) should be offered to all existing people using the service, and people who subsequently move in to the home. The registered provider should note National Minimum Standard 24. If locks are fitted, and where appropriate people are provided with keys, this will ensure people who use the service can lock their bedroom door if they wish. This will improve their security and privacy. However, people who the inspector spoke to, said they felt their personal belongings were safe and secure in the home. People who use the service have their meals in the downstairs dining room, or in their bedrooms. The inspector shared lunch with people who use the service on the first day of the inspection. The meal was roast pork, fresh vegetables, and potatoes, followed by a dessert. The meal was to a good standard. All people who use the service said they enjoyed the food provided, although some people said they would have liked apple sauce with the main meal. Suitable records of meals provided are maintained. Special diets (e.g. pureed meals) are provided if required. Trelawney House, Polladras DS0000053715.V364856.R01.S.doc Version 5.2 Page 15 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 adequate. This judgement has been made using available evidence including a visit to this service. A suitable complaints procedure is in place. The adult protection policy and recruitment checks, in relation to Protection of Vulnerable Adults ‘First’ checks, need improvement. Improvement in these areas should give people who use the service more confidence about adult protection processes at the home. EVIDENCE: There is a complaints procedure, however contact details for CSCI need to be updated. The registered provider or Commission for Social Care Inspection have not received any complaints regarding this service. People who use the service said they had no concerns, complaints or allegations about the service. They said they would feel confident approaching staff or management if they had any problems. The registered provider said it had not been necessary to make any safeguarding referrals to the Department of Adult Social Care (social services), or to refer any ex staff to the Criminal Records Bureau for inclusion on the Protection of Vulnerable Adults list (i.e. a list of people who are not suitable to work with vulnerable people). There are currently two adult protection policies in two files, in the office. One of these should be removed, and it would be better if the policy file was kept in the office so it is more accessible to care staff. Whatever is the correct policy needs some development to make it more robust. It needs to be clearer Trelawney House, Polladras DS0000053715.V364856.R01.S.doc Version 5.2 Page 16 regarding what people living and working in the home should do if there is an allegation: 1. Firstly, any accusations must be reported to Cornwall County Council’s Department of Adult Social Care, who are the coordinating agency for any investigation. The manager, registered provider or other persons should not investigate any allegations, beyond basic information gathering, unless delegated by social services to do so. 2. The policy states any allegations should be reported to CSCI. Although CSCI should be informed of incidents reportable under regulation 37 [Care Homes Regulations 2001] (as such an allegation is), the Department of Adult Care is the coordinating agency regarding the investigation of such matters. 3. The policy should state how people using the service, and their representatives, will be informed of what to do if they have any allegations of abuse or poor practice. 4. The policy should state what pre employment checks and training staff will receive. 5. The policy should detail how staff will be informed (e.g. on induction) of correct protocols they should follow if there is an allegation. 6. Contact addresses and phone numbers should be in the policy and readily available to staff, people who use the service and their representatives. For example the telephone number of the police should be provided as well as the phone number of social services and CSCI. Personnel files showed some staff had received training regarding adult safeguarding (whistleblowing) from the county council. All staff should receive this training as opportunities arise. The inspector was concerned regarding recruitment checks completed on one member of staff, for example in relation to a Protection of Vulnerable Adults ‘First’ check (POVA First) being completed. This is detailed in the ‘Staffing’ section of this report. Trelawney House, Polladras DS0000053715.V364856.R01.S.doc Version 5.2 Page 17 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, 26 Quality in this outcome area is generally good, although improvement is required to eradicate offensive odours in some of the bedrooms. This judgement has been made using available evidence including a visit to this service. Trelawney provides a pleasant, homely environment for the people who live there. EVIDENCE: The building was inspected. The building appears to be well maintained, generally clean, pleasantly decorated and homely. The home is situated in a rural area surrounded by beautiful countryside. There is a pleasant garden, which people can use. A bench is provided outside the back door for people’s benefit. All communal rooms are homely and comfortable, and bedrooms are individualised and comfortable. A lift is provided for people to use-unusual for such a small home. The kitchen has been refurbished. The majority of bedrooms have an ensuite toilet and shower. Some of the bedrooms smelt of urine, and cleaning routines need to be improved so offensive odours are either kept to an absolute minimum or eradicated. Some of the bedrooms have Trelawney House, Polladras DS0000053715.V364856.R01.S.doc Version 5.2 Page 18 a shower facility. However these facilities offer limited access for people with mobility problems and do not appear to be used. There is a bathroom, which has a bath chair to assist access. The toilet seat was loose, but the registered provider said he would tighten this up after the inspector reported the fault. Satisfactory laundry facilities are provided. Trelawney House, Polladras DS0000053715.V364856.R01.S.doc Version 5.2 Page 19 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 poor. This judgement has been made using available evidence including a visit to this service. Staffing levels appear satisfactory to meet current people’s needs. Improvements are required to staff recruitment checks-particularly in regard to Criminal Records Bureau checks / Protection of Vulnerable Adult First checks (POVA First checks). Some improvement is required to staff training. These measures will ensure people who use the service are better protected from staff deemed unsuitable to work with vulnerable people. The measures will ensure people using the service are supported by staff who are appropriately trained to meet their needs. EVIDENCE: On the day of the inspection the following staffing was provided: • 0800-1430hrs-two members of staff • 1430-2100hrs- two members of staff • 2100-0800hrs- one waking night staff. The staffing levels appear satisfactory to meet the current needs of people currently living at the home. The registered providers (Mr and Mrs Gatzianidis) also work in the home. On the day of the inspection, Mr Gatzianidis had worked the previous night shift and was preparing meals for the home /meals on wheels service. Mrs Gatzianidis was working the forthcoming night shift. Trelawney House, Polladras DS0000053715.V364856.R01.S.doc Version 5.2 Page 20 People who use the service were positive regarding staff attitudes. Staff were observed working in a positive manner with people who use the service. The registered provider has a suitable approach to providing National Vocational Qualifications for care staff. Currently 57 of staff have an NVQ 2 or 3, although some of the other staff are currently working towards this qualification. Staff recruitment records need improvement. The records of twelve staff employed were assessed. All staff have completed an application form. All staff have evidence proving their identity. Most have a valid Protection of Vulnerable Adults Check / Criminal Records Bureau check. However the following needs improvement, as required by the regulations, particularly for staff employed in future: 1. People employed should have two written references. It is important that one of these references is from the person’s previous employer and/or where the person has worked in a caring capacity. This will help check the employee is suitable to work with vulnerable people. In the case of at least one person this was not done. The provider therefore does not have a record why the person left working for a previous employer, where they worked in a similar caring capacity. 2. Each person should have a Protection of Vulnerable Adults First (POVA First) check, followed by a Criminal Records Bureau check /Protection of Vulnerable Adults check (CRB/POVA). The person employed can only commence employment once the POVA First check is obtained. They cannot work unsupervised with vulnerable people until a full CRB/POVA check is obtained. This is outlined in guidance issued by CSCI and the CRB. In the case of one person, these checks were completed. However the person left the registered provider’s employment for several months, then recommenced employment with them. However the checks were not re completed as is required by law. 3. A statement by the person applying for the job as to their mental /physical health. This is required by the regulations and helps the provider to ascertain whether applicants are deemed fit to work in a care home. In regard to POVA First, CRB/POVA, obtaining staff references the registered provider has now been notified regarding this matter on four occasions. Failure of the registered provider to obtain appropriate checks on new staff, could in future result in the Commission for Social Care Inspection taking enforcement action. The inspector spoke to one member of staff regarding staff induction arrangements. The person said they had shadowed a senior member of staff when they commenced employment. There is evidence of staff induction on staff files (e.g. a staff induction checklist). This is adequate, and provides Trelawney House, Polladras DS0000053715.V364856.R01.S.doc Version 5.2 Page 21 scope for expansion regarding issues which should be covered during a new member of staff’s first weeks of service. The registered provider’s approach to equal opportunities and anti discrimination is to a satisfactory standard. Staff training records were inspected for a sample of twelve staff. By law all staff must have: • Regular fire training in accordance with the requirements of the fire authority. • There must always be at least one first aider on duty (at appointed person level). • All staff must have manual handling training and regular updates of this (e.g. annually.) • All staff must have basic training in infection control. • If staff handle food they must receive training regarding food hygiene. • All new staff must have an induction and there should be a record of this. Since the last key inspection in July 2007, there is only little evidence that staff have received further training required by law. For example: • Fire Training. There was evidence one member of staff had received video based training in February 2008. Six staff had received this training in either February 2007 or May 2007. One member of staff had received this training in 2004, and one person in 2006. Three staff did not have evidence of receiving any training in this area. First aid. Three people received this training in 2007. Five people last received this training in 2005. However, two of these people’s certificates have now expired. This includes one of the registered provider’s who regularly works alone on night shift. The other four staff have not received this training, although this is okay, as long as these people do not work alone, or without other staff who have a valid certificate. Food Hygiene. Seven of the staff had received this training. Five people have not received this training. This is okay as long as these people never handle any food, otherwise they must receive appropriate training. Mr Gatzianidis obtained his food hygiene certificate in February 2005. It is recommended this is updated, and he completes a food hygiene certificate at the Intermediate level. Manual Handling. Only seven of the sample have received any training in this area. Only two of these staff have received training in the last year in this area. All staff should receive at least an annual update. Infection control. Only seven of the sample have received any training in this area. • • • • The registered provider was notified regarding this requirement in the previous inspection report dated 9th July 2007. The Commission for Social Care Inspection is concerned regarding the unsatisfactory progress made regarding this matter. If there is not sufficient improvement regarding these matters, within the timescale set, the commission may take enforcement action. Trelawney House, Polladras DS0000053715.V364856.R01.S.doc Version 5.2 Page 22 As some of the people using the service have a mental health need and /or dementia it is important staff receive training in these areas. The home can only work with people with these needs where they develop while the person resides there. However, as the registered provider is not registered to work with people with either mental health problems or dementia, the registered persons cannot admit people with these needs to the home. Trelawney House, Polladras DS0000053715.V364856.R01.S.doc Version 5.2 Page 23 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, 35, 38 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. Action is required to improve pre admission assessment procedures, care planning, staff recruitment, adult safeguarding procedures, staff training, quality assurance and to minimise health and safety risks. This will ensure people using the service can be assured they live in a safe environment and receive support from appropriately recruited and trained staff. EVIDENCE: The registered providers appear suitably experienced to manage the home. The providers work day to day in the home and have a good knowledge of people who live there. People who live in the home, who the inspector was able to speak to, were positive about the registered providers approach. The commission does however have concerns regarding the registered providers’ non-compliance with the regulations in several areas, and action is required by them to ensure improvement and compliance with the regulations. Trelawney House, Polladras DS0000053715.V364856.R01.S.doc Version 5.2 Page 24 The commission is concerned regarding the lack of notifications (required under regulation 37 of the Care Homes Regulations 2001) received by the commission. According to our records we have not received any since 20th July 2007. This is despite there being at least one death, and one incident resulting in an accident and emergency admission to hospital. These incidents have occurred since the last key inspection in July 2007. Subsequently the registered provider needs to refamiliarise themselves with what incidents and occurrences need to be reported to the commission. They must notify the commission verbally (as necessary) and always in writing as required by the regulations. The registered provider has a quality assurance policy, which was last reviewed in March 2007. This does not appear to have been implemented however. It would be better if the policy was rewritten to actually reflect what the registered providers do / intend to do, to monitor / maintain and improve the quality of the service. Surveys of people’s views of the service have been completed but these are not dated, and it is not clear whether these were completed within the last year. However ‘Residents meetings’ do occur sometimes in the home. The last one minuted occurred in February 2008. Staff meetings also appear to occur sometimes. Some further monitoring needs to take place by the registered provider to ensure the regulatory issues highlighted in the report are checked, and either maintained or improved. Management subsequently need to consider refining their systems to ensure there are improvements in some areas (e.g. management of medication, recruitment checks, staff training and health and safety). How management do this should be included in the organisation’s quality assurance policy. The commission will be requesting a CSCI Improvement Plan as a consequence of this inspection regarding the requirements issued. Subsequently the registered providers need to: 1. Revise its quality assurance policy to state how standards will be maintained and developed for example regarding assessment, care planning, medication, policies and procedures, environmental standards, recruitment procedures, staff training, and health and safety standards. 2. Subsequently develop a system to ensure these matters are regularly checked and there is a more proactive approach to ensuring standards are met, maintained and improved. The registered provider stated to the inspector that no monies belonging to people who use the service are looked after. The registered provider also does not act as appointee for the financial benefits for any people living in the care home. Monies of people using the service are either maintained via individual solicitors or people’s relatives via Power of Attorney arrangements. Otherwise Trelawney House, Polladras DS0000053715.V364856.R01.S.doc Version 5.2 Page 25 people who use the service or their representatives are responsible for their finances, and fees are paid via bank transfer. Suitable insurance for the building and people using it appears to be in place. The registered persons have a health and safety policy. The home has a fire risk assessment. This is dated 25/1/2005. The records for testing emergency call points for the fire system and emergency lighting are not up to date. Staff tested this equipment regularly until 28/12/2007. No further records appear to have been maintained. The fire system appears to have been serviced on 29.3.2007 and subsequently there does not appear to be any further records of this being tested by an external contractor. This is of concern for the commission, and subsequently an immediate requirement has been issued. Fire extinguishers were last tested on 13/7/2007. These need to be tested more regularly, if the fire authority requires this. Health and safety risk assessments have been completed on 6/10/2006 and 11/4/2007. These should be reviewed annually so the registered provider can check any health and safety risks are being minimised. A legionella risk assessment was completed on 20/11/2006. This included a survey of remedial work required, and a recommended schedule of testing. However there are no records of testing after January 2008.There is a record that the environmental health officer visited regarding standards in the kitchen. The lift was serviced on 7/12/2008. The same company serviced the bath hoist at the same time. A satisfactory gas safety certificate was obtained on 8/1/2008. There is however no record the hoist in room 1 has been tested. The electrical circuit was tested in June 2007 but was deemed by the contractor as ‘unsatisfactory’. An invoice dated 24/4/2008 appears to state remedial work was completed. The registered provider must forward a copy of a ‘hardwire’ certificate when this is obtained, and within the timescale set. Portable electrical appliances were last tested on 12/9/2006. These should be tested annually or at frequencies determined by the Health and Safety Executive. Some concerns have been raised in the ‘staffing’ section of the report regarding some aspects of health and safety training provided. Trelawney House, Polladras DS0000053715.V364856.R01.S.doc Version 5.2 Page 26 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 2 1 X X X HEALTH AND PERSONAL CARE Standard No Score 7 1 8 2 9 2 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 2 3 X X X X X X 2 STAFFING Standard No Score 27 3 28 3 29 1 30 1 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 1 X 1 X 3 X X 1 Trelawney House, Polladras DS0000053715.V364856.R01.S.doc Version 5.2 Page 27 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 OP2 Regulation 5 Requirement Timescale for action 01/07/08 2. OP3 3. OP7 OP8 All people using the service should be issued with a statement outlining the terms and conditions of their residency / contract. This should be issued at the time of admission to the home. This will ensure all people using the service are aware of their rights and responsibilities. 14 A suitable assessment regarding 01/07/08 the needs of people using the service must be completed before they are admitted to the service. This will help ensure people using the service subsequently have their individual wishes and needs met to a satisfactory standard. 12, 13, 15 Each person who uses the 01/09/08 service must have a care plan. Each care plan must contain appropriate information and be reviewed on a regular basis. Each person should have a moving and handling assessment which is regularly reviewed and updated. Other risk assessments regarding the person should be completed as necessary. Care plans should include information DS0000053715.V364856.R01.S.doc Version 5.2 Trelawney House, Polladras Page 28 4. OP7 OP8 5. OP9 6. OP18 7. OP26 regarding when people see medical professionals e.g. dentists and chiropodists. Suitable care plans will help ensure people who use the service receive appropriate care and support from the registered provider. 12, 13, 15 Ensure foot plates are always used on wheelchairs at all times. Unless outlined in the care plan, people should only remain in a wheelchair if they are being transferred. This will ensure the risk of accident is minimised when people are being transferred by wheelchair, and people are always comfortable. 13 The management and storage of medication must be improved, with reference Royal Pharmaceutical Society Guidelines and Care Homes Regulations 2001. Issues outlined in the report need to be addressed. All staff involved with the handling of medication must receive appropriate training e.g. from a pharmacist. People who use the service can then be more assured their medication is appropriately stored and managed. (Timescale of 01/08/07 not met 2nd Notification) 10, 12, The registered provider must 13, 19 have a suitable adult safeguarding policy. Matters outlined in the report must be addressed. Having an appropriate policy will help to give people who use the service, and other stakeholders, more assurance that agreed multi disciplinary procedures will be followed when necessary. 13, 16, 23 Cleaning routines need improvement to remove DS0000053715.V364856.R01.S.doc 01/07/08 01/07/08 01/09/08 01/07/08 Trelawney House, Polladras Version 5.2 Page 29 8. OP29 OP18 OP31 7, 10, 12, 13, 19 9. OP30 OP38 10(3),12, 13(5)(6) 16(2)(j) 18, 23(4)(5) offensive odours in all rooms. This will ensure people using the service live in an odour free environment. The registered provider must ensure suitable checks are performed on all new staff working in the home as outlined in the regulations (for example POVA First check, CRB /POVA check, two written references). Guidance issued by CSCI, and other statutory authorities must be followed. This will help ensure people who use the service are protected from people who are unsuitable to work with the vulnerable. (Previous timescale of 01/08/07 not met. Fourth Notification) Staff must receive training required by law. For example: • First aid • Fire training • Food hygiene • Manual Handling • Infection control. (Previous timescale of 01/01/08 not met. Second Notification) Staff must also receive training regarding: • Mental health needs • Dementia While people are accommodated at the home with these needs. By staff having training in these areas, this will help ensure people who use the service receive appropriate care and support from staff who have suitable knowledge and skills. It will also help ensure risks to people’s health and safety are minimised. 01/07/08 01/09/08 Trelawney House, Polladras DS0000053715.V364856.R01.S.doc Version 5.2 Page 30 10. OP31 7, 37 11. OP31 OP33 7, 9, 12, 13, 24 12. OP38 OP31 7, 12, 13,23(4) 13. OP38 13, 23 The registered provider must report in writing notifiable incidents and events to the commission as listed under regulation 37 of the Care Homes Act 2001 Develop the quality assurance system to monitor standards in the home for example regarding care planning, medication, staff recruitment, staff training, health and safety etc. Measures taken should be included in the quality assurance policy. This will help improve service quality and help minimise risks to staff and people who use the service. The registered provider must: (1) Test and keep records of testing of fire equipment (e.g. fire alarms, call points, emergency lighting, fire doors etc.) at frequencies set by the fire authority. (2) Ensure there are suitable records for the maintenance of equipment and these are available for inspection. (3) Confirm this in writing with appropriate evidence by 21/6/2008 Previous timescale of 1/10/2007 not met. Second Notification. Immediate Requirement The registered provider must ensure health and safety checks required by law are completed: (1) (2) Satisfactory results of the testing the electrical hardwire circuit. Review health and safety risk assessments 01/07/08 01/09/08 21/05/08 01/09/08 Trelawney House, Polladras DS0000053715.V364856.R01.S.doc Version 5.2 Page 31 e.g. at least annually. Satisfactory evidence of testing to prevent legionella. Previous timescale of 1/10/2007 not met. Second Notification. (4) Ensure all moving and handling equipment is tested e.g. at least annually. (5) Ensure portable electrical appliances are tested in line with Health and Safety Executive guidelines. Copies of appropriate documentation must be forwarded to the Commission within the timescale set. Satisfactory documentation must always be available for inspection. (3) These measures will help to ensure risks to the health and safety of people living and working in the home are kept to a minimum. 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 OP3 Good Practice Recommendations There should be regular reviews between the representatives of a person living in the home, the registered provider and the person’s Community Psychiatric Nurse. There should be appropriate consultation with these people regarding care planning for this person. Existing people who use the service should be offered a DS0000053715.V364856.R01.S.doc Version 5.2 Page 32 2. OP10 Trelawney House, Polladras 3. 4. OP12 OP30 suitable lock and key for their bedroom door. People subsequently admitted to the service should also be offered this facility. This will ensure people who use the service can lock their bedroom door if they wish to improve security and privacy. Develop further opportunities for activities and stimulation in the home on a day-to-day basis. The registered provider completes an Intermediate Food Hygiene training course. Trelawney House, Polladras DS0000053715.V364856.R01.S.doc Version 5.2 Page 33 Commission for Social Care Inspection South West Colston 33 33 Colston Avenue Bristol BS1 4UA 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 Trelawney House, Polladras DS0000053715.V364856.R01.S.doc Version 5.2 Page 34 - 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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