Inspection on 13/02/08 for Trentside Manor

This inspection was carried out on 13th February 2008.

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

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Trentside Manor 04/02/09

Similar services:

Maple Lodge

Heathlands

Aston Court Nursing Home

Breme

Ravenhurst

Bank House

Inspirations

Ashcroft Hollow Nursing Home

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

CARE HOMES FOR OLDER PEOPLE Trentside Manor Endon Road Norton Green Stoke-on-Trent Staffordshire ST6 8PA Lead Inspector Peter Dawson Unannounced Inspection 13th February 2008 09:00 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 Trentside Manor DS0000070469.V359636.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. Trentside Manor DS0000070469.V359636.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Trentside Manor Address Endon Road Norton Green Stoke-on-Trent Staffordshire ST6 8PA 01782 535 402 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) Trentside Manor Care Ltd Kerry Louise Rowson Care Home 15 Category(ies) of Dementia (4), Learning disability over 65 years registration, with number of age (6), Old age, not falling within any other of places category (15) Trentside Manor DS0000070469.V359636.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following categoy of service only: Care Home only - Code PC To service users of the following gender: Either Whose primary care needs on admission to the home are within the following categories: Learning Disabilities (LD) (E) 6 Dementia (DE) 4 Older People (OP) 15 The maximum number of service users to be accommodated is 15. 2. Date of last inspection Brief Description of the Service: Trentside Manor provides care and accommodation for up to 15 older people. The home has registration to admit some people with dementia care needs and people with a physical disability. The home changed ownership in October 2007 and new registration and new Manager appointed from that date. There was a history of non-compliance with reguirements made at inspections previously but many of the longstanding and outstanding issues have already been addressed by the now owners and Manager. The home is situated in the village of Norton Green, there is a strong community identity in the village which the home is presently taking advantage of. There are local shops, GP practice, dentist in the village which are easily accessed. Accommodation at Trenside Manor is on the ground floor only for residents. All bedrooms are for single use, only one has en-suite facilities but there are adequate bathroom and toilet areas located near to bedrooms and communal areas. There is a very pleasant large open garden area to the rear which has recently been cleared and with good access from the lounge area provides a good facility during the summer – the view is onto local open fields. Trentside Manor DS0000070469.V359636.R01.S.doc Version 5.2 Page 5 Trentside Manor DS0000070469.V359636.R01.S.doc Version 5.2 Page 6 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 1 star. This means the people who use this service experience adequate quality outcomes. This unannounced key inspection of this new service was carried out on one day by one inspector from 08:30 – 17:00. The inspector was assisted by an Expert by Experience. This was someone with personal experience of using a similar service and trained to take part in the inspection of a service. This Expert by Experience talked with residents, staff and visitors at Trentside Manor to get a view of the service, particularly to assess how the change of ownership and management had impacted on the service for residents. A report was provided on his findings and are incorporated into this report. There were 15 people in residence at the time of this inspection (no vacancies) All residents were seen and the majority spoken with together and separately during the day of the inspection. Three visitors were seen and spoken with and also a visiting District Nurse. There was an inspection of the communal areas of the home and a sample of bedrooms were also seen. All staff on duty were spoken with and made a valuable contribution to the inspection. Records relating to the inspection process were examined including care plans, risk assessments, medication and staffing records, staff rosters, fire records, policies & procedures and equipment maintenance logs. The ownership of the home changed with a new registration on 19/10/07. The new Manager commenced the same date and has been approved as the Registered Manager by the Commission for Social Care Inspection. The Statement of Purpose was not completed/ available. Weekly fees for the service were therefore not in writing, the Manager said that they were in the range of £341 - £395 per week. What the service does well: Trentside Manor DS0000070469.V359636.R01.S.doc Version 5.2 Page 7 A small home with 15 residents providing a personalised service to a relatively small group of people where close relationships are established between residents, staff and visitors. There is a welcoming warm, homely atmosphere. Staff find time to sit and talk to residents as well as meeting the practical care needs of residents. Comments from residents included: “It I wonderful here, they treat you really well and kindly” “staff never ignore you they always have kind words to say to you” “I have settled here well, it is better than where I was before and I want to stay”. Visitors spoke highly of the service provided one said “staff are excellent, nothing it too much trouble, my mother is very happy here”. A good standard environment with well personalised bedrooms. There were numerous examples of personal items and memorabilia brought from home. Residents spoke unanimously about the good standard of food and the choices available to them a resident said “you can have anything you want”. Fresh fruit is a particular food feature with an abundance of fruit available in the lounge areas. Staff encourage residents to eat this between mealtimes. Staff recruitment procedures are good, the usual checks and references carried out prior to employment to ensure residents are thus protected. The home are establishing a close relationship with the local community group who see Trentside Manor as part of the small, close village identity. Residents with dementia care needs are provided with individual interventions and 1:1 activities to maximise their potential and ensure they are included in all aspects of daily life in the home. What has improved since the last inspection? Ownership of the home changed on 19th October 2007 and a new Manager appointed from that date. There had been a long period without a Registered Manager which disadvantaged the home. Trentside Manor DS0000070469.V359636.R01.S.doc Version 5.2 Page 8 The lounge and dining area (previously integrated) has been separated. The lounge area cleared of all hazardous furniture to increase safety. Residents now use the large lounge area sitting around the perimeter providing all with a view of the garden, increased natural light and safety to move within the lounge. A dining room is established in a smaller room off the lounge area. New furniture has been purchased and greatly improved the presentation of the dining facilities. Well laid tables with good table-linen, crockery and cutlery provide a relaxed dining atmosphere. The reception area has been cleared/changed with seating and information about the home presented in a more welcoming, homely way for visitors. There are now regular meetings with the new providers who visit the home and available to discuss any issues with relatives or residents. There are now regular residents meetings and also staff meetings improving communication and feedback from residents. The new Manager has positive ideas for the home. She has improved the quality of recording, particularly in care planning information. There are regular reviews of care plans, key workers allocated and risk assessments and other areas of documentation in the home that were previously poor have been improved. Activities for residents are a priority with an activities post of 12 hours per week established. The Manager isalso forging positive links with the community – all with the objective of improving quality of life for residents. What they could do better: The Statement of Purpose should be completed, copies given to all residents and copies available in the home for visitors. Social histories should be completed to provide more detailed information for staff allowing greater knowledge of chosen lifestyle and social, recreational and emotional needs of residents. Trentside Manor DS0000070469.V359636.R01.S.doc Version 5.2 Page 9 Some aspects of medication could be improved with more accurate recording of variable dose medication and ensuring that MAR sheets reflect the medication prescribed and administered. Safeguarding of residents could be improved with copies of current Safeguarding procedures available in the home for reference and all staff involved in updated training to ensure protection of residents. Some areas of staff training remain outstanding. Some dates are booked others awaited for other courses. This shortfall should be addressed as soon as possible. Copies of the GSCC Codes of Conduct should be given to all staff. The removal of bleach from use would improve safety of residents. Data sheets for all items in use are needed. 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. Trentside Manor DS0000070469.V359636.R01.S.doc Version 5.2 Page 10 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 Trentside Manor DS0000070469.V359636.R01.S.doc Version 5.2 Page 11 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): Standards 1-5 were inspected on this visit. Quality in this outcome area is adequate. The statement of purpose is required to be available for prospective residents and their families. All have a copy of the service users guide and a contract upon admission. Pre-admission assessments are carried out to ensure needs can be identified and met. All are invited to spend time in the home prior to their decision about admission. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Trentside Manor DS0000070469.V359636.R01.S.doc Version 5.2 Page 12 A requirement of the last report to provide a Service Users Guide has been actioned. All residents now have a copy (seen in bedrooms) and there is one available in the home. This document gave all the required information. The Statement of Purpose was reported to have been updated to include the change of ownership and new management but not printed-off and was not available at this time. This must be done and include the weekly fees charged. A copy should be readily available in the home to inform prospective residents and their families about service provision. Pre admission assessments were seen with the care plans of 2 residents and contained all the required information in Standard 3. Care Management assessments were also present in the files seen. A copy of the homes contract was also provided and was seen. Prospective residents are invited to the home prior to admission to ensure they are able to make an informed decision about suitability of the home. A resident admitted from another home confirmed that she had been invited to come to Trenstside Manor before admission and had spent the day there before deciding upon admission. Trentside Manor DS0000070469.V359636.R01.S.doc Version 5.2 Page 13 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): Standards 7 –10 were inspected on this visit. There was good evidence of identified needs of residents set out in care plans, the only omission being social histories. Health care needs of residents are found to be fully met, endorsed by a visiting District Nurse. Some aspects of medication administration could be improved. Respect, dignity and privacy is upheld. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Care plans were previously inadequate under the former ownership/management. This has improved considerably. A sample of care plans of recently admitted and longer-term residents were seen and contained good information about personal and health care needs. Trentside Manor DS0000070469.V359636.R01.S.doc Version 5.2 Page 14 Information contained clear instructions to staff on aspects of personal care. The care plan of a resident admitted 3 weeks prior to the inspection contained detailed information about dental care, toileting, bowel movement etc and information about diagnosed medical conditions. Blood-sugar levels were to be monitored by staff, a monitoring machine being provided by the nursing service. An allergy to penicillin was clearly marked in the care plan and also on the MAR sheets in red ink. Social histories were not present in care plans seen. It is important to provide a social history to enable staff to have information about holistic aspects of the lives of residents to enable them to provide support for the recreation, social and emotional care for residents. Advice was given about securing this information. The records of a resident being re-assessed due to agitation and physical aggression were seen and discussed with the Manager. Records showed referral to GP/Psychiatrist/CPN. A behavioural risk assessment had been established together with behavioural chart monitoring progress on a 24 hour basis. Information in the care plan had been carefully reviewed and there was good person-centred information about eating, sleeping, individual relationships and needs. There were clear instructions to staff of the actions to be taken when challenging behaviours were presented. It is hoped that the home may be able to continue to meet the needs of this resident. Currently a medication review is underway with the CPN to assist in this objective. For all residents there were concise and informative health care sheets summarising the visits of health care professionals with reasons and outcomes. The Continence Advisor has given some training and advice to staff and further training offered and awaited. There was evidence of Occupational Therapists, Physiotherapists, CPN, Palliative Care Nurses and other health care professionals being consulted/involved to provide information and support in particular areas of healthcare need. A visiting District Nurse was spoken with who has been visiting the home for about 3 years. She confirmed there are currently no pressure area management issues in the home and was visiting only in relation to a dressing for a foot wound and the usual blood/routine checks. She said that relationships with the home were “excellent”, she found staff pro-active about health care matters with early referrals and that they were conscientious in following advice/instructions given. There was an observed relaxed, friendly and professional relationship between her and the members of staff on duty. She had no reservations about any healthcare matters in the home at this time. There has been some difficulty in securing visits for residents from the local GP surgery recently due to imposed deadlines by the surgery for home visit Trentside Manor DS0000070469.V359636.R01.S.doc Version 5.2 Page 15 referral times etc. This was discussed with the Manager who is changing her own referral practice and has further pursued the matter with the GP practice in question. Weight records showed that all residents are weighed monthly - and weekly where there are concerns about weight loss. There are monthly reviews of care plans by the Key Worker Team which includes a Senior Carer and 3 Carers. Reviews then checked/overseen by the Manager. Medication is supplied by Boots Chemists and administered by Senior Carers in Monitored Dose Form (blister packs). Records were generally well completed although 2 shortfalls were noted: the actual dose given for variable does medication was not always recorded (e.g. 1 or two tablets) and there was glyceryl trinitrate in tablet and spray form for a resident which was dated and not on the MAR (medication administration record). This must be disposed of/returned to the pharmacy. It seemed that this medication may have been brought to the home at the point of admission. Trentside Manor DS0000070469.V359636.R01.S.doc Version 5.2 Page 16 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): Standards 12 – 15 were inspected on this visit. Quality in this outcome area is good. Residents and visitors confirmed lifestyles were known and acted upon. Improvements in activities have taken place and more planned, there is a positive link with the community. Residents are given choice and control over their lives. Food provision has been further improved with satisfied residents. This judgement has been made using available evidence including a visit to this service. EVIDENCE: At the time of the last inspection activities and stimulation for residents was found to be minimal. There have been considerable improvements since that time. The layout of the main lounge/dining area has been changed to provide peripheral seating in the lounge area reducing the risks of falling and providing Trentside Manor DS0000070469.V359636.R01.S.doc Version 5.2 Page 17 all residents with a view of the garden area and more natural light. The dining area has been moved to a smaller but adequate room, new furniture provided presenting an attractive dining area with well presented linen and tableware. These changes have provided opportunities for residents to engage more readily with visitors and with each other. The home have a link with the Norton Green Residents Association (community group) being in a small village, Norton Manor is known and considered a part of the community. Fund raising and social events include the home and there has been an Xmas Fayre and also bonfire for the residents arranged by the community group. A member of staff has changed roles and now specifically employed to lead activities in the home. This is a new arrangement and allocated hours are 6 hours on each of 2 days, it is anticipated that this will expand activities further, once vacancies for care staff are filled. There is a flexible list of activities throughout the week but dependent upon resident choice on the day. The Expert by Experience spent time with residents and staff throughout the mid day period including lunch. He said that there was reminiscence material available, some simple games and CD’s of interest to residents. He commented that “ it is obvious that the staff are very much encouraged to engage with the residents and that after lunch many of the staff were in the lounge in one to one conversations with residents, the cook was playing cards with a resident”. This gave an observational flavour of the engagement between residents and staff. The Expert felt that availability of daily newspapers was needed, some large print books should be provided and further visits to provide gentle exercise for residents would all expand the options and quality of life of residents. He said that “Trentside Manor left a good impression, the home was smoothly run and the residents spoke highly of the care they received. The food on the day was excellent and the weekly menu looked varied”. One resident was seen in her room listening to a talking book - regularly obtained for her. There are now residents meetings to allow a direct input into the daily running of the home and feedback from residents. Food provision was satisfactory to residents. There is a menu board outlining daily meals, with a choice of 3 main courses at lunchtime and 3 sweets. Choice has been extended since the last inspection. The Expert by Experience who took lunch with the residents commented that residents were allowed time and given assistance in a sensitive way to eat their meals and the quality of food was good. Trentside Manor DS0000070469.V359636.R01.S.doc Version 5.2 Page 18 There was a large bowl of fresh fruit in the middle of the lounge area, frequently replenished and many drinks were on tables with easy access by residents. Three visitors were seen. All spoke highly of the care provided and commitment of staff. Two relatives were visiting mother/grandmother with their dog – also a regular visitor and a point of interest and comment from many residents. A relative visiting her recently admitted mother said that she was “totally satisfied” with the way her mother had been helped to settle in the home and giving total licence to provide choice of furniture and the many personal effects she wished to bring. This relative is the Manager of a Local Authority home and commented very favourably about this home in the private sector which was relatively new to her. Trentside Manor DS0000070469.V359636.R01.S.doc Version 5.2 Page 19 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): Standards 16 & 18 were inspected on this visit. Quality in this outcome area is adequate. The complaints procedure is readily available and ensures complaints are acted upon. Some updating training and information of the protection of residents from abuse is needed. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The complaints procedure is now widely available in the home - previously it was not. It is now included in the Service Users Guide a copy of which has been given to all residents. There is also a copy posted in the home for visitors. There were concerns at the time of the last inspection that without a Manager or complaints procedure, complaints and concerns could not be expressed. The new Manager has spent time with individuals and in residents meetings reenforcing the procedures for making complaints. There are also forms in the reception area for making written complaints. No complaints have been received by the home or by the Commission since the last inspection. Trentside Manor DS0000070469.V359636.R01.S.doc Version 5.2 Page 20 The new Safeguarding procedures are generally not known. A copy of the Safeguarding Procedures should be obtained and available to all staff and training sourced to provide all staff with updated training in Safeguarding Vulnerable Adults. This will provide staff with training in the broad definitions of abuse and the procedures for reporting suspected or actual abuse. Trentside Manor DS0000070469.V359636.R01.S.doc Version 5.2 Page 21 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): Standards 19 – 26 were inspected on this visit. Quality in this outcome area is good. There is a safe, well maintained environment with good access to all areas. Specialist equipment is provided to maximise independence. Bedrooms are safe, comfortable and well personalised. Standards of hygiene throughout are good. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Three necessary improvements have been made the environment since the new registration: Trentside Manor DS0000070469.V359636.R01.S.doc Version 5.2 Page 22 The lounge/dining areas have been re-arranged to provide a large lounge area which is safer and separate dining area – this allows the opportunity for visitors to see residents with more space and privacy in the communal areas or in bedrooms with total privacy. The rearrangement has allowed all residents to have more natural light, views of the garden and a safer environment. The external grounds were overgrown, have been cleared and will allow good access to a pleasant garden area as summer approaches. Equipment is now provided with input from Occupational Therapists - for example two new frames have been fitted at the side of beds to assist mobility into/out of bed and improve safety. This is considered (by the OT) to be a better option than bedguards. All resident accommodation at this time is on the ground floor. The new owners have plans to develop the large first floor area in the future. All bedrooms are for single use. There is only 1 en-suite bedroom, but there are 2 assisted bathrooms and adequate toilet areas. Some residents have commodes. Trentside Manor has traditionally maintained a satisfactory standard environment to ensure the comfort and safety of residents and infection control standards have been good - This continues, all areas of the home are clean, well maintained and comfortable. Some replacement furniture has been provided. The dining room furniture has all been replaced. New lounge chairs are on order. The reception area has been improved with some seating providing a more welcoming relaxed area for visitors. The new owners and Manager have maximised the use of communal space whilst upgrading those areas too. A sample of bedrooms seen were well furnished, clean, comfortable and well personalised. A new resident and her family had purchased new bedroom furniture, had shelves erected etc to ensure her room was as she wished. All bedrooms have a lockable box in their wardrobes and residents hold the key. A maintenance person is employed who ensures the ongoing and daily maintenance of the building. Infection control practices are good with paper towels, liquid soap, hand sanitizer and protective clothing readily available. It is recommended that the use of red alginate (degradable) bags could be used to reduce handling of incontinent laundry and further improve infection control. Trentside Manor DS0000070469.V359636.R01.S.doc Version 5.2 Page 23 Trentside Manor DS0000070469.V359636.R01.S.doc Version 5.2 Page 24 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): Standards 27 – 30 were inspected on this visit. Quality in this outcome area is good. The numbers and skill mix of staff are adequate. Some shortfalls in staff training are in hand and needed, although NVQ training has been adequate. Recruitment procedures protect residents. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The staffing levels of this home throughout the 24 hour period (15 people) are 3:2:2 plus the Manager who works during the week, effectively making 4:3:2. The night staffing level is now for 2 waking night staff following some concerns expressed previously by the Fire Officer. Support staff include catering 8 – 2 daily, housekeeping and maintenance person. Twelve hours are now allocated for activities. The above staffing levels appear adequate for the dependency levels of the current resident group (low – medium). The home now has a staff training matrix monitoring training undertaken and highlighting shortfalls. There has been training in most areas of required Trentside Manor DS0000070469.V359636.R01.S.doc Version 5.2 Page 25 statutory training since the last inspection. The new Manager is an approved Moving & Handling trainer. Care staff prepare tea and there has recently been updated Food Hygiene training. All staff have received training in infection control. There are some shortfalls in training which are either planned or awaiting dates for training – this is in areas of Dementia care, medication, first aid and Health & Safety. Some courses are arranged February – April with other dates awaited. A requirement is made to complete outstanding training within 3 months. This is anticipated. Safeguarding training mentioned earlier in this report is required for all staff. A copy of the GSCC Codes of Conduct are still needed for all staff and will be provided by the Manager. A sample of staff files were seen and recently appointed member of staff interviewed. Files contained all required references, checks and documentation required under Schedule 2. Induction is now provided for new staff on an accredited scheme. This is an improvement on the previous arrangements. The majority of staff have received NVQ training. Staff meetings are now held regularly the last being 7/11/07 & 10/1/08 (minutes seen). Supervision is also now in place to provide at least 6 sessions per year. Trentside Manor DS0000070469.V359636.R01.S.doc Version 5.2 Page 26 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): Standards 31-33 and 36 – 38 Quality in this outcome area is good. The new Registered Manager ensures the home is well run and managed in the interests of residents. Staff supervision is good and the health & safety of residents is paramount. This judgement has been made using available evidence including a visit to this service. EVIDENCE: This home under the previous registration was without a Registered Manager for a considerable time and was disadvantaged generally as a result. Trentside Manor DS0000070469.V359636.R01.S.doc Version 5.2 Page 27 The new owners took over the home on 19/10/07 and the New Registered Manager commenced at the same time. Considerable improvements in the running and management of the home are evident. The Manager has experience and is presently studying the required Registered Managers Award which she is due to complete later this year. She is enthusiastic and keen to improve the service and quality of life for residents. She takes a positive lead in the home and staff commented upon the improvements made since the changes of ownership and management. It is important that staff are able also to take ownership of those improvements and this seems to be the case. There is a very positive, relaxed, friendly atmosphere in the home. Staff seen to engage very positively with residents. It was pleasing to see staff sitting and talking to residents when personal tasks were completed. Three visiting relatives felt that there had been improvements to the home in the past months and were clearly pleased with the results. There are regular monthly meetings with the two owners and more regular meetings/visits from the Responsible Individual. The Manager reports good relationships and support from providers. The home has recently been awarded the Investors in People award, this was approved on 28/01/08 and included the usual quality review assessments. The home also has a Quality Review process including feedback from residents, relatives, visitors and professionals – these were not seen on this visit. Fire records showed regular checks of equipment and fire drills for staff with evacuations. The Handyperson is a Fire Marshall with a background in fire protection. He provides training for staff in fire safety including written and oral tests and issues certificates when judged competent. Night staffing levels have been increased to ensure adequate protection and service to residents. Fire compartments in the home have a maximum of 4 bedrooms in each that also ensures good protection. The use of bleach in the home was discussed and the Manager agreed that proprietary sanitizers would adequately suffice. Bleach should be removed from the COSHH cupboard within the home and data sheets obtained for all other cleaning materials in use. Trentside Manor DS0000070469.V359636.R01.S.doc Version 5.2 Page 28 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 2 3 3 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 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 3 3 3 3 3 3 3 STAFFING Standard No Score 27 2 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 3 X X 3 3 2 Trentside Manor DS0000070469.V359636.R01.S.doc Version 5.2 Page 29 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 OP1 Regulation 4(1)(2) Requirement Update & complete Statement of Purpose. A copy must be available in the home for residents and visitors. Dosage of variable dose medication must be recorded. Prescribed medication must reflect all entries on MAR sheets. Medication not on MAR sheets must be disposed of. A copy of the Safeguarding procedures should be obtained and alls taff must have updated training in this vital area. Planned outstanding training for staff should be completed within 3 months. A copy of the GSCC Codes of conduct must be given to all staff. Substitute bleach with sanitizer and provide data sheets for all COSHH items used. Timescale for action 14/03/08 2 3 OP9 OP9 13(2) 13(2) 14/02/08 14/02/08 4 OP18 13(6) 14/04/08 5 6 7 OP27 OP29 OP38 18(1) 18(4) 13(4) 14/05/08 14/03/08 14/03/08 Trentside Manor DS0000070469.V359636.R01.S.doc Version 5.2 Page 30 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 Refer to Standard OP7 OP26 Good Practice Recommendations Social histories should be provided for all residents to inform care plans & enable staff to meet social, recreational and emotional needs. Consider use of alginate (degradable) bags for intontinent laundry to reduce handling and improve infection control. Trentside Manor DS0000070469.V359636.R01.S.doc Version 5.2 Page 31 Commission for Social Care Inspection West Midlands West Midlands Regional Contact Team 3rd Floor 77 Paradise Circus Queensway Birmingham, B1 2DT 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 Trentside Manor DS0000070469.V359636.R01.S.doc Version 5.2 Page 32 - 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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