Inspection on 11/01/06 for Trepassey

This inspection was carried out on 11th January 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector 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

Trepassey 15/01/07

Trepassey 13/03/06

Trepassey 18/03/05

Trepassey 05/07/04

Trepassey 21/12/03

Similar services:

Chirnside House

Keer Sands Residential Home

Ruskin Lodge

Bushell House

Langrigg House

Parkside

Dystlegh Grange

Thornton Lodge

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

CARE HOMES FOR OLDER PEOPLE Trepassey Hillside Road Heswall Wirral CH60 OBW Lead Inspector Beate Roth Unannounced Inspection 11th January 2006 10:15 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 Trepassey DS0000018949.V276746.R01.S.doc Version 5.1 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Trepassey DS0000018949.V276746.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Trepassey Address Hillside Road Heswall Wirral CH60 OBW 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) 0151 342 2889 0151 342 7031 Cheshire Residential Homes Trust Mrs P Lucas Care Home 24 Category(ies) of Old age, not falling within any other category registration, with number (24) of places Trepassey DS0000018949.V276746.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 18th March 2005 Brief Description of the Service: Trepassey is a residential care home that provides personal care and accommodation for up to 24 older people. The home is owned by a registered charity, the Cheshire Residential Homes Trust and was opened in 1958. Trepassey is located in a quiet residential area of Heswell and benefits from views across the River Dee estuary across to Wales. The town centre is less than a mile away and a bus service passes the end of the road. The home is a three-storey detached house set in well-kept sloping gardens with access to a level patio area at the front of the building. All bedrooms are single and have an en-suite toilet or shower/toilet facilities. Bedrooms are located on each floor. Communal accommodation within the home consists of 2 lounges, dining room, reception hall and a sunroom. There is a passenger lift that serves all floors and bathing aids are available. Parking is available within the grounds of the home. Trepassey DS0000018949.V276746.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection took place over seven hours. During the inspection time was spent in the office examining records and policies and procedures and talking to the manager and deputy managers. A tour of the home was undertaken. Service users and staff were spoken with. A staff handover meeting was observed. What the service does well: What has improved since the last inspection? What they could do better: Where service users need support from staff with their behaviour, due to the challenges it can present, the action that staff are to take is to be clearly documented in the care plan. A risk assessment is needed for the use of wallmounted heaters in the bedrooms and the protective cover around the hot pipe in a service users bedroom is to be secured. Evidence that the electrical wiring at the home is safe is to be provided to CSCI. Trepassey DS0000018949.V276746.R01.S.doc Version 5.1 Page 6 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. Trepassey DS0000018949.V276746.R01.S.doc Version 5.1 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Trepassey DS0000018949.V276746.R01.S.doc Version 5.1 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 2, 3 and 5 An appropriate assessment of whether the home is suitable for new service users takes place. Service users are provided with opportunities to visit the home to decide if the home will meet their needs. EVIDENCE: There was evidence of appropriate assessments being carried out before new service users move to the home. A sample of assessments were seen and indicated that sufficient information is obtained that would form the basis for care planning. Following an initial enquiry prospective service users are sent a brochure, an application form and a request for written permission to contact their G.P. for a statement of their health. The majority of service users are self-funding however, if they are funded by the local authority a social worker carries out a needs assessment and the home receives a copy of the care plan. This is followed by a visit to the prospective service user, which is undertaken by the manager or one of the deputy managers. A pre-admission assessment form is completed and a list of prompt questions is used as an aide to elicit the necessary information required. Trepassey DS0000018949.V276746.R01.S.doc Version 5.1 Page 9 Prospective service users and their relatives are invited to visit the home before deciding whether to move in for a 28-day trial period. Prospective service users can visit the home for lunch and for an overnight stay. Each service user is provided with a contract/statement of terms and conditions. The contract contains all the required information. Trepassey DS0000018949.V276746.R01.S.doc Version 5.1 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8 and 10 The health, personal and social care needs of service users are in general well supported by the care planning processes in place at the home. EVIDENCE: A sample of care plans were seen. The documentation was clear and detailed the actions staff are required to take to ensure that all aspects of health, personal and social care needs of individual service users are met. There was evidence that senior care staff complete care plan evaluations once a month. Information around the action staff take to support service users with behaviour that can be challenging needs to be documented. Staff have been made aware verbally of the action they are to take. The records at the home and a discussion with the manager indicated that referrals are made to health professionals in accordance with the needs of service users. A record is made of visits by health professionals and the outcome is documented. The record of accidents was examined and was appropriately maintained. It is recommended that the record of an accident be placed on the relevant service user or staff file in accordance with guidance from the Health and Safety Executive. Trepassey DS0000018949.V276746.R01.S.doc Version 5.1 Page 11 Staff are provided with guidance on how to meet a service users needs in a dignified manner and how to respect their privacy. Written information is also available for staff regarding this. Staff were observed carrying out a handover meeting, during which, staff beginning their working day are informed about the current needs and wellbeing of the service users. Service users were referred to in a respectful way and it was evident from this that staff are very aware as to how the privacy of service users is to be maintained. Trepassey DS0000018949.V276746.R01.S.doc Version 5.1 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13 and 15 The routines of daily living are flexible and activities reflect service users interests. Service users receive, varied, well-balanced meals in pleasant surroundings. EVIDENCE: Observations and a discussion with the manager and service users indicated that the routines of daily living are flexible. Service users are encouraged to pursue their hobbies and interests. A deputy manager undertakes the role of an activities co-ordinator and in-house activities such as armchair aerobics, word games and bingo take place during the week. In addition the activities co-ordinator arranges entertainment for service users and forthcoming events are listed on a poster once a month. Events that take place are recorded and have included performances, talks from local people of interest and craft activities. Seasonal events are also arranged and recently the home provided a number of Christmas activities such as a trip to the pantomime and parties. Service users are asked about the activities that they would like the home to organise. Visitors are welcome at the home at any reasonable time. Representatives from local churches visit the home. A mobile shop also visits the home. In Trepassey DS0000018949.V276746.R01.S.doc Version 5.1 Page 13 addition, the majority of service users go out with their families and friends. Service users said that their visitors are made to feel welcome at the home. Observations of the dining area indicated that a pleasant environment is provided for service users to have their meals. Visitors may eat with the person they are visiting as long as sufficient notice is provided. Breakfasts are provided following consultation with each service user and are served in the bedrooms or dining area. The records of menus indicated that a variety of meals that would provide a balanced diet are available. Any special dietary needs and the likes and dislikes of service users are written in to a service users care plan. Service users reported that the food is good and that they like the meals provided. Trepassey DS0000018949.V276746.R01.S.doc Version 5.1 Page 14 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 The home has a satisfactory complaints system which service users know how to access. The adult protection procedures at the home safeguard service users. EVIDENCE: There was evidence that service users know how to make a complaint. A record of complaints is maintained. This indicated that 2 complaints concerning the same issue had been made since the last inspection and that they had been and responded to quickly and appropriately managed. The home has a written complaints procedure, which is included in the service users guide and a copy is displayed within the home. This does not indicate the timescale for dealing with complaints and clearly detail the stages for making a complaint. The procedure should also indicate that CSCI is not part of social services. Monthly care plan evaluations have a section for recording complaints and service users are able to raise any issues at the quarterly residents meetings. The home has a copy of the Metropolitan Borough of Wirral’s procedures for the protection of vulnerable adults. Staff have been provided with guidance around recognising abuse and how to appropriately report concerns about abuse. The staff spoken with were aware of the procedure to follow. Trepassey DS0000018949.V276746.R01.S.doc Version 5.1 Page 15 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 25 and 26 The home is clean and in general safe and well maintained, providing service users with a pleasant environment to live in. EVIDENCE: A tour of the home was undertaken and a sample of bedrooms seen. There was evidence of on-going decoration to maintain standards at the home. Following a requirement from the previous inspection the first floor landing carpet has been replaced. Since the last inspection further works undertaken include, redecoration of the first floor landing, refurbishment of a bathroom and some bedrooms have been redecorated and re-carpeted. A planned maintenance and renewal programme for the fabric and decoration of the premises is in the process of being drawn up. A requirement was made at a previous inspection that the 2 bathrooms with temporary radiator covers must have a permanent fitment. Trepassey DS0000018949.V276746.R01.S.doc Version 5.1 Page 16 At this inspection the manager reported that thermostatic mixing valves with lockable temperature controls have been fitted to the water outlets in these bathrooms so that the water does not exceed 43 degrees centigrade. The manager reported that the 2 radiators (heated towel rails) in question are heated by the water from these taps. These radiators were not hot at the time of the inspection. The manager reported that the temperature of these radiators is monitored and that the water temperature is regularly tested. The manager recorded a risk assessment for these radiators at the time of the inspection to ensure that staff are aware of the need to monitor the temperature in order to fully safeguard the well being of the service users. Radiators in the other communal areas and bedrooms have been fitted with radiator covers. Water temperature is controlled so it does not exceed 43 degrees centigrade. In bedroom 19 the protective cover used to address a risk presented by hot pipes by the bed had become loose exposing the pipe at the foot of the bed. Any covers used to protect service users from hot pipes must be secure at all times. The service user was not occupying this room at the time of the inspection and the manager reported that this would be addressed before their return. At the last inspection the inspector was informed that in a particular part of the home some bedrooms are not warm enough and as a result service users have obtained freestanding heaters. A requirement was made that the central heating system must work efficiently (or be replaced) in order to produce heat at the appropriate temperature. It was recommended that risk assessments are undertaken for the temporary use of freestanding heaters until the heating problem is resolved. At this inspection, there have been no changes to the central heating system. The home did not feel cold. The manager reported that in general the heating throughout the home is sufficient, especially as the radiator covers mean the radiator temperature can now be increased. During cold spells the manager reported that some areas of the home are cold. There is single glazing to the windows in these areas. The freestanding heaters have been replaced with wall-mounted heaters. A sample of these heaters were seen in bedrooms. These were within reach of service users. One was hot to touch and could be a potential hazard. A risk assessment around the use of the wall-mounted heaters is to be undertaken before they are provided. On the day of this inspection the premises were found to be clean and malodour free. The laundry is situated on the first floor of the home. A washing machine and tumble dryer are contained within a very small room. Although a system has been put in place to suit the facilities available, which includes using an outside cleaning service for the cleaning of bedding and towels, it would benefit staff if a larger area where made available for washing and drying clothes. At present it would be difficult to manage clothing that can Trepassey DS0000018949.V276746.R01.S.doc Version 5.1 Page 17 only be hand washed. Plans to extend the home to provide a larger laundry area and further storage facilities are currently being looked at. Trepassey DS0000018949.V276746.R01.S.doc Version 5.1 Page 18 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28 and 29 There are sufficient numbers of staff to meet the needs of service users. The recruitment processes safeguard service users. EVIDENCE: The rotas and a discussion with staff indicated that there are sufficient numbers of care staff to meet the needs of the service users. A sufficient number of domestic and catering hours are provided. Service users spoken to during the inspection made positive comments about staff. They said that staff are helpful and kind. A discussion with the manager and staff indicated that staffing levels are provided in accordance with the needs of the service users. Staff are encouraged to undertake a National Vocational Qualification in Care of Older People. At present there is not 50 of staff with an NVQ qualification or equivalent. 6 out of 8 of the senior staff have completed an NVQ. There are 14 care staff, 1 has completed an NVQ 3, 3 are currently undertaking this course, 3 further staff are completing access to nursing qualifications and 1 member of staff has completed an access to nursing course. The recruitment records for 2 new staff were seen and contained the required information. The recruitment process was discussed with the manager. This process includes potential staff completing an application form and attending an interview where competence to appropriately care for service users is assessed. Trepassey DS0000018949.V276746.R01.S.doc Version 5.1 Page 19 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 32 and 37 Service users are in general, supported by the management systems at the home. EVIDENCE: The registered manager has many years experience within the care sector and has been at the home for over 20 years. The Registered Manager is a Registered General Nurse (RGN) and also has the Registered Managers Award. The management approach of the home ensures that the views of staff and service users are listened to and creates an open atmosphere. There is an equal opportunities policy and staff have access to written information as to the standards expected of them at work. Staff meetings are held. There are clear handover meetings between staff at the start of every new shift. The views of service users are obtained either in a group to look at specific issues or individually. Trepassey DS0000018949.V276746.R01.S.doc Version 5.1 Page 20 The training records showed that staff are provided with training around safe working practices. Records demonstrated forthcoming training courses that staff are attending to update their health and safety training if needed. A sample of safety check records and certificates were examined. There was no evidence of an up to date safety test certificate for the electrical wiring at the home. There were several certificates for the electrical wiring; these indicated that the electrical wiring should have been inspected in January 2005, October 2005 and December 2004. During the inspection the electrician who carried out the last test of the electrical wiring visited the home and reported that the electrical wiring is generally in good condition and that he has been maintaining the condition of the wiring by carrying out remedial works. There was written evidence of remedial works being carried out in 2004. Evidence that the electrical wiring at the home is currently safe is to be provided to CSCI. Trepassey DS0000018949.V276746.R01.S.doc Version 5.1 Page 21 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X 3 3 X 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 X 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 X 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X X 2 3 STAFFING Standard No Score 27 3 28 2 29 3 30 X MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 X X X X X 2 Trepassey DS0000018949.V276746.R01.S.doc Version 5.1 Page 22 Are there any outstanding requirements from the last inspection? No STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP7 Regulation 15 Requirement The registered person must ensure that at all times staff have access to written information on how to support service users with behaviour that can be challenging. The registered person must provide a risk assessment around the use of the wallmounted heaters before they are provided in service users bedrooms. The registered person must ensure that where protective covers are used to address a risk presented by hot pipes in bedrooms, these are secure at all times. The registered person must provide evidence that the electrical wiring at the home is safe. Timescale for action 11/01/06 2 OP25 13 11/01/06 3 OP25 13 11/01/06 4 OP38 23 11/02/06 Trepassey DS0000018949.V276746.R01.S.doc Version 5.1 Page 23 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 OP8 Good Practice Recommendations It is recommended that the record of an accident be placed on the relevant service user or staff file in accordance with guidance from the Health and Safety Executive. The complaint procedure should detail the timescale for dealing with complaints and clearly detail the stages for making a complaint. The procedure should also indicate that CSCI is not part of social services. A larger area should be provided for staff to carry out the laundry of service users clothing. A minimum of 50 of staff are to hold an NVQ 2 or equivalent. 2 OP16 3 4 OP26 OP28 Trepassey DS0000018949.V276746.R01.S.doc Version 5.1 Page 24 Commission for Social Care Inspection Liverpool Satellite Office 3rd Floor Campbell Square 10 Duke Street Liverpool L1 5AS National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Trepassey DS0000018949.V276746.R01.S.doc Version 5.1 Page 25 - 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. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!