Inspection on 13/03/06 for Trepassey

This inspection was carried out on 13th March 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 11/01/06

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 13th March 2006 01:30 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Trepassey DS0000018949.V286668.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.V286668.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.V286668.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 11th January 2006 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 Heswall 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.V286668.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 5 and half hours. During the inspection time was spent in the office examining records and policies and procedures and talking to the manager. A tour of the home was undertaken. Service users and staff were spoken with. What the service does well: What has improved since the last inspection? What they could do better: The service user care plans need to provide sufficient information on the action staff are to take to support service users and ensure their safety. Where service users administer their medication, the risk assessment completed by the home, needs to indicate how this decision was reached. Service users would benefit from further staff completing a recognised care qualification. In order to meet the National Minimum standards for Care Homes for Older People, it needs to be demonstrated that the induction currently provided meets the National Training Organisation (NTO) workforce training targets. Some improvements are needed to the fire safety practices. Trepassey DS0000018949.V286668.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.V286668.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.V286668.R01.S.doc Version 5.1 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 3 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. Trepassey DS0000018949.V286668.R01.S.doc Version 5.1 Page 9 A pre-admission assessment form is completed and a list of prompt questions is used as an aide to elicit the necessary information required. Service users are invited to make visits to the home to view the facilities, meet service users and staff. Trepassey DS0000018949.V286668.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, 9 and 10 The health, personal and social care needs of service users are in general well supported by the care planning processes and procedures in place at the home. The privacy and dignity of service users is well promoted. EVIDENCE: A sample of care plans were seen. The documentation was clear and in general, detailed the actions staff are required to take to ensure that the health, personal and social care needs of service users are met. The action staff are to take to support a service user who has been getting confused when going to the local shops and the action to be taken to assist service users when bathing needs to be clearly documented. There was evidence that senior care staff complete care plan evaluations once a month. Service users spoken with described the care they receive as “good”, “excellent”, and one service user said, “you couldn’t fault it.” 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. Trepassey DS0000018949.V286668.R01.S.doc Version 5.1 Page 11 The record of accidents was examined and was appropriately maintained. A record of an accident is placed on the relevant service user or staff file in accordance with guidance from the Health and Safety Executive. A monthly audit of accidents takes place which assists with care planning. The Medication Administration Record sheets for five service users and the corresponding medication were seen and were in general in order. Care needs to be taken to record the amount of medication received from the pharmacist and to record the amount of medication given when this can vary, so as to enable a clear audit to be made of medication held at the home. This information was not available for one type of medication. Medication is stored securely in lockable cabinets, which are secured to the wall. Staff who administer medication have received training in the safe handling of medication. No homely remedies are kept. Some service users self-administer their medication in accordance with a risk assessment. A sample of risk assessments were seen and need to provide more detailed information. These assessments do not indicate if the service user is able to store their medication securely, read and comprehend the instructions for medications and whether they can physically administer the medication. The medication procedure covers the main issues regarding administration. A copy of the Royal Pharmaceutical Guidelines around the administration of medicines in care homes is also available. The medication procedure should detail the specific arrangements at the home for administering medication. 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. The service users spoken with said that the staff are very “polite,” “well –mannered,” and “friendly.” Trepassey DS0000018949.V286668.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): 13 and 14 The social and emotional wellbeing of service users’ is supported by the arrangements for maintaining community links, encouraging visitors and promoting independence. EVIDENCE: Visitors are welcome at the home at any reasonable time. Service users said that their visitors are made to feel welcome at the home and that they can choose whether to see their visitors. The majority of service users go out with their families and friends. Representatives from local churches visit the home. A mobile shop also visits the home. Discussion with service users and staff indicated that the home encourages service users to make decisions about their day to day lives at the home, such as when they will get up and go to bed and what they will do each day. Each of the service users bedrooms seen had been personalised with items brought in from their own homes. Service users and their relatives are made aware of how to contact advocacy services. Trepassey DS0000018949.V286668.R01.S.doc Version 5.1 Page 13 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 The home has a satisfactory complaints system which service users know how to access. EVIDENCE: There was evidence that service users know how to make a complaint. A record of complaints is maintained. This indicated that complaints concerning the same issue had been made and that they had been 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 indicates the timescale for dealing with complaints and that the Commission for Social Care Inspection can be approached if a complainant considers the home has not dealt with a complaint appropriately. Monthly care plan evaluations have a section for recording complaints and service users are able to raise any issues at the quarterly residents meetings. Trepassey DS0000018949.V286668.R01.S.doc Version 5.1 Page 14 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. The home is well maintained. There was evidence of on-going decoration to maintain standards at the home. A planned maintenance and renewal programme for the fabric and decoration of the premises is being drawn up. The manager was in the process of ordering new carpet for the sunroom at the time of the inspection. There was evidence of safe working practices. Radiators in the communal areas and bedrooms have been fitted with radiator covers. A risk assessment is available for the two heated towel rails. Water temperature is controlled so it does not exceed 43 degrees centigrade. Trepassey DS0000018949.V286668.R01.S.doc Version 5.1 Page 15 At the last inspection, the protective cover to a pipe at the foot of a bed had come loose exposing the pipe and presenting a possible hazard. The manager attended to this immediately after the inspection. The manager informed the inspector that a regular check of any covers used to protect service users from hot pipes is occurring. At the last inspection a requirement was made that a risk assessment around the use of wall-mounted heaters be undertaken before they are provided. At this inspection, risk assessments are available, indicating that the manager considers the risk is negligible, as a service user could not fall against them in the position they are placed. The manager needs to make sure that these risk assessment are regularly reviewed. It is recommended that these heaters be moved out of the reach of service users. 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 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.V286668.R01.S.doc Version 5.1 Page 16 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 30 There are sufficient numbers of staff to meet the needs of service users. Service users would benefit from further staff completing a recognised care qualification. 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” and that there “are always staff around if they are needed.” 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. An induction is provided for all new staff. The induction covers all policies and procedures, care practices and the operation of the home. The health and safety training that each member of staff needs is identified and courses are arranged. There was evidence of this in the records seen. Trepassey DS0000018949.V286668.R01.S.doc Version 5.1 Page 17 Some staff have attended a TOPPS training day during which the TOPPS induction standards were covered. It was discussed with the manager that in order to meet the National Minimum Standards for Care Homes for Older People, it needs to be demonstrated that the induction currently provided meets the National Training Organisation (NTO) workforce training targets. Trepassey DS0000018949.V286668.R01.S.doc Version 5.1 Page 18 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 and 38 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. She is a Registered General Nurse (RGN) and has an NVQ level 4 in management. There are quality assurance systems in place. There are arrangements for obtaining the views of service users and their relatives. Residents meetings are held. Questionnaires are sent out. A member of staff said that their views are taken into account in relation to the operation of the home. Staff meetings are held and supervision is given to staff. The service users were informed of this inspection and were encouraged to meet with the inspector. Trepassey DS0000018949.V286668.R01.S.doc Version 5.1 Page 19 In accordance with the Care Homes Regulations 2001 (Regulation 26) members of the committee visit the home once a month and complete a report, which is forwarded to the CSCI. Some personal allowances are held on behalf of service users. A sample of records were inspected against the allowances remaining and found to be in order. Receipts are maintained and records are signed by service users and staff. 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. Records showed that fire safety training is provided to staff and that the next date for this training is 23 March 2006. The records of fire safety training for night staff indicated that this is not occurring on a 3 monthly basis as recommended by the fire service. It is recommended by the fire service that training in the fire safety procedure take place on a 3 monthly basis. The records of emergency lighting indicated that these tests have not been occurring on a monthly basis. At this inspection, there was evidence of an up to date safety test certificate for the electrical wiring at the home. Trepassey DS0000018949.V286668.R01.S.doc Version 5.1 Page 20 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 3 X 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 X 13 3 14 3 15 X COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 X 3 X X X X X 3 3 STAFFING Standard No Score 27 3 28 2 29 X 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 2 Trepassey DS0000018949.V286668.R01.S.doc Version 5.1 Page 21 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 the service user care plans provide sufficient information on the action staff are to take to support service users and ensure their safety. The registered person must ensure that the assessments of service users ability to administer their medication, detail how this decision was reached. The registered person must ensure that the tests of the emergency lighting take place on a monthly basis. Training in the fire safety procedure must be provided to all staff at suitable intervals. Timescale for action 13/03/06 2 OP9 13 13/03/06 3 OP38 23 13/03/06 Trepassey DS0000018949.V286668.R01.S.doc Version 5.1 Page 22 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 2 3 4 5 Refer to Standard OP9 OP19 OP26 OP28 OP30 Good Practice Recommendations The medication procedure should detail the specific arrangements at the home for administering medication. It is recommended that the wall-mounted heaters be moved out of the reach of service users. 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. In order to meet the National Minimum Standards for Care Homes for Older People, it needs to be demonstrated that the induction currently provided meets the National Training Organisation (NTO) workforce training targets. Training in the fire safety procedure should be provided to night staff at 3 monthly intervals as recommended by the fire service. 6 OP38 Trepassey DS0000018949.V286668.R01.S.doc Version 5.1 Page 23 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.V286668.R01.S.doc Version 5.1 Page 24 - 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!