Inspection on 12/01/07 for Treseder House

This inspection was carried out on 12th January 2007.

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

The inspector found no outstanding requirements from the previous inspection report, but made 2 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Treseder House 02/03/06

Treseder House 03/10/05

Treseder House 04/02/05

Treseder House 16/07/04

Treseder House 18/03/04

Similar services:

2 Perhaver Park

The Vicarage

St George`s

5 Seafield Road

Credence House

Radfords

Honeybourne House

32 Beaumont Way

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

CARE HOME ADULTS 18-65 Treseder House 111 Moresk Road Truro Cornwall TR1 1BP Lead Inspector Ian Wright Key Unannounced Inspection 12th January 2007 16:15 Treseder House DS0000009138.V326678.R02.S.doc Version 5.2 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 Treseder House DS0000009138.V326678.R02.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 Adults 18-65. 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. Treseder House DS0000009138.V326678.R02.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Treseder House Address 111 Moresk Road Truro Cornwall TR1 1BP 01872 274172 01872 274172 H5010@mencap.org.uk www.mencap.org.uk Royal Mencap Society 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) Care Home 8 Category(ies) of Learning disability (8) registration, with number of places Treseder House DS0000009138.V326678.R02.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. Registration of Miss Rachael Lee as Manager until 31st January 2006. Date of last inspection 2nd March 2006 Brief Description of the Service: Treseder is situated in a pleasant residential area close to the city of Truro. The home provides care and support for 8 adults with learning disabilities. The home is a large detached property. All service users have their own bedrooms. The home has a large lounge / dining room, kitchen, and appropriate bathroom and toilet facilities. The home has spacious grounds, which are well maintained and there is a patio with seating. The present service users can access all parts of the home and garden, however the home would not be suitable for wheelchair users. Car parking space is available at the front of the home. A copy of the inspection report is kept in the lounge. It is suggested a full copy of the report is requested from management or CSCI if required. The range of fees at the time of the inspection is £260 to £660 per week. There are additional charges e.g. for hairdressing, newspapers etc. Treseder House DS0000009138.V326678.R02.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This key inspection took place in seven and quarter hours over two days. All of the key standards were inspected. The methodology used for this inspection was: • To case track three service users. This included, where possible, meeting and discussing with the service users their experiences, and inspecting their records. • Discussing with staff their experiences working in the home. • Discussion with other service users. • Observing care practices. • Discussing care practices with management. • Inspecting records and the care environment. Other evidence gathered since the previous inspection, such as notifications received from the home (e.g. regarding any incidents which occurred), was used to help form the judgements made in the report. What the service does well: What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Treseder House DS0000009138.V326678.R02.S.doc Version 5.2 Page 6 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Treseder House DS0000009138.V326678.R02.S.doc Version 5.2 Page 7 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 2, 5 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users are issued with a copy of Mencap’s terms and conditions of residency at the time of admission. Service users subsequently receive suitable information regarding their rights and responsibilities. The pre admission assessment procedure is good, and, should enable the registered provider to ascertain they can meet the needs of service users, before admission is arranged. EVIDENCE: Copies of individualised copy of terms and conditions of residency are contained on all service user files, in line with Mencap policies and procedures. Copies of social services contracts of care were available for inspection on some service user files. The home has not had any recent admissions, but the registered provider has developed a suitable assessment policy and procedure, which will be used if there are new admissions. Treseder House DS0000009138.V326678.R02.S.doc Version 5.2 Page 8 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7, 9 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. All service users have a care plan and these are reviewed. Care plans ensure staff have suitable information to provide care. Service users are encouraged to make decisions about their lives with suitable assistance as required. The registered persons approach to handling service users monies is good so service users can be assured their finances are maintained appropriately where staff are involved in this area of their lives. The registered persons have a suitable approach to risk, so service users can be assured they will be supported to take risks as part of an independent lifestyle. EVIDENCE: There is a copy of a care plan in each service user file. Staff said care plans were accessible to them. Some service users said they were aware of their care plans and are involved in drawing them up. The care plan format is comprehensive and gives clear guidance to staff regarding service user needs. Care plans are also available in pictorial form which may be helpful to service users in helping them to understand their care plans Treseder House DS0000009138.V326678.R02.S.doc Version 5.2 Page 9 Service users and staff said service users are encouraged to make decisions regarding their lives. Suitable risk assessments are in place to assess any risks or actions to promote independence. Staff look after some service user monies, for which suitable records (including a risk assessment) are maintained. The registered provider has a satisfactory policy regarding diversity and equality. There are currently no service users from ethnic minorities, although the registered provider stated the home would be more than happy to accommodate service users from other cultures. The local population is predominantly Cornish, and from ‘White-UK’ background. Women service users have equal opportunity compared with their male counterparts. Issues regarding sexuality seem to be suitably addressed. Issues regarding disability and sexuality seem appropriately addressed. Treseder House DS0000009138.V326678.R02.S.doc Version 5.2 Page 10 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15, 16, 17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users can participate in a suitable range of activities, and are able to mix with the wider community. Service users are encouraged to maintain relationships with friends and relatives. Service users rights are respected, and service users are enabled to take a suitable amount of responsibility in their daily lives. Suitable arrangements are in place so service users enjoy a healthy and varied diet. EVIDENCE: Service users said they attend a range of day activities including attending work placements, educational courses and leisure facilities. Service users and staff said other activities are also arranged in the evenings and at weekends if they wish to go out. Service users can have an annual holiday, which they have to pay for. Last year some service users went to the USA, which they really enjoyed. The home has a ‘multi purpose vehicle’ for service user use. Treseder House DS0000009138.V326678.R02.S.doc Version 5.2 Page 11 Service users said they visit friends and relatives regularly, and they are encouraged to maintain contact via the telephone or post. Visiting arrangements are flexible, and there is suitable space for service users to receive visitors privately. Service users said they could get up and go to bed when they wish, although some may need reminding to get up on the days they attend activities. Service users said staff worked with them in a way, which respects their privacy and dignity. Service users said staff knock on bedroom doors, and their mail is not opened without their agreement. Locks are fitted to bedroom doors. Service users and staff said service users have some involvement in household tasks for example doing laundry, cleaning tasks, shopping and cooking. Service users said they enjoyed the food provided. Suitable records are maintained of meals eaten by individual service users. Special diets are catered for where this is required. Treseder House DS0000009138.V326678.R02.S.doc Version 5.2 Page 12 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19,20 Quality in this outcome area is generally good. This judgement has been made using available evidence including a visit to this service. Personal care is delivered to a good standard, and there are suitable links with medical professionals. The management of service users medicines is generally to a good standard, although some improvement is required recording medication when it is administered. EVIDENCE: Service users said they received suitable care and support from staff. Any personal care needs are documented in care plans. Staff the inspector spoke to seem clear regarding what assistance service users need. Care plans document appropriate links with GP’s, dentists, opticians, chiropodists and other professionals. Service users said they regularly saw medical professionals when required. The manager and other staff reported no problems with links with medical professionals. Medication is stored securely, and is generally dispensed appropriately. However there are some gaps in staff signing for medication when it is administered. Secondly one dosage of medication appeared to be signed for although it was not administered. Otherwise the management of the system Treseder House DS0000009138.V326678.R02.S.doc Version 5.2 Page 13 and records kept are satisfactory. Most staff have received suitable external training regarding medication, although at least one member of the relief staff (if they administer medication) needs to receive this training. Treseder House DS0000009138.V326678.R02.S.doc Version 5.2 Page 14 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22, 23 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Complaints are dealt with appropriately although the registered provider’s Complaints Procedure does not meet the national minimum standard. Mencap has a satisfactory adult protection policy, which provides a suitable framework to protect service users if they are at risk. EVIDENCE: The registered provider has developed a complaints procedure. The manager has included a summary of this in the statement of purpose / service user guide. The inspector read the organisation’s complaints policy in the ‘Operations Manual.’ This requires updating, for example the organisational policy refers to the National Care Standards Commission, which has now been superseded by the Commission for Social Care Inspection. The policy also regards complainants’ right to contact the Commission as the last stage of the procedure, rather than stating complainants can contact the Commission at any time as outlined in NMS 22.3. The registered provider has been notified regarding this in several CSCI reports for Mencap care homes in Cornwall. However, the manager has put up a poster in the kitchen regarding how service users and their representatives can contact CSCI if they have a concern or complaint. Service users said they would have confidence in staff / management if they had a concern or a complaint, and they felt the matter would be dealt with appropriately. Mencap has an appropriate adult protection policy. New staff attend the Mencap training regarding abuse (Protect Me) as part of the organisation’s foundation training. Most staff have also attended training regarding the Treseder House DS0000009138.V326678.R02.S.doc Version 5.2 Page 15 prevention of abuse run by Cornwall County Council. All staff have a Criminal Records Bureau (CRB) check and where appropriate a Protection of Vulnerable Adults (POVA) check. Staff and service users all said they had not witnessed any bad or abusive practices. Treseder House DS0000009138.V326678.R02.S.doc Version 5.2 Page 16 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Treseder provides a pleasant, homely and clean environment for service users. EVIDENCE: The building was inspected. The home offers a pleasant and homely environment for service users. Bedrooms and communal areas are of suitable size to meet the needs of service users. One of the bathrooms looks like it will soon need to be redecorated, and the lock on one of the bathroom doors needs to be fixed. Otherwise decorations and maintenance seem satisfactory. Suitable cleaning routines are in place. Treseder House DS0000009138.V326678.R02.S.doc Version 5.2 Page 17 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 33, 34, 35 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Staffing levels appear satisfactory so service users can be assured they will get suitable levels of staff support. Recruitment records are good. Suitable recruitment procedures and records help to ensure service users know they are in safe hands. Staff training is to a satisfactory standard although some improvements are necessary. Equal opportunities issues regarding recruitment and work practices seem appropriate. EVIDENCE: Rotas indicate the registered provider provides suitable staffing to meet service users needs. Service users stated they believed staffing levels to satisfactory. There is usually two staff on duty in the afternoon / evening on weekdays. At weekends there are two staff on duty during the day. This level of cover is appropriate considering the number and current needs of the service users living at Treseder. The inspector inspected staff files. The registered provider obtains suitable information regarding the recruitment of staff. This includes two references and evidence confirming the person’s identity. Staff also have a Criminal Treseder House DS0000009138.V326678.R02.S.doc Version 5.2 Page 18 Records Bureau (CRB) check and Protection of Vulnerable Adults (POVA) check (as applicable) when they commence employment. A staff induction system is in place for new staff. This involves staff working ‘shadow’ shifts with managers / more experienced staff. Mencap has a comprehensive induction and foundation course programme, which all new staff have to complete. The in house induction checklist could be improved, and the manager said she would address this issue. Mencap has a suitable training programme. This includes fire training, first aid, food hygiene, manual handling, and infection control. Staff also receive training in epilepsy, autism and dementia. There are minor gaps in training required by regulation. For example one member of staff needs to receive training regarding medication training, one member of staff needs to have training in infection control and one person training in the awareness of people with autism, otherwise basic training seems comprehensive. The registered manager said she would ensure staff receive the training where it was lacking. Mencap has a suitable approach to ensuring staff have the opportunity to obtain a National Vocational Qualification in care. According to the preinspection questionnaire currently 25 of staff have either a NVQ 2 or 3. However some of the other staff are undertaking this qualification, which when they have completed this training, will ensure over 50 of staff have at least an NVQ 2. Treseder House DS0000009138.V326678.R02.S.doc Version 5.2 Page 19 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. 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 are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39, 42 Quality in this outcome area is generally good. This judgement has been made using available evidence including a visit to this service. The home is suitably managed but an application for the manager to become registered with the commission needs to be submitted as soon as possible, so service users can be assured the person is suitably registered. There is a good quality assurance system in place to enable service users and other stakeholders to be consulted about their views. The management of health and safety issues is good so service users can be assured they live in a safe environment. EVIDENCE: Ms Lorna Brydon appears to be a suitable candidate to be registered with the Commission for Social Care Inspection. Ms Brydon previously successfully managed Waterloo House, another Mencap home in Cornwall. Ms Brydon however is due to go on maternity leave in March 2007, and a second Treseder House DS0000009138.V326678.R02.S.doc Version 5.2 Page 20 application will need to be submitted for a registered manager, to manage the home while Ms Brydon is on maternity leave. Staff and service users were positive about Ms Brydon’s management approach. MENCAP has a suitable approach to quality assurance. A survey was completed in 2006 regarding stakeholder views and these were positive. A continuous development plan has also been produced, and the area manager monitors this. The manager also arranges regular staff meetings and regular residents meetings. The registered provider has a suitable health and safety policy. Records kept of checks required by regulation are satisfactory. For example there are suitable records of the testing of fire equipment, the central heating system, portable electrical appliances and the electrical hardwire circuit. Accident records are maintained. Health and safety risk assessments are satisfactory, but could be reviewed as they were written in November 2004. A suitable fire risk assessment has also been completed. Suitable insurance cover appears to be in place. Staff also complete monthly health and safety checks. Treseder House DS0000009138.V326678.R02.S.doc Version 5.2 Page 21 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 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 X 2 3 3 X 4 X 5 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 3 34 3 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 X 2 X 3 X X 3 X Treseder House DS0000009138.V326678.R02.S.doc Version 5.2 Page 22 NO 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 YA20 Regulation 7, 12, 13, 19 9 Requirement Medication must be correctly administered, and signed for when administered. Submit a plan and applications for registered manager’s position for next 18 months Timescale for action 01/02/07 2. YA37 01/03/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Treseder House DS0000009138.V326678.R02.S.doc Version 5.2 Page 23 Commission for Social Care Inspection St Austell Office John Keay House Tregonissey Road St Austell Cornwall PL25 4AD 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 Treseder House DS0000009138.V326678.R02.S.doc Version 5.2 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. 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