Inspection on 03/10/05 for Treseder House

This inspection was carried out on 3rd October 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. 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 there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 3 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Treseder House 12/01/07

Treseder House 02/03/06

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 Unannounced Inspection 3rd October 2005 14:00 Treseder House DS0000009138.V257197.R01.S.doc Version 5.0 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.V257197.R01.S.doc Version 5.0 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.V257197.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Treseder House Address 111 Moresk Road Truro Cornwall TR1 1BP 01872 274172 01872 274172 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) Royal Mencap (Housing & Support Services) Ms Lesley Saunders Care Home 8 Category(ies) of Learning disability (8) registration, with number of places Treseder House DS0000009138.V257197.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. Registration of Miss Rachael Lee as Manager until 31st January 2006. Date of last inspection 4th February 2005 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. Treseder House DS0000009138.V257197.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection took place over four hours. The inspection was carried out on an unannounced basis. The inspector was able to speak to the majority of service users, the registered manager and the staff members on duty. The inspector examined care and service records, and inspected the building. 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. Treseder House DS0000009138.V257197.R01.S.doc Version 5.0 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.V257197.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1,2,4, 5 The registered provider has suitable procedures to assist service users to make appropriate decisions to move to the home. However service users and their representatives must be issued with appropriate information regarding the service provided (e.g. service user guide). EVIDENCE: Ms Saunders said service users (and where appropriate their representatives) have not been issued with a copy of the service user guide. This requirement is subsequently renotified. Ms Saunders said a new service user has been admitted since the last inspection. The person was able to visit before formal admission was arranged. Ms Saunders outlined an appropriate assessment procedure, which was followed when the new service user was resettled to Treseder. This included overnight stays before formal admission was arranged. Appropriate preadmission assessment information was completed by staff and stored on the service user’s file. Service users at Treseder are issued with an assured tenancy agreement on admission. Copies of this information is stored on service user files. Treseder House DS0000009138.V257197.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7, 8, 9, 10 Appropriate policies and procedures, and documentation is in place regarding care planning and risk assessment. Service users are consulted about major and day-to-day decisions. Documentation is stored confidentially. EVIDENCE: A copy of a care plan is contained in each service user’s file. These are reviewed appropriately. Service users stated they are enabled to make decisions e.g. regarding day activities and life events. Service users said there are regular residents meetings, which enable them to make comments about life in the home. Minutes are kept of these meetings. Service users are involved in other aspects of life in the home; for example meal preparation and cleaning. Service users said they are encouraged to take appropriate risks e.g. go out on their own. Suitable risk assessments are maintained on each service user’s file and these are reviewed appropriately. All information is stored confidentially. Discussions regarding care take place in private and not in front of service users. Treseder House DS0000009138.V257197.R01.S.doc Version 5.0 Page 9 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 15, 16 Suitable opportunities are available for service users to have work experience and educational opportunities. Contact with family and friends is encouraged. Service users rights are respected, and they have opportunity to take responsibility for aspects of their lives. EVIDENCE: Service users said they are given suitable opportunities to participate in work experience and educational opportunities. For example service users work in various placements such as cafes, horticultural centres, shops etc. Service users also attend college courses and attend the local day centre. Service users said they have appropriate opportunities to maintain links with their families and friends. Visiting arrangements are appropriate. Daily routines are flexible and tailored according to individual needs. Independence and choices are encouraged. Service users stated they felt very much at home and are supported appropriately by staff. If any restrictions are placed on service users, Ms Saunders said these are documented in a risk assessment. Treseder House DS0000009138.V257197.R01.S.doc Version 5.0 Page 10 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 Service users receive personal care in a manner which respects their respect and dignity. There are appropriate links with relevant professionals so service users physical and emotional health needs are met. EVIDENCE: Service users said they were happy with how personal care and support is provided. The inspector observed staff working with service users in an appropriate manner. Care interventions are appropriately documented in care plans. No service users have pressure sores. There have been three admissions to the accident and emergency department. These incidents appear to have been unavoidable and handled appropriately. Accident and incident records are appropriately maintained. Staff stated links with general practitioners, and other professionals such as social workers and community nurses are satisfactory. Suitable records are maintained regarding hospital and other health care appointments. Treseder House DS0000009138.V257197.R01.S.doc Version 5.0 Page 11 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 The registered provider has a generally suitable complaints policy although this requires amendment to provide service users with information how to contact the Commission for Social Care Inspection. The complaints procedure is effectively implemented. EVIDENCE: A generally suitable complaints policy was inspected. However this still requires some amendment i.e. the following information should be included in the policy: • To include information (address, phone number etc.) how service users can contact the Commission for Social Care Inspection (CSCI). • To inform complainants they can contact the CSCI at any time as outlined in NMS 22.3. This information must be available for inspection and issued to service users and where appropriate their representatives e.g. as part of the service user guide. The registered manager said the complaints procedure is regularly discussed in residents meetings so service users know how they can make a complaint. Service users have a copy of the complaints procedure in written form and on audiotape. Treseder House DS0000009138.V257197.R01.S.doc Version 5.0 Page 12 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24-30 Treseder is a suitable environment for service users accommodated there. EVIDENCE: The building was inspected. The home offers a pleasant and homely environment for service users. Decorations, furnishings and fittings are to a good standard. Bedrooms and communal areas are of suitable size and meet the needs of service users. Service user bedrooms are pleasantly decorated according to individual tastes. Furnishings are appropriate. Toilet and bathroom facilities are appropriate. Service users do not have any physical frailty or disability, therefore aids and adaptations are minimal. The home was clean and hygienic on the day of the inspection. Treseder House DS0000009138.V257197.R01.S.doc Version 5.0 Page 13 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 36 Staff employed are clear about their roles and responsibilities. Staffing levels are satisfactory to meet the needs of service users. Staff receive appropriate supervision from management. EVIDENCE: All staff are issued with a job description when they commence employment. Staff appear to have a clear understanding of their roles. The minimum staffing is currently one person on duty at any time. The registered manager said other staff have been recruited following a period when there has been several vacancies. This should ensure additional staff are available to assist service users in the home and in the community. The registered manager said staff receive formal one to one supervision on a monthly basis. Appropriate records regarding staff supervision are kept on staff files. A deputy manager is also employed to assist with day-to-day supervision of staff. Treseder House DS0000009138.V257197.R01.S.doc Version 5.0 Page 14 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 38, 40, 42 The registered manager ensures the effective management of the home, and suitable systems are in place to evidence this. EVIDENCE: Treseder appears to be well managed, and staff and service users appear to receive appropriate support. Ms Saunders-the registered manager has recently returned to manage the home after a period of time on secondment. The registered manager has suitable experience, knowledge and qualifications to manage the home. For example the registered manager has completed the registered manager’s award. Staff on duty stated they received appropriate support, and have the opportunity to contribute to how the home is managed. Staff receive regular supervision, and staff meetings occur regularly. Regular residents meetings are also held. Mencap has a suitable range of policies and procedures, and suitable records are maintained. Treseder House DS0000009138.V257197.R01.S.doc Version 5.0 Page 15 Mencap has a suitable approach to preventing any health and safety risks. Suitable procedures are in place to test fire prevention, gas and electrical equipment, and there is satisfactory evidence that testing is completed. For example portable appliance testing and gas appliances were both tested in June 2005. Suitable health and safety risk assessments were completed in November 2004. Testing of fire prevention equipment was appropriately documented. Appropriate checks appear to be in place regarding the prevention of Legionella. Treseder House DS0000009138.V257197.R01.S.doc Version 5.0 Page 16 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score 2 3 x 3 3 Standard No 22 23 Score 2 X ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 3 3 3 3 3 Standard No 24 25 26 27 28 29 30 STAFFING Score 3 3 3 3 3 3 3 LIFESTYLES Standard No Score 11 x 12 3 13 x 14 x 15 3 16 3 17 Standard No 31 32 33 34 35 36 Score 3 x 3 x x 3 CONDUCT AND MANAGEMENT OF THE HOME x PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Treseder House Score 3 3 x x Standard No 37 38 39 40 41 42 43 Score 3 3 x 3 x 3 x DS0000009138.V257197.R01.S.doc Version 5.0 Page 17 YES 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 YA1 Regulation 4,5,6 Requirement The registered manager is required to issue the service user guide to service users (and where appropriate their representatives) Timescale of 1.4.05 not met 2nd Notification 2 YA21 12 The registered provider is required to expand the home’s death and dying policy to cover the care of service users who are ageing or ill, with reference to the national minimum standard. 2nd Notification The registered provider must amend the homes complaints procedure to: • Include information (address, phone number etc.) how service users can contact the Commission for Social Care Inspection (CSCI) • State that complainants can contact the CSCI at any time as outlined in NMS 22.3 This information must be available for inspection and issued to service users and DS0000009138.V257197.R01.S.doc Timescale for action 01/12/05 01/12/05 3 YA22 22 01/12/05 Treseder House Version 5.0 Page 18 where appropriate their representatives. 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.V257197.R01.S.doc Version 5.0 Page 19 Commission for Social Care Inspection St Austell Office John Keay House Tregonissey Road St Austell Cornwall PL25 4AD 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 Treseder House DS0000009138.V257197.R01.S.doc Version 5.0 Page 20 - 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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