CARE HOME ADULTS 18-65
Trevayler Residential Care Home 309 Burton Road Derby Derbyshire DE23 6AG Lead Inspector
Steve Smith Unannounced Inspection 13th September 2005 09:30 Trevayler Residential Care Home DS0000002003.V254299.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 Trevayler Residential Care Home DS0000002003.V254299.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. Trevayler Residential Care Home DS0000002003.V254299.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION
Name of service Trevayler Residential Care Home Address 309 Burton Road Derby Derbyshire DE23 6AG 01332 348080 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) 2 Care Vacant Care Home 23 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (23) of places Trevayler Residential Care Home DS0000002003.V254299.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION
Conditions of registration: Date of last inspection 16th February 2005 Brief Description of the Service: Trevayler Care Home provides care for 23 people recovering from mental health problems. The level of care available is dependent on Residents difficulties and is provided on three levels: that available for dependent Residents, semi-independent Residents and independent Residents. Independent Residents live in a separate property next door to the main house, and is fully self-contained. All Residents have a room of their own. There are two lounges in the main house, with one being much larger that the other. One lounge is available to those Service Users who wish to smoke. There is also one dining room and one kitchen area. The Home operates a rota for Residents to assist staff in preparing meals. Residents also take turns to assist with cleaning and maintaining the Home, again on a rota basis. The ‘work’ carried out by Residents is part of the rehabilitation process operated by the Home. Trevayler Residential Care Home DS0000002003.V254299.R01.S.doc Version 5.0 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This unannounced inspection took place in just over 6 hours. Discussion was held with the Acting Manager and two Residents. Some of the Home’s records were examined, and the public areas and some of the bedrooms of the Home were looked at. What the service does well:
All new Residents placed at the Home were provided with an assessment of need completed by Social Services Depts or Health Authorities. The Acting Manager ensured that someone from the Home assessed all new Residents before each placement was confirmed. Good records were maintained on each Resident staying at the Home, and these were reviewed at six monthly intervals. Residents interviewed were extremely pleased with the assistance provided by staff of the Home. They said that they could help with providing educational courses, obtaining jobs and the management of money. They also could be supportive of those Residents with a tendency to self-harm themselves. Residents also said that staff helped Residents of the Home find voluntary work or to take part in numerous courses provided by local educational facilities. They also assisted in resolving benefit problems. Residents also said that staff were happy to accompany them to local shops and leisure facilities. Residents could visit their own homes, if this were felt to be appropriate, and relatives could visit and on occasions stay the night at the Home. Residents were provided with keys to their bedrooms and to the main front door of the Home. They were also aware of the rules on smoking, alcohol and drug taking. Residents were expected to assist in the cleaning of the Home and to help plan and provide meals for all fellow Residents. Residents were expected to attend the morning meetings; held at 10.00 am each morning. However, except when fire checks were being undertaken staff did not enter Residents bedrooms without invitation from the Resident. Keyworkers, allocated to each Resident, could be changed if the Resident did not get on with the member of staff allocated. Staff monitored health care with the assistance of local Doctors. The Manager operated a satisfactory complaints procedure, in which both written and verbally complaints would be addressed. The Home was found to operate within the Derby Adult Protection procedure to ensure that staff or others did not abuse Residents. Trevayler Residential Care Home DS0000002003.V254299.R01.S.doc Version 5.0 Page 6 The premises were well maintained and Residents were encouraged to keep their bedrooms clean and tidy. Good records were maintained for the selection and appointment of all staff in the Home. Appropriate training was also provided for staff throughout each year. The Registered Providers and Manager provided effective quality assurance measures for the operation of the Home. What has improved since the last inspection? What they could do better:
The Acting Manager was encouraged to maintain a confidential section within each Resident’s file. She was also encouraged to review and sign each Residents record on at least a monthly basis. The Registered Providers and Manager need to ensure that adequate staffing is always provided in the Home. The Acting Manager needs to have completed her NVQ level 4 in Management and Care by 31 December 2006. When providing quality assurance systems in the Home the Registered Providers and Acting Manager need to ensure that the views of relatives, friends, GPs and CPNs are obtained, and recorded, on how the Home is achieving goals for its Residents. Please contact the provider for advice of actions taken in response to this
Trevayler Residential Care Home DS0000002003.V254299.R01.S.doc Version 5.0 Page 7 inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Trevayler Residential Care Home DS0000002003.V254299.R01.S.doc Version 5.0 Page 8 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 Trevayler Residential Care Home DS0000002003.V254299.R01.S.doc Version 5.0 Page 9 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): Standard 2. New Residents moving to the Home were always provided with an assessment of need, to ensure all needs could be met by the Home. EVIDENCE: The Home received referrals of new Residents via the Care Management teams of Social Services Depts or Health Authorities, mainly from the local area. The Acting Manager said that placing authorities always provide adequate information when Residents were placed in the Home. However, no selffunding Service Users were currently placed in the Home, but should this be necessary, she would conduct her own assessments of self-funding potential Residents. All Residents referred through Social Services Depts or Health Authorities were assessed by the Acting Manager prior to the beginning of their placement. Trevayler Residential Care Home DS0000002003.V254299.R01.S.doc Version 5.0 Page 10 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): Standards 6, 7 & 9. The Acting Manager and staff enabled Residents to take appropriate risks, ensuring that the risks were appropriate to their abilities. EVIDENCE: To help assess Standard 6, the Resident’s Plan of Care, the records of 2 Residents were examined using case tracking methodology. The files showed that the Home maintains good records for all Residents, including well laid out risk assessments. Each file had been drawn up with the involvement of each Resident, and were written in a style appropriate to the Resident. Residents were seen to sign the record at regular intervals. Each plan of care was reviewed at six monthly intervals and updated as necessary. However, the Acting Manager did not sign each file at regular intervals, to
show that she had reviewed the contents of the file, and the files looked at did not contain a confidential section. Trevayler Residential Care Home DS0000002003.V254299.R01.S.doc Version 5.0 Page 11 Two Residents were spoken to about their plans of care and life in the Home. Both said that staff were very helpful and easy to talk to, and that in the main they would always discuss their plan for each day with them. Residents were aware that staff could help provide educational courses, help to obtain jobs, and assistance in meeting people. They said that staff helped the Residents to manage their money. They also spoke highly of staff action with Residents who could/did self harm themselves. Staff helped Residents manage their personal allowance. Records of this were examined, and were found to be in good order. The Acting Manager told the Inspector that staff informed the Residents of risk assessment strategies used in the Home prior to their moving in. She also said that staff would respond promptly to any unexplained absence of each Resident from the Home. Trevayler Residential Care Home DS0000002003.V254299.R01.S.doc Version 5.0 Page 12 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): Standard 12, 13, 15, 16 & 17. Links with the local community were good and supported and enriched Residents social and educational opportunities. EVIDENCE: The Residents spoken to said that staff had helped some Residents in the Home to find voluntary work, or to take any of a number of courses available. Any benefit problems the Residents experienced were well supported by staff, who were happy to attend Benefit Agency appointments and to give appropriate advice. Residents said that staff regularly took them out to community facilities such as shops and leisure centres. They also assisted in providing days out, such as to Blackpool, or to more local events, when staff would obtain taxis for Residents. Trevayler Residential Care Home DS0000002003.V254299.R01.S.doc Version 5.0 Page 13 One Resident said that staff supported Residents to vote in national and local elections, describing evening events when Residents discussed voting options. Staff also assisted in providing transport to polling booths. Residents spoken to were able to say that some Residents were supported by staff to go home at weekends, if it was felt appropriate for them to do so. Visiting relatives were also able to stay overnight, after discussion with the Resident. Residents said that the system in operation in the Home was for Residents to move from dependent living, to semi-independent living, to independent living. Staff only entered bedrooms with the invitation of the Resident, unless ‘fire checks’ where being undertaken. Each Resident had a key to their bedroom and to the main door of the Home. Residents spoken to were very aware of the rules in the Home on smoking, alcohol and drugs taking. Residents undertook cooking on a rota basis, assisted by staff. Residents chose the menus for each week, which involved a choice of two main dishes each day. Special diets could be arranged if necessary. Trevayler Residential Care Home DS0000002003.V254299.R01.S.doc Version 5.0 Page 14 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): Standards 18, 19 & 20. Residents’ personal needs were well met, ensuring that their privacy, dignity and independence were maintained. The system of administering medication was good, and arrangements were in place to ensure Residents medication needs were met. EVIDENCE: Residents said that staff allowed them to maintain their own privacy, but occasionally would check on Residents to ensure their safety. They also said that they could get up at any time in the morning, but had to be available by 10.00 am. Baths and showers could be taken whenever they wished. Residents’ key workers could be changed if the Resident and the member of staff did not get along together. Residents spoken to were able to say whom their key workers were. The Acting Manager said that Residents health care needs were addressed within the Home, with the assistance of the local Doctors and the local hospital, if necessary. Trevayler Residential Care Home DS0000002003.V254299.R01.S.doc Version 5.0 Page 15 The medication procedures followed within the Home were examined, and a good system was found to be in operation. Trevayler Residential Care Home DS0000002003.V254299.R01.S.doc Version 5.0 Page 16 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): Standards 22 & 23. Complaints made to the Registered Providers were appropriately addressed to meet Service Users needs. The protection policies and procedures provided by the Home meant that Service Users were well protected. EVIDENCE: The Residents spoken to were aware of the complaints procedure; one of them pointing out that it was listed in the Residents Guide. The Acting Manager was able to confirm that she addressed all complaints, whether written or verbally passed on. She also said that Residents were regularly reminded of the complaints procedure in the community meetings, which were held at least weekly. The Acting Manager said that the Home had details of the Derby Adult Protection procedure and its own procedure to ensure that Residents were protected from abuse. The Acting Manager also had a Whistle Blowing policy and had the relevant information on the Public Interest Disclosure Act of 1998, and on the Dept of Health guidance ‘No Secrets’. She said that all allegations and incidents of abuse would be followed up and action would, if necessary, be taken. She also agreed to refer any incidents of abuse by her staff to the Protection of Vulnerable Adults register, but to date this had not been necessary. The policies and practices of the Home ensured that physical or verbal aggression by Residents was understood by staff and that staff would only intervene as a last resort to protect the Resident, other Residents or staff. The Home had satisfactory policies and procedures to deal with Service Users money and financial affairs. The Acting Manager said that the Home had a Trevayler Residential Care Home DS0000002003.V254299.R01.S.doc Version 5.0 Page 17 policy to inform staff that they could not benefit, in any way, from Service Users wills. Trevayler Residential Care Home DS0000002003.V254299.R01.S.doc Version 5.0 Page 18 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): Standards 24, 26 & 30. The Home was well maintained throughout, providing all Residents with a safe, comfortable environment in which to live. EVIDENCE: The premises of the Home were judged to be suitable for caring for Residents. They were found to be safe and well maintained. Improvements had been made to aspects of the Home, which was positive to observe. On this visit only the bedrooms of two Residents were examined, and these where found to be satisfactory. Bedrooms did not always contain the correct amount of furniture required by the Regulations. However, the Acting Manager said that this had been discussed with Residents, on an individual basis, and that after deciding on the quantity of furniture they wanted within their bedrooms, Residents had signed to say that this was satisfactory. Residents said that they were encouraged by staff to keep their bedrooms clean and tidy. An inspection of the Home confirmed that the laundry floor was impermeable and that the laundry walls were readily cleanable. The Trevayler Residential Care Home DS0000002003.V254299.R01.S.doc Version 5.0 Page 19 Assistant Manager was able to confirm that foul laundry was washed at a temperature of at least 650 C for at least 10 minutes. Trevayler Residential Care Home DS0000002003.V254299.R01.S.doc Version 5.0 Page 20 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): Standards 33, 34 & 35. Adequate staffing was not provided consistently within the Home, when compared with the Residential Forum, to meet the needs of Service Users. EVIDENCE: Staffing provided in the Home was compared with the details provided by the Residential Forum. This showed that during the four weeks beginning 1 August 2005 the Home was providing 384.5 hours, 386.5 hours, 398 hours and 342 hours of care for Residents respectively. The Residential Forum suggested that for a home providing for 23 Residents, at the Low Dependency level, that 395 hours of care time would be required to meet their needs. When the ‘Low Dependency’ level was compared with the staffing times provided it could be seen that staffing fell short of the required hours by between 8.5 hours and 53 hours each week. On only one occasion was staffing seen to be above the ‘Low Dependency’ level. These figures were calculated without the Acting Manager’s working time included, as recommended by the Residential Forum. The records of two staff employed since April 2002 were examined to see whether the Registered Providers had obtained all relevant information about them. It was found that all necessary information had been obtained for each
Trevayler Residential Care Home DS0000002003.V254299.R01.S.doc Version 5.0 Page 21 member of staff. The Acting Manager said that she provide all staff with copies of the General Social Care Council codes of practices when they started work in the Home. The Assistant Manager and Registered Providers ensured that all staff received appropriate training, which included induction, foundation and additional training appropriate to the aims of the Home. Trevayler Residential Care Home DS0000002003.V254299.R01.S.doc Version 5.0 Page 22 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): Standards 37 & 39. Satisfactory management systems for the Home were provided, thus Service Users benefited from a well run and managed establishment. EVIDENCE: The Acting Manager was currently undertaking study to secure her qualification at NVQ Level 4 in Management and Care. She anticipates that the course should be completed approximately by December 2006. The Acting Manager ensured that effective quality assurance measures were used within the Home. An annual development plan was provided together with surveys of Residents opinions on the operation of the Home. The views of family and friends of Residents, and of professionals, such as GPs and CPNs, were obtained during the formal 6 monthly reviews of care. However, the Acting Manager said these views are not recorded. Trevayler Residential Care Home DS0000002003.V254299.R01.S.doc Version 5.0 Page 23 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 X 3 X X X Standard No 22 23 Score 3 3 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 3 3 X 3 X Standard No 24 25 26 27 28 29 30
STAFFING Score 3 X 3 X X X 3 LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 X 16 X 17 Standard No 31 32 33 34 35 36 Score X X 2 3 3 X CONDUCT AND MANAGEMENT OF THE HOME X PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21
Trevayler Residential Care Home Score 3 3 3 X Standard No 37 38 39 40 41 42 43 Score 3 X 2 X X X X DS0000002003.V254299.R01.S.doc Version 5.0 Page 24 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 YA39 Regulation 24 Requirement The Registered Providers and Acting Manager must ensure that the views of relatives, friends, GPs and CPNs are obtained, and recorded, on how the Home is achieving goals for Residents. Timescale for action 08/11/05 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 Refer to Standard YA6 YA6 YA33 Good Practice Recommendations All Residents files should contain a confidential section, as necessary. The Acting Manager should regularly review and sign each Service User’s records. This should occur at least monthly, and could be done in a red or green pen. The Registered Providers should provide day care and night care staffing at least in line with that suggested by the Residential Forum. This figure should not include the Acting Managers working time. The Acting Manager needs to be become qualified to NVQ level 4 in Management and Care by 31 December 2006. 4 YA37 Trevayler Residential Care Home DS0000002003.V254299.R01.S.doc Version 5.0 Page 25 Commission for Social Care Inspection Derbyshire Area Office Cardinal Square Nottingham Road Derby DE1 3QT National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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