CARE HOME ADULTS 18-65
Trevayler Residential Care Home 309 Burton Road Derby Derbyshire DE23 6AG Lead Inspector
Steve Smith Unannounced Inspection 3rd January 2006 10:20 Trevayler Residential Care Home DS0000002003.V278120.R01.S.doc Version 5.1 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.V278120.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 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.V278120.R01.S.doc Version 5.1 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.V278120.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION
Conditions of registration: Date of last inspection 12th September 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 Residents 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.V278120.R01.S.doc Version 5.1 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This unannounced inspection took place in just over 3 hours. Discussion was held with the Acting Manager. Some of the Home’s records were examined, and some of the public areas of the Home were looked at. What the service does well: What has improved since the last inspection? What they could do better:
The Acting Manager was reminded that she needed to have completed her training at NVQ level 4 in Management and Care by the end of December 2006. The Registered Providers and Acting Manager were reminded that staffing should not drop below that recommended by the Residential Forum. The staff should also be provided with training in Infection Control. Trevayler Residential Care Home DS0000002003.V278120.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. Trevayler Residential Care Home DS0000002003.V278120.R01.S.doc Version 5.1 Page 7 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.V278120.R01.S.doc Version 5.1 Page 8 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): These Standards were not examined during this inspection of the Home. EVIDENCE: Trevayler Residential Care Home DS0000002003.V278120.R01.S.doc Version 5.1 Page 9 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): These Standards were not examined during this inspection of the Home. EVIDENCE: Trevayler Residential Care Home DS0000002003.V278120.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): These Standards were not examined during this inspection of the Home. EVIDENCE: Trevayler Residential Care Home DS0000002003.V278120.R01.S.doc Version 5.1 Page 11 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): These Standards were not examined during this inspection of the Home. EVIDENCE: Trevayler Residential Care Home DS0000002003.V278120.R01.S.doc Version 5.1 Page 12 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): These Standards were not examined during this inspection of the Home. EVIDENCE: Trevayler Residential Care Home DS0000002003.V278120.R01.S.doc Version 5.1 Page 13 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): These Standards were not examined during this inspection of the Home. EVIDENCE: Trevayler Residential Care Home DS0000002003.V278120.R01.S.doc Version 5.1 Page 14 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): Standard 33. Adequate staffing was not provided consistently within the Home, when compared with the Residential Forum, to meet the needs of Residents. EVIDENCE: Staffing provided in the Home was compared with the details provided by the Residential Forum. This showed that during the four weeks beginning 26 December 2005 to 16 January 2006 the Home was providing 330 hours, 341 hours, 386.5 hours and 382.5 hours of care for Residents each week respectively. The Residential Forum suggested that for a home providing for 23 Residents, at the Low Dependency level, that 372 hours of care time would be the minimum required to meet their needs. When the ‘Low Dependency’ level figure was compared with the staffing times provided it could be seen that staffing fell short of the required hours by between 31 hours and 42 hours, across the Christmas and New Year period. However, for the projected two week period that followed the staff time was over that recommended by the Residential Forum by between 10.5 hours and 14.5 hours each week. These figures were calculated without the Acting Manager’s working time included, as recommended by the Residential Forum Trevayler Residential Care Home DS0000002003.V278120.R01.S.doc Version 5.1 Page 15 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 and 42. Satisfactory management systems for the Home were provided, thus Service Users benefited from a well run and managed establishment. However, the Acting Manager needed to complete her training at NVQ level 4 in Management and Care. EVIDENCE: During this inspection the Acting Manager was interviewed to determine her fitness to be become the Manager of the Home. She completed the interview very well, and subsequently has been confirmed as the Manager of the Home. However, as the Acting Manager, she ensured that the Home had written aims and objectives, which the Home achieved, that the policies and procedures of the Home were implemented and that the Home‘s budget was properly managed. She also ensured that all Residents had a written contract or statement of terms and conditions of residency. Trevayler Residential Care Home DS0000002003.V278120.R01.S.doc Version 5.1 Page 16 During the previous 12 months the Acting Manager had undertaken much of the training undertaken by staff of the Home, together with a course on the supervision of staff and her NVQ level 4 in Management and Care, which is ongoing. Staff of the Home do not have to physically assist Residents staying in the Home. However, they had undertaken courses in the safe moving of objects, via a Moving and Handling course. All staff had also undertaken training in Fire Safety and in Food Hygiene. All staff had also obtained qualifications in First Aid and as First Aiders. However, the Acting Manager said that none of the staff had qualifications in Infection Control. The Acting Manager said that all Residents had been risk assessed to determine their vulnerability and measures had been put in place to provide protection where necessary. The Home had complied with all necessary legislation, such as Health and Safety at Work Act 1974, and the Manual Handling legislation of 1992. Risk assessments had been carried out for all safe working practices in the Home, including a written statement of the policy, organisation and arrangements for maintaining safe working practices. Trevayler Residential Care Home DS0000002003.V278120.R01.S.doc Version 5.1 Page 17 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 X 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 X 23 X ENVIRONMENT Standard No Score 24 X 25 X 26 X 27 X 28 X 29 X 30 X STAFFING Standard No Score 31 X 32 X 33 2 34 X 35 X 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score X X X X X LIFESTYLES Standard No Score 11 X 12 X 13 X 14 X 15 X 16 X 17 X PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score X X X X 2 X X X X 3 X Trevayler Residential Care Home DS0000002003.V278120.R01.S.doc Version 5.1 Page 18 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. Standard Regulation Requirement The Acting Manager must become qualified to NVQ level 4 in Management and Care by 31 December 2006. Timescale for action 31/12/06 1. YA37 24 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 YA33 YA42 Good Practice Recommendations 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. All care staff should receive training in Infection Control. 1 2 Trevayler Residential Care Home DS0000002003.V278120.R01.S.doc Version 5.1 Page 19 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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