Inspection on 07/02/06 for Trezela

This inspection was carried out on 7th February 2006.

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

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Trezela 28/10/08

Trezela 21/11/06

Trezela 06/10/05

Trezela 01/03/05

Trezela 23/11/04

Similar services:

2 Perhaver Park

The Vicarage

St George`s

5 Seafield Road

Credence House

Radfords

Trevaylor Manor

Honeybourne House

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

CARE HOME ADULTS 18-65 Trezela 23 Egloshayle Road Wadebridge Cornwall PL27 6AD Lead Inspector Elaine Bruce Unannounced Inspection 7th February 2006 09:30 Trezela DS0000009241.V268523.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 Trezela DS0000009241.V268523.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. Trezela DS0000009241.V268523.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Trezela Address 23 Egloshayle Road Wadebridge Cornwall PL27 6AD 01208 813756 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) Mrs Janet Brewer Mrs Patricia Lang Care Home 8 Category(ies) of Learning disability (8), Mental disorder, registration, with number excluding learning disability or dementia (8) of places Trezela DS0000009241.V268523.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. Service users to include up to 8 adults with a mental illness (MD) up to the age 65 years on admission. Service users to include up to 8 adults with a learning disability (LD) up to the age of 65 years on admission. Total number of service users not to exceed 8 Date of last inspection 6th October 2005 Brief Description of the Service: Trezela House provides care for up to eight people with mental health needs. Although the certificate of registration indicates that service users with a learning disability can be accommodated this is not the case at this time. The premises are a large, two storey detached house in central Wadebridge overlooking the River Camel and playing fields. On the ground floor there is a dining room, sitting room, conservatory, two separate WC’s and a staff room/sleeping in room with an adjacent WC. On the first floor there are five single bedrooms, one shared bedroom, a bathroom and a shower room. There is no lift or stair lift. The home is not suitable for a service user with a physical disability. Suitably qualified staff provide personal care. Visitors are welcome to the home and are asked to sign in on admission. There is a very small garden/patio area at the front of the house. There is no car park with parking on street. The home is accessed from the road by a number of steep steps. Trezela DS0000009241.V268523.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection at Trezela was an unannounced inspection on the 7th February 2006. The inspection took place from 0930 to 1400. The registered manager was present during the course of the inspection and the registered provider for the first part of the inspection. A number of service users were in the home at the inspection and they were all spoken to. The service users expressed very positive comments during the course of the inspection on the standard of care that they are receiving. What the service does well: What has improved since the last inspection? What they could do better: There are no comments under this heading at this inspection. Trezela DS0000009241.V268523.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. Trezela DS0000009241.V268523.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 Trezela DS0000009241.V268523.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): 3,4 and 5 A detailed professional pre admission procedure takes place at Trelzela to establish that the home is appropriate for a new service user. There are no vacancies at this time. EVIDENCE: A pre admission assessment is carried out by the registered provider and the registered manager prior to any admission to the home. It is unusual for there to be a vacancy at the home as generally the service users stay at Trezela for a long time. There are no vacancies at this time. Prior to admission the service user visits the home for a short stay and then a longer stay to ensure that the home is right for them. Good information is included in the service user guide on the admission process. When admitted to the home each service user is provided with a contract of care that details the terms and conditions of their placement. Trezela DS0000009241.V268523.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): 6,7,8,9 and 10 The service user’s health, personal and social care needs are being met by the staff and multidisciplinary staff as required. EVIDENCE: Each service user has a care plan in place which is reviewed on a regular basis and in many cases is based on the care management assessment process. The plan is agreed and signed by the service user where appropriate. Risk assessments are included within the care plans. The home operates a key worker system: the service users are well aware of this and know who their key worker is. Each care plan is supplemented by daily records and includes detailed information of all external professionals visits/involvement (for example general practitioner, community psychiatric nurses and practice nurses). The service users can access their care plans should they so wish. All records are held confidentially. Included in the care planning documentation is information on how the service users spend their time at the home. This documentation evidences that they Trezela DS0000009241.V268523.R01.S.doc Version 5.1 Page 10 are involved in all aspects of life within the home to include cleaning duties and fire drill practices and service user meetings for example. Trezela DS0000009241.V268523.R01.S.doc Version 5.1 Page 11 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): 11,12,13,14,15 and 16 Trezela is providing it’s service users with good lifestyle opportunities that include being a part of the community, attending appropriate social care activities, having visitors and enjoying being part of a “family group”. EVIDENCE: Care plans evidence that personal development needs of each service user have been given full consideration and a diary evidences the daily routines for each service user. The routines are very client centre based and usually involve attending a number of activities in the week for example adult training centres or colleges. All the service users are very much involved in the community to include regular shopping in Wadebridge, which is a short walk from the home. The service user guide identifies the rights and responsibilities of each service user at Trezela. It is though recommended that this information is expanded to include the fact that there may be household duties ie cleaning expected of the service user if that is assessed as appropriate. Trezela DS0000009241.V268523.R01.S.doc Version 5.1 Page 12 On the day of the inspection the service users were in and out of the home to attend for example the doctor’s surgery and shopping for personal items. Trezela DS0000009241.V268523.R01.S.doc Version 5.1 Page 13 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 and 21 A keyworker system at the home allows the staff and service user to build a good relationship to ensure that all care needs are met in a way that the service user prefers. EVIDENCE: Although Trezela is a small home they operate a key worker system which appears to work very well. Care plans clearly identify all information on each service user to include for example their daily bedtime routine which is individual to each person at the home. It was noted in one care plan that the service user had been assessed as suitable to have the facility to make hot drinks in his bedroom and this had been put in place. It is also noted in the care plans that where wishes around illness and death have been discussed these have been logged, but it is also noted that there are references to these conversations being inappropriate in some cases. Trezela DS0000009241.V268523.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23 The home has a satisfactory complaints policy and procedure provided to the service user and their representative. The adult protection policy and procedure requires further improvements to clearly guide staff on procedures. EVIDENCE: The home has a detailed complaints policy and procedure that includes timescales for response as required by The National Minimum Standards. The policy and procedure is provided to the service users and their representatives. It is also displayed in the home. The home has an adult protection policy and procedure in place and has obtained the local social services procedures. It is recommended that this documentation be reviewed to ensure that the process is very clear on adult protection procedures. The home also has in place a whistle blowing policy and procedure. All the staff have undertaken adult protection training. It is noted that staff date and sign a record sheet when they have read a particular policy and procedure. Trezela DS0000009241.V268523.R01.S.doc Version 5.1 Page 15 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): The environmental standards were not assessed at this inspection. EVIDENCE: Trezela DS0000009241.V268523.R01.S.doc Version 5.1 Page 16 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): 36 Staff at the home are being regularly supervised by the registered manager. EVIDENCE: Evidence is in place that all the staff at the home are receiving regular staff supervision by the registered manager. A yearly appraisal takes place and staff have the opportunity to complete documentation prior to the appraisal. It is noted that the staff team is a very stable staff team and that the staff have a variety of roles and responsibilities at the home to include for example caring, cooking and cleaning. Trezela DS0000009241.V268523.R01.S.doc Version 5.1 Page 17 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): 37,40,41 and 43 Service users benefit from the leadership and management approach of the home. EVIDENCE: The registered manager works 25 hours a week which has been recently reviewed to allow her to concentrate fully on management hours during this time. It is a credit to her that the standards assessed are met considering her hours are part time. The large number of policies and procedures at the home are reviewed and updated by the manager. Staff evidence that they are regularly reading the policies and procedures. It is recommended that consideration be given to reviewing some of the policies and procedures in the home to generally update them. Trezela DS0000009241.V268523.R01.S.doc Version 5.1 Page 18 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 3 4 3 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 x 25 x 26 x 27 x 28 x 29 x 30 x STAFFING Standard No Score 31 x 32 x 33 x 34 x 35 x 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 3 3 3 LIFESTYLES Standard No Score 11 3 12 3 13 3 14 3 15 3 16 3 17 x PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 x x 3 3 x x 3 3 x 3 Trezela DS0000009241.V268523.R01.S.doc Version 5.1 Page 19 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. Standard Regulation Requirement Timescale for action 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. Refer to Standard YA16 Good Practice Recommendations To include more information in the service user guide on the rights and responsibilities of the service user for example a reference to cleaning duties that may take place at Trezela. To review the medication policy and procedure and bring together all good practice documentation in one document. To highlight in the adult protection policy and procedure the clear process to be followed. It is recommended that information is included in the service user guide and statement of purpose that the home is not suitable for a service user with a physical disability. It is also recommended that the information on the bedroom sizes in the home be converted into square metres. To review and update (where necessary) all the policies DS0000009241.V268523.R01.S.doc Version 5.1 Page 20 2. 3. 4. YA20 YA23 YA1 5. Trezela YA40 and procedures in the home. Trezela DS0000009241.V268523.R01.S.doc Version 5.1 Page 21 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 Trezela DS0000009241.V268523.R01.S.doc Version 5.1 Page 22 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!