Inspection on 01/12/06 for Trinity Court

This inspection was carried out on 1st December 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 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

Trinity Court 03/03/10

Trinity Court 30/11/09

Trinity Court 11/03/09

Trinity Court 25/10/05

Trinity Court 17/11/04

Trinity Court 01/07/04

Trinity Court 27/01/04

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

CARE HOME ADULTS 18-65 Trinity Court Station Road Staplehurst Kent TN12 0PZ Lead Inspector Mrs Ann Block Key Unannounced Inspection 1st December 2006 09:05 Trinity Court DS0000049502.V321039.R01.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 Trinity Court DS0000049502.V321039.R01.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. Trinity Court DS0000049502.V321039.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Trinity Court Address Station Road Staplehurst Kent TN12 0PZ 01580 895288 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) kingston@consensushealthcare.org Consensus Support Services Limited Mrs Lisa Jane Colaluca Care Home 10 Category(ies) of Learning disability (10) registration, with number of places Trinity Court DS0000049502.V321039.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 25th October 2005 Brief Description of the Service: Trinity Court caters for 10 adults with a learning disability who may also have behaviour that challenges. Current fees range from £1243.21 to £1831.94 per week. Clients pay separately for hairdressing, toiletries and horse riding. There is a staff team consisting of support workers, seniors, an assistant manager, deputy manager and manager. Trinity Court is a detached three storey property on the outskirts of Staplehurst. The lower two floors are available for use by service users. The home provides for 10 single en-suite bedrooms and a range of day spaces. There is a large secure garden to the rear of the property. There is easy access to local shops, medical centre, post office and pubs. Car parking space is available to the front of the property. Buses to local towns stop close by. A main line station is ¼ mile away. Trinity Court DS0000049502.V321039.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced site visit was carried out between 9.05 am and 4.15 pm on Friday 1st December 2006. The commission was represented by regulatory inspector Ann Block. Some clients, the manager and assistant manager, senior support workers and support workers on duty chatted to the inspector about life in the home. The home has 10 clients, two returned from a week’s holiday in the New Forest during the site visit. The inspector has been lead inspector since the service was first registered. As the inspector is familiar with the service some judgements have been made from previous knowledge, confirmed by observation of the client group, talking with clients and staff and looking at supporting documentation. Due to the nature of the service, it is difficult to reliably incorporate client’s accurate reflections of the service in the report. Feedback was provided to the manager during the site visit. As part of the inspection process comment cards were sent to the service to forward to families, professionals and visitors. At the time of writing this report, two had been returned to the commission. What the service does well: Clients have a good quality of life where they have plenty to occupy them and staff who are kind, competent and motivated to support them. Clients live in a group of people with whom they are well matched through good admission procedures. Clients’ safety is maintained through staff presence and a safe environment. Clients are encouraged to be healthy and receive medical treatment when necessary. Staff are aware that clients have the right to have full and interesting lives where they can make real choices. Staff look for opportunities for clients to enjoy physical exercise, social activities and develop daily living skills. Staff get to know the clients so that they are aware when a client is happy, anxious or angry. Staff feel they are well supported by each other and senior staff. Trinity Court DS0000049502.V321039.R01.S.doc Version 5.2 Page 6 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. Trinity Court DS0000049502.V321039.R01.S.doc Version 5.2 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 Trinity Court DS0000049502.V321039.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 1,2,3 & 5 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Prospective clients and placing agencies benefit from good systems to ensure needs can be met at Trinity Court at the time of admission. EVIDENCE: Systems are in place for families and placing agencies to have written and practical information about the service Trinity Court can provide. The statement of purpose and service users guide are updated as needed. The service users guide is available in pictorial format. There have been no new admissions during the last year. At the time of the site visit there was one vacancy, a client had moved on following achievements made whilst at Trinity Court. Through the assessment procedure the manager takes great care to ensure any prospective client would benefit from living at the home, would integrate with the existing client group and that staff have the skills necessary to work with the client. As there have been no actual admissions, other aspects of the admission process were not explored. Trinity Court DS0000049502.V321039.R01.S.doc Version 5.2 Page 9 The staff team has a range of skills and expertise in working with adults with a learning disability and challenging behaviour. Clients and placing agencies have confidence in the staff team and have made comment that clients have progressed whilst living in the home. A written contract is provided. There remains no easy to understand contract for use with people with learning disabilities. Trinity Court does not offer respite care. Trinity Court DS0000049502.V321039.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7,8,9 & 10 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Clients, their needs and wishes, are the focal point of the service but would be better evidenced by clear recording of how this will be provided. EVIDENCE: Care plans have been restructured to make them more accessible to staff and more user friendly. Separate files are held - the main care file, a health file and archived information. Staff said that they thought the new system was better and much easier to use. Clients know they have their own files but do not choose to take part in recording information. The keyworker is the person who holds responsibility for gathering information and working closely with the client to update information and prepare for reviews. Trinity Court DS0000049502.V321039.R01.S.doc Version 5.2 Page 11 There is still use of terminology which could be simplified, some duplication of information and a need to be more specific about ‘how’ an intervention will be provided. Risk assessments, whilst also having improved, still have deficits in specific action to take to reduce the risk. Although written information still requires work, in practice staff knowledge and understanding of clients was excellent. Staff on duty all showed commitment to providing as good a life as possible for clients and those spoken with knew a considerable amount about their key clients. Staff are aware they should offer a united approach to behaviours which might challenge and that a good risk assessment process is fundamental to this. Management of risk regarding challenging behaviour ensures clients are treated in a non-confrontational and dignified manner possible to maintain safety for the client and others. Where staff do not act in this manner prompt action is taken. Staff recognise that the service is for clients benefit. Everything possible is done to ensure that clients’ wishes are identified. Where it is difficult to identify choice verbally, staff are skilled in using a range of communication systems to assess wishes. A member of staff spoke of a proposal for staff to train in the use of signing as they felt a client would benefit from this. Family and professionals are involved where appropriate The majority of clients have limited understanding of money and have their finances dealt with mainly by the organisation as appointee with staff support. Staff are diligent in checking money held is correct. Monies and receipts checked were properly accounted for. As the home contracts to provide clients with their meals, clients’ meals out are paid for through petty cash. With a minor exception, confidentiality is well maintained with clients affairs recognised as being private. Information is only shared on a need to know basis. Trinity Court DS0000049502.V321039.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 11,12,13,14,15,16 & 17 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Clients live a full and varied life which is recognised as their right EVIDENCE: Staff are expected to watch for any opportunity to promote clients personal development for example increasing confidence, being able to make choices, taking part in household routines, learning new skills and improving social behaviours. Clients have scope to enjoy a range of activities. Staff are aware that clients choice may change and are responsive to that. During the site visit, a client was going to college. Other day activities include opportunities such as swimming, horse riding, trampolining, shopping trips, visits to the cinema and Trinity Court DS0000049502.V321039.R01.S.doc Version 5.2 Page 13 theatre, meals out and trips to the pub. Clients are encouraged to choose their activities. Staff believe that opportunities should be provided for clients which follow as normal a lifestyle as possible. The service is good at providing individual opportunities rather than simply choosing things that everyone should attend. Each client has a weekly schedule which is flexible. The majority of clients have been on holiday. During the site visit two clients returned from a week’s holiday in the New Forest which staff accompanying them said had gone really well. A client said she had been to Camber Sands and had been shopping for clothes which she liked. Additional days out have been provided for those who definitely didnt want a holiday away from the house. Client have a people carrier they use, supplemented as necessary by staff cars which are insured for business use. Clients are encouraged to use local facilities wherever possible and to feel part of village life. Family relationships are encouraged. One client spoke of visits from his mother, another client has alternate weekends at the family home. Staff provide transport and escorts if necessary for family visits, as they are aware that family contact is very important to some clients. A recent achievement was to promote family relationships following a long term breakdown of communication. Staff said wherever possible they liaise with family about the client, but the needs and wishes of the client comes first. Families may be involved in reviews if that is what the client desires. There is a good balance between clients’ rights and responsibilities. Clients are reminded about their responsibilities in a gentle and non-confrontational way. Clients are reminded that other clients deserve respect. Staff also promote the rights of individual clients and of people with disabilities in the wider setting. Clients may have a key to their room within a risk assessment framework. Clients are reminded they must not enter another’s room without permission. For clients’ safety, access to unsecured area such as the front of the house is restricted. Clients have a large secure rear garden. External doors to the garden are monitored so staff are aware who has gone outside. Staff are allocated duties at the start of each shift which will include any one to one staffing needed. It was pleasing to see how staff on one to one ensured they engaged with the client and if necessary provided unobtrusive monitoring. Staff clearly enjoy the company of clients and ensure they are included in general conversation. Flexibility is offered both in time of eating the meal and where to sit. Usually the main meal is at lunchtime but this may be altered if necessary. Clients have the opportunity to choose their main meal with two prepared choices and alternatives available. Other meals offer a choice of menu with the fridge well stocked to choose from. Clients are encouraged to use the dining room as part Trinity Court DS0000049502.V321039.R01.S.doc Version 5.2 Page 14 of developing social skills. Assistance to eat is very well managed with aids to eating provided. Where possible clients assist with meal preparation, where they are shown the basics of cookery. Clients’ weights are monitored and good diets encouraged. Where there are problems food and fluid records are held and action taken. Trinity Court DS0000049502.V321039.R01.S.doc Version 5.2 Page 15 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 excellent. This judgement has been made using available evidence including a visit to this service. Clients’ health and care needs are very well met, promoting rights, choice and wellbeing. EVIDENCE: The manner in which staff work with clients to meet client choice as far as possible is commendable and reduces the risk of conflict situations and possible challenging behaviours. Staff on duty not only acted in this manner but also were able to explain why they did so. Staff offer gentle and respectful approaches when encouraging clients to maintain their dignity such as with clothing and other areas of personal care. These individual preferences are often included in the care plan although this remains an area for development. The shift allocation process acknowledges that clients have preferences about who works with them, and this is met as far as possible. Rosters will not put a client or staff at risk. Staff are aware of personal boundaries and gender guidelines and follow these guidelines in their work. Each client has two Trinity Court DS0000049502.V321039.R01.S.doc Version 5.2 Page 16 keyworkers to provide continuity and familiarity. The keyworker system is very effective both for the client and staff working with them. The service is excellent in promoting clients health and ensuring that clients’ rights to receive health and associated services are met. Staff work in conjunction with a range of health professionals so that clients receive in and out patient treatment, and may remain at the home as long as possible. One health situation had been discussed with a range of professionals and risk assessed before being implemented. It remains excellently managed with staff trained in the processes resulting in the client’s health having significantly improved. Health records show attendance and dental, optical and chiropody services. Feedback from health professionals mentions satisfaction with the service. Medication practices are good. A potting up system is used. Whilst this system is not normally recommended, it is well managed and safer for clients and staff. Accurate administration of medication records are maintained with storage of medication clean and well ordered. Medication is checked in on arrival and any discrepancies notified to the prescriber. Staff are alert to indicators that medication should be reviewed. Staff receive training in the administration of medication and may not administer medication until trained. Similarly, staff may only carry out any invasive medication practices when trained and risk assessed. Trinity Court DS0000049502.V321039.R01.S.doc Version 5.2 Page 17 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 and 23 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Clients’ rights to protection from the risks of harm or abuse are promoted. Complaints are taken seriously and actioned but access to independent advocates would support the process. EVIDENCE: The service has a clear written complaint procedure which gives timescales for each stage of the process and contact details. A pictorial complaint procedure is also available. The role of the keyworker system includes supporting clients to make comment about the service they receive. Currently there is no access to independent local advocates. Whilst it is commendable that staff provide support to complain, there should be access to independent advocates separate from the service providers. Complaints are recognised as part of an overall quality assurance system. Complaints are recorded on an individual basis with documented evidence of the processes of addressing the complaint and monitoring of outcomes. All recent complaints have been properly recorded and dealt with. Training in adult protection is included in the training schedules with staff recorded as having received training and updates scheduled. The service is proactive in ensuring clients are protected from abuse whilst recognising the rights of staff and visitors also to be safe. Where a risk is identified, policies Trinity Court DS0000049502.V321039.R01.S.doc Version 5.2 Page 18 and environmental action is taken. Staff understand the different forms abuse might take and monitor any indicators of potentially abusive situations. Where necessary action will be taken to prevent unsuitable staff working with vulnerable people in future. Trinity Court DS0000049502.V321039.R01.S.doc Version 5.2 Page 19 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): 24,25,26,27,28,29 & 30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Clients have a pleasant, homely environment in which to live but which is at risk from delays in carrying out maintenance and renewal needs. EVIDENCE: Trinity Court was adapted some years ago from a domestic property to a home for older people, and then completely refurbished by the previous owners to become a home for adults with a learning disability. As most of the work was to the rear of the building, the front retains its domestic regency style appearance. The previous owners were very responsive to any maintenance and renewal request, understanding that catering for clients with behaviours which might challenge result in higher than average renewals and repairs costs. The current owners, Consensus, do not evidence the same approach. There was Trinity Court DS0000049502.V321039.R01.S.doc Version 5.2 Page 20 evidence of unnecessary delays in carrying out maintenance of property and appliances. An organisational maintenance person visits for two consecutive days a month. Any interim maintenance or renewals requests have to be placed through orders to the head office. Whilst safety was not being compromised at the time of the site visit, this situation results in stress for clients and staff and does not ensure that the premises are properly maintained or fit for purpose. At the time of the site visit, the building bordered on adequacy for clients. Due to the evidence of a gradual deterioration in standards and lack of timely response to maintenance and renewal requests, a requirement has been made for the providers to ensure the property is well maintained and fit for purpose,. If this requirement is not met, regulatory action will be taken. Client’s rooms are individual with personal effects in place. Every effort is made to make sure that staff can identify client choice in décor where there is limited communication leading to some very interesting and appropriate surroundings. Privacy is very well promoted as each bedroom has its own ensuite. Two en-suites have been turned into wet rooms. A large communal bathroom offers further choice. Additional toilets and a shower for staff use are available. One toilet is continually being replaced due to damage. Whilst money is spent on replacing the toilet with similar domestic ones, and recent work put a protective framework round the cistern, no agreement had been gained to replace the unit with a more appropriate one. Clients have fittings and aids to make their environment safer and a more practical space in which to be. Aids to continence are discrete and do not impinge on the homely environment. Staff use a radio communication system to call for assistance if necessary. The two lounges give homely and bright areas to watch TV, interact with staff or just take a break. A new carpet is planned with measuring etc carried out last May, there is no date set for fitting even though the existing carpet is worn and dirty. The dining room is practical and modern, however a mural started by clients is now looking shabby and worn. Upstairs there is the office, a training room and a joint staff/visitors room. Gardens to the rear can be accessed from the side or from the main lounge. Doors are alarmed and monitored by staff for client safety. There are plans to set up the chalet at the end of the garden for activities. Clients have use of a patio and large lawned area. Clients are assisted in maintaining a clean and tidy environment by staff, whose duties include cleaning. Trinity Court DS0000049502.V321039.R01.S.doc Version 5.2 Page 21 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): 31,32,33,34,35 & 36 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Clients have motivated, trained and committed staff who provide friendship, care and support but where sound recruitment processes would continue to ensure this happens. EVIDENCE: Staff understand they are there to work for the benefit of clients, the duties they are expected to perform are recorded in a job description. Staff have good relationships with clients, the keyworker role enables clients to become familiar with two key staff who work more closely together. A core of staff have worked at the home for some time and are well known to clients and familiar with their needs and preferences. Opportunities are provided for people who express a wish to work with the client group but who may be new to, or have limited experience of the caring profession. The providers have recently bought a training consortium and are using this to provide training for staff. The training matrix recorded a range of training Trinity Court DS0000049502.V321039.R01.S.doc Version 5.2 Page 22 having already been undertaken. Staff said a questionnaire had been sent out asking what training they needed. One member of staff spoke of training she would like to help her work more effectively with her key clients. NVQ training is encouraged with a number of staff having achieved their level 2 and planning to start level 3, another had just completed her level 3 and was planning to undertake level 4. Staff felt overall the team was strong and had the right attitude to working with people with learning disabilities. They considered information was shared and there was good support in the team. Each shift starts with a handover and shift allocation. A staff roster is held. Staff felt there were sufficient staff on duty to provide 1:1 client supervision where appropriate, general care and support tasks, leisure activities and domestic tasks although comment was made that more establishment staff would be useful. Staff will also carry out additional shifts to cover leave, take clients out on activities and attend training. Where necessary agency staff are used, preferably with the same people supplied by the agency. Consensus have brought in their own application forms and referencing requests which address deficits mentioned at the last inspection. Unfortunately, these had not been used efficiently in respect of the last person recruited. Whilst there were a number of written references, there was no reference from an employer where the applicant had worked with vulnerable people. There was limited evidence that anomalies in responses on the application form had been questioned. Criminal records bureau and protection of vulnerable adults (POVA) checks are carried out. Staff said they had supervision within a line management structure. A record is held of supervision dates and the manager monitors that it is being carried out. Staff giving supervision have either had external training or have experience and mentoring in the supervisory role. Staff felt the supervision sessions were useful and a place where they could discuss clients, training and development needs and personal issues if applicable to their work. Staff are aware that there is a disciplinary and grievance procedure which will be implemented as required. Trinity Court DS0000049502.V321039.R01.S.doc Version 5.2 Page 23 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): 37,38,39,40,41,42 & 43 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Clients benefit from a well managed and safe service EVIDENCE: The current manager has worked for many years with people with a learning disability, including those who may display challenging behaviour. She was deputy manager at Trinity Court before her promotion. She is in the later stages of completing the NVQ Registered Managers award, in addition she keeps up to date with training and new ideas. Staff spoke well of the manager, saying she is approachable, ably balancing administrative duties with being available for clients. House and team Trinity Court DS0000049502.V321039.R01.S.doc Version 5.2 Page 24 meetings are held. Staff encourage clients to express their views of the service in the manner best for them. Staff said they are able to make comment about the service and feel they are listened to. Staff meetings are considered effective and two way, with good feedback. Creativity is welcomed. There remains no detailed quality assurance system. Comments from families and professionals are listened to, but not through any formal mechanisms. A set of policies and procedures is available for staff to underpin the work they are required to carry out. Staff said they must read and sign both existing policies and any new or amended ones. New staff are required to read policies as part of their induction. Whilst clients benefit from good polices and procedures they have little interest in policy making and development. Since the service opened the standard of record keeping is continually improving. The manager understands the need to ensure records are accurate and are stored safely. Staff are reminded of their responsibilities with senior staff taking a lead role in record management. Clients may access records held about them, as with policies, few have any interest in doing so. Clients have their health and safety in the home protected to a good standard, although there are deficits in corporate responsiveness as detailed in standard 24. Information provided as part of the inspection recorded that routine maintenance of supplies and equipment is carried out with certificates available for inspection. Staff have formal fire training annually with interim fire drills held. Incidents which affect the wellbeing of clients are notified to the commission giving accountability that suitable action is being taken. The current providers ensure that monthly visits are carried out to assess the service with a report made and action to be taken recorded. The manager has access to budget forecasts and expenditure. Current business insurance and employers liability insurance is in place. Trinity Court DS0000049502.V321039.R01.S.doc Version 5.2 Page 25 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 3 2 3 3 3 4 x 5 2 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 1 25 3 26 3 27 3 28 3 29 3 30 3 STAFFING Standard No Score 31 3 32 3 33 3 34 1 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 3 2 3 LIFESTYLES Standard No Score 11 3 12 4 13 3 14 4 15 3 16 4 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 4 3 3 x 3 3 2 3 3 3 3 Trinity Court DS0000049502.V321039.R01.S.doc Version 5.2 Page 26 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 YA24 Regulation 25 (1) & (2) Requirement Timescale for action 30/12/06 2 YA34 19 (1) The registered person shall at all times ensure that the premises used as the care home are fit for the purpose of achieving the aims and objectives set out in the statement of purpose in that: • The home must be properly maintained, clean and reasonably decorated • Equipment must be maintained in good working order • The home kept in a good state of repair internally and externally • Suitable adaptations made. A person shall not work at the 30/12/06 care home unless: As far as practicable, the reason for leaving any previous work with vulnerable people has been confirmed in writing. Trinity Court DS0000049502.V321039.R01.S.doc Version 5.2 Page 27 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 YA5 Good Practice Recommendations Each service user should have a contract between the home and themselves, where possible in a format which is understandable by the service user concerned, or if necessary with the assistance of an advocate. This recommendation is repeated from the inspections of 17 November 2004, 3 May 2005 and 25 October 2005. Client’s personal goals, both long and short term, should be written clearly and simply with steps detailed to reach these goals, with care plans kept up to date. This recommendation is repeated from the inspections of 3 May 2005 and 25 October 2005. Risk assessments should be reliably responsive to incidents, information received and observation of the client. The resultant risk assessment should provide staff with unambiguous steps to reduce the likelihood or consequences of the risk. This recommendation is repeated from the inspections of 25 October 2005. As an area for development, it is recommended that clients have access to local independent advocates who can support clients to make comment about quality of life and the service provided. Recruitment practice should evidence that employment history is accurate with any gaps in employment recorded and anomalies explained. As planned, a comprehensive coordinated quality assurance system should be implemented. This recommendation is repeated from the inspections of 17 November 2004 and 25 October 2005 2 YA6 3 YA9 4 YA22 5 YA34 6 YA39 Trinity Court DS0000049502.V321039.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Maidstone Local Office The Oast Hermitage Court Hermitage Lane Maidstone ME16 9NT 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 Trinity Court DS0000049502.V321039.R01.S.doc Version 5.2 Page 29 - 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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