Inspection on 25/10/05 for Trinity Court

This inspection was carried out on 25th October 2005.

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 there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Trinity Court 03/03/10

Trinity Court 30/11/09

Trinity Court 11/03/09

Trinity Court 01/12/06

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 Announced Inspection 25th October 2005 10:00 Trinity Court DS0000049502.V261850.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 Trinity Court DS0000049502.V261850.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. Trinity Court DS0000049502.V261850.R01.S.doc Version 5.0 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) Aitch Care Homes (London) Limited Vacant Care Home 10 Category(ies) of Learning disability (10) registration, with number of places Trinity Court DS0000049502.V261850.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 3rd May 2005 Brief Description of the Service: Trinity Court is a completely refurbished detached three storey property on the outskirts of Staplehurst. The lower two floors are available for use by service users, the top floor being used for storage at present. It 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.Trinity Court caters for 10 adults with a learning disability who may also have behaviour that challenges.There is a staff team consisting of support workers, seniors, a deputy manager and manager.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.V261850.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This announced inspection was carried out between 10.00 am and 6.40 pm. The commission was represented by regulatory inspector Ann Block. One client, the manager and deputy manager, senior support workers and support workers on duty chatted to the inspector about life in the home. The home has 10 clients, one of whom was staying with family at the time of inspection. 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. As part of the inspection process comment cards were received from clients’ families and professionals. Comments included: ‘I like living here’ (from a client) ‘I am very pleased indeed on my sons progress since the has been cared for at Trinity Court. Thanks to all!’ ‘I found the support, environment & information to be of a high standard in my opinion.’ ‘I like coming to Trinity Court, the staff are all friendly and helpful. I have never needed to make a complaint as I consider the home very well run with very few problems.’ What the service does well: Clients have a good quality of life where they have plenty to occupy them, staff who are kind, competent and motivated to support them and a modern, nicely furnished home with plenty of indoor and outdoor space. Clients’ safety is maintained through staff presence and a safe environment. Staff are aware that clients have the right to have a full and interesting lifestyle. Staff look for opportunities for clients to enjoy physical exercise, social activities, develop daily living skills and make choices . 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, senior staff and the owning company. Clients’ admission assessments and staff recruitment are thorough to provide a well functioning home. Trinity Court DS0000049502.V261850.R01.S.doc Version 5.0 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. Trinity Court DS0000049502.V261850.R01.S.doc Version 5.0 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.V261850.R01.S.doc Version 5.0 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): 1,2,3,4 &5 Clients and placing agencies have good systems to judge whether the client would benefit from living at Trinity Court. EVIDENCE: Good systems are available for families and placing agencies to have written and practical information about the service Trinity Court can provide. The manager has updated the statement of purpose and service users guide to reflect recent staff changes. The former manager was promoted to placements manager. She had assessed a client who moved in during the summer. As part of the assessment process comprehensive information had been obtained from the clients previous placement and professionals. The client and family had visited the home, seen the vacant room and talked about what could be offered at Trinity Court. The client had met other clients and some of the staff team. The admission procedure recognised the goal to support the client to move from an educational environment to an adult service where he would be able to develop an adult lifestyle and social network. To confirm the assessment process, a letter stating that the home can meet needs must be provided to the client either directly or though their advocate. 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 Trinity Court DS0000049502.V261850.R01.S.doc Version 5.0 Page 9 have confidence in the staff team and made comment that clients have progressed whilst living in the home. A written contract is provided, the majority of clients have a completed contract. Trinity Court does not offer respite care. Trinity Court DS0000049502.V261850.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): 6,7,8,9 & 10 Clients, their needs and wishes, are the focal point of the service EVIDENCE: Care plans are very comprehensive but it was recognised that they had become unwieldy and not user friendly. Staff are in the process of reviewing the format, with some plans already presented in a simpler style. To encourage easy access to key information, consistency of information and ease of review, care files need to be concise and focussed. Staff record on a shift basis and are encouraged to relate the day to specific goals. A communication book is used to record additional information. The system should ensure that all staff have access and knowledge of updates to the care plan and their relevance to the clients life. Clients’ needs are generally very well known. Clients showed that they were respected and listened to by staff working with them. A senior had made progress in starting to set out goals for clients. A further development would be to ensure that goals are reliably written in a simple, specific manner - as some are, so that staff have access to agreed standards of working with the client. Trinity Court DS0000049502.V261850.R01.S.doc Version 5.0 Page 11 As with care plans, work to improve the risk assessment system, including responsiveness to events, is taking place. The author has at times generalised the risk and how it should be managed, not reliably giving staff clear directions. Some risks, the majority known and acted on by staff, had not been recorded. As many care plans refer to ‘see guidelines’, these guidelines need to be very clear and readily accessible. 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. Staff on duty excellently demonstrated this during the inspection. The majority of clients have limited understanding of money and have their finances dealt with by appointees. The organisation are appointee for many clients. ACH alerts Trinity Court 4 weekly by e-mail that monies have been transferred into the Trinity Court account. Records of clients receiving money due showed that clients then receive an amount for personal allowance 4 weekly. Larger amounts are requested through Head Office. Record keeping now better shows the reason for money spent on a client’s behalf. Staff are diligent in checking money held is correct. The system for paying for meals out needs to be clarified to prevent clients effectively paying twice. Clients can be assured that information obtained about them will be kept confidential, only being shared on a need to know basis. When the revised care plan system is up and running, confidentiality may be better maintained by using a complete ‘refer to’ system in the communication book rather than putting detail with client initials. Trinity Court DS0000049502.V261850.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): 11,12,13,14,15,16 & 17 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 to promote general wellbeing. During the inspection, some clients went out riding, others had gone to a day service, some were going to a birthday party later that evening. Other day activities include opportunities such as college, swimming, trampolining, shopping trips, visits to the cinema and 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. Each client has a weekly schedule which is flexible. The majority of clients have been on holiday, ACH provide £250 towards an annual holiday. Additional days out have been provided for those who definitely didnt want a Trinity Court DS0000049502.V261850.R01.S.doc Version 5.0 Page 13 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. Again, staff mentioned the terrific support clients receive from the local pub. A client said he still had regular visits from family, which to him were a large part of his life. Another client has alternate weekends at the family home. Staff provide transport and escorts if necessary, as they are aware that family contact is very important to some clients. 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. Clients have the opportunity to choose their main meal with two prepared choices and alternatives available. The evening lighter meal is even more flexible with clients having jacket potato with a range of fillings, and sandwiches for tea during the inspection. Meals are provided at around the same time of day to assist those clients who like routine. Flexibility is offered both in time of eating the meal and where to sit. Clients are encouraged to use the dining room as part of developing social skills. Supplementary feeding is very well managed. Where possible clients assist with meal preparation, where they are shown the basics of cookery. Clients’ weights are monitored and good diets encouraged. One client has chosen a weight loss programme and is being supported by staff. Where there are problems food and fluid records are held and action taken. Trinity Court DS0000049502.V261850.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): 18,19,20 & 21 Clients’ health and support needs are well met. EVIDENCE: Staff fully understand that to work with clients they like best will reduce conflict situations and possible challenging behaviours. Staff offer gentle and respectful approaches when encouraging clients to maintain their dignity such as with clothing. Care plans record detail of how clients like to be supported, including how they like to be bathed, what clothes they prefer and how choices would be determined. Staff have a better understanding of need than care plans record. Clients are praised for achievements, however small. 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 spoke of personal boundaries and gender guidelines. Each client has two keyworkers to provide continuity and familiarity. The service is excellent in promoting clients health and will strongly defend clients’ rights to receive health and associated services. Staff work in conjunction with a range of health professionals to ensure 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 Trinity Court DS0000049502.V261850.R01.S.doc Version 5.0 Page 15 assessed before being implemented. It is being excellently managed with staff trained in the processes resulting in the client’s health having dramatically improved. Health records show attendance and dental, optical and chiropody services. Records of health appointments would benefit from being concise and consistent. 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. 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. Trinity Court DS0000049502.V261850.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): 22 & 23 Clients are protected from the risks of abuse. Complaints are taken seriously and actioned. 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. Clients and others are aware that they can complain about the service and that action will be taken to address the problem. Complaints are recognised as part of an overall quality assurance system. Complaints are now recorded on an individual basis with documented evidence of the processes of addressing the complaint and monitoring of outcomes. Training in adult protection is included in the training schedules with many staff already trained. The service is proactive in ensuring clients are protected from abuse whilst recognising the rights of staff and visitors also to be safe. 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.V261850.R01.S.doc Version 5.0 Page 17 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24,25,26,27,28,29 & 30 Clients live in a spacious, well maintained and decorated home. EVIDENCE: Trinity Court was adapted some years ago from a domestic property to a home for older people, then completely refurbished 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. Clients have a clean attractive and homely place in which to live which is well maintained. Clients are encouraged to respect their surroundings with a good balance between safety and an attractive, age appropriate environment. 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. Trinity Court DS0000049502.V261850.R01.S.doc Version 5.0 Page 18 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 comfortable and bright areas to watch TV, interact with staff or just take a break. The dining room is practical and modern, clients have started work on a mural to depict the seasons. Upstairs there is a meeting room which can be used by visitors and a sensory room. The company is to provide a computer for the sensory room as one client in particular has an interest in computing. 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. One client likes to use the sun house at the end of the garden to be private. Clients have use of a patio and large lawned area. Clients are assisted in maintaining a pleasant environment by staff, whose duties include cleaning and by the sound organisational maintenance arrangements. The laundry is locked for safety but provides equipment and space for staff to work. Trinity Court DS0000049502.V261850.R01.S.doc Version 5.0 Page 19 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31,32,33,34,35 & 36 Clients have motivated, trained and committed staff who provide friendship, care and support. 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. Newer staff understood they would need to observe good practice and how best to work with individual clients. More experienced staff also recognise there may be areas in which they were not so familiar and knew to take advice from senior staff or professionals. The service aims to identify potential when recruiting staff, in addition to taking staff with experience. Training is provided both locally and using a training provider who, according to staff who have attended the training, is excellent. A member of staff spoke of a course on dealing with challenging behaviour and was impressed at the scope of the course. Staff are encouraged to work towards NVQ qualifications. Staff felt the team was strong and had the right attitude to working with people with learning disabilities. They considered information was shared and Trinity Court DS0000049502.V261850.R01.S.doc Version 5.0 Page 20 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. 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. Head Office take lead responsibility for recruitment of staff with the home manager being involved in the actual selection process. Head Office ensure the service is provided with copies of relevant documents, it would be useful for ACH to date stamp receipt of documents as an audit trail. Staff are recruited in a professional manner using an application form, recorded interview, references, criminal records bureau and protection of vulnerable adults (POVA) checks. Previous training would more likely to be declared if the application form gave space to record additional training. Seeing and copying original certificates would verify such training. Whilst in the majority of cases references provided had been accurate and useful, information requested should reliably provide the employer with judgments about the person’s performance and verification of reason for leaving. Staff said they had regular supervision within a line management structure. 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.V261850.R01.S.doc Version 5.0 Page 21 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37,38,39,40,41,42 & 43 Clients benefit from a well managed, safe and well maintained 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 recent 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 meetings are held. Staff ensure clients have opportunities 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 know they will be listened to. Staff meetings are considered to be effective and two way, with good feedback. Creativity is welcomed. Trinity Court DS0000049502.V261850.R01.S.doc Version 5.0 Page 22 A quality assurance system is being implemented. Questionnaires are already set up to send to clients’ families, professionals and other stakeholders. The system is still in its infancy. 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 said they had been 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, with weekly health and safety walking routes taking place, equipment serviced as required and any repairs carried out promptly. Information provided as part of the inspection recorded that routine maintenance of supplies and equipment is carried out. Staff have formal fire training annually with interim fire drills held. Staff were able to state actions to take in the event of fire. Two staff who work mainly at night need to attend a fire practice shortly. Incidents which affect the wellbeing of clients are notified to the commission giving accountability that suitable action is being taken. ACH, the owning company, are proactive in providing a high standard of service to the clients with whom they contract. There is a very good balance between support and delegation. Managers of Trinity Court have habitually said they receive consistent and professional support from the operations managers and directors of ACH. Money is invested to provide a high standard of service. The Operations Manager makes monthly visits with a focussed and objective report made which is shared with the manager and the commission. Trinity Court DS0000049502.V261850.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 3 4 2 3 2 Standard No 22 23 Score 3 3 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 2 2 3 2 3 Standard No 24 25 26 27 28 29 30 STAFFING Score 3 4 3 4 3 3 3 LIFESTYLES Standard No Score 11 3 12 3 13 3 14 4 15 3 16 3 17 Standard No 31 32 33 34 35 36 Score 3 3 3 2 3 3 CONDUCT AND MANAGEMENT OF THE HOME 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Trinity Court Score 3 2 3 x Standard No 37 38 39 40 41 42 43 Score 3 3 2 3 3 3 4 DS0000049502.V261850.R01.S.doc Version 5.0 Page 24 Are there any outstanding requirements from the last inspection? Yes 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 3.8 Regulation 14 (1) (d) Requirement The registered person must confirm in writing to the service user that having regard to the assessment the care home is suitable for the purpose of meeting the service users needs in respect of his health and welfare. This remains a requirement from the inspections of 1 July 2004 and 17 Nov 2004 To be fully implemented by 31 October 2005 and thereafter Timescale for action 31/10/05 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 Refer to Standard 5 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 Trinity Court DS0000049502.V261850.R01.S.doc Version 5.0 Page 25 November 2004 and 3 May 2005. 2 6 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 inspection of 3 May 2005. Staff should consider and record useful evaluations of behaviours when entering in client’s daily notes. This recommendation is repeated from the inspection of 3 May 2005. The system for clients to pay for meals out should be clarified and set procedures put in place to prevent a client potentially paying twice. 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. Records of health appointments should be concise and consistent. The application form should give space to record additional training, with the training verified by seeing and copying original certificates. Reference information should reliably provide the service with judgments about the person’s performance and verification of reason for leaving. As planned, a comprehensive coordinated quality assurance system should be implemented. This recommendation is repeated from the inspection of 17 November 2004 3 6 4 7.7 5 9 6 7 19.2 34.1 8 34.2 9 39 Trinity Court DS0000049502.V261850.R01.S.doc Version 5.0 Page 26 Commission for Social Care Inspection Maidstone Local Office The Oast Hermitage Court Hermitage Lane Maidstone ME16 9NT 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 Trinity Court DS0000049502.V261850.R01.S.doc Version 5.0 Page 27 - 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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