Inspection on 13/02/06 for Trinity Court Nursing Home

This inspection was carried out on 13th 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

Trinity Court Nursing Home 05/07/07

Trinity Court Nursing Home 12/06/06

Trinity Court Nursing Home 11/05/05

Trinity Court Nursing Home 01/11/04

Trinity Court Nursing Home 20/04/04

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

CARE HOMES FOR OLDER PEOPLE Trinity Court Nursing Home 165-167 Trinity Road Tooting London SW17 Lead Inspector Janet Pitt Unannounced Inspection 13th February 2006 10:15 X10015.doc Version 1.40 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 Nursing Home DS0000019130.V283824.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 Older People. 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 Nursing Home DS0000019130.V283824.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Trinity Court Nursing Home Address 165-167 Trinity Road Tooting London SW17 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) 020 8767 8767 02086823280 Newslease Limited Care Home 37 Category(ies) of Dementia - over 65 years of age (10), Mental registration, with number Disorder, excluding learning disability or of places dementia - over 65 years of age (1), Old age, not falling within any other category (37) Trinity Court Nursing Home DS0000019130.V283824.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. The Home can admit one named service user under the age of 65 years. The category of MD (E) is for one named service user for the duration of their residence in the home. Date of last inspection Brief Description of the Service: Trinity Court is situated on the main A214 Trinity Road, between Wandsworth and Tooting. Nursing care is provided for thirty-seven residents, ten of who may have dementia. Accommodation is provided over three floors. There are twenty-nine single rooms and four shared rooms. The home has two passenger lifts and there are plans to extend to home to increase resident numbers to fifty and provide more communal space. The home has a large level garden, which can be accessed via a ramp from the lounge area. Trinity Court Nursing Home DS0000019130.V283824.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection was undertaken unannounced by one inspector. The inspection commenced at 10:15am and concluded at 1pm. The inspection focused on Standards not assessed at the previous inspection and requirements made. During the course of the inspection three members of staff and two residents were spoken with. Records relating to care, staff recruitment and staff training were examined. What the service does well: What has improved since the last inspection? What they could do better: Daily records must be improved to reflect care given and not contain entries such as ‘all care rendered’ or ‘care as planned’. Staff records evidence that there is a suitable recruitment process in place, but there must be a record of staff receiving copies of their job descriptions. Trinity Court Nursing Home DS0000019130.V283824.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. Trinity Court Nursing Home DS0000019130.V283824.R01.S.doc Version 5.1 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Trinity Court Nursing Home DS0000019130.V283824.R01.S.doc Version 5.1 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): EVIDENCE: None of these Standards were assessed, but core Standards were met at the previous inspection. Trinity Court Nursing Home DS0000019130.V283824.R01.S.doc Version 5.1 Page 9 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8 and 9 Residents daily care records have improved; however there must be consistent recording of care given. Wound care records indicate whether treatment is effective and if healing is promoted. EVIDENCE: There has been improvement in residents care plans and it is now clearer what care is required, which will enable staff to meet care needs. There was evidence of residents or their representatives being involved in the process and interventions by other health professionals. Daily records need to be improved to reflect actual care given, and not contain entries such as ‘all care given’, and how residents spend their days. Recording of wound care has improved, photographs are taken monthly of wounds and dressing changes were noted to be detailed in the daily records. There is also a record of involvement of the tissue viability nurse. This indicates that appropriate attention is being given to wounds to promote healing. Immediate requirements were made in respect to medications at the previous inspection, the provider indicated in an action plan that requirements were complied with. Trinity Court Nursing Home DS0000019130.V283824.R01.S.doc Version 5.1 Page 10 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15 Residents are able to choose from a menu and can enjoy meals in a sociable setting. Staff are attentive to residents needs at meal times. There have been improvements to activities that residents are able to participate in. EVIDENCE: Residents are able to participate in a wider selection of activities than at the previous inspection, but further improvement is needed. An aromatherapist visits monthly and the provider said that a member of staff has been trained to undertake activities. Plans for the new communal area include areas for group or individual activities to take place. Residents are able to receive visitors and there was evidence in the care documentation and visitors book confirming this. Residents were seen to be enjoying a sociable lunch. There was sufficient staff to assist when required and it was noted that staff sat beside residents to assist them. One member of staff was heard checking that a resident had had sufficient to eat, prior to clearing their plate. The meal was served hot and the portion size was adequate, special diets were observed to be catered for. Trinity Court Nursing Home DS0000019130.V283824.R01.S.doc Version 5.1 Page 11 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 Residents can be confident that complaints will be handled appropriately. Lack of Adult Protection investigations indicates that residents are protected from abuse. EVIDENCE: The acting manager confirmed that there had been no changes to the Adult Protection policies and there has been no requirement for an investigation. The home benefits from a trainer who covers how to deal with abuse in training sessions. The complaints record indicated that there have been no complaints since the previous inspection. Trinity Court Nursing Home DS0000019130.V283824.R01.S.doc Version 5.1 Page 12 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): EVIDENCE: None of these Standards were inspected due to ongoing building works, but will inspected be once the extension is completed. Trinity Court Nursing Home DS0000019130.V283824.R01.S.doc Version 5.1 Page 13 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30 Residents are supported by adequate numbers of competent staff. Regular training is provided to enable staff to carry out their job. Good recruitment procedures protect residents from harm, but it must be evidenced that staff have a copy of their job description. EVIDENCE: Staffing levels are maintained at an acceptable level to make sure that residents’ needs are met. Residents are protected by the home’s recruitment policy, which makes sure that appropriate checks are undertaken on new employees. Staff files examined indicated that Criminal Records Bureau checks are carried out and nursing qualification are verified. Files examined did not have a copy of the workers job description. Other information required by the regulations was present. The acting manager stated that staff are provided with a copy of their job description, there must be a record on file to indicate that this has been done. The trainer for the home has recently returned. The trainer confirmed that induction training is given as required by the Standard and she is currently making sure that mandatory training is up to date. Fire training has been booked for March 2006. Each member of staff has their own individual training record, which provides information of what training has occurred and what training is needed. Trinity Court Nursing Home DS0000019130.V283824.R01.S.doc Version 5.1 Page 14 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. 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 and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 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 and 35 Residents are supported by a management and staff team who are approachable and responsive to their needs. EVIDENCE: Residents are supported by an acting manager who has many years experience managing Trinity Court, whilst a new manager is appointed. Then provider stated that interviews have commenced for the manager’s post. The inspector was provided with a copy of a questionnaire that is due to be sent to residents and their representatives to enable them to comment on aspects of care, food and accommodation. There are plans that this will be repeated quarterly and responses collated, with action plans if required. The acting manager stated that the administrator handles personal allowances of residents and a record is maintained. Two residents have a solicitor as their power of attorney. Trinity Court Nursing Home DS0000019130.V283824.R01.S.doc Version 5.1 Page 15 The health and safety of residents is being maintained whilst building work is going on and one resident commented that the building works had not caused them any concern with regards to noise. Trinity Court Nursing Home DS0000019130.V283824.R01.S.doc Version 5.1 Page 16 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People 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 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X X X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 X X X X X X X X STAFFING Standard No Score 27 3 28 3 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 3 X 3 X X X Trinity Court Nursing Home DS0000019130.V283824.R01.S.doc Version 5.1 Page 17 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. 1 2 Standard OP7 OP12 Regulation 15 16 (2) (m) Requirement The registered person must ensure that daily records accurately detail care given. The registered person must ensure that the activities programme is developed to ensure that residents are able to participate in a variety of activities, which reflect their choice. The registered person must ensure that it is evidenced that staff have received a copy of their job description. Timescale for action 30/05/06 30/06/06 3 OP29 17 Sch 4 30/05/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Trinity Court Nursing Home DS0000019130.V283824.R01.S.doc Version 5.1 Page 18 Commission for Social Care Inspection SW London Area Office Ground Floor 41-47 Hartfield Road Wimbledon London SW19 3RG 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 Nursing Home DS0000019130.V283824.R01.S.doc Version 5.1 Page 19 - 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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