Inspection on 05/07/07 for Trinity Court Nursing Home

This inspection was carried out on 5th July 2007.

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 12/06/06

Trinity Court Nursing Home 13/02/06

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 7HL Lead Inspector Davina McLaverty Unannounced Inspection 5th July 2007 10:00 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.V344145.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 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.V344145.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Trinity Court Nursing Home Address 165-167 Trinity Road Tooting London SW17 7HL 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 020 8682 3280 azimjivraj@hotmail.com Newslease Limited Savitribai Gooljar Care Home 50 Category(ies) of Dementia - over 65 years of age (11), Mental registration, with number disorder, excluding learning disability or of places dementia (5), Mental Disorder, excluding learning disability or dementia - over 65 years of age (1), Old age, not falling within any other category (50) Trinity Court Nursing Home DS0000019130.V344145.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 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. The service user category Mental Disorder (MD) is for 5 service users between the ages 55 - 65 years. 15th March 2007 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 fifty residents, eleven of who may have dementia. Accommodation is provided over three floors. There are fortyeight single rooms and one double room. The home has one passenger lift and recently completed building works provide a fifty bed home with improved and enlarged communal space. The home has a large level garden, which can be accessed from the lounge area. There is also a wooden patio at the rear of the building with garden tables and chairs. This area is used for barbeques etc. The gardens are well maintained with flowers and lawn area. Parking facilities are available at the front and rear of the building. The home is easily accessible for everyone including wheelchair users. Fees range form £610 -£800 per week. Trinity Court Nursing Home DS0000019130.V344145.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. One inspector and one regulation manager carried out this inspection and a total of five and a half hours was spent in the home. The manager and owner were present throughout the inspection. A number of records were examined and discussions took place with six staff and two visiting health professionals and one relative. Questionnaires were left with the homes manager to distribute to staff, residents, relatives and purchasers of the service. Four questionnaires were received at the time of writing this report. No concerns were raised and some of the comments received are included in the report. Prior to the inspection being carried out the home as required, had submitted their annual quality assurance assessment questionnaires, which has also been used to formulate some of the judgements, detailed in this report. What the service does well: What has improved since the last inspection? The home now provides individualised care through using person centred planning. Mealtimes are more relaxed with staff supporting residents at their individual pace. Trinity Court Nursing Home DS0000019130.V344145.R01.S.doc Version 5.2 Page 6 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 Nursing Home DS0000019130.V344145.R01.S.doc Version 5.2 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.V344145.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 1,3,4 & 5 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Sufficient information is available to prospective residents and relatives to assist them in deciding whether they want to live in the home. Full needs assessments are completed before people move, to ensure that their individual needs can be met. EVIDENCE: The home’s Statement of Purpose and Service user guide is being updated but current documents seen, evidence that information is available to prospective residents and their relatives to make a decision regarding the suitability of the home. Visits to the home are arranged wherever possible. The home has a comprehensive admission procedure in place. A large number of residents are referred by Social Services. Copies of Social Workers assessments were seen on files, as well as the assessment of the homes manager. The manager stated Trinity Court Nursing Home DS0000019130.V344145.R01.S.doc Version 5.2 Page 9 that she or a senior staff will carry out their own assessment to follow up on any issues on the referral form as well as to ensure that the persons needs can be met. Once an individual comes to live in the home a care plan is written based on these assessments. Trinity Court Nursing Home DS0000019130.V344145.R01.S.doc Version 5.2 Page 10 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. JUDGEMENT – we looked at outcomes for the following standard(s): 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. Care plans and risk assessments are developed with the person using the service. However, they must be regularly reviewed to ensure that their needs are continuing to be met. Staff are committed in supporting residents to lead, where able, the life they choose. Medication is well managed within the home with good systems in place. EVIDENCE: Since the previous inspection new care plans have been introduced. The new system is comprehensive, although the manager reported that the staff team are still getting use to them. There is space on the plans for residents and staff to sign to indicate their agreement with the plan, as well as space on the plan to include likes and dislikes and a brief social history. However, these sections Trinity Court Nursing Home DS0000019130.V344145.R01.S.doc Version 5.2 Page 11 were not always completed. The manager reported that she hopes to provide in the future, life history books for all the residents; a sample book was shown to the inspectors. A Key worker system is in place and a key worker is appointed to each resident prior to admission. One of the key workers roles is to ensure documentation is kept up to date, however, evidence of monthly review was seen on two of the four files examined. Daily records seen on residents were informative outlining how residents spent their day. Positive comments were received from residents, relatives and health care professionals on the care provided. The care provided was described as “ very good” by several residents who also stated that they were well looked after and that the staff were kind. Arrangements are in place for residents to receive regular health care checks. The GP visits the home twice a week, and can be called out in an emergency. Feedback from the visiting Doctor on the day of the inspection was good. Staff spoken with were knowledgeable of the residents and their individual health care needs. Details of hospital and chiropodists appointments were seen on the files examined. A relative spoken with stated that in their view the home is committed to keeping residents as well as possible. Residents seen all appeared well cared for and were appropriately dressed and well groomed. Medication was seen to be well managed, records were up to date and medication was stored appropriately. Staff who administer medication have completed external training. Staff were observed to offer advice and support to individuals in a discreet manner and to knock on doors and wait to be invited in before entering, thus respecting residents need for a degree of privacy. Trinity Court Nursing Home DS0000019130.V344145.R01.S.doc Version 5.2 Page 12 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14 & 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home offers a good range of activities and staff endeavours to support residents with their personal activities and interests. EVIDENCE: The homes Annual Quality Assurance Assessment states that the following “We provide varied social activities in accordance with the individualised and /or appropriate expressions of want from our residents plus group activities in which every resident is encouraged to join in, subject to their individual capabilities”. Inspectors found this to be the case. Residents are encouraged to participate but their individual wish is always respected. A record is maintained of activities that take place. Visitors seen on the day of the inspection and through questionnaires received confirmed that they felt welcomed in the home by staff at any time. Staff encourages residents to maintain contact with family and friends. Trinity Court Nursing Home DS0000019130.V344145.R01.S.doc Version 5.2 Page 13 Discussion with residents and staff indicated that residents make their own decisions on daily living activities such as when to get up, go to bed, what to do and what to eat. One relative in their questionnaire stated that they felt that they would like to see more verbal interaction with staff and residents. They also would like music or the TV to be played in lounges to relieve boredom. On the days on the inspection music and TV was seen to be used appropriately throughout the day. Another relative in their questionnaire stated “ I visit the home on a regular basis and I think that Trinity Court provides an excellent all round service.” The manager stated that the home receives regular visits from several church ministers and communion is offered to those who request it. An inspector observed the lunchtime meal being served. Care staff were seen to be sensitive to the needs of those residents who find it difficult to eat and gave appropriate assistance with feeding. Drinks were available for residents with their meals. Staff were aware of the importance of feeding at the pace of the resident, making them feel comfortable and unhurried. Residents spoken with were complimentary of the quality and quantity of food. The chef was seen to discuss the meal with residents. Comments received on the food included “ the meals are very good and well presented” and “there is a choice of meals which I like”. The menu was also seen and the meals on it were balanced and nutritional and cater for the varying cultural and dietary needs of the individuals using the service. Trinity Court Nursing Home DS0000019130.V344145.R01.S.doc Version 5.2 Page 14 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. JUDGEMENT – we looked at outcomes for the following standard(s): 16 & 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home has a complaints procedure in place. Residents and visitors confirmed that they were aware of the procedure. Staff receive training on safeguarding vulnerable adults, which ensures that they are aware of their responsibilities in relation to protecting residents. EVIDENCE: The home has a formal complaints procedure, which gives details of arrangements for dealing with complaints and concerns. The complaints book was examined and one complaint had been recorded which was still being investigated. One relative in their questionnaire said that in their view “ all complaints are dealt with very efficiently”. Staff spoken with were aware of the importance of safeguarding vulnerable adults and were fully conversant with the homes whistle blowing procedure, which provides a mechanism for staff to register any concerns they have about malpractice. Since the last inspection there has been three safeguarding adults meetings with Social Services. All were investigated by Social Services but none were found to be proven. The proprietor has treated each one seriously and has worked with the lead agency in providing information regarding care practices Trinity Court Nursing Home DS0000019130.V344145.R01.S.doc Version 5.2 Page 15 within the home. The home has a copy of the local authorities procedures for the reporting of and investigation of abuse. Trinity Court Nursing Home DS0000019130.V344145.R01.S.doc Version 5.2 Page 16 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. JUDGEMENT – we looked at outcomes for the following standard(s): 19,20,21,25 & 26. Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. The provider has ensured that the physical environment of the home provides for the individual requirements of the people who use the service who live there. The environment is able to meet changing needs of people who use services, along with their cultural and specialist care needs. EVIDENCE: The inspectors support the text made in the homes AQAA that states, “ our investment in infrastructure and equipment has resulted in a safe, secure and homely environment for out residents, including the lounge, dining room and garden areas. We maintain a high level of cleaning and maintenance through out the home”. Trinity Court Nursing Home DS0000019130.V344145.R01.S.doc Version 5.2 Page 17 The environment is fully able to meet changing needs of people who use services, along with their cultural and specialist care needs. It is fully accessible throughout to people with physical disabilities, adaptations and specialist equipment are designed to fit within the homely environment. People spoken to were happy with the environment. Comments from individuals included my room is “lovely”, “I like living here” and staff are helpful”. Relatives spoken with were also positive about the environment and its maintenance. Residents are encouraged and supported to personalise their rooms with pictures and their own furniture if they wish. A high standard of hygiene is maintained throughout the home. The home has a good infection control policy and will seek advice from external specialists when required. Trinity Court Nursing Home DS0000019130.V344145.R01.S.doc Version 5.2 Page 18 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. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29 & 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The number and skills of staff was appropriate at the time of the inspection. The home recruitment practices must improve to provide adequate protection for residents by ensuring that staff do not start working within the home without all required checks being carried out and written confirmation obtained. The home must ensure that all new staff completes a formal induction training, which is recorded on their file and is easily accessible. EVIDENCE: On the day of the inspection staff were available in sufficient numbers to meet the needs of residents. The roster also confirmed that adequate staff are employed. Management is currently looking at recruiting a Registered Mental Health Nurse as well as increasing the number of RGN and care staff on certain days of the week to ensure that the day runs more smoothly. The staff were seen to interact positively with residents throughout the visit seeking their opinion and preferences on a range of issues and were proactive in engaging residents in a meaningful way. Residents spoke highly of staff and the care they provide. Trinity Court Nursing Home DS0000019130.V344145.R01.S.doc Version 5.2 Page 19 The service has a recruitment procedure that meets the regulations and National Minimum Standards; however, this policy was seen not to be followed. Three of the files failed to evidence that that a POVA check had been carried out. Written references were not available on three of the files examined. In discussion with the proprietor and manager inspectors were informed that POVA checks were carried out and confirmation was given. The same was said of references where the referee had been contacted by telephone. However, failure to obtain written documentation following these checks potentially could place residents at risk. No staff should be employed without all the required checks being carried out and written confirmation received by the home. Staff meetings and supervision take place regularly and staff spoken with said that they found both helpful. The service ensures that all staff receive relevant training that is focussed on delivering improved outcomes for people using the service. However, evidence of the induction and statutory training was not clearly evident on the files examined. Discussion with Matron took place as to how this could be improved. Trinity Court Nursing Home DS0000019130.V344145.R01.S.doc Version 5.2 Page 20 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. JUDGEMENT – we looked at outcomes for the following standard(s): 31,33, 35, 36 and 38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The views of the residents and staff who use the service are listened to, valued and reflected in the development of the home. The home’s health and safety policies promote peoples safety. EVIDENCE: The registered manager has appropriate qualifications and experience for her role and was able to demonstrate a clear sense of direction. Equality and diversity issues are given priority and all individuals are encouraged to achieve their goals with staff support, if required. Trinity Court Nursing Home DS0000019130.V344145.R01.S.doc Version 5.2 Page 21 A quality assurance system is in place in which the views of residents, relatives and other stakeholders are sought. Monthly regulation 26 visits are taking place and the Commission is notified accordingly under regulation 37. Supervision was seen to be taking place. Residents and relative meetings have been introduced and as already stated one relative stated how good these meetings are. Health and safety checks take place to make sure that people are kept safe. A sample of records examined included COSHH assessments, landlords gas record, fire records and the portable appliance tests all of which were seen to be in order. Trinity Court Nursing Home DS0000019130.V344145.R01.S.doc Version 5.2 Page 22 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 3 X 3 3 3 X HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 4 4 4 X 4 X 4 4 STAFFING Standard No Score 27 3 28 3 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 3 X 3 Trinity Court Nursing Home DS0000019130.V344145.R01.S.doc Version 5.2 Page 23 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 OP7 Regulation 12 (1) (a) Requirement The care plans must be updated monthly to ensure that residents needs have not changed. The home must ensure that POVA first checks are obtained before any staff starts work in the home and that written references are obtained. The home must ensure that there is a clear record of staff induction and mandatory/refresher training for all staff. Timescale for action 30/08/07 2 OP29 19(4)(a) (b) Schedule 2 12 (1) (a) 30/07/07 3. OP30 30/10/07 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.V344145.R01.S.doc Version 5.2 Page 24 Commission for Social Care Inspection SW London Area Office Ground Floor 41-47 Hartfield Road Wimbledon London SW19 3RG 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 Nursing Home DS0000019130.V344145.R01.S.doc Version 5.2 Page 25 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!