CARE HOMES FOR OLDER PEOPLE
Trinity Fold Blackwall Halifax West Yorkshire HX1 2BZ Lead Inspector
Cheryl Stovin unannounced 5th May 2005 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 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 Fold J52J01_s997_trinity fold_v225545_050505.doc Version 1.30 Page 3 SERVICE INFORMATION
Name of service Trinity Fold Address Blackwall, Halifax, HX1 6BZ Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 01422 350887 01422 361947 Anchor Trust Ms A. Ackroyd Care Home 48 Category(ies) of 48 Older People registration, with number of places Trinity Fold J52J01_s997_trinity fold_v225545_050505.doc Version 1.30 Page 4 SERVICE INFORMATION
Conditions of registration: Conditons of registration are listed on the certificate displayed within the establishment. Date of last inspection 13/1/05 Brief Description of the Service: Trinity Fold is owned and managed by Anchor Trust and is registered to provide accommodation and care for up to 48 older people. The establishment is situated very close to the town centre of Halifax with easy access to public transport facilities. The property is purpose built and provides accommodation consisting of 48 individual bed-sitting rooms, each equipped with a kitchenette area and all having the provision of en-suite facilities. The bed-sitting rooms are unfurnished and service users are encouraged to furnish and equip the rooms with their own possessions. This results in the rooms being highly personalised in a style which truly reflects the occupants tastes and interests, this in turn aids orientation and independence. Communal areas are spacious and comfortable with sufficient space for social and recreational activities to take place. Externally there are well maintained and accessible garden areas and sufficient parking space for staff and visitors. Trinity Fold J52J01_s997_trinity fold_v225545_050505.doc Version 1.30 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This inspection took place over four hours on 5th May 2005. Four service users and several members of staff were consulted as to their views on the standard of services and facilities provided within the establishment. The residents spoken to all expressed great satisfaction with the facilities and care they receive at Trinity Fold. What the service does well:
The home is staffed by a well trained and motivated workforce committed to providing a high standard of care and attention to the service users. Service users’ choice and preferences regarding routines of daily living are assessed on admission and flexible packages of care are arranged to ensure that service users experience their preferred choice of lifestyle. An activities co-ordinator has recently been employed and works flexibly to enable a range of activities to take place at different times of the day and week, the activities on offer are displayed and include bingo, quizzes, carpet bowls and visiting entertainers. In addition to the organised activities, impromptu outings are also arranged. Service users are also encouraged and enabled to follow their own interests and hobbies. The residents’ committee is active and they are responsible for arranging the destinations for outings. Regular religious services are held within the establishment enabling service users to fulfil their spiritual needs. The local branch of the Mothers’ Union, of which several service users are members, regularly meets at the establishment. Anchor homes has a “pets’ policy” which enables service users to bring with them much loved well behaved pets. Details of the policy and the service users’ rights and responsibilities regarding pet ownership are detailed in the licence agreement. The service users’ private accommodation consists of 48 individual bed-sitting rooms all equipped with a kitchenette area and en-suite facilities. The rooms are unfurnished, apart from carpeting, and unless there is a reason why it is not possible, service users are expected to furnish and equip the rooms with their own possessions. This results in each of the bed-sitting rooms being highly personalised which truly reflects the individuals’ own tastes and interests. This in turn aids orientation and independence. Service users hold the key to their own front door, which is equipped with a door bell and a letter box. Trinity Fold J52J01_s997_trinity fold_v225545_050505.doc Version 1.30 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 Fold J52J01_s997_trinity fold_v225545_050505.doc Version 1.30 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 Standards Statutory Requirements Identified During the Inspection Trinity Fold J52J01_s997_trinity fold_v225545_050505.doc Version 1.30 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 standard(s) None of these standards were assessed on this occasion. EVIDENCE: Trinity Fold J52J01_s997_trinity fold_v225545_050505.doc Version 1.30 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 standard(s) 7,8,10 Service users’ needs are thoroughly assessed and the home has a good approach to promoting the service users’ health care. EVIDENCE: A detailed and holistic lifestyle agreement is in place for each service user. Individuals are encouraged to contribute to the drawing up of this document and to contribute to the written information recorded. Individual preferences regarding personal care and activities of daily living are recorded and flexible support packages are provided to ensure that service users receive care in accordance with their wishes. Service users’ physical and psychological health care needs are assessed and recorded in the plan of care. Specialist medical and nursing interventions are provided where appropriate, with the district nursing team visiting on a regular basis. Service users are encouraged to choose their own GP and are registered with local practices. Trinity Fold J52J01_s997_trinity fold_v225545_050505.doc Version 1.30 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 standard(s) 12,13,14 Service users are encouraged to exercise control and choice over their lives and are asked for their views on the service provided. EVIDENCE: Service users’ choice and preferences regarding routines of daily living are assessed on admission and flexible packages of care are arranged to ensure that service users experience their preferred choice of lifestyle. An activities co-ordinator has recently been employed and works flexibly to enable a range of activities to take place at different times of the day and week, the activities on offer are displayed and include bingo, quizzes, carpet bowls and visiting entertainers. In addition to the organised activities, impromptu outings are also arranged. Service users are also encouraged and enabled to follow their own interests and hobbies. Visitors are welcome to visit the establishment at any reasonable hour and visitors consulted during the inspection stated that they are always made to feel welcome. Guests can be greeted in the privacy of the service user’s own flat or in the spacious communal areas. Trinity Fold J52J01_s997_trinity fold_v225545_050505.doc Version 1.30 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 standard(s) 16,18 The home has robust systems to ensure that service users are safeguarded from abuse and that complaints are dealt with promptly. The home does, however, need to refer an ex member of staff to the POVA list. EVIDENCE: The establishment holds and adheres to the corporate Anchor complaints procedure which is displayed within the home. The organisation actively encourages comments and suggestions regarding the way the service is delivered. All staff have received training in adult protection awareness. Trinity Fold J52J01_s997_trinity fold_v225545_050505.doc Version 1.30 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 standard(s) 19,20,23,24,25,26 The home is well maintained, with high standards of cleanliness throughout, providing a pleasant and safe environment for service users. EVIDENCE: The establishment is purpose built and is situated very close to the town centre of Halifax with easy access to public transport facilities. The property is well maintained, both internally and externally, with a routine programme of maintenance and refurbishment. Safe, attractive and accessible garden areas with seating are provided for the service users to enjoy, especially during the summer months. The service users’ private accommodation consists of 48 individual bed-sitting rooms all equipped with a kitchenette area and en-suite facilities. The rooms are unfurnished, apart from carpeting and, unless there is a reason why it is not possible, service users are expected to furnish and equip the rooms with their own possessions. This results in each of the bed-sitting rooms being highly personalised which truly reflects the individuals’ own tastes and interests. This in turn aids orientation and independence. Service users hold the key to their own front door, which is equipped with a door bell and a letter box, staff do not enter without permission, except in an emergency
Trinity Fold J52J01_s997_trinity fold_v225545_050505.doc Version 1.30 Page 13 situation. Communal areas are spacious and comfortable with sufficient space for social and recreational activities. Trinity Fold J52J01_s997_trinity fold_v225545_050505.doc Version 1.30 Page 14 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27,28,29,30 The home is appropriately staffed to ensure the needs of the service users are met. EVIDENCE: The establishment is staffed by a well trained and motivated workforce in sufficient numbers to meet the needs of the service users. There is a commitment to NVQ training within the establishment with 85 of the staff team holding at least their NVQ II award. Staff were observed to be meeting the needs of the service users in a sensitive and caring manner with appropriate use of informality and humour. The service users with whom the inspector consulted expressed great satisfaction with the staff team as a whole. Trinity Fold J52J01_s997_trinity fold_v225545_050505.doc Version 1.30 Page 15 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) None of these standards were assessed on this occasion. EVIDENCE: Trinity Fold J52J01_s997_trinity fold_v225545_050505.doc Version 1.30 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score N/A N/A N/A N/A N/A N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 N/A 10 3 11 N/A DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 N/A
COMPLAINTS AND PROTECTION 3 3 3 N/A 3 4 x x STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 N/A 1 N/A N/A N/A N/A N/A N/A N/A N/A Trinity Fold J52J01_s997_trinity fold_v225545_050505.doc Version 1.30 Page 17 no 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. Standard 18 Regulation 19 Requirement An ex member of staff convicted of an offence of theft must be referred to the POVA register. Timescale for action July 2005 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 Good Practice Recommendations Trinity Fold J52J01_s997_trinity fold_v225545_050505.doc Version 1.30 Page 18 Commission for Social Care Inspection Park View House Woodvale Office Park Brighouse HD6 4AB National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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