Inspection on 12/12/06 for Trinity House

This inspection was carried out on 12th December 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found no outstanding requirements from the previous inspection report, but made 6 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Trinity House 08/12/05

Trinity House 07/07/05

Trinity House 20/12/04

Trinity House 24/08/04

Trinity House 25/02/04

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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 House 47 High Street Manningtree Essex CO11 1AH Lead Inspector Brian Bailey Key Unannounced Inspection 12th December 2006 11:50 Trinity House DS0000017986.V323091.R01.S.doc Version 5.2 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Trinity House DS0000017986.V323091.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Trinity House DS0000017986.V323091.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Trinity House Address 47 High Street Manningtree Essex CO11 1AH 01206 394550 01206 391216 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) Acorn Village Limited Mr Jeffrey Allan Peck Care Home 6 Category(ies) of Learning disability (6), Learning disability over registration, with number 65 years of age (1) of places Trinity House DS0000017986.V323091.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. Persons of either sex, under the age of 65 years, who require care by reason of a learning disability (not to exceed 6 persons) One named person, over the age of 65 years, who requires by care by reason of a learning disability, whose name has been provided to the National Care Standards Commission The total number of service users accommodated in the home must not exceed 6 persons 8th December 2005 3. Date of last inspection Brief Description of the Service: Trinity House is registered under the Care Standards Act 2000 as a care home providing personal care and accommodation for 6 adults with learning disabilities, including one service user over the age of 65 years. Acorn Village Limited manages the home, a registered Charitable Trust established in 1972, that also runs a larger home for adults with learning disabilities at Mistley, Essex. The registered manager of Trinity House is Jeffrey Peck. Trinity House is located in the village of Manningtree, approximately 15 miles from Colchester. This period house is well maintained and presents as a homely environment. The accommodation is arranged on three floors. Bedrooms are for single occupancy and are located on the first and second floor. Communal rooms consist of a kitchen/diner and a sitting room. There is a small garden to the rear of the property. The home is ideally situated for access to the local community and facilities that include a supermarket, shops, bank and library. The home is unsuitable for persons with mobility difficulties because of the narrow staircases that lead to the bedrooms. As at 13/12/06 the range of fees charged for accommodation were stated as being £384 to £783 per week. Extras to fees are toiletries, hairdressing, private chiropody and leisure pursuits. Trinity House DS0000017986.V323091.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was a key unannounced inspection looking at the core standards for the care of adults. This report is based on a range of information that has been accumulated from our inspection records, a site visit to the home that took place on 12/12/06 at 1:50am, discussions and observations with residents, staff, questionnaires issued by CSCI and the records kept at the home. Comment cards were returned from relatives and residents and all indicated they were satisfied with the service provided. What the service does well: What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Trinity House DS0000017986.V323091.R01.S.doc Version 5.2 Page 6 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 House DS0000017986.V323091.R01.S.doc Version 5.2 Page 7 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 3 and 4. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Clear information is available to residents about the home and ongoing assessments of needs ensures the type and level of care provided is appropriate. EVIDENCE: All six residents have lived at Trinity House for several years. In the event of a vacancy, the manager would follow the organisation’s procedures to ensure that any prospective resident would have every opportunity to visit the home prior to any decisions being taken regarding living at the home. A prospective resident would be able to see the facilities available, meet the other residents and staff and to talk to them about the range of services provided to see whether the home would meet their needs. A range of information would also be available including the statement of purpose and resident guide. An assessment would also be carried out to enable the home to determine whether the person’s needs could be met. Records show that assessment and reviews are carried out on a regular basis. The home employs a trained and experienced team of staff, who are supported by a manager and an external staff team based at Acorn Village at Mistley, Essex. Trinity House DS0000017986.V323091.R01.S.doc Version 5.2 Page 8 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 & 9. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Resident’s benefit from being actively involved in the day to day running of the home and from being supported by a team of interested and experienced staff. EVIDENCE: Residents continue to be encouraged and enabled to participate in the day-today running of the home, with the kitchen being a favourite meeting place for residents and staff to meet. At the time of the visit, a resident was working with a support worker to try and identify the meal to be cooked that evening and the food that would have to be purchased. The atmosphere was calm and at no time were residents ignored or excluded from the conversation. From information provided on survey forms and from residents spoken with, they are offered choices and they gave examples of the activities they like to be involved in, the places they enjoy visiting, preferred holidays, pub visits, meals out and shopping. They spoke of looking forward to meal out with staff before Christmas. Residents spoken to were welcoming and looked at home in the surroundings, and from observation, have established excellent and warm relationships with Trinity House DS0000017986.V323091.R01.S.doc Version 5.2 Page 9 the staff. Residents were aware of the activities they had planned and said they were happy to continue with them, although they felt they could change their minds if they wanted to. Trinity House DS0000017986.V323091.R01.S.doc Version 5.2 Page 10 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15, 16 & 17. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents benefit from being supported as individuals and that they are given every opportunity to exercise their rights and to maintain contact with their family and friends. Residents are provided with a healthy and varied diet. EVIDENCE: Records were available that showed the meals selected by residents. Each resident has a day when they are able to choose the main meal of the day, however they did confirm that that they were able to select an alternative if they wanted and examples were given. They said they enjoyed going out for meals and spoke of having recently gone out with staff for a meal at a local pub. They also spoke of helping with food shopping and selecting items of food that they liked. Staff were observed to offer help and guidance to residents when choosing the menu and making the shopping list but did not take over. Food stocks were low although staff said they were due to go shopping. Residents’ rights and wishes to eat their meals in private and at their own pace was respected. Residents were observed to help themselves and to make sandwiches of their choice at the lunchtime. Trinity House DS0000017986.V323091.R01.S.doc Version 5.2 Page 11 Residents have unrestricted access to the house and garden and are able to entertain visitors in their rooms or the communal rooms. Staff were observed to talk to residents in a friendly and respectful manner at all times and acknowledged residents’ rights to choose when to be alone or in company. It continued to be evident from discussions with residents and staff, that living and working at Trinity House is enjoyable, lively and fun. Trinity House DS0000017986.V323091.R01.S.doc Version 5.2 Page 12 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 & 20. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Arrangements are in place to meet residents’ physical and emotional health care needs. EVIDENCE: Three residents continue to look after their own medication, which is kept in a locked cupboard in their rooms, but are assisted and monitored closely by staff. Risk assessments were available and decisions regarding who has control were recorded. Staff who assist with the administration of medication had received training from the community pharmacist. As indicated at previous inspections and from discussions with staff and residents, the home continues to provide residents with appropriate levels of care and in a manner that maximises their independence and rights to privacy and dignity. Residents determine their own lifestyle according to their level of ability. They are able to move freely around the home and to choose whether they wish to spend time on their own or in the company of staff or other residents. Staff were again observed to undertake their duties in a friendly, open and supportive way, using appropriate language. It was apparent that staff had established excellent relationships with residents who had been empowered to Trinity House DS0000017986.V323091.R01.S.doc Version 5.2 Page 13 treat the home as their own. Records showed that residents‘ health care needs are addressed appropriately. Trinity House DS0000017986.V323091.R01.S.doc Version 5.2 Page 14 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22 & 23. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home has appropriate arrangements in place to protect residents from abuse and to listen to any concerns or complaints. EVIDENCE: The home had an appropriate complaints procedure. No complaints had been received by the home or CSCI. Residents spoken with said they had no concerns and felt safe, and were happy living at Trinity House. A clear policy and procedure on the protection of vulnerable adults from abuse was available to all staff. Staff training had been provided to ensure they were aware of the main issues, procedures and definitions of abuse. Trinity House DS0000017986.V323091.R01.S.doc Version 5.2 Page 15 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24-28 and 30. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents benefit from being provided with a comfortable and homely environment, although some aspects of Health & Safety are a potential risk unless remedial action is taken. EVIDENCE: The home is ideally located in the centre of Manningtree and suitable for six residents. Local facilities are easily accessible with local shops, supermarket, banks, post office and a library nearby. Residents’ accommodation consists of six single bedrooms, four on the first floor and two on the second floor, which have en-suite WC facilities. All are provided with wash hand basins. It was noted that radiators in bedrooms and the bathroom were unguarded and the surface temperatures in two bedrooms was very hot. This is a potential hazard to residents and should be assessed to minimize the risk. Staff and residents said that an alarm fitted to a bedroom door to alert staff to movement during the night is so loud when activated that it wakes the whole house and is frightening. A reassessment is required to determine whether the objective for having the alarm is best achieved by this Trinity House DS0000017986.V323091.R01.S.doc Version 5.2 Page 16 means and is it an infringements of rights. The office is located on the first floor. Carpets in some areas will need to be replaced in the near future. The home is comfortable and homely in appearance and is well maintained, and has a rear garden that is reasonably private. The kitchen was clean and tidy. Trinity House DS0000017986.V323091.R01.S.doc Version 5.2 Page 17 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 33, 34 and 35. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents benefit from being supported by a team of trained and motivated staff. EVIDENCE: It was again very evident from observation and discussion with staff that they work well together as a team and are committed to supporting residents and meeting the aims and objectives of the home. Residents were at ease in their company and interaction between staff and residents was excellent. Staff training continues with three of the ten staff having completed a National Vocational Qualification at level 2, two staff are currently taking the qualification, three staff have NVQ level 3 and two staff are taking it. The registered manager has National Vocational Qualifications and the Registered Managers Award and is an NVQ Assessor. All staff have had food hygiene, fire, first aid and moving and handling training and the deputy manager has received supervision training. The staff roster was available that showed that the level of staff provided meets the requirements of the residents and the Department of Health guidelines for staffing “Residential Forum”. Trinity House DS0000017986.V323091.R01.S.doc Version 5.2 Page 18 The recruitment of staff continues to be carried according to set procedures that include obtaining two satisfactory references and Criminal Bureau Disclosure checks for all staff. Although the disclosures are kept at Acorn Village, the manager confirmed that information is available to show that disclosures had been obtained and when these had been received for each member of staff. Trinity House DS0000017986.V323091.R01.S.doc Version 5.2 Page 19 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 and 42. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Resident’s benefit from living in a home that is well managed. EVIDENCE: The manager is suitably trained and experienced to manage Trinity House, having obtained a National Vocational Qualification level 4 and the Registered Managers Award. The home has a Quality Assurance system in place, but evidence was not available to show when the views of relatives, residents and health care professionals was last obtained. One record indicated this was in 2004, but a survey should be conducted on an annual basis. The results of the survey would then need to be summarised and published and a copy sent to CSCI. Survey forms issued by CSCI in September 2006 show that relatives are confident about the standard of support provided at the home and feel reassured about the future. Survey forms completed by key workers in Trinity House DS0000017986.V323091.R01.S.doc Version 5.2 Page 20 conjunction with residents also indicate satisfaction with the home, knowing who speak to should they have a complaint and feeling they are able to make choices. Evidence was available to show that the home has a good standard of compliance with the health and safety requirements, although as already stated under “Environment” three issues were identified that require attention. Records checked showed that all equipment and services were being serviced appropriately. The last recorded fire drill was held on 14/11/06. Trinity House DS0000017986.V323091.R01.S.doc Version 5.2 Page 21 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 3 2 3 3 3 4 3 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 2 25 3 26 3 27 3 28 3 29 2 30 3 STAFFING Standard No Score 31 X 32 3 33 3 34 3 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 3 X 2 X X 2 X Trinity House DS0000017986.V323091.R01.S.doc Version 5.2 Page 22 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 YA24 YA42 Regulation 23 Requirement The registered person must take the appropriate action to ensure that residents are not placed at risk from the very hot surface temperatures of radiators. The registered person must reassess whether the alarm bell on the second floor is appropriate, an infringement or acceptable in its present form. The registered person must risk assess the need for a grab rail to be fitted by the steps in the bedroom adjacent to the bathroom on the first floor. The Quality Assurance system must be extended to include a regular survey of residents, relatives and other interested persons. COSHH data sheets must be relevant to products purchased. (Timescale of 1/2/06 not met) Timescale for action 01/02/07 2 YA24 23 01/02/07 3 YA29 23 01/02/07 4. YA39 24 01/04/07 5 YA42 12 01/02/07 Trinity House DS0000017986.V323091.R01.S.doc Version 5.2 Page 23 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 YA28 Good Practice Recommendations The registered person should consider making changes to the layout of the lounge to improve its appearance and provide more space. 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