Inspection on 07/07/05 for Trinity House

This inspection was carried out on 7th July 2005.

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

Other inspections for this house

Trinity House 12/12/06

Trinity House 08/12/05

Trinity House 20/12/04

Trinity House 24/08/04

Trinity House 25/02/04

Similar services:

Coopers Mill Ltd

Bramley Avenue (73)

Paradise Lodge

Grangewood

Upaya Ananda

Newton Court (1-2)

Kings Lane (32)

Pemdale

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 Final Report Unannounced 7th July 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 Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationary 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 I56 105 S17986 Trinity House V237414 UI 7.7.05 Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Trinity House Address 47 High Street, Manningtree, Essex CO11 1AH 01206 394550 01208 391216 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) Acorn Village Limited Mr Jeffrey Allan Peck Care Home 6 Category(ies) of Learning disability (LD) 6 registration, with number Learning disability over 65 years of age (LD(E)) of places 1 Trinity House I56 105 S17986 Trinity House V237414 UI 7.7.05 Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: 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 care by reason of a learning disability, whose name has been provided to the Commission for Socail Care Inspection The total number of service users accommodated in the home must not exceed 6 persons. Date of last inspection 20th December 2004 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. The home is managed by Acorn Village Limited, a registered Charitable Trust established in 1972, that also runs a 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 12 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 owing to a narrow staircases leading to bedroom accommodation.. Trinity House I56 105 S17986 Trinity House V237414 UI 7.7.05 Stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place on Thursday 7th July 2005 at 11.15am. Four staff were on duty including a senior support worker. The staff and residents spoken with provided positive views about the home and 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. Trinity House I56 105 S17986 Trinity House V237414 UI 7.7.05 Stage 4.doc Version 1.40 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 Standards Statutory Requirements Identified During the Inspection Trinity House I56 105 S17986 Trinity House V237414 UI 7.7.05 Stage 4.doc Version 1.40 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 1, 2 & 5. 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: The home has an informative statement of purpose and service users’ guide that meets the requirements of the National Minimum Standards. Residents are provided with a statement of the home’s terms and conditions between the home and resident, which includes details of all services that are extra to the fees. All six residents have lived at Trinity House for several years. At the previous inspection, the manager was clear that a full assessment would be obtained should a new admission to the home take place in the future. It was again evident from discussion with the staff that the home has the capacity and expertise to meet the needs of service users. Staff were well trained, committed and knowledgeable about the needs of residents and how their needs were to be met. Evidence was available to show the home was making changes to the way information is recorded and that residents are totally involved in the process. Trinity House I56 105 S17986 Trinity House V237414 UI 7.7.05 Stage 4.doc Version 1.40 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 6, 7 and 9. Residents’ care needs are well documented and individual risk assessments are in place. Residents have a care plan which they have been actively involved in preparing and which includes their wishes. EVIDENCE: Care plans were available for each resident and from the care plans sample checked, information was detailed and reviews are carried out at regular intervals. The home was in the process of making significant changes to the way care records were kept. From evidence available, residents are totally involved in the process and determine the content and layout of the care record. The file checked was easy to follow and contained photographs and information that confirmed that the resident was the focus and sole purpose for the file. Staff spoken with stated that in the time residents had spent living at the home, all had made some progress in their levels of confidence, independence and assertiveness. The home continued to offer every opportunity for residents to be involved in the day to day running of the home according to their level of ability. Residents are encouraged and enabled to take responsible risks according to their Trinity House I56 105 S17986 Trinity House V237414 UI 7.7.05 Stage 4.doc Version 1.40 Page 9 assessed abilities. Residents spoken with provided examples of how they are enabled to act independently and of those occasions when staff support was required. It was evident from discussions with staff and residents that the home operates as a “family like” unit where residents and staff discuss everyday issues in a relaxed and comfortable manner. Residents were observed as confident in their surroundings, at ease in the company of staff and free to move about the home as they wished.. Trinity House I56 105 S17986 Trinity House V237414 UI 7.7.05 Stage 4.doc Version 1.40 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12 & 13. Residents undertake an interesting and stimulating range of activities that are appropriate to the people involved. EVIDENCE: Evidence was available to show that all residents are enabled to participate in a range of interesting and stimulating activities. Each person has their own preferred activities identified and every effort is made by staff to ensure these are achieved. During the inspection a resident spoke about how enjoyable horse riding sessions were and liked going to the pub and Acorn Village for various other activities. The resident liked the opportunities available, the quality of the meals, the staff, and bedroom and described the lifestyle at Trinity as “I’ve got it made”. Residents spoke of how they were able to access the local community. They spoke of using the local shops, barbers, library, building society and pubs in Manningtree and of other facilities in the area. Depending on ability, residents are either accompanied by staff or assessed as being able to leave the house independently. Trinity House I56 105 S17986 Trinity House V237414 UI 7.7.05 Stage 4.doc Version 1.40 Page 11 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 18 & 19. Arrangements are in place to meet residents’ physical and emotional health care needs. EVIDENCE: 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 treat the home as their own. Records showed that residents‘ health care needs are addressed appropriately. Trinity House I56 105 S17986 Trinity House V237414 UI 7.7.05 Stage 4.doc Version 1.40 Page 12 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 22 & 23 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 or complaints 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 and definitions of abuse. Trinity House I56 105 S17986 Trinity House V237414 UI 7.7.05 Stage 4.doc Version 1.40 Page 13 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 24, 26 & 30. Residents benefit from being provided with a comfortable and safe accommodation. EVIDENCE: The home is ideally located in the centre of Manningtree and suitable for six service users. 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. The office is located on the first floor. The home is comfortable and homely in appearance and well maintained and has a rear garden that is reasonably private. Since the last inspection, new lounge armchairs have been purchased and all windows replaced with new double gazed units. The home was clean and tidy. Two residents’ bedrooms seen were homely in appearance and had been personalised by the residents. A shower unit in one bedroom is to be replaced. The kitchen was clean and tidy. Trinity House I56 105 S17986 Trinity House V237414 UI 7.7.05 Stage 4.doc Version 1.40 Page 14 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 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 33 & 35 Residents benefit from being supported by a team of well trained and motivated staff. EVIDENCE: 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”. A total of ten staff plus the manager are employed at Trinity House. The manager is currently taking the Registered Managers Award. Two staff are taking a National Vocational Qualification at level 3 and two staff NVQ level 2 One staff member has a NVQ 3 and three staff have a NVQ at level 2. Records showed that staff have also been provided with opportunities for other training that includes health and safety, the safe handling and administration of medication, the protection of vulnerable adults from abuse, communication, confidentiality and Maketon. Staff demonstrated that they seek the views of residents and involve them at every opportunity. Trinity House I56 105 S17986 Trinity House V237414 UI 7.7.05 Stage 4.doc Version 1.40 Page 15 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 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 42 Residents live in a safe environment although one aspect of health and safety may present a risk to residents and staff. EVIDENCE: Evidence was available to show that the home has a good standard of compliance with the health and safety requirements. Records checked showed that all equipment and services were being serviced appropriately. The last recorded fire drill was held on 26/5/05. The Control of Substances Hazardous to Health data sheets were available although these were not directly relevant to the products purchased. It was recommended that the home always buy their cleaning materials from the same source to ensure they have the correct data in the event of an accident. Trinity House I56 105 S17986 Trinity House V237414 UI 7.7.05 Stage 4.doc Version 1.40 Page 16 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score 3 3 x x 3 Standard No 22 23 ENVIRONMENT Score 3 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 3 3 x 3 x Score Standard No 24 25 26 27 28 29 30 STAFFING Score 3 x 3 x x x 3 Standard No 11 12 13 14 15 16 17 x 3 3 x x x x Standard No 31 32 33 34 35 36 Score x x 3 x 3 x CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Trinity House Score x 3 x x Standard No 37 38 39 40 41 42 43 Score x x x x x 2 x I56 105 S17986 Trinity House V237414 UI 7.7.05 Stage 4.doc Version 1.40 Page 17 yes 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 42 Regulation 12 Requirement COSHH data sheets must be relavant to products purchsed. Timescale for action 1/9/05 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard Good Practice Recommendations Trinity House I56 105 S17986 Trinity House V237414 UI 7.7.05 Stage 4.doc Version 1.40 Page 18 Commission for Social Care Inspection Fairfax House Causton Road Colchester CO1 1RJ 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. 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