CARE HOME ADULTS 18-65
Trinity House 47 High Street Manningtree Essex CO11 1AH Lead Inspector
Brian Bailey Unannounced Inspection 12:15p 8 & 14 December 2005
th th Trinity House DS0000017986.V270404.R01.S.doc Version 5.0 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.V270404.R01.S.doc Version 5.0 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.V270404.R01.S.doc Version 5.0 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.V270404.R01.S.doc Version 5.0 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 7th July 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 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 staircase leading to bedroom accommodation. Trinity House DS0000017986.V270404.R01.S.doc Version 5.0 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This unannounced inspection took place on 8th December at 12.15pm but as there was only one resident at home, an additional visit was carried on 14th December 2005 at 5.30pm. This was the home’s second unannounced inspection in the inspection year 2005/06. During the course of the two visits, all residents and five staff were spoken to. A partial tour of the building was carried out and the key standards not checked at the last inspection of Trinity House on 7th July 2005 were assessed, although this inspection focussed mainly on observing and meeting and discussing what it is like to live at the home with residents and staff. The inspection process was an enjoyable experience; residents and staff were happy to contribute and their views were positive about all aspects. What the service does well: What has improved since the last inspection?
A shower unit, a bed and an armchair in one bedroom have been renewed following advice from an Occupational Therapist.
Trinity House DS0000017986.V270404.R01.S.doc Version 5.0 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. Trinity House DS0000017986.V270404.R01.S.doc Version 5.0 Page 7 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.V270404.R01.S.doc Version 5.0 Page 8 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 the following standard(s): 3 and 4. Prospective residents would be provided with information and opportunities to visit in order to assess whether the home would meet their needs. 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. 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.V270404.R01.S.doc Version 5.0 Page 9 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 the following standard(s): 8. Residents 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: It was evident from the two visits that residents are encouraged and enabled to participate in the day-to-day running of the home. The kitchen appears to be a favourite meeting place for residents and staff to meet and spend time together chatting, planning and preparing meals. The atmosphere on both occasions was totally relaxed and at no time were residents ignored or excluded from the conversation. Residents spoken to said they are offered choices and gave numerous examples of the activities they like to be involved in, the places they enjoy visiting, preferred holidays, pub visits, meals out and shopping. Residents were observed to help with the washing up after their evening meal and to come and go as they pleased. Residents spoken to were welcoming and happy to contribute to the inspection process; they were relaxed and from observation, had excellent relationships with the staff. Residents were aware of the activities they had planned and
Trinity House DS0000017986.V270404.R01.S.doc Version 5.0 Page 10 said they were happy to continue with them, although they felt they could change their minds if they wanted to. Trinity House DS0000017986.V270404.R01.S.doc Version 5.0 Page 11 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 the following standard(s): 15, 16 and 17. 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 spoke of selecting an alternative if they wanted and gave examples. Residents said they liked the food and that they had sufficient. From observation of an evening meal, the meal looked very appetising and portions varied according to the wishes and appetite of residents. 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 aware that as residents choose the menu, they had to offer guidance on occasions to ensure there wasn’t too much repetition and the diet was a healthy option. Good food stocks were available that included fresh fruit and vegetables. Residents’
Trinity House DS0000017986.V270404.R01.S.doc Version 5.0 Page 12 rights and wishes to eat their meals in private and at their own pace was respected. 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 was evident from discussions with residents and staff, that living and working at Trinity House is enjoyable, lively and fun. Trinity House DS0000017986.V270404.R01.S.doc Version 5.0 Page 13 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 the following standard(s): 20. A safe system for looking after and administering medication by trained staff is in place. EVIDENCE: Three residents 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. Trinity House DS0000017986.V270404.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 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, procedures and definitions of abuse. The manager was clear that should a situation arise and the manager was off duty, staff would follow a procedure and contact senior staff based at Acorn Village and other appropriate people. Trinity House DS0000017986.V270404.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24 and 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 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. 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. In discussion with staff and residents, it was generally felt that the appearance of the lounge could be improved and more space provided if the step arrangement at the doorway could be redesigned. This would be especially helpful when all residents and staff are in the room. Trinity House DS0000017986.V270404.R01.S.doc Version 5.0 Page 16 Since the last inspection, a new shower unit, armchair and a bed have been provided in one bedroom following advice from an Occupational Therapist. The kitchen was clean and tidy. Trinity House DS0000017986.V270404.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32 and 34. Residents benefit from being supported by a team of well trained and motivated staff. EVIDENCE: It was apparent from observation and discussion with staff that they are motivated and committed to meeting the aims and objectives of the home. They had developed an excellent rapport with residents and worked well together. 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 NVQ 2, 3 & 4 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. Trinity House DS0000017986.V270404.R01.S.doc Version 5.0 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, information was available to show that disclosures had been obtained and when these had been received for all staff. However, the provider (Acorn Village HR Department) should issue a letter to Trinity House that states:
• • • • • • the name of the person; date of disclosure; level of disclosure; including POVA Check (if requested) the disclosure reference number; date POVAFirst check was received (if this was sought); and POVAFirst Reference number. Trinity House DS0000017986.V270404.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37 and 39. The home is managed effectively and residents enjoy the benefits of a safe and secure setting. 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 still needs to conduct regular surveys of residents, relatives, health care professionals and other persons interested in the well-being of residents to obtain their views. The results of the survey will need to be published and reflect any issues raised by the surveys. The manager was reminded that the home has COSHH data sheets relevant to products purchased. The manager stated that action was being taken to address this.
Trinity House DS0000017986.V270404.R01.S.doc Version 5.0 Page 20 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 X X 3 3 X Standard No 22 23 Score 3 3 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score X X 3 X X Standard No 24 25 26 27 28 29 30
STAFFING Score 3 X X X X X 3 LIFESTYLES Standard No Score 11 X 12 X 13 X 14 X 15 3 16 3 17 Standard No 31 32 33 34 35 36 Score X 3 X 2 X X CONDUCT AND MANAGEMENT OF THE HOME 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21
Trinity House Score X X 3 X Standard No 37 38 39 40 41 42 43 Score 3 X 2 X X 2 X DS0000017986.V270404.R01.S.doc Version 5.0 Page 21 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. 2 Standard YA42 YA34 Regulation 12 19 Requirement Timescale for action 01/02/06 3 YA39 24 COSHH data sheets must be relevant to products purchased. (Timescale of 1/9/05 not met) Information must be at the home 01/02/06 to show details of Criminal Record Bureau disclosures obtained for each member of staff. The Quality Assurance system 01/03/06 must be extended to include a regular survey of residents, relatives and other interested persons. 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. Trinity House DS0000017986.V270404.R01.S.doc Version 5.0 Page 22 Commission for Social Care Inspection Colchester Local Office 1st Floor, Fairfax House Causton Road Colchester Essex CO1 1RJ National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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