Inspection on 12/01/09 for Trinity House Care Centre

This inspection was carried out on 12th January 2009.

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 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 House Care Centre 03/07/07

Trinity House Care Centre 03/10/06

Trinity House Care Centre 31/01/06

Trinity House Care Centre 12/10/05

Trinity House Care Centre 29/03/05

Trinity House Care Centre 09/11/04

Similar services:

Maple Lodge

Heathlands

Aston Court Nursing Home

Breme

Ravenhurst

Bank House

Inspirations

Ashcroft Hollow Nursing Home

Extracts from inspection reports are licensed from CQC, this page was updated on 19/06/2009.

CARE HOMES FOR OLDER PEOPLE Trinity House Care Centre Mace Street Cradley Heath West Midlands B64 6HP Lead Inspector Jean Edwards Unannounced Inspection 12th January 2009 07:30 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 House Care Centre DS0000004830.V373638.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 House Care Centre DS0000004830.V373638.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Trinity House Care Centre Address Mace Street Cradley Heath West Midlands B64 6HP 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) 01384 634350 01384 412138 trinityhouse@schealthcare.co.uk www.southerncrosshealthcare.co.uk Southern Cross Care Homes No 2 Ltd Jayne Griparis Care Home 35 Category(ies) of Dementia - over 65 years of age (1), Old age, registration, with number not falling within any other category (35) of places Trinity House Care Centre DS0000004830.V373638.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following categories of service only: Care Home with nursing To service users of the following gender: Either Whose primary care needs on admission to the home are within the following categories: Old age not falling within any other category (OP) 35 Dementia over 65 years of age (DE)(E) 1 The maximum number of service users to be accommodated is 35. 2. Date of last inspection 3rd July 2007 Brief Description of the Service: Trinity House Care Centre is situated in a residential area of Cradley Heath, which it close to the shops and local amenities. The home has three storeys and accommodates service users on all three floors. There are 31 single bedrooms and 2 double bedrooms all of which have en suite facilities. There are two lounges within the home situated on the first and ground floor. A large conservatory adjoins the lounge and is used as a dining room. The grounds are well maintained and there is a small car park to the rear of the property. The home is well maintained and is pleasantly decorated. The home had published information about fees stating fees vary between £334 and £719* and are dependant on the needs of the service user and the type of room that will be occupied. Items that are not covered by the fee include hairdressing, toiletries, chiropody and newspapers. * Please note fees will include the free nursing care contribution when applicable. Trinity House Care Centre DS0000004830.V373638.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. We, the Commission for Social Care Inspection (CSCI), undertook an unannounced key inspection visit. This meant that the home had not been given prior notice of the inspection visit. We visited the home over two days. We monitored the compliance with all Key National Minimum Standards at this visit. The range of inspection methods to obtain evidence and make judgements included: discussions with the registered manager, operational manager and staff on duty during the visit. We also had discussions with people living at the home, and made observations of people without verbal communications. Other information was gathered before this inspection visit including notification of incidents, accidents and events submitted to the CSCI. The registered persons submitted the homes Annual Quality Assurance Assessment (AQAA) as requested. We sent resident surveys, relatives surveys, health care professional and staff surveys to the home to be distributed and requested they be returned to the CSCI office in Birmingham. The collated results form part of this report. We toured the premises, including the grounds, communal areas of the home, the bathrooms, toilets, laundry, kitchen areas, and peoples bedrooms, with their permission, where possible. What the service does well: People living at the home told us that it was clean, warm and homely with kind and thoughtful staff, who were “wonderful”. Everyone had a very thorough assessment of their needs before they came to live at the home and this was used to plan how those needs and personal preferences would be met. There were also safe systems in place for people who wished to hold small amounts of money within the home. The support and assistance of other health care professionals was sought to make sure all health care needs are known about and met. We received comments from CSCI healthcare professional surveys, which included, the service has promptly sought medical advice when needed. They are very proactive in the managing other health care needs. Record-keeping good. People told us that they enjoyed the food, which was described as, excellent and plenty of it”. There was a choice of tasty, appetising home cooked meals and snacks and drinks were available throughout the day. The dining area provided an attractive place to eat and socialise, though people could choose to have meals in their own rooms if they wished. Trinity House Care Centre DS0000004830.V373638.R01.S.doc Version 5.2 Page 6 The staff were well trained in areas such as food handling, first aid, infection control, fire safety and moving and handling. The ratio of care staff with NVQ 2 training was 65 , which was positive. All staff had regular supervision to assist their development, review their practice and make sure they had the skills to give people the care and assistance they needed. Comments from CSCI surveys included, I have consistently witnessed good practice, knocking bedroom doors, speaking and listening respectfully. Other comments from CSCI surveys about what the home does well included, maintaining dignity and confidentiality, interacts well with service users and meeting their needs, good menus and kitchen service provided, well equipped home, training good. What has improved since the last inspection? The organisation had recruited a well qualified, experienced registered manager who had made considerable improvements in a short time. We received positive responses from staff including, Our home manager is the best we came across. She will roll her sleeves to anything and I admire her for that Senior Managers from the organisation had continued to undertake quality checks on all areas of the service to ensure that people were provided with a service, which met their needs and safeguarded them from risks of harm. The registered manager had taken a very proactive approach to complaints and the protection of vulnerable people, minimising risks of harm and improving the quality of service provided. She had also put in place a range of meetings and consultations so that people could share their views about the service. Examples were the monthly breakfast club, weekly surgeries for relatives and dignity champion. We were able to confirm the improvements claimed in the homes AQAA that there was now individualised person centred care in a friendly, homely atmosphere. There was generally a well informed team of staff, which enabled them to deliver good standards of care. Training had been continued for all grades of staff and it was very positive that a ratio of 65 of care staff had achieved NVQ level 2 or above, with more candidates undertaking training for these Awards. The registered manager had implemented a robust recruitment and selection process for new staff. This meant that people living in the home had good safeguards from risks of harm. The home was attractively decorated, with more proactive improvements planned. The organisation had continued to invest in new equipment, and Trinity House Care Centre DS0000004830.V373638.R01.S.doc Version 5.2 Page 7 importantly repaired the faulty passenger service lifts, which had caused distress and complaints. 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 Care Centre DS0000004830.V373638.R01.S.doc Version 5.2 Page 8 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 House Care Centre DS0000004830.V373638.R01.S.doc Version 5.2 Page 9 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, 2, 3, 4 Quality in this outcome area is Good. The home has a comprehensive and easy to read of purpose and service user guide and people living at the home have contracts terms and conditions of occupancy. This has the effect that people and their advocates have good information regarding their rights and entitlements, and how care will be provided. The home uses comprehensive assessment tools, which means that each persons needs are thoroughly assessed to ensure that their needs and preferences will be met. The home actively encourages introductory visits and there is evidence to demonstrate that people have been given the opportunity and time to make decisions, which are right for them. This Home does not provide intermediate care; therefore Standard 6 is not applicable. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The information contained in the homes AQAA about what it did well stated, Trinity House Care Centre DS0000004830.V373638.R01.S.doc Version 5.2 Page 10 Relatives and prospective service users are encouraged to look around the home and are offered the opportunity to spend the day or a few hours at the home before admission. People who come to live at the home have their needs assessed prior to admission. They are visited in hospital or their own homes by a senior nurse to discuss their needs and draft care plans are formulated. This gives the assurance that staff know they will be able to meet the service users needs before offering a placement. Brochures are given or posted to interested parties. The homes statement of purpose, service users guide and last inspection report are available to assist in enabling prospective service users and their families to make informed choices regarding admission to the home The homes AQQA cited the following supporting evidence to demonstrate what it did well, Service user enquiry form, service users guide, statement of purpose, last inspection report, activities programme, sample menu, news letter. Pre admission assessment book, draft care plan, letter to confirm needs can be met, service user contracts/terms and conditions of the home. The Homes AQAA also told us that in the past 12 months the following improvements had been made; Good response to enquires and pre-admission assessments are carried out on a timely basis. Additional electric profiling beds and pressure relieving mattresses. New service user assisted bath to the first floor bathroom. We viewed copies copy of the homes statement of purpose and service user guide, which was also provided in an audio format. The documents clearly set out the aims and objectives of Southern Cross and provided good clear information about the home. The documents included information about the range of fees, which gave people comprehensive information about the service to help them make decisions about the choice of home. We looked at a sample of case files of people recently admitted to the home, which demonstrated evidence that each person was provided with a contract and statement of terms and conditions. These were Southern Cross documents, which were easy to read and understand and set out in detail what was included in the fee, the role and responsibility of the provider, and the rights and obligations of the person living at the home. We saw evidence from a sample of care records at the home, from CSCI surveys responses and during discussions, which verified the good practices in the homes AQAA. Examples were pre admission assessments, which were conducted professionally and sensitively and had usually involved the family or representative of the person. The Southern Cross comprehensive preadmission assessment documentation was well completed and individual preferences were recorded such as rising, retiring, preferred activities, likes Trinity House Care Centre DS0000004830.V373638.R01.S.doc Version 5.2 Page 11 and dislikes. This meant that staff had good and accurate information about each persons needs and how they wished to be cared for. The staff we spoke to during the inspection were knowledgeable about each persons needs and preferences. They told us they felt well supported with good access to information and training to give them the skills to meet the needs of people living at the home. Trinity House Care Centre DS0000004830.V373638.R01.S.doc Version 5.2 Page 12 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 adequate. Each person has comprehensive care plans and risk assessments, which generally provides staff with the information and guidance to meet peoples needs and preferences. Good multi disciplinary working takes place on a regular basis, giving people assurances that their health needs care needs are identified and met. The service has a comprehensive medicine policy, which provides guidance for staff but medication practices do not always ensure people living at the home receive their medication as prescribed. People living at this home can be assured that they will receive dignity and respect at all times. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The homes AQAA stated, We use a range of assessments and input from the service users/families and health care professionals to develop individualised care. These are evaluated monthly or more frequently as indicated by the service users changing condition. The care plans detail the action required by Trinity House Care Centre DS0000004830.V373638.R01.S.doc Version 5.2 Page 13 staff to meet the identified needs of the service user. Healthcare. Needs area fully met by all service users being registered with a GP of their choice. We also liaise with other healthcare professionals – dietician, heart failure nurse, community psychiatric nurse, social worker, physiotherapist, speech and language therapist, dentist, optician, chiropodist, tissue viability nurse specialist. Named nurse and key worker system are in place. We manage medications in line with company policy and procedures. All staff administering medication have received accredited training and competency assessments. We treat all service users with respect and uphold their dignity. We looked at a sample of care provided for people with complex needs and we were able to verify the majority of claims made in the homes AQAA. We received positive comments from the CSCI healthcare professional surveys returned, such as, my client has only been in the home for just over four weeks, but so far the home has sought information regarding health care needs and have promptly acted upon the information received. We saw that people living at the home had comprehensive care plans, which staff instructions about what care they required and their personal preferences. Care plans were generally updated monthly and whenever possible staff tried to involve the person or their representative in the review. We looked at a sample of peoples care records and saw generally good evidence of healthcare screening tools, risk assessments and care planning implemented, monitored and maintained. This meant each person living at the home could feel assured that all their care needs were known about, understood and would be met. We also saw that there were risk assessments in place for the reduction of pressure ulcer development, falls, nutrition and moving and handling, which were reviewed monthly. We looked at the care of a person needing to be nursed entirely in bed, and requiring end of life care. This person was being cared for on nursing profile beds, which would minimise some of the discomfort when needing a change of position. We saw that the staff were knowledgeable and sensitive to this persons needs. We also saw a person with very limited movement, poor nutrition and a high Waterlow score with a support plan in place to maintain skin integrity. This person had developed a pressure ulcer whilst in hospital, behind the knee, which had deteriorated to grade 4, exposing the ligament and tendon. There were very good wound care plans in place, which included photographs and measurements. The home had made good progress with treatment to debride the wound and try to promote healing. Following discussions with the registered manager we established that a Regulation 37 notifications had been made to the CSCI and a safeguarding referral had been made to the safeguarding manager at Sandwell MBC. This demonstrated a good awareness Trinity House Care Centre DS0000004830.V373638.R01.S.doc Version 5.2 Page 14 of responsibilities and robust approach to safeguarding people from risks of harm. The home had a named nurse and key worker system, which should enable staff to establish special relationships and work on a one to one basis. We were told each person had access to community services such as chiropody, dentistry and the optician. We looked at the homes systems for the administration of medication for people living at the home. We noted that the home had copies of Southern Cross Health Care medication policies and procedures, providing comprehensive guidance for trained nurses administering medicines. We saw that there were 2 medication trolleys available but the nurse administering medicines told us everyones medication was stored in one trolley, which was transported around the three floors of the home. We discretely observed the administration of some peoples medicines, which was done a sensitive and person centred way. However the morning medication round had stated at 8.00am and had not been fully completed at 12.20, mid day. We acknowledged that the nurses had large amounts of medication to administer, some to unfamiliar people, some with complex needs. We considered the situation was posing the risks that people may not be given their prescribed medication at evenly spaced intervals. There may be excessive periods overnight or there may be insufficient time between antibiotics and pain relieving medicines. We noted that the MAR (Medication Administration Record) sheets had not been used to record receipt of all prescriptions, receipts of medicines, disposals, and destructions. Some medicines for people admitted recently were recorded as handwritten entries; many did not contain full details, and were not routinely signed and witnessed by two staff, increasing risk of errors. There were also an unacceptable number of gaps in the MAR sheets with no signature or code for non- administration. We tried to audit a sample of medication administered but were not always successful because receipt of medicines were not always recorded on the MAR records. An example was where someone was admitted from home and the quantity received for Allendronic Acid 70mgs weekly was not recorded. However there was a signature for 04/01/2009, and no signature for 11/01/2009. We asked the nurse to show us the container and we were told, there is none. Following further discussion no one was sure that this medication had been received or given. The registered manager made an immediate investigation and arranged for the persons relative to contact the GP for a new prescription. Furthermore the instructions for the administration of Allendronic Acid were not sufficiently detailed. This needed to be given at least half an hour before first food and drink with a full glass of water and arrangements for the person to be sitting upright or standing for half an hour following administration. We noted another person prescribed Allendronic Acid 70 mg weekly, had a pack brought in by Trinity House Care Centre DS0000004830.V373638.R01.S.doc Version 5.2 Page 15 relatives but this was not recorded on the MAR sheet. The medication was recorded on the pack as dispensed by the pharmacist on 24/12/08, there was one signature to indicate administration on 30/12/08 and the pack contained the full 4 doses. There were no other signatures or codes. We were unable to establish whether this person had received any of their prescribed Allendronic Acid. Another two audits indicated that there were discrepancies, though incomplete records and incomplete entries of variable dosages of medication such as Paracetamol and Warfarin made reconciliation difficult. We looked at the homes Controlled Drugs storage, controlled drugs held and the records of controlled drugs. We again had difficulty because official receipts of a controlled drug, liquid Temazepam had not been logged in the controlled drugs register or retained in compliance with legislation. We noted that there were had been 3 150 ml containers supplied since November 2008, two remained but the most recent bottle was being used, which did not demonstrate good stock control. The registered manager obtained copies of the receipts of the Temazepam from the pharmacy provider, which established there were no missing supplies. However a recording error had been made regarding the administration highlighting a small discrepancy of 5 mls. There registered manager and operations managers agreed to undertake an investigation and take appropriate action where needed, and will advise the CSCI of the outcome. The registered manager told us that she had undertaken formal supervision with staff, particularly the nurses, for their professional development. There was evidence that the registered manager had started to undertake rigorous quality monitoring audits of the medication system and competency assessments of nurses managing and administering medication. The registered manager shared her concerns that the nurses were not demonstrating compliance with the NMC guidelines for maintaining records and required and that additional monitoring and competency assessments were being implemented with training and support given as necessary. These were essential measures to ensure people receive their medicines as prescribed for their health and well being. We saw that staff treated people living at the home with respect and protecting their privacy throughout the inspection. During discussions staff demonstrated a good understanding of how to protect residents privacy and dignity. Trinity House Care Centre DS0000004830.V373638.R01.S.doc Version 5.2 Page 16 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. There is ample evidence of planned and spontaneous activities available on a regular basis offering people opportunities to take part in socially stimulating activities. People are enabled and encouraged to maintain good contact with family and friends. The dietary needs of each person are well catered for with a balanced and varied selection of foods that meets their preferences and nutritional needs. This judgement has been made using available evidence including a visit to this service. EVIDENCE: We noted that staff listened to people living at the home and made considerable efforts to provide flexible daily living routines, which enabled people to enjoy a good quality of life according to their personal preferences. We saw that people could get up for breakfast or have their meal in their bedroom at a leisurely pace. Throughout the two days there was a calm atmosphere, allowing people time to get up, go to bed and have drinks and food at times to suit them. We saw that there was a key worker system, which operated well and enabled closer relationships between staff and the people living at the home, where Trinity House Care Centre DS0000004830.V373638.R01.S.doc Version 5.2 Page 17 likes, dislikes and needs were known about and met. Key workers and the Activities Co-ordinator used the information and their knowledge of people to plan activities, which each person enjoyed. It was positive that people were aware of key workers names knew there always someone who would listen and respond. There was a good understanding for activities and access to socialisation. The home had developed a very good system of activities and socialisation, facilitated by the Activities Co-ordinator, who was also the homes Dignity Champion. We saw information for displaying and bringing peoples attention to community events and activities. It was very positive that it was understood and respected that some people preferred to spend their time in their own bedrooms, and they were supported with individual interests. A very positive initiative was the monthly breakfast club started by the registered manager, where a special breakfast was served and she and the activities co-ordinator held an informal meeting with people living at the home to encourage them to share their views and experiences of the home. We noted that there were a small number of people who were being nursed in bed or in their rooms. We saw that real efforts were made to maintain personal contact and socialisation according to their abilities and needs. We observed staff popping in to them throughout the inspection visit. We were told that one person liked the radio as background music and staff made sure this was tuned to the persons preference, Classic FM. We looked at a sample of peoples individual activities records, which were well completed, with refusals recorded and activities offered evaluated. The activities co-ordinator was employed for 20 hours each week and sometimes returned to events in the evenings, she also devised some new activities in her own time. Some examples of activities were a pub evening at the home, therapy sessions from Timeless Partnership, live music sessions, bingo, quizzes, and interactive games such as racing. The activities coordinator also produces a newsletter, with information, word searches, birthdays and a monthly theme. There were church services provided in the home from the Dudley Christian Fellowship, the local Baptist Church and Holy Trinity Church. We were told that there had not been many opportunities for trips and outings. This reflected comments such as, staffing levels limit opportunities to access community but within staffing levels choices are acted upon, received in response to the CSCI surveys. We also received positive comments from healthcare professional surveys such as, evident from review striving towards addressing all individuals needs including self care, productivity and leisure. Supporting client to maintain independence. Trinity House Care Centre DS0000004830.V373638.R01.S.doc Version 5.2 Page 18 We saw evidence that family and friends were welcomed and people spoken to told us they knew they could visit the home at any time. We were told that staff always made time to talk to visitors and share information with the consent of the person concerned. This was confirmed with positive comments from CSCI surveys such as, Social needs are also met very well with regular activities brought in, friendships are facilitated and encouraged. During the tour of the home there was good evidence that people were encouraged to bring in their personal possessions to personalise their room. We saw inventories of personal possessions on the sample of files examined, however not all were fully completed, or signed and dated by the person or their representative and witnessed by the member of staff. We discussed nutrition with the manager and staff, who were knowledgeable about each persons nutritional needs. We were told that a vegetarian choice was always offered, there were also diabetic and soft diets. We noted that tasty snacks and drinks were offered at various times each day. There was also added calorific value at mealtimes for people with poor appetite or at risk of weight loss, using cream, butter, cheese and pulses. It was very positive that a variety of fruit juices were available. Examples were apple, orange, grapefruit, pineapple and tomato. We discretely observed mealtimes and saw that staff were aware of the needs of people who found it difficult to eat and we noted that they offered sensitive assistance with feeding. They were aware of the importance of offering food at the persons pace, so that they were not hurried. The dining areas, especially the conservatory looked inviting with attractive tablecloths, napkins, crockery, wine glasses and condiments. The meals looked and smelled appetising, and meal times were protected to provide a sociable, enjoyable experience. We asked a sample of people about the food at meal times, and received very favourable comments, food wonderful and plenty of it, and lovely, always have a choice. We saw that visitors were invited to make drinks for themselves and the people they are visiting, which was very positive. Trinity House Care Centre DS0000004830.V373638.R01.S.doc Version 5.2 Page 19 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. People can be sure that any concerns and complaints are listened to and action is taken to look into them, with systems in place to record investigations and outcomes. There are good arrangements in place to safeguard people living at the home from risks of harm. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The homes AQAA cited the following evidence of what was done well, We record all complaints and inform appropriate others. Our complaints policy and procedure is available for all service users/relatives and representatives, which includes details for the company’s senior management team, social services and the commission for social care and inspection. We have an open door policy fro service users/relatives and staff. Staff are trained in abuse awareness. We liaise with the adults protection team for advice on any issues that concern us. The AQAA stated that there were improvements in the last 12 months, Implemented appropriate complaints register and have a more organised paper trail We saw that Trinity Care Centre had an up to date Southern Cross Healthcare complaints procedure, which was displayed in the reception area and contained in the service user guide. Information supplied as part of the Homes AQAA Trinity House Care Centre DS0000004830.V373638.R01.S.doc Version 5.2 Page 20 indicated that the home had received 16 complaints, in 12 months, which have been investigated by the provider within 28 days, with satisfactory outcomes. One complaint was upheld and resolutions implemented. The organisation had new complaint forms to record formal complaints, which were improved and much better for providing detailed information. We looked at the homes complaints log and noted that there were a total of 19 complaints. It was very positive that all complaints were recorded diligently and many recent complaints related to the defective passenger lift, which we saw was now in full working order. We discussed the results of the CSCI residents surveys, in which that 6 out of 14 people stated they did not know how to make a complaint. The registered manager assured us that she would discuss the complaints procedure at the next breakfast club meeting. There was evidence that each persons right to vote is registered as they wish. People were enrolled on the electoral register and had a proxy or postal vote to allow them to vote in elections, according to their citizens rights and wishes. We were told that the home had not received any allegations of abuse of vulnerable persons. There was a copy of Sandwell MBC multi-agency procedures relating to safeguarding vulnerable persons living at the home, however this was not the most up to date version. We recommended that the up to date edition of Sandwell MBCs Safeguarding Procedure be obtained and staff should be given time to read and familiarise themselves with signatures obtained to demonstrate their awareness. We saw from the homes training plan that 28 staff, which was 78 of the staff team, had been attended training, which provided appropriate awareness of safeguarding vulnerable adults. Staff spoken to were aware of what they needed to do should an incident occur. Trinity House Care Centre DS0000004830.V373638.R01.S.doc Version 5.2 Page 21 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, 21, 24, 25, 26. Quality in this outcome area is good. The standard of the decor within this home is good with evidence of improvement through proactive planning and continuous maintenance. The home presents as a safe, homely and comfortable environment for people living there. There are effective systems in place for maintaining infection control. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Trinity Care Centre Nursing Home was purpose built on three floors. It provided a bright and cheerful interior and the exterior of the premises was enhanced with containers, with display of winter flowering pansies. The tour of the building identified that a number of improvements have been made and the program of redecoration and refurbishment was continuing, with the majority of requirements for repairs and redecoration issued at the last inspection completed. Trinity House Care Centre DS0000004830.V373638.R01.S.doc Version 5.2 Page 22 The homes AQAA cited the following evidence as improvements made in the last 12 months; we provide a safe and homely environment. Staff receive training in infection control and health and safety. Specialist equipment is available for service users whose needs have been assessed as requiring such equipment. The internal and external structure of the home is well maintained. Service users are encouraged to add some of their own personal possessions if they so wish. We were told the following improvements had been made, We have made considerable investment in electric profiling beds, pressure relieving equipment, integral bedrails and bumpers and bed wedges to reduce the risk of entrapment. We also saw that a new shower had been provided and the room renovated to create a pleasant environment for people to enjoy bathing and showering. We saw evidence of a full audit of the home from which a prioritised programme of repairs, redecoration and replacement of equipment had been devised and was in the process of implementation. There was good visible evidence that the home continued to be refurbished, redecorated and repaired on an ongoing basis. . During discussion with people they told us they liked living at the home and that they regarded it as their home. We were told that the home was always clean, warm, and comfortable. The home had a courtyard garden, which could be accessed via the very attractive conservatory, was paved to enable people in wheelchairs access. The courtyard garden had raised flowerbeds, specially made tables and chairs, appealing statues and hanging baskets. The laundry areas were well equipped with commercial washers and a tumble dryer. The laundry service was exceptionally well organised and the designated laundry staff demonstrated very good standards of infection control. There was a laundry procedure and measures in place for supplies of disposable gloves and aprons readily available in the laundry. We noted that an additional tumble dryer would enhance the service to people living in the home. The homes main kitchen was also maintained in exceptionally good order, and it was clean and tidy and well organised. We noted that appropriate food hygiene and safety measures in place, with well-kept records, monitored by the registered manager, the organisation and Environmental Services. We saw the hairdressing room on the second floor, which had magnificent views and looked inviting, with mirrors and pictures. There were some additional improvements required at this visit, such as the replacement of damaged and heavily stained sluice facilities and the replacement of the defective flooring in the first floor bathroom. Equipment and facilities, which cannot be repaired or have impaired integrity, have the Trinity House Care Centre DS0000004830.V373638.R01.S.doc Version 5.2 Page 23 potential to place people at risk of infection. The home has had people admitted with MRSA and Clostridium Difficile infections and up date facilities must be installed and maintained to provide the highest level of infection control for people living at the home. We pointed out minor issues during the tour of the premises such as damaged non slip mat, scrubbing brush in sluice and defective over-bed light which were rectified immediately during the visit. We noted that the parker bath was not plumbed in and this should be rectified as soon as possible. The registered manager discussed proposed changes to the refurbished room on the second floor, which had housed the bath. The proposal was that as each person on the second floor had en-suite bathing facilities, the additional storage the former bathroom could create would have benefits for access around the corridors and communal areas. We agreed we would forward the proposal to the Regional Registration Team, with the proviso that each person was consulted and any agreed changes to be incorporated into an updated Statement of Purpose and Service User Guide. Trinity House Care Centre DS0000004830.V373638.R01.S.doc Version 5.2 Page 24 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 adequate. This home continues to maintain generally stable substantive staffing levels and people receive generally consistent and good standards of care, though there may not always be sufficient trained staff to effectively met peoples clinical needs. The staff recruitment processes are robust, which means that there are effective safeguards for people living at the home. The organisation and registered manager demonstrate a strong commitment to staff training and development. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The homes AQAA cited the following as evidence of what they do well, There is a qualified registered nurse on duty 24 hours a day. Staff numbers and skill mixes are maintained on a daily basis. Staff are recruited in line with company policy and procedures including CRB and POVA checks. Staff under go induction training. We have three in- house trainers. The homes AQAA also identified improvements, which could be aimed for over the next 12 months. These were, Recruit more permanent staff. Maintain training levels above 85 . Trinity House Care Centre DS0000004830.V373638.R01.S.doc Version 5.2 Page 25 We highlighted to the registered manager and operations manager that the home needed an increase to the numbers of registered nurses to ensure each persons needs were met in a timely way. We noted that there were 5 registered nurses to cover all shifts each week. Three employed to work on nights and two nurses working day shifts. One of these nurses was the deputy manager, who was allocated some supernumerary hours for supervision and monitoring. We noted that the nurses generally worked long day shifts; this meant they had to have reasonable rest breaks, not identifiable on the rota. We referred to the length of time was being taken to administer medication, especially in the mornings, when morning medication was still being administered after 12:30pm. We also made reference to comments received in response to the CSCI surveys. These included, the home is usually short staffed and from healthcare professionals, staffing levels limit opportunities to access community but within staffing levels choices are acted upon, and my own client has their needs met, not enough staff to attend church weekly although services are brought in. The registered manager acknowledged the validity of our observations and agreed that if additional staffing resources could be agreed with the organisation there would be real benefits for people living at the home. We were able to verify some good practices claimed from observations, discussions and examination of samples of records during this visit. We noted that there were 32 people accommodated, with a variety of dependency levels and diverse needs. The registered manager told us that she reviewed staffing levels on a regular basis, taking account of the occupancy and dependency levels of the people accommodated, which demonstrated good practice. However assessment of staffing rotas and information from the inspection visit and staff personnel records demonstrated that the home was sometimes not maintaining satisfactory staffing levels to met each persons needs fully or in a timely way. We also noted that a person with learning disabilities, whose primary needs were nursing care, and had been moved from another home, which had closed needed more individual support and assistance. We strongly recommended that the registered manager undertook a detailed assessment of individual needs and negotiated additional hours to support this persons lifestyle. The Home had a relatively stable staff team of 32 people including 20 care staff, 2 domestic staff, 2 laundry staff, 1 housekeeper, 1 activities coordinator, 1 gardener, maintenance staff, 1 administration staff, 5 first level nurses, the Registered Manager and catering staff. Eleven staff had left the homes employ since in the past 12 months for various reasons. The home had also experienced a higher level of absences due to sickness and maternity leave. The homes AQAA recorded that temporary or agency staff had covered 66 nursing shifts and 354 care shifts in the past 12 months. Trinity House Care Centre DS0000004830.V373638.R01.S.doc Version 5.2 Page 26 We looked at a random sample of staff personnel files, which were satisfactory. Interview questions and answers were retained on staff personnel files as a matter of good practice. The registered manager demonstrated robust recruitment practice, with very well ordered staff files and comprehensive documentation. There was good evidence that the PIN numbers for registered nurses were verified, recorded with expiry dates and were monitored appropriately. We noted that the organisation continued to demonstrate a strong commitment to staff training and development and had continued to provide all staff with appropriate training to raise awareness and skills to respond to peoples changing needs. We saw evidence that 65 of care staff had achieved an NVQ level 2 care award with new candidates registered for training. We were told that staff had an annual appraisal and saw evidence of a formal structured supervision system, and dates to show that staff, including nurses received regular supervision meetings and support and action plans where needed to develop and improve their practice. During discussions it was evident that staff felt supported. The comments received on CSCI surveys from staff included, I feel I can talk to the manager about my work load and look at ways to make targets easier to reach. Trinity House Care Centre DS0000004830.V373638.R01.S.doc Version 5.2 Page 27 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, 32, 33, 35, 36, 38. Quality in this outcome area is good. The registered manager provides effective leadership and good clear communication systems. The majority of staff demonstrate good awareness of their roles and responsibilities, which means that people can be assured of good standards of care and attention. The systems for consultation at Trinity Care Centre Nursing Home are good with ample evidence demonstrating that peoples views about the service are both sought and acted upon. The standard of record keeping and health and safety compliance at this home is very good, providing people with safeguards from risks of harm. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Trinity House Care Centre DS0000004830.V373638.R01.S.doc Version 5.2 Page 28 The Registered Manager, Jayne Griparis, appointed approximately 6 months previously, was in day-to-day control of the home. She was a Registered General Nurse (RGN), with the Registered Managers Award (RMA) and she had considerable nursing and managerial experience. We noted that a Regional Manager, the nominated representative of the Responsible Individual from Southern Cross Healthcare, provided supervision, support for the registered manager. This person had also undertaken regular quality monitoring audits and monitored the conduct of the home through monthly unannounced Regulation 26 visits and reports. We saw evidence of generally positive quality audits, which meant positive outcomes for people receiving the service, during this inspection visit. There were clear lines of accountability within the home, and through the management structure. We noted that the registered manager had devised and implemented the homes annual development plan for the current year. We saw very good evidence that the registered manager had used comprehensive self auditing systems, some introduced by Southern Cross Healthcare. These included monthly audits of areas such as peoples case files, tissue and pressure, staff personnel files, staffing levels and accidents, incidents and falls, with remedial actions to minimise risks identified. The manager was required to score the homes performance and compliance in each area. The registered manager and staff team have made commendable efforts to involve people living at the home, their relatives, representatives and other community stakeholders in the running of the home. We noted the initiative of regular breakfast club meetings with people living at the home and any relatives wishing to attend. The homes survey questionnaires had been distributed to residents and families and completed forms have been returned, with the results collated and published. We saw evidence that the results had been acted upon in any area where there were concerns or where performance needed improvement. It was very positive that the dates of the next residents and relatives meetings were published in the homes newsletter for the forthcoming 6 months. The registered manager had also alternated the times of meetings between 2pm and 7pm and refreshments were offered to encourage people to attend. The registered manager also held weekly surgeries for anyone wanting to talk to her on an individual basis, though she told us there was only a small take up of this service. However it was positive that relatives had been keen to be involved in fund raising activities, especially at Christmas, which the registered manager hoped to build on. We noted that staff meetings were taking place regularly, also at alternating times to encourage staff participation, with minutes posted on notice boards for staff unable to attend. The structured formal supervision system appeared to be working well and supervision sessions identified training needs, personal development and support. The registered manager was using the supervision system to assist nurses who she had identified were not always keeping accurate and up to date records and had been involved in errors with the Trinity House Care Centre DS0000004830.V373638.R01.S.doc Version 5.2 Page 29 medication system. This had obvious benefits for their work with people living at the home. We noted that people who came to live at the home were offered the opportunity to manage their own money if they wished, and the home provided facilities to help keep it safe. Where the home managed money on each persons behalf a system was in place to record transactions and accounts for spending. However we noted that residents monies in temporary safekeeping were held in a pooled account. Diligent records were kept of each persons account within the pooled account. We discussed these issues with the registered manager and agreed to seek advice from the CSCI PRM allocated to Southern Cross Services in the Midlands. We received a written response confirming National discussions had taken place between the organisation and CSCI. The following information was shared, Southern Cross are introducing an IT banking system called integrated funds solution. It brings together the system used to manage fees etc., with a system that can offer one bank account for service users to choose to use. This account is separate from any business accounts of the company and allows for individual named sub accounts for services users. Each service user accrues interest on their individual amount at the given rate for the account. The CSCI head of finance, and PRM attended presentations on this system sometime ago and have offered advice with regards to regulation and NMS only. CSCI would not endorse a commercial product. The system is accessible from the care service with security measures built in; we were told that there is a comprehensive auditing and reconciliation system operated from the system operator and the company. The system does not replace the need for records, receipts and signatures to be held in the care service to justify account activity and service user spending. We would also expect to see that residents using this have chosen to do so with full information and have agreed to its terms and conditions (on file) and that that decision is reviewed regularly. We have included this information in this report for guidance. We looked at a sample of heath and safety, fire safety and maintenance documentation, which was satisfactory and very well organised. There was ample evidence that all staff receive mandatory training commensurate with their roles; fire training, drills twice each year, moving and handling, first aid, food hygiene, health and safety and infection control training, commensurate with duties undertaken. There had been 88 recorded accidents, including incidents involving people living at the home in the past 12 months. We discussed one persons accident, incident, accident records, and body maps, which did not entirely reconcile. The registered manager agreed to investigate the discrepancies with the records with the nurses and put any remedial measures needed in place. The registered manager had an effective system for auditing, analysing and evaluating accidents involving residents, with effective measures implemented. Trinity House Care Centre DS0000004830.V373638.R01.S.doc Version 5.2 Page 30 Trinity House Care Centre DS0000004830.V373638.R01.S.doc Version 5.2 Page 31 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 3 4 3 X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 4 15 4 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 3 18 3 3 X 3 X X 3 3 3 STAFFING Standard No Score 27 2 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 3 X 2 3 2 3 Trinity House Care Centre DS0000004830.V373638.R01.S.doc Version 5.2 Page 32 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 OP9 Regulation 13(2) Requirement The registered persons must ensure that the records of the receipt, administration and disposal of all medicines for the people who use the service are robust and accurate to demonstrate that all medication is administered as prescribed. This is to safeguard the health and well being of people living at the home. 2. OP9 13(2) The registered persons must ensure that appropriate information relating to medication is kept, for example, in risk assessments and care plans to ensure that staff know how to use and monitor all medication including when required and as directed medication to ensure that all medication is administered safely, correctly and as intended by the prescriber to meet individual health needs. This is to safeguard the health Trinity House Care Centre DS0000004830.V373638.R01.S.doc Version 5.2 Page 33 Timescale for action 01/04/09 01/04/09 and well being of people living at the home. 3. OP9 13(2) The registered persons must take action to ensure that Staff who administer medication are assessed as competent and their practice must ensure that people living at the home receive their medication safely and correctly. This is to safeguard the health and well being of people living at the home. 4. OP30 18 The registered persons must take action to ensure staffing levels are reviewed in conjunction with occupancy and dependency levels to ensure that each persons needs are consistently being met throughout the day and night. This is to safeguard the health, well being and safety of people living at the home. 5. OP38 13(4) The registered persons must make the following improvements to the environment: 1) Replace the heavily stained sluices with equipment which will promote good infection control measures 2) Replace the defective flooring in the first floor bathroom. This is to safeguard the health and well being of people living at the home. 01/05/09 01/04/09 01/04/09 Trinity House Care Centre DS0000004830.V373638.R01.S.doc Version 5.2 Page 34 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 OP9 Good Practice Recommendations It is strongly recommended that staff record the date and time medication is commenced on the original container for ease of auditing. That all handwritten entries on MAR sheets are signed and witnessed by two trained competent staff to minimise the risks of errors. It is recommended that the up to date edition of Sandwell MBCs Safeguarding Procedure be obtained and staff should be given time to read and familiarise themselves with signatures obtained to demonstrate their awareness. It is strongly recommended that an additional tumble dryer be provided to enhance the laundry service for people living in the home. It was strongly recommended that the registered manager undertook a detailed assessment of an individual person with learning disabilities and nursing needs and negotiated additional staffing hours to support their lifestyle. 2. OP9 3. OP18 4. OP19 5. OP27 Trinity House Care Centre DS0000004830.V373638.R01.S.doc Version 5.2 Page 35 Commission for Social Care Inspection West Midlands West Midlands Regional Contact Team 3rd Floor 77 Paradise Circus Queensway Birmingham, B1 2DT 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 House Care Centre DS0000004830.V373638.R01.S.doc Version 5.2 Page 36 - 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. 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