Inspection on 12/10/05 for Trinity House Care Centre

This inspection was carried out on 12th October 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 Care Centre 12/01/09

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 29/03/05

Trinity House Care Centre 09/11/04

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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 09/07/2008.

CARE HOMES FOR OLDER PEOPLE Trinity House Care Centre Mace Street Cradley Heath West Midlands B64 6HP Lead Inspector Mrs Amanda Hennessy Unannounced Inspection 12th October 2005 09:30 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.V261940.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 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.V261940.R01.S.doc Version 5.0 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 Southern Cross Care Homes No 2 Limited Mrs Jane Griparis Care Home 35 Category(ies) of Old age, not falling within any other category registration, with number (35) of places Trinity House Care Centre DS0000004830.V261940.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. One service user who may be aged 60 years and over. Once the service user reaches 65 years or the placement is terminated, the condition will be removed and reverted to the original registration. One service user identified in the variation report of the 12 August 2004 may be accommodated at the home in the category DE. This will remain until such time that the service users placement is terminated. One service user (female) identified in the variation report dated 4.4.2005 may be 61 years and over. This will remain until such time that the service users placement is terminated. 2. 3. Date of last inspection 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. Trinity House Care Centre DS0000004830.V261940.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection and was carried out by two inspectors Mrs Mandy Beck and Mrs Amanda Hennessy. It took place between the hours of 1.30pm and 5.30pm. Care records were reviewed of five of the service users. Other time spent on the inspection included a tour of the building, talking to both service users and staff. Since the last inspection the homes ownership had changed and is now owned by Southern Cross Healthcare. The home has also had a change of manager; Amanda Shaw is currently in post as manager but needs to apply to register with the Commission for Social Care Inspection as soon as possible. The home has addressed 13 of the previous 17 requirements a further 6 requirements were made as a result of this inspection. Two further requirements were not assessed at this inspection What the service does well: What has improved since the last inspection? The home now has both a new manager and a new owner, both of whom appear to be enthusiastic about building on the homes strengths and addressing it’s weaknesses. Some of the outstanding requirements from the previous inspection had been met. There was evidence that service users had regular access to outside agencies such as chiropody and dentistry. Blood sugar monitoring is also being recorded appropriately further safeguarding service users. Fire testing is now being done on weekly basis and recorded. Trinity House Care Centre DS0000004830.V261940.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 Care Centre DS0000004830.V261940.R01.S.doc Version 5.0 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Trinity House Care Centre DS0000004830.V261940.R01.S.doc Version 5.0 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6 Service users who enter the home for intermediate care do not always have a comprehensive assessment of their needs which makes planning and delivery of their care difficult and maximising their potential problematical. EVIDENCE: Service users records reviewed during the inspection included two service users admitted for intermediate care beds. The documentation is disjointed and confusing to read because it is shared between two files, the single assessment process notes and the home’s own notes. In some cases assessment documentation had not been completed neither had care plans or care risk assessments. Staff are often not able to assess the service user before they enter the home into an intermediate care bed and therefore cannot be sure they can meet service user needs prior to admission. Staff have not received formal training about the ethos of intermediate care and it’s Trinity House Care Centre DS0000004830.V261940.R01.S.doc Version 5.0 Page 9 objectives and remain unsure of what is expected of them. There is evidence that specialist services visit service users during their short stay at the home. Trinity House Care Centre DS0000004830.V261940.R01.S.doc Version 5.0 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9 Service users health, personal and social care needs are not set out in an individual plan of care in which makes it difficult to understand what their needs are and if they are being met. Medication is administered safely. EVIDENCE: Individual plans of care are available for most service users but little progress has been made on the requirement to ensure that there are adequate records demonstrating levels of personal care received by each service user. Entries in daily notes give little indication of the actual care given, this was evident in one service users notes who had an indwelling catheter, grade 2 pressure sore and needed a hoist to help him with all transfers. These needs were not transferred to care plans subsequently no plan is available to meet these needs. Care risk assessments were not completed in some cases giving no indication of service user need or their management. Service users who had bed rails on their beds also had no risk assessment in place to justify their use and to indicate the management and reduction of risk. Service users are at risk of not having their healthcare needs met as a result of inconsistent record Trinity House Care Centre DS0000004830.V261940.R01.S.doc Version 5.0 Page 11 keeping. Service users have access to specialist medical, nursing, dental and optical services according to need. The home has appropriate policies for the safe handling and administration of medicines with all medicines being administered by qualified nurses. Clarity about the administration of those medicines with an “as directed” order on them needs to be sought, so that frequency of administration can be understood. Requirements made at previous inspection had been addressed. There is an appropriate record of prescriptions that have been ordered, when the prescription has been checked and medicines that have been received. Medicines are stored in the fridge where appropriate. The drugs fridge temperature is checked daily but they also need to record the maximum and minimum temperatures to ensure that medicines are safely stored. Medicines with a limited life after opening had no opening date recorded as required. The storage and administration of controlled drugs was checked and was found to be appropriate. The medication administration records were checked and were generally found to be completed appropriately. Trinity House Care Centre DS0000004830.V261940.R01.S.doc Version 5.0 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): None of the above standards were assessed at this inspection EVIDENCE: Trinity House Care Centre DS0000004830.V261940.R01.S.doc Version 5.0 Page 13 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16,18 The home has appropriate and comprehensive policies and procedures to highlight concerns and complaints and to safeguard residents from abuse. EVIDENCE: The home has a detailed complaints procedure. The complaints procedure is displayed in the main reception area of the home and is also included in the service user guide. The home has received one complaint in the previous twelve months. This was investigated by the homes regional manager, the family withdrew their complaint. The home also has a “whistle blowing” policy for staff to highlight concerns whilst feeling safe to do so. Comprehensive adult protection procedures are in place and identify appropriate contact with the Police, Social Services and the Commission for Social Care Inspection. The majority of staff have received training in adult protection and awareness of what constitutes abuse. Trinity House Care Centre DS0000004830.V261940.R01.S.doc Version 5.0 Page 14 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19,26 The home is well maintained and pleasantly decorated. Infection control practices are generally satisfactory but need to be further developed to further safeguard service users. EVIDENCE: Areas of the home seen were found to be well maintained, pleasantly decorated, homely and clean. There is a small pleasant patio area which can be accessed off the dining room. There is good access throughout the building where residents are accommodated, with a range of aids and adaptations available for dependent people. Infection control procedures within the home generally meet required guidelines and requirements. It was noted that sheets and incontinence aids were being washed at too low a temperature to minimise the risk of cross infection, this was immediately brought to the attention of the Manager. The laundry floor is not impermeable and cannot be easily cleaned as required. Trinity House Care Centre DS0000004830.V261940.R01.S.doc Version 5.0 Page 15 Trinity House Care Centre DS0000004830.V261940.R01.S.doc Version 5.0 Page 16 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27 Staff numbers do not meet the dependency and needs of the service users and should be increased EVIDENCE: Staffing numbers and the skills and expertise of staff meet the needs of residents during the day. The home is staffed with the following: 08.00-14.00 1 trained nurse and 6 care staff 14.00-20.00 1 trained nurse and 5 care staff 20.00-08.00 1 trained nurse and 2 care staff night care staff levels were a concern at the time of inspection and place service users at increased risk. An immediate requirement was issued asking for a review of staffing numbers and of the dependency of service users to ensure that there needs are being met. The home also has domestic, laundry and catering staff employed daily. Trinity House Care Centre DS0000004830.V261940.R01.S.doc Version 5.0 Page 17 Trinity House Care Centre DS0000004830.V261940.R01.S.doc Version 5.0 Page 18 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 33,35 The home does have a quality assurance system but there is a need to undertake a service user survey to ensure that the home is being run in their best interests. Service users monies are stored safely within the home EVIDENCE: Southern Cross homes have an identified Quality plan for all their homes. Quality audits are undertaken six monthly with corrective actions identified, with a copy of the audit sent to both the Area Manager, Regional Manager and Regional Director. The home undertake audits of pressure sores, service users weights, accident statistics, vacancies and recruitment, the kitchen and a review of all regulation 37 notifications that have been sent to the Commission for Social Care Inspection (CSCI). Service user surveys are undertaken by the company but details of the findings are not consistently communicated with the Home Manager. The Manager was advised to undertake a survey of all service users views on the home. Trinity House Care Centre DS0000004830.V261940.R01.S.doc Version 5.0 Page 19 A random sample of service users monies was chosen, there were some discrepancies in all of the files. One service user had more money than the balance recorded; another had no receipts of proof of purchases. There is only one signature for all transactions and no evidence that the service users have any involvement in managing their money. This must be addressed and regular audits need to be carried out to prevent errors and omissions occurring in future. Trinity House Care Centre DS0000004830.V261940.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 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 X X X X X 1 HEALTH AND PERSONAL CARE Standard No Score 7 1 8 1 9 3 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 x 13 X 14 X 15 X COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X X X X STAFFING Standard No Score 27 2 28 X 29 X 30 X MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X X 2 X 2 X X X Trinity House Care Centre DS0000004830.V261940.R01.S.doc Version 5.0 Page 21 Are there any outstanding requirements from the last inspection? Yes 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 OP6 Regulation 18 Requirement The home must ensure that it can meet the needs of those service users in an intermediate care bed prior to their admission Staff should receive appropriate training so that they feel confident to meet the needs of those service users. Service user plans must be in sufficient detail to provide clear guidance to staff on the actions to be taken to meet their health and welfare needs. Service user plans must be kept under review The laundry floor must be continuous and laundry must be laundered at the required temperatures to minimise the risk of cross infection. Review the staffing arrangements for the night shift to ensure that sufficient staff are deployed to meet the needs of the people who use the service The manager must apply for registration with the commission A review of service users views of the home must be undertaken DS0000004830.V261940.R01.S.doc Timescale for action 31/12/05 2 OP7 15 31/10/05 3 OP26 13(3) 31/12/05 4 OP27 18 14/10/05 5 6 OP31 OP33 8 24(2) 31/10/05 31/12/05 Trinity House Care Centre Version 5.0 Page 22 7 OP30 18/23 8 OP35 13 with the results shared with service users and all interested parties including the Commission for Social Care Inspection. All staff must receive regular mandatory training to include adult protection, infection control, food hygiene, moving and handling, fire safety awareness, health and safety and first aid (previous requirement partially met) The registered manager must be able to demonstrate that regular audits of service users finances are being undertaken. A policy for managing service user finances must be available for inspection. (previous timescale of 31/05/05 not met) 30/09/06 30/12/05 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 6 Good Practice Recommendations The home has further training for intermediate care and develop clear protocols for accepting service users into their home. Trinity House Care Centre DS0000004830.V261940.R01.S.doc Version 5.0 Page 23 Commission for Social Care Inspection Halesowen Record Management Unit Mucklow Office Park, West Point, Ground Floor Mucklow Hill Halesowen West Midlands B62 8DA 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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