Inspection on 31/01/06 for Trinity House Care Centre

This inspection was carried out on 31st January 2006.

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

The inspector found 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 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 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 Announced Inspection 31st January 2006 09:30a 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.V274839.R01.S.doc Version 5.1 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.V274839.R01.S.doc Version 5.1 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.V274839.R01.S.doc Version 5.1 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. 12th October 2005 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.V274839.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an announced inspection undertaken by one Inspector. The inspection took place between 9.30am and 4.30pm. Care records were reviewed of four service users. Other time spent on the inspection included a tour of the building, talking to both service users and staff, a review of staff records and maintenance contracts and records. Feedback cards from residents and visitors were forwarded direct to the Commission for Social Care Inspection the home also sent pre inspection information about the home. Amanda Shaw is the home manager and has applied to be the home’s registered manager. The home has addressed four of the previous eight requirements a further eleven requirements were made as a result of this inspection. What the service does well: What has improved since the last inspection? What they could do better: Care assessment and planning care must be more effective to ensure that all service users needs are identified and that their needs are transferred into their plan of care. Staff must also ensure that they involve service users in both planning and evaluating their care. There is a need to ensure that there is Trinity House Care Centre DS0000004830.V274839.R01.S.doc Version 5.1 Page 6 a review of how pressure sores are managed to ensure that there is appropriate and required pressure equipment available. Staff must ensure that information is available about service user’s life history and preferred leisure interests to enable them to ensure that their social needs that meet their capabilities are met. The home has previously been disadvantaged by a lack of training opportunities for its staff. Staff are being encouraged to attend both mandatory and development training but there remains a considerable amount of training required to ensure that all staff have all required training. 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.V274839.R01.S.doc Version 5.1 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.V274839.R01.S.doc Version 5.1 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): 3 Pre admission assessments of needs are not complete which makes planning and delivery of their care difficult. EVIDENCE: Service users who are admitted for long term care do have a comprehensive assessment of their needs. Short stay service users admitted for intermediate care are assessed by a local Primary Care Trust member of staff but the assessment of these service users needs do not meet the requirements of the National Minimum Standards. Staff must ensure that whenever possible the service user or their representative are involved in the assessment of needs and this is recorded. A photograph of the resident was not available in any of the care files seen. A record of the service users financial appointee is not always recorded. Trinity House Care Centre DS0000004830.V274839.R01.S.doc Version 5.1 Page 9 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): 7,10 Care plans are not accurate and do not include all service users needs which does not give assurance that their needs will be met. Service users privacy is respected. EVIDENCE: Individual plans of care are available for service users. Care plans do not accurately represent service users needs and choices. One service user who had identified that she preferred a bath had a care plan that identified that she should have at least a weekly shower. It was also noted that the above service user had no record that she had had either a bath or shower since her admission in early December. There was only one record that another service user had had a shower within four weeks of their admission. It was again highlighted that service users care plans did not reflect changes to their needs. Instruction given by a Tissue Viability Nurse to manage and assist the healing of a pressure sore had not been transferred into their plan of care. Service users do not have appropriate pressure relieving equipment to protect their skin and assist the healing of existing pressure sores. Trinity House Care Centre DS0000004830.V274839.R01.S.doc Version 5.1 Page 10 Service users spoken to during the inspection and comment cards returned before the inspection said that staff treat them with respect and uphold their right to privacy. Trinity House Care Centre DS0000004830.V274839.R01.S.doc Version 5.1 Page 11 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): 12,13, 14, 15 Service users social needs and recreational needs are not fully explored this gives no assurance that social and recreational needs are met. Services users are able to exercise choice and control over their lives and maintain contact with friends and family. Meals are nutritious offering a healthy and well balanced diet for the service users. EVIDENCE: Daily routines are flexible, service users can choice where they spend their day, have their meals, get up and go to bed. There is only limited information about service user’s life history and preferred leisure interests. There is need for staff to transfer service users preferred recreational and leisure interests into a social plan of care. The home has monthly visits for the mobile library, with staff ensuring that residents who are unable to see to read have access to talking books. One service user was celebrating her hundredth birthday. Staff had arranged a number of surprises for the celebration including a visit from children from the local school who come into the home every week to read to the service users, a visit from the local paper. The service users family visited Trinity House Care Centre DS0000004830.V274839.R01.S.doc Version 5.1 Page 12 and said that they greatly appreciated the care that their mother receives. Families spoken to say that they are encouraged and enjoy, taking part in the various social events that the home holds. Service users and visitors spoken to during the inspection and comment cards forwarded to the Commission for Social Care said that visitors are also always made welcome. The home has open visiting hours although visitors wishing to visit either early in the morning or late at night should check with staff. Service users spoken to say that they are able to get up and go to bed when they wish, have a choice of meals and are able to choose whether they take part in the activities and social events. The home has a four weekly menu which offers choice tasty and nutritious food. Breakfast is served from 7.30 until approximately 10.30am. Lunch is served at 12.30. Tea is served at 17.00. Supper is served at 20.30 Residents and staff confirm that snacks and a supper are available should they require anything later in the evening. Residents or their families are asked to give their choice of meal for the next day. On the day of the inspection there was: chicken and mushroom pie or fish pie with mashed potatoes, carrots and cauliflower. Coconut cake and custard, fresh fruit or yogurt for pudding. The home also prepares soft, pureed and diabetic meals as required. Residents spoken to made positive comments about the food. Staff were seen to offer discreet assistance to residents cutting up their food and feeding those residents who are totally dependent. Trinity House Care Centre DS0000004830.V274839.R01.S.doc Version 5.1 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): 18 The home safeguards service users from abuse. EVIDENCE: The home has a Southern Cross adult protection policy. Local authority adult protection policies are available but the home needs ensure that local policies are referenced and incorporated into their adult protection policy. All staff spoken to had good awareness of what is abuse and appropriate actions to be undertaken in response to any abuse allegations. Staff training in abuse awareness is ongoing for all staff. Trinity House Care Centre DS0000004830.V274839.R01.S.doc Version 5.1 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 The home is clean, well maintained and pleasantly decorated. EVIDENCE: Areas of the home seen were found to be clean, well maintained, pleasantly decorated and free from any offensive odour. A requirement to address infection control requirements in relation to the laundry floor have not been addressed. Trinity House Care Centre DS0000004830.V274839.R01.S.doc Version 5.1 Page 15 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): 28,29,30 Staff training opportunities have previously been limited but must be increased to ensure that the home has an experienced and well trained work force. Recruitment and selection procedures are generally robust and to protect service users. EVIDENCE: The home has 6 of its twenty-two care staff qualified to a minimum of National Vocational level (NVQ) two in care. The home is not meeting the requirement of 50 of care staff with NVQ level 2 however a further 3 care staff have almost completed their NVQ qualification. Recruitment and selection safe guards service users. Staff files of recently recruited staff included required information with the exception of a photograph of the new staff. It is advised that an employment history of at least ten years is requested. The Manager is also advised to ensure that she undertakes a risk assessment if staff are employed without a criminal records check but with confirmation that the member of staff does not appear on the protection of vulnerable adults list. All new staff have induction training but the new training is not as comprehensive as the previous training. The Manager was unable to confirm that the induction training programme is to National Training Organisation standards. Staff do not undertake foundation training as they are encouraged to enrol to undertake their NVQ qualification. Staff receive at least three training days each year. Trinity House Care Centre DS0000004830.V274839.R01.S.doc Version 5.1 Page 16 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): 36,38 EVIDENCE: The Home has an experienced Home Manager. Staff are supervised on a day by day basis by a qualified nurse on duty at all times and senior care staff. Staff supervision has commenced but records seen show that supervision is not undertaken as frequently as required. The Manager also needs to review the frequency that new staff receive formal supervision. Procedures to protect service users include regular and required checks on the fire alarm, emergency lighting, fire extinguishers, nurse call points and hot water. There is a need that the storage and distribution temperature of hot water for each hot water cylinder is recorded monthly. Trinity House Care Centre DS0000004830.V274839.R01.S.doc Version 5.1 Page 17 Records identify that the majority of staff regularly attend mandatory training in fire safety, moving and handling, food hygiene, first aid, health and safety, infection control and protection of vulnerable adults. Staff do not all have two fire drills each year as required. The home has been experiencing problems with the central heating system, this has almost been resolved but as a result no service certificate was available. Maintenance records and contracts reviewed were found to be up to date with the exception of the five yearly electrical installation test certificate. Trinity House Care Centre DS0000004830.V274839.R01.S.doc Version 5.1 Page 18 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 2 x x x HEALTH AND PERSONAL CARE Standard No Score 7 1 8 x 9 x 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 x 17 x 18 2 3 x x x x x x x STAFFING Standard No Score 27 x 28 1 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score x x x x x 2 x 2 Trinity House Care Centre DS0000004830.V274839.R01.S.doc Version 5.1 Page 19 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 OP3 Regulation 14 Requirement Service admitted to the home must have a comprehensive assessment of their needs. Service users or their representative must be involved in the assessment of their needs and this should be recorded. 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. Part met- assessment of needs not complete and staff have not received required training. 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. Part met- care plans do not identify all needs Trinity House Care Centre DS0000004830.V274839.R01.S.doc Version 5.1 Page 20 Timescale for action 28/02/06 2 OP6 18 30/03/06 3 OP7 15 28/02/06 4 OP8 15 5 OP18 13(6) Service users must have appropriate pressure relieving equipment (mattresses, cushions, foot muffs and leg troughs). The home’s Adult Protection is updated and refers to the local social services Adult protection policy. The laundry floor must be continuous and laundry must be laundered at the required temperatures to minimise the risk of cross infection. Part met- quotes have been obtained but work has not commenced. The home must have at least 50 of its care staff qualified to a minimum of NVQ level 2. The recruitment and selection of staff must meet all the requirements of the regulationsThe manager must ensure that a photograph is available of all staff. 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) All staff must attend induction and foundation training to National Training Organisation specifications. Staff must receive required supervision which is appropriately recorded. 28/02/06 31/03/06 6 OP26 13(3) 31/03/06 7 8 OP28 OP29 18 19 30/06/06 28/02/06 9 OP30 18/23 30/06/06 10 OP30 18 30/06/06 11 OP36 18 31/03/06 Trinity House Care Centre DS0000004830.V274839.R01.S.doc Version 5.1 Page 21 12 13 OP38 OP38 16,23 16,23 14 OP38 16,23 15 OP38 23 The storage and distribution temperature of hot water is recorded. A copy of the central heating service certificate is forwarded to the Commission for Social Care Inspection. A copy of the five year electrical installation test certificate is forwarded to the Commission for Social Care Inspection. Staff must receive two fire drills each year. 28/02/06 15/03/06 15/03/06 31/03/06 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 2 3 4 5 Refer to Standard OP8 OP8 OP18 OP29 OP29 Good Practice Recommendations The Manager seeks advice about for which service users the pressure reducing foam mattresses should be used. The type of pressure relieving equipment required for the service users is identified within their plan of care. A flow chart is available of Adult Protection procedures. An employment history for new staff of at least ten years is requested. A risk assessment is undertaken if staff are employed without a criminal records check but with confirmation that the member of staff does not appear on the protection of vulnerable adults list. Trinity House Care Centre DS0000004830.V274839.R01.S.doc Version 5.1 Page 22 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. Extracts may not be used or reproduced without the express permission of CSCI Trinity House Care Centre DS0000004830.V274839.R01.S.doc Version 5.1 Page 23 - 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. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!