Inspection on 22/04/08 for Trinity Street

This inspection was carried out on 22nd April 2008.

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 no outstanding requirements from the previous inspection report, but made 3 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Trinity Street 27/04/07

Trinity Street 31/10/06

Trinity Street 26/01/06

Trinity Street 13/07/05

Trinity Street 29/03/05

Trinity Street 29/09/04

Trinity Street 16/03/04

Similar services:

Whiteley House

Tyndale Avenue

2-10 Norfolk Road

Bennfield House Nursing Home

Eastfield Residential Home

Sign Health

Springwood

Fairburn Mews

Extracts from inspection reports are licensed from CQC, this page was updated on 28/09/2008.

CARE HOME ADULTS 18-65 Trinity Street 27 Trinity Street Batley Carr Dewsbury West Yorkshire WF17 7JZ Lead Inspector David White Key Unannounced Inspection 22nd April 2008 09:00 Trinity Street DS0000026333.V362503.R01.S.doc Version 5.2 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 Street DS0000026333.V362503.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 Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Trinity Street DS0000026333.V362503.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Trinity Street Address 27 Trinity Street Batley Carr Dewsbury West Yorkshire WF17 7JZ 01924 456160 01924 458001 Trinity.street@richmondfellowship.org.uk 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) Richmond Fellowship Vacant post Care Home 12 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (12) of places Trinity Street DS0000026333.V362503.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 27th April 2007 Brief Description of the Service: Trinity Street is a care home providing personal care and accommodation for up to 12 adults with enduring mental health problems. Nursing care is not provided. It is operated by the Richmond Fellowship, a national charitable organisation specialising in the care of people with mental health problems. The home is situated in a suburb of Dewsbury with good local amenities and easy access into the town centre. The home is purpose built and consists of 3 bungalows interlinked by glass corridors containing small conservatory areas. There are enclosed gardens to one side of the property. Each of the bungalows contains 4 single bedrooms with wash hand basins, and self-contained facilities for the communal use of people who live at the home. At the time of the visit on 22nd April 2008 the fees were 273.16 per week. This does not include costs for hairdressing, chiropody and toiletries. Information about the home in the form of a statement of purpose and a resident handbook as well as the latest Commission for Social Care Inspection report is available at the home. Trinity Street DS0000026333.V362503.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 1 star. This means that people who use the service experience adequate quality outcomes. The Commission for Social Care Inspection inspects homes at a frequency determined by how the home has been risk assessed. The inspection process has now become a cycle of activity rather than a series of one-off events. Information is gathered from a variety of sources, one being a site visit. More information about the inspection process can be found on our website www.csci.org.uk We went to the home without telling them that we were going to visit. This report follows the visit that took place on the 22nd April 2008. The visit lasted from 9am until 4pm. The purpose of the visit was to make sure that the home was operating and being managed in the best interests of people living there. Information has been used from different sources for this report. These sources include: • • • Reviewing information that has been received about the home since the last inspection. Information provided by the manager on an Annual Quality Assurance Assessment questionnaire. Surveys returned from four people who live at the home, two relatives and a social care professional. During the visit time was spent talking to three people who live at the home, three members of the care staff, the administrator and the manager. Documentation and records were also looked at as part of the site visit and time was spent observing the interaction between people at the home and staff. This all helped in gaining an insight into what life is like for people living in the home. The manager was available throughout the site visit and the findings were discussed with her at the end of the inspection. What the service does well: A thorough assessment is carried out before people move into the home. This means that people can be sure that the home will be able to meet their needs properly. Trinity Street DS0000026333.V362503.R01.S.doc Version 5.2 Page 6 People who live at the home feel that their needs are met. They are encouraged to make their own choices and this gives them control over their lives. A relative of one person who lives at the home commented ‘I did lose hope that there was no light at the end of the tunnel. Richmond Fellowship is that light. It has given my relative back his life and therefore mine’. People’s privacy and dignity is well maintained by staff who are sensitive and respectful to their needs. This helps in making sure people receive care in the way they prefer. A social care professional who has involvement with the home commented ‘the service respects people’s privacy and individual choices’. People who live at the home and a relative commented that the home is ‘clean and comfortable’. This helps to make the home a pleasant place to live for people. People said they are treated well and that any issues of concern are properly dealt with. They also feel their views are listened to. One person said ‘if I make a suggestion it is taken on board’. Staff have a good understanding of equality and diversity issues. This helps in making sure that people are respected as individuals and their rights are protected. The home makes sure that all new staff are fully checked before they start work and this helps to make sure that people are protected from possible harm. The home encourages people to tell them about the service. There are regular meetings for people living in the home and questionnaires are sent out approximately once a year. This enables people who live at the home to help in decision-making about how the home is run. What has improved since the last inspection? New person centred planning has been introduced. This helps to put the person using the service in control of planning their support needs and future goals. A financial agreement has been drawn up to say that people who use the service are in agreement with any monies that are held on their behalf by the home. The home has obtained information from agencies to confirm that workers who they supply to the home have been properly checked before being employed by the agency. This safeguards people from any potential harm. Staff are now receiving supervision on a more regular basis. This will help in making sure that they receive the support and guidance to meet people’s needs safely. Trinity Street DS0000026333.V362503.R01.S.doc Version 5.2 Page 7 The home has been re-decorated throughout and new furniture and beds have been bought. Bathroom areas have been fitted with new tiles to reduce any risks from cross infection. This makes the home a more pleasant, comfortable and safer environment in which to live. A karaoke machine, outside games and a computer have been purchased at the request of people who live at the home. This provides people who live at the home with more opportunity to do things they enjoy. Stock levels of ‘as required’ medication are now recorded in a better way so that this medication can be more easily accounted for. This will help in identifying how much medication is being used to make sure people’s health needs are being properly met and will minimise any potential risks to people. What they could do better: Fire doors could be closed at all times and not held open by unauthorised means so that people are not at any risk from the spread of fire. Better medication systems and procedures could be put in place to make sure that people receive medication when they need it and to reduce the risk of medication errors occurring. This will help in making sure that peoples’ health needs are properly met. Arrangements could be put in place for the checking of the home’s electrical systems so that any risks to people can be identified and acted on to protect their safety. Records of medications that are returned to the supplying pharmacist could be signed and dated by the member of staff returning them. This will help in identifying possible explanations if any discrepancies occur. Better staffing arrangements could be put in place on a weekend. This would enable people to have more opportunities to pursue their social interests. Care plan reviews could take place on a more regular basis so that if people’s needs are changing, care can be planned and updated to reflect this. Staff could have some mental health training to help develop their skills and knowledge in meeting the needs of people with mental health problems. Trinity Street DS0000026333.V362503.R01.S.doc Version 5.2 Page 8 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 Street DS0000026333.V362503.R01.S.doc Version 5.2 Page 9 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Trinity Street DS0000026333.V362503.R01.S.doc Version 5.2 Page 10 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 2. People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence including a visit to this service. People who use the service can be sure that the home will meet their needs following assessment. Written information is also available to them to help them with their decision-making about whether the home can meet their needs. EVIDENCE: The home has thorough pre-admission assessment procedures that are followed before people move into the home. When people are being considered for the home they and their relatives are sent information about the home and the referral process. Arrangements are then put in place for the manager or senior staff to go and see the person to carry out an assessment of their needs. Information is also collected from other sources such as the placing authority to support the home in their decision making about whether they have the skills and resources to meet the person’s needs. The assessment process includes a risk assessment of any risks that the person may be to themselves or others so that these can be identified at an early stage and a decision can be made about whether the home will be able to Trinity Street DS0000026333.V362503.R01.S.doc Version 5.2 Page 11 manage any identified risks safely. People are also asked to carry out a selfassessment of their needs including any perceived risks that they think they may present. Any person who is thinking about moving into the home is offered trial visits beforehand. The care records of a recently admitted person showed that a detailed assessment had been undertaken before the person moved into the home. Surveys returned by people who live at the home indicated that in most cases they were given enough information before moving in although one person felt that this was not the case. One person said, ‘I was given information about the home and had a visit before moving in’. A new application form intended for use in the referral process has been developed by Richmond Fellowship and is being used by the home as part of a pilot scheme. The manager said that this will provide more detailed information about people who are being considered for the home. She also said that it should speed up the pre-admission process so that people are not waiting too long for a placement if a bed becomes available. Placements can take longer if a female or male bed is needed and one is not available at that particular time. Trinity Street DS0000026333.V362503.R01.S.doc Version 5.2 Page 12 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 and 9. People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence including a visit to this service. People who use the service are involved in decisions about their lives. Improvements have been made to the way in which care is planned although this could be better monitored. EVIDENCE: Each person has an Individual Support Plan describing how people wish to be supported in meeting their needs. A lot of work has gone into improving the quality of the care planning documentation and there is now more emphasis on how each person prefers to be supported in meeting their aims and aspirations. There is information about people’s wishes for the present and future and their likes and dislikes. People living at the home said that they could choose their daily routines. One person said ‘I can get up when I want and choose what I want to do with my day’. Staff could describe the care and support they give to people and were observed to encourage people to make Trinity Street DS0000026333.V362503.R01.S.doc Version 5.2 Page 13 their own choices. Comments in a survey returned by a social care professional made said, ‘the service respects people’s privacy and individual choices as far as is practicably possible’. The majority of people are able to verbally express their needs. One person has communication difficulties and has speech and therapy input to help with this. There was evidence within the care plans that people are encouraged to be involved in the care planning process. People said that they have regular meetings with their key workers and records of these meetings are well maintained. One person said, ‘if I make a suggestion it is taken on board’. A new bed had been bought at the request of a person living at the home who suffers from back problems. Individual Support Plans are reviewed on a sixmonthly basis to look at how progress is being made in meeting people’s goals. Care plan reviews involving people living at the home, their relatives and relevant others are not consistently reviewed. Two people’s care records showed that reviews had not taken place for well over a year. This needs addressing so that any changing needs can be identified, actions are put in place and to make sure that staff are aware of each person’s up to date needs. Each care plan includes a range of risk assessments to promote people’s independence and safety. People who use the service are involved in the risk assessment process and there was evidence that these are being reviewed. Risk assessments take into account possible risks from self-harm as well as any potential risks to others. The daily records have improved and now reflect the support that has been given and the progress made by individuals. A relative survey told us they were very pleased with the care and services on offer and commented ‘I did lose hope that there was no light at the end of the tunnel. Richmond Fellowship is that light. It has given my relative back his life and therefore mine’. Trinity Street DS0000026333.V362503.R01.S.doc Version 5.2 Page 14 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15, 16 and 17. People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence including a visit to this service. People enjoy activities and have the opportunity to pursue their leisure interests most of the time. EVIDENCE: The home supports people to be independent and to pursue their hobbies and interests. People have access to college, voluntary work, local day services and other local facilities. One person said that they enjoyed their visits to the pub. Another person had previously attended a day service but did not enjoy it after a while so stopped going and staff respected this decision. Some people had enjoyed a holiday to Skegness last year and are looking forward to a planned holiday to Blackpool that is paid for by Richmond Fellowship. Two people had recently attended a theatre to see a show. The manager said that greater effort has been made to provide more in-house activities. Since our last visit a karaoke machine and a computer have been purchased at the request of Trinity Street DS0000026333.V362503.R01.S.doc Version 5.2 Page 15 people living at the home as well as some outdoor games and some people are involved in a gardening group. Some people prefer a more relaxed lifestyle and this is respected. In one person’s care plan it is stated that this individual likes to attend a church service on a Sunday. At times staff have been able to support the person to be able to do this. However, there have been occasions when this has not been possible because of staffing shortfalls. One person said, ‘it would be nice to be able to go for a ride in the home’s transport on a weekend but sometimes this is not possible because there are not enough staff on duty’. At the time of the visit people who live at the home looked to be getting on well together. One person did say that disagreements did happen from time to time but said that this was to be expected. People did say that they feel safe at the home. The home encourages people to maintain relationships with their family and friends and surveys returned by relatives all indicated that they are kept informed about matters. People said they liked the meals that are on offer. Meals are planned in advance with people and alternative meals are available if a person does not like what is on offer on a particular day. Some people are involved in the planning and cooking of their own meals although in most cases staff cook the main meal of the day. The menu is varied and there is a good selection of fresh produce and home cooked food available. Specialist diets are catered for as in the case of two people and consideration is given to healthy eating options. Where there are concerns about a person’s weight this is monitored and action is taken to address any areas of concern. People could be seen eating their meals in a relaxed unhurried atmosphere and have access to kitchens whenever they choose for drinks and snacks. Trinity Street DS0000026333.V362503.R01.S.doc Version 5.2 Page 16 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 and 20. People who use the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence including a visit to this service. Staff provide support in a respectful and dignified way. People who live in the home are at risk because of shortfalls in the medication systems and procedures. EVIDENCE: Each person’s support plan describes how support is to be given. One person said, ‘if I need any support this is given in private’ and each person has their own bedroom key. At the time of the visit staff could be seen knocking on people’s bedroom doors and only entered when invited to do so. One female needs support with bathing and receives this from female staff. A survey returned by a relative commented ‘I have been very happy with the support and kindness given to my relative. It has definitely helped his mental health’. Another relative said, ‘residents are given respect and gain self-respect and confidence’. Trinity Street DS0000026333.V362503.R01.S.doc Version 5.2 Page 17 People have a General Practitioner (GP) and access to other NHS services. A mobile hairdresser visits the home for people who do not wish to visit a hairdresser. People are supported to attend healthcare appointments. The manager has introduced new documentation about health care information so that it is easier to access information about the reasons for appointments and the outcomes from these. Some people who use the service have specialist health needs and referrals are made as needed as could be seen at the time of the visit when a Community Psychiatric Nurse was visiting the home in response to concerns raised by the home about the mental health of someone at the home. Another person was waiting for the District Nurse to visit to attend to a skin problem. Some changes have been made to the medication systems and procedures, however some areas of concern remain. Records of stock balances of ‘as needed’ are now better recorded so it can be more easily accountable for. This minimises risks from medication errors and helps in monitoring peoples’ health needs. People who wish to administer their own medication are able to do so. A risk assessment is completed first to make sure it is safe for them to do so. One person who is self-medicating had recently taken all their daily medication in one dose. The care records show that the risk assessment has been reviewed and measures have been put in place to minimise any risks to the person. Staff who administer medication receive the appropriate training. We have received two notifications in the last five months about medication errors. In one case a person was being given the wrong dosage of medication for a week. In a further recent incident a person was given another person’s medication. At the time of the visit one person was prescribed medication on a ‘when needed’ basis to alleviate pain. The Medication Administration Records showed that the person was taking this medication at regular intervals. However this medication had run out the previous day and had not been replaced. Whilst a member of staff was able to confirm that replacement stock had been ordered, this shortfall should have been picked up earlier to ensure there was sufficient medication at all times. In another case a person’s medication prescribed to alleviate pain had also run out and the home had experienced difficulty in arranging for a new stock supply to be sent from the supplying pharmacist. This delay had resulted in the person missing some doses of medication. It is also recommended that the record of medications that are returned to the supplying pharmacist is signed and dated to produce an audit trail if any discrepancies are found. Audits of the medication systems are carried out on a weekly basis but had failed to recognise these shortfalls that are impacting on peoples’ health needs being properly met. Trinity Street DS0000026333.V362503.R01.S.doc Version 5.2 Page 18 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23. People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence including a visit to this service. People who use the service and their relatives have their views listened to, taken seriously and acted on. Systems are in place to safeguard people from abuse. EVIDENCE: The home has a detailed complaints procedure. People living in the home are given a copy of this and said that they would know how and who to raise any concerns with. One person had made a complaint and the complaints records showed that this had been properly investigated and the person making the complaint had been informed in writing about the outcomes. Surveys returned by people living in the home all said that staff treated them well and acted on any concerns. Regular key worker and other meetings are held with people living at the home to give them the opportunity to voice any concerns. Some staff have received safeguarding vulnerable adults training whilst others that are relatively new to the service are due to attend the training. The manager said that safeguarding matters are discussed as part of the induction process for new staff. Staff spoken to demonstrated a good understanding of what constituted abuse and actions to be taken if it was suspected or had occurred. Since the previous inspection visit there has been one safeguarding matter. This was referred to the appropriate agency and dealt with properly. Trinity Street DS0000026333.V362503.R01.S.doc Version 5.2 Page 19 A number of policies are in the process of being updated. These include the policy on violence and aggression and the use of restraint. Individual risk assessments are carried out to identify any risks and measures that need to be taken to minimise these. Staff have received training on how to manage challenging behaviour. The home manages monies on behalf of two people who need support with this. A financial agreement has been drawn up with the involvement of both people to say they are in agreement with this arrangement and all incoming and outgoing monies are accounted for. Trinity Street DS0000026333.V362503.R01.S.doc Version 5.2 Page 20 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24 and 30. People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence including a visit to this service. The home is clean and a number of improvements have been made to the home to make it more comfortable and pleasant for people living there. EVIDENCE: The home offers sufficient space and is clean. There are twelve single bedrooms, with wash-hand basins, divided into units of four rooms in three interconnected bungalows. A bathroom and at least one shower are available in each unit. People said they like their bedrooms and the improvements that have been made to the environment. One person said that ‘the place is better since it has been re-decorated’ and a staff member said the home was ‘brighter and more pleasant’ because of this. New furniture and several beds have been replaced and bathroom tiles have been fitted to make bathroom areas more hygienic. Aids and adaptations are in place to help people with their independence and mobility. One person who has difficulty getting in and Trinity Street DS0000026333.V362503.R01.S.doc Version 5.2 Page 21 out of the bath is able to use a shower that has been fitted to meet his needs. Environment checks are carried out on a weekly basis and any jobs are referred to contractors. A relative said, ‘the home is clean, comfortable and safe’. A survey returned by a social care professional commented ‘the home provides a pleasant living environment with good standards of cleanliness and food’. A relative said, ‘it offers a real home, most important for people with mental health problems’. Some people who use the service smoke and are able to do this either outside or in their own bedrooms. People can sit outside in the garden if they wish to do so and can have their meals out there if they choose to do so. There are separate laundry facilities where people with staff support if needed attend to their personal clothing and bedding. Staff could be seen wearing protective clothing when cleaning and cooking. Trinity Street DS0000026333.V362503.R01.S.doc Version 5.2 Page 22 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 33, 34, 35 and 36. People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence including a visit to this service. People are receiving good cares from a staff team who are trained to meet their needs. Staffing levels are sufficient during the week but could be better planned at weekends. EVIDENCE: The duty rotas show that throughout the week there are generally three staff on duty at all times through the day as well as managers. At night there is one waking night staff and one person who sleeps on the premises. At all times there is a support worker on-call who may be asked to cover at short notice. On a weekend there are sometimes three staff but on occasions this has fallen to two staff in total during the day. A member of staff said, ‘it can be difficult and frustrating when there are only two staff on duty as we are limited in what we are able to do as two people need to stay in the home at all times’. A person living at the home who likes to go to church was not always able to do this and another person commented ‘it would be nice to go out in the minibus on a weekend but that this was not always possible because of staffing’. Some Trinity Street DS0000026333.V362503.R01.S.doc Version 5.2 Page 23 people are unable to go out without staff support so would not be able to have the option of going out if only two staff were on duty. During the week the home employs a cleaner who maintains very good standards of hygiene and cleanliness throughout the home. The home currently has three vacancies and the manager is hoping to appoint some new staff shortly. In the meantime agency staff are being used, however the home is using the same agency staff on a full-time basis to help provide some consistency. Recruitment is properly managed by the home and is based on equal opportunities and non-discriminatory practice. The staff files of the three most recently employed members of staff show that procedures are followed with all the necessary checks in place prior to new staff starting work at the home so protecting people who use the service from possible harm. Written information has been obtained from agencies about the staff they supply to the home to make sure that proper checks have been carried out to confirm their suitability. Staff said that they enjoy working at the home and receive a good range of training. Staff training is mainly up to date. Some staff are waiting to do some training that has been planned for following their induction that is detailed and covers various aspects of best practice. All staff have attended equality and diversity training and staff demonstrated a good understanding of issues relating to this area of their work. Some training is provided that is specific to the needs of the people living at the home. This includes mental health legislation, managing challenging behaviour and suicide awareness. It is also recommended that staff receive some training about mental health and how it can affect people. This was discussed with the manager who was in agreement that specific training in this area would be beneficial. A survey returned by a social care professional commented ‘some staff are unaware of some aspects of mental health and the impact this has on the individual’s ability to function’. This will help to develop staff skills and knowledge in this area in meeting peoples’ needs. Most of the staff have either completed or are doing a National Vocational Qualification (NVQ). Regular staff meetings are held to enable staff to receive support and to give their views and opinions about the home. Staff said that they receive supervision sessions on a regular basis and these are recorded. A survey returned by a relative said, ‘my relative has only good things to say about staff who are friendly, kind, modern and good cooks apparently’. Trinity Street DS0000026333.V362503.R01.S.doc Version 5.2 Page 24 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 and 42. People who use the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence including a visit to this service. The home is well managed and the interests of the people who use the service are seen as important but the absence of a registered manager leaves the service vulnerable. Two aspects of health and safety need addressing to make sure people are not put at risk. EVIDENCE: The manager is experienced in this area of care and has completed the Registered Manager’s Award and NVQ level 4 in Health and Social Care. She has been in post for eighteen months but has still not registered with the commission. The manager said that she has now submitted her application to register as the manager of the home with the commission and is presently Trinity Street DS0000026333.V362503.R01.S.doc Version 5.2 Page 25 waiting for some checks to be completed before the application can progress. Two deputy managers support the manager in providing leadership to the home. People who live at the home and staff said that the manager is open in her approach and encourages people to have their say about how the home is run. A survey returned by a relative said, ‘I am satisfied with the way the home is run’. Since the previous inspection visit the manager has been working hard to make improvements. This could be especially seen in the improved standard of the care planning documentation which is now more person centred. Changes to the environment have improved the comfort of people who live at the home. Issues outstanding from the previous inspection visit have all been satisfactorily addressed. The Annual Quality Assurance Assessment (AQAA) that was sent to us by the manager before we visited the home gave us clear information about changes that have been made and about where further improvements need to be made. The AQAA indicated that a number of policies and procedures had not been reviewed for some time. The manager said that Richmond Fellowship is in the process of reviewing and updating their policies and procedures. A senior manager from Richmond Fellowship carries out monthly visits to the home to monitor performance and to address any areas of need. People living at the home are encouraged to attend the Richmond Fellowship Service User Involvement Group and contribute towards how care and services can be improved across services. Richmond Fellowship has recently carried out an audit of the home and has produced a report of their findings from which an action plan has been developed. New formats are being developed for the surveys and questionnaires that are sent out to people who use the service, relatives and others who have an involvement with the home. Regular meetings are held with people at the home and staff to enable them to voice their views and opinions. The complaints records showed that any issues of concern are properly dealt with. Health and safety is mostly well maintained although two areas need addressing. Staff receive a range of health and safety training and this is updated annually. Fire safety is maintained through fire safety checks and regular staff training. The manager has carried out a fire risk assessment of the premises. However, on the day of the site visit a fire extinguisher was being used to prop open a fire door. This practice would put people at risk in the event of a fire. Action was taken immediately to remove the fire extinguisher from the door so that people were not put at any risk. A number of health and safety certificates were up to date, however there is no record that the electrical wiring systems in the home have been checked and this needs to be done so that any risks to the safety of people can be identified and Trinity Street DS0000026333.V362503.R01.S.doc Version 5.2 Page 26 any actions taken. This issue had not been identified through the home’s audit systems. Trinity Street DS0000026333.V362503.R01.S.doc Version 5.2 Page 27 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 X 2 3 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 2 34 3 35 2 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 X 3 X LIFESTYLES Standard No Score 11 X 12 2 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 1 X 2 X 3 X X 2 X Trinity Street DS0000026333.V362503.R01.S.doc Version 5.2 Page 28 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 YA20 Regulation 13 (4) (c) • Requirement Better medications systems and procedures must be put in place to minimise risks from medication errors and to ensure that people receive their prescribed medication at all times. The current medication audit systems must be improved upon so that and issues are identified at an early stage to minimise risks to people and to make sure people’s health care is being properly met. 22/04/08 Timescale for action 22/06/08 • 2. YA42 13 (4) (a) & (4) (c) • To reduce risks to people from the spread of fire, fire doors must be kept closed unless agreed otherwise by the fire officer. Trinity Street DS0000026333.V362503.R01.S.doc Version 5.2 Page 29 3. YA42 13 (4) (a) & (4) (c) An electrical wiring certificate must be obtained to confirm that the electrical systems are safe and any required work has been completed. This will minimise possible risks to peoples’ health and safety. 22/06/08 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. 6. Refer to Standard YA6 YA12 YA20 YA33 YA35 YA42 Good Practice Recommendations Care plan reviews should take place on a more regular basis to ensure that any changing needs are met and people receive care based on their current needs. Better arrangements should be put in place so that people have more opportunity to pursue their leisure interests on a weekend. Records of medications that are returned to the supplying chemist should be signed and dated to produce an audit trail if any discrepancies occur. Staffing levels on a weekend should be reviewed in order to ensure that peoples’ needs are being met at all times. Staff should receive some mental health training in order to enhance their knowledge and skills in caring for people with mental health problems. A review should be undertaken of the way systems are audited at the home to keep people safe from unnecessary risk. Trinity Street DS0000026333.V362503.R01.S.doc Version 5.2 Page 30 Commission for Social Care Inspection North Eastern Region St Nicholas Building St Nicholas Street Newcastle Upon Tyne NE1 1NB 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. 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