Inspection on 26/01/06 for Trinity Street

This inspection was carried out on 26th January 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Poor. 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. These are things the inspector asked to be changed, but found they had not done. The inspector also made 9 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Trinity Street 22/04/08

Trinity Street 27/04/07

Trinity Street 31/10/06

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 09/07/2008.

CARE HOME ADULTS 18-65 Trinity Street 27 Trinity Street Batley Carr Dewsbury West Yorkshire WF17 7JZ Lead Inspector Jacinta Lockwood Unannounced Inspection 26th January 2006 10:00 Trinity Street DS0000026333.V266459.R01.S.doc Version 5.1 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.V266459.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 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.V266459.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Trinity Street Address 27 Trinity Street Batley Carr Dewsbury West Yorkshire WF17 7JZ 01924 456160 01924 458001 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 Ms Paula Malone Care Home 12 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (12) of places Trinity Street DS0000026333.V266459.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Conditions of this registration are listed on the registration certificate displayed at the service. Date of last inspection 13th July 2005 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 residents. Trinity Street DS0000026333.V266459.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. Two inspectors carried out an unannounced inspection of 27 Trinity Street on 26 January 2006. The inspection started at 10am and ended at 2pm. The following inspection methods were used: Observation, discussion with five service users, staff and management. A sample of records were inspected, including the statement of purpose, care plans, minutes of meetings/action plan, food records, medication, staff training, health and safety records. A limited tour was made of the building. At the time of the inspection there were two service user and three staff vacancies. The inspectors would like to thank service users, staff and management for their time and hospitality throughout the inspection. What the service does well: What has improved since the last inspection? Trinity Street DS0000026333.V266459.R01.S.doc Version 5.1 Page 6 Some requirements and recommendations have been addressed since the last inspection. A new medication system has been introduced which should make operation of the system easier for staff. Staff at the home worked well with a service user and other agencies to ensure the smooth transition of the service user to another service area. 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 Street DS0000026333.V266459.R01.S.doc Version 5.1 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Trinity Street DS0000026333.V266459.R01.S.doc Version 5.1 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1 Information is available to service users so that they can make an informed choice about where to live. EVIDENCE: The statement of purpose has been amended to include all required information. The document is informative and available to current and prospective service users. Trinity Street DS0000026333.V266459.R01.S.doc Version 5.1 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 78 Service users are involved in care planning and are supported by staff to make decisions about their lives. Service users are consulted and supported to participate in the life of the home. EVIDENCE: The above standards were only assessed to follow up previous recommendations, which have been addressed. Trinity Street DS0000026333.V266459.R01.S.doc Version 5.1 Page 10 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15, 16, 17 Service users access a wide range of community based facilities and activities. Service users are supported, as appropriate, to maintain personal relationships. Service users’ rights and responsibilities are recognised and respected. Generally, service users are offered a healthy diet. EVIDENCE: It was evident from discussion with staff, service users and available information that service users are able to take part in a range of appropriate social, leisure and educational activities. They access community based facilities using public transport or on foot. Service users are supported, as appropriate, to have personal, family and sexual relationships. And advice is provided as necessary. Service users have access to advocacy services. Trinity Street DS0000026333.V266459.R01.S.doc Version 5.1 Page 11 Service users are supported to make individual choices in their day-to-day lives. All service users are offered a key to their rooms, and toilet and bathroom facilities are fitted with privacy locks. Service users have unrestricted access to all areas of the home with the exception of the office, where staff supervision is required. Service users were observed to choose when to spend time alone or in the company of other service users or staff. The home’s statement of purpose notes that domestic skills training is pursued via the cookery club and on a daily basis as and when service users wish to be involved. The record of food shows that healthy meals are provided, but there were gaps in recording. Fresh fruit was available. Service users can choose to eat the food provided at the home and are asked what foods they would like. But staff reported that a lot of food is wasted; as service users often prefer to buy take away meals. Staff also reported that the weekly cookery club has been discontinued at the request of service users. The inspectors suggest that menus be discussed at service user meetings, or individually, and the reintroduction of the cookery club be discussed with them so that they can be actively supported to help plan, prepare and serve well-balanced and healthy meals. Trinity Street DS0000026333.V266459.R01.S.doc Version 5.1 Page 12 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 20 Where appropriate, service users retain, administer and control their own medication in accordance with the home’s policies and procedures. EVIDENCE: Medication administered by staff is stored securely. And service users who self-medicate have secure storage in their private accommodation. Policies and procedures are in place and service users who control their own medicines sign a contract for doing so. All staff are receiving NVQ training in the safe handling of medication. Generally medication was accounted for, but an amount of medication had not been entered into stock and one dose of analgesic was unaccounted for. Accurate and up-to-date medication records must be maintained. A requirement is made in this matter. Trinity Street DS0000026333.V266459.R01.S.doc Version 5.1 Page 13 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 23 Processes are in place to ensure that service users are protected from abuse, neglect and self-harm. EVIDENCE: All but three staff have received adult protection training. The manager reported that those who have not yet done so are to receive the training. A recommendation is made in this matter. A recent adult protection matter was dealt with in a professional and sensitive manner by staff within the service, who involved relevant professionals at all stages of the process. Although not assessed on this occasion, the inspectors noted that the complaints procedure displayed on the home’s notice board needs updating with the name of the Commission for Social Care Inspection. The Commission’s contact details were available. Trinity Street DS0000026333.V266459.R01.S.doc Version 5.1 Page 14 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 26, 27, 30 Maintenance and refurbishment work is necessary to provide service users with a homely and safe environment. Not all areas of the home are clean and hygienic. EVIDENCE: The home offers good communal space for service users. There are twelve single rooms, with wash hand basins, divided into units of four rooms in three interconnected bungalows. Each bungalow has a lounge and dining/kitchen area. Some service users’ showed the inspectors their bedrooms, which reflected their personal tastes and interests. Service users said they liked their rooms and that they were comfortable. Bedroom doors are fitted with locks and secure storage is also available. Some recommendations regarding the environment have been addressed. However, as noted during this and previous inspections, and also in a monthly management report from the service provider, maintenance and refurbishment works are necessary to improve facilities and the living environment for service users. A requirement and recommendations are made in this matter. Trinity Street DS0000026333.V266459.R01.S.doc Version 5.1 Page 15 The temperature control to some radiators was missing. And temperature readings of 57 degrees and 67 degrees Celsius were recorded on the day of the inspection. Such high temperatures pose a potential risk to service users and action must be taken to ensure radiators have low surface temperatures. Water temperature records are maintained but entries such as “satisfactory level” are not appropriate and the actual reading should be recorded. Hot water temperature readings were taken and ranged from 36 degrees to 45 degrees Celsius. Water should be delivered close to 43 degrees Celsius and where water temperatures are too low, the temperature should be adjusted. Hot water to one bathroom sink was only a trickle and this should be addressed. Liquid soap and paper towels were not available in all communal wash areas and this should be addressed to ensure satisfactory standards of hygiene are promoted. The dustbin currently in use in one of the kitchens should be replaced with a lidded bin of a type more appropriate to a homely environment. Also, suitable waste bins should be provided in smoking areas to minimise any risk of fire. A domestic member of staff is employed to keep the home clean but, clearly, there are limits as to what she can do in the time available to ensure that satisfactory standards of hygiene are maintained. The inspectors recommend that domestic hours are increased. There are spacious grounds surrounding the property, accessible for outdoor activities such as barbeques. Trinity Street DS0000026333.V266459.R01.S.doc Version 5.1 Page 16 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 33 There is an effective staff team that supports the service users. EVIDENCE: A range of relevant training has been provided to staff. However, staff training records had not been updated, so full training information was not available. Some certificates of relevant basic training were seen. The deputy manager has received first aid training, but other staff have yet to receive training in first aid. Owing to a turnover of staff, only three members of staff have a relevant NVQ qualification; one member of staff is working towards NVQ and one is registered for the course. The registered manager is an NVQ assessor. Progress needs to be made in this area to achieve the minimum of 50 of staff qualified to NVQ level 2 or an equivalent qualification. There are currently three staff vacancies. Action was being taken to recruit to these posts. Existing staff and agency staff are covering the vacancies. A team ‘away day’ was held on 25 January and staff made positive comments about this. Staff reported that morale was good. Staff were seen to respect and interact with service users in a skilled and positive manner. Service users said that good relationships existed with staff and that staff supported them with activities of daily living. Trinity Street DS0000026333.V266459.R01.S.doc Version 5.1 Page 17 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 39, 42 Processes are in place that allow for consultation with service users. Until fire safety issues have been adequately addressed, the health and safety of those living and working at the home is not protected. EVIDENCE: There are opportunities for service users to be consulted on a one-to-one basis and during service user meetings as well as during monthly management visits, about the running of the home. However, a quality audit that involves consultation with service users, family, friends and advocates and other stakeholders such as healthcare professionals has yet to be carried out. The inspectors were informed that Richmond Fellowship now has a performance and quality team who are to oversee this. Health and safety information is available. Checks are carried out, although there were some gaps in recording, and equipment is serviced to ensure the health and safety of those living, working at and visiting the premises. Fire Trinity Street DS0000026333.V266459.R01.S.doc Version 5.1 Page 18 safety training has taken place and is due again. A member of staff is yet to complete fire safety competent person training and this should be addressed. It was evident that not all notifiable incidents are being reported to the Commission as required. The inspectors were supplied with incident forms at the time of the inspection. However, all notifiable incidents must be reported without delay and confirmed in writing to the Commission in future. Fire drills are recorded, but it is not clear from the record which members of staff were involved. Staff involved in fire drills should sign a register of attendance. Although the home has designated smoking areas, there are occasions when service users smoke in their bedrooms. There are gaps to the bottom of some bedroom fire doors, which would not prevent smoke seepage in the event of a fire. Action must be taken to rectify this situation as a matter of priority. Also, an audit of all fire doors should be carried out to ensure they meet fire safety requirements. Trinity Street DS0000026333.V266459.R01.S.doc Version 5.1 Page 19 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 3 2 X 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 X 23 2 ENVIRONMENT Standard No Score 24 1 25 X 26 3 27 1 28 X 29 X 30 1 STAFFING Standard No Score 31 X 32 2 33 3 34 X 35 X 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score X 3 3 X X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 1 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score X X 1 X X X 1 X X 1 X Trinity Street DS0000026333.V266459.R01.S.doc Version 5.1 Page 20 Yes Are there any outstanding requirements from the last inspection? 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 YA17 Regulation 17(2) Sch 4(13) Timescale for action Records must be kept of the food 23/02/06 provided for service users in sufficient detail to enable any person inspecting the record to determine whether the diet is satisfactory, in relation to nutrition and otherwise, and of any special diets prepared for individual service users. Therefore there should be no gaps in recording. (Timescale of 15.05.05 and 17.08.05 not met.) Action must be taken to ensure 23/02/06 that medication stock can be reconciled with records held. (Timescale of 17.08.05 not met.) The care home must be kept in a 30/04/06 good state of internal repair. Action must be taken to ensure 23/02/06 that hot water is delivered at a temperature around 43 degrees Celsius. (Timescales of 15.11.04, 31.05.05 and 24.08.05 not met.) All parts of the care home must 23/02/06 be kept clean. (Timescale of 17.08.05 not fully met.) Suitable arrangements must be 30/03/06 made for the training of staff in DS0000026333.V266459.R01.S.doc Version 5.1 Page 21 Requirement 2. YA20 13(2) 3. 4. YA24 YA27 23(2)(b) 23(2)(j) 5. 6. YA30 YA32 23(2)(d) 13(4) Trinity Street 7. YA39 24 8. 9. YA42 YA42 37 23(4)(c) (i) first aid. (Timescales of 31.01.05, 30.06.05 and 07.09.05 not met). A review of the quality of care at the home, which provides for consultation with service users and their representatives, must be carried out. A copy of a report in respect of any review must be supplied to the Commission and made available to service users. Notifiable incidents must be reported to the Commission, as required. Following consultation with the fire authority, adequate arrangements must be made for containing fires, therefore, bedroom fire doors must not have gaps which allow smoke seepage. The home’s fire risk assessment must be reviewed in light of this finding. 30/04/06 23/02/06 10/02/06 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. Refer to Standard YA17 YA23 YA24 Good Practice Recommendations Service users should be supported to help plan, prepare and serve well-balanced, healthy meals. Those staff who have not yet done so should receive formal adult protection training. A full maintenance audit of the premises should be carried out. And an action plan, together with timescales, for completing identified works, including those identified in the body of this report, should be supplied to the Commission by 03.03.06. Radiator temperature control fittings should be replaced. And radiators should be guarded or have guaranteed low temperature surfaces. Light fittings should be fitted with light shades. This was DS0000026333.V266459.R01.S.doc Version 5.1 Page 22 4. 5. YA24 YA24 Trinity Street 6. YA24 7. YA27 8. 9. 10. 11. 12. YA30 YA32 YA32 YA42 YA42 13. 14. YA42 YA42 not assessed at this inspection and the recommendation is brought forward. The dustbin currently in use in one of the kitchens should be replaced with a lidded bin of a type more appropriate to a homely environment. And all kitchen waste bins should have lids in place. The shower cubicle in bungalow 29 should meet the needs of current service users. The registered person should explore how the shower cubicle in bungalow 29 could be increased in size. The shower cubicle should be included in the maintenance plan requested at 3 above. Domestic hours should be increased to ensure that satisfactory standards of hygiene are maintained throughout the home. Staff training records should be brought up to date. 50 of care staff should achieve an NVQ level 2 (or equivalent) care award. There should be no gaps in recording health and safety checks. Fire safety training records should include details of the nature of the training provided together with a record signed by persons receiving the training, including fire drill training. An audit of all fire doors should be undertaken to ensure that they meet fire safety requirements. Suitable waste bins should be provided in smoking areas to minimise the risk of fire. Trinity Street DS0000026333.V266459.R01.S.doc Version 5.1 Page 23 Commission for Social Care Inspection Brighouse Area Office Park View House Woodvale Office Park Woodvale Road Brighouse HD6 4AB 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 Street DS0000026333.V266459.R01.S.doc Version 5.1 Page 24 - 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. 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