Inspection on 31/10/06 for Trinity Street

This inspection was carried out on 31st October 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. These are things the inspector asked to be changed, but found they had not done. The inspector also made 10 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 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 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 31st October 2006 09.50 Trinity Street DS0000026333.V317433.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.V317433.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.V317433.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 Care Home 12 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (12) of places Trinity Street DS0000026333.V317433.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 26th January 2006 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. The Commission for Social Care Inspection was informed on 18.09.06 that the current scale of charges was £270.00 per week. Information about the home in the form of a Statement of Purpose and Service User’s Guide as well as the latest Commission for Social Care Inspection report are available at the home. Trinity Street DS0000026333.V317433.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. As part of this inspection, one inspector visited Trinity Street on 31.10.06. The inspector gave short notice of the visit so that the home’s manager could arrange to be present. The visited started at 9.50am and ended at 6.45pm. During this visit the inspector made observations, spoke with five service users, the home’s manager and four members of staff. To enable residents, their relatives and health and social care professionals to comment on the service, questionnaires were sent out to eleven service users, ten relatives and thirteen health and social care professionals. At the time of writing, one resident survey, one relatives survey and four health and social care professionals surveys had been returned. The inspection findings are also based on a range of accumulated evidence received by CSCI since registration, for example, notifiable incident reports when residents are involved in an accident or incident. A pre-inspection questionnaire completed by the home’s manager was also used to inform this inspection. The records of two residents were inspected, including care plans, risk assessments, medication and accounting records held by the home. Other records sampled included the food menu, complaints log, staffing rota, staff recruitment and training records, health and safety records, maintenance records and some policies and procedures. A tour of the building was made, including the bedrooms of two residents whose care was case-tracked as part of the inspection. The inspector would like to thank residents, staff and management for their time and hospitality throughout the inspection. What the service does well: Residents have a gradual introduction to the home including overnight stays before they are formally admitted. They are involved in the development of their support plans and risk assessments, which provide a good level of information. It was evident from observation and discussion with residents and staff and from surveys received that staff at Trinity Street work in a positive way with residents, supporting them to make decisions about the lives and to lead an independent lifestyle. Trinity Street DS0000026333.V317433.R01.S.doc Version 5.2 Page 6 A relative and all health and social care professionals returning surveys indicated that they are satisfied with the overall care provided to residents. One commented that the clients she works with “Have all settled well and they frequently report to me the positive impact living at Trinity Street has had on their lives.” Residents spoken with and who returned a survey reported that staff understood their needs. Comments were received such as staff are “really supportive” and “staff understand me”. Individual additional support is available through psychiatric services. Staff at the home work well with other agencies thus ensuring residents are supported and their needs met. What has improved since the last inspection? What they could do better: A new manager, June Archer, is now in post. It is positive to note that the manager has completed an audit of the home and identified areas for improvement. The audit reflected some of the areas for improvement identified during this inspection. Medication is an area of particular concern as not all stock could be reconciled with records. This is an area where poor practice has been identified during previous inspections and where improvements must be made so that residents are not placed at unnecessary risk. Failure to demonstrate improvement in this area will result in the Commission considering the use of enforcement action. Improvements need to be made to some areas of record keeping so that all records required by regulation are available, complete and up-to-date. The environment of the home is showing signs of wear and tear and action needs to be taken so that the home provides a more comfortable and homely environment for those people living there. Trinity Street DS0000026333.V317433.R01.S.doc Version 5.2 Page 7 Staff training is ongoing but all staff need to receive all required and recommended training so that they have an increased range of knowledge and skills necessary when providing care and support to residents. 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.V317433.R01.S.doc Version 5.2 Page 8 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.V317433.R01.S.doc Version 5.2 Page 9 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, 3, 4, 5 Residents’ individual needs and aspirations are assessed before they are offered a place at the care home. Residents are given information about the home and are able to visit the home before making a decision to live there. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home’s manager explained that before someone is admitted to Trinity Street a community care assessment is obtained. Staff from the home also meet with the prospective resident to carry out a risk assessment and to gather further information from them or their supporter. If the placement is felt to be appropriate, taking into consideration the needs of existing residents, then visits to the home are arranged so that the prospective resident can make an informed choice about the care home. Information about the home in the form of a resident’s handbook is provided. Staff at the home go through the home’s ‘house rules’ and licence agreement with the prospective resident. Once agreed, and the offer of a placement confirmed, both parties sign the licence agreement. Trinity Street DS0000026333.V317433.R01.S.doc Version 5.2 Page 10 Assessment information forms the basis of the individual support plan to which the resident and support staff contribute. Records and discussion with residents support the above. Trinity Street DS0000026333.V317433.R01.S.doc Version 5.2 Page 11 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, 9 Residents assessed and changing needs are reflected in their individual support plans, which show that residents are supported to make decisions about their lives and to take risks as part of an independent lifestyle. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Residents confirmed that they are involved in the development of their individual support plan, which is based on assessment information and they had signed the records seen to indicate their agreement. Support plans were person centred and had been reviewed. Survey information indicates that any specialist advice is incorporated into the residents’ care plan. As discussed with management, daily reports should more clearly reflect staff interventions and residents’ goals as recorded on the support plan, so that it’s Trinity Street DS0000026333.V317433.R01.S.doc Version 5.2 Page 12 evident to anyone reading the report whether the interventions are effective and whether the goals are being achieved or need reviewing. (See Recommendations.) It was evident from discussion with residents, staff and records seen that residents are supported to make decisions about their lives and to take risks as part of an independent lifestyle. Trinity Street DS0000026333.V317433.R01.S.doc Version 5.2 Page 13 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, 17 Residents have access to a wide range of community based facilities and activities. They are supported, as appropriate, to maintain personal relationships. Residents’ rights and responsibilities are recognised and respected. Generally, service users are offered a healthy diet. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. EVIDENCE: It was evident from discussion with staff, residents and available information that residents 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. Trinity Street DS0000026333.V317433.R01.S.doc Version 5.2 Page 14 Residents have access to advocacy services should these be required. Residents confirmed in discussion and from a survey that they are supported to make individual choices in their day-to-day life. All residents are offered and some were seen to have key to their rooms, and toilet and bathroom facilities are fitted with privacy locks. Residents have unrestricted access to all areas of the home with the exception of the office, where staff supervision is required. Residents were observed to choose when to spend time alone or in the company of other residents or staff. Information on healthy eating options was displayed in kitchen areas. The home’s menus show that healthy meals are provided and the main meal of the day looked appetising and nutritious. However, full details of the food available are not always recorded, for example the range of vegetables and whether these are provided. (See Requirements.) Fresh fruit was freely available to residents in each of the bungalows. The manager explained that staff support residents to prepare meals, but that involvement in the ‘cookery club’ is ad hoc as some residents prefer to buy take away food. A resident explained they could be involved in cooking if they wanted to. The manager also explained that they are looking at ways to involve residents more in the preparation of meals. This is to be recommended so that residents can develop their skills in this area. (See Recommendations.) Trinity Street DS0000026333.V317433.R01.S.doc Version 5.2 Page 15 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, 20 Residents attend to their own personal hygiene needs. The residents have access to a range of services that ensure their physical and emotional health needs are met. The residents, where able, may manage their own medication in accordance with the home’s policies and procedures. However, poor record keeping in some areas of medicines management has the potential to place residents at risk. Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Residents attend to their own personal hygiene needs unless they are ill when staff make arrangements to support them. Residents choose how to dress and appearance reflects individual tastes. It was evident from records, survey information and discussion with residents and staff that residents’ physical and emotional healthcare needs are met. A Trinity Street DS0000026333.V317433.R01.S.doc Version 5.2 Page 16 resident said staff had accompanied her to an outpatient appointment and a district nurse also called to attend to a resident during this visit. Three of the four health and social care professionals surveys noted that staff demonstrate a clear understanding of the care needs of residents. However, one felt that some did not. Where residents are able, they are supported and encouraged to retain responsibility for their own medication. Policies and procedures are in place and residents who control their own medicines sign a contract for doing so. Secure storage is provided in individual bedrooms. No current residents selfmedicate. A resident spoken with said that medication was received when it was needed. Health and social care professionals returning surveys indicated that residents’ medication is appropriately managed in the home. The medications for two residents were checked. Medications are stored securely at the home. Controlled drugs were checked and reconciled with records held. One medication stock amount had not been carried forward and one sample of medication could not be reconciled with the records. Poor management of the medication system has been identified during previous inspections and has the potential to place residents at risk. Action must be taken to ensure that medication records are up to date and accurately reflect the stock of medication held at the home. (See Requirements.) Failure to improve practice in this area will result in the Commission considering the use of enforcement action. Trinity Street DS0000026333.V317433.R01.S.doc Version 5.2 Page 17 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, 23 The registered provider takes complaints seriously and acts upon them. Systems are in place to ensure that residents are protected from abuse, neglect and self-harm. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Complaints information was on display in the home. It was evident from the complaints record that residents had used the procedure and that action had been taken with a 28-day timescale. Residents spoken with were satisfied that their concerns would be listened to and acted upon. No complaints had been received by health and social care professionals returning surveys and a relative indicated they were aware of the complaints procedure and had never had to make a complaint. A record of complaints is maintained at the home. The inspector recommends that the complaint records clearly identify whether or not a complaint has been upheld. (See Recommendations.) Residents’ monies are stored securely. Residents have access to their monies with support from staff. Two samples of residents’ monies were checked and reconciled with records held. Trinity Street DS0000026333.V317433.R01.S.doc Version 5.2 Page 18 Staff spoken with confirmed they had received adult protection training. Training certificates were seen. The manager stated that adult protection is covered during induction and that further training had been arranged. Records show that not all staff have yet received training in adult protection. A previous recommendation is carried forward. (See Recommendations.) There was some evidence to indicate that Criminal Record Bureau (CRB) checks are carried out on staff employed to work at the home to ensure they are suitable to work with vulnerable adults. Relevant policies and procedures are available. Trinity Street DS0000026333.V317433.R01.S.doc Version 5.2 Page 19 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, 30 Maintenance and refurbishment work is necessary to provide service users with a comfortable and homely environment. The home was generally clean and hygienic. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home offers good communal space for residents. 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. Laundry facilities are available for residents to do their own washing with staff support if necessary. Trinity Street DS0000026333.V317433.R01.S.doc Version 5.2 Page 20 Some residents showed the inspector their bedrooms, which reflected their personal tastes and interests. Residents said they liked their rooms and that they were comfortable. Bedroom doors are fitted with locks and residents were seen to have their own keys. As observed and discussed with management during the visit, identified activities which residents carry out in their private accommodation should be risk assessed to ensure that residents’ health and safety are not compromised. (See Requirements.) Some recommendations and requirements from the last inspection have been addressed, for example, a new, larger shower cubicle has been installed and the home was generally clean. However, some areas of the home are still showing signs of wear and tear and do not provide a comfortable and homely environment for residents and, particularly in the bathroom and toilet areas, do not support the promotion of good hygiene because paper towels and liquid soap were not available in all areas and because there is blistered and peeling paintwork. The manager explained that an audit of the environment has taken place and that some refurbishment of the home is to be carried out. Until outstanding issues have been addressed, a previous requirement stands. (See Requirements.) There were no unpleasant odours in the home. A daily checklist has been introduced for use at handover meetings to inform staff of any outstanding tasks that require completing so that the home is kept clean. A resident returning a survey indicated that the home is always fresh and clean. There are spacious grounds surrounding the property, accessible for outdoor activities such as barbeques. The garden area to the rear of the property was being well maintained with attractive planting. Trinity Street DS0000026333.V317433.R01.S.doc Version 5.2 Page 21 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, 34, 35 Staff training and monitoring systems are in place to ensure that staff are appropriately trained and competent to support residents. Not all staff recruitment records were available to clearly evidence that recruitment practices are sufficiently robust. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Staff were seen to respect and interact with residents in a skilled and positive manner. Residents said that good relationships existed with staff; that staff understood their needs and supported them with activities of daily living. Records show that a range of relevant training is provided to staff and staff confirmed this. Staff training is also evaluated to see how staff are putting what they have learned into practice. An annual training needs analysis is in place, which is monitored monthly during staff supervision. Staff also have an annual appraisal. And new staff receive induction training linked to induction Trinity Street DS0000026333.V317433.R01.S.doc Version 5.2 Page 22 standards. The manager reported that a range of training, including first aid, has been booked for staff. However, until all staff currently employed have completed first aid training, a previous requirement stands. (See Requirements.) Training to NVQ (National Vocational Qualification) Level 2 and 3 is ongoing. The manager reported that currently 25 of staff have an NVQ Level 2 or above. A previous recommendation for a minimum of 50 of staff to hold an NVQ or equivalent award is brought forward within this report. (See Recommendations.) Not all staff recruitment records were available for inspection. However, some evidence was seen that references are obtained and CRB (Criminal Record Bureau) checks are carried out before a person begins working at the home. The manager was aware of the lack of staff records and was taking action to address this. However, a requirement is made for staff recruitment records to be available at the care home as required by legislation. (See Requirements.) Trinity Street DS0000026333.V317433.R01.S.doc Version 5.2 Page 23 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, 42 The home is generally well run. Residents have opportunities to express their views about the service, but a formal quality audit of the service has yet to take place. Generally, the health, safety and welfare of residents are promoted. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. EVIDENCE: June Archer is the new manager of the home. She has many years’ experience of working with this client group. Ms Archer who has enrolled on the NVQ Level 4, Registered Manager’s Award has yet to make an application to be Trinity Street DS0000026333.V317433.R01.S.doc Version 5.2 Page 24 registered with the Commission for Social Care Inspection but is aware of the need to do so. Ms Archer explained that she is in the process of identifying areas for improvement within the home. She showed the inspector a service improvement action plan, which it is positive to note, identified areas for improvement also highlighted during this visit. Residents and staff spoke positively about Ms Archer’s management of the home and said that she was approachable. The manager explained and residents confirmed that they have an opportunity to contribute their views about the running of the home through resident meetings. Informal and formal meetings with residents and Ms Archer provide further opportunities for residents to discuss matters of importance to them. Ms Archer also explained that she is looking into mechanisms for feeding back to residents the outcome of issues raised during residents’ meetings. Ms Archer explained that a quality audit has not taken place to date but that one was due. A previous requirement regarding this is carried forward within this report. (See Requirements.) Monthly management visits to the home take place and records were available. These visits allow the service provider to assess the quality of service provided at Trinity Street. Health and safety at the home is generally well managed but records were not always up to date or available. There was evidence that staff fire safety training including fire drills is ongoing and staff spoken with confirmed this. However, not all staff have yet received fire safety training. (See Requirements.) Also, records of such training should be maintained in sufficient detail as recommended by the fire authority. For example, the names of all staff involved in fire drills should be recorded so that it is clear who has received training. (See Recommendations.) The fire system is serviced and checked on a regular basis. Although it was reported that emergency lighting is checked, records to evidence this were not up to date. (See Requirements.) Gas safety records were seen, but the most recent copy certificate was not available for inspection and this should be addressed. (See Recommendations.) Records of accidents and incidents are maintained and although incidents have been reported to the Commission as required by legislation, one incident regarding a medication error had not been notified. All notifiable incidents must be reported as required. (See Requirements.) Trinity Street DS0000026333.V317433.R01.S.doc Version 5.2 Page 25 First aid equipment was available, but as noted under the section of Staffing above, not all staff have received first aid training although action is being taken to address this. Trinity Street DS0000026333.V317433.R01.S.doc Version 5.2 Page 26 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 3 4 3 5 3 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 2 25 X 26 X 27 X 28 X 29 X 30 2 STAFFING Standard No Score 31 x 32 2 33 x 34 2 35 2 36 x CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 X LIFESTYLES Standard No Score 11 x 12 3 13 3 14 x 15 3 16 3 17 2 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 1 x 2 X 2 X X 2 x Trinity Street DS0000026333.V317433.R01.S.doc Version 5.2 Page 27 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) Requirement Records must be kept of the food 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, 17.08.05 and 23.02.06 not fully met.) Action must be taken to ensure that medication stock can be reconciled with records held. (Timescale of 17.08.05 and 23.02.06 not met.) Activities identified during this visit, which residents conduct in their private accommodation and which impinge on health and safety, must be risk assessed. The care home must be kept in a good state of internal repair. (Timescale of 30/04/06 not met.) DS0000026333.V317433.R01.S.doc Timescale for action 05/12/06 2. YA20 13(2) 20/11/06 3 YA24 13(4)(b) 01/12/06 4 YA24 23(2)(b) 05/01/07 Trinity Street Version 5.2 Page 28 5. YA32 13(4) Suitable arrangements must be made for the training of staff in first aid. (Timescales of 31.01.05, 30.06.05, 07.09.05 and 30.03.06 not fully met). All staff recruitment information required by regulation must be kept at the care home and be available for inspection. 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. (Timescale of 30.04.06 not met.) All staff working at the care home must receive fire safety training, including fire drills. Records of any tests of emergency lighting equipment must be complete and up-todate. All incidents notifiable under Regulation 37 of The Care Homes Regulations 2001 must be reported to the Commission without delay and confirmed in writing. 22/12/06 6 YA34 7. YA39 17(2) Schedule 4 19(1)(a)(b) Schedule 2 24 05/12/06 05/01/07 8 9 YA42 YA42 23(4)(d) 23(4)(c)(v) 08/12/06 05/12/06 10 YA42 37 01/12/06 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 Refer to Standard YA6 Good Practice Recommendations Daily reports should more clearly reflect staff interventions and residents’ goals as recorded on the support plan, so that it’s evident to anyone reading the report whether the DS0000026333.V317433.R01.S.doc Version 5.2 Page 29 Trinity Street 2 3 4. 5. 6. 7. YA17 YA22 YA23 YA32 YA42 YA42 8 9. YA42 YA24 10. YA24 interventions are effective and goals are being achieved or need reviewing. Residents should be actively supported to help plan, prepare and serve meals. (Recommendation carried forward.) The home’s complaints log should clearly identify whether or not a complaint has been upheld. Those staff who have not yet done so should receive formal adult protection training. (Recommendation carried forward.) 50 of care staff should achieve an NVQ level 2 (or equivalent) care award. (Recommendation carried forward.) 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 up-to-date copy of the Gas Safety Certificate should be available for inspection. 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. (Recommendation carried forward.) Radiators should be guarded or have guaranteed low temperature surfaces. (Recommendation carried forward.) Trinity Street DS0000026333.V317433.R01.S.doc Version 5.2 Page 30 Commission for Social Care Inspection Brighouse Area Office Park View House Woodvale Office Park Woodvale Road Brighouse HD6 4AB 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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