Inspection on 18/02/08 for Tripletrees

This inspection was carried out on 18th February 2008.

CSCI found this care home to be providing an Good service.

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Tripletrees 11/12/08

Tripletrees 18/07/07

Tripletrees 11/05/06

Tripletrees 04/10/05

Tripletrees 24/05/05

Tripletrees 07/10/04

Tripletrees 15/06/04

Similar services:

Springfield House

Sutton Lodge Nursing Home

The Shelley

St Helier`s Residential Hotel

1 Marten Road

St Joseph`s

Ridgemount

Wingham Court

Extracts from inspection reports are licensed from CQC, this page was updated on 09/07/2008.

CARE HOMES FOR OLDER PEOPLE Tripletrees 70 Ferndale Road Burgess Hill West Sussex RH15 0HD Lead Inspector Annie Taggart Unannounced Inspection 18th February 2008 11:00 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Tripletrees DS0000014806.V357035.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 Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Tripletrees DS0000014806.V357035.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Tripletrees Address 70 Ferndale Road Burgess Hill West Sussex RH15 0HD 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) 01444 243054 01444 248344 Follett Care Limited Mrs Mary Follett Care Home 28 Category(ies) of Dementia - over 65 years of age (3), Mental registration, with number Disorder, excluding learning disability or of places dementia - over 65 years of age (3), Old age, not falling within any other category (28) Tripletrees DS0000014806.V357035.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. A maximum of 28 service users may be accommodated at any time. A maximum of 3 service users over the age of 65 years in the DE(E) Dementia service user category may be accommodated. A maximum of 3 service users over the age of 65 years in the MD(E) Mental Disorder service user category may be accommodated. Date of last inspection Brief Description of the Service: Tripletrees is a care home, registered to provide personal care for a maximum of twenty-eight older persons to include a maximum of three residents with dementia/mental disorder. Tripletrees is a large detached and extended property, situated in Burgess Hill, being close to shops, local amenities and transport links. The accommodation is arranged on three floors and comprises of twenty-four single bedrooms and two double rooms that are served by a passenger lift and stair lift. Residents benefit from a large lounge and dining room on the ground floor. The home is owned by Follett Care Limited and is managed by Mrs M Follett. The current fees are £ 425 to £595 per week Tripletrees DS0000014806.V357035.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 2 star. This means the people who use this service experience good quality outcomes. In order to prepare for the visit, telephone surveys were held with three family members, all made very positive comments about the care being provided in the home. An Annual Quality Assurance (AQAA) had been completed by the home for the last inspection and information from this and the last inspection report was also used to inform this visit. The unannounced visit was carried out at 11am on Monday 18th February by Annie Taggart Inspector and lasted for three hours. We also again visited the home on Thursday 21st February for a further two hours to gain access to staff files and other records not available, as the manager was absent during the first visit. During the visit we spent time with the people living in the home, both in their private bedrooms and in communal areas and we spoke to the staff on duty and observed staff practice. We were also able to speak with a senior nurse practitioner, a relative and the mobile library person, all of who visit the home on a regular basis. Five care plans and all supporting documentation such as daily records were looked at and we also looked at four staff records and the system for the recording and administration of medication. We looked at menus and food records, saw the main meal of the day being prepared and served and we asked people what choice they had in the meals that are provided. Records for the running of the business including the quality assurance process, health and safety and incident and accident recording were seen. Feedback was given to the Registered Manager, Mrs Follett, following the second visit. Tripletrees DS0000014806.V357035.R01.S.doc Version 5.2 Page 6 What the service does well: What has improved since the last inspection? What they could do better: The programme of redecoration and updating of the building should be continued. The quality assurance system should be extended to families and professionals involved with the home. Tripletrees DS0000014806.V357035.R01.S.doc Version 5.2 Page 7 In order to ensure that service users and staff are protected in the event of a fire occurring, risk assessments should be carried out for people who wish to keep their bedroom doors open and suitable equipment provided to ensure that doors would automatically close when the fire alarm sounds. 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. Tripletrees DS0000014806.V357035.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Tripletrees DS0000014806.V357035.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1 3 5 and 6 Outcomes for service users in this area are good. This judgement has been made using available evidence including a visit to this service. There is good information available about the services on offer and prospective service users have their needs and wishes assessed and recorded. EVIDENCE: The home has a Statement of Purpose and Service User Guide in place, that provide good information about the home. To ensure that the home can meet individual needs, comprehensive pre admission assessments are carried out with the involvement of service users and their families. We saw the assessments for four people and all contained a life history, detailed information regarding personal choice and individual preferences and also information regarding health and personal care needs. Tripletrees DS0000014806.V357035.R01.S.doc Version 5.2 Page 10 During the visit a telephone enquiry was made about the home, the manager gave an overview of the services on offer, said she would sent the person an information pack and explained she would need to carry out an assessment at the person’s home to ensure that their needs could be met. The people living in the home confirmed that they were able to make visits to the home or stay for a short break prior to moving in. Tripletrees does not offer intermediate care. Tripletrees DS0000014806.V357035.R01.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7 8 9 and 10 Outcomes for service users in this area are good. This judgement has been made using available evidence including a visit to this service. In order to ensure that people’s individual needs are being met, care plans are in place, people have access to good healthcare support and are treated with respect. EVIDENCE: For each person living in the home there is a detailed plan of care in place, which covers all areas of daily living choices and provides the staff team with information about how each person wishes to be supported. We tracked the care plans for five people and they contained risk assessments both personal and environmental, nutritional assessments, preferences for daily routines and information regarding health and social care needs. For two people who were being cared for in bed there were up to date records regarding the regular care and nutrition being provided both during the day Tripletrees DS0000014806.V357035.R01.S.doc Version 5.2 Page 12 and at night and daily records and the handover book showed that the staff team are aware of changes in people’s needs. Care plans are regularly updated with a full review taking place annually and the plans we saw had been agreed and signed by service users or their representatives. Records show that the home works well with other professionals such as local doctors and district nurses and service users said that if they felt unwell the staff would contact their G.P. and family. A healthcare professional said that appropriate referrals were made for people in good time and that people’s healthcare needs were being met by the home. A monitored dose system for medication administration is in use in the home and records show that the staff that administer medication have received training. Medication was securely stored in a well organised and clean medication cabinet and records were up to date. The people living in the home said that they were treated with dignity and respect and that the staff team were very kind and caring. One person said, “ it was very difficult for me to give up my home and come to a care home but everyone is kind and I am happy here”. A family member said, “ I think the home is just wonderful and I come away happy every time I visit my Mum. She is well looked after and always looks nice and the home rings me up if they have any concerns about her health. The staff are marvellous, just so caring and always cheerful and friendly”. Tripletrees DS0000014806.V357035.R01.S.doc Version 5.2 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12 13 14 and 15 Outcomes for service users in this area are good. This judgement has been made using available evidence including a visit to this service. The people living in the home have opportunities for entertainment and activities, their families and friends are made welcome and they have a choice of fresh home cooked meals. EVIDENCE: The home offers a range of daily activities and entertainment opportunities and people said they were free to join in or choose not to do so. During the visits people were joining in an activity or reading newspapers and magazines, were chatting to each other and moving freely about the home. People also said that they really enjoyed the attractive gardens in better weather. The home employs an activities co-ordinator and detailed records are kept of the activities people attend and how they are involved. Activities include reminiscence and chat sessions, crafts, quizzes, external entertainers and visits to garden centres. During the visit preparations were being made for an Easter bonnet competition. Tripletrees DS0000014806.V357035.R01.S.doc Version 5.2 Page 14 People confirmed that their visitors are made welcome at any time and also that their religious beliefs are catered for. Menus and food records show that a variety of fresh, home cooked meals are provided and most people were very complimentary about the meals on offer. One person said they were sometimes dissatisfied with the standard of meals but records and observation on the day of the visit showed that likes and dislikes are recorded and alternative meals are always available. We saw lunch, the main meal of the day being prepared and served and fresh ingredients were used and the meal was attractively presented. Nutritional screening records are in place for people and where problems are identified, professional advice is gained by the home. Tripletrees DS0000014806.V357035.R01.S.doc Version 5.2 Page 15 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 Outcomes for service users in this area are good. This judgement has been made using available evidence including a visit to this service. People can be confident that their complaints and concerns will be acted upon and the home’s working practices are designed to protect people from risk of abuse. EVIDENCE: The home has a complaints procedure in place, a copy of which is displayed in large print in the home. The people living in the home said that they felt confidant that their complaints and concerns would be taken seriously by the manager and that they would be acted upon as soon as possible. A visiting relative said, “ you only have to bring any concern to the notice of the manager and it is dealt with straight away”. No formal complaints have been recorded since the last visit. Records show that staff receive training in abuse awareness both by attending sessions and from video training and questionnaires. The people on duty were aware of their responsibilities and said that they would report any suspected abuse straight away. Tripletrees DS0000014806.V357035.R01.S.doc Version 5.2 Page 16 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19 22 25 and 26 Outcomes for service users in this area are adequate. This judgement has been made using available evidence including a visit to this service. Although Tripletrees offers a homely and comfortable environment, there are risks to service users in the event of a fire occurring by some bedroom doors being wedged open. EVIDENCE: Tripletrees offers a warm, comfortable and homely environment for the people who live there and people said that they were happy with the facilities being provided. The home is situated over three floors, with a passenger lift and stair lift in place for access to the upper floors. Some areas of the home, including the bedroom of one service user are looking a bit tired, shabby and in need of updating but the senior carer on duty told us that a programme of redecoration and refurbishment was underway in Tripletrees DS0000014806.V357035.R01.S.doc Version 5.2 Page 17 order to address this. This was later confirmed by Mrs Follett who was able to show us a detailed improvement plan for 07/08 Some work has already been undertaken, several bedrooms have been recently redecorated and new carpets fitted to some bedrooms and communal areas. People’s private bedrooms were homely and comfortable had been personalised by the people living in them. Some people also had some of their own furniture and telephones in place. The call bell system was in working order and water temperatures in ensuite rooms and bathrooms were at a safe level. In four bedrooms, doors had been propped open either with wedges or furniture, which would have caused a hazard to service users and staff in the event of a fire occurring. This was pointed out to the senior carer on duty who said that some people wanted their doors open when they were in their rooms and became distressed if they were closed. A Requirement has been made for the home to risk assess the danger to people by bedroom doors being propped open and for suitable equipment to be provided for people who wish to keep their door open to ensure that their doors automatically close in the event of a fire. Mrs Follett said that she would address this as soon as possible. Tripletrees DS0000014806.V357035.R01.S.doc Version 5.2 Page 18 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27 28 29 and 30 Outcomes for service users in this area are good. This judgement has been made using available evidence including a visit to this service. The people living in the home are supported by a competent and caring staff team and to ensure that people are protected a robust recruitment process is carried out. EVIDENCE: Staffing rotas showed that there are sufficient numbers of staff on duty to meet the needs of the people currently living in the home and people said that the staff team were kind and caring and very responsive to their needs and wishes. Although two ancillary staff had not attended work due to sickness on the day of the first visit, there were still sufficient care staff on duty to ensure that people’s preferences and routines were met. Comments included, “ The staff here are lovely and will do anything for you” and “ I get up when I want to and the staff are very kind. They will always come when you ring the bell at night and make you a cup of tea”. Tripletrees DS0000014806.V357035.R01.S.doc Version 5.2 Page 19 A mobile library person who regularly visits the home said, “ this home is always friendly and happy and the people who live here always seem to have something to do. The staff are very friendly, never ignore people and buzzers are answered straight away, I do not find this in all of the care homes I visit”. A Requirment made at the last two visits regarding recruitment records has now been met in that the manager now has a list of all Criminal Bureau Checks (CRB) in place for all of the staff team. We saw the files of four members of staff, two had recently been recruited and all had the required documentation including references and a CRB check. For one person who had just taken up employment a POVA First had been received and on both days of the visit, this person was shadowing a senior member of staff. Records show that staff receive a structured induction and attend all mandatory training such as first aid, moving and handling and infection control. The home also carries out video and questionnaire training for subjects such as dementia awareness and understanding learning disability. Tripletrees DS0000014806.V357035.R01.S.doc Version 5.2 Page 20 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31 33 35 36 and 38. Outcomes for service users in this area are good. This judgement has been made using available evidence including a visit to this service. The home is managed by a competent and caring manager, who runs the home in the best interests of the people living there. Records are in good order and health and safety issues are addressed but improvements are needed to ensure people’s safety in the event of a fire occurring. EVIDENCE: The home is managed by the owner, who has many years of experience in the management of care homes and has the required qualifications. Service users, families and the staff on duty spoke highly of Mrs. Follett and said that she managed the home in an open and supportive manner. Tripletrees DS0000014806.V357035.R01.S.doc Version 5.2 Page 21 A family member said, “ The manager is very accessible, you can go to her with anything and she will go out of her way to help you”. Mrs Follett has started to implement a quality assurance process by sending questionnaires to service users and those returned were seen at the visit. Surveys are also in place for families and professionals and Mrs. Follett said that these were due to be sent out in the next month. A large number of letter and cards of compliments and thanks are also on file in the home. The staff on duty said that they received supervision although this was not always formal as Mrs. Follett worked alongside them on a daily basis offering guidance and support. We saw records for the running of the business including incidents and accident recording, staff fire training and maintenance records and all were current and in good order. There is a rolling programme of development for the home and this includes full redecoration and improvement of the environment in 07/08. As detailed in this report improvements are needed to fire systems in order to keep people safe who wish to keep their bedrooms doors open. Tripletrees DS0000014806.V357035.R01.S.doc Version 5.2 Page 22 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 X 3 X 3 3 HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 X X 3 X X 3 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X 3 2 Tripletrees DS0000014806.V357035.R01.S.doc Version 5.2 Page 23 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 OP19 Regulation 23 (4) (a) Requirement In order to ensure that service users and staff are protected in the event of a fire occurring, risk assessments should be carried out for people who wish to keep their bedroom doors open and suitable equipment provided to ensure door will automatically close when the fire alarm sounds. Timescale for action 01/04/08 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Tripletrees DS0000014806.V357035.R01.S.doc Version 5.2 Page 24 Commission for Social Care Inspection Maidstone Office The Oast Hermitage Court Hermitage Lane Maidstone, Kent ME16 9NT 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. Extracts may not be used or reproduced without the express permission of CSCI Tripletrees DS0000014806.V357035.R01.S.doc Version 5.2 Page 25 - 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. 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