Inspection on 18/07/07 for Tripletrees

This inspection was carried out on 18th July 2007.

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

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Tripletrees 11/12/08

Tripletrees 18/02/08

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 Mr D Bannier Unannounced Inspection 18th July 2007 10:00 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 DS0000014806.V341562.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. DS0000014806.V341562.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) DS0000014806.V341562.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. DS0000014806.V341562.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection has followed the Inspecting for Better Lives methodology and is called a key inspection as it assesses those standards determined by the Commission as key standards. This inspection will also determine the frequency of inspections hereafter. The registered provider returned an Annual Quality Assessment Form (AQAA) prior to the inspection. Six residents returned surveys, entitled “Have Your Say” sent to them by the Commission, designed to enable residents to give their opinions about how the care home is being run. The information received from each of these documents will be referred to in this report. A visit to Tripletree was made on Wednesday 18th July 2007 to meet with and talk to residents, the Manager, staff on duty, observe care practices, see residents’ accommodation and to examine a selection of records. As this was an unannounced inspection the care home had no notice of this visit. It lasted approximately six and half hours. What the service does well: Residents said they were well looked after. The care that staff provide meets their identified needs. Care practices seen demonstrated that staff provide care with patience and a sense of humour, but also with respect for residents. Residents said they have been provided with sufficient activities in order to keep them occupied if they wish to take part in them. DS0000014806.V341562.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: New staff are still commencing work in the home without a satisfactory Criminal Records Bureau (CRB) check having been cleared to ensure the protection of the residents. Mrs Follett is required to make recruitment practices more robust. She must be able to demonstrate that a CRB check has been applied for before the member of staff starts work and they are appropriately supervised until a satisfactory check has been returned. A robust quality assurance system should be developed so that the management of the care home can be monitored in order to identify improvements needed. The system employed should include a method for consulting residents so that Mrs Follett can demonstrate the care home is being run in the best interests of residents. DS0000014806.V341562.R01.S.doc Version 5.2 Page 7 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. DS0000014806.V341562.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 DS0000014806.V341562.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 and 6 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents have been provided with information about the home in order to decide if they wish to move in. No resident moves into the home without having had his or her needs assessed. This care home does not provide intermediate care. EVIDENCE: The names of three residents, who had been admitted on a permanent basis, were identified for case tracking purposes. The inspector spoke to each of them and also looked through their care records. The inspector also spoke to other residents who were not part of the case tracking exercise. DS0000014806.V341562.R01.S.doc Version 5.2 Page 10 Residents said that they were satisfied with the care and services provided to them. One resident said, “ Both my sons live nearby, that is why I came here.” Another resident said, “I moved here to be nearer my niece.” A relative, who was visiting at the same time as the inspector said, “The home has a nice happy atmosphere.” Surveys returned by residents confirmed they had received enough information about the care home before moving in so they could decide if it was the right place for them. One resident commented, “The information given on a visit showed all facilities. The home is near my niece’s house.” Records seen showed that the registered provider has ensured residents’ needs have been assessed prior to admission. Following discussions about the needs of identified residents, staff on duty were able to demonstrate they were fully briefed about the care required by the four residents identified and what was expected of them. Information supplied by the registered provider confirmed that, “ The home’s Statement of Purpose and Service User’s Guide clearly states the facilities that the care home can provide to enable residents to make a choice as to whether the home can meet their needs. Residents and their families are given the opportunity to visit the home before making a decision. This may take the form of a meal, afternoon tea or an overnight stay. A pre admission assessment on the prospective resident is carried out to ensure that the home can meet their care and social needs.” DS0000014806.V341562.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 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Staff have appropriate information to ensure they are able to meet residents’ needs. The registered provider has ensured residents’ health care needs have been fully met. The registered provider has ensured residents are protected by the home’s policies and procedures for dealing with medicines. Current care practices have ensured residents feel they are treated with respect and their right to privacy has been upheld. EVIDENCE: DS0000014806.V341562.R01.S.doc Version 5.2 Page 12 Care plans have been drawn up from the information gathered when residents’ needs were assessed. Care plans are informative and include appropriate information and instructions which staff are expected to follow. This will ensure residents’ care is provided in a consistent and continuous manner. Records seen also demonstrated that care plans and assessments are reviewed on a regular basis to ensure they are up to date. Care plans included a record of nursing interventions made by District Nurses and visits made by GP’s to provide residents with medical treatment. It was noted that, on occasion, assessments and care plans had not been dated. This means it is not clear whether the information available is up to date. Following discussion the registered manager confirmed that, in future she will ensure this is done. From direct observations, residents appeared to be relaxed when talking with staff and very well cared for. One resident told the inspector, “It is wonderful here. The staff are fantastic. You would go a long, long way to find a nicer place.” Another resident said “I am very happy here. The staff are very nice.” Surveys returned by residents confirmed they receive the care and support they need. They also confirmed residents felt the received the medical support they needed. One resident commented, “The staff are all available to support me when I am feeling sad sometimes. It is marvellous.” Another resident commented, “Certain medicines are available here.” The inspector examined medication records. Records had been well maintained and were up to date. A monitored dosage system (MDS) employing blister packs is used to administer medication. The inspector was advised that the current practice is for medication to be given to residents directly from packs and containers marked by the dispensing chemist, with the name of the resident the dosage and strength and time the medication is to be given. The staff member giving medication is expected to check these details before medication is administered. Following discussions with senior staff it was agreed it would make the system safer if residents’ photographs were kept with the medication records. This would safeguard against residents being given the wrong medication. There were no residents administering their own medication at this time. From direct observations the inspector noted that staff treated residents with respect. Care practices also ensured residents’ right to dignity have been upheld. Whilst visiting residents’ private accommodation staff advised the inspector if a resident was in the process of getting up and it was not appropriate for the inspector to visit. Staff were seen to speak to residents courteously, using the name preferred by the resident. Information supplied by the registered provider confirmed, “The service users’ health, personal and social care needs are set out in an individual plan of care. The care plans are robust, relevant and up to date, to ensure that all service DS0000014806.V341562.R01.S.doc Version 5.2 Page 13 users receive appropriate health care provision. Specialist equipment is provided as necessary through the District Nurse, including the provision of pressure relieving mattresses and cushions. A policy is held for the prevention and treatment of pressure sores, and appropriate risk assessments have been carried out with regard to this for all service users. Advice is sought from the Continence Advisor when this is necessary. There is a comprehensive risk assessment within the care plan, including the prevention of falls. Residents have a choice of GP, and nutritional screening and weight monitoring have been reviewed and are carried out on a monthly basis. Our Medication Policy ensures that staff adhere to procedures for the receipt, recording, storage handling, administration, and disposal of medicines. Service users may take responsibility for self-medicating if they wish, within a risk management framework. Staff accreditation and medication training is carried out by the local pharmacist.” DS0000014806.V341562.R01.S.doc Version 5.2 Page 14 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 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social and recreational interests and needs. Residents maintain contact with family and friends Residents receive a wholesome appealing balanced diet. EVIDENCE: Residents’ social, and recreational interests have been recorded in individual care plans. A programme of activities were displayed on the residents’ notice board and included bingo, craft sessions such as painting, drawing and making cards, music and sing-along sessions, board games and quizzes. One relative, who visits frequently, told the inspector, “There is always something going on DS0000014806.V341562.R01.S.doc Version 5.2 Page 15 when I visit. Music, bingo or reminiscence sessions.” On the day of his visit the inspector noted that, during the morning one resident was sitting in the dining room designing colour schemes for a garden in a sketchbook. Two other residents were working on a puzzle with a member of staff. A group of residents were sitting in the lounge listening to music featuring Dame Vera Lynn. One resident has a pet canary that is kept in a cage in their bedroom. Residents’ surveys confirmed that there are always activities arranged by the care home that they can taken part in. One resident commented, “We play hangman and bingo. We listen to music. We debate and we can watch if we want to. We have a television.” A second resident commented, “ I enjoy the activities which I take part in daily.” A television and a music centre have been provided in the lounge. Some residents have also bought televisions for their own rooms. There is also equipment available for residents to play board games such as scrabble and dominoes. Information supplied by the registered provider confirmed that, “Service user’s preferences for activities were sought upon admission. The routines of daily living and activities made available are flexible and varied to suit users’ expectations, preferences and capacities. We have a designated activities officer and regular activities include bingo, skittles, drawing, painting, videos, karaoke, dancing and reminiscence.” Visitors are welcomed to Tripletree. One resident told the inspector, “Both my sons live nearby, that’s why I came here. They can visit me often.” Another resident said, “I moved here to be nearer to my niece. She can visit me when she wants.” The same relative told the inspector, “ I can visit as often as I like. I am always made welcome when I visit my aunt.” Surveys returned by residents confirmed that the care home always helps their families and friends to keep in touch with them. Information supplied by the registered provider confirmed that,” Visitors are welcomed at reasonable times. This is included in the Service User’s Guide.” On the day of his visit the inspector noted that the lunchtime meal was chicken fricassee, potatoes, carrots and cauliflower followed by rhubarb crumble and custard. According to the menu residents who did not want this could have an omelette as an alternative. The inspector went into the dining room during lunch. Residents told the inspector that they were enjoying their meal. From menus seen the inspector concluded that residents have been provided with a varied, wholesome and balanced diet. Comments made about the food were varied. One resident said, “The food is not quite as good as it was, it used to be fantastic.” A second resident said, “The food is very good, I have no complaints at all.” Surveys returned by DS0000014806.V341562.R01.S.doc Version 5.2 Page 16 residents confirmed that they always like the meals at the home. One resident commented, “They are varied and tasty. I enjoy my breakfast and love the desserts!” Information supplied by the registered provider stated that, Service users receive a wholesome, appealing and balanced diet, in pleasing surroundings and at times convenient to them.” DS0000014806.V341562.R01.S.doc Version 5.2 Page 17 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 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents and their relatives know that their complaints will be listened to, taken seriously and, where necessary, acted upon. The registered provider has ensured that residents are protected from abuse EVIDENCE: The registered provider has drawn up a written complaint procedure. This clearly identified who residents, or their relatives should speak to if they wished to make a complaint. The procedure also sets out the steps any investigation would go through and the timescales by which the complainant would be notified of the outcome. Information supplied by the registered provider confirmed that no complaints had been received in the last 12 months. Surveys returned by residents confirmed they knew how to make a complaint. They also confirmed that the registered provider has responded appropriately when concerns have been raised about their care. DS0000014806.V341562.R01.S.doc Version 5.2 Page 18 One resident told the inspector, “If I needed to make a complaint I would speak to the person in charge of the home.” Another resident said, “ I am treated well, I can’t complain. But if I needed to, I would speak to the person in charge.” Information supplied by the registered provider stated that, “The home has a clear complaints procedure which is also included in the Statement of Purpose. A record is maintained in the home of any complaints made, with details of investigation and action taken. Any small issues or concerns which can be resolved quickly, would not be recorded. Service users and their families and friends are confident that their complaints will be listened to, taken seriously and acted upon. ” According to records seen training provided to staff includes training in Adult Protection procedures. It was also noted that the registered provider has a copy of the Adult Protection procedures published by West Sussex Local Authority. Staff on duty, who were spoken to, were able to tell the inspector about different types of abuse and to whom they should report any instance they may find. Information supplied by the registered provider stated that, “Service users are protected from abuse.” DS0000014806.V341562.R01.S.doc Version 5.2 Page 19 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 and 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents live in a safe, well-maintained environment. The home is clean, pleasant and hygienic EVIDENCE: It was noted the premises were very clean, tidy and well maintained. The inspector viewed a number of bedrooms, the lounge and the dining room. These were very clean and tidy, and well maintained. Residents have been able to personalise their own rooms by bringing small items of furniture, pictures, ornaments and family photographs. However, some items of furniture supplied by the care home, such as armchairs and occasional tables were looking DS0000014806.V341562.R01.S.doc Version 5.2 Page 20 shabby and need of being replaced. A senior member of staff informed the inspector that the registered provider was in the process of refurbishing and redecorating each room when it fell vacant. The inspector noted that some rooms had been redecorated and refurbished. Residents spoken to confirmed they were very happy with the accommodation provided. The relative of a resident told the inspector, “There is always a nice, happy atmosphere. You would be lucky to find another home like this. There are no smells; it is always nice and clean.” Surveys returned by residents confirmed that the home is always fresh and clean. One resident commented, “There is no “old people” smells. Another resident commented, “I can speak very highly of the housekeepers at the care home.” During the last inspection a requirement was made regarding the uneven paving in an area of the garden. The registered provider informed the inspector that she was intending to extend the care home to include a conservatory. This would mean this area of paving would no longer be in use. In the meantime the registered provider has chained off the pathway to prevent residents and visitors using it. Several bathrooms and WC’s seen were clean and maintained to a good standard of hygiene. Some bathrooms have been fitted with bathing aids to assist residents in getting in and out of baths. Toilets seen have also been equipped with appropriate aids such as toilet seats and grab rails to assist residents. The registered provider has recently installed an assisted bath and a shower for residents’ use. Once the room has been tiled and decorated residents will be able to make use of the facilities. Information supplied by the registered provider prior to the visit indicated that the premises has been visited by the Fire Officer and Environmental Health officer to ensure it is safe and meets requirements in terms of fire safety and health and safety regulations. The registered provider has also confirmed that any shortfalls identified have been rectified. Equipment such as gas installations, electrical wiring and equipment have been regularly checked and maintained to ensure they are safe to use. It also confirmed that, “ Bedrooms are comfortable, clean and tidy, offering accommodation to meet the residents’ needs. One ceiling remote control hoist and an “assistance standing” hoist have been installed to enable service users to have the specialist equipment to maximise their independence. All of the Fire Officer’s requirements have been met. The resident’s room which contains a fire exit has been cleared and confirmed to CSCI by the Fire Officer. The resident occupying the room has also signed confirmation of their agreement to the room being kept unlocked. A new shower unit and walk in baht have DS0000014806.V341562.R01.S.doc Version 5.2 Page 21 been installed, together with a sink in the laundry room. Ongoing day to day maintenance continues.” DS0000014806.V341562.R01.S.doc Version 5.2 Page 22 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 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. The registered provider has ensured there are enough staff on duty with appropriate experience and skills to meet the needs of residents accommodated. The registered provider has not ensured residents are supported and protected by the home’s recruitment policy and practices. Staff have received training and are competent to do their jobs. EVIDENCE: The inspector noted that three care staff were on duty. A trainee carer was also on duty who was assigned to serve meals, cups of tea and undertake general duties except for providing personal care to residents. This is because the member of staff is not yet 18 years of age. The inspector was advised the activities coordinator was unable to work due to sickness. The inspector noted that the trainee carer was taking part in an activity with two residents in the dining room; they were working on a jigsaw puzzle. In addition there was a housekeeper and a chef to ensure the premises are kept clean and residents DS0000014806.V341562.R01.S.doc Version 5.2 Page 23 are provided with cooked meals, snacks and drinks throughout the day. Following observations of care practices, talking to residents and staff, and examining the staff rota and a selection of care records, the inspector concluded there were sufficient staff on duty to meet the needs of residents currently accommodated. Surveys returned by residents confirmed there are always staff available when residents need them. One resident told the inspector, “ The staff are fantastic. They have patience with us and always have a good humour. Nothing is too much trouble for them. You can do what you want. They don’t tell you to do this or do that.” Another resident said, “the staff are nice. I am treated very well.” A relative, who was visiting, said, “ The staff are very good.” The inspector examined the records of two staff recruited since the last inspection. Records examined included completed application forms, proof of identity and a statement of health. Whilst this information had been obtained prior to appointment, the inspector noted that it continues to be the practice for staff to begin working at the care home before a criminal records check (CRB) has been obtained. Following discussion, the registered provider was reminded of her responsibilities to ensure residents are protected from abuse. As the registered provider was unable to clearly demonstrate she had applied for CRB checks before staff commence work and had ensured they had been appropriately supervised until they had been returned this remains a requirement. Information supplied by the registered provider also confirmed that, what they could do better is, “Ensure that the recruitment procedure fully protects the residents from abuse.” Records of training provided were also examined and demonstrated that training for all staff has included mandatory training such as fire safety, adult protection and health and safety. Surveys returned by residents confirmed that care staff always have the right skills and experience to look after people properly. It was also confirmed that staff listen to residents and act on what they say. The inspector spoke to two staff who were on duty the confirmed the training they had received. They were also able to explain to the inspector about the current care requirements of three residents who had been identified for case tracking purposes. According to information provided before the inspection took place, six care assistants hold the National Vocational Qualification (NVQ) in Care at Level 2 or above, whilst six care assistants are working towards the same award. Information supplied by the registered provider also confirmed what the care home does well is, “Commitment to service users; commitment to philosophy DS0000014806.V341562.R01.S.doc Version 5.2 Page 24 and aims; training and development; team objectives and goals; coaching and mentoring; use of external training resources and events; shared learning.” DS0000014806.V341562.R01.S.doc Version 5.2 Page 25 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 and 38 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. Mrs Follett has failed to take appropriate action to ensure the care home has been well managed in that she has not made the necessary improvements to the recruitment procedure. Mrs Follett has yet to introduce a quality assurance programme to ensure the care home is being run in the interests of residents. EVIDENCE: DS0000014806.V341562.R01.S.doc Version 5.2 Page 26 The registered manager for Tripletree is Mrs Follett, who is also the registered provider of this care home. Concern was expressed regarding the lack of improvement to the recruitment procedure despite it being made a requirement at the last inspection. Staff on duty who were spoken to confirmed there have been regular supervision sessions and staff meetings to ensure everyone knows what is expected of them. Although minutes of such meetings are taken they were not examined on this occasion. Residents were asked in surveys how they thought the home can improve. One resident commented, “Very happy how the home is run.” Another resident commented, “It can’t improve because I am very happy how the home is run.” A third resident commented, “The home is a happy place. I could not wish for anything better. I could not manage on my own! The home is very well managed.” One resident, who was spoken to told the inspector, “Mrs Follett works on the floor with the care staff. To me, that is the making of a business.” Mrs Follett returned a completed the Annual Quality Assurance Assessment (AQAA) before this visit was carried out and has been used to inform the inspection process. However, Mrs Follett was unable to provide documentary evidence to confirm that a quality assurance system was in place. When the inspector asked Mrs Follett about Quality Assurance she gave the inspector a folder that included the AQAA documents she had used. According to the information supplied by the registered provider, “Service users are consulted during our self assessment process. In addition, a quarterly residents’ meeting is held to ensure that the views of people using our service are promoted and incorporated into what we do. An identified area for improvement over the next 12 months is, “Quality Assurance development, reviews and updates.” In summary Mrs Follett has identified this as an area that can be improved upon, “It is hoped that the introduction of a robust quality assurance programme, incorporating regular reviews and feedbacks, will assist in the implementation of any necessary improvements.” The premises have been well maintained, ensuring a safe environment in which residents can live and staff can work. The registered provider has supplied information that indicates equipment such as boilers, other gas installations and electrical equipment have been regularly serviced and maintained. Residents have told the inspector that they are very satisfied with the accommodation and services provided. According to training records staff have been provided training in such subjects as moving and handling, food hygiene, infection control, health and safety. Staff on duty, who were spoken to confirmed the training they had received. DS0000014806.V341562.R01.S.doc Version 5.2 Page 27 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for 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 X N/A 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 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 1 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 1 X 1 X X X X 3 DS0000014806.V341562.R01.S.doc Version 5.2 Page 28 Are there any outstanding requirements from the last inspection? YES STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP29 Regulation 19(1)(b) Requirement Recruitment procedures and practices must be sufficiently robust in that all checks are undertaken prior to employment of any staff in the home to ensure residents are protected from possible abuse. Previous timescale of 30/11/06 not met. Timescale for action 12/09/07 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 DS0000014806.V341562.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection Hampshire Office 4th Floor Overline House Blechynden Terrace Southampton SO15 1GW 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 DS0000014806.V341562.R01.S.doc Version 5.2 Page 30 - 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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