Inspection on 04/12/06 for Troydale Farm

This inspection was carried out on 4th December 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. 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

Troydale Farm 27/11/07

Troydale Farm 20/02/06

Troydale Farm 02/11/05

Troydale Farm 09/12/04

Troydale Farm 03/08/04

Similar services:

Snydale Care Home

Abbey The

Larchfield Manor

Hawkhills

Beeches The - North Yorkshire County Council

The Grove Waltham

Carentan House

Ravensworth Lodge

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

CARE HOMES FOR OLDER PEOPLE Troydale Farm Troydale Lane Pudsey Leeds West Yorkshire LS28 9JT Lead Inspector Catherine Paling Key Unannounced Inspection 09:40 4th December 2006 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 Troydale Farm DS0000001517.V320035.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. Troydale Farm DS0000001517.V320035.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Troydale Farm Address Troydale Lane Pudsey Leeds West Yorkshire LS28 9JT 0113 255 5984 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) Mrs Edna Gilbank Mrs Edna Gilbank Care Home 13 Category(ies) of Old age, not falling within any other category registration, with number (13) of places Troydale Farm DS0000001517.V320035.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 20th February 2006 Brief Description of the Service: Troydale care home was built as a farmhouse in 1706 and was first registered as a care home in July 1989. The house has been sympathetically converted and many of the original features have been retained. The home now provides personal care for up to thirteen older people with a moderate level of disability. Nursing care is not provided. Troydale is set in farmland in the Tong-Cockersdale conservation area and has extensive views over Troydale valley. It has pleasant gardens and car parking is provided in the grounds. The home is only a short distance from Pudsey town centre and has public transport links with Leeds and Bradford. Accommodation is provided in nine single and two double rooms on two floors. Bedrooms are fitted with washbasins and there are a number of communal toilets and bathrooms. The communal lounge and dining room are on the ground floor. There is level access to the home and a stair lift provides access to the first floor. Information about the home is provided in the form of a statement of purpose and service user guide. Both these documents are currently being reviewed and updated together with the terms and conditions for residents. The current fees charged are £390 per week. There are additional charges for hairdressing; newspapers; toiletries; dental treatment and chiropody. There is a charge for escort to hospital appointment and this is dependant on the agency rate of pay. This information was provided by the home in October 2006. Troydale Farm DS0000001517.V320035.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The Commission for Social Care Inspection (CSCI) inspects homes at a frequency determined by how the home has been risk assessed. The inspection process has now become a cycle of activity rather than a series of one-off events. Information is gathered from a variety of sources, one being a site visit. All regulated services will have at least one key inspection between 1st April 2006 and 30th June 2007. This is a major evaluation of the quality of a service and any risk it might present. It focuses on the outcomes for people using it. All of the core National Minimum Standards are assessed and this forms the evidence of the outcomes experienced by residents. More information about the inspection process can be found on our website www.csci.org.uk On some occasions it may be necessary to carry out additional site visits, some visits may focus on a specific area and are known as random inspections. The visit took place on 4th December 2006 and was unannounced. One inspector was at the home from 09:40 until 14:20. The deputy manager assisted during the visit and the owner was also available. The purpose of the inspection was to make sure the home was operating and being managed for the benefit and well being of the residents and in accordance with requirements. Before the inspection accumulated evidence about the home was reviewed. This included looking at any reported incidents, accidents and complaints. This information was used to plan the inspection visit. There had not been any recent reported incidents and no complaints have been received since the last visit. A number of documents were looked at during the visit and all areas of the home used by residents were visited. A good proportion of time was spent talking with residents as well as with the deputy manager and the owner. The registered manager completed and returned a pre-inspection questionnaire (PIQ) to provide additional information about the home in advance of the inspection. Some comment cards were left at the home providing the opportunity for residents and/or visitors to comment on the home, if they wish. Information provided in this way may be shared with the owner but the source will not be identified. What the service does well: Troydale Farm DS0000001517.V320035.R01.S.doc Version 5.2 Page 6 Troydale provides comfortable accommodation in a relaxed, welcoming and homely environment. There is a good rapport between staff residents and their relatives. Residents said that the food is always good and there is always home baking provided. Activities such as quizzes are a regular part of day-to-day life and it was clear that residents enjoyed these and there was a programme of events planned for Christmas. All residents have their needs assessed before being admitted to the home and staff were knowledgeable about how to care for the residents The owner manager and the staff are clearly committed to providing a good quality of life for the residents. What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Troydale Farm DS0000001517.V320035.R01.S.doc Version 5.2 Page 7 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 Troydale Farm DS0000001517.V320035.R01.S.doc Version 5.2 Page 8 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, 2 and 3. (Standard 6 does not apply to this service) Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. There is sufficient information available at the home for residents and their families to make an informed choice about moving into the home. All residents have their needs fully assessed before they are admitted to the home. EVIDENCE: There is detailed information available to residents and their families in the form of a statement of purpose. Both these documents together with the home’s terms and conditions are currently under review. Once these documents have been reviewed copies will be made available to the residents/relatives and to the CSCI. The manager assesses the needs of every resident before they are admitted to the home and gets her information from whatever sources are available so that residents can be assured that their needs can be met at the home. Troydale Farm DS0000001517.V320035.R01.S.doc Version 5.2 Page 9 There was clear documented evidence that residents and their families are supported throughout the admission process and that great care is taken in helping residents settle at the home. Troydale Farm DS0000001517.V320035.R01.S.doc Version 5.2 Page 10 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. Care plans provide clear and detailed instructions for staff to follow and provide evidence that care needs are met. Medication administration practices are safe. Staff treat residents with respect and show a good awareness of residents’ needs. EVIDENCE: The care of three residents was case tracked using their individual care records. Records provide good detail of care and reflect the differing needs of the individual residents. There was clear evidence of the involvement of the residents and/or their relatives with the staff in the development of the care plans. One recently admitted resident had had some difficulty with coming to terms with the move into care. The records clearly evidenced how staff intervened and gave support to the resident and liaised with relatives. Another resident Troydale Farm DS0000001517.V320035.R01.S.doc Version 5.2 Page 11 had expressed a wish to see their General Practitioner alone and this had been respected. Detailed and effective risk assessments are in place and provide staff with instruction on how to manage an identified risk. Observation and discussion with residents showed that staff respect their privacy and dignity. Patient and caring interaction was seen between residents and the staff. There were no residents in the home who were self-medicating. Medicines are stored safely and the required records were up to date and accurate. The manager said that medicines are reviewed regularly by the General Practitioners or at the request of the home. This is good practice. Input from other healthcare professionals is clearly documented within the records. All the staff who are involved in helping residents with their medicines have received accredited training. In addition, training booklets have been developed on medicine administration at the home and staff are working through these as part of the in-house training provision. Troydale Farm DS0000001517.V320035.R01.S.doc Version 5.2 Page 12 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 are encouraged to make choices in their daily lives and to maintain contact with their friends and families. Visitors are made very welcome at the home. Residents are provided with a varied and nutritious diet. EVIDENCE: Residents are able to spend their day how they choose. One resident prefers to spend time in their room listening to music and staff go in to chat when they can. Others come down to lounge at various times through the morning. On the day of the visit staff and residents were involved in putting up Christmas decorations. There was a programme of planned events for the Christmas period including entertainers, a Christmas party, a carol concert from a local school and outings for the more able residents. On the afternoon of the visit residents took part in a seasonal quiz organised by a member of the staff team. Troydale Farm DS0000001517.V320035.R01.S.doc Version 5.2 Page 13 Visitors are made very welcome and offered refreshments and privacy for their visit. Visitors spoken with on the day of the visit said that they were always made welcome and the staff looked after their relative very well. The cook has been at the home for number of years and understands the needs of the residents very well. There is home baking available all the time and on the day of the visit Christmas puddings and cakes were being made. Troydale Farm DS0000001517.V320035.R01.S.doc Version 5.2 Page 14 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. The level of staff understanding gives assurance that any complaints would be taken seriously. Residents feel safe and staff are aware of adult protection. EVIDENCE: There is a complaints procedure in place that is made available to residents and their families. Residents and their families are clear about who to talk to if they have an issue of concern. Staff are vigilant and intervene if they think residents have any concerns. It is a small close knit home and residents feel safe and well cared for. There have not been any recent complaints. Adult protection procedures are in place as well as whistle blowing procedures for staff. Part of the home’s internal monitoring systems includes a survey of the residents when they are asked whether they know how and who to complain to. It was recorded for all three of the residents who were case tracked that they had been told how to complain and knew who to talk to if they had a concern. Troydale Farm DS0000001517.V320035.R01.S.doc Version 5.2 Page 15 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, 20, 21, 22, 23, 24, 25 and 26. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is clean, comfortable and well maintained. The absence of radiator guards in some areas creates the opportunity for residents to be placed at risk. EVIDENCE: Many of the rooms incorporate original features and all were attractive and inviting. There are no en suites but all rooms have a wash hand basin and there are sufficient communal sanitary facilities available for residents. All parts of the home were clean and free of unpleasant odours. The ongoing refurbishment of the home continues. The owner has started to fit radiator covers but there are still some which are not yet protected. There is a planned programme in place to protect all the radiators over the coming year. Troydale Farm DS0000001517.V320035.R01.S.doc Version 5.2 Page 16 The communal rooms on the ground floor are furnished and decorated in a domestic style and are appropriate to the needs of residents. The laundry is suitably equipped to meet residents’ needs. Troydale Farm DS0000001517.V320035.R01.S.doc Version 5.2 Page 17 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 good. This judgement has been made using available evidence including a visit to this service. Well-trained and competent staff meet the needs of the residents. Residents are protected by the recruitment procedures. EVIDENCE: Duty rotas indicated that there are sufficient care staff on duty to meet the needs of the residents. Care staff are supported in their role by a cook and a cleaner. There is one waking night staff and the owner, who lives in the adjacent house provides on call support overnight. Over 50 of the care staff have achieved a National Vocational Qualification (NVQ) in care at level 2. The deputy manager has achieved NVQ level 3 in care and the manager has almost completed NVQ level 4 in care. There is a clear commitment to making sure that the staff are trained and competent. Training videos are used on a wide range of subjects. These require staff to complete a questionnaire after they have watched the video and these are sent away for marking. 1st aid training has now been provided for staff. The manager has completed a course to enable her to provide fire training. In addition there is a range of workbooks that have been designed in house for staff to work through. Feedback from these workbooks is given at 1:1 Troydale Farm DS0000001517.V320035.R01.S.doc Version 5.2 Page 18 supervision sessions or discussed within the staff group. Staff are enthusiastic about training. The recruitment files looked at on the day of the visit for recently employed staff were not up to date. This was acknowledged by the manager following the inspection and she agreed that these would be corrected promptly. All the necessary checks are carried out before staff start work at the home. Troydale Farm DS0000001517.V320035.R01.S.doc Version 5.2 Page 19 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, 32, 33, 35, 36 and 38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is well managed. The interests of the residents are very important to the manager and staff and are safeguarded at all times. EVIDENCE: Mrs Gilbank is the registered provider and registered manager although she takes more of an administrative role. Mrs Riley, takes on most of the responsibility for the day-to-day management of the home with a deputy providing good support. The long-term plan is to formalise this arrangement with Mrs Riley becoming the registered manager. Mrs Riley is currently doing an NVQ level 4 in care. On completion of this she will then undertake a management qualification. In a telephone call following the inspection it was clear that she is enthusiastic about her training and committed to the ongoing development of the home. Troydale Farm DS0000001517.V320035.R01.S.doc Version 5.2 Page 20 There is a comprehensive quality assurance system in place with a range of in house audits carried out on a regular basis. There is an ongoing development plan in place with clear targets for the end of 2006 and 2007. Review of the Statement of purpose, service user guide, terms and conditions, policies and procedures were included on this plan. Self audit/review of the service is also carried out against the National Minimum Standards. Residents are surveyed to gauge their views of the service, as are staff and relatives. There is open communication with residents and relatives and regular meetings are also held. The residents deal with their own financial arrangements and the home’s staff do not hold any valuables or money for safekeeping. There is an established system in place for the supervision of staff and the person carrying out supervision has been trained to do so. The format used indicated that personal development, training and goal setting are amongst the topics covered. The only concern about health and safety was in relation to the absence of radiator guards in some rooms, further information on this is provided in the environment section of this report. Troydale Farm DS0000001517.V320035.R01.S.doc Version 5.2 Page 21 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 3 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 3 3 3 3 3 2 3 STAFFING Standard No Score 27 3 28 3 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 3 X 3 3 3 2 Troydale Farm DS0000001517.V320035.R01.S.doc Version 5.2 Page 22 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 OP25 Regulation 13(4) Requirement Radiators must be fitted with guards or replaced with Low Surface Temperature radiators. Timescale of 30/06/06 not met. Timescale for action 03/09/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 Refer to Standard OP29 Good Practice Recommendations The manager should make sure that all the required information about recruitment is held within the individual staff files. Troydale Farm DS0000001517.V320035.R01.S.doc Version 5.2 Page 23 Commission for Social Care Inspection Aire House Town Street Rodley Leeds LS13 1HP 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 Troydale Farm DS0000001517.V320035.R01.S.doc Version 5.2 Page 24 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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