Inspection on 15/08/05 for Twelvetrees

This inspection was carried out on 15th August 2005.

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 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

Twelvetrees 29/05/07

Twelvetrees 09/03/06

Twelvetrees 28/10/04

Twelvetrees 30/07/04

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 Twelvetrees 17 Priory Road Sheffield South Yorkshire S7 1LW Lead Inspector Shirley Samuels Unannounced 15th August 2005 18:15-21:00 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 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. Twelvetrees J55 S32153 Twelvetrees V237080 180805 UI Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Twelvetrees Address 17 Priory Road Sheffield South Yorkshire S7 1LW 0114 2555155 0114 2555005 None Mr Simon Charles Mills Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Ms Kathryn Jane Moore PC Care Home Only 29 Category(ies) of OP Old Age (29) registration, with number of places Twelvetrees J55 S32153 Twelvetrees V237080 180805 UI Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: Total care hours must be maintained at a minimum of 530.98 hours per week. (This excludes the registered manager`s hours). Date of last inspection 28th October 2004 Brief Description of the Service: Twelvetrees is a Victorian house that has been converted to offer 24-hour care for up to 29 older people. There are 21 single rooms and 4 double rooms. The home is well decorated. It is in a residential area on the south side of Sheffield. The establishment offers both long and short-term care. There is an eightperson lift allowing easy access to all levels of the home. There are spacious bathrooms and toilets suitable for people with disabilities. They offer a choice of services such as hairdressing, chiropody, dentist and optician all at the service users request. The homes service user guide states “care is provided by a carefully selected team of qualified carers, of whom receive regular training and appraisal to maximise motivation and team spirit. With an exceptionally low staff turnover and many long serving employees”. Twelvetrees J55 S32153 Twelvetrees V237080 180805 UI Stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection carried out over three hours. Eight service users, three members of staff and the senior care the person in charge was spoken to. A selection of records was checked and an inspection of the building was made. Observation was made of the care provided and the approach of staff to service users. During the inspection staff assisted service users to have a bath getting ready for bed and providing service users with drinks and snacks, laundry duties and report writing. Staff worked well together in a coordinated way, and service users were supervised, reassured and relaxed. What the service does well: What has improved since the last inspection? Medication procedures have been improved, and the written procedure on adult protection has been amended to include reporting allegations of abuse to the social services adult protection team. Twelvetrees J55 S32153 Twelvetrees V237080 180805 UI Stage 4.doc Version 1.40 Page 6 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. Twelvetrees J55 S32153 Twelvetrees V237080 180805 UI Stage 4.doc Version 1.40 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 Standards Statutory Requirements Identified During the Inspection Twelvetrees J55 S32153 Twelvetrees V237080 180805 UI Stage 4.doc Version 1.40 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 3 & 5 Service users do not move into the home without having their needs assessed. EVIDENCE: Three-service user flies were checked they all included assessments that were carried out prior to moving into the home. This ensured that the staff had the information they needed to make a judgement about whether they could meet the service users needs are not. Service users who had recently moved into the home said the owner of the home visited them. The service was explained to them and they were provided with written information in the form of a brochure. They were also able to visit the home before moving in. They confirmed that they were on a trial period and were trying with assistance to make a decision about whether to move into the home on a permanent basis. This ensured they were informed and knew what to expect when they moved into the home and were given the time and assistance they needed to make a decision about their future. Twelvetrees J55 S32153 Twelvetrees V237080 180805 UI Stage 4.doc Version 1.40 Page 9 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 7, 9 &10 Service users health, personal and social care needs were set out in a plan of care. Service users, where appropriate, were able to be responsible for their own medication and were protected by the homes policies and procedures for managing medication. Service users were treated with dignity and their right to privacy was upheld. Twelvetrees J55 S32153 Twelvetrees V237080 180805 UI Stage 4.doc Version 1.40 Page 10 EVIDENCE: Three-service user files were checked on each was a care plan. Two of the care plans were still under development as the service users had recently moved into the home and had not as yet made a decision to stay at the home. These service users said they were not aware of their care plan but said the staff had spoken to them about their care needs wishes and preferences. For the third service user the care plan was comprehensive and was regularly reviewed. Ensuring that service users current and changing needs was recorded and available to staff. There was a medication procedure in place, which allowed where appropriate service users to administer their own medication and staff received training on safe administration practice. Medication was securely stored, and in the main the records kept meet the required standards. For one service user who was seriously ill, the records showed that the GP had made regular visits. The medication records showed that medication had not been administered as the service user had difficulty swallowing and administration caused distress. This discontinuation of administration, had not, according to the records been authorised by the GP. There was one example of pain controlling tablets prescribed to be administered two four times daily when required. The Mar sheet indicated that these tablets were only offered ones a day. Service users said they were treated with respect, the staff always talked to them in a proper manner and were respectful and addressed them in the way they preferred. They described the staff as “gems”, “ always there for me”, “they will do anything for you”, “smashing no complaints”, “alright” and “well mannered”. Staff said on a daily basis they tried to promote the privacy and dignity of service users by asking their permission, giving choices, being sensitive during personal care tasks, choices about who they wanted to provide care, closing door and knocking before entering. Observations were made of staff asking service users what they wanted offering choice and encouraging service users to make choices. This promoted a sense of wellbeing and control over their lives. Twelvetrees J55 S32153 Twelvetrees V237080 180805 UI Stage 4.doc Version 1.40 Page 11 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12,13 14 &15 Service users found that the lifestyle experienced at the home matched with their expectations. They were able to maintain contact with friends and family and representatives of the community if they wished. Service users received a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. Twelvetrees J55 S32153 Twelvetrees V237080 180805 UI Stage 4.doc Version 1.40 Page 12 EVIDENCE: Regular activities were arranged. Service users were able choose whether to take part or not. Records were kept of activities and who had taken part. Service users said they went out into the country to the coast for meal and afternoon tea. Entertainment was also provided inside the home. Service users said they were free to go out alone and they used public transport to travel into town. This promoted their independence and choice. Service users said they were able to maintain contact with family and friends and they were made welcome when they visited and were able to see service users in private. Service users said they were happy with the food provided. A choice was offered and they could choose whether to eat their meals in the dining room or in their bedroom. Twelvetrees J55 S32153 Twelvetrees V237080 180805 UI Stage 4.doc Version 1.40 Page 13 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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 16 &18 Service users and their family and friends are confident that their complaints will be listened to taken seriously and acted upon. Service users are protected from abuse. EVIDENCE: Service users said they were given written information about how to make a complaint when they moved into the home. They also added, they had someone they could talk to if they were unhappy about anything, and felt able to raise issues with staff. There is a procedure in place for recording complaints, the outcome of any investigation and of any action taken. Ensuring complaints were taken seriously and acted upon. Service users said they felt safe at the home. Staff had received training in adult protection, and were able to verbalise the action they would take following an allegation. They were also able to give examples of types of abuse. Since the last inspection the homes policy has been amended to include the reporting of any allegation to the Sheffield social services department. Twelvetrees J55 S32153 Twelvetrees V237080 180805 UI Stage 4.doc Version 1.40 Page 14 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 19 & 26 Service users live in a safe well-maintained environment, the home is clean pleasant and hygienic. Twelvetrees J55 S32153 Twelvetrees V237080 180805 UI Stage 4.doc Version 1.40 Page 15 EVIDENCE: Service users said they were happy with their bedrooms they, said the home was “nice and clean” and “welcoming”. There is a programme of routine maintenance and renewal of fabric and decoration. Since the last inspection some areas have been refurbished. The grounds were kept tidy safe and attractive the garden areas were accessible to service users who helped to plant flowers and maintain the garden. This area provided service users with a comfortable, pleasant and safe place to sit and enjoy during the summer months. All areas were clean pleasant and hygienic. Staff were able to demonstrate the procedures they took to prevent cross infection and said they were provided with gloves, aprons etc, to promote the health of service users and themselves. Procedures were in place for the handling, storage and collection of clinical waste to reduce the risk of infection. Lockers were provided in the laundry area for staff to lock away their valuables however staff coats were noted hanging from the doors of the lockers, posing a risk of cross infection. Staff said a rail was provided away from the laundry. Twelvetrees J55 S32153 Twelvetrees V237080 180805 UI Stage 4.doc Version 1.40 Page 16 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27 The number and skill mix of staff meets Service users needs. EVIDENCE: There is a stable staff team, staff said there is always enough staff on duty to meet the needs of the service users. The service users said “there are always staff around when you need help”, “they always come quickly when I ring my buzzer”, “they all seem to know what they are doing even the young ones”. One service user spoke of the compassion and care extended to her and explained how the owner and the manager had taken her to visit her very ill son in hospital. She said she was touched by this and added that the every day care and support she received from all the staff was always “just as she needed”. This promoted a sense of wellbeing. Staff were observed approaching service users sensitively and offering assistance where needed. They explained what assistance was to be an offered and encouraged service user to do what they could for themselves. Promoting independence and choice. Twelvetrees J55 S32153 Twelvetrees V237080 180805 UI Stage 4.doc Version 1.40 Page 17 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 37 & 38 A procedure in place for the secure storage of service users information was not being used. The health safety and welfare of service users and staff are promoted and protected. Twelvetrees J55 S32153 Twelvetrees V237080 180805 UI Stage 4.doc Version 1.40 Page 18 EVIDENCE: A secure room is provided for the storage of service users files. On arrival the room was not locked therefore leaving service users files accessible to unauthorised persons. Staff said they had received moving and handling training the techniques observed were in line with good practice. Staff confirmed that moving and handling equipment was provided and serviced regularly. All areas accessible to service users were safe and free from hazard. Staff said they had received health and safety training and were able to give examples of how they maintained a safe environment eg checking equipment, recognising and removing hazards and reporting faults. Staff received regular fire instruction training, weekly checks were made on the fire system and fire drills took place. This ensured that in an emergency staff knew the action to take to reduce the risk of harm to service users. Twelvetrees J55 S32153 Twelvetrees V237080 180805 UI Stage 4.doc Version 1.40 Page 19 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score x x 3 x 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 x 9 2 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 3 14 3 15 3 COMPLAINTS AND PROTECTION 3 x x x x x x 2 STAFFING Standard No Score 27 3 28 x 29 x 30 x MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x 3 x x x x x x 2 3 Twelvetrees J55 S32153 Twelvetrees V237080 180805 UI Stage 4.doc Version 1.40 Page 20 NO Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard 9 Regulation 13 Requirement The Gp must be consulted about the difficulties of administering medicatin. In the event of the service user not being able to make a choice are express their wishes. Any decision not to administer medication must be made by the GP. The prescription lable and the administration recording section of the MAR sheet must reflect the prescribed frequency. Staff clothing must not be stored in the laundry area. Timescale for action 15/8/05 As required on the day of the inspection. 2. 9 13 3. 26 13 4. 37 17 Service users records must be kept secure. 15/8/05 as required on the day of the inspection. 15/8/05 as required on the day of the inspection. 15/8/05 as required on the day of the inspection. 5. Twelvetrees J55 S32153 Twelvetrees V237080 180805 UI Stage 4.doc Version 1.40 Page 21 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 Good Practice Recommendations Twelvetrees J55 S32153 Twelvetrees V237080 180805 UI Stage 4.doc Version 1.40 Page 22 Commission for Social Care Inspection Ground Floor, Unit 3 Waterside Court Bold Street Sheffield, S9 2LR National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. 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