Inspection on 29/05/07 for Twelvetrees

This inspection was carried out on 29th May 2007.

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

Twelvetrees 09/03/06

Twelvetrees 15/08/05

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 Val Hoyle Key Unannounced Inspection 29th May 2007 09:30 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 Twelvetrees DS0000032153.V331052.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. Twelvetrees DS0000032153.V331052.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Twelvetrees Address 17 Priory Road Sheffield South Yorkshire S7 1LW 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) 0114 255 5155 0114 255 5005 simon.mills@btinternet.com Mr Simon Charles Mills Ms Kathryn Jane Moore Care Home 29 Category(ies) of Old age, not falling within any other category registration, with number (29) of places Twelvetrees DS0000032153.V331052.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. Total care hours must be maintained at a minimum of 530.98 hours per week. (This excludes the registered manager`s hours). 9th March 2006 Date of last inspection 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. Information gained on the29th May 2007 indicate the current fees range from £311 up to £498. Additional charges include private chiropody £7 hairdressing from £5, and newspapers. Twelvetrees DS0000032153.V331052.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This key unannounced inspection took place over 6 hours, this included a partial inspection of the building. Three peoples care plans and supporting documentation were examined. Eight people who use the service and four staff were spoken to during the visit, their views are included throughout the report. Occupancy at the home remains high with 27 of the 29 beds occupied. The manager said the two vacant beds were being kept vacant to give flexibility while building work continues at the home. There are plans to extend the building to include four additional bedrooms and a lounge/dining area, which will enhance the current facilities. Five CSCI service users questionnaires were sent to the home and four surveys were returned. One letter had been received from a relative who expressed very positive comments about the care provided at the home. One staff questionnaire was returned. The information has been collated and their views are contained within this report. The registered manager was present throughout this visit and assisted with the inspection process. The registered manager had completed and returned the pre-inspection questionnaire and the information gained is included in this report. What the service does well: Excellent assessments ensure people who live at the home were receiving appropriate care, from staff who are well trained and motivated. Relative’s visitors and health professionals all praised the home and said the care was excellent. People who use the service feel involved in the development of their care plan. A number of people say staff helps them to maintain their independence but they feel reassured to know staff were always there when needed. The home provides excellent activities, which keep people who use the service stimulated and involved. People say they enjoy the outings and the entertainment provided at the home. Relatives say there is always a ‘buzz’ in the home when they visit, with lots of laughter between residents and staff. Twelvetrees DS0000032153.V331052.R01.S.doc Version 5.2 Page 6 The environment provides an excellent standard of cleanliness and staff are commended for their efforts. A good refurbishment plan ensures the premises were well maintained, for the safety of people who live at the home. Work had commenced to develop the building further which will include major refurbishment of the existing premises. This demonstrates a commitment to improve services for the people who live at the home. The home had a stable staff group who had worked at the home for a number of years. They were motivated, enthusiastic and well trained, and people who use the service spoke highly of the staff. The team is led by a manager, who encourages staff to be involved in promoting an excellent service. The staff team had gained and retained ‘Investors in People Award’ which recognises the ongoing commitment to develop the workforce. 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. Twelvetrees DS0000032153.V331052.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 Twelvetrees DS0000032153.V331052.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): 3. People who use the service experience excellent quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People who use the service were assessed before moving into the home to ensure their needs can be met. EVIDENCE: All new people receive a full comprehensive needs assessment before admission this is carried out by manager or responsible person who have the required skills and competencies. The service is highly efficient in obtaining a summary of any assessment undertaken by the placing authority, and insists on receiving a copy of the care plan before admission. Staff confirmed that information contained in the assessment was essential to understand what they needed to do to ensure people’s needs were met. Twelvetrees DS0000032153.V331052.R01.S.doc Version 5.2 Page 9 Three assessments were examined and they focused on achieving positive outcomes for people who use the service. Before agreeing admission the manager and staff carefully considers the needs assessment for each individual prospective person and the capacity of the home to meet their needs. Prospective people who use services are given the opportunity to spend time in the home, before making final decisions about where to live. One person said family had visited several homes before recommending Twelvetrees as the best home to meet the needs of their relative. Inspection reports and the internet were also used by the relative to choose the home. All CSCI surveys received confirmed that people who use the service were provided with sufficient information about the service before moving into the home. Twelvetrees DS0000032153.V331052.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. People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Care plans provide staff with sufficient information to meet the needs of people who use the service. Arrangements for dealing with health issues are met with support from health professionals. Medication policies and procedures were well managed ensuring the safe administration of medication. EVIDENCE: Three care plans were examined; these were well written and provided sufficient information to enable staff to meet the needs of the people who use the service. The care plans include regular evaluations, and daily records assess the individual’s progress. Comprehensive risk assessments ensure people can maintain their independence, while remaining safe. All CSCI surveys received confirmed that people’s needs were always met by staff that are well trained. Surveys say that staff always listen to people who use the Twelvetrees DS0000032153.V331052.R01.S.doc Version 5.2 Page 11 service, and people said staff were excellent, well trained and always provided a good service. Records examined and discussion with the staff confirmed people’s healthcare needs were met. The manager said doctors provide a good service, and district nurses also attend the home to carry out injections, take bloods and attend to dressing for people who live at the home. A visiting district nurse said staff were very good, they were very willing to assist in supporting individuals to their bedrooms for treatment. She said the staff provided excellent care. An audit of medication stocks and records was examined and were found to be correct ensuring the health and safety of people who use the service. Senior carers had responsibility for administering medications and they had attended training to ensure medicines were administered safely. The local pharmacist is contracted to undertake periodic checks to ensure the stock levels are maintained and procedures are followed. Medication was stored securely, there were separate, locked rooms for storing medication that contain a locked fridge and a controlled drugs cabinet. Throughout this visit staff were seen interacting with people who use the service in a kind manner, they spent time talking to people and were observed knocking on bedroom doors before entering. All people were referred to by their first name and this was agreed in the care plans examined. CSCI service user surveys received confirmed that staff always treated people who use the service with respect and maintain their dignity at all times. A letter received by CSCI, from a relative said staff were courteous, caring and professional. Twelvetrees DS0000032153.V331052.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. People who use the service experience excellent quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Excellent social activities are organised which are appropriate to the needs of the people who use the service. Mealtimes are well managed and people are encouraged to make choices and control over their own lives. People who use the service can maintain contact with family and friends, and have good opportunities to maintain links with the local community. EVIDENCE: There was a warm and friendly atmosphere on entering the home and a sense of wellbeing throughout the home. Staff are commended for creating a pleasant ambiance in the lounges. People who live at the home said activities and outings were very good. One person said a trip to the botanical gardens was very enjoyable while others said they enjoyed making teddy bears and buns for tea. Activities were arranged to meet the needs of the people who live at the home and staff frequently ask people what they want to do and where they want to go. Mobile library and newspapers were available and the more independent people could access local shops. CSCI surveys received confirm that people who use the service were happy with the activities provided at the Twelvetrees DS0000032153.V331052.R01.S.doc Version 5.2 Page 13 home. One relative said resident’s are encouraged to join in the numerous activities provided and there is always plenty of laughter and enjoyment at he events. The home had developed a professional looking newsletter that keeps people who live at the home fully informed about the forthcoming events. Visiting relatives said they were always made to feel welcome and staff were very caring. They also said that they were confident in staff’s ability to provide the care needed for their relative. The cook gave examples of the menus provided and said alternatives were always available. Staff asks people what foods they liked and the meals were included in the menus. The meals are transported and served to the three dining areas via a hot trolley. Mealtimes were well managed by staff who have a good understanding of peoples dietary needs. Staff were seen giving assistance in an unobtrusive way, and meals served to people in their bedrooms were accompanied with a drink. People said they had enjoyed their meal of salmon fish cakes with fresh vegetables and sautéed potatoes, followed by fruit crumble. The quality was very good and plentiful. Twelvetrees DS0000032153.V331052.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. People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People who use the service can access the complaints procedures and the manager ensures any concerns are recorded and investigated appropriately. Adult protection policies, procedures and training of staff promote the protection of service users from abuse. EVIDENCE: There is a complaints procedure that is available to people who use the service and visitors. The procedure is also referred to in the service users guide, identifying the stages to follow; this includes the time scales to respond to complaints. The address and telephone number of the Commission for Social Care Inspection is included in the procedure, although the address needs to state the CSCI Sheffield office details. Examination of the complaints records show that there were no complaints recorded since the last visit to the home. People who use the service said that they are confident that the manager or the responsible person would deal with any concerns they may have. Twelvetrees DS0000032153.V331052.R01.S.doc Version 5.2 Page 15 There is a comprehensive Adult Abuse and Whistleblowing policy and staff follow the procedures to those standards. The registered manager would investigate fully any allegations of abuse and would follow the necessary procedures if any were substantiated. The registered manager holds discussions with staff to talk over issues and how to recognise different forms of abuse, although training records indicate that formal training on the protection of vulnerable adults is required. Twelvetrees DS0000032153.V331052.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 and 26. People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People using the service are provided with a clean, comfortable environment, although some refurbishment is planned to improve furnishings and carpets. There were sufficient staff to maintain good hygiene standards. EVIDENCE: A partial tour of the building found excellent standards of cleanliness and hygiene. Staff are commended for their efforts to make the environment smell and look fresh. Building work has commenced to build an extension at the rear of the building. The manager said there are plans for an additional 4 bedrooms, lounge with air conditioning, and new call system. There will also be a major refurbishment of the existing facilities, and the development of a treatment room for visiting professionals. Twelvetrees DS0000032153.V331052.R01.S.doc Version 5.2 Page 17 People who use the service had been fully consulted about the building alterations and they said they were looking forward to seeing the new facilities. The work schedule has been managed to ensure the least disruption to the routines for the people living at the home. Twelvetrees DS0000032153.V331052.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. People who use the service experience excellent quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Staff have the skills and knowledge to fulfil their roles within the home, a stable staff group ensures continuity of care by staff that knows the people who use the service. Recruitment policies are followed ensuring the safety and protection of people who live at the home. EVIDENCE: Training records examined show the staff have the required skills and competencies to deliver a good service to people who use the service. Discussion with the manager and staff confirms that there is a stable staff group who had worked at the home for a good number of years. Staff say they enjoy working at the home, and feel supported. There was a robust induction and probationary package, which is service specific. The manager only confirms permanent employment when satisfied that competence and progress has been shown to be satisfactory against their high standards. Twelvetrees DS0000032153.V331052.R01.S.doc Version 5.2 Page 19 Staff rotas and observation during this visit show there were sufficient staff to meet the needs of people who live at the home. Staff were deployed to work on the three floors of the home, which ensures people are safe and well looked after. Staff had the required skills to meet the needs of people, and they are commended for meeting the requirement of 50 NVQ level two qualified staff. A number of staff are progressing with or completed NVQ level three There were robust recruitment and selection procedures that ensure people who use the service are safe and protected. A number of staff recruitment files were examined, and there was evidence that all the required employment checks have been undertaken prior to commencing work at the home. Evidence confirms all staff had a CRB check, although some of staff CRB’s were over three years old. Good practise suggests that a new CRB check should be carried out every three years, to ensure the information is up to date. Twelvetrees DS0000032153.V331052.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 and 38. People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People who use the service were protected by sound management practises, and their views were actively sought to improve the service, although not by formal quality surveys. The financial interests of people were safeguarded, and good health and safety procedures ensured they are protected. EVIDENCE: The registered manager has a wealth of experience and knowledge and was able to demonstrate her ability to manage the home. She had achieved the required management and care qualifications and she is a qualified nurse. She operated an open door policy to ensure she was accessible to staff and people Twelvetrees DS0000032153.V331052.R01.S.doc Version 5.2 Page 21 who use the service. People spoke highly of the manager and said she was very caring. Staff and group meetings ensured that staff were informed about training opportunities and the day to day running of the home, they were also encouraged to be involved in decision making. The manager and staff are commended for there ongoing commitment to developing the workforce. Achieving ‘Investors in People’ is recognition of the hard work undertaken in the home to make the service excellent. Residents meetings are used to ensure they play an active part in making decisions about how the home is run. The manager consults with people on an individual basis to gain their views, although there appears to be no formal quality assurance systems used recently. The introduction of quality assurance surveys for people who use the service and their relatives would acknowledge the high quality of service offered to people at the home. People who use the service are able to manage their own finances, although most prefer the manager to assist with dealing with their personal allowances. A number of peoples personal allowance records were examined and checked, the records were accurate and there were clear auditing procedures. Accident reports were analysed by the manager to ensure risk assessments were developed where required. Maintenance and service records examined were up to date and current to the services provided. The manager has the required Health and Safety policies and procedures and displays the relevant notices. Fire safety procedures are in place and service records were examined and were current, ensuring the safety of people who live at the home. Twelvetrees DS0000032153.V331052.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 X X 4 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 4 13 4 14 4 15 4 COMPLAINTS AND PROTECTION Standard No Score 16 4 17 X 18 2 4 X X X X X X 4 STAFFING Standard No Score 27 4 28 4 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 4 X 2 X 3 X X 3 Twelvetrees DS0000032153.V331052.R01.S.doc Version 5.2 Page 23 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. 2. Standard OP18 OP33 Regulation 18 24(1)(a)( b)(2)(3) Requirement Staff must received training on the protection of vulnerable adults. Quality assurance surveys must take place annually and the results must be published, to inform people about the service Timescale for action 01/09/07 01/09/07 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 CRB checks should be renewed after 3 years Twelvetrees DS0000032153.V331052.R01.S.doc Version 5.2 Page 24 Commission for Social Care Inspection Sheffield Area Office Ground Floor, Unit 3 Waterside Court Bold Street Sheffield S9 2LR 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 Twelvetrees DS0000032153.V331052.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. 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. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!