CARE HOMES FOR OLDER PEOPLE
Twelvetrees 17 Priory Road Sheffield South Yorkshire S7 1LW Lead Inspector
Jayne Barnett-Middleton Unannounced Inspection 14:00 9 March 2006
th 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.V268791.R01.S.doc Version 5.0 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.V268791.R01.S.doc Version 5.0 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.V268791.R01.S.doc Version 5.0 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). 15th August 2005 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. Twelvetrees DS0000032153.V268791.R01.S.doc Version 5.0 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This was an unannounced inspection carried out from 14.00 pm to 18.00 pm. Most of the residents were seen during the inspection. Seven residents, three staff and the registered manager were spoken to. A sample of records was examined and a partial inspection of the building was carried out. The inspector wishes to thank the registered manager, staff and residents for their time and co-operation throughout the inspection process. What the service does well: What has improved since the last inspection?
All previous requirements had been met. The manager said that PRN Medication, when administered, was now clearly recorded, promoting the safe administration of medication.
Twelvetrees DS0000032153.V268791.R01.S.doc Version 5.0 Page 6 Resident files and information were securely stored. Staff coats were now being stored out of the laundry area, reducing the risk of cross infection. 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 DS0000032153.V268791.R01.S.doc Version 5.0 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.V268791.R01.S.doc Version 5.0 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 the following standard(s): 3 and 5. Residents were not admitted to the home without their needs being assessed, to ensure the home was able to meet their health, social and care needs. Prospective residents and their relatives were invited to visit the home to asses the quality, facilities and suitability of the home. EVIDENCE: Three care files were checked and each contained a full needs assessment which has been carried out prior to the residents admission. Two residents who had recently moved into the home said that the owner had also visited them prior to their admission. This confirmed that the service was appropriate for the resident and provided staff with the information to formulate an individual plan of care. Several residents confirmed that they and their relatives had been invited to visit the home prior to their admission. One commented that they had looked around several homes and that she had chosen the home, as in her opinion, it was “The best of the lot”.
Twelvetrees DS0000032153.V268791.R01.S.doc Version 5.0 Page 9 The home does not provide an intermediate care service. Twelvetrees DS0000032153.V268791.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8 and 10. Care plans were in place for all residents. These were detailed and were reviewed frequently. Resident’s physical and emotional needs were met. There was evidence that a range of healthcare professionals regularly visited the home to meet the resident’s needs. Residents spoke positively about the healthcare that was provided and all said that their healthcare needs were met. Residents received personal support, which promoted their privacy, dignity and independence. EVIDENCE: Care plans were in place for all residents. Three care plans were checked and all set out in detail the action that was required by staff to ensure that all aspects of the residents care needs were met. The plans had been reviewed on a monthly basis to ensure that the changing needs of the resident were reflected in their plan of care. There was an excellent daily recording format, which detailed the specific care that had been offered to residents, ensuring
Twelvetrees DS0000032153.V268791.R01.S.doc Version 5.0 Page 11 that the residents’ current and changing needs was recorded and available to staff. Healthcare records were maintained and these evidenced that residents were receiving regular visits from their general practitioner, chiropodist and dentist. Residents said that their healthcare needs were met commenting, “ Anything I need, I only have to ask”. One resident spoke in detail about the healthcare appointments that she attended and stated, “ The staff will always take me”. Staff were observed to treat residents with dignity and respect. Residents spoke positively about the care that they received and described the staff team as “smashing” and “helpful”. Twelvetrees DS0000032153.V268791.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13 and 14. Routines within the home were flexible and residents were encouraged to spend their day as they wished. There was a good programme of activities available and regular day trips were planned. Residents were able to receive visitors at any reasonable time. EVIDENCE: Residents were observed to be following their preferred routines. Residents said that the routines within the home were flexible confirming, “ I can do as I please” and “ I still get out and about”. There was a good range of activities available, which included crafts, aromatherapy and professional entertainment. One resident spoke highly of the craft sessions that they enjoyed, and spoke about the various items that they had made. Regular trips were organised. Residents said that they had enjoyed the recent trips to Clumber Park, Chatsworth house, Matlock and the railway museum. A library service had recently started to visit the home on a regular basis. Residents said that they made good use of this service stating that there was a good range of large print books to choose from.
Twelvetrees DS0000032153.V268791.R01.S.doc Version 5.0 Page 13 Residents said that their family and friends were able to visit them at any reasonable time within the privacy of their bedroom. Twelvetrees DS0000032153.V268791.R01.S.doc Version 5.0 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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16. The complaints procedure was clear and accessible. Residents were confident that any complaints would be listened to and action taken to deal with complaints promptly. EVIDENCE: The complaints procedure ensured that residents and their relatives were aware of how to make a complaint and who would deal with them. No complaints had been received since the last inspection. All residents spoke positively about the attitude of the manager and the staff team. They stated that they had “no complaints” yet felt that the staff team were approachable and that they would always listen to any concerns that they may have. Twelvetrees DS0000032153.V268791.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19 and 26. The home was very clean, comfortable and well maintained. Residents were provided with an environment that was safe, accessible and homely. EVIDENCE: The home was very clean, tidy and odour free. All areas seen were well maintained and pleasantly decorated. There were homely touches of pictures and ornaments and it was evident that the manager and staff took pride in providing a homely environment for residents. The manager said that there was a programme of redecoration and that there were plans to redecorate some lounges and to replace the ground floor carpet. Several bedrooms were checked and all were clean and pleasantly decorated. All the rooms had been personalised by the resident.
Twelvetrees DS0000032153.V268791.R01.S.doc Version 5.0 Page 16 All areas seen were very clean and a very good standard of cleanliness was observed. The grounds were safe, tidy and very well maintained. Residents said that they enjoyed spending time in the garden area during the summer months. Twelvetrees DS0000032153.V268791.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27,29 and 30. Many of the staff employed have worked at the home for many years and therefore know the residents well and can offer them a consistent service. Staff had received training to meet the resident’s general and specific needs. A good range of training was available for staff. The home operated a recruitment procedure that promoted the protection of residents. EVIDENCE: Residents spoke positively about the manager and staff describing them as “smashing”, “nice” and “hard working”. The Staff and manager were friendly, approachable and relaxed to talk about the care that they provided. Positive and appropriate relationships were observed between staff and residents. A training and induction programme for staff was in place enabling them to meet the assessed and changing needs of residents. Staff confirmed that they had attended various training courses that included food hygiene, adult protection, moving and handling and First aid. Records demonstrated that a good range of training was offered to staff. The manager said that refresher training was ongoing and that food hygiene and moving and handling training
Twelvetrees DS0000032153.V268791.R01.S.doc Version 5.0 Page 18 was scheduled to take place, ensuring that staff were conversant with changing practice and legislation. A recruitment policy and procedure was in place. Two files checked contained a good range of information including two references, declaration of health and qualifications/training. Both files contained an employment history. However, there were gaps noted and the reasons for the staff member not working were not recorded. These need to be fully completed to ensure that the residents are fully protected. All staff employed had undertaken a Criminal Records Bureau Check at the enhanced level to promote the protection of residents. Twelvetrees DS0000032153.V268791.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31,35 and 38. Residents and staff benefited from the ethos, leadership and management approach. Staff morale was good and all staff spoke positively about the manager. Resident’s financial interests were safeguarded by the procedures at the home. The homes policies and procedures promoted the health, safety and welfare of service users and staff. EVIDENCE: The manager had many years experience within the caring profession that enabled her to contribute to the care of residents and communicate a clear sense of leadership to staff. Staff said that there were very well supported by the owner and manager and felt that there was “good team spirit”.
Twelvetrees DS0000032153.V268791.R01.S.doc Version 5.0 Page 20 All residents spoke highly of the staff describing the service that they received as “superior”, “A one” and “you can’t better it”. Arrangements were in place for residents who were unable to manage their monies due to their mental health. Monies were securely stored and records checked evidenced that service users were able to access their monies for hair care and personal items as they wished. Areas seen were safe and free from hazard. The home was well maintained which promoted a safe living environment for residents. The staff had received regular training to promote the health, safety and welfare of residents and their colleagues. Twelvetrees DS0000032153.V268791.R01.S.doc Version 5.0 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 X X 3 X 3 X HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 X 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 3 14 3 15 X COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 X 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 X 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X X X 3 X X 3 Twelvetrees DS0000032153.V268791.R01.S.doc Version 5.0 Page 22 Are there any outstanding requirements from the last inspection? No. STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP29 Regulation 18 Requirement Staff files must include a full employment history of the employee and any gaps in employment must be accounted for. Timescale for action 01/06/06 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 Twelvetrees DS0000032153.V268791.R01.S.doc Version 5.0 Page 23 Commission for Social Care Inspection Sheffield Area Office 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. Extracts may not be used or reproduced without the express permission of CSCI Twelvetrees DS0000032153.V268791.R01.S.doc Version 5.0 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. 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!
