Inspection on 09/01/08 for Ty Gwyn Residential Care Home

This inspection was carried out on 9th January 2008.

CSCI found this care home to be providing an Adequate service.

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

Ty Gwyn Residential Care Home 10/02/09

Similar services:

Hillside

Applegarth

122 Scorer Street

Jubilee Villa Care Home

Thornham Grove

Beech Lodge

8 Thorndale Road (Homefield College)

Hunter`s Lodge

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

CARE HOMES FOR OLDER PEOPLE Ty Gwyn Residential Care Home 2 Hall Walk Enderby Leicester Leicestershire LE19 4AH Lead Inspector Debbie Williams Unannounced Inspection 9th January 2008 10:00 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Ty Gwyn Residential Care Home DS0000070637.V355745.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. Ty Gwyn Residential Care Home DS0000070637.V355745.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Ty Gwyn Residential Care Home Address 2 Hall Walk Enderby Leicester Leicestershire LE19 4AH 0116 2864271 0116 2866077 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) Sun Care Homes Ltd Vacant Care Home 12 Category(ies) of Learning disability (12) registration, with number of places Ty Gwyn Residential Care Home DS0000070637.V355745.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered provider may provide the following category of service only: Care Home only - Code PC To service users of the following gender: Either Whose primary care needs on admission to the home is within the following category: 2. Learning Disability - Code LD The maximum number of service users who can be accommodated is: 12 New Service Date of last inspection Brief Description of the Service: Ty Gwyn is a registered home for adults with a Learning Disability; the home itself is a listed building, set back from the road, in a large plot. The home has a large garden surrounding the home, and is accessible to service users. The home is situated in the village of Enderby. The village offers local amenities including a post office, restaurants, supermarket, and retail outlets. At the time of this inspection the weekly fees were in line with social services funding scales and no additional top ups were charged. Ty Gwyn Residential Care Home DS0000070637.V355745.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 1 star. This means the people who use this service experience adequate quality outcomes. The focus of the inspections undertaken by the Commission for Social Care Inspection is upon outcomes for service users and their views of the service provided. The primary method of inspection used was ‘case tracking’ which involved selecting three service users and tracking the care they received through looking at their records, discussion, where possible, with them and care staff and observation of care practices. Evidence from the providers Annual Quality Assurance assessment was also used. The annual quality assurance assessment was received shortly after this inspection took place. Ten resident, relative and staff surveys were sent out prior to this inspection, three residents surveys were returned with mostly positive responses to questions asked. Two relative surveys were returned with mostly positive responses to questions asked and positive comments made. Three staff surveys were returned with positive responses to questions asked and positive comments made. This was the first key inspection since the current owner became the registered provider. The inspection was facilitated by an acting manager who is no longer employed at the home. One outcome area was assessed as poor and an immediate requirement was made regarding staffing numbers at the home. Residents spoken with were satisfied with the service provided and praised the staff employed. Shortly prior to this inspection concerns were raised regarding staffing levels, staff training, day care services and the provision of resources. These concerns were investigated by social services. The provider has responded to these concerns in a positive and professional manner and worked with social services towards a resolution. Ty Gwyn Residential Care Home DS0000070637.V355745.R01.S.doc Version 5.2 Page 6 What the service does well: What has improved since the last inspection? What they could do better: The provider must ensure that the numbers of staff employed meet the complex needs and dependency levels of the residents accommodated. Electrical circuits and stair lifts must be serviced or tested as recommended by regulatory body recommendations. The service users guide should be updated to ensure that all information is up to date and accurate. The service users guide should be available in formats which are accessible to people who use the service. Attention is required to general decoration in the corridors and communal areas in order to bring it up to a reasonable standard and provide a comfortable and attractive environment for residents. Ty Gwyn Residential Care Home DS0000070637.V355745.R01.S.doc Version 5.2 Page 7 An effective quality assurance and quality monitoring system should be introduced. This should be based on seeking the views of the residents accommodated. 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. Ty Gwyn Residential Care Home DS0000070637.V355745.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Ty Gwyn Residential Care Home DS0000070637.V355745.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 1,3 and 5 (standard 6 is not applicable to this service) Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Prospective residents are not provided with information they require to make an informed decision about moving into the home. EVIDENCE: The provider’s statement of purpose and service users guide had not been updated to include the new providers details and information. The acting manager said they would carry out a full needs assessment for prospective residents before they moved into the home. Assessment records seen contained all the required assessment details including risk assessments, individual preferences and cultural/religious needs. Ty Gwyn Residential Care Home DS0000070637.V355745.R01.S.doc Version 5.2 Page 10 Social services assessment information was included within assessment records. One resident spoken with confirmed they had visited the home three times and had meals at the home before deciding to move in. Ty Gwyn Residential Care Home DS0000070637.V355745.R01.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 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. People who live in the home are treated with respect and their health and social care needs are met. EVIDENCE: Care records seen included individual care plans that were reviewed at least monthly. Evidence was seen of resident’s involvement in the care planning and review process. Evidence was also seen of good access to healthcare services such as GP’s, community psychiatric nurses, hospital appointments, dentists and opticians. Records were seen of consultation with community learning disability support services. Social services care plans were included within individual care records. Ty Gwyn Residential Care Home DS0000070637.V355745.R01.S.doc Version 5.2 Page 12 One resident spoken with said that staff made appointments with their GP whenever required. Daily records were maintained; these gave detailed accounts of resident’s wellbeing (or otherwise) and of the events of the day. Risk assessments including any restrictions on personal choice were in place. Medication administration records were seen and appeared accurate. The procedure for administration of medication was kept with the administration records; there was also a separate medication policy. Only senior care staff administer medication. All senior care staff had completed an accredited distance-learning course in the safe handling of medications (records of this were seen). Staff also undergo a period of supervised practice before being assessed as competent. Where medication was prescribed to modify mood or behaviour, a protocol was in place in individual care records describing why and when this medication should be used. One resident spoken with said that staff managed their medication well and always administered it promptly at the prescribed time. Interactions observed between staff and residents appeared positive and respectful. Maintaining privacy and dignity is addressed during staff induction training. Records of staff induction training were seen. One resident spoken with said that staff were kind and treated them with respect. A relatives survey stated that ‘everyone is treated with respect, love and care. Nothing is too much trouble and staff are friendly, cheerful and professional’. Ty Gwyn Residential Care Home DS0000070637.V355745.R01.S.doc Version 5.2 Page 13 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): Standards 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 able to exercise choice and autonomy, Individual needs and preferences are met. EVIDENCE: One resident spoken with said they attended a day centre twice a week and confirmed that staff help her to maintain independence and enable her to make choices about daily life. One relatives survey returned stated that their relative attended church every week. Residents go out for a pub lunch every Wednesday. Other activities include watching DVD’s or playing games. Where possible residents can become involved in day-to-day tasks such as drying crockery etc. Ty Gwyn Residential Care Home DS0000070637.V355745.R01.S.doc Version 5.2 Page 14 One resident has a pet rabbit that the staff helps them to care for. The acting manager said that staff have very limited time to facilitate activities for residents, this comment was also made in one relatives survey. Individual preferences and cultural needs were recorded within care plans. The acting manager said that all staff were due to attend person centred planning training. One resident spoken with said the meals provided were very good and there was always a choice available, there was always plenty of hot drinks and fresh fruit was provided every day. The arrangements for grocery shopping had recently been changed in order to provide more choice and fresher produce for residents. There were no separate catering staff, all care staff had completed food hygiene courses and further training had been arranged to take place in February. Visitors were made welcome at the home and there were no restrictions on visiting times. Residents meetings are held monthly. Ty Gwyn Residential Care Home DS0000070637.V355745.R01.S.doc Version 5.2 Page 15 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): Standards 16 and 18. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are protected by safeguarding and complaints policies and procedures. EVIDENCE: One resident spoken with said they would feel confident making a compliant to staff should they need to. Relatives and residents surveys returned indicated that residents did know how to make a complaint. Staff have worked through safeguarding adults workbooks, these were seen within staff personnel files. The acting manager was aware of the correct safeguarding procedures to following the event of suspected abuse. A copy of national safeguarding policies and procedures was seen in the staff office. Ty Gwyn Residential Care Home DS0000070637.V355745.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): Standards 19 and 26. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents live in a homely and comfortable environment but this could be enhanced if more attention was given to general décor. EVIDENCE: One resident spoken with said they were happy with their room, they had been able to personalise their room with their own possessions and said it was always kept very clean. All returned resident’s surveys indicated that the home was kept fresh and clean. A partial tour of the premises was undertaken, some attention was required to general décor in order to bring the premises up to a reasonable standard. Ty Gwyn Residential Care Home DS0000070637.V355745.R01.S.doc Version 5.2 Page 17 Comments made in one relatives survey also stated that some attention was required to decoration. All areas of the home were clean and hygienic. There was a separate laundry area. There were no separate catering, domestic or laundry staff and care staff were responsible for these tasks. Staff had received infection control training. Ty Gwyn Residential Care Home DS0000070637.V355745.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): Standards 27, 28, 29 and 30. Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. Staffing numbers are not sufficient to meet the needs of residents accommodated. EVIDENCE: One resident spoken with said they could do with more staff, especially at night. One relatives survey returned stated that ‘more staff would enable carers to spend more time with residents, perhaps organising games etc’. Staffing levels were discussed. Only two care staff were on duty during daytime hours and one during the night. There were no separate catering or domestic staff. One of the home’s residents required one to one care and some of the residents had complex high dependency needs. An immediate requirement was made regarding staffing levels at the home. This was made in response to staffing information provided by the acting manager who facilitated this inspection; this staff member no longer works at the home. Information given by the provider following this inspection disputes the information this staff member provided. A sample-staffing roster was provided indicating that more staff were on duty during daytime hours. Ty Gwyn Residential Care Home DS0000070637.V355745.R01.S.doc Version 5.2 Page 19 This still did not demonstrate that staffing numbers were sufficient to meet resident’s needs. The personnel files for three staff members were seen; these contained all relevant references and Criminal record bureau checks. Training workbooks and training certificates were seen, the last record of training provided was in May 2007, the acting manager said that more staff training was being arranged. All care staff had achieved National Vocational Qualifications in care. Ty Gwyn Residential Care Home DS0000070637.V355745.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): Standards 31, 33,35 and 38. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The health, safety and welfare of residents would be better promoted with the introduction of a quality assurance system and a robust maintenance and servicing programme. EVIDENCE: The acting manager facilitated this inspection but has since left employment at the home. The provider has confirmed that a new acting manager is now in place; this acting manager has been employed at the home for many years and is working towards a National Vocational Qualification level 4 in care. Staff meetings were regularly held. Ty Gwyn Residential Care Home DS0000070637.V355745.R01.S.doc Version 5.2 Page 21 The acting manager said that all staff were working through a health and safety workbook which included fire safety, control of hazardous substances and security. Risk assessments were in place for individual residents and for premises and safe working practices. There was no quality assurance programme in place at the time of this inspection; the acting manager said that the provider planned to introduce one. Information provided within the provider’s annual quality assurance questionnaire stated that advocacy was used to represent residents with their financial affairs. Information provided regarding the maintenance and servicing of equipment stated that not all equipment had been tested in line with regulatory bodies recommendations. Ty Gwyn Residential Care Home DS0000070637.V355745.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 2 3 3 x 3 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 x 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 x 18 3 2 x x x x x x 3 STAFFING Standard No Score 27 1 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 x 2 x 3 x x 2 Ty Gwyn Residential Care Home DS0000070637.V355745.R01.S.doc Version 5.2 Page 23 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 OP27 Regulation 18(a) Requirement Staff must be employed in sufficient numbers to meet the needs of residents living in the home. Electrical circuits and stair lifts must be serviced or tested as recommended by regulatory body recommendations. Timescale for action 09/01/08 2 OP38 23(b) 30/04/08 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 OP1 Good Practice Recommendations It is recommended that the service users guide is updated to ensure that all information is up to date and accurate. The service users guide should be available in formats which are accessible to people who use the service. Some attention is required to general decoration in the corridors and communal areas in order to bring it up to a reasonable standard and provide a comfortable environment for residents. An effective quality assurance and quality monitoring DS0000070637.V355745.R01.S.doc Version 5.2 Page 24 2 OP19 3 OP33 Ty Gwyn Residential Care Home system should be introduced. This should be based on seeking the views of residents accommodated. Ty Gwyn Residential Care Home DS0000070637.V355745.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection Nottingham Area Office Edgeley House Riverside Business Park Tottle Road Nottingham NG2 1RT 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 Ty Gwyn Residential Care Home DS0000070637.V355745.R01.S.doc Version 5.2 Page 26 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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