Care Home: Trinity Street

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What the care home does well What has improved since the last inspection? What the care home could do better: Key inspection report CARE HOME ADULTS 18-65 Trinity Street 27 Trinity Street Batley Carr Dewsbury West Yorkshire WF17 7JZ Lead Inspector David White Key Unannounced Inspection 14th April 2009 09:00 Trinity Street DS0000026333.V374775.R01.S.doc Version 5.2 Page 1 This report is a review of the quality of outcomes that people experience in this care home. We believe high quality care should: • • • • • Be safe Have the right outcomes, including clinical outcomes Be a good experience for the people that use it Help prevent illness, and promote healthy, independent living Be available to those who need it when they need it. We review the quality of the service against outcomes from the National Minimum Standards (NMS). Those standards are written by the Department of Health for each type of care service. Copies of the National Minimum Standards – Care home adults 18-65 can be found at www.dh.gov.uk or bought from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop. The mission of the Care Quality Commission is to make care better for people by: • Regulating health and adult social care services to ensure quality and safety standards, drive improvement and stamp out bad practice • Protecting the rights of people who use services, particularly the most vulnerable and those detained under the Mental Health Act 1983 • Providing accessible, trustworthy information on the quality of care and services so people can make better decisions about their care and so that commissioners and providers of services can improve services. • Providing independent public accountability on how commissioners and providers of services are improving the quality of care and providing value for money. Trinity Street DS0000026333.V374775.R01.S.doc Version 5.2 Page 2 Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report Care Quality Commission General Public 0870 240 7535 (telephone order line) Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CQC copyright, with the title and date of publication of the document specified. www.cqc.org.uk Internet address Trinity Street DS0000026333.V374775.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Trinity Street Address 27 Trinity Street Batley Carr Dewsbury West Yorkshire WF17 7JZ 01924 456160 01924 458001 Trinity.street@richmondfellowship.org.uk 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) Richmond Fellowship Care Home 12 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (12) of places Trinity Street DS0000026333.V374775.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 22nd April 2008 Brief Description of the Service: Trinity Street is a care home providing personal care and accommodation for up to 12 adults with enduring mental health problems. Nursing care is not provided. It is operated by the Richmond Fellowship, a national charitable organisation specialising in the care of people with mental health problems. The home is situated in a suburb of Dewsbury with good local amenities and easy access into the town centre. The home is purpose built and consists of 3 bungalows interlinked by glass corridors containing small conservatory areas. There are enclosed gardens to one side of the property. Each of the bungalows contains 4 single bedrooms with wash hand basins, and self-contained facilities for the communal use of people who live at the home. At the time of the visit on 14th April 2009 the fees were £278.62 upwards per week. This did not include costs for hairdressing, chiropody and toiletries. Information about the home is available in the form of a statement of purpose and a resident handbook as well as previous inspection reports. Trinity Street DS0000026333.V374775.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 2 stars. This means that people who use the service experience good quality outcomes. The inspection process has now become a cycle of activity rather than a series of one-off events. Information is gathered from a variety of sources, one being a site visit. We have reviewed our practice when making requirements, to improve national consistency. Some requirements from previous inspection reports may have been deleted or carried forward into this report as recommendations-but only when it is considered that people who use services are not being put at significant risk of harm. In future, if a requirement is repeated, it is likely that enforcement action will be taken. We went to the home without telling them that we were going to visit. This report follows the visit that took place on the 14th April 2009. The visit lasted from 9am until 3.00pm. The purpose of the visit was to make sure that the home was operating and being managed in the best interests of people living there. Information has been used from different sources for this report. These sources include: • • • Reviewing information that has been received about the home since the last inspection. Information provided by the manager on an Annual Quality Assurance Assessment questionnaire. Surveys returned from people who live at the home, staff who work there and health professionals who visit the home. During the visit time was spent talking to people who live at the home, care staff, the deputy manager and the acting manager. Staff were observed caring for people in communal rooms and various records relating to care, staff, and maintenance were looked at as well as some parts of the building. The acting manager was available throughout the site visit and the findings were discussed with her at the end of the inspection. Trinity Street DS0000026333.V374775.R01.S.doc Version 5.2 Page 6 What the service does well: • • Good pre-admission assessments are in place to make sure that people are only admitted to the home if their needs can be safely met. People are encouraged to make their own choices about how they live their lives. Health professionals who visit the home said, ‘we feel the service works hard to promote autonomy and independence’. The home has good links with local health care services so that if people become unwell they can receive the right kind of support promptly. Health professionals commented ‘Our opinion is that Richmond Fellowship works hard to meet people’s mental health needs appropriately and seeks assistance when necessary’. People living at the home said they feel safe being there and are treated well. One person at the home said, ‘staff are good to me and give me support when I need it’ The home provides a clean and comfortable environment for people to live in. Staff are well trained in areas relevant to their work so helping to make sure that people’s needs are met. One staff member said, ‘we receive excellent training’. • • • • What has improved since the last inspection? • Better medication systems and procedures have been put in place to minimise risks to people and to make sure people receive their prescribed medication. This has been helped by improvements in the audit systems that identify any discrepancies at an earlier stage. Fire doors are no longer kept open by unauthorised means so that they are able to close freely in the event of the fire alarm sounding. The commission has received information to confirm that the electrical wiring systems in the home have been satisfactorily checked and are safe. • • Trinity Street DS0000026333.V374775.R01.S.doc Version 5.2 Page 7 • • • Care plan reviews are now taking place more often so that if people’s needs change, this can be identified at an earlier stage and acted on. Staffing levels on a weekend have improved to enable people who need support to be able to pursue their leisure interests. Records are now kept of medications that are returned to the supplying pharmacist so that medication can be more easily accounted for if any discrepancies occur. Staff receive a range of training about different aspects of mental health to develop their knowledge and understanding of the needs of people at the home. There has been an improvement in the way care and services are monitored. This means that standards have improved and risks to people from poor practice have been minimised. • • What they could do better: • • A lockable drugs fridge could be obtained so that medication that needs to be stored in a cool place is more secure. When verbal references are obtained on behalf of people who are being considered to work at the home, this could be followed up in writing to confirm the identity of the person providing the reference. Staff could have some training about the recently introduced Mental Capacity Act so that they can support people who live in the home with their choices, rights and entitlements if these people lose the capacity to make their own decisions. A permanent manager could be appointed to help in making sure that the home is run in a consistent way and standards are maintained and improved on. More formal systems could be put in place to seek the opinions of relatives and others who have involvement in the home. This will help in monitoring the performance of the home and in identifying areas where improvement is needed. • • • Trinity Street DS0000026333.V374775.R01.S.doc Version 5.2 Page 8 If you want to know what action the person responsible for this care home is taking following this report, you can contact them using the details on page 4. The report of this inspection is available from our website www.cqc.org.uk. You can get printed copies from enquiries@cqc.org.uk or by telephoning our order line – 0870 240 7535. Trinity Street DS0000026333.V374775.R01.S.doc Version 5.2 Page 9 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Trinity Street DS0000026333.V374775.R01.S.doc Version 5.2 Page 10 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 1 and 2 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 are properly assessed before moving into the home so that both the person and the service could feel confident that the person’s needs would be fully met. EVIDENCE: When people are being considered for a placement at the home the referrals procedure involves documentation being sent out to the person making the referral and the person who is thinking moving to the home. The information includes information about the service, a Service User Guide, a selfassessment to be completed by the person who is being considered for the placement and the appeals procedure if someone is not happy about the decision made as to whether they are suitable for the home. There is also a resident’s handbook that has been updated at the request of people at the home. Surveys returned by five people who live at the home said they were given enough information about the home before they moved there, one person did not feel this was the case. Trinity Street DS0000026333.V374775.R01.S.doc Version 5.2 Page 11 Information is obtained from various sources before a decision is made about whether the person’s needs can be met by the home. Referrers are asked to send care plans and risk assessments with application forms. The manager and another person then carry out their own assessment of the person’s needs including any areas of risk. People are encouraged to visit the service with other relevant people to help them with their decision-making. At this stage it is explained what level of commitment the home expects from the individual and the type of support that will be offered. The care records seen included comprehensive assessments of the individual’s needs and showed that pre-admission procedures had been properly followed. Trinity Street DS0000026333.V374775.R01.S.doc Version 5.2 Page 12 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 and 9 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 living in the home are supported to make their own decisions and be independent whilst taking into account any risks from this. EVIDENCE: The home is gradually introducing the ‘Recovery Star’ care planning system. All staff have received training about this in preparation for the new system. One staff member said, ‘the new care plans will enable information about individuals to be better linked together’. Other staff said the new system would be more person centred and would promote people’s recovery from mental health problems. Trinity Street DS0000026333.V374775.R01.S.doc Version 5.2 Page 13 Currently each person has an Individual Support Plan detailing their individual needs and how these are to be met. The plans focus on various aspects of daily living and how the person wishes to be supported with this. Personal information within the care plans detail people’s likes and dislikes and their desires and aims for the future. The majority of people living at the home are able to communicate their needs. One person has communication difficulties and has received support from a speech and language therapist to help with this. Staff also carry out activities to support the person with their communication and to make sure that their needs are understood and met. The care records showed that where possible people had been involved in drawing up their care plans. People living at the home who were spoken with said that they meet up with their key worker to discuss their care and records from these meetings are recorded. Care plan reviews now take place on a more regular basis and involve the person, their relatives and relevant others who are involved in their care. People said they are encouraged to make their own decisions and this could be observed at the time of the site visit. Risk assessments are in place to support people to be independent whilst considering their safety. A survey returned by a group of health professionals commented ‘we feel the service works hard to promote autonomy and independence’. Where people had been identified as being a risk to themselves or others, a risk assessment had been undertaken to identify and minimise possible risks from this. Risk management and crisis plans provided guidance to staff on how to recognise signs that an individual may be becoming unwell and specific actions to be taken to make sure the person receives the right kind of support quickly. Throughout the day staff were observed to be respectful towards people living at the home. They knocked on people’s doors and waited for a response before entering people’s bedrooms. Daily records are well maintained and detailed. Handover periods take place between shifts to make sure that information is passed on. One staff member said, ‘communication between staff is very good’. Trinity Street DS0000026333.V374775.R01.S.doc Version 5.2 Page 14 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): This is what people staying in this care home experience: 12, 13, 15, 16 and 17 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 live a lifestyle to suit their needs and have involvement in the local community. EVIDENCE: People said they could spend their time as they chose. Some people preferred to spend most of their time around the home whilst others went out and attended local services. People were supported to pursue hobbies, leisure and recreational interests. One person spoken to said that they particularly enjoyed attending a photography course at a day centre and had enjoyed a trip to York railway museum. Another person has an interest in music and visits Leeds to Trinity Street DS0000026333.V374775.R01.S.doc Version 5.2 Page 15 buy specialist records. Someone living at the home had done some voluntary work at a local charity shop but had made the decision to stop working there, as they no longer enjoyed doing this. There are in-house activities and these are planned for on an activity calendar that is on display in the home. Some people enjoyed using the karaoke machine and computer. Others liked to watch television. The home has a minibus and there had been various trips out. One person said, ‘it is a nice place to live and I like going to the pantomimes’. At the request of people at the home a holiday has been arranged for Skegness for later in the year. One person likes to attend church on a Sunday morning and staffing levels have improved on a weekend to accommodate this. Another person living at the home is from another cultural background and their cultural festivals are celebrated by the home. People are encouraged to maintain their relationships with family and friends and could see them whenever they wished. All the surveys returned by people living in the home indicated that they enjoy the meals. People at the home had different capabilities. Those that are able to cook for themselves are encouraged to do so. Other people needed staff to prepare and cook their meals for them. Staff hold meetings with people from the home to discuss what they would like on the menu and this was regularly reviewed. There is always a choice of meal at mealtimes and the menus accommodated people with specific dietary needs and those from different cultural backgrounds. Trinity Street DS0000026333.V374775.R01.S.doc Version 5.2 Page 16 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 and 20 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 receive the personal and health care support they need. There have been some improvements to the medication systems, which have minimised the risk to people from poor medication practices. EVIDENCE: Staff were observed to give good support with any personal care needs and made sure these were carried out in private to respect people’s dignity. The support that people require is documented in their care records. One person at the home said, ‘staff are good to me and give me support when I need it’. Each person is registered with a GP (General Practitioner) and has access to dentists, opticians and chiropody services. Most of the people living at the home have support from local mental health service teams and referrals are Trinity Street DS0000026333.V374775.R01.S.doc Version 5.2 Page 17 made to other specialist services as needed. One person found some weight gain to be distressing and had been supported to contact the local Weight Watchers group and an aqua aerobics group. Another person needed physical support whilst bathing and a referral had been made for an Occupational Therapist (OT) to carry out an assessment of the person’s needs and to offer advice. One person has a back problem and a request has been made to the GP for a referral to be made to OT to look at possible alternative mattresses that may be used for the person’s bed. The manager said that links with other health care agencies had improved. A survey returned by a group of health care professionals said, ‘Our opinion as a team is that Richmond Fellowship work hard to meet people’s health needs appropriately and seek assistance when necessary’. At the previous inspection visit there were a number of concerns about the medication systems. During the last year the home has notified the commission about medication errors involving two members of staff. Appropriate actions were taken following these errors to seek advice so that the people involved were not at any risk. The management of the service investigated these incidents and found that the mistakes had been caused by human error and subsequent action has been taken to minimise the risk of further errors. There have been improvements to the medication systems and procedures that have led to better and safer working practices at the home that have resulted in no further recent incidents of medication errors. All staff have now had beginners and advanced Boots training and further training is planned for all staff. Staff have also undertaken in-house training about understanding administration and storage of medication. The medication policy has been discussed within a staff meeting and all staff have signed to confirm their understanding of this. Boxed medication counts take place on a shift-to-shift basis to check stock balances and staff sign to say checks have been completed. There are weekly checks of all PRN (medication to be given as needed) medication to check the records with the stock balances. There are weekly medication audits by the management of the home and spot checks are carried out on all people who self-medicate. Two staff are now responsible for administering medications, one to administer the medication and another to act as a witness in making sure the correct medication and dosage is being given. The medication records were found to be up to date and accurate. Medication to be given on a ‘when needed’ basis was available. Medications received and returned to the supplying pharmacist are now recorded so that an audit trail can be found if any discrepancies occur. Staff said that the changes to the medication system had made them ‘more vigilant’ and helped to make sure that proper medication procedures were followed. People who wish to selfmedicate are risk assessed beforehand to make sure they are safe to do this. This is reviewed on an ongoing basis to reflect people’s changing needs. Trinity Street DS0000026333.V374775.R01.S.doc Version 5.2 Page 18 Currently medications that need to be stored in a cool place are stored in the fridge in the upstairs office. It is recommended that these be stored in a lockable drugs fridge so that they are more secure. Trinity Street DS0000026333.V374775.R01.S.doc Version 5.2 Page 19 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23 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’s concerns are appropriately dealt with and their interests are safeguarded. EVIDENCE: The home has a complaints procedure that is on display in the home. A copy of this is made available to people when they move into the home. Surveys returned by people living at the home all said that they are treated well and would know how to make a complaint. The home has a complaints book to log any complaints. This showed that there have been no complaints made since our last inspection visit. A health professional survey commented ‘the service is receptive to our advice and any concerns we have’. The home has a policy and procedure for safeguarding people from abuse. Staff also have access to the local authority safeguarding of adults policy and procedure. All staff receive training about protecting vulnerable adults from abuse. Staff spoken to were clear of their roles and responsibilities in when and to whom they should report concerns. The home has had two incidents where people were at risk of potential harm. In both cases information had been Trinity Street DS0000026333.V374775.R01.S.doc Version 5.2 Page 20 passed onto the appropriate agencies and referrals had been made to make sure people were safe. There had been an incident earlier in the year when some people who were visiting the home had caused a disturbance. This behaviour was having a detrimental effect on one particular individual and others at the home. The home had contacted the police so that appropriate action could be taken to safeguard the interests of people living in the home and staff who worked there. The care records showed that there had been occasions when some people at the home had used abusive language. The acting manager had written letters to these people to inform them that this behaviour was not acceptable. A local advocacy agency had recently visited the home to speak to people living at the home and staff about what they do and the advice and support they can offer. Trinity Street DS0000026333.V374775.R01.S.doc Version 5.2 Page 21 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 24 and 30. 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. The home is clean and comfortable for the people living there. EVIDENCE: All accommodation is on the ground floor and there is ramped access to and from the home so it is suitable for people with mobility difficulties. The home is separated into three interconnected bungalows that accommodate four people in each bungalow. There are communal lounges and toilet and bathroom areas in each part of the home. Aids and adaptations are in place to help people with their independence and mobility including a walk in shower facility. Bedrooms are personalised to suit individual tastes. A number of people in the home enjoy smoking and are able to do this in their own bedrooms if assessed as Trinity Street DS0000026333.V374775.R01.S.doc Version 5.2 Page 22 being safe to do so. There is also a smoking shelter in the garden where people can smoke. People said they are happy with their living environment and feel safe within it. Some changes have been made to improve the quality of the environment. Furniture and fittings have been replaced in communal areas. Four bedrooms have been re-decorated. Bedroom floors are to be laminated and individual sets of bedding and towels are to be given to each individual. New bathroom tiles have been fitted to provide a more hygienic look to the bathroom areas. Work is shortly about to start on the fitting of three new kitchens. The garden areas are also being developed to enable people who live at the home to become involved in gardening. At the time of the site visit the home did not have a cleaner. The manager said that interviews for the post were to take place later on in the week. In the interim period staff were carrying out cleaning duties. Surveys returned by people living in the home all said that the home was always or usually kept fresh and clean and this could be seen at the time of the visit. Some people are able to look after their own laundry whilst staff provide support for others who need help with this. All staff had attended infection control training. Trinity Street DS0000026333.V374775.R01.S.doc Version 5.2 Page 23 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34, 35 and 36. 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 are supported by a sufficient number of staff who are well trained to meet their needs although one aspect of the recruitment process could be improved to make sure people are safeguarded from unsuitable workers. EVIDENCE: People living at the home and staff who work there said that there are sufficient staff on duty on most occasions to meet people’s needs. Staff consistency has been improved through the employment of more permanent staff and a reduction in the number of agency staff that are used. The service currently has two vacancies for care staff and interviews for these posts were impending at the time of the site visit. During the week there are usually three staff on duty through the day as well as the manager and administrator. At weekends there are three staff in a morning and mostly two staff in an afternoon. At night there is a member of night staff and one other staff Trinity Street DS0000026333.V374775.R01.S.doc Version 5.2 Page 24 member who sleeps on the premises. Staffing levels can alter and are planned around the needs of individuals. One member of staff said, ‘staff work very well together as a team’. The member of staff also said, ‘it will be better when we get a cleaner so that we can spend more time with people’. People living at the home said that staff can always be accessed and that staffing levels are sufficient. The majority of staff have either completed or are doing NVQ (National Vocational Qualification). This helps in establishing a knowledgeable and skilled staff team. Three staff files were looked at and these showed that overall appropriate recruitment procedures are being followed to safeguard people from unsuitable workers. However, in one case a verbal reference had been obtained from a referee and this had not been followed up in writing to confirm the identity of the person providing the reference. The acting manager was unable to explain this as the person had been employed before she became the acting manager. Staff training records are well organised and easy to follow so that it is clear as to what kind of training staff had undertaken and when updates are needed. Staff described their training as ‘very good’. One staff survey commented ‘training is excellent’. As well as mandatory training in safe working practices, staff also undertake more specific training. This includes courses on enduring mental health and recovery from this, equality and diversity, working with people who have complex needs, suicide awareness and substance and alcohol misuse. New staff have a full induction before they are expected to carry out any tasks they are unsure of. A staff member said, ‘I receive very good support from the staff team’. The acting manager has obtained some information about the recently introduced Mental Capacity Act in the form of a leaflet and is disseminating this information to other staff. Staff also said that some training about the Mental Capacity Act would be of benefit so that they are clear about how to protect people’s rights if they lose the capacity to make their own decisions. Staff commented that they have regular supervision sessions and records of these are kept in individual staff files. Trinity Street DS0000026333.V374775.R01.S.doc Version 5.2 Page 25 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. 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 are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 and 42. 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. The acting manager has made some improvements to the running of the home although the appointment of a permanent manager would help to make sure that the home is run in a consistent way to maintain and improve the care and services on offer. People’s best interests are put first and proper attention is given to maintaining their health and safety. EVIDENCE: Trinity Street DS0000026333.V374775.R01.S.doc Version 5.2 Page 26 The previous registered manager left her post in November 2008. Since that time an acting manager has been running the home. The acting manager previously worked at the home as the deputy manager and has NVQ level 3. The post of manager has been advertised and the acting manager said that dates have been arranged to shortlist people. This has been a lengthy process and should be prioritised so that a permanent manager is appointed and can apply to register with the commission. The acting manager works alongside the deputy manager in providing leadership to the home. Staff felt that progress made under the previous manager has been maintained since the acting manager took over. One staff member said, ‘the atmosphere is more pleasant to work in’. Another staff member commented ‘the acting manager is good at supporting people and is approachable’. Issues outstanding from the previous inspection visit have all been addressed. People living at the home said that they hold regular meetings with the staff team to discuss issues relating to their care. They also take part in house meetings to discuss such things as menu planning and organising trips out and holidays. Staff said they are encouraged to voice their opinions within staff meetings. An area manager from Richmond Fellowship visits the home every month to monitor performance and to identify areas of need. Reports of their findings were available along with the actions that were to be taken following their visits. Care plan reviews are regularly held and enable relatives and professionals who have involvement with individuals to offer their views about the cares and services on offer. The acting manager was not aware of any formal systems that are in place to seek the views of relatives and other stakeholders who are involved with the home. The Annual Quality Assurance Assessment (AQAA) that was sent to us before the visit showed that all the required health and safety checks were up to date. Information received following the previous inspection visit confirmed that the electrical wiring systems had been previously checked and were satisfactory. During a look around the environment there was no evidence that fire doors were being wedged open by unauthorised means as had been found at the previous inspection visit. Better audit systems are now in place to monitor care practices and to minimise risk to people. The staff training records show that staff undertake a range of health and safety training that is updated as needed. Trinity Street DS0000026333.V374775.R01.S.doc Version 5.2 Page 27 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 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 3 2 3 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 2 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 X 2 X 2 X X 3 X Version 5.2 Page 28 Trinity Street DS0000026333.V374775.R01.S.doc 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 YA34 Regulation 19 Requirement Verbal references that are obtained as part of the recruitment process must be followed up in writing to confirm the identity of the person providing the reference. Timescale for action 31/05/09 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. 2. Refer to Standard YA20 YA35 Good Practice Recommendations A lockable fridge should be used to store medication that needs to be kept cool so that the medication is more secure. Staff should receive training about the Mental Capacity Act to develop their knowledge and understanding. This will help in making sure people’s choices, rights and entitlements are acted on in accordance with their wishes should they lose the capacity to make their own decisions. A permanent manager should be appointed to make sure that the home is run in a consistent way and in the best interests of people living there. DS0000026333.V374775.R01.S.doc Version 5.2 Page 29 3. YA37 Trinity Street 4. YA39 Formal systems should be put in place to seek the views of relatives and other stakeholders who are involved with the home about the care and services on offer. This will provide the service with feedback about what it is doing well and areas for improvement. Trinity Street DS0000026333.V374775.R01.S.doc Version 5.2 Page 30 Care Quality Commission North Eastern Region St Nicholas Building St Nicholas Street Newcastle Upon Tyne NE1 1NB National Enquiry Line: Telephone: 03000 616161 Email: enquiries@cqc.org.uk Web: www.cqc.org.uk We want people to be able to access this information. 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