Inspection on 16/08/05 for Tregarne

This inspection was carried out on 16th August 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Tregarne 05/07/07

Tregarne 12/09/06

Tregarne 19/12/05

Tregarne 22/03/05

Tregarne 14/09/04

Tregarne 23/03/04

Similar services:

2 Perhaver Park

The Vicarage

7 Hyde Road

St George`s

5 Seafield Road

Credence House

Radfords

Trevaylor Manor

Extracts from inspection reports are licensed from CQC, this page was updated on 19/06/2009.

CARE HOME ADULTS 18-65 Tregarne Hostel North Street St Austell Cornwall PL25 5QE Lead Inspector Elaine Bruce Announced 16 August 2005 09:00 a.m. The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationary 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. Tregarne Hostel D52-D04 S41927 Tregarne Hostel V194898 160805 Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Tregarne Hostel Address North Street St Austell Cornwall PL25 5QE 01726 72429 Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Cornwall County Council Mrs Elisabeth-Anne Philp Care Home 16 Category(ies) of Learning disability (16) registration, with number Physical disability (16) of places Sensory impairment (16) Tregarne Hostel D52-D04 S41927 Tregarne Hostel V194898 160805 Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: None Date of last inspection 22 March 2005 Brief Description of the Service: Tregarne is a split level detached property within walking distance of St Austell town centre. The home is a social services establishment that provides short stay care for up to sixteen service users with a learning disability. The accommodation is located on the ground and first floors. Each floor is self contained and therefore has the ability to function independently. One floor of the home has been adapted to meet the needs of service users with a physical disability. The home has the benefit of a fully equipped sensory room and a small computer suite. The property has pleasant spacious gardens to three sides and a parking area. Tregarne Hostel D52-D04 S41927 Tregarne Hostel V194898 160805 Stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection took place on the 16th August 2005 over five and a half hours and was carried out as an announced inspection. A tour of the premises took place and care records, staff files and policies and procedures were inspected. Tregarne is providing short stay accommodation to service users with a complex range of needs, dependency levels and ages from 18 to 70 years. The home generally offers service users planned respite and over the year this service is delivered to 95 service users. Two of the service users were at the home during the course of the inspection with everyone else out at their various day care activities. The registered manager was available for the inspection. What the service does well: What has improved since the last inspection? Tregarne Hostel D52-D04 S41927 Tregarne Hostel V194898 160805 Stage 4.doc Version 1.40 Page 6 What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Tregarne Hostel D52-D04 S41927 Tregarne Hostel V194898 160805 Stage 4.doc Version 1.40 Page 7 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 Standards Statutory Requirements Identified During the Inspection Tregarne Hostel D52-D04 S41927 Tregarne Hostel V194898 160805 Stage 4.doc Version 1.40 Page 8 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 1 and 2 The service user guide and statement of purpose document provide service users and prospective service users with details of what the home provides helping an informed decision about admission to the home. All service users access the home by a care management process that involves a social care and financial assessment. The current service and facilities at Tregarne are in demand. EVIDENCE: A statement of purpose document is in place at the home meeting all the requirements of legislation. This document has been issued to the relatives/representatives of the service users at the home. The service user guide is a very good document that has been produced in an appropriate format to enhance communication with the service users. All service users access the home by a care management assessment process that involves a social care and financial assessment. The assessment is requested at the time of referral and is then discussed at a pre admission “panel” meeting with senior staff of social services and Tregarne. Tregarne Hostel D52-D04 S41927 Tregarne Hostel V194898 160805 Stage 4.doc Version 1.40 Page 9 Tregarne Hostel D52-D04 S41927 Tregarne Hostel V194898 160805 Stage 4.doc Version 1.40 Page 10 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 6 and 9 The service users health, personal and social care needs are evidenced as being met in care planning documentation. EVIDENCE: Each service user has a plan of care that is generated from the assessment received at referral and from information gained at the pre-admission meeting and previous knowledge of the service user. The care plans are very service user focused and are supported by daily recording. There is evidence in place that the care plans are regularly reviewed. Risk assessment information is included in the care planning documentation. The home operates a key worker system which gives the responsibility of care planning to that staff member. Tregarne Hostel D52-D04 S41927 Tregarne Hostel V194898 160805 Stage 4.doc Version 1.40 Page 11 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 15 The home is a short stay facility and therefore all service users have established on-going family or carer links. EVIDENCE: The home is a short stay facility and therefore all service users have established on-going family or carer links. The home operates an open door visiting policy and everyone is asked to sign the visitors’ book on arrival to the home. Tregarne Hostel D52-D04 S41927 Tregarne Hostel V194898 160805 Stage 4.doc Version 1.40 Page 12 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 19 and 20 The service user’s health, personal and social care needs are being met by the staff and multidisciplinary staff as required to include safe medication administration. EVIDENCE: As Tregarne is a short stay facility the permanent carers retain the overall responsibility for service users physical and emotional health. Should someone become ill whilst staying at the home staff contact their carers and if necessary seek advice from the service users own general practitioner. If this is not possible the home has the facility to register an individual with a local practice as a temporary resident. Some service users receive support from a district nurse or other specialist professional during their stay. All recording of any accidents in the home is taking place appropriately as required by legislation. The home has a medication policy and procedure in place to guide staff on safe administration. It is recommended that staff sign to evidence when they have read this important policy and procedure. All senior officers employed at the home have the medication administration responsibilities. They have received accredited medication training. The home does not maintain stocks of medication as the service users bring the medicines they require for their stay and any surplus is returned home when they leave. Service users selfTregarne Hostel D52-D04 S41927 Tregarne Hostel V194898 160805 Stage 4.doc Version 1.40 Page 13 medicating are provided with a lockable space in which to store medication. Medication administration records were found to be completed appropriately on the day of the inspection. Tregarne Hostel D52-D04 S41927 Tregarne Hostel V194898 160805 Stage 4.doc Version 1.40 Page 14 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 22 and 23 The home has a good service users focused complaints policy and procedure provided to the service users in the service user guide. It is recommended that staff receive adult protection training to ensure that they are provided with the knowledge and understanding of adult protection issues to protect service users from abuse. EVIDENCE: The home’s complaints policy and procedure is included in the service user guide. This documentation has been well considered resulting in a service user friendly document. The registered manager is recording any complaints/concerns that are raised by the service users or carers. A more formal complaints policy and procedure is included in the statement of purpose document. The home has in place a comprehensive adult protection policy and procedure available to guide staff on good practice. Included in this documentation is a whistle blowing policy and procedure. It is recommended that staff receive adult protection training that is currently available via the social services department. Tregarne Hostel D52-D04 S41927 Tregarne Hostel V194898 160805 Stage 4.doc Version 1.40 Page 15 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) The environmental standards were not assessed at this inspection as there are plans for considerable changes and improvements to take place soon to the premises. EVIDENCE: Tregarne Hostel D52-D04 S41927 Tregarne Hostel V194898 160805 Stage 4.doc Version 1.40 Page 16 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 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31,32,33,35 and 36 The service users are cared for by a stable staff team who receive regular training to ensure that they can meet the care needs of the service users at all times. EVIDENCE: All staff employed at the home have detailed Cornwall County Council job descriptions that specify their roles and responsibilities. Up to six carers, ancillary staff, driver and additional managers hours are provided during the morning, which is considered a peak time of activity. As the service users attend day care activities the staffing levels are reduced. They are then increased again for evenings and weekend activities. The home has a stable staff team with no recent recruitment required, although soon a night staff post will be advertised. Some completed relatives/visitors comments cards which are produced by the CSCI indicated that there can be difficulties with staffing levels (at certain times) and this should be noted and monitored. The home employs two waking night staff members. The duty officer sleeps in the home and is on call to the two waking night staff if required. Tregarne Hostel D52-D04 S41927 Tregarne Hostel V194898 160805 Stage 4.doc Version 1.40 Page 17 Staff are receiving regular training to include first aid (all staff employed have this qualification), moving and handling and health and safety training. Epilepsy training has recently taken place along with medication training and visual impairment. Staff receive regular supervision from a senior staff member and documentation is fully in place to evidence this. A mentorship scheme is also in place at the home. Tregarne Hostel D52-D04 S41927 Tregarne Hostel V194898 160805 Stage 4.doc Version 1.40 Page 18 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 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 37,39 The registered manger is responsible for running a service that is in high demand for a range of service users, some of whom have very complicated care needs. She undertakes regular training and is supported by the social services department to enable her to do her job competently. EVIDENCE: The registered manger has been in post at Tregarne since March 2003. She is a qualified nurse (RNMH) and an NVQ assessor. She is presently undertaking studies for the Registered Managers Award qualification. This year she has also undertaken training in management skills and managing personal safety as well as a course on the introduction to outlook and the internet. The registered managers manager fulfils the requirements of legislation by undertaking regular visits to the home and producing a written report of a monthly visit to the CSCI. Tregarne Hostel D52-D04 S41927 Tregarne Hostel V194898 160805 Stage 4.doc Version 1.40 Page 19 The manager involves staff in regular meetings which include full team meetings twice a year and smaller monthly team meetings to include the night staff. Prior to the inspection the inspector received a very high volume of service user and relative/visitor comment cards. Generally this documentation indicates a high level of satisfaction with the service being offered at Tregarne. It is a credit to the manager that so many comment cards are received as this is a very large exercise for her to undertake. In addition to this the home completes it’s own yearly quality assurance and quality monitoring system resulting in a very professional document being published showing the findings of the audit. Tregarne Hostel D52-D04 S41927 Tregarne Hostel V194898 160805 Stage 4.doc Version 1.40 Page 20 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score 3 3 x x x Standard No 22 23 ENVIRONMENT Score 3 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 3 x x 3 x Score Standard No 24 25 26 27 28 29 30 STAFFING Score x x x x x x x Standard No 11 12 13 14 15 16 17 x x x x 3 x x Standard No 31 32 33 34 35 36 Score 3 3 3 x 3 3 CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Tregarne Hostel Score x 3 3 x Standard No 37 38 39 40 41 42 43 Score 3 x 3 x x x x D52-D04 S41927 Tregarne Hostel V194898 160805 Stage 4.doc Version 1.40 Page 21 NO Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard Regulation Requirement Timescale for action 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. 3. Refer to Standard 20 23 33 Good Practice Recommendations For staff to sign to evidence when they have read the medication policy and procedure. For staff to receive adult protection training. To monitor the staffing levels to ensure that they meet the care needs of the service users at all times. Tregarne Hostel D52-D04 S41927 Tregarne Hostel V194898 160805 Stage 4.doc Version 1.40 Page 22 Commission for Social Care Inspection John Keay House Tregonissey Road St Austell Cornwall, PL25 4AD 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 Tregarne Hostel D52-D04 S41927 Tregarne Hostel V194898 160805 Stage 4.doc Version 1.40 Page 23 - 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. 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