Inspection on 15/11/05 for Tregenna House

This inspection was carried out on 15th November 2005.

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

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Tregenna House 23/07/09

Tregenna House 26/07/07

Tregenna House 03/07/06

Tregenna House 12/05/05

Tregenna House 16/11/04

Tregenna House 06/05/04

Similar services:

Trevaylor Manor

Stallcombe House

Stroud Lodge

The Woodmill

Woodland Vale

Bolealler House

Claremont Nursing Home

Althea Park House

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

CARE HOMES FOR OLDER PEOPLE Tregenna House Pendarves Road Camborne Cornwall TR14 7QG Lead Inspector Diana Penrose Unannounced Inspection 15th November 2005 09:30 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Tregenna House DS0000009261.V266448.R01.S.doc Version 5.0 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Tregenna House DS0000009261.V266448.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Tregenna House Address Pendarves Road Camborne Cornwall TR14 7QG 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) 01209 713040 01209 715356 enquiries@tregannahousenursinghome.co.uk Issuemarket Limited Miss Amanda Johnstone Care Home 40 Category(ies) of Dementia - over 65 years of age (40), Mental registration, with number Disorder, excluding learning disability or of places dementia - over 65 years of age (40) Tregenna House DS0000009261.V266448.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. To include up to 19 named service users category OP nursing, outside of the new registration categories. 12th May 2005 Date of last inspection Brief Description of the Service: Tregenna House is a large two storey Victorian property with a modern single storey extension at the back. The building is situated in large grounds close to the town of Camborne. There is parking to the front of the home and an enclosed garden to the rear. The home provides nursing and residential care for up to thirty-nine elderly residents with a mental disorder or dementia. Accommodation is over two floors; the ground floor provides accommodation for 23 residents. There is a large lounge with a dining area at one end. The Registered Providers hope to build a conservatory and move the dining area as it is in the walk through from the old building to the extension. The kitchen is on the ground floor with a hatchway opening into the dining area. The first floor, Bluebell Wing, provides accommodation for 16 residents with more limited mobility. There are two lounges upstairs with dining facilities incorporated. Meals are transported from downstairs but there is a kitchenette for making snacks and drinks. There is a large enclosed garden at the back of the home, which the Registered Providers hope to design so that it is suitable for residents with a dementia. Suitably qualified nurses and care assistants provide nursing and personal care within a relaxed friendly atmosphere. Tregenna House DS0000009261.V266448.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspector visited Tregenna House Nursing Home on the 15 November 2005 and spent six hours and twenty minutes at the home. This was an unannounced visit. The purpose of the inspection was to gain an update on the progress of compliance to the requirements that were identified in the last inspection report dated 12.05.05. In addition the inspector focused on the following key areas of care: choice of home, care planning, medications, complaints, adult protection, some of the environment and some management areas. On the day of inspection 39 residents were living in the home. The methods used to undertake the inspection were to meet with a number of residents, staff and the administrator to gain their views on the services Tregenna offers. The Registered Manager was attending a training course on the day of the inspection. Tregenna’s records, policies and procedures were examined and the inspector toured the building. This report summarises the findings of this inspection. What the service does well: What has improved since the last inspection? Tregenna House DS0000009261.V266448.R01.S.doc Version 5.0 Page 6 The environment has again improved. A new carpet has been fitted in the downstairs lounge and new chairs have been purchased. Some bedrooms have been fitted with washable floor covering to combat odours and infection risks. One resident said she was very pleased with her flooring and it was much easier to keep clean. New pedal bins have been provided in bathrooms and three new washer disinfectors have been hired for the sluices. The laundry has been upgraded to two washers and two driers and all laundry is dealt with in house. New bedding has been purchased and a new ironing press to cope with the increased workload. Medicine trolleys have been replaced on both floors. New heated food trolleys have been introduced and the care staff distribute the meals to ensure the residents have what they want and the quantity they want. This appeared to work well at lunchtime. A keyworker system has been introduced and staff said it is working well. What they could do better: Tregenna House DS0000009261.V266448.R01.S.doc Version 5.0 Page 7 Eleven requirements and fourteen recommendations were notified following this inspection. The home will benefit when the policies and procedures have been reviewed and updated. The policies must be available to staff and they must be fully aware of those relevant to their working practice. The home must implement a safekeeping policy and procedure that guides and informs staff on the safekeeping of residents’ money and valuables, staff must again be made aware of this policy. There should be a form for the resident or their representative to sign to agree to the home handling their money. The care plans must be expanded and be developed from the assessment criteria. The resident or their representative must be involved in the compilation of the care plan whenever possible. All care records should be complete, dated and signed. The records required by legislation must be maintained. The handwriting of medicines onto the medicine administration charts must be witnessed with two signatures recorded. There needs to be individual hoist slings for all residents requiring a hoist with records kept of the laundering arrangements. A new chair is needed for the bath hoist in the extension for infection control purposes. There must be an audit of all commodes and replacements made where needed. Tregenna House DS0000009261.V266448.R01.S.doc Version 5.0 Page 8 The Registered Manager should have an annual appraisal to discuss and address her role, her professional development and training needs. 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. Tregenna House DS0000009261.V266448.R01.S.doc Version 5.0 Page 9 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 Tregenna House DS0000009261.V266448.R01.S.doc Version 5.0 Page 10 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1 Prospective residents are given information about the home, when this is fully updated it will enable them to make a more informed decision. EVIDENCE: The statement of purpose was almost fully updated, a copy must be sent to the Commission on completion. There is a copy of the residents guide in each bedroom. Tregenna House DS0000009261.V266448.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 9 and 10 Individual care plans are generated for each resident but do not fully inform and direct the staff in the care provision. There is a system and policy in place for dealing with resident’s medicines; extra safeguards need to be in place to ensure residents safety. Systems are in place to ensure that residents are respected and their privacy is upheld at all times. EVIDENCE: All residents had a written care plan. There was no evidence that the resident or their representative were involved in the compilation and those inspected had not been signed by the resident or representative. A reason must be stated if involvement is not possible. The care files contain a lot of forms; not all were completed in the files inspected. Relevant risk assessments are included and the daily records are informative. Care plans are generally reviewed monthly and a staff member had signed most of them. The care plans must be expanded to include the minimum criteria listed in standard 3.3. They should detail things the residents can do for themselves as well as things they need assistance with. There needs to be a separate risk assessment for the use of cot-sides and consent agreed between the nursing staff, GP and relatives. Staff said the new keyworker system is advantageous. Tregenna House DS0000009261.V266448.R01.S.doc Version 5.0 Page 12 A monitored dosage system of medication is used in the home. New medicine trolleys have been provided and are much appreciated by the staff. Records for the receipt of medicines must be improved to include all medicines. Administration records are satisfactory. There is a photograph of each resident with their medication administration chart. Any handwritten medicine or instruction on the medication administration charts must be witnessed with two signatures recorded. The medicines policy inspected may not have been the updated version. It must include the use of oxygen and medicinal creams and lotions. Creams should be dated when opened and disposed of after the appropriate time period; generally one month for pots and three months for tubes. The file of patient information leaflets (PIL) could not be found, these should be available at all times for reference. It is recommended that the homely remedy list be updated along with the relevant section in the policy. An up to date policy and The Royal Pharmaceutical Guidelines for the Administration of Medicines in Care Homes must be available for staff reference at all times. Residents’ privacy was upheld during the inspection. Residents said they are treated with respect and their privacy is upheld at all times. Shared rooms are provided with appropriate screens. Tregenna House DS0000009261.V266448.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 14 Residents are helped to maintain control over their lives and staff respect their individual preferences and choice. EVIDENCE: Staff said that residents maintain control over their lives for as long as they are able. They are given choices in respect of food, clothes to wear and daily routines, for example. They all have their own possessions in their rooms. Two residents said they stay in their rooms because it is their choice. One said she can eat whatever she likes at mealtimes and the cook is excellent. Staff address residents by their preferred name. Tregenna House DS0000009261.V266448.R01.S.doc Version 5.0 Page 14 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 The home has a satisfactory complaints procedure that ensures complaints will be listened to and acted upon. Arrangements are in place for the protection of residents safeguarding them from harm or abuse. EVIDENCE: There is a suitable complaints policy in the home and a method for recording complaints, the action taken and the outcome. There have been no complaints. Thank you letters and cards are kept. The home has a whistleblowing policy that refers to the ‘No Secrets’ document. The home also has a copy of the Local Authority inter agency procedures, alerters guide and a draft copy of the national framework for safeguarding adults. It is recommended that a flow chart or simplified procedure be compiled for staff to reference easily. It needs to be clear on who to report to and state that CSCI must be notified. There is a secure facility for the storage of money in the home. Staff said they will be attending POVA training, the previous course was cancelled. Tregenna House DS0000009261.V266448.R01.S.doc Version 5.0 Page 15 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19 The home and grounds are well maintained providing a safe environment for residents, staff and visitors. The home is clean and free from offensive odours; further controls are necessary to prevent the risk of infection EVIDENCE: The home is well maintained, decorated and furnished to a good standard. It is clean, homely and comfortable with no offensive odours. The downstairs lounge carpet has been replaced and new chairs purchased. Some bedroom carpets have been replaced with waterproof flooring to improve the control of odours; one resident said she thought it was very nice and much easier to keep clean. New pedal bins have been purchased and the administrator said the replacement of the bath hoist chair is in hand. The grounds are tidy and reasonably accessible; it is still hoped to improve the enclosed garden with particular design features to benefit residents with a dementia. Residents said they are very happy in their surroundings. The laundry has been upgraded with two washers and two driers now installed. All laundry is now done in house and new bedding has been purchased; some residents commented that it is all the same, plain ivory. The bedding suits all décor however residents’ choice must be taken into consideration. Tregenna House DS0000009261.V266448.R01.S.doc Version 5.0 Page 16 Three new washer disinfectors have been installed in the sluices, on a hire basis. There must be an audit of all commodes in the home and replacements made where necessary, some are an infection risk as they are chipped and rusty. Some staff said they have attended infection control training. Handwashing facilities are appropriate and alcohol hand cleansing gel is in use. Tregenna House DS0000009261.V266448.R01.S.doc Version 5.0 Page 17 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27 and 29 Staffing levels meet the needs of residents and staff morale appears to be good. Recruitment procedures are not robust enough to offer maximum protection to the residents EVIDENCE: The rota showed there are sufficient numbers of staff on duty. There is a nurse on duty, on each floor at all times and the night staff stay awake. Staff said the staffing levels are good in the home but there has been sickness recently. Residents said the staff are caring and there are usually enough. Staff were observed to interact very well with residents and in a kind, relaxed manner. Four staff files were inspected and some lacked documents namely interview records, copies of certificates of qualifications and training, two references and copies of a signed contract of employment. Some CRB disclosures have been applied for but not yet received. POVA disclosures are received via e-mail. The administrator said that staff work under supervision whilst awaiting receipt of their CRB check. Training records could not be accessed to inspect. Tregenna House DS0000009261.V266448.R01.S.doc Version 5.0 Page 18 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 35 There is a suitable system in the home for dealing with residents’ money that ensures the residents’ financial interests are safeguarded. EVIDENCE: The home holds money for some residents but does not encourage this practice. Pocket money is stored securely in a safe; the rest of the money is held in a non-interest bank account separate to the business account. Appropriate electronic records are maintained of all transactions, the accounts are printed each month for the resident or their representative. Receipts are kept for purchases and for money received on behalf of residents. The administrator is appointee for two residents and this is dealt with appropriately. There must be a policy for the management of resident’s money. Tregenna House DS0000009261.V266448.R01.S.doc Version 5.0 Page 19 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 X X X X X HEALTH AND PERSONAL CARE Standard No Score 7 2 8 X 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 X 14 3 15 X COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 X 29 2 30 X MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X X X X 2 X X 3 Tregenna House DS0000009261.V266448.R01.S.doc Version 5.0 Page 20 Are there any outstanding requirements from the last inspection? Yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 2 Standard OP1 OP7 Regulation 4 (2) 15 (1) Requirement A copy of the updated statement of purpose must be sent to the Commission The resident or their representative must be involved in the compilation of their care plan whenever possible. Care plans must be expanded to include all of the criteria listed under standard 3.3 A record must be kept of the incidence of pressure sores Records for the receipt of medicines must include all medicines. The transcribing onto the MAR charts must be witnessed with two signatures recorded An up to date policy and The Royal Pharmaceutical Guidelines must be available for staff reference at all times There must be an audit of all commodes in the home and replacements made where necessary Personnel files must contain all of the documents required by DS0000009261.V266448.R01.S.doc Timescale for action 09/01/06 15/11/05 3 4 5 6 7 OP7 OP8 OP9 OP9 OP9 15 17(1)a Sch 3(3)n 13(2) Sch 3(3)i 13(2)(4) (c) 13 (2) 17/02/06 09/01/06 15/11/05 15/11/05 09/01/06 8 OP26 13(4) 17/02/06 9 OP29 19 Sch 2 17/02/06 Tregenna House Version 5.0 Page 21 10 11 OP35 OP38 12 (1) 13(6) 12,13 legislation There must be a policy for the management of residents money The homes policies and procedures must be reviewed and updated 17/02/06 17/02/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 2 3 4 5 6 7 8 9 10 11 12 13 14 Refer to Standard OP7 OP7 OP9 OP9 OP9 OP9 OP14 OP18 OP26 OP26 OP29 OP35 OP36 OP36 Good Practice Recommendations There needs to be a separate risk assessment for the use of cot-sides and consent agreed and signed All paperwork used should be fully completed dated and signed The home’s medicines policy should include the use of oxygen and medicinal creams and lotions Medicinal creams should be dated when opened and disposed of after the appropriate time period The homely remedy list needs to be updated along with the relevant section in the policy Patient information leaflets should be available at all times for reference Residents views should be sought when refurbishing the home or purchasing bedding and so on A flow chart or simplified adult protection procedure should be compiled for staff to reference easily There should be individual hoist slings for residents with records kept of the laundering arrangements The bath hoist chair in the downstairs extension should be replaced The pre-employment health questionnaire should be more comprehensive There should be a form for the resident or their representative to sign to agree to the home handling their money. There should be a policy in place for staff supervision. The Registered Manager should have an appraisal annually Tregenna House DS0000009261.V266448.R01.S.doc Version 5.0 Page 22 Commission for Social Care Inspection St Austell Office 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 Tregenna House DS0000009261.V266448.R01.S.doc Version 5.0 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. 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