Inspection on 03/07/06 for Tregenna House

This inspection was carried out on 3rd July 2006.

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

Tregenna House 23/07/09

Tregenna House 26/07/07

Tregenna House 15/11/05

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 3rd July 2006 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.V297715.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Tregenna House DS0000009261.V297715.R01.S.doc Version 5.2 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.V297715.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. To include up to 19 named residents category OP nursing, outside of the new registration categories. Residents to include one named person under the age of 65 years to be accommodated for respite care on a regular basis. To admit up to two people aged 60 years to 64 years, outside the registered age category. 15th November 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 kitchen is on the ground floor with a hatchway opening into the dining area. The Registered Providers have plans to build a further five ground floor bedrooms with en suite facilities and to convert an existing double bedroom, downstairs, into a small lounge. Extra storage will be provided and changing facilities for the catering staff. 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 is being designed specifically for residents with a dementia. A large area of garden at the side of the home is being improved with vegetable and herb beds. Suitably qualified nurses and care assistants provide nursing and personal care within a very relaxed, friendly atmosphere. Information about the home is available in the form of a residents’ guide, which can be supplied to enquirers on request. A copy of most recent inspection report is available in the home. Fees range from £630 to £1200 per week this information was supplied to the Commission during the inspection. Additional charges are made in respect of private healthcare provision, hairdressing and personal items such as newspapers, confectionary and toiletries. Tregenna House DS0000009261.V297715.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. An inspector visited Tregenna Nursing Home on the 3rd and 4th July 2006 and spent eleven and a quarter hours at the home. This was a key inspection and an unannounced visit. The purpose of the inspection was to ensure that residents’ needs are properly met, in accordance with good care practices and the laws regulating care homes. The focus was on ensuring that residents’ placements in the home result in good outcomes for them. It was also to gain an update on the progress of compliance to the requirements identified in the last inspection report dated 15/11/05. All of the key standards were inspected. On the day of inspection 40 residents were living in the home and one was attending for day-care at weekends. The methods used to undertake the inspection were to meet with a number of residents, staff and the registered manager to gain their views on the services offered by Tregenna Nursing Home. Records, policies and procedures were examined and the inspector toured the building. This report summarises the findings of this inspection. Staff said the care they provide is to a very good standard. Residents expressed satisfaction with their care and all of the services provided by the home. Everyone spoke highly about the quality of the food. Overall the home is providing a good quality of care to the residents placed there with notable improvements since the last inspection. What the service does well: The registered manager is competent and runs the home well. Staff and residents said she is approachable and of a kind and caring nature. The management endeavour to ensure that working practices are safe and an external consultant is employed to deal with health and safety training and audits. The home provides a warm, clean, homely environment that is well-maintained and safe for residents, staff and visitors. There is an ongoing programme of redecoration and refurbishment, which is improving the general appearance of the home and comfort for the residents. All laundry is dealt with on site and residents are very satisfied with the service provided. To reduce the risk of infection liquid soap and paper towels are provided for staff along with alcohol hand cleansing gel, protective clothing such as plastic gloves and aprons are supplied and used. Care provided is to a good standard and residents are only admitted following a full assessment to ensure the home can meet their needs. Residents said their care needs are met and they are very happy living in the home. They said Tregenna House DS0000009261.V297715.R01.S.doc Version 5.2 Page 6 the staff are kind and very caring. Staff interact very well with the residents and the atmosphere is relaxed and friendly. Doctors and other healthcare professionals visit the home as required. Residents’ privacy was upheld during the inspection and staff were observed knocking on doors before entering. Residents said they are treated with respect and their privacy is upheld at all times. Their money is suitably dealt with and residents can manage their own money according to their individual risk assessment and ability. Residents have an individual care plan and relevant risk assessments are undertaken. Medicines are stored safely and securely and only qualified nurses administer the medicines. Friends and family are welcome in the home and residents can go out according to their wishes and ability. The visitor’s book shows the home receives a lot of visitors. Activities take place, organised by the activities coordinator, these include a lot of one to one sessions and outings for individuals to locations of their choice. The standard of the food provided is very good, all residents and staff spoke really highly of the cook and said she goes out of her way to provide what the residents want. There are two qualified nurses on duty at all times and sufficient care staff to look after for the residents living in the home. Residents said there are enough staff and they are always willing to help. Staff were observed to interact well with residents in a very kind, relaxed manner. Care staff are actively encouraged to undertake NVQ training and there are other training courses and study sessions on offer. The home has had no complaints but has received many thank you letters and cards that are kept in a file. What has improved since the last inspection? Staffing has improved sine the last inspection with 16 qualified nurses now employed, some are bank staff that work when the need arises. The registered manager said this has helped to cover sickness and annual leave. Staff training has increases and there are posters on notice boards showing what is on offer. The registered manager keeps a training plan for all staff. An e learning Tregenna House DS0000009261.V297715.R01.S.doc Version 5.2 Page 7 computer package has been purchased with learning packs on dementia for staff to work through. Staff meetings are held regularly and minutes are kept. More rooms have had the flooring replaced and a quote has been received for a further five rooms. The bath hoist has been re-coated and is now in a much better condition, a shower wet-room has been developed downstairs. Seven new commodes have been purchased following the audit. New dining tables and chairs have been purchased and residents said they are much better. The Princes Trust is designing the garden and work is in progress. The rear garden is being designed specifically for residents with dementia with a sensory area and rabbits to be kept as pets. What they could do better: Assessment documents need to be completed appropriately and indicate who is involved they should also be signed by the person doing the assessment. Care plans must be further developed to include all of the criteria listed in standard 3.3, at present the plans are variable and not all include social needs. All care paperwork should be signed and dated and a risk assessment needs to be compiled for the use of cot-sides. There are issues around medicines that must be addressed however the registered manager stated that she is tackling these. They are mainly in respect of record keeping. The Royal Pharmaceutical Guidelines for the Administration of Medicines in Care Homes must be available to staff and the homes policy should include the use of creams and lotions. Some liquid medicines labelled for individuals are being administered to other residents who are prescribed the same medicine; this needs to be sorted out. Although the care staff do not administer medicines to residents basic medication training should be provided for all care staff, especially on induction. This should include what to do if a resident requests a medicine and the administration of creams and so on. The registered manager should compile a training matrix whereby she can easily assess and audit staff attendance to ensure they attend according to the law. The records at the moment make it difficult to ascertain who has done the training and when without going through each individual file which is very time consuming. The homes policies and procedures must be reviewed and a supervision policy compiled; the registered manager said this is in progress. A flow chart or Tregenna House DS0000009261.V297715.R01.S.doc Version 5.2 Page 8 simplified adult protection procedure still needs to be compiled for staff to reference easily as the policy is very long and detailed to reference quickly. There should be a form for the resident or their representative to sign to agree to the home handling their money. Housekeeping staff are deficient at the moment although recruitment is in progress. This has meant the home has become untidy in some areas. The lack of storage does not help the situation and hopefully this will be addressed with the proposed building work. 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.V297715.R01.S.doc Version 5.2 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.V297715.R01.S.doc Version 5.2 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 and 3 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Prospective residents are given information about the home enabling them to make an informed decision. Residents are only admitted to the home following an assessment of their needs, however, the pre admission assessment process must be fully completed and address all care needs and ensure the home can provide adequate care. EVIDENCE: Evidence was provided in the form of documentation, records and discussion with the registered manager. There is a statement of purpose, which is being reviewed to include details of forthcoming building work and improvements to the home. There is a copy of the residents guide in each bedroom. Prospective resident’s needs are assessed prior to admission to the home and recorded using the Standex system. The forms inspected did not have all of the sections completed and not all were signed by the nurse undertaking the Tregenna House DS0000009261.V297715.R01.S.doc Version 5.2 Page 11 assessment. The form should also state who is involved in the assessment. Information is received from hospital staff and this was evident. Tregenna House DS0000009261.V297715.R01.S.doc Version 5.2 Page 12 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10 Quality in this outcome area is adequate to good. This judgement has been made using available evidence including a visit to this service. Individual care plans are generated for each resident but do not fully inform and direct the staff in their care provision. Residents have access to health care services as necessary to ensure their assessed needs are met. There are systems and policies in place for dealing with residents medicines; some extra vigilance in record keeping will help to ensure residents safety. Systems are in place to ensure that residents are respected and their privacy is upheld at all times. EVIDENCE: Evidence was provided in the form of documentation, records, observation, and interviews with residents, staff and the registered manager. All residents have a written care plan and the resident or their representative is involved in the compilation. The plans are signed by the residents or representative when possible. The plans inspected were all reviewed on a monthly basis; they need to be signed by the person doing the review. 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. They should fully inform and direct the care Tregenna House DS0000009261.V297715.R01.S.doc Version 5.2 Page 13 staff on the care to be provided. Relevant risk assessments are included and these must be reflected in the care plans. Both nursing and care staff write the daily records and these are informative. A key-worker system is in place and works well. Residents said their needs are met and staff said the standard of care provided is good. Care practice observed was to a high standard. Doctors and other healthcare professionals visit as appropriate and records are kept. Residents spoke of going to the hospital for appointments. The home has suitable equipment for moving and handling and pressure relief. Residents needing a hoist have an individual sling that is washed regularly. The pressure setting of air mattresses is recorded. A monitored dosage system of medication is used in the home. No residents administer their own medicines. Records for the receipt of medicines were not consistent and there were some gaps in the administration records, the registered manager said this was being addressed. Disposal records must include any medicines refused or dropped on the floor and so on. Any handwritten medicine or instruction on the medication administration charts must be witnessed with two signatures recorded. There is a photograph of each resident with his or her medication administration chart. A nurse said the pharmacist comes in and talks to staff about medicine issues and medicine alerts are received. Information from the pharmacist was available to staff. Care staff do not administer medicines, however it is recommended that basic training be provided, especially on induction. Staff must be aware of the management of medicines in the home and should know what they can and cannot do. For example how to respond when a resident asks for pain relief, the homes policy on the use of creams and lotions and their involvement in this. The medicines policy has been updated and was available to staff. It must include the use of medicinal creams and lotions. Creams are dated when opened. Patient information leaflets (PIL) are available for reference. The Royal Pharmaceutical Guidelines for the Administration of Medicines in Care Homes must be available for staff reference at all times. Medicines prescribed for an individual resident must not be administered to anyone else. Residents’ privacy was upheld during the inspection and staff were observed knocking on doors before entering. Residents said they are treated with respect and their privacy is upheld at all times. They said they receive their mail unopened. Shared rooms are provided with appropriate screens. Systems are in place to deter residents wandering into other resident’s rooms; for example one resident has a gate across her doorway, which she feels comfortable with. Tregenna House DS0000009261.V297715.R01.S.doc Version 5.2 Page 14 Tregenna House DS0000009261.V297715.R01.S.doc Version 5.2 Page 15 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home provides a range of activities and aims to offer a lifestyle that meets individual residents needs. Links with family, friends and the community are good and allow residents the opportunity to socialise. Residents are helped to maintain control over their lives and staff respect their individual preferences and choice. Dietary needs of residents are well catered for with a varied selection of food available that aims to meet their taste and preference. EVIDENCE: Evidence was provided in the form of records, observation, and interviews with residents, staff and the registered manager. The home has an activities co-ordinator who was spoken very highly of by residents and staff. Activities take place in the home and residents can choose whether or not to join in. These activities include bingo, puzzles, reminiscence and baking. Entertainers and musicians visit the home and the residents appreciate them. Some residents participate in gardening and pottery. There is a lot of one to one social interaction and residents are given opportunities to go out. One resident went out for the day, with a member of staff, during the inspection, he said he goes out regularly and can go where he wants. Tregenna House DS0000009261.V297715.R01.S.doc Version 5.2 Page 16 Residents said they choose when they get up and go to bed. They said they receive visitors when they wish and can receive them in private, the visitor’s book showed that several people visit the home each day. Staff said residents are encouraged to live the lives they wish and they always try to improve on this. There is a four-week menu which is set, however residents can have an alternative if they wish, one resident said she often has an alternative. Another said if she fancies something different the cook would go out and get it for her. Everyone spoken with praised the cook and spoke really highly of the food. Fresh fruit and vegetables are provided and cakes are homemade. Special occasions are celebrated and birthday cakes are provided. Residents enjoyed their lunch and there was little waste. Tregenna House DS0000009261.V297715.R01.S.doc Version 5.2 Page 17 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 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home has a satisfactory complaints procedure that ensures complaints are listened to and acted upon. Arrangements are in place for the protection of residents safeguarding them from harm or abuse. EVIDENCE: Evidence was provided in the form of documentation and discussion with staff and the registered manager. 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 have been attending POVA training either with Social Services or in house. The registered manager has a video for training puposes. Tregenna House DS0000009261.V297715.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19 and 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. 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 making it a pleasant place to live in. EVIDENCE: Evidence was provided in the form of a tour of the building, interviews with residents, staff and registered manager. The home is decorated and furnished to a good standard. It is clean, homely and comfortable. It is well maintained; the maintenance man said it is a continuous job with an old building. Some bedroom carpets have been replaced with waterproof flooring to improve the control of odours. The bath hoist chair has been upgraded and seven new commodes purchased. A shower wet-room has been provided downstairs. New tables and chairs have been purchased for the dining room downstairs and these are appreciated. There is Tregenna House DS0000009261.V297715.R01.S.doc Version 5.2 Page 19 a lack of storage space in the home and this along with the current shortage of housekeeping staff makes the home look rather untidy. The storage of incontinence products appears to be a particular problem. Individual bedrooms are personalised with pictures and belongings. Residents said they are very happy in their surroundings. The grounds are tidy and reasonably accessible work is being undertaken in part of the garden by the Prince’s Trust. Vegetable and herb beds are incorporated and the area will be safe for residents to go outside or participate in gardening. The enclosed garden at the back is being designed specifically for residents with dementia. The management hope to provide pet rabbits for the residents. All laundry is done in house. The laundry had been upgraded at the last inspection with two washers and two driers installed. There are three sluices with washer disinfectors. Hand-washing facilities are appropriate and alcohol hand cleansing gel is in use. Staff were observed wearing disposable gloves and aprons. Staff said they have attended infection control training Tregenna House DS0000009261.V297715.R01.S.doc Version 5.2 Page 20 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, 28, 29 and 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Staffing levels meet the needs of residents and staff morale is good. Residents are in safe hands and benefit from the 50 of care staff trained to at least NVQ level 2 in care. Recruitment procedures are robust and offer protection to the residents. The home provides appropriate training for staff to help them be more competent in their roles. EVIDENCE: Evidence was provided in the form of documentation, records, observation, and interviews with residents, relatives, staff and registered manager. The rota showed there are sufficient numbers of care staff on duty. There is a nurse on duty, on each floor at all times and the night staff stay awake at night. Staff said the staffing levels are good in the home although sickness can sometimes cause problems. Residents said the staff are very caring and there are enough. Staff were observed to interact very well with residents and in a kind, relaxed manner. Care practice observed was appropriate and safe. Several male care staff have been employed and appears to be working very well. One resident said she feels safer with men as they are stronger. Another said he gets on very well with one male carer and they go out sometimes. The home has been approved to take nursing students from November 2006. Housekeeping staff are short at the moment, new recruits are awaiting the return of necessary employment checks. Tregenna House DS0000009261.V297715.R01.S.doc Version 5.2 Page 21 The registered manager has a good approach to ensuring staff have a National Vocational Qualification in care. 50 of staff have an NVQ either at level 2 or 3 and copies of NVQ certificates are kept on file. Other staff are undertaking NVQ training. There is a robust recruitment procedure. Four staff files were inspected and included all of the documents required by legislation. New recruits had their induction paperwork with them and this was inspected. The registered manager’s approach to staff training is good. The registered manager said that staff receive statutory training as required. The records are held individually which makes it difficult to assess that this is up to date. It is recommended that the registered manager compile a training matrix whereby she can easily assess and audit staff attendance to ensure they attend according to the law. Staff said they have attended adult protection training either with Social Services or in house. Some are going to attend dementia training provided by Dementia Voice. There is also an E learning pack for dementia training in the home. External study days are on offer to staff and a list is displayed. These include record keeping, palliative care, bowel and bladder dysfunction, venepuncture, Parkinson’s Disease, medication matters and promoting physical activity. Nurses said they attend relevant courses to keep up to date. Tregenna House DS0000009261.V297715.R01.S.doc Version 5.2 Page 22 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 and 38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The Registered Manager is a person of good character and fit to run the home. The home is run in the best interest of the residents and they benefit from the Quality Assurance systems in place. There is a suitable system in the home for dealing with residents’ money that ensures that the residents’ financial interests are safeguarded. Appropriate training and safety checks are undertaken to ensure the health safety and welfare of residents and staff. EVIDENCE: Evidence was provided in the form of documentation, records, observation, and interviews with residents, staff and the registered manager. The registered manager is competent and experienced to run the home. She is a qualified mental nurse and has enrolled on the Registered Managers’ Award Tregenna House DS0000009261.V297715.R01.S.doc Version 5.2 Page 23 course, progression is slow and she is considering an alternative course. This must be done soon to ensure compliance with regulations. She said she keeps herself up to date on current issues by reading relevant magazines and surfing the internet. Recent training includes bladder dysfunction, medicine matters and non-aggressive physical intervention. Staff and residents said the registered manager runs the home very well, is very approachable and treats everyone fairly. Staff appreciate her participation as part of the team and said she works extremely hard. Residents said they could talk to her when they wish and would feel comfortable approaching her if they needed to complain for any reason. The home has a satisfactory quality assurance process in place. This includes a bi-annual survey to ascertain the views of residents and their representatives. A matrix is compiled from the results and an action plan put in place. Accidents are audited and complaints would be if they had any. Staff meetings are held and staff are encouraged to air their views, minutes of meetings are maintained. There are no resident or relatives meetings at the moment as the registered manager said they did not work out well. There is a suitable policy for the management of resident’s money. The home holds money for most residents and one of the company directors is appointee for three residents and deals with their money appropriately. Resident’s money is held in a non-interest bank account separate to the business account. Pocket money is stored securely in a safe in the form of petty cash and receipts are kept for all money removed from the safe. 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. There will be two signatures on the sheets in future when the accounts are checked. There is a procedure for staff to follow when the administration staff are not in the home. The home has a health and safety policy. An external consultant has undertaken the health and safety audit and fire risk assessment. An action plan is in place and he provides necessary training for staff. Service and equipment checks are undertaken with records maintained. Fire safety records are kept and staff receive instruction at each weekly fire drill. Tregenna House DS0000009261.V297715.R01.S.doc Version 5.2 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 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 4 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 3 Tregenna House DS0000009261.V297715.R01.S.doc Version 5.2 Page 25 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 OP7 Regulation 15 Requirement Timescale for action 01/01/07 2 OP9 13(2)(4)( c) 3 OP38 12,13 Care plans must be expanded to include all of the criteria listed under standard 3.3 and also reflect the findings of individual risk assessments • Any handwritten 07/08/06 information on MAR charts must be witnessed with two signatures recorded. • The receipt of medicines and the administration records must be completed appropriately. • Disposal records must include all medicines disposed of. • The Royal Pharmaceutical Guidelines must be available for staff reference at all times. • Medicines prescribed for an individual resident must not be administered to anyone else. The homes policies and 01/01/07 procedures must be reviewed and updated Tregenna House DS0000009261.V297715.R01.S.doc Version 5.2 Page 26 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 Refer to Standard OP3 Good Practice Recommendations All sections of the assessment form should be completed and signed by the person undertaking the assessment. • The assessment form should indicate who is involved in the assessment. • There needs to be a separate risk assessment for the use of cot-sides and consent agreed and signed. • All care paperwork used should be fully completed dated and signed, including care plan reviews • The home’s medicines policy should include the use of medicinal creams and lotions. • Basic medication training should be provided for all care staff, especially on induction A flow chart or simplified adult protection procedure should be compiled for staff to reference easily The registered manager should compile a training matrix whereby she can easily assess and audit staff attendance to ensure they attend according to the law. 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. • 2 OP7 3 OP9 4 5 6 7 OP18 OP30 OP35 OP36 Tregenna House DS0000009261.V297715.R01.S.doc Version 5.2 Page 27 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.V297715.R01.S.doc Version 5.2 Page 28 - 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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