Inspection on 02/11/07 for Tregertha Court

This inspection was carried out on 2nd November 2007.

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

Other inspections for this house

Tregertha Court 23/01/07

Tregertha Court 09/12/05

Tregertha Court 21/07/05

Tregertha Court 06/10/04

Tregertha Court 16/06/04

Tregertha Court 23/03/04

Similar services:

Fairfields Country Rest Home

Poldhu

Queensmount

Trevaylor Manor

Didsbury Court Rest Home

Stallcombe House

Belma

Hunters Care Centre

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

CARE HOMES FOR OLDER PEOPLE Tregertha Court Station Road East Looe Cornwall PL13 1HN Lead Inspector Mandy Norton Key Unannounced Inspection 10:00 2 November 2007 nd 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 Tregertha Court DS0000009233.V349800.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. Tregertha Court DS0000009233.V349800.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Tregertha Court Address Station Road East Looe Cornwall PL13 1HN 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) 01503 262014 F/P 01503 262014 enquiries@tregerthacourt.co.uk Tregertha Court Limited Miss Lorna Catherine Elizabeth Lee Care Home 38 Category(ies) of Dementia - over 65 years of age (3), Mental registration, with number Disorder, excluding learning disability or of places dementia - over 65 years of age (3), Old age, not falling within any other category (35) Tregertha Court DS0000009233.V349800.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 4. Service users to include up to 35 adults of old age (OP) Service uses to include up to 3 adults aged over 65 years with a mental illness (MD(E)) Service users to include up to 3 adults aged over 65 years with dementia (DE(E)) Total number of service users not to exceed 38. Date of last inspection 23rd January 2007 Brief Description of the Service: Tregertha Court is part of the Adlington group of homes, a privately owned, family run company. It is situated in Looe overlooking the river and on the outskirts of the town. It is approached by a ramped access as well as railed steps. A number of the bedrooms are en-suite and those in the front of the home have good views. There are four double rooms. The first and second floors are reached by a series of stairs or stair-lifts. There are two lounges at the front of the home that include large conservatories and views of the river and a further lounge and large dining room at the back of the home, all on the ground floor. There is seating outside the front of the home and a small garden area to the side. Limited car parking is available. The current scale of charges range between £300 to £500. Service Users are expected to pay for the following items themselves: hairdressing, chiropody, newspapers and shopping. The home has a Statement of Purpose and Service Users Guide, both of these are available in the office. Each person has a copy of the Service User Guide in their bedroom. The last inspection report is displayed at the front entrance. Tregertha Court DS0000009233.V349800.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place from 11.00 am until 2.40 pm on the 2nd November It was conducted with the manager. A tour of the home was carried out and some of the people living in the home were spoken to during the visit. This report also contains information taken from the completed annual quality assurance assessment (a document that is completed annually detailing ongoing improvements and achievements) and discussion with staff on the day of the inspection. There were 29 people living in the home at the time of the inspection. What the service does well: What has improved since the last inspection? Tregertha Court DS0000009233.V349800.R01.S.doc Version 5.2 Page 6 The new manager has made a number of positive changes since the last inspection and as a result has met most of the requirements made following the last inspection. Redecoration and refurbishment is ongoing; more hoists have been fitted to some of the baths making them more accessible for people, one of the conservatories at the front of the home has been replaced and rooms are redecorated once they become vacant. This makes the home a comfortable place to live. Some new carpet is on order for some of the staircases and will be fitted in the near future. An updated fire risk assessment has been drawn up and fire safety measures are in place as required. The manager has improved the recruitment process by having a system that ensures employment gaps are explored as well as requiring 2 written references and a Criminal Records Bureau (CRB) check to be carried out. A more robust induction process has been implemented for new staff and appraisal and supervision sessions are ongoing. This means people living in the home have appropriate staff looking after them. What they could do better: The improvement in the bathroom facilities needs to continue. To ensure people have access to an assisted bath on each floor. Some of the stair carpets are worn and need replacing but the manager said that new ones are on order and will be fitted in the near future. The care plans have a lot of good information in them, however specific areas of care need to be better highlighted on a separate page so that they can be easily identified ensuring that all of peoples needs are met. The Service Users Guide should contain information about people being able to have a lock fitted to their door and /or lockable space provided until such time as all the doors have locks and each room has some lockable space. The laundry is not situated in a good place and the provider should consider relocating it so that staff do not have to go outside and use steep steps to get to it. Staff could potentially trip or fall and should not be carrying heavy laundry bags up and down the steps. The manager needs to review the amount of night staff on duty to ensure that peoples needs are being met at all times. It was advised that she review the time that accidents occur in the home to see if it is most often at night. Tregertha Court DS0000009233.V349800.R01.S.doc Version 5.2 Page 7 Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Tregertha Court DS0000009233.V349800.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Tregertha Court DS0000009233.V349800.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 3 & 6 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People who use this service have good information about the home in order to make an informed decision about whether the service is right for them. The personalised needs assessment means that people’s diverse needs are identified and planned for before they move to the home EVIDENCE: A requirement was set following the last inspection (January 2007) to ensure all people were assessed prior to being admitted to the home. The manager visits all prospective service users at home and undertakes a thorough initial assessment of their care needs using the front sheet of the ‘Standex system’ in use at the home, to record the information. A completed assessment examined showed that she had visited the person in hospital and had been able to get Tregertha Court DS0000009233.V349800.R01.S.doc Version 5.2 Page 10 sufficient information from the person and the staff about their current needs and was able to say that the home could meet those needs. Written admission documentation was adequate and included a copy of the care management assessment. Basic information was available to staff to ensure they could meet the social, emotional and care needs of new people moving into the home. A Statement of Purpose is available to everybody moving into the home (one is kept in each room) and brochures and the last inspection report are displayed in the entrance foyer. A written contract of terms and conditions of residence is on each persons file. The current fees are included and clearly laid out. This means that the relevant people have the information they need about the service they will receive and how much it will cost them. The company administrator ensures the contracts are issued and have the relevant information included in them. Tregertha Court DS0000009233.V349800.R01.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9 & 10 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The practice regarding the planning and delivery of care means that people living at the home can be sure that their health and personal care needs will be generally fully met. EVIDENCE: Peoples care plans showed improvement and were generally complete. Two out of the four care plans examined had signatures from the people concerned to say they agreed with its contents. There was a lot of general information about people and their needs in the plans but specific areas such as catheter or wound care were not detailed on separate pages and therefore did not stand out and actions required to be taken could be missed. Tregertha Court DS0000009233.V349800.R01.S.doc Version 5.2 Page 12 The senior carer on duty explained about how the staff are allocated around the home on a daily basis to ensure peoples needs are met. The staff use the communications book for quick reference about peoples individual needs on that day and report back to the senior carer any problems or concerns, these are then documented into the care plans. The senior carer was seen carrying out this task after the mornings work had been completed. She said the staff have a daily handover about the people and their needs. These practices ensure people get the personal care they need. People and staff observed during the visit were interacting well. Personal care was being carried out in private. A number of people were enjoying an activity session in one lounge and a number of others were reading or watching the television in another lounge which meant their personal preferences were being considered. Staff had an overall understanding of the needs of the small number of people with dementia and were seen to be patient and kind when interacting with them. The deputy manager was dealing with a visiting GP during the inspection and the manager said that they have a good working relationship with the local GP practice with whom most of the people living at the home are registered. The community nurses based at the surgery visit the home to do dressings, catheter care and provide healthcare support should it be necessary. The manager said that part of the key workers role is to ensure hearing aids, dentures and other aids are regularly checked as well as making sure that clothing is in a good condition with no damage or buttons missing. The administration and recording of medication was satisfactory. The medication is locked in the treatment room and dispensed to the people around the home when required from a small trolley. The manager said that all of the staff who dispense medicines within the home have had training via Boots The Chemist. This means that people can be confident that the staff are competent in management of medicines. Tregertha Court DS0000009233.V349800.R01.S.doc Version 5.2 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 & 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. A range of activities within the home and community meaning the service users have a range of opportunities to participate in stimulating and motivating activities. People in the home knew what activities were ongoing despite the programme not being displayed at the time of the inspection. Meals and mealtimes are not rushed making them an enjoyable, social occasion for the service users EVIDENCE: An activity plan is ongoing in the home giving people the opportunity to take part in a variety of activities both within the home and community. The plan was not displayed in the home on the day of the inspection. On arrival at the home a number of people were partaking in a game of ‘balloon tennis’ with the activity co-ordinator who works in the home 3 days a week. In another lounge people were watching the TV and one person was playing the piano. The TV had a snowy picture, the person watching it said that it is Tregertha Court DS0000009233.V349800.R01.S.doc Version 5.2 Page 14 not always like that and it depended on the weather, however it was ‘ fine to watch’. In the third lounge the hairdressing was taking place for a number of people. The manager said that bingo was always played on a Friday afternoon and the people like it so much the staff have to arrange to take a session if the activity co-ordinator is off. People were seen gathering for the bingo as the inspection was being completed. Care plans examined had information about people’s hobbies and interests. People were seen going out of the home with relatives and one was sitting outside enjoying the views over the river. Visitors were seen coming an going during the inspection and were chatting to staff on a friendly basis. Menus were varied and nutritionally balanced. The dining area is large and tastefully laid out, with a small vase of fresh flowers on each table and a bowl of fresh fruit available for people to access at any time. The meals are served to people in the dining room via a hatch from the kitchen (which is adjacent to the dining room) so it is hot. Meals are delivered to those people who choose to eat in their rooms straight from the kitchen and the meal is covered to ensure it reaches the person at the right temperature. The mealtime was not observed but a number of staff were seen escorting people to the dining room prior to the meal and afterwards and nobody was hurrying or appearing rushed. The manager said they aim to make mealtimes a social occasion. Sufficient staff were available to help people requiring some assistance. Tregertha Court DS0000009233.V349800.R01.S.doc Version 5.2 Page 15 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16 & 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People feel safe and listened to. Formal complaints and reporting of abuse policies and procedures are in place. They are available to all staff and the manager and deputy manager would be consistent in their approach to any concerns raised. EVIDENCE: A complaints procedure was available to everybody living in the home and is included in the Service User Guide (kept in each persons room). It was advised to move the complaints procedure, displayed within the home, to a lower positions o that people who use a wheelchair or mobility aid can see it. There is a compliments/complaints/comments book in the entrance foyer. It contained no complaints and had a variety of thank you cards and letters in it. The manager has a good understanding of service users’ rights as citizens. Whilst this was not talked about in detail the information available around the home and training sessions and letters from local authorities displayed in the office mean that the staff consider the rights of people as individuals. There are no ongoing safeguarding issues. The manager has had training, from the local authority, about safeguarding and there is clear policy detailing what Tregertha Court DS0000009233.V349800.R01.S.doc Version 5.2 Page 16 to do in the event of a situation being reported. The ‘annual quality assurance assessment’ states that safeguarding training has increased and more staff training is to be ongoing over the next 12 months. The policies and procedures are available to staff at all times. Staff have information about safeguarding during their induction period and as part of National Vocational Qualification training. Tregertha Court DS0000009233.V349800.R01.S.doc Version 5.2 Page 17 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 21, 22, 23, 24 & 26 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The lack of suitable bathrooms and the subsequent amount of moving around the home to access a suitable bathroom using stair-lifts means that people with a physical disability and therefore needing a specialised bath with a hoist may be disadvantaged. The current position of the laundry gives rise to possible risks of cross infection if staff use the kitchen as a through-fare to reach the laundry and potential health and safety risks to staff who have to move heavy bags of laundry up and down steep steps in all weather conditions. EVIDENCE: Access to the home is via steps or a ramp at the front of the home. The home was clean and tidy. The duty rota shows that there are domestic staff on duty 7 days a week, this is managed by a housekeeper and 3 domestics. Chemicals were stored appropriately when not in use. Tregertha Court DS0000009233.V349800.R01.S.doc Version 5.2 Page 18 Individual’s bedrooms (situated on the 1st and second floors) were personalised. The annual quality assurance assessment states that bedrooms are redecorated when they become vacant and often the person moving in is consulted about the colours they would like. The communal areas (3 lounges and 1 dining room all on the ground floor) were all in use throughout the day. They had a variety of seating for people to use. One had a TV and a piano, the two at the front of the house and had wide ranging views over the river that people enjoy and they are also used for activities. The manager said that the main lounge has had the conservatory renewed since the last inspection. A number of rooms at the front of the house also enjoy wide ranging views of West Looe and the river. Aids and equipment provided was in good condition and had been regularly serviced. A recommendation was made following the last inspection about the bathing facilities in the home that they should be more suited to the needs of the people who currently occupy the home and who are likely to be accommodated in the future. During a tour of the home the manager pointed out areas where the bathrooms had been improved with some new bath hoists. The annual quality assurance assessment states that although improvements have been made further upgrading is needed to meet the needs of the people living in the home and to minimise people having to go to another floor to use a bathroom. Some of the carpets in the corridors of the home are worn and in need of replacement. The manager said that new carpet is on order and will be replacing the worn areas in the near future. Access to the first and second floor where all the accommodation is situated is via a number of stair lifts on all of the staircases. The layout of the building means that individuals may need to use two or three separate stair lifts to get to their bedroom. This means that staff need to offer assistance to many people. There is the additional risk of people with confusion trying to use a staircase when they are no longer able to safely use stairs. A number of the rooms have en-suite bathrooms, with baths but the manager said that none of the people currently living at the home are able to use these independently. Not all of the rooms have locks on their doors and lockable space for personal items and money. The manager said that if a person wants to have either a lock on their door or a lockable space this can be done on an individual basis (as long as it is deemed safe following an assessment). At least one door was seen to have a lock fitted. It was recommended that the Statement of Purpose includes this information about having a lock fitted and /or lockable space provided so that people are aware of the possibility. Tregertha Court DS0000009233.V349800.R01.S.doc Version 5.2 Page 19 There is a large laundry in the basement area of the home, with washing machines that are suited to coping with the laundry from a care home. The access to the laundry is by going outside the home down a number of steep steps and is not suitable for staff who have to carry heavy bags of soiled and clean linen. There is access from inside the home via the kitchen, which cannot be used as carrying laundry through a kitchen is unacceptable. The manager needs to be sure that staff do not use this as a through-fare when she is not there. It is recommended that the provider consider alternative areas of the home that could be used as a laundry. Tregertha Court DS0000009233.V349800.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. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 & 30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The management team shows a responsible attitude and implements changes and improvements in order to improve quality and outcomes for people living in the home. The night staffing levels need to be reviewed regularly to ensure needs are being met at night as well as during the day. EVIDENCE: The duty rota showed that for 29 people there were sufficient care staff on duty during the day. They are supported by the manager, domestic, catering and laundry staff. Overnight there are 2 care staff. The night staff do not do any laundry or serve any breakfasts and only have very few medicines to dispense. The manager was asked to review night staffing levels as 2 carers for 29 people is not sufficient given the layout of the building and use of numerous stair-lifts where people need to be observed on an individual basis when using them. She was asked to think about the increasing dependency of some of the people living in Tregertha Court DS0000009233.V349800.R01.S.doc Version 5.2 Page 21 the home and review the accidents that have occurred in the home to see if they are generally overnight. The manager said that the induction process has been improved. A new member of staffs file examined had a nearly complete induction pack included in it. The annual quality assurance assessment states that retention of staff is good and the manager said there are currently no vacancies. Staff files seen were well ordered and there was a systematic approach to recruitment. The files examined had 2 written references, CRB checks and information about gaps in employment history. Obtaining 2 written references and exploring employment gaps had been made a requirement following the last inspection. Records showed that training has taken place that includes dementia care, food hygiene, fire safety (outside trainer), manual handling (in house training by the manager) and safeguarding (adult protection). All staff who administer medication have had training from Boots The Chemist. The annual quality assurance assessment states that induction has been ‘improved and more rigorously applied’, and support for people wishing to do National Vocational Qualification training is ongoing. Tregertha Court DS0000009233.V349800.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. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 & 38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The management arrangements are meeting the needs of the service, and the quality of the service is continually improving. EVIDENCE: The people living at the home have contact with the owner or their representative who visits the home regularly and asks people questions about how satisfied they are with the care and the support they are getting. The subsequent report is submitted to the Commission, once the provider has seen it, as required. Tregertha Court DS0000009233.V349800.R01.S.doc Version 5.2 Page 23 The company administrator surveys 3 people at random each month and any concerns that are raised are discussed at the monthly provider visits and appropriate actions taken if necessary. The annual quality assurance assessment states that there are clear lines of accountability and the staff have detailed job descriptions. The manager has achieved her Registered Managers Award. She has an open door policy and a number of staff approached her during the inspection with a variety of queries that she managed effectively. The home is well organised, records were generally up to date, clear and in good order. Staff knew what they were doing and there were clear systems for delegating care tasks between staff. A communication book is in use and enables staff to highlight any changes that may have taken place with the people living in the home and any other information that staff need to be made aware of. Supervision sessions and staff meetings are ongoing according to the manager and the annual quality assurance assessment. An immediate requirement was made following the last inspection about adequate fire precautions being maintained. The manager asked the local fire officer to visit and review their fire risk assessment document. Changes have been made to the risk assessment following advice and wedges are no longer used in doors. The fire log – book was completed as required. The annual quality assurance assessment contained details of recent servicing dates of equipment. Some documentation was checked to confirm this information. The manager encourages people to manage their own financial affairs if at all possible. There is clear documentation for those people for whom they manage money. Receipts are kept for auditing purposes. The laundry is accessed by going outside the building and via steep steps. Staff have to carry full laundry bags up and down these steps and there is potential for staff to trip or fall and /or for problems due to the difficulty with the manual handling of the bags. Tregertha Court DS0000009233.V349800.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 3 X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 3 2 3 3 2 X 2 STAFFING Standard No Score 27 1 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 2 Tregertha Court DS0000009233.V349800.R01.S.doc Version 5.2 Page 25 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. Standard OP27 Regulation 18 (1) a Requirement The registered person shall, having regard to the size of the care home, the statement of purpose and the number and needs of service usersEnsure that at all times suitably qualified, competent and experience persons are working at the care home in such numbers as are appropriate for the health and welfare of service users. This means that the Registered Person must review the level of staffing, particularly at night, and ensure that there are sufficient to meet the needs of the Service Users. (Carried over from the previous inspection) Timescale for action 01/03/08 Tregertha Court DS0000009233.V349800.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 OP21 Good Practice Recommendations The registered person should continue to ensure that people have sufficient and suitable bathing/ shower facilities,that are adapted to meet their needs. Doors to service users’ private accommodation should be fitted with locks suited to service users’ capabilities and accessible to staff in emergencies. Service users should be provided with keys unless their risk assessment suggests otherwise. Each service user should have lockable space for medication, money and valuables and is provided with the key which he or she can retain (unless the reason for not doing so is explained in the care plan). Service User plans should set out in detail the actions which need to be taken by care staff to ensure that all aspects of the health, personal and social care needs of the service user are met. The registered provider should ensure that the worm carpets are replaced in the near future. The registered provider should consider moving the laundry to a more accessible position or making the current one more accessible and safe for staff. The registered provider should consider how manual handling of the laundry bags, when full, can be improved. 2. OP24 3. OP24 4. OP7 5. 6. OP19 OP26 OP38 Tregertha Court DS0000009233.V349800.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Ashburton Office Unit D1 Linhay Business Park Ashburton TQ13 7UP National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Tregertha Court DS0000009233.V349800.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. 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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