Inspection on 23/01/07 for Tregertha Court

This inspection was carried out on 23rd January 2007.

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

Tregertha Court 02/11/07

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 Helen Tworkowski Key Unannounced Inspection 23rd January 2007 9:30 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 Tregertha Court DS0000009233.V317516.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.V317516.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 Lorna Catherine Elizabeth Jee 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.V317516.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 9th December 2005 Brief Description of the Service: Tregertha Court is part of the Aldington 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 ensuite 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 stairlifts. There are two communal sitting areas at the front of the home that include large conservatories. There is seating outside the front door, for use in good weather and a newer small garden at the side of the home. Limited car parking available. The current scale of charges are from £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 Service User has a copy of the Service User Guide in their bedroom. Tregertha Court DS0000009233.V317516.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was a key inspection, covering all of the main areas of the service provided at Tregertha Court. The Inspection included two site visits, the first was unannounced on 23rd January 07 (9.30 am - 5.00pm), the second on the 24th January 07 (9.15 am – 3.00 pm). As part of these visits the inspector looked around the building, looked at records relating to the care provided, the staff, and in relation to health and safety. The inspector looked at the care of four individuals, and spoke with them. The inspector also spoke with the Manager, Lorna Jee, (who was present in the home throughout much of the inspection), to five of the staff, observed medication being administered and ate lunch with service users. The inspector also sent out ten surveys to service users, nine were returned; 16 surveys were sent to care staff, nine were returned. Two surveys were received from Social Services Care Managers and two surveys were returned from GPs. In addition the Inspector spoke with the District Nurse who was visiting. The Registered Manager completed a pre-inspection questionnaire. What the service does well: What has improved since the last inspection? What they could do better: Reports on the running of the home made each month must be forwarded to the Commission, this was required at the last inspection and has not been met. Tregertha Court DS0000009233.V317516.R01.S.doc Version 5.2 Page 6 Fire doors were found to be wedged open during this inspection; an immediate requirement was made for this practice to cease. Wedging fire doors open could place Service Users at risk is there should be a fire in the home. Recruitment practices are not as robust as they should be, not all necessary checks are made to ensure that individual are suited to the work before they are employed. Staffing levels, particularly at night are low, and could lead to Service User needs not being met or not met as quickly as they should be. Service User assessments are not always completed before new people move to Tregertha Court. This means that needs may not be met or may not be met consistently. Not all of the bathrooms at Tregertha Court have hoists; this means that Service users sometimes have to go to a different floor before they can use a bath. Service Users should be provided with suitable locks to their rooms and lockable facilities in their rooms for valuables. Also, Service User’s money, held on their behalf by Tregertha Court, should not be pooled and proper accounts should be kept. Service User Plans, documents that should detail the care to be provided, need to contain more detail so that they specify the actions staff are to take to meet each persons needs. This is to ensure a consistent service. 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.V317516.R01.S.doc Version 5.2 Page 7 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.V317516.R01.S.doc Version 5.2 Page 8 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 and 3. Standard 6 is not applicable. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Service Users are provided with clear information about what they can expect from the home. Service User pre-admission assessments lack sufficient detail that will ensure that a consistent service will be provided. EVIDENCE: Tregertha Court has a Statement of Purpose and Service Users Guide that provide information about the home. During this visit copies of the Service User Guide were seen in individual bedrooms. The manager, Lorna Jee, confirmed that each person was given a copy to keep in their room. Six of the service users responding to the survey felt that they had had enough information about the home before moving, whilst two felt they did not. Before a person moves to a care home an assessment must be made to find out about what a prospective service users needs are. This helps ensures that when they move that their needs will be known and met from the time they move. The Manager said that she completed the assessments, but had not Tregertha Court DS0000009233.V317516.R01.S.doc Version 5.2 Page 9 always made a written record. The records of three people who had recently moved to the home were looked at. One person had no written information, the assessment records for the other two people contained very limited information about needs. Some of the people who move to Tregertha have dementia. This means they may not be able to explain about what they need, or how they would like things done. The process of assessment is part of the way staff get to know a person, what they need help with and what is important to them. Tregertha Court DS0000009233.V317516.R01.S.doc Version 5.2 Page 10 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. There is a good system in place to manage medication so that Service Users can be assured they will get the right medication at the right time. The Service Users Plans lack detail and sufficient information to provide a consistent service. EVIDENCE: Five of the people responding to the Service User survey said that they always received the support and care needed, whilst four people said that this was usually the case. The details about what care is to be provided should be recorded in a document known as a Service Users Plan. This document should contain detailed information about the person’s needs and describe in detail how these are to be met. This is particularly important for people with dementia who may not be able to express their needs and preferences. A system called a “Cardex” is used at Tregertha. The information provided is very limited, for example general statements are made “all care to be provided”, rather than what specifically a person needs help with and what they might be able to manage on their own. All four of the files looked at Tregertha Court DS0000009233.V317516.R01.S.doc Version 5.2 Page 11 lacked any detailed information. One person had a sensory impairment, and there was no information about how long they had had this disability or how it affected their ability to cope with day to day life. There was virtually no information about how people had spent their lives or what was important to them. This is very important in providing care for people who have dementia. Service Users plans and risk assessments (documents that identify how risks are to be managed) had all been reviewed each month, staff spoken with confirmed that they had read them. The District Nurse who was visiting Tregertha Court during the inspection said that they were happy with the care provided, and they were called when needed and staff carried out the care that was needed. The two GPs who responded to a survey confirmed that were satisfied with the overall care provided to service users within the home. Staff were observed during this inspection, and they spoke to Service Users in an appropriate manner, and treated Service Users with respect and dignity. All nine of the people responding to the service user survey said that staff listened and acted upon what was said. The home uses a monitored dose system for medication; this is prepared in bubble packs by the pharmacist. The Inspector was shown how the system works by one of the senior care staff. There were good records of administration and staff were careful to ensure that each person got the correct medication. Tregertha Court DS0000009233.V317516.R01.S.doc Version 5.2 Page 12 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. Service Users are provided with well cooked and presented meals. Service Users are offered an interesting range of activities that are adapted to suit different peoples’ needs. EVIDENCE: Four of the Service Users responding to survey said that they always enjoyed the meals, four said they usually enjoyed them, whilst one person said they sometimes did. Tregertha employs a cook and kitchen assistants to prepare the meals. Service users are given the choice of eating in their rooms or in the dining room. There are two sittings for meals- though there seemed to be some overlap. The menu is traditional and this seemed to be enjoyed by the service users, on the first day of the inspection the meal was roast lamb, on the second day it was chicken and mushroom pie. Both meals were well cooked and looked appetizing. Care staff told the Inspector that fresh vegetables are used, and it was noted that fresh fruit was provided for Service Users to help themselves. Alternative options are provided where individuals do not like particular meals or have dietary needs. The inspector discussed with the manager having a choice as part of the main menu. Tregertha Court DS0000009233.V317516.R01.S.doc Version 5.2 Page 13 The home employs an activity co-ordinator who works three days a week. The inspector spoke with the co-ordinator who was enthusiastic about involving people of all abilities in a range of activities. Care staff were also involved in carrying out activities on the days when the co-ordinator was not present. These activities seemed to be being enjoyed by those taking part. Service users spoken to were clear that they could make choices about what happened. Service users are able to manage their own money or to have it held by staff at Tregertha on their behalf. Tregertha Court DS0000009233.V317516.R01.S.doc Version 5.2 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. 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. Service users feel able to raise concerns about what happens at Tregertha Court. There are good systems in place to ensure that Service Users are protected from abuse, and are able to raise concerns. EVIDENCE: The complaints procedure is part of the Service User guide; a copy of the guide is in each person’s room. All nine of the people answering the survey said that always or usually knew who to speak to if they were not happy. The Manager confirmed that they had received no complaints since the last inspection, neither has the Commission. The Registered Manager said that she had recently received training to enable her to train the staff in relation to the Protection of Vulnerable Adults, and this was documented in her records. The manger had a training pack, and confirmed that she was planning the training. When the Inspector spoke to staff, they were clear about what to do if they saw something that they were concerned about. Seven of the nine staff responding to the survey said that they were aware of child and adult protection procedures. Tregertha Court DS0000009233.V317516.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 22, 23, 24, 25, 26 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Tregertha Court provides clean and comfortable accommodation. There is a lack of bathing facilities suited to the needs of people with a physical disability. EVIDENCE: The lounge and dining accommodation at Tregertha is on the ground floor, the majority of the bedrooms are on the first and second floor. The lounge and dining rooms are comfortable and spacious. All of the staircases have stair lifts. 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 will need to offer assistance to many of the service users. It also poses an additional risk to people who may through confusion try to use a staircase when they are no longer able to safely use stairs. (see staffing). A number of the rooms have ensuite bathrooms, with baths. However the Manager confirmed that few of the service users are now Tregertha Court DS0000009233.V317516.R01.S.doc Version 5.2 Page 16 able to use these baths as they need a hoist to get in the bath. There are three bathrooms in the home that currently have a hoist, this is for the use of over thirty people. Some people need to go to a different floor to be able to use a bath with a hoist. The manager said that they hope to have a further hoist in operation in the near future, however some service users may still need to go to a different floor to be able to use a bath. The bathing facilities in the home should be reviewed, so that the facilities are suited to the needs of the service users who currently occupy the home and who are likely to be accommodated in the future. The rooms at the front of Tregertha Court have views over the river estuary and West Looe. This aspect of the accommodation was clearly valued by some of the Service Users spoken with. Some of the rooms had bars across the windows to protect Service Users from falling out, however these did restrict the view in some cases. The Inspector recommends that the Manager discuss with Environmental Health the most appropriate way to ensure that Service Users are protected from inadvertently falling, but also are able to enjoy the beautiful view. The bedrooms were all of different shapes and sizes; many individuals had chosen to bring items of their own furniture into the home. Some individuals had very tidy rooms, other people had chosen a more cluttered way of living. People at Tregertha Court did not appear to feel constrained to conform to any particular standard imposed by staff. Only one of the bedrooms had a door lock, the manager said that locks would be fitted if any one wanted one. It was noted during the Inspection that at least one person was in hospital and it was not possible to lock her room whilst she was away, and that people did stay at Tregertha for respite. Some of the people at Tregertha Court do have dementia and in some situation people can become confused and wander into other people’s rooms. Service Users should be provided with suitable door locks on their bedrooms. It should be possible to lock the door from the inside (without the use of a key), and to lock it from the outside with a key. Staff must be able to over ride the lock in an emergency if necessary. Locks are also available that are suited to people who may be confused. These locks are released on the inside when the handle is depressed. None of the rooms had any lockable facility for money, valuables or for medication (if Service Users should choose to self medicate). Lockable facilities should be provided in all rooms. 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. Separate laundry and cleaning staff are employed. At this unannounced Inspection the house was clean and in good order. The Inspector discussed with the Manager one area where there was a particular difficulty with odour, but in general the home was fresh and clean. All nine of the people responding to the survey said that the home was always or usually fresh and clean. Tregertha Court DS0000009233.V317516.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Care Staff are well trained and competent. Staffing levels at night are very low. There are structured recruitment procedures however these are not robust potentially placing Service Users at risk. EVIDENCE: Nine people responded to the Service User survey regarding whether staff are available when needed. Seven people said that they were usually available when needed; two people said that they were always available when needed. Tregertha Court is registered to admit three people with dementia, however the Manager confirmed that some of the people who have lived at the home for some time had developed dementia or a degree of confusion. In addition the home provides day care for up to four people each day. All of this has an affect on the number of staff needed to provide support. The sample rotas provided as part of the Pre Inspection Questionnaire show that the during the week there five care staff on during the day time and evening, plus the manager or deputy and domestic, laundry and kitchen staff. From 8 pm there were two waking night staff plus the deputy manager until 10pm. From 10pm there were two waking night staff. At weekends there are fewer domestic staff and there are only two waking night staff plus a domestic between 8 pm and 10pm. From 10pm till 8am there are just the two waking night staff. The Inspector discussed the fact that waking night staff currently Tregertha Court DS0000009233.V317516.R01.S.doc Version 5.2 Page 18 can take a break (for up to an hour) in the staff room which is in the basement accessed by an external stair case and garage. There is no way that one member of staff can contact another without going outside the building. Tregertha Court is a large building with many corridors. Night staff need to be able to contact each other in an emergency. Also this level of staffing is very low given the numbers of service users, their needs, and the layout of the building. The registered provider is required to review the level of staffing at night and to ensure that an appropriate level is provided. The Inspector spoke with the Manager about the level of staffing at night and she confirmed that at times the staffing at night was considered to be low. Each person recruited to work in a care home must go through a process that ensures that they are suitable to work with vulnerable people, this includes making checks from previous employers and of any criminal records. The inspector looked at the files of four people who had been recruited since the last inspection. The files were well ordered and there was a systematic approach to recruitment. Each prospective employee had an application form, however these did not contain a comprehensive work history, with all gaps clarified. This is required by regulation. There were references on file, and verbal references had been taken for some people prior to starting work, however written references had not been received before employment. Also sometimes it was not clear how the references related to the person’s employment history, sometimes the references were not the most appropriate, and for some people they had not been received until long after they had started work. References are one of the ways that employers ensure that an applicant is suited to the work. Regulations require that two written references are taken prior to employment. There were reference numbers relating to Criminal Records Bureau checks on the file, the Inspector was told that the actual documents were held at another office. It was not possible to ascertain if these checks had been initiated prior to the individual starting work. It was also not possible to see if a further check called at Protection of Vulnerable Adults check had been made. The Commission can in certain instances allow for checks to be held in an office other than at the Care Home, guidance available on this has not been followed. This Guidance is available on the Commissions website. The Inspector was told that all care staff are inducted into work at the home, though no actual completed induction was available for inspection. There were dates on records to show that new staff had received training in relation to Fire Safety, moving and handling and other aspects of the work. The Manager said that staff other than care staff, e.g. domestic staff and activities co-ordinators did not receive a formal induction. The Inspector discussed the need for all staff to receive an induction appropriate to their role in the home. There are staff training records that show that staff have received training including in relation to dementia care. The Pre- Inspection Questionnaire states Tregertha Court DS0000009233.V317516.R01.S.doc Version 5.2 Page 19 that that 40 of staff have NVQ (National Vocational Qualification) 2 in Care or above, and three further staff were awaiting confirmation of their NVQ level 2, meaning that over 50 of staff have this Vocational Qualification. Six of the staff responding to the staff survey stated that they were not asked to care for people outside their area of expertise; two said they were. One care worker commented on the survey that staff were not given enough support when it came to working with violent or abusive Service Users. This was discussed with the manager and it was not considered that there were violent or abusive Service Users at the home. One other worker commented that it was “ a warm, welcoming, caring and friendly place to work”. Tregertha Court DS0000009233.V317516.R01.S.doc Version 5.2 Page 20 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 adequate. This judgement has been made using available evidence including a visit to this service. Tregertha Court is generally well managed, however aspects of fire safety are poor and could place service users at risk. EVIDENCE: The Registered Manager, Lorna Jee, confirmed that she had completed her Registered Managers Award, and that she was in the process of awaiting for it to be confirmed. 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. The Inspector discussed with the Manager systems such as a communication book that might alert staff to issues, and to highlight care plans that have changed and that they need to read. All such communications are currently verbal. Tregertha Court DS0000009233.V317516.R01.S.doc Version 5.2 Page 21 On a set day each month a representative from the company visits Tregertha Court, to check on the running of the home. By regulation these visits should be unannounced and a copy of the reports should be sent to the Commission, no copies have been received. Records of these visits were seen, they include interviews with two or three service users each month. It was not clear how or if comments made by service users were acted on. Some monies are kept by Tregertha Court on behalf of Service Users. Records are kept of these transactions, though it was not possible to check these records against receipts. It is recommended that the system for the management of receipts is changed so that is possible to audit the system at any time. It was also noted that at times some service users had gone “overdrawn”, and this in effect meant that they were borrowing money from other service users. Service Users money must not be loaned to other Service Users. It was also confirmed that some Service Users had arranged for their pension to be paid into a bank account relating to the running of the business, as they had no account of their own. The element of the pension that was rent was kept by the business, and the element of the pension that was “personal allowance” was then paid to the service user in cash. It was confirmed that this arrangement only existed for a few Service Users who had lived at Tregertha Court for many years, and no arrangements were ever entered into for new Service Users. It is against regulation for any monies belonging to Service Users to be paid into a bank account related to the running of the business, however it was agreed this arrangement could continue, if the service users were happy and able to consent to it. No such arrangement must be made with any future Service Users. The risk assessments for the environment are carried out by a company that visits once per year. This company produces a very comprehensive and through document that identifies all the outstanding issues and checks that have to be made. Ms Jee said that all the requirements and recommendations are carried out but the evidence was in different files. The Inspector discussed with Ms Jee how she might more easily demonstrate and cross reference the action plan, so no issues were missed. During the tour of the building it was noted that many of the Service Users bedroom doors were wedged open with wooden door wedges that were specifically for that purpose. The door to the kitchen was also wedged open. These doors are fire doors and must not be wedged open. There are a number of devices available that may be suitable to be used to safely hold open doors. An immediate requirement was made that the practice of wedging fire doors must cease. The advice of the Fire Brigade should be sought. The inspector also discussed with the Manager the use of disposable gloves that were being worn by care staff when they did not need to use them. Tregertha Court DS0000009233.V317516.R01.S.doc Version 5.2 Page 22 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 1 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 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 3 3 2 2 3 2 3 3 STAFFING Standard No Score 27 1 28 3 29 1 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 2 X 2 X X 1 Tregertha Court DS0000009233.V317516.R01.S.doc Version 5.2 Page 23 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 OP37 Regulation 26 Requirement The responsible individual’s monthly visit reports must be forwarded to the Commission for Social Care Inspection on a frequent & regular basis. (This requirement was made at the last inspection and has not been met). Immediate Requirement: The registered person shall after consultation with the fire authority take adequate precautions against the risk of fire, including the provision of suitable fire equipment. This means fire doors must not be wedged open. The registered person shall not provide accommodation to a service user at the care home unless, so far as it shall have been practicable to do soa) needs of the service user have been assessed by a suitably qualified or suitable trained person; b) the registered person has obtained a copy of the assessment. DS0000009233.V317516.R01.S.doc Timescale for action 01/03/07 2. OP38 23 (4) a 30/01/07 3. OP3 14(1)a,b 01/03/07 Tregertha Court Version 5.2 Page 24 4. OP29 19 (1) b The register person shall not employ a person to work at the care home unlessb) subject to paragraphs (6), (8) and (9), he has obtained in respect of that person the information and documents specified in paragraphs 1 to 9 of Schedule 2. This means that the registered person must ensure, before employment, they have obtained a full employment history, have two written references and obtained a Protection of Vulnerable Check (POVA First). The registered person shall, having regard to the size of the care home, the statement of purpose and the number and needs of service usersa) ensure 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. 01/03/07 5. OP27 18 (1) a 01/03/07 Tregertha Court DS0000009233.V317516.R01.S.doc Version 5.2 Page 25 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. Refer to Standard OP21 OP24 Good Practice Recommendations The registered person should ensure that 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. Where the money of individual service users is handled, the manager ensures that the personal allowances of these service users are not pooled and appropriate records and receipts are collected. 3. OP24 4. OP7 5. OP35 Tregertha Court DS0000009233.V317516.R01.S.doc Version 5.2 Page 26 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.V317516.R01.S.doc Version 5.2 Page 27 - 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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