Inspection on 09/12/05 for Tregertha Court

This inspection was carried out on 9th December 2005.

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

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

Other inspections for this house

Tregertha Court 02/11/07

Tregertha Court 23/01/07

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 Philippa Cutting Unannounced Inspection 9th December 2005 09:30 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Tregertha Court DS0000009233.V254329.R01.S.doc Version 5.0 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Tregertha Court DS0000009233.V254329.R01.S.doc Version 5.0 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 01503 262014 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.V254329.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 4. Total number of service users not to exceed 38. 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)) 21st July 2005 Date of last inspection 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 activity on the outskirts of the town. It is approached by a ramped access as well as railed steps. An older property with an interesting history, it now offers care and accommodation on three floors to older people. The upper floors are reached by stairs or stairlifts. A number of rooms are ensuite and those in the front of the home have good views. 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. Tregertha Court DS0000009233.V254329.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. An unannounced inspection was carried out between 9.30 am – 4.0 pm on Friday December 9th 2005, the last inspection having been made in July 2005. On this occasion service users & staff spoke with the inspector, the premises were inspected and there were opportunities to talk to visiting professionals (community nurses) and relatives. Their comments were positive. The registered manager was not available but senior carers and the deputy manager provided help and information. Recommendation and requirements from the last inspection have been addressed. What the service does well: What has improved since the last inspection? What they could do better: The responsible individual needs to forward his monthly reports on a more regular basis to the Commission for Social Care Inspection. Tregertha Court DS0000009233.V254329.R01.S.doc Version 5.0 Page 6 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. Tregertha Court DS0000009233.V254329.R01.S.doc Version 5.0 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.V254329.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 5 Service users felt they had had sufficient information to enable them to choose a home that suited their needs. EVIDENCE: These records were not inspected but service users told the inspector that that they had either chosen the home because it enabled them to remain in the vicinity of family and friends, or relatives had visited and felt the home was suitable for the person’s needs. A number of permanent service users had visited the home for day care prior to seeking full time accommodation & care. The registered manager (by telephone the following day) said that she visited everyone prior to offering accommodation in order to determine that the home’s services and help needed by a service user was compatible. Copies of the home’s service user’s guide were seen in rooms. Tregertha Court DS0000009233.V254329.R01.S.doc Version 5.0 Page 9 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): 7,8,10,11 The home ensures that service users receive the care they need from the staff or other agencies as needed. Problems are referred on to specialists where this is necessary. EVIDENCE: All service users have a care plan that sets out their needs and is freely available to staff. It reviewed regularly with periodic updates. The inspector queried that there appeared to be very few changes for the majority of service users. Staff said, after reflection, that they thought this was an accurate picture, as people had generally remained well. A number were being seen by the community nursing services and the community psychiatric nurse was involved with one person. Otherwise people were accessing medical services and hospital departments on an ‘as needed’ basis. Medication was not looked at in any detail on this occasion other than to check the Controlled Drugs register. Tregertha Court DS0000009233.V254329.R01.S.doc Version 5.0 Page 10 Staff were seen to interact politely and appropriately with service users who required assistance with their personal care or hygiene, being discreet in their approach. A number of letters were noted that expressed thanks from families for the care a relative had received in the last days of his/her life. Tregertha Court DS0000009233.V254329.R01.S.doc Version 5.0 Page 11 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): 12,13,14,15 Service users are provided with opportunities to maintain their previous life styles and contacts as much as they are able or wish. The home respects choices that service users make. EVIDENCE: Tregertha Court encourages the service users to retain contact with families and friends as much as possible or in accordance with the service user’s wishes. Relatives visiting the home during the inspection said they were pleased with the care their relative received and felt the staff were helpful and caring. A programme of activities planned for the coming week & Christmas period was posted on the notice board. One session of ‘Christmas Bingo’ had been cancelled due to unforeseen circumstances but staff organised another activity instead for those who wished to join in. The Bingo had been rescheduled by popular demand. Several people commented positively on a choir that had visited the previous evening. Meals are served in the dining room in two sittings although people can have their meals in their room if they prefer, as some do. People were generally Tregertha Court DS0000009233.V254329.R01.S.doc Version 5.0 Page 12 complementary about the food. The cook said that she had a good budget and used fresh food and vegetables daily. Tregertha Court DS0000009233.V254329.R01.S.doc Version 5.0 Page 13 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): 16,17,18 A procedure is in place to enable service users to complain about the service if they need to. Information regarding the protection of vulnerable adults (PoVA) is in place. EVIDENCE: The home has a complaints procedure available for service users or families but none have been received since the last inspection. The registered manager has attended a seminar on PoVA. It would be helpful for other staff, especially seniors to have an opportunity to attend similar sessions. Age Concern is approached if a service user needs advocacy assistance and has no one else to assist. Tregertha Court DS0000009233.V254329.R01.S.doc Version 5.0 Page 14 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): 19,20,21,22,23,24,25,26 Service users live in a well maintained home. There are some limitations due to the home’s layout and age but equipment has been put in place to minimise any problems and promote peoples’ independence. EVIDENCE: The premises were inspected. A concern regarding security, noted at a previous inspection, has been addressed. Redecoration is on going with rooms being painted and made ready when they are vacated. Most of the passages have been painted; the main staircase has yet to be done but the inspector was told that this is on the schedule for attention soon. Communal rooms had been decorated for Christmas and were looking festive. There are two large lounge/conservatories plus a smaller room. One conservatory has been designated as a smoking area. Few service users smoke now but those that did appreciated a place where they could do so. Tregertha Court DS0000009233.V254329.R01.S.doc Version 5.0 Page 15 The layout of the home means that there are several long passages to negotiate on the upper floors in particular. Staff are aware of which service users need more help and can offer assistance with a wheel chair if necessary. There are sufficient bathrooms and toilets, some of which are en suite. They are mainly ‘conventional’ baths and toilets that are designed for use by physical able people. Whilst bath hoists, raised seats and rails are provided, the home may wish to give consideration to altering its facilities to create a wet floor shower room and/or a toilet designed to assist people who rely more on a wheelchair? Service users’ rooms were seen to be personalised to a greater or lesser degree, depending on each person’s preference. They all have adequate heating and ventilation. It was nice to see that rooms were being aired. The laundry area is busy but the inspector was told that the machines were satisfactory and dealt with the loads required. It was not clear how anyone working in the laundry would summon help in the event of an emergency of accident occurring in the laundry. The staff member said that other staff brought laundry in fairly frequently so anyone in difficulties would be found. It would be prudent to look at this situation and include it, and any action, in the home’s health & safety policy. Tregertha Court DS0000009233.V254329.R01.S.doc Version 5.0 Page 16 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): 27,28,29,30 Staff caring for service users are all vetted before being employed. Training is encouraged. EVIDENCE: The home employs a team of staff who constitute a stable work force. References and Criminal Records Bureau checks are taken up on all staff prior to starting work. New staff are supervised during a period of induction that is recorded. The home was advised that a new induction standard has been introduce which will become mandatory in September 2006. People are encouraged to undertake National Vocational Qualifications training and other relevant training such as first aid, health & safety, basic food hygiene etc. Tregertha Court DS0000009233.V254329.R01.S.doc Version 5.0 Page 17 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): 31,32,33,34,35,36,37 The registered manager is competent and experienced. The home maintains records to safeguard the service users’ well being. EVIDENCE: The registered manager was absent on the day of the inspection, senior carers and the deputy manager being on site. Feed back from the inspection was given to the registered manager subsequently. The registered manager and her senior staff have considerable experience in caring. They seek to include the views of all staff and service users in the management of the home. The responsible individual visits regularly and there is administration support available. The responsible individual fulfils his responsibilities with regard to completing reports on his visits but neglects to forward these to the Commission for Social Care Inspection on a regular basis. Tregertha Court DS0000009233.V254329.R01.S.doc Version 5.0 Page 18 The home’s registration certificate was displayed and was correct for the current service users. The insurance certificate was however out of date. A new one had been issued to the company but had not, the inspector was told yet been passed onto the home. It was six weeks out of date. The home prefers not to involve itself in handling money for service users although they will keep cash in safekeeping. A record of any expenses incurred by or on behalf of a service user is recorded. A record of staff supervision has been established. The records required by statute are maintained. The accident records (which accord with the Data Protection Act 1998) are filled out for all accidents with any patterns of falls being noted. Fire training and testing are recorded and up to date. The home has a health & safety policy that is overseen by an outside contractor. Tregertha Court DS0000009233.V254329.R01.S.doc Version 5.0 Page 19 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X X X 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 X 10 3 11 3 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 3 18 3 3 3 3 3 3 3 3 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 3 3 3 3 3 X Tregertha Court DS0000009233.V254329.R01.S.doc Version 5.0 Page 20 Are there any outstanding requirements from the last inspection? No 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 Timescale for action 01/01/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 2. 3. Refer to Standard OP7 OP21 OP38 Good Practice Recommendations Service users, or a relative, should continue to be encouraged ton sign their care plan to demonstrate agreement with them. The registered manager should consider the merits of upgrading bathing and toilet facilities to meet the increasing needs of frailer service users. A means of summoning help to the laundry in an emergency should be considered. Tregertha Court DS0000009233.V254329.R01.S.doc Version 5.0 Page 21 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 Tregertha Court DS0000009233.V254329.R01.S.doc Version 5.0 Page 22 - 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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