Inspection on 10/08/06 for Tregolls Manor

This inspection was carried out on 10th August 2006.

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

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

Other inspections for this house

Tregolls Manor 17/01/08

Tregolls Manor 07/02/06

Tregolls Manor 02/08/05

Tregolls Manor 07/10/04

Tregolls Manor 22/04/04

Similar services:

Fairfields Country Rest Home

Poldhu

Queensmount

Trevaylor Manor

Didsbury Court Rest Home

Belma

Hunters Care Centre

Manor Lodge

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

CARE HOMES FOR OLDER PEOPLE Tregolls Manor Tregolls Road Truro Cornwall TR1 1XQ Lead Inspector Diana Penrose Unannounced Inspection 10th August 2006 10:00 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 Tregolls Manor DS0000009142.V299730.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. Tregolls Manor DS0000009142.V299730.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Tregolls Manor Address Tregolls Road Truro Cornwall TR1 1XQ 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) 01872 223330 01872 225412 tregolls.manor@btconnect.com Tregolls Manor Homes Limited Mrs Rosemary Ann Evans Care Home 25 Category(ies) of Old age, not falling within any other category registration, with number (25) of places Tregolls Manor DS0000009142.V299730.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 7th February 2006 Brief Description of the Service: Tregolls Manor is a detached property set off one of the main routes out of Truro and occupies an elevated position. There is level access to the home from the car park and there are accessible paths for ambulant residents to the rear of the building. The accommodation and facilities occupy three floors and a lift for eight persons accesses all three floors. The home is well maintained and furnished to a high decorative standard. The patio and garden areas are well maintained, sheltered and offer privacy. The home provides care and accommodation for up to twenty-five residents with low dependency needs and who are over 65 years of age. Information about the home is available in the form of a residents’ guide, which can be supplied to enquirers on request. A copy of most recent inspection report is available in the home. Fees range from £550 to £850 per week; this information was supplied to the Commission in the pre inspection questionnaire received on 24/07/06. Additional charges are made in respect of private healthcare provision, hairdressing and personal items such as newspapers, confectionary and toiletries. Tregolls Manor DS0000009142.V299730.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. An inspector visited Tregolls manor Care Home on the 10 August 2006 and spent seven hours at the home. This was a key inspection and an unannounced visit. The purpose of the inspection was to ensure that residents’ needs are properly met, in accordance with good care practices and the laws regulating care homes. The focus was on ensuring that residents’ placements in the home result in good outcomes for them. It was also to gain an update on the progress of compliance to the requirements identified in the last inspection report dated 16/03/06. All of the key standards were inspected. On the day of inspection 23 residents were living in the home, 3 of these were receiving respite care. The methods used to undertake the inspection were to meet with a number of residents, relatives, staff and the deputy manager to gain their views on the services offered by Tregolls Manor Care Home. Records, policies and procedures were examined and the inspector toured the building. Information was also received from the registered manager prior to this inspection in the form of a pre-inspection questionnaire. This report summarises the findings of this inspection. Residents and relatives expressed satisfaction with the care and services provided at the home. Overall the home is providing a good quality of care to the residents placed there. What the service does well: The home is furbished, decorated and maintained to a very high standard; it is warm, very clean and homely with no unpleasant odours. There are plenty of comfortable areas to sit and relax. The grounds are tidy, safe and attractive with sufficient seating. There is a laundry on site and residents are satisfied with the service provided. There are systems in place to reduce the risk of infection and hand-washing facilities for staff are good. Protective clothing such as gloves and aprons are used. Residents spoken with said they live as they wish and their personal preferences are respected. They said they are happy with the care provided and the staff are very kind and patient. Several residents administer their own medicines and all manage their own finances or have them managed by a representative. Residents said their privacy and dignity are respected and this was observed during the inspection. Residents have their own telephone line to their room and several have large print numbers. There are choices on the menu and plenty of outings to choose from. The home has a Mercedes limousine and a minibus to transport residents into town or on trips out. Tregolls Manor DS0000009142.V299730.R01.S.doc Version 5.2 Page 6 Each resident is assessed prior to admission and an individual care plan is then compiled. Appropriate risk assessments are included. The plans are reviewed every month and any changes recorded. Daily records are kept for each resident and they are informative. There is a suitable policy in place for the administration, storage and disposal of medicines. Each resident has a lockable cabinet in their room. There are robust recruitment procedures in place and the records were in order. Staff are competent in their roles and 75 of care staff are qualified to at least NVQ level 2 in care. Other training takes place as identified during the annual appraisals or supervision sessions. The management team endeavour to ensure that working practices are safe and every effort is made to meet the requirements and recommendations set by the Commission for Social Care Inspection and other statutory bodies. What has improved since the last inspection? What they could do better: Care plans require more detail in respect of social, religious and emotional needs. They also require more comprehensive instruction and direction to enable staff to provide the necessary care. When appropriate resident’s sleeping patterns should be recorded in their care plans. Records in respect of medicines must be improved. The amount of medicines received for those self-administering must be recorded to enable checks to be made. Any handwritten details on the medication administration records must be witnessed and signed by two people, this requirement has been notified in a previous report. There were gaps in the administration records; all medicines administered must be signed on the charts as given or a reason for their omission recorded. The moving and handling policy must be reviewed and updated to include the areas discussed at the last inspection. Tregolls Manor DS0000009142.V299730.R01.S.doc Version 5.2 Page 7 Training records should be improved with a more comprehensive matrix to ensure compliance with legislation; this may have been addressed but the deputy manager could not access the computer. A sluice with a washer disinfector should be provided for infection control purposes. 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. Tregolls Manor DS0000009142.V299730.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 Tregolls Manor DS0000009142.V299730.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 3 (6 is N/A) Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are only admitted to the home following an assessment of their needs to ensure the home can provide suitable care. EVIDENCE: Evidence was provided in the form of records, and talking with the deputy manager. Completed assessment documents were inspected and the process explained by the deputy manager. Forms inspected were detailed, completed appropriately, dated and signed. Residents said the registered manager visited them prior to admission; one was invited for Sunday lunch at the home prior to making any decision to move in. Tregolls Manor DS0000009142.V299730.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Individual care plans are generated for each service user but do not fully inform and direct the staff in their care provision. Service users have access to health care services as necessary to ensure their assessed needs are met. There are suitable systems and policies in place for dealing with service users medicines; extra vigilance in record keeping is required to ensure service users safety. Systems are in place to ensure that service users are respected and their privacy is upheld at all times. EVIDENCE: Evidence was provided in the form of documentation, records, observation, interviews with residents, staff and deputy manager. Each resident has a written care plan with risk some assessments included. The care plans require more detail to ensure that staff are fully informed and directed in the care to be provided for each individual resident. There was information held for residents in one part of the system but there were no directions for staff in the care plans on how to deal with this. The plans should state what the residents can do for themselves as well as the care to be Tregolls Manor DS0000009142.V299730.R01.S.doc Version 5.2 Page 11 provided for them. Planning for social, emotional and religious needs requires expansion. Care plans are compiled with the resident or representative, signed if possible and reviewed monthly. Care plans are accompanied by a Kardex system that holds personal details, medical history and daily records. The daily records are detailed and more informative, details of GP and District Nurse visits are now recorded and it is also recorded when residents have a bath and so on. There is a photograph of each resident on file. Residents said they are cared for very well and there is no discrimination. Doctors and other healthcare professionals visit as appropriate and records are kept. The home has suitable equipment for moving and handling and pressure relief. There is documentary evidence of equipment provided for individual residents. One resident receiving respite care said a commode had been provided and that a chair from her own home was collected for her, as Adult Social Care could not supply a suitable chair. The home has a suitable medicines policy and there is a system in place for the administration of medicines. All care staff receive training in the safe handling of medicines. Storage is safe and secure in each resident’s room or bathroom. A monitored dose system is used. The name and the amount of medicines received into the home is recorded and signed for on the medicine administration chart. The amount of medicines received must also be recorded for those self-medicating to enable random checks to be made. The transcribing of medicines or changes on the medication administration record charts is not always signed by two members of staff. All medicines administered must be signed on the charts as given or a reason for their omission recorded. There were a number of gaps on the medication administration records, which questions whether or not residents received their medicines appropriately. The carer administering medicines at lunchtime did so in a professional manner. There are suitable arrangements for ensuring that resident’s privacy and dignity are respected. Residents have their own telephone line to their room. Resident’s said their privacy was respected and this was observed during the inspection. Tregolls Manor DS0000009142.V299730.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home provides a range of activities and aims to offer a lifestyle that meets individual residents needs. Links with family, friends and the community are good and allow residents the opportunity to socialise. Residents are helped to maintain control over their lives and staff respect their individual preferences and choice. Dietary needs of residents are well catered for with a varied selection of food available that aims to meet their taste and preference. EVIDENCE: Evidence was provided in the form of documentation, records, observation, interviews with residents, relatives, and deputy manager. A monthly calendar of events is given to each resident. These are mainly trips out during the summer months. A limousine and a mini bus, suitable for the disabled, are available for outings. Other activities such as bingo and quizzes are provided in the autumn and winter, mainly on a Wednesday and organised by one of the care staff. One resident said that religious services are held in the home but she chose to be visited by the Minister from her church. Residents spoken with said there is not a lot going on in the home but they were not really interested in organised activities. There are drinks parties in the home and residents said they enjoy them. All residents spoken with said Tregolls Manor DS0000009142.V299730.R01.S.doc Version 5.2 Page 13 they could do as they please and most tended to stay in their rooms rather than go to the lounges. Residents said they choose when they get up and go to bed. They choose what clothes to wear and how they spend their day. They said they receive visitors when they wish and can receive them in private, the visitor’s book showed that several people visit the home each day. It was observed that one resident went out into the grounds with her daughter during the inspection. Residents can control their own finances and administer their own medication according to their wishes and individual risk assessment. They have their own possessions and furniture around them. There are choices on the menu and the daily routines are flexible. Meals are served in a spacious dining room that aims to provide a comfortable and social dining experience. There are white tablecloths and napkins and fresh flowers on each table. Residents can eat in their bedroom if they prefer. Resident’s nutritional needs are assessed. The cook does regular surveys to obtain the views of the residents. She said she meets with residents who make specific comments to see if arrangements can be made to improve or meet their individual needs. Meals are chosen in advance from a menu that has excellent choices including fresh vegetables each day; the sweet trolley contains a good selection of fresh fruit and several different puddings. Water, fruit juices and alcoholic beverages are served with meals. Special occasions are celebrated, including Birthdays, Valentines Day, Mothers Day, Fathers Day, Christmas and so on. Residents said the food is very good, one said that if there is something she would prefer that is not on the menu the cook will oblige. Homemade cakes are provided with afternoon tea. Each resident is provided with a fresh supply of bottled water each day, in his or her room. Tregolls Manor DS0000009142.V299730.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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home has a satisfactory complaints procedure that ensures complaints are listened to and acted upon. Arrangements are in place for the protection of residents safeguarding them from harm or abuse. EVIDENCE: Evidence was provided in the form of documentation and talking to the deputy manager. There is a suitable complaints policy in the home and a method for recording complaints, the action taken and the outcome. There have been 0 complaints to the home since the last inspection. There has been one complaint to the Commission in respect of individual resident’s care. This was found to be unsubstantiated but two recommendations were made to improve record keeping. The home has an adult protection policy that includes the reporting of all abuse incidents to the Commission for Social Care Inspection. There is a copy of the local inter agency procedures included. There is a whistle-blowing policy. Staff receive in house training on abuse with the use of a training video and abuse is included in the NVQ training for care staff. Tregolls Manor DS0000009142.V299730.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19 and 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home and grounds are well maintained providing a safe environment for residents, staff and visitors. The home is clean and free from offensive odours making it a pleasant place to live in. EVIDENCE: Evidence was provided in the form of records, observation, interviews with residents, relatives, laundry staff and deputy manager. The home is very clean, warm and comfortable. It is decorated, furnished and maintained to a high standard. There are plenty of cosy areas to sit and relax although most residents tend to stay in their bedrooms. The grounds are tidy and safe with attractive flowers and shrubs. The rear garden is accessible to residents and there are areas for walking and sitting outside. Most rooms have en-suite facilities. Some residents said they chose their room on admission to the home, one said he moved to a bigger room after he had lived in the home for a while as the other one was a bit cramped. Residents said they are happy Tregolls Manor DS0000009142.V299730.R01.S.doc Version 5.2 Page 16 with their rooms and they have their own possessions around them. Assisted bathing facilities are provided and one resident commented that the bathing facilities are excellent. There are no unpleasant odours in the home and all areas are clean. The laundry is suitable for the size of home. All laundry is undertaken in house, dry cleaning is sent out to Cornish Linen Services. The washing products used are designed to eliminate bacteria such as MRSA. There are infection control policies in place and protective clothing is in use. It is recommended that a sluice with a washer disinfector be provided Tregolls Manor DS0000009142.V299730.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Staffing levels meet the needs of residents and staff morale is good. Residents are in safe hands and benefit from the number of care staff that have achieved an NVQ qualification. Recruitment procedures are robust and offer protection to the residents. The home provides training for staff to help them be more competent in their roles; improved record keeping would be beneficial. EVIDENCE: Evidence was provided in the form of documentation, records, observation, interviews with residents, relatives, staff and deputy manager. Residents said the staff are all kind and caring and they work very hard. There are on average 3-4 care staff on duty in the mornings, 3 in the afternoons and 2 at night. The deputy manager said there will soon be 4 on duty in the mornings all of time when a new member of staff is recruited. A senior carer is on duty at all times. 75 of care staff have achieved the NVQ level 2 in care, or above, others are enrolled on the course. Three of the care staff are qualified nurses. Recruitment procedures are robust with all records and checks maintained. Staff photographs have been included in the personnel files. Tregolls Manor DS0000009142.V299730.R01.S.doc Version 5.2 Page 18 There is an induction programme in place that includes the Skills for Care criteria. Training needs are identified during the annual appraisal system and records of needs are kept on file. Statutory training takes place and there is a matrix in the statement of purpose. From the training book there is still insufficient evidence to determine that all staff have attended statutory training at the appropriate intervals. Although the deputy manager and the maintenance man said that two fire training sessions take place each year with further training provided when fire drills take place. The training records need to be improved to ascertain who has done what and to ensure there is compliance with legislation. It was recommended at the last inspection that a more comprehensive training matrix be maintained. The deputy manager said the registered manager has worked on this but he could not access the computer. Staff said they had received recent moving and handling training and all spoken with had received medication training. This was verified in the records. Tregolls Manor DS0000009142.V299730.R01.S.doc Version 5.2 Page 19 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 and 38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The Registered Manager is a person of good character and fit to run the home. The home is run in the best interest of the residents and they benefit from the Quality Assurance systems in place. There is a suitable system in the home for dealing with residents’ money with safeguards in place to protect the residents’ financial interests. Appropriate training and safety checks are undertaken to ensure the health safety and welfare of service users and staff. EVIDENCE: Evidence was provided in the form of documentation, records, observation, interviews with residents, maintenance man and deputy manager. The registered manager is a Registered Nurse who is competent and experienced to run the home. She was recovering from surgery at the time of Tregolls Manor DS0000009142.V299730.R01.S.doc Version 5.2 Page 20 this inspection and was missed by the residents. The deputy manager is very capable of running the home in her absence and has recently completed the Registered Managers’ Award. He said he keeps up to date with all statutory training. Residents said the management of the home is good and they have no problems. The home has achieved the Investors in People Award. Quality assurance questionnaires are distributed annually to service users and the views of relatives and visitors are sought. The results of the annual survey are reported in the statement of purpose, a copy must be sent to the Commission for Social Care Inspection. In general the results are positive, the deputy manager said a member of the management team discusses issues with the residents and hopefully resolves any problems. He said this would be recorded in the daily records. It is recommended that the quality assurance survey forms be dated so as to clarify when the survey took place. Staff meeting minutes show that staff can air their views and issues are addressed. The home has a policy not to hold money or valuables for residents. All residents have a lockable facility in their rooms and can be taken to the bank when they wish. Residents are encouraged to control their own money or have a relative or representative control it. The management endeavour to ensure that working practices are safe. Service and maintenance checks take place as required. The five yearly electrical wiring testing has just been completed. The moving and handling policy requires reviewing and updating to include the roles and responsibilities of the employer and employee, dealing with emergencies, the process of risk assessment and what is included in the staff training. There is a person trained in first aid on duty at all times. Staff have received food hygiene training and the cook has achieved the Intermediate Food Hygiene Certificate. Accident reporting complies with data protection and there are few accidents. Health and safety and fire risk assessments have been undertaken. Tregolls Manor DS0000009142.V299730.R01.S.doc Version 5.2 Page 21 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 4 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 3 Tregolls Manor DS0000009142.V299730.R01.S.doc Version 5.2 Page 22 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 OP7 Regulation 15 • Requirement Care plans require more detail to ensure that staff are fully informed and directed in the care to be provided for individual residents • Planning for social, emotional and religious needs requires expansion. • The amount of medicines received must be recorded on the charts for those self-medicating • Transcribing onto MAR charts must be witnessed and signed by two people • All medicines administered must be signed on the charts as given or a reason for their omission recorded. The moving and handling policy must be reviewed and updated. Re-notified. Timescale for action 05/02/07 2 OP9 13(2) 10/09/06 3 OP38 13(5) 05/02/07 Tregolls Manor DS0000009142.V299730.R01.S.doc Version 5.2 Page 23 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 OP26 OP30 Good Practice Recommendations As necessary residents sleeping patterns should be recorded in their care plans A sluice with a washer disinfector should be provided for infection control purposes Training records should be improved with a more comprehensive matrix to ensure compliance with legislation Tregolls Manor DS0000009142.V299730.R01.S.doc Version 5.2 Page 24 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 Tregolls Manor DS0000009142.V299730.R01.S.doc Version 5.2 Page 25 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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