CARE HOMES FOR OLDER PEOPLE
Tregolls Manor Tregolls Road Truro Cornwall TR1 1XQ Lead Inspector
Diana Penrose Announced 02 August 2005 09:30 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 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 D52-D04 S9142 Tregolls V234018 020805 Stage 0.doc Version 1.40 Page 3 SERVICE INFORMATION
Name of service Tregolls Manor Address Tregolls Road Truro Cornwall TR1 1XQ 01872 223330 01872 225412 Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Tregolls Manor Homes Limited Mrs Rosemary Evans Care Home 25 Category(ies) of Old age, not falling within any other category registration, with number (25) of places Tregolls Manor D52-D04 S9142 Tregolls V234018 020805 Stage 0.doc Version 1.40 Page 4 SERVICE INFORMATION
Conditions of registration: none Date of last inspection 07/10/04 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 Service Users.The accommodation and facilities occupy three floors within the building 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 aims to provide care and accommodation for up to twenty-five service users with low dependency needs and who are over 65 years of age. Tregolls Manor D52-D04 S9142 Tregolls V234018 020805 Stage 0.doc Version 1.40 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. The inspector visited Tregolls Manor Care Home on the 02 August 2005 and spent six and three quarter hours at the home. This was an announced visit. The purpose of the inspection was to gain an update on the progress of compliance to the requirements that were identified in the last inspection report dated 07.10.04. In addition the inspector focused on the following key areas of care: assessment and care planning, health care, medications, leisure, complaints, some of the environment, recruitment and health and safety. On the day of inspection 22 service users were resident in the home. The methods used to undertake the inspection were to meet with a number of residents, staff, the registered manager and registered provider to gain their views on the services that Tregolls Manor offer. Tregolls Manor records, policies and procedures were examined and the inspector toured the building. This report summarises the findings of this inspection. What the service does well:
The home makes every effort to meet the requirements and recommendations set by the Commission for Social Care Inspection. The Registered Manager visits prospective service users whenever possible prior to admission. She undertakes an assessment to make sure the home can meet the needs of the person before making any decision to admit them to the home. She gets as much information as possible and contacts the family, GP and Nurses as necessary. The assessment is recorded and used to produce a written plan of the care to be given to the service user. The care plan is detailed to ensure staff know what is required to meet the persons needs and assessments are included to reduce any risks. Service users said they are involved with the care planning process. The plans are reviewed every month and any changes recorded. Daily records are kept for each service user and they are informative. Service users spoken with said their health needs are met and they have access to their GP or other health professionals when required. There is equipment in the home for assisting with the moving and handling of service users. There is also equipment to help prevent pressure sores developing, for example special mattresses and cushions. Staff are trained to use any equipment provided. There is a medicines policy and reference books for staff to refer to. Where appropriate service users administer their own medicines otherwise they are administered by the care staff. The care staff have received appropriate medicines training. Storage is secure within the service users room or bathroom.
Tregolls Manor D52-D04 S9142 Tregolls V234018 020805 Stage 0.doc Version 1.40 Page 6 A range of activities are provided according to the wishes of the service users. A monthly calendar of events is given to each service users so they know what is going on. Outings are provided and there is a limousine and a mini bus provided for this purpose. The mini bus is fitted with equipment for any disabled service users. Outings include visits to Trevarno Gardens, The Shire Horse Centre and the Screech Owl Centre. Service users spoke about their trip to the Isles of Scilly last year. There is a record of visitors to the home. Service users said they could receive visitors in private and at any time and could go out whenever they liked. They can entertain their visitors in the home and socialising is encouraged. Each room has a private telephone line. Community groups come into the home, for example Truro Choir and the Cathedral Church Choir. All service users spoken with said they are free to live their lives as they wish. They can control their own finances and administer their own medication for example. They have their own possessions and furniture around them. There are choices on the menu and the daily routines are flexible. The food provided is to an excellent standard and very well presented. The dining room is spacious and light with linen tablecloths and napkins. Service users said it is like a five star hotel. There is a complaints procedure that is included in the statement of purpose. There have been very few complaints. 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 plenty of seating. There is a laundry on site and service users were generally happy with the service provided. There is a policy and procedures in place to reduce the risk of infection. Hand-washing facilities for staff are good and gloves and aprons are used. There are suitable staffing levels in the home and a good skills mix. Staff are pleasant, courteous and caring, service users said this is always the case. Service users said the staff work hard and some have been at the home for a long time. The home has a recruitment policy and prospective employees are interviewed prior to employment. 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 also sought. A report is compiled and improvement action taken if needed. The management of the home try to make sure that working practices are safe. Staff have regular training and equipment service checks are undertaken and up to date. Accidents are reported as they should be and audited by the Registered Manager to try and prevent future occurrences. What has improved since the last inspection?
Four bedrooms have been re-decorated since the last inspection. New garden furniture has been purchased and the railings around the garden are being painted.
Tregolls Manor D52-D04 S9142 Tregolls V234018 020805 Stage 0.doc Version 1.40 Page 7 Care staff are offered regular formal supervision and are free to talk to the Registered Manager at any time. Annual appraisals are undertaken and recorded. A full survey of the water system in the home has been undertaken and regular monitoring takes place for the prevention of legionella. There has also been an asbestos survey undertaken which was satisfactory. Individual staff training units have been signed by the Registered Manager rather than ticked, to identify who has checked the unit. The quality assurance questionnaires now incorporate the views of relatives and visitors. The results of the survey have been published in the statement of purpose and a copy has been given to the Commission for Social Care Inspection. What they could do better:
There must be a photograph of each service user on file to comply with legislation. There is a medicines policy, which must be reviewed and updated to reflect current working practices. The number of medicines received into the home must be recorded on the medication administration record chart. Any medicines or changes handwritten on the charts must be signed by the person writing it and by a witness. To improve infection control a sluice with a washer disinfector should be provided for the disinfecting of commode pots and urinals. The recruitment policy must be updated and include the recruitment procedure. All new employees must have two references on file prior to starting work in the home. The CRB for all prospective employees must be applied for prior to starting work and the POVA check must be obtained before work can commence. Staff must work under supervision until a satisfactory CRB check has been received. Gaps in employment must be discussed and records of interviews kept. It is recommended that a photograph of each employee be maintained. A copy of any qualification certificates must be held on file. Please contact the provider for advice of actions taken in response to this
Tregolls Manor D52-D04 S9142 Tregolls V234018 020805 Stage 0.doc Version 1.40 Page 8 inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Tregolls Manor D52-D04 S9142 Tregolls V234018 020805 Stage 0.doc Version 1.40 Page 9 DETAILS OF INSPECTOR FINDINGS CONTENTS
Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Standards Statutory Requirements Identified During the Inspection Tregolls Manor D52-D04 S9142 Tregolls V234018 020805 Stage 0.doc Version 1.40 Page 10 Choice of Home
The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 3 Service users are only admitted to the home following an assessment of their needs to ensure the home can provide adequate care. EVIDENCE: The Registered Manager visits prospective service users whenever possible. She explained the procedure for the initial assessment of prospective service users and completed assessment documents were inspected. Information from hospital staff is obtained if appropriate. An individual plan of care is compiled from the initial assessment. Tregolls Manor D52-D04 S9142 Tregolls V234018 020805 Stage 0.doc Version 1.40 Page 11 Health and Personal Care
The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 7,8 and 9 Individual care plans are generated for each resident that 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; some extra vigilance in record keeping will help to ensure service users safety. EVIDENCE: Each service user has a written care plan, which is reviewed monthly. Risk assessments are included. The care plans are compiled with the service user or representative and generally signed. Daily records are maintained and informative. There must be a photograph of each service user on file. Service users spoken with said their health needs were met and they had access to their GP or other health professionals when required. Pressure relieving equipment and equipment for moving and handling is provided. Staff receive training in the use of any equipment provided. There is a medicines policy, which must be reviewed and updated. There is a system in place for the administration of medicines. Storage is safe and secure in each service users room or bathroom. A monitored dose system is used. The number of all medicines received into the home must be recorded and signed for on the medicine administration chart. The transcribing of medicines or
Tregolls Manor D52-D04 S9142 Tregolls V234018 020805 Stage 0.doc Version 1.40 Page 12 changes on the medication administration record charts must be signed by two members of staff. Tregolls Manor D52-D04 S9142 Tregolls V234018 020805 Stage 0.doc Version 1.40 Page 13 Daily Life and Social Activities
The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12, 13, 14 and 15 The home provides a range of activities and aims to offer a lifestyle that meets individual service users needs. Links with family, friends and the community are good and allows service users the opportunity to socialise. Service users are helped to maintain control over their lives and staff respect their individual preferences and choice. Dietary needs of service users are well catered for with a varied selection of food available that meets their taste and preference. EVIDENCE: Activities and outings are provided according to the service users wishes. A monthly calendar of events is given to each service user. There are film shows, bingo, quizzes and Holy Communion. A limousine and a mini bus, suitable for the disabled, are available to service users. Trips out include Trevarno, The shire Horse Centre and the Screech Owl Centre. Service users spoke about their trip to the Isles of Scilly last year. There is a record of visitors to the home. Service users said they could receive visitors in private and at any time and could go out whenever they liked. Each room has a private telephone line. Community groups come into the home, for example Truro Choir and the Cathedral Church Choir. All service users spoken with said they are free to live their lives as they wish. They can control their own finances and administer their own medication for example. They have their own possessions and furniture around them. There are choices on the menu and the daily routines are flexible.
Tregolls Manor D52-D04 S9142 Tregolls V234018 020805 Stage 0.doc Version 1.40 Page 14 Food is chosen in advance from a menu that has excellent choices, the sweet trolley contains a good selection of fresh fruit and several different puddings. The meal sampled was delicious and presented to a high standard. Special occasions are celebrated, birthday cakes are provided. The dining room is spacious and light. Service users were more than happy with the food provided. Tregolls Manor D52-D04 S9142 Tregolls V234018 020805 Stage 0.doc Version 1.40 Page 15 Complaints and Protection
The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 16 The home has a satisfactory complaints procedure that ensures complaints are listened to and acted upon. EVIDENCE: There is a suitable complaints policy in the home and a system for recording complaints and the outcomes. One complaint has been reported anonymously to the CSCI since the last inspection and was not upheld. Tregolls Manor D52-D04 S9142 Tregolls V234018 020805 Stage 0.doc Version 1.40 Page 16 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 standard(s) 19 and 26 The home and grounds are very well maintained providing a safe environment for residents, staff and visitors. The home is very clean and free from unpleasant odours making it a pleasant place for service users to live in. EVIDENCE: The home is very clean, warm and homely. It is decorated, furbished and maintained to a high standard. There are plenty of comfortable areas to sit and relax. The grounds are tidy, safe and attractive with flowers and shrubs. There are ample areas for walking and sitting outside. There were no unpleasant odours in the home. The laundry was suitable for the size of the home. The laundry worker had undertaken several training sessions. All laundry was undertaken in house, dry cleaning was sent out to Cornish Linen Services. There were infection control policies in place and protective clothing was in use. It is recommended that a sluice with a washer disinfector be provided. Tregolls Manor D52-D04 S9142 Tregolls V234018 020805 Stage 0.doc Version 1.40 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27 and 29 The number of staff available is sufficient to meet the needs of the service users. Recruitment procedures are not robust enough to offer maximum protection to the service users EVIDENCE: Staffing is organised in accordance with the department of health’s residential forum calculations and is dependency lead. Staff were courteous and friendly, they interacted well with service users. Service users said the staff are kind and considerate and they work very hard. In general service users felt there were sufficient staff. The home operates an equal opportunities policy. The recruitment policy needs to be updated and include the recruitment procedure. Personnel files were inspected and not all employees had references on file prior to starting work in the home. The CRB for all prospective employees must be applied for prior to starting work and the POVA check must be obtained before work can commence. Staff must work under supervision until a satisfactory CRB check has been received. Gaps in employment must be discussed and records of interviews kept. It is recommended that a photograph of each employee be maintained. A copy of any qualification certificates must be held on file. Tregolls Manor D52-D04 S9142 Tregolls V234018 020805 Stage 0.doc Version 1.40 Page 18 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 33 and 38 The home is run in the best interest of the residents and they benefit from the Quality Assurance systems in place. Appropriate training and safety checks are undertaken to ensure the health safety and welfare of service users and staff. EVIDENCE: 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 is sent to the Commission for Social Care Inspection. There is an annual development plan for the home. Residents meetings have been tried but unsuccessful, service users said they did not need meetings. The management endeavour to ensure that working practices are safe. Relevant service checks take place as required. Staff receive statutory training regularly. There is a person trained in first aid on duty at all times. The kitchen staff have all received food hygiene training. Accident reporting complies with
Tregolls Manor D52-D04 S9142 Tregolls V234018 020805 Stage 0.doc Version 1.40 Page 19 data protection and the Registered Manager audits all accidents in the home. Health and safety risk assessments have been undertaken. Tregolls Manor D52-D04 S9142 Tregolls V234018 020805 Stage 0.doc Version 1.40 Page 20 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score x x 3 x x x HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 10 x 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 4
COMPLAINTS AND PROTECTION 3 x x x x x x 3 STAFFING Standard No Score 27 3 28 2 29 x 30 x MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x x x x 3 x x x x 3 Tregolls Manor D52-D04 S9142 Tregolls V234018 020805 Stage 0.doc Version 1.40 Page 21 no Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. 2. 3. Standard 37 9 9 Regulation 17(1) a Sch 3 (2) 13(2) 13(2) Requirement There must be a photograph of each service user on file The medicines policy must be reviewed and updated The number of all medicines received into the home must be recorded and signed for on the medicine administration chart. The transcribing onto the medication administration record charts must be signed by two members of staff. The recruitment policy must be updated to include the procedure used All new employees must have two references on file prior to starting work in the home The CRB for all prospective employees must be applied for prior to starting work and the POVA check must be obtained before work can commence. Staff must work under supervision until a satisfactory CRB check has been received Gaps in employment must be discussed and a written explanation kept There must be documentary evidence of any staff Timescale for action 03/10/05 09/01/06 02/08/05 4. 5. 6. 29 29 29 12(1) 13(4) Sch 2.3Sch 4 .6(c ) 19 09/01/06 02/08/05 02/08/05 7. 8. 29 29 Sch 2 (6) Sch 2 (5) 02/08/05 03/10/05
Page 22 Tregolls Manor D52-D04 S9142 Tregolls V234018 020805 Stage 0.doc Version 1.40 qualification certificates on file. 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 26 29 Good Practice Recommendations A sluice with a washer disinfector should be provided for infection control purposes A photograph of each employee should be maintained in their file Tregolls Manor D52-D04 S9142 Tregolls V234018 020805 Stage 0.doc Version 1.40 Page 23 Commission for Social Care Inspection 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 D52-D04 S9142 Tregolls V234018 020805 Stage 0.doc Version 1.40 Page 24 - 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. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!
