CARE HOMES FOR OLDER PEOPLE
Tregolls Manor Tregolls Road Truro Cornwall TR1 1XQ Lead Inspector
Diana Penrose Unannounced Inspection 7th February 2006 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 Tregolls Manor DS0000009142.V281979.R01.S.doc Version 5.1 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.V281979.R01.S.doc Version 5.1 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.V281979.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION
Conditions of registration: Date of last inspection 2nd August 2005 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.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 personal care and accommodation for up to twenty-five residents with low dependency needs and who are over 65 years of age. Tregolls Manor DS0000009142.V281979.R01.S.doc Version 5.1 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. The inspector visited Tregolls Manor Care Home on the 07 February 2006 and spent six hours at the home. This was an unannounced visit. The purpose of the inspection was to gain an update on the progress of compliance to requirements identified in the last inspection report dated 02.08.05. In addition the inspector focused on the following key areas of care: choice of home, care planning, medication, leisure, adult protection, some of the environment, training and Health and Safety. On the day of inspection 18 residents were accommodated in the home, 1 of whom was receiving respite care. The methods used to undertake the inspection were to meet with a number of residents, staff and the registered manager to gain their views on the services offered by 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 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 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. Prospective residents are given comprehensive information about the home enabling them to make an informed decision. Residents spoken with said they live as they wish and their personal preferences are respected. Several residents administer their own medicines and several manage their own finances. Residents also confirmed that their privacy and dignity are respected and this was observed during the inspection. Residents have their own telephone line to their room. There are choices on the menu and plenty of activities and outings to choose from. The home has a Mercedes limousine and a minibus to transport residents. Each resident has an individual care plan that ensures staff know how to meet their needs. Appropriate risk assessments are included. Residents said they are involved with the care planning process and the plans inspected were signed. 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 system in place for the administration, storage and disposal of medicines. Each resident has a lockable cabinet in their room. There are robust recruitment procedures. The staff are competent in their roles and 89 of care staff are qualified to NVQ level 2 in care. Other training takes place as identified during the annual appraisals. Residents said they are more
Tregolls Manor DS0000009142.V281979.R01.S.doc Version 5.1 Page 6 than happy with the care provided and the staff are very kind and patient and they all know what they are doing. The management 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: 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.V281979.R01.S.doc Version 5.1 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 Tregolls Manor DS0000009142.V281979.R01.S.doc Version 5.1 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): 1 Prospective residents are given information about the home enabling them to make an informed decision. EVIDENCE: The home has a suitable statement of purpose and residents guide that include all of the required information. The statement of purpose is given to prospective residents and residents in the home have a copy of the resident’s guide. Tregolls Manor DS0000009142.V281979.R01.S.doc Version 5.1 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, 9 and 10 Individual care plans are generated for each resident that inform and direct the staff in their care provision. There are suitable systems and policies in place for dealing with residents medicines and assure residents safety. Systems are in place to ensure that residents are respected and their privacy is upheld at all times. EVIDENCE: Each resident has a written care plan with risk assessments included. The care plans are accompanied by a Kardex system that holds further information and daily records. The care plans are compiled with the resident or representative signed and reviewed monthly. The daily records are detailed and informative. There is now a photograph of each resident on file, as required at the last inspection. The medicines policy has been reviewed and updated. There is a system in place for the administration of medicines. Storage is safe and secure in each residents’ room or bathroom. A monitored dose system is used. The number of medicines received into the home is recorded and signed for on the medicine administration chart. The transcribing of medicines or changes on the medication administration record charts is signed by two members of staff. All care staff have received training in the safe handling of medicines.
Tregolls Manor DS0000009142.V281979.R01.S.doc Version 5.1 Page 10 There are suitable arrangements for ensuring that resident’s privacy and dignity are respected. Residents have their own telephone line to their room. All residents spoken with said their privacy was respected. Tregolls Manor DS0000009142.V281979.R01.S.doc Version 5.1 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 and 14 The home provides a range of activities and aims to offer a lifestyle that meets individual residents needs. Residents are helped to maintain control over their lives and staff respect their individual preferences and choice. EVIDENCE: Activities and outings are provided in line with resident’s wishes. A monthly calendar of events is given to each resident. There are several trips out arranged for February including tea at Trelissick Gardens, shopping trips, visits to Carlyon Bay and Portreath and drinks at the Cathedral. A limousine and a mini bus, suitable for the disabled, are available for outings. One resident talked about going to the Hall for Cornwall. Other activities include a Valentines dinner and entertainment by singers. All residents 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 DS0000009142.V281979.R01.S.doc Version 5.1 Page 12 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): 18 Arrangements are in place for the protection of residents safeguarding them from harm or abuse; an addition to the policy is necessary. EVIDENCE: The home has an adult protection policy that must include the reporting of all abuse incidents to the Commission for Social Care Inspection. There is a copy of the local inter agency procedures on the staff notice board. 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. The Registered Manager has offered external training to staff. Tregolls Manor DS0000009142.V281979.R01.S.doc Version 5.1 Page 13 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 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 residents 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 is suitable for the size of the home. The laundry worker has undertaken several training sessions. All laundry is undertaken in house, dry cleaning is sent out to Cornish Linen Services. 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.V281979.R01.S.doc Version 5.1 Page 14 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): 28, 29 and 30 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, however photographs of staff must now be on file. The home provides training for staff to help them be more competent in their roles; improved record keeping would be beneficial. EVIDENCE: Eighty nine per cent of the care staff have achieved the NVQ level 2 in care. Three of the care staff are qualified nurses. Truro College is the NVQ provider for care staff and Cornwall College at Camborne is the provider for catering courses. Recruitment procedures are robust with all records and checks maintained. The Registered Manager must now ensure that there is proof of identity on staff files including a recent photograph. There is an induction programme in place that leads on to a foundation programme and ultimately NVQ training. Training needs are identified during the annual appraisal system and records of needs are kept on file. A great deal of NVQ training has taken place recently and subjects covered on the course include infection control, moving and handling, Health and Safety, dementia, conflict and challenging behaviour. A nurse from the hospital has provided diabetes training. Statutory training takes place and there is a matrix in the statement of purpose. There is insufficient evidence to determine that all staff have attended statutory training at the appropriate intervals. The training records need to be improved to ascertain who has done what and to ensure there is
Tregolls Manor DS0000009142.V281979.R01.S.doc Version 5.1 Page 15 compliance with legislation. It is recommended that a more comprehensive training matrix be maintained. Tregolls Manor DS0000009142.V281979.R01.S.doc Version 5.1 Page 16 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): 35 and 38 There is a suitable system in the home that ensures the residents’ financial interests are safeguarded. Safety checks are undertaken more attention is required in respect of statutory training and records to further ensure the health safety and welfare of residents and staff EVIDENCE: 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. There is evidence that statutory training takes place however it is not evident that fire training takes place at the appropriate intervals. 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,
Tregolls Manor DS0000009142.V281979.R01.S.doc Version 5.1 Page 17 training and equipment maintenance, checking and cleaning. 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 the Registered Manager audits all accidents in the home. Health and safety risk assessments have been undertaken. Tregolls Manor DS0000009142.V281979.R01.S.doc Version 5.1 Page 18 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 X X X X HEALTH AND PERSONAL CARE Standard No Score 7 3 8 X 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 X 14 3 15 X COMPLAINTS AND PROTECTION Standard No Score 16 X 17 X 18 3 3 X X X X X X 3 STAFFING Standard No Score 27 X 28 4 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X X X X 3 X X 2 Tregolls Manor DS0000009142.V281979.R01.S.doc Version 5.1 Page 19 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 OP29 Regulation 7,9,19 Sch 2(1) 23(4) (d) 13(5) 13 (6) 37 Requirement Proof of identity including a recent photograph of each employee must be maintained in their file All staff must attend statutory fire training at the appropriate intervals. The moving and handling policy must be reviewed and updated. The adult protection policy must include the reporting of incidents and allegations to the CSCI Timescale for action 08/05/06 2 3 4 OP38 OP38 OP18 08/05/06 08/05/06 08/05/06 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 Refer to Standard OP26 OP30 Good Practice Recommendations 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
DS0000009142.V281979.R01.S.doc Version 5.1 Page 20 Tregolls Manor Tregolls Manor DS0000009142.V281979.R01.S.doc Version 5.1 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
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