Inspection on 15/11/06 for Tregothnan Retirement Home

This inspection was carried out on 15th November 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 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

Tregothnan Retirement Home 05/11/09

Tregothnan Retirement Home 29/12/08

Tregothnan Retirement Home 24/11/05

Tregothnan Retirement Home 13/05/05

Similar services:

Chirnside House

Keer Sands Residential Home

Ruskin Lodge

Bushell House

Langrigg House

Parkside

Dystlegh Grange

Thornton Lodge

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

CARE HOMES FOR OLDER PEOPLE Tregothnan Retirement Home 112 Balmoral Road Morecambe Lancashire LA3 1ST Lead Inspector Mrs Joy Howson-Booth Unannounced Inspection 10:15 15 November 2006 th 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 Tregothnan Retirement Home DS0000062631.V311963.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. Tregothnan Retirement Home DS0000062631.V311963.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Tregothnan Retirement Home Address 112 Balmoral Road Morecambe Lancashire LA3 1ST 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) 01524 412259 Thackray Care Services Ltd Mr Robert Thackray Care Home 13 Category(ies) of Old age, not falling within any other category registration, with number (13), Physical disability (2) of places Tregothnan Retirement Home DS0000062631.V311963.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The home is registered for a maximum of 13 service users to include up to 13 service users in the category OP (older persons) and 2 named service users in the category PD (physical disability) over 55 years of age 24th November 2005 Date of last inspection Brief Description of the Service: Tregothnan Residential Home is situated on one of the main roads leading into the West End of Morecambe, in a fairly quiet residential area, close to local shops and amenities. There is a ramp leading up to the side of the front door for use by wheelchair users, but there is still a small step to enter the front door. The home is a Victorian terrace built over three floors, accessible by a passenger lift. Four of the bedrooms have an ensuite facility and, for the remainder, there is a bathroom/toilet within easy reach. There are communal areas including a small roof terrace, a dining room and lounge. There are toilets on all floors which are accessible to residents. The current range of fees are from £320.00 to £367.00 per week. Further details over fees can be obtained from the registered manager of the home. Tregothnan Retirement Home DS0000062631.V311963.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This is the first site visit and was unannounced so the registered manager, staff and residents were not aware of the visit. The site visit forms part of the overall inspection for the home which makes sure people are being cared for properly and to make sure the home is a safe place for people to live in. As well as the site visit, judgements have been made about the service based on information supplied by the registered manager. Comment cards were also sent out to service user and GP surgeries and made available to relatives. Unfortunately non were received. The site visit took place over one day and included taking time to sit and speak with residents, observing staff on duty performing the day-to-day routines, speaking with staff, examining documents held in the home and speaking with the registered manager. The inspector looked around the home, including communal rooms, bathrooms and toilets. The tour also provided an opportunity to find out about any improvements made and to see if the home was a comfortable, clean and safe for people to live in. A visiting physiotherapist was spoken with during the site visit who expressed her satisfaction of the care and input provided to the people she works with. Additional information was also supplied from a pre-inspection questionnaire completed by the registered manager. The site visit was positive with everyone welcoming, friendly and co-operative during the visit. Tregothnan has been assessed as a good home, although a small number of standards have shown shortfalls during this inspection. A number of recommendations have also been made. What the service does well: Tregothnan continues to provide a pleasant and homely environment which has a relaxed and homely atmosphere. The registered manager and staff try hard to make sure equal care is given to all residents, considering their individual choices and preferences, and giving equal support to all, irrespective of their race, gender, disability, sexuality, age religion or beliefs. The registered manager works at the home on a daily basis which gives an opportunity to talk with the residents and pick up immediately on any concerns or issues. The home has achieved the Investors in People Award – this award Tregothnan Retirement Home DS0000062631.V311963.R01.S.doc Version 5.2 Page 6 means that the home looks at how they can make continual improvements through supporting and training its staff. There is equal consideration given to all prospective employees, with both female and male staff being employed. Training and development programmes are offered to all members of staff. A number of staff have worked at the home for sometime and know the residents very well. The home has achieved 66 of the care staff trained to National Vocational Qualifications (NVQ) which means that residents are cared for by suitably qualified staff. The carers were friendly and understood the personal needs of each resident. At the time of the visit the inspector saw friendly and caring exchanges between the staff on duty and the people living at the home, with each resident being treated as an individual and given the time and attention needed. Residents are encouraged to retain their independence. A physiotherapist who was visiting her clients was spoken with. She stated she was “very impressed” with the home and has seen a very good improvement in the people she works with as staff ensure physio programmes are undertaken on a daily basis. Residents are able to maintain their own lifestyles and daily routines and staff support is provided, when needed. Information supplied by the home confirms that there are a range of policies and procedures which ensure residents are provided with the care they need and respects their rights irrespective of their race, gender, disability, sexuality, age, religion or beliefs. The home is well maintained and homely with communal rooms being accessible to the residents. For the bedrooms upstairs there is a passenger lift for the residents to use. There are a range of aids and adaptations to help residents maintain their independence, including handrails and individual aids, for example zimmer frames and wheelchairs. Residents own rooms are well maintained and homely. Residents are also encouraged to bring in treasured personal items to personalise their rooms. Communal rooms are well maintained and provide a homely and comfortable environment for the residents to use. During the site visit, a number of residents were seen and spoken with and all appeared to be well cared for and content. More than one resident stated that the home’s manager “cannot do too much for you” and “nothing is too much trouble”. Comments about staff included “they are very good”; “they are very caring and look after me very well”. From discussions with the residents and staff on duty the registered manager works hard to ensure the home is maintained to a high standard and is approachable for any ideas and suggestions. Tregothnan Retirement Home DS0000062631.V311963.R01.S.doc Version 5.2 Page 7 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. The summary of this inspection report can be made available in other formats on request. Tregothnan Retirement Home DS0000062631.V311963.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 Tregothnan Retirement Home DS0000062631.V311963.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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 1, 3 and 6 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Good verbal information is provided about the home to residents but they are not given written information to refer back to. The home gathers enough information about prospective residents to ensure needs can be met. EVIDENCE: Discussions with three recently admitted residents confirmed that they had been given some information, for example the home’s brochure, but not with a copy of the Service User Guide. However, all confirmed that the home’s manager had spoken with them and their relatives personally on arrival and they had been given verbal information about the home. The registered manager advised that it is a requirement of the Care Homes Regulations 2001 that all residents must be provided with a copy of the Service User Guide. The registered manager confirmed he would address this promptly. Tregothnan Retirement Home DS0000062631.V311963.R01.S.doc Version 5.2 Page 10 Three pre-admission assessments were examined for newly admitted residents which evidenced that the home is obtaining information about the person prior to admission which is then used as a base care plan to be added to during the trial period. This information also includes their disabilities, preferences and religious needs. If needed, the registered manager confirmed that the preadmission assessment would also include cultural needs. Residents spoken with all confirmed that they were made to feel very welcome on admission, for example, they were provided with refreshments to enjoy with their relatives. Importantly, resident spoken with said they were given time to adjust to their new surroundings and staff were caring and sensitive in their approach. Staff spoken with all confirmed that prior to a new admission they are told about the person, about their needs, disabilities, etc., and are able to read the pre-admission assessment. Staff also confirmed that they are able to spend time with any new admission to ensure they feel welcomed and are settled in their rooms. Standard 6 does not apply to this home as there are no intermediate care facilities offered. Tregothnan Retirement Home DS0000062631.V311963.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 7, 8, 9 and 10 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home makes sure the health and personal care needs of the residents are met. EVIDENCE: Three residents were case tracked which included examination of their individual care plans. All evidenced a full and comprehensive care plan which covers health and personal care, preferred name, individual wishes and routines. The care plans also evidenced whether the resident wished to have a newspaper each day; their preferred relationships; how they wished to take part in the electoral system; religious needs and wishes and also included personal information like – “likes to have a cup of tea to dunk his biscuits in”!. The care plans also included a range of risk assessments including manual handling and falls risk assessments. There was evidence that the care plans had been reviewed since admission. Tregothnan Retirement Home DS0000062631.V311963.R01.S.doc Version 5.2 Page 12 The care plans also evidenced that healthcare input had been provided from external professionals including chiropodist; physiotherapist; speech therapist. During the site visit the community physiotherapist was spoken with. She was very happy with the care that is provided and said she is “very impressed” with the home. Comment was made that the homes manager and the staff are very good and she has no concerns at all about the care provided. The physiotherapist said that she has seen a vast improvement in the people she works with since their admission. She feels this is down to the hard work and encouragement given by the manager and staff and the fact that the physio programmes she has set in place are adhered to. There has been a very small turnover of staff since the last inspection which means that residents are being cared for by staff who are familiar to them and also knowledgeable about their individual needs. Observations of staff undertaking their day-to-day care tasks evidenced that they are sensitive, thoughtful and respectful to the residents and there is a genuine feeling that the residents needs are anticipated and come first. Staff spoken with confirmed they had access to the individual residents’ care plans and, through discussion, evidenced that they have a very good understanding of the individual needs and wishes of the residents. Staff also talked competently about individual health and personal care needs and how these are met on a day-to-day basis by themselves and also through input from healthcare professionals. It was also seen that the home respects the resident’s rights to privacy. All the residents spoken with spoken highly of the care provided by the staff and feel that they are well looked after. More than one resident stated that the home’s manager “cannot do too much for you” and “nothing is too much trouble”. Comments about staff included “they are very good”; “they are very caring and look after me very well”. Medication stocks and records were examined and the registered manager advised over a small number of anomalies. The registered manager also provided information over a recent medication issue – further information is to be provided to the Commission over this incident. Advice was given to the registered manager to ensure that only those staff who are trained administer medications. The registered manager confirmed he would address the concerns raised. Tregothnan Retirement Home DS0000062631.V311963.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 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. Residents are supported to enjoy a good lifestyle which follows their own preferences. EVIDENCE: Residents spoken with were happy with their day-to-day routines and are able to follow their own activities and lifestyles. Residents confirmed that a range of activities are provided, and enjoyed, including Tai Chi and music. The two younger residents confirmed they are able to follow their own lifestyles but are somewhat limited to access the wider community at present due to mobility issues. Care plans evidenced that lifestyles and choices are ascertained and also respected. In addition, residents are asked if there were anything specific they would like to do, for example, have a daily newspaper. Residents are Tregothnan Retirement Home DS0000062631.V311963.R01.S.doc Version 5.2 Page 14 supported to enjoy their faith and the home supports them to do this. Residents are also asked about whether they wish to vote and in what way. Each resident has their own daily diary where staff record day to day activities, visitors, outings, etc. as well as information pertinent to that resident. Staff spoken with were all conversant with the individual likes and dislikes of the residents and showed respect for individual lifestyles and choices. Staff confirmed that they enjoy spending time talking with residents and value the personal care time as this gives them an opportunity to spend some quality 1 to 1 time with the resident. In the main lounge it was noted that the television was on all day. When asked, one resident said that the TV is “on all the time” and those less able to speak up are not given a choice of which programme to watch as the more mobile residents will choose. This comment was relayed to the registered manager who is to observe and speak with residents about this. The records of meals served were examined and evidenced that a range of meals are provided which appear to be nutritionally good. It was also noted that individual likes are addressed, for example, curries and pizzas being bought in for one resident. The provision of vegetables needs to be looked as there is often only a limited choice. In addition, there were only a small number of occasions when an alternative meal had been provided. The teatime meals had a good range of alternatives provided, although some residents commented they often get the same thing offered. Both residents and staff confirmed that drinks and snacks are available at any time. One resident said that she likes coffee and staff make sure she has her own pot of coffee which she really enjoys. As advised at previous inspections, the registered manager should speak with residents and review meals provided to find out if any changes are needed. At the last inspection it was recommended that a dedicated cook should be employed so that the home can ensure a good nutritional balance in the food provided. Staff spoken with felt that it would be helpful if they were trained in nutrition of the elderly which would certainly help in planning menus. Tregothnan Retirement Home DS0000062631.V311963.R01.S.doc Version 5.2 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. 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. Residents are confident that they can voice any issues and they are safeguarded by staff at the home. EVIDENCE: The registered manager confirmed there have been no changes to the complaints procedure for the home. As mentioned earlier, each resident is to be provided with their own copy of the Service User Guide which provides written details what they should do if they are not happy with any aspect of the service. The complaints procedure was seen on display in the hallway. Residents spoken with all confirmed that they had been told verbally that if they were not happy with anything they would speak with a member of staff or the registered manager. Since the last inspection only one complaint has been made. This was made by an external professional to the Commission and was referred to the registered manager to investigate. The complaint was regarding the care provided to one of the residents. The complaint was withdrawn. Tregothnan Retirement Home DS0000062631.V311963.R01.S.doc Version 5.2 Page 16 Staff spoken with confirmed that if a resident were to make a complaint they would first try to solve the problem but would ensure the registered manager was told. If they were not able to deal with the complaint they would write this down in the communication book and also verbally inform the registered manager. Regarding adult protection, the home has demonstrated that it can follow the safeguarding adults procedure. Staff also confirmed that they have had training in safeguarding adults; one member of staff has completed National Vocational Qualification Level III and is aware of the procedure to follow should abuse be suspected. Tregothnan Retirement Home DS0000062631.V311963.R01.S.doc Version 5.2 Page 17 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 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 provides a safe and homely environment for the residents to live in. EVIDENCE: A tour of the home found it to be warm, clean and tidy and providing an appropriate environment for the residents accommodated. Upper floors are accessed by use of the passenger lift. Residents spoken with all confirmed their rooms and the home generally is kept clean and tidy and they are happy with their environment. Residents also confirmed they are able to access all the communal areas of the home and are Tregothnan Retirement Home DS0000062631.V311963.R01.S.doc Version 5.2 Page 18 free to use both these and their own rooms as they wish to do so. Individual rooms have been personalised with treasured and familiar possessions by the residents. The registered manager confirmed there is an ongoing redecoration programme in the home, with most individual rooms now being redecorated and recarpeted. Importantly, residents are asked about choices of colours for their rooms. The registered manager confirmed that there have been no changes to the infection control procedures in the home which were satisfactory at previous inspections. Tregothnan Retirement Home DS0000062631.V311963.R01.S.doc Version 5.2 Page 19 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 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. There are sufficient staff on duty who are trained and are competent to meet residents needs. EVIDENCE: Staff files were examined for the two members of staff recruited since the last inspection. These files evidenced that all the appropriate checks are being carried out prior to starting work. Examination of the application forms submitted noted that the registered manager had not obtained a full employment history for either member of staff, nor was a date of commencement of employment recorded on their files. Criminal Records Bureau checks and POVA checks were seen for these members of staff. The staffing rota was examined and found that sufficient staff are on duty for the number and needs of the residents presently accommodated. Staff spoken with confirmed they felt there was enough staff on duty. Residents spoken with also confirmed that staff attend to them promptly and they never feel rushed or hurried. Tregothnan Retirement Home DS0000062631.V311963.R01.S.doc Version 5.2 Page 20 As mentioned earlier, there is a very low turnover of staff at the home which means resident are cared for by people who are familiar to them and know their needs. Training records were seen which evidenced ongoing training, both for new staff and existing staff, and copies of training certificates. Staff spoken with confirmed they had completed mandatory training. One member of staff has National Vocational Qualification (NVQ) Level III, another has just started NVQ Level III and 8 members of staff are already trained to NVQ Level II. There is also a member of staff on the home’s bank who has NVQ Level III. This equates to 66 of staff being trained and exceeds the required 50 as outlined in the National Minimum Standards. Tregothnan Retirement Home DS0000062631.V311963.R01.S.doc Version 5.2 Page 21 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 31, 33, 35, 36 and 38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is well managed by a manager experienced and competent to do so. EVIDENCE: The registered manager confirmed he achieved the National Vocational Qualification Level IV in June 2006 and the Registered Managers Award in July 2006. Management hours are included on the staffing rota but advice is given that these should accurately reflect the management hours worked. Tregothnan Retirement Home DS0000062631.V311963.R01.S.doc Version 5.2 Page 22 Any further quality assurance developments appear to have been put on hold at present, although existing systems remain in place. Discussion took place over the need to evidence quality assurance feedback from residents, relatives and other visiting professionals and the registered manager is to look at ways of doing this. The financial records and records of charges and payments were seen for the residents in the home. These are being appropriately maintained by the registered manager. The registered manager confirmed that there is no formal review of the homes policies and procedures and was advised that this should be addressed. A review date should be recorded on each policy. Staff supervision records were also seen on file. Advice was given that this should include the topics outlined in National Minimum Standard 36. Discussions with staff confirmed that they receive supervision from the registered manager. The accident record book was seen and appears to be being accurately and appropriately maintained. Information provided by the home states that equipment and facilities are regularly checked and maintained and appropriate health and safety systems are in place. Staff spoken with confirmed that the home’s aids and adaptations, facilities, etc., are appropriately maintained and if any maintenance or health and safety issues are raised these are dealt with promptly by the registered manager. Staff also confirmed that fire drills are held on a regular basis. Residents and staff spoken with all felt the home is well managed and the registered manager is very approachable and supportive. Tregothnan Retirement Home DS0000062631.V311963.R01.S.doc Version 5.2 Page 23 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 2 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 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 2 X 3 3 X 3 Tregothnan Retirement Home DS0000062631.V311963.R01.S.doc Version 5.2 Page 24 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. 2. Standard OP1 OP9 Regulation 5(2) 13(2) Requirement A copy of the service user guide must be provided to each service user Medication must be safely and correctly administered to residents. A full report and actions taken, along with a Regulation 37 notification, must be sent to the Commission Timescale for action 30/11/06 15/11/06 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 OP33 OP12 Good Practice Recommendations The Quality Monitoring system in the home should be further developed to include resident, relatives and other healthcare professional formal feedback Residents should be consulted over communal activities such as watching television Activities in the home should continue to be developed to ensure all residents are provided with social stimulation Residents should be consulted over the meals provided, a DS0000062631.V311963.R01.S.doc Version 5.2 Page 25 3. OP15 Tregothnan Retirement Home 4. 5. 6. 7. OP29 OP38 OP36 OP29 review taken place, particularly to review the vegetables provided and also ensure a nutritional balance is being maintained. Staff should also access training in nutrition so that they can ensure a good nutritional balance is provided A full employment history should be obtained for any prospective member of staff The registered manager should evidence that the home’s policies and procedures are reviewed at least annually or sooner if needed The registered manager should ensure that supervision covers all the areas outlined in Standard 36 of the National Minimum Standards Staff files should evidence the date of commencement of employment Tregothnan Retirement Home DS0000062631.V311963.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection North Lancashire Area Office 2nd Floor, Unit 1, Tustin Court Port Way Preston PR2 2YQ National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. 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