Inspection on 24/11/05 for Tregothnan Retirement Home

This inspection was carried out on 24th November 2005.

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

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

Other inspections for this house

Tregothnan Retirement Home 05/11/09

Tregothnan Retirement Home 29/12/08

Tregothnan Retirement Home 15/11/06

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 Announced Inspection 24th November 2005 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 Tregothnan Retirement Home DS0000062631.V256711.R01.S.doc Version 5.0 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Tregothnan Retirement Home DS0000062631.V256711.R01.S.doc Version 5.0 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) of places Tregothnan Retirement Home DS0000062631.V256711.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 4. The organization must at all times employ a suitably qualified & experienced manager who is registered with the Commission for Social Care Inspection The registered manager must achieve the Registered Managers Award by 2005 Radiator covers must be installed on all radiators in the home by 31 March 2005 The home is registered for a maximum of 13 service in the category OP (Older Persons) 13th May 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. Tregothnan Retirement Home DS0000062631.V256711.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was announced and carried out over one day. The purpose of this inspection was to assess the service against the key National Minimum Standards which remain outstanding for this inspection year. This inspection focussed on environmental standards and health and safety within the home. At the time of this inspection there were 8 residents in the home, 5 of these were spoken with. A visiting relative was also spoken with who confirmed he was very happy with the care provided to his relative by the staff at the home. A member of staff on duty was also spoken with. As well as this, discussions took place with the registered manager over the admission of a resident to the home and their care documentation was also examined. Feedback received from residents indicated that they felt very well looked after at the home, were well cared for by the staff and felt that the registered manager ran the service very well. Comment cards were sent to the home for distribution to residents, GP’s and other health professionals and relatives but none were returned at the time of writing this report. What the service does well: Tregothnan continues to be a small, friendly and family run home, with friendly and caring staff who are managed by a dedicated and experienced manager. The home has achieved the Investors in People award. The home continues to have a very low staff turnover which means that residents’ needs are known and staff faces are familiar. Staff continue to have the support and guidance of the registered manager, and the training programme is ongoing for all staff. The registered manager continues to support residents to know that this is “their home” and is to be run as such, with family and friends welcomed. As with other inspections, there is always a very good atmosphere in the home, with residents and staff seeming to get on very well with each other. Residents continue to maintain their own lifestyles, with support from staff, as needed. Healthcare needs are addressed as they arise and the manager helps all the residents to keep their appointments and have healthcare input as often as they require. Tregothnan Retirement Home DS0000062631.V256711.R01.S.doc Version 5.0 Page 6 Where requirements or recommendations are made during any inspection, it is positive to know that the registered manager will address these promptly. The health and safety of residents are staff is maintained by the registered manager, with appropriate trades people attending to servicing, maintenance and upkeep of the home and its equipment. Since the last inspection, the registered manager has completed the work for the National Vocational Qualification Level IV and is hoping to achieve the Registered Managers Award by the end of 2005. What has improved since the last inspection? What they could do better: Although the pre-admission information document has been improved there still needs to be an awareness that an assessment should be carried out by someone qualified to do so from the home. This would then provide information which is based on knowledge of the home, its layout and facilities and the presenting needs of the prospective resident which can be seen first hand. As part of this assessment, the registered provide may wish to include perhaps an overnight or weekend stay to ensure that all the prospective resident’s needs can be met. The quality monitoring system used by the home should include external healthcare and other professionals. Tregothnan Retirement Home DS0000062631.V256711.R01.S.doc Version 5.0 Page 7 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. Tregothnan Retirement Home DS0000062631.V256711.R01.S.doc Version 5.0 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.V256711.R01.S.doc Version 5.0 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 Full assessments are not being carried out by the home which means that residents needs may not be identified fully prior to admission. EVIDENCE: From examination of an assessment and discussion with the registered manager it was highlighted that, whilst an assessment had been obtained from the named Social Worker, the home had failed to clarify this information with an assessment of their own. Further advice and guidance was provided to the registered manager that the home must ensure a full pre-admission assessment is carried out, either by himself or a senior person at the home who is qualified to do so. This may mean a personal visit, or an assessment/trial visit to the home prior to any formal decision being made regarding admission. Tregothnan Retirement Home DS0000062631.V256711.R01.S.doc Version 5.0 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 and 9 The care plans provide information which enable staff to be aware of needs and how these are to be met. Systems have been put in place to ensure medication is safely administered to residents EVIDENCE: Following a requirement highlighted at the previous inspection, a care plan was examined during this inspection and found to contain much more detailed and clear information over the needs of the residents and how these are to be met by the staff at the home. At the previous inspection requirements were set by the Pharmacist Inspector regarding the administration of medication in the home. During this inspection visit, the registered manager confirmed that he has put in place systems to ensure all the requirements highlighted by the Pharmacist have been addressed. Advice was also provided to the registered manager that risk assessments should also cover areas of administration of medication, particularly if this is an area identified during the assessment process. Tregothnan Retirement Home DS0000062631.V256711.R01.S.doc Version 5.0 Page 11 Tregothnan Retirement Home DS0000062631.V256711.R01.S.doc Version 5.0 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): 15 The home is now maintaining the appropriate records regarding food served to residents. EVIDENCE: A requirement highlighted at the previous inspection required the home to record meals served to residents. The menu book was seen which details the meals served along with any variations provided to individual residents. Tregothnan Retirement Home DS0000062631.V256711.R01.S.doc Version 5.0 Page 13 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): All the key standards were assessed and met at the previous inspection visit. EVIDENCE: Tregothnan Retirement Home DS0000062631.V256711.R01.S.doc Version 5.0 Page 14 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Tregothnan is generally a safe place for people to live in, residents feel safe and their accommodation is comfortable. EVIDENCE: The home was toured and found to be well maintained, warm and providing a homely environment for the residents. All the radiators have radiator covers in place. All water outlets have thermostatic controlled valves in place. Risk assessments are carried out by the registered manager, including a home’s risk assessment and individual risk assessments for residents. Residents rooms are personalised with treasured items and personal possessions. Tregothnan Retirement Home DS0000062631.V256711.R01.S.doc Version 5.0 Page 15 Environmental Health visited in October 2005. There were no offensive odours found during this inspection – the home was clean and tidy. Tregothnan Retirement Home DS0000062631.V256711.R01.S.doc Version 5.0 Page 16 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 29 Standards 27, 28 and 30 were assessed and found to be met at the previous inspection visit. Recruitment procedures are being followed which mean the residents can be confident only staff who are suitable care for them. EVIDENCE: A requirement highlighted at the previous inspection required the home to ensure that staff do not commence work at the home until a satisfactory Criminal Record Bureau disclosure check has been received. During this inspection Criminal Record Bureau disclosure forms were seen for all staff who work at the home. Tregothnan Retirement Home DS0000062631.V256711.R01.S.doc Version 5.0 Page 17 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 33, 35 and 38 Standards 31, 32 and 36 were assessed during the previous inspection visit and found to be met. EVIDENCE: A requirement highlighted at the previous inspection required quality monitoring systems to be put in place which would enable residents, relatives, and visiting professionals to provide feedback over the service provided. At this inspection visit, the registered manager confirmed that feedback is gained through personal visits and discussions and via telephone calls. Advice is given that a more formal system could still be put in place whereby records of comments and feedback could be used as part of the service audit required for Investors in People. Tregothnan Retirement Home DS0000062631.V256711.R01.S.doc Version 5.0 Page 18 The registered manager confirmed that for the 8 residents in the home either relatives, external appointee or relatives have responsibility for managing financial aspects for the residents at the home. Personal allowance monies are held for one resident and these financial records were examined and found to be appropriately maintained. The home has a safe where monies and valuables can be safely stored and the home has a receipt book which is used as needed. A requirement highlighted at the previous inspection required update training in the fire procedure for the home and update mandatory training to be provided to staff. The registered manager confirmed that : all but one member of staff has had moving and handling training; all staff have received fire safety training; most staff have done first aid training and those remaining are to do a first aid course planned for December 2005; food hygiene training has been provided to all appropriate staff; and infection control training has been done by most staff, with others to do the course over the forthcoming months. The pre-inspection questionnaire submitted by the registered manager confirmed that fire officer’s last visited in November 2005, fire safety equipment was checked in February 2005 and the home last had a fire drill in June 2005, although a weekly fire alarm test takes place. The pre-inspection questionnaire also confirmed that regular testing and maintenance of systems and facilities are carried out by appropriately trained trades people. The home has COSHH assessments in place Soiled waste is disposed of by an arrangement with the local council and separate marked bags are used. The registered manager confirmed that there are no window restrictors in place and these would not be required for current residents. Advice was given that a risk assessment should take place for any future residents. It was confirmed that security is maintained in the premises at all times, with night staff having responsibility for checking and ensuring the building is safe at night. The registered manager confirmed that the home complies with the requirements of standards 38.3 and 38.4 in terms of health and safety of staff and residents and compliance with relevant legislation. Tregothnan Retirement Home DS0000062631.V256711.R01.S.doc Version 5.0 Page 19 Policies and procedures are in place within the home for safe working practices and care practices. Confirmation was given that risk assessments are carried out, including a “home’s risk assessment” and use of hoist. The home’s accident book was examined and found to be maintained. Advice was given over one accident which stated that no injuries had occurred but discussions with the resident concerned indicated they had banged their head and trapped their foot. The registered manager was advised to remind staff that accidents must be accurately recorded. The registered manager confirmed that staff receive induction training to the TOPSS (now Skills for Care) standard at the local college. A new course is to commence with staff from the home in January 2006. Staff are continuing with the National Qualification Training programme set up by the home. Tregothnan Retirement Home DS0000062631.V256711.R01.S.doc Version 5.0 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 Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 2 X X N/a HEALTH AND PERSONAL CARE Standard No Score 7 3 8 X 9 3 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 X 14 X 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 X 17 X 18 X 3 X X X X X X 3 STAFFING Standard No Score 27 X 28 X 29 3 30 X MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X X 2 X 3 X X 3 Tregothnan Retirement Home DS0000062631.V256711.R01.S.doc Version 5.0 Page 21 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 OP3 Regulation 14 Requirement The home must obtain full information prior to admission taking place, and ensure full information is obtained within 5 days for any emergency admission. Previous timescale of 19.5.05 not met Quality monitoring systems that are in place must evidence that other professionals, outside agencies, relatives/visitors to the home have been consulted about the quality of the service provided. Previous timescale of 31.8.05 not met Timescale for action 24/11/05 2 OP33 24 31/03/06 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 Refer to Standard OP38 Good Practice Recommendations Risk assessment should also include administration of DS0000062631.V256711.R01.S.doc Version 5.0 Page 22 Tregothnan Retirement Home 2 OP38 medication Staff should be reminded to ensure that all accidents are accurately recorded Tregothnan Retirement Home DS0000062631.V256711.R01.S.doc Version 5.0 Page 23 Commission for Social Care Inspection North Lancashire Area Office 2nd Floor, Unit 1 Tustin Court Port Way Preston PR2 2YQ 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 Tregothnan Retirement Home DS0000062631.V256711.R01.S.doc Version 5.0 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!