CARE HOMES FOR OLDER PEOPLE
Cornwallis Trewidden Road St Ives Cornwall TR26 2BX Lead Inspector
Diana Penrose Unannounced Inspection 22nd May 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 Cornwallis DS0000009008.V293721.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. Cornwallis DS0000009008.V293721.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION
Name of service Cornwallis Address Trewidden Road St Ives Cornwall TR26 2BX 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) 01736 796856 01736 797143 Cornwallis Care Services Limited Mrs Sherran Thompson Care Home 51 Category(ies) of Dementia - over 65 years of age (51), Mental registration, with number Disorder, excluding learning disability or of places dementia - over 65 years of age (51) Cornwallis DS0000009008.V293721.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION
Conditions of registration: Date of last inspection 24th February 2006 Brief Description of the Service: Cornwallis Nursing Home is a detached property located above the town of St Ives, Cornwall. It is a three-storey dwelling and is situated at the top of a hill. The home offers nursing care for up to fifty-one elderly residents with a dementia or mental health problem. Residents accommodation is spread over three floors. Resident’s private bedrooms are shared or single, with bedrooms on the first floor having en suite provision. There are two communal lounge/dining areas, plus a conservatory, which has sea views. The conservatory has been out of use for some time due to repairs being needed. All rooms have call bells and assisted bathing facilities are provided. The garden area is secure and accessible to residents. There are opportunities for socialising and visitors are openly encouraged. Information about the home is available in the form of a residents’ guide, which can be supplied to enquirers on request. A copy of most recent inspection report is available in the home. Fees range from £467 to £525 per week according to the registered manager, who supplied this information during this inspection. Additional charges are made in respect of private healthcare provision, hairdressing and personal items such as newspapers, confectionary and toiletries. Cornwallis DS0000009008.V293721.R01.S.doc Version 5.1 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. Two inspectors visited Cornwallis Nursing Home on the 22 May 2006 and spent seven hours at the home. This was a key inspection and an unannounced visit. The purpose of the inspection was to ensure that residents’ needs are properly met, in accordance with good care practices and the laws regulating care homes. The focus was on ensuring that residents’ placements in the home result in good outcomes for them. It was also to gain an update on the progress of compliance to the requirements identified in the last inspection report dated 16/03/06. All of the key standards were inspected. On the day of inspection 30 residents were living in the home. The methods used to undertake the inspection were to meet with a number of residents, relatives, staff and the registered manager to gain their views on the services offered by Cornwallis Nursing Home. Records, policies and procedures were examined and the inspectors toured the building. This report summarises the findings of this inspection. Residents and relatives expressed satisfaction with the care and services provided at the home. Overall the home is providing an adequate quality of care to the residents placed there, with notable improvements over the past year. What the service does well:
The registered provider, registered manager and staff welcome the inspectors and other agencies into the home. They are keen to discuss ways in which to improve standards in the care provided to the residents. Residents have their care needs assessed prior to their admission to the home so they can be confident it will be suitable for them. Each resident has a care plan compiled from the initial assessment; the new format is very detailed and informs and directs staff in the care to be provided. Pre-admission assessment and planning considers residents’ personal, social and health care needs, including age and needs relating to their individual diverse backgrounds, such as cultural issues and their religious beliefs. Residents and their relatives said that health and personal care needs are met and staff treat residents with respect making the quality of their lives as good as possible. Care practice was observed to be satisfactory during the inspection and residents were treated with respect. A GP visits the home each week and a psychiatrist each month, other healthcare professionals visit when required. There is a consultation room for residents to be seen in private. Equipment for moving and handling purposes and pressure relief are provided. The system for medications has improved and records inspected were satisfactory.
Cornwallis DS0000009008.V293721.R01.S.doc Version 5.1 Page 6 Activities take place and residents can choose whether they join in. Some residents are able to go out accompanied by members of staff; trips to town or a pub are arranged. The registered manager hopes to improve trips out over the summer months and hopes to get the regular use of a bus. Staff said residents could receive visitors at any time; the visitor’s book showed several people visit the home each day. The food provided is to a good standard and appropriate assistance is given to residents at meal times. Meals are unhurried and relaxed. Snacks and drinks are available between meals. Residents said they enjoyed their meals and had enough to eat. Suitable policies are in place for dealing with complaints and prevention of abuse. Staff have also received relevant training on how to recognise and report incidents of abuse. There have been no complaints and adult protection incidents have been dealt with appropriately. The home provides a warm, clean, homely environment that is free from odours. The building is well maintained and the garden is tidy and accessible. Suitable numbers of staff are employed with a qualified nurse on duty at all times. Staff receive appropriate NVQ training and the registered manager said that 95 of care staff have achieved at least NVQ level 2 in care. Recruitment procedures are robust and appropriate checks are undertaken. There is a training policy and staff receive relevant training. The registered manager is competent to run the home and keeps herself up to date with current issues regarding her client group. She undertakes training appropriate to her role and is the trainer for moving and handling and fire safety. Staff said the registered manager is very fair and consistent and runs the home well. The home has a satisfactory quality assurance process in place that includes a system of auditing complaints, discussing improvements and completing a survey to ascertain the views of residents and their representatives. Resident’s money is handled safely and residents have their own bank accounts. Good records are maintained and receipts are kept. Health and safety systems are in place and statutory training is provided for staff. Health and Safety and fire risk assessments have been undertaken. Accidents are reported and audited by the registered manager. What has improved since the last inspection?
All care staff have been issued with new uniforms, green tunics and trousers, all staff spoken with said they are much better and very comfortable. The registered manager said that 95 of care staff are now qualified to at least NVQ level 2 in care; this is excellent progress. Activities provided are more varied and there are plans to increase trips out over the summer months. Room four has been decorated and new carpet is awaited for the room. Lighting has been improved in the resident’s toilets downstairs with back up lights provided for use in the event of a power cut. New trolleys have been provided to store the care notes and six new commodes have been purchased.
Cornwallis DS0000009008.V293721.R01.S.doc Version 5.1 Page 7 The registered manager has made significant improvements to the homes record keeping and quality assurance processes over the past year. She has undertaken training enabling her to train the staff in moving and handling and fire safety and has taken on this responsibility very well. 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. Cornwallis DS0000009008.V293721.R01.S.doc Version 5.1 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 Cornwallis DS0000009008.V293721.R01.S.doc Version 5.1 Page 9 Choice of Home
The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 3, 6 is N/A Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents are only admitted to the home following an assessment of their needs, however, the pre admission assessment process must be complete to ensure the home can provide appropriate individualised care. EVIDENCE: Evidence was provided in the form of records, interviews with service users, and discussion with the registered manager. The statement of purpose had been reviewed previously. Several resident files were inspected. Records show that a senior member of staff assesses prospective residents before admission is arranged. Some assessment forms inspected had been completed in detail however one inspected as part of an adult protection investigation recently had not been fully completed dated or signed by the person completing it. The registered manager said she had addressed this with staff, however, it will be checked on future visits to the home.
Cornwallis DS0000009008.V293721.R01.S.doc Version 5.1 Page 10 The home does not provide intermediate care. The registered manager said she would make this clear in the statement of purpose. Cornwallis DS0000009008.V293721.R01.S.doc Version 5.1 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 the following standard(s): 7, 8, 9 & 10 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Individual care plans are generated for each resident; the new format when fully implemented will better inform and direct the staff in the care provision. Residents have access to health care services as necessary to ensure their assessed needs are met. There is a suitable system in place for dealing with service users medicines; ensuring the policy is more specific to the home and recording all medicines disposed of will better assure service users safety. Systems are in place to ensure that residents are respected and their privacy is upheld EVIDENCE: Evidence was provided in the form of records, interviews with residents, relatives and staff and discussion with the registered manager. Several resident files were inspected. Records show that residents have a care plan, and there is evidence that these are regularly reviewed. The plans set out their personal, health and social care needs, including needs relating to their individual and diverse backgrounds such as their age, cultural background, physical and sensory ability, sex, sexuality and religion, as appropriate. The plans must be compiled with the resident or their representative whenever
Cornwallis DS0000009008.V293721.R01.S.doc Version 5.1 Page 12 possible. The registered manager had discussions with relatives during the inspection regarding suitable age related activities and social interaction for a resident. Some of the files inspected had not been transferred to the new documentation and were therefore incomplete, staff had to refer to both files. The new documentation has not yet been audited but this is intended to take place soon and every two months there after. Records of daily events for each individual resident are kept and appear comprehensive. Daily records inspected in depth recently as part of an adult protection investigation showed a lack of continuity and detail. A GP visits the home every week and a psychiatrist visits every month, the community specialist nurses are also involved when required. Pressure relieving equipment is in use and there are 25 adjustable nursing beds. Although individual records regarding wound care are maintained a record must be kept of the ongoing incidence of pressure sores. There is equipment for moving and handling purposes and the Registered Manager has undertaken a course enabling her to be the home’s moving and handling trainer. The home has access to an occupational therapist and physiotherapy can be arranged via the GP. The inspectors spoke to several residents who said their personal care and health care needs were met by staff. Relatives also said the care provided is good. The medication system was inspected and has improved. Storage and administration records were satisfactory. Each member of staff responsible for administering medication needs to receive an update regarding the handling of medication, and the registered persons must arrange this. She said training is going to be arranged with the pharmacist. The medicines policy must state what the home actually does; at present it is a very generic policy. Disposal of medicines is satisfactory however medicines refused or dropped on the floor and so on must be recorded as being disposed. Staff were observed knocking on doors prior to entering, during the inspection, although most residents were in the lounges. Curtain screens are provided in shared rooms. There is access to a telephone in the office. GP consultations are conducted in a private room specifically for that purpose. There is a privacy and dignity policy available to staff. Cornwallis DS0000009008.V293721.R01.S.doc Version 5.1 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 the following standard(s): 12, 13, 14 & 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home provides a range of activities and aims to offer a lifestyle that meets individual service users needs. Links with family and friends are good and allow residents 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 residents are well catered for with a varied selection of food available that aims to meet their taste and preference; appropriate support is given to assist residents to eat their meals. EVIDENCE: Evidence was provided in the form of records, interviews with residents, relatives, and staff. Activities were observed and discussion took place with the registered manager. Some activities take place in the home and residents can choose whether to join in. The registered manager said they are hoping to take some residents to the theatre and the regular use of a bus is being looked into. She hopes to take about twelve residents out on a picnic. She said the garden is being used much more and a resident’s friend has been coming in to do poetry readings. Residents, the inspector was able to speak to, say they could choose what time they get up and go to bed. Interaction between staff and residents seems
Cornwallis DS0000009008.V293721.R01.S.doc Version 5.1 Page 14 positive. Staff said residents could receive visitors at any time; the visitor’s book showed several people visit the home each day. There is a revolving menu, but there is evidence staff provide residents with a choice of meals according to their wishes and needs. Special diets are catered for. The inspector observed the main meal and staff seemed to provide residents with suitable support over the mealtime. Residents, the inspector was able to speak to, all said they enjoyed their meals and said they had enough food. The meal prepared on the day of the inspection appeared appealing and well presented. It was one resident’s birthday on the day of inspection and a special cake was made and enjoyed by the residents. The home has a policy that restricts visitors during mealtimes to respect resident’s privacy and dignity. The registered manager said that risk assessments are undertaken as some residents benefit from a relative being present at mealtimes. Cornwallis DS0000009008.V293721.R01.S.doc Version 5.1 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 the following standard(s): 16 & 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home has a satisfactory complaints procedure that ensures complaints are listened to and acted upon. Arrangements are in place for the protection of residents safeguarding them from harm or abuse. EVIDENCE: Evidence was in the form of policies, records and talking with the registered manager. There is a suitable complaints policy in the home; a minor adjustment was made to the policy during the inspection. The policy is available to staff and is included in the statement of purpose. There is a checklist that forms part of the admission process and includes giving a copy of the statement of purpose to new residents or their representative. There is a file for holding thank you letters and cards. There have been no complaints since the last inspection. There is an appropriate adult protection policy that includes local authority procedures. There is also a whistle blowing policy. Almost all staff have now received POVA training. The Nursing and Midwifery Council are investigating an alleged POVA incident, regarding a nurse in March 2005. One ex member of staff has been referred for inclusion on the POVA register following investigations of an incident that occurred in October 2005.
Cornwallis DS0000009008.V293721.R01.S.doc Version 5.1 Page 16 A family recently raised concerns regarding the care of their father in the home; issues are being investigated by the Adult Social Care Department. The family were advised to lodge a complaint to the home. CSCI inspected documentation in respect of the resident and four requirements were notified. The registered manager is addressing the issues. Cornwallis DS0000009008.V293721.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 22 & 26 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. A satisfactory environment is provided for residents that is safe and well maintained, a more varied colour scheme would enhance the appearance and benefit residents with dementia. Assisted bathing facilities must be provided. Bathing facilities are provided but need improvement for people who are frail and disabled. The home is clean and free from offensive odours making it a pleasant place to live in. EVIDENCE: The inspectors toured the building. The home is very clean, and appears generally safe. There are two large lounges, which are pleasantly decorated and well furnished. The home smells pleasant. The entrance hall and downstairs hallway is well decorated and furnished. The carpets in the main shared areas have been replaced in the last year, and are a great improvement. Bedroom corridors, bathrooms and bedrooms tend to be painted white. This detracts from creating a homely feel at Cornwallis, and does little to reflect the
Cornwallis DS0000009008.V293721.R01.S.doc Version 5.1 Page 18 individuality of residents. It also must create difficulty for people who are confused or have dementia to find their way around. The registered persons subsequently need to make improvements to these areas. It is also recommended they seek advice specialists such as Dementia Voice, regarding appropriate decoration and colour schemes. There are several books available to assist homes to provide suitable decoration for people with dementia. References are available from the inspector. Bathroom facilities need improvement. Many of the bathing facilities are domestic in type and not suitable for residents who are in pain and / or have mobility problems. Facilities therefore must be improved for example the provision of assisted bathing facilities for residents such as a ‘Parker’ type bath and / or walk in shower. Laundry facilities are satisfactory. There are some ongoing problems with the name tagging of clothing, although the registered manager is trying to address this issue. Cornwallis DS0000009008.V293721.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 & 30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Staffing levels appear to be satisfactory so residents can be assured they will receive appropriate levels of support from staff. Residents’ benefit from an excellent number of care staff trained to at least NVQ level 2 in care. Recruitment procedures are robust and offer protection to the service users. Staff training needs improvement so staff receive training required by law. EVIDENCE: Evidence was provided in the form of records, talking with staff and discussion with the registered manager. The rota was inspected, and the inspector was provided with the names of staff on duty on the day of the inspection. There seemed to be suitable numbers of staff on duty. On the day • From • From • From of the inspection the following staff were on duty: 0800 to 2000 2 nursing staff. 0800 to 1400 6 care staff. 1400 until 2000 8 care staff. Waking night staff are provided. Auxiliary staff such as cooks, cleaners and maintenance staff are also provided. Cornwallis DS0000009008.V293721.R01.S.doc Version 5.1 Page 20 Staff support was observed to be professional and competent. Residents said staff were supportive, friendly and caring. Staff records were inspected, and information obtained for recruitment purposes was satisfactory. The registered manager appears to have a satisfactory approach to ensuring staff have a National Vocational Qualification in care. The registered manager said 95 of staff have an NVQ either at level 2 or 3. However, copies of NVQ certificates must be kept on file so the Commission can be provided with suitable evidence to assess this standard. There is a robust recruitment procedure. Staff files inspected were kept tidy and the records and checks required by legislation were maintained. The registered provider’s approach to staff training needs improvement. By law all staff must have moving and handling, fire and infection control training. The law also states there must always be one approved first aider on duty. All food handlers such as the cooks, and care staff handling food, must have a foodhandling certificate. New staff must also receive a comprehensive induction. Records inspected show some gaps in training required by regulation, and some certificates were not available for inspection. However moving and handling training seems satisfactory. Training must be provided to all staff that handle medication, and there must be evidence of attendance. The registered manager said staff receive training regarding dementia awareness, however there was insufficient evidence that all staff had received this (e.g. a certificate). There was evidence in staff files that new staff had received an induction. There was evidence that some staff had received some other training, for example challenging behaviour, death and dying and the prevention of abuse. Cornwallis DS0000009008.V293721.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 & 38 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The Registered Manager is a registered mental nurse who keeps up to date with issues regarding the elderly; she is fit to run the home. A suitable quality assurance policy and procedure is in operation to enable residents and their relatives to be consulted about the home. There is a suitable system in the home for dealing with residents’ money, information must be added to the policy to ensure that residents’ financial interests are safeguarded when the registered manager is not in the home. Health and safety measures are adequate but need some improvement so residents can be assured they live in a safe environment. EVIDENCE: Evidence was provided in the form of policies, records, talking with staff and discussion with the registered manager.
Cornwallis DS0000009008.V293721.R01.S.doc Version 5.1 Page 22 The registered manager is competent to run the home. She is a qualified mental nurse and has almost completed the Registered Managers’ Award. She is the home’s trainer for moving and handling and fire safety and has recently undertaken POVA training. She said she is two thirds of the way through a venepuncture course and in July she is going on a course for the assessment and appraisal of staff. She keeps herself up to date on current issues by reading relevant magazines and surfing the internet. Staff said the registered manager runs the home well, is very approachable and treats everyone very fairly. The home has a satisfactory quality assurance process in place. This includes a system of auditing complaints, discussing what improvements are required with staff, and completing a survey to ascertain the views of residents and their representatives. It is also clear the registered manager has made significant improvements to the management of the home in the last year. There is a policy for the safekeeping of resident’s money that includes a limit on how much money can be held per person. It must include the procedure for staff to follow out of office hours or when the registered manager is not available. Pocket money is held for all residents and they all have their own bank accounts. There is an audit sheet for each resident and all transactions have two signatures. The records are also checked at random each month by the accounts department. The money checked was correct. The registered manager said that relatives could have a copy of the records on request. Receipts are kept. The home has a health and safety policy. Health and safety records were inspected. A fire risk assessment is in place. There is a suitable system to test fire alarm call points and emergency lighting. The home has a satisfactory moving and handling policy, and there is evidence hoists are tested. Evidence of lift maintenance was not inspected on this occasion. There is a policy regarding the prevention of Legionella and a risk assessment is in place regarding this. Portable electrical appliances were last tested in October 2005. There is no evidence the five yearly electrical hardwire test has been completed. The boiler and gas appliances were tested on 13/4/06. The inspector tried to seek assistance from staff via the nurse call system. The particular call point did not seem to work. The registered manager said there had been ongoing problems with the system. The system must be checked as a matter of priority to ascertain if any other call points do not work, and appropriate action must be taken to ensure the system works satisfactorily. There is a programme of health and safety training required by law, although some gaps were highlighted in the previous section of the report.
Cornwallis DS0000009008.V293721.R01.S.doc Version 5.1 Page 23 Cornwallis DS0000009008.V293721.R01.S.doc Version 5.1 Page 24 SCORING OF OUTCOMES
This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from:
4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable
CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 3 11 N/A 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 N/A 18 3 2 X X 2 X X X 3 STAFFING Standard No Score 27 3 28 4 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 2 Cornwallis DS0000009008.V293721.R01.S.doc Version 5.1 Page 25 Are there any outstanding requirements from the last inspection? YES STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP7 Regulation 15 (1) Requirement Care plans must be compiled with the resident or their representative whenever possible A record must be maintained of the incidence of pressure sores Medicines dropped on the floor or refused must be recorded as disposed of The medicines policy must state what the home actually does The registered persons must develop a programme to redecorate corridors, bedrooms and bathrooms etc. to create a more diverse colour scheme. The programme should be completed at least by June 2008. This will assist people with dementia and /or are confused. The registered persons should seek advice from e.g. Dementia Voice, regarding appropriate decoration and colour schemes for people with dementia. The registered provider must improve bathing facilities throughout the home. The
DS0000009008.V293721.R01.S.doc Timescale for action 01/07/06 2 3 4 5 6 OP8 OP9 OP9 OP19 17.1(a) Sch 3(n) 13(2) 13(2) 16, 23 01/07/06 22/05/06 01/07/06 01/09/06 7 OP21 16, 23 01/09/06 Cornwallis Version 5.1 Page 26 8 OP30 18 9 OP30 18, 19 registered provider must provide the Commission with an action plan outlining what improvements will be made giving suitable timescales. The registered persons must provide staff with suitable training: (1) As required by regulation such as fire training, first aid (as applicable), food hygiene (as applicable), infection control and manual handling. (2) All staff who handle medication must have suitable external training (3) All staff must have training regarding people with mental health needs and dementia. There must be evidence staff have received suitable training (e.g. copies of National Vocational Qualification and other training certificates). The registered persons must: Expand the training policy to state what specific training individual staff will receive by when. Provide all staff with appropriate training as required by regulation (e.g. fire training, manual handling, food handling, infection control and first aid). All training provided must meet legal requirements. 01/11/06 01/07/06 10 OP35 11
Cornwallis OP38 The policy for resident’s money must be reviewed to include the action to be taken by staff in the absence of the registered manager. 12, 13, 23 The registered persons must
DS0000009008.V293721.R01.S.doc 13(6) 01/07/06 01/07/06
Page 27 Version 5.1 12 OP38 13, 23 take appropriate action to ensure the nurse call system is working effectively. The registered persons must 01/07/06 ensure the home’s electrical hardwire circuit is tested and ensure documentation of this is available for inspection. Testing must be completed at least every five years 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 OP7 OP27 Good Practice Recommendations The new care plans need to cover residents’ social history The domestic staff should work their contracted hours solely in the home and not be responsible for the Porthia offices at the same time All staff should have terms and conditions of employment and a job description The registered manager is advised to check that current in-house training programmes meet legal requirements with the appropriate regulatory body (e.g. fire authority and Health and Safety Executive) 3 4 OP29 OP30 Cornwallis DS0000009008.V293721.R01.S.doc Version 5.1 Page 28 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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