CARE HOMES FOR OLDER PEOPLE
Cornwallis Trewidden Road St Ives Cornwall TR26 2BX Lead Inspector
Diana Penrose Unannounced Inspection 24th February 2006 09:30 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information
Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Cornwallis DS0000009008.V284466.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.V284466.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.V284466.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION
Conditions of registration: Date of last inspection 2nd September 2005 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. Residents 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. All rooms have call bells and one assisted bathing facility is provided. The garden area is secure and accessible to residents. There are opportunities for socialising and visitors are openly encouraged. Cornwallis DS0000009008.V284466.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 24 February 2006 and spent the day at the home. This was an unannounced visit. The purpose of the inspection was to gain an update on the progress of compliance to requirements identified in the last inspection report dated 04.05.05 and the last visit to the home on 27.01.06. In addition the inspectors focused on the following key areas of care: assessment and care planning, healthcare, leisure, complaints, adult protection, some of the environment, staffing, recruitment, training, quality assurance, residents money and Health and Safety On the day of inspection 31 residents were living in the home. The methods used to undertake the inspection were to meet with a number of residents, staff and the registered manager to gain their views on the services offered by Cornwallis. Records, policies and procedures were examined and the inspectors toured the building. This report summarises the findings of this inspection. 12 requirements and 8 recommendations have been notified in this report however it is acknowledged that 22 requirements and 13 recommendations have been complied with since the last inspection. The inspectors have continued to monitor the home on a monthly basis since the last statutory inspection. The home has also received considerable help and support from health and adult social care services. This along with the appointment of a registered manager and financial input from the registered provider has seen a significant improvement in the care and services provided at Cornwallis and they are to be congratulated. 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. 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. Prospective residents are assessed prior to admission to ensure the home can meet their needs. The new format includes risk assessments to make it more comprehensive. Each resident has a care plan compiled from the initial assessment, improvements are being made to the care planning documentation. A GP visits the home each week and a psychiatrist each month, dentists and other healthcare professionals visit when required. A GP and a dentist told the inspector that the care in the home had improved significantly and they were satisfied with the care provided.
Cornwallis DS0000009008.V284466.R01.S.doc Version 5.1 Page 6 Equipment for moving and handling purposes and pressure relief are provided. Staff treat residents with respect and interact well with them. Activities take place and a programme is displayed in each lounge. Some residents are able to go out accompanied by members of staff; trips to town or a pub are arranged. 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. 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. Suitable numbers of staff are employed with a qualified nurse on duty at all times. Staff receive appropriate NVQ training and 50 of care staff have achieved at least NVQ level 2 in care while others are on the course. Recruitment procedures are robust and appropriate checks are undertaken. The records required by legislation are on file. There is a training policy and staff receive relevant training. Resident’s money is handled safely. 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?
The registered manager has complied with 22 of the requirements and 13 recommendations notified at the last inspection. Changes have been made to the care planning process since the last inspection and further changes are taking place. The style of care plan is a vast improvement. The medicines policy has been reviewed and updated with other improvements made around medicines. Other policies have been updated and staff said they were aware of these. The residents’ lounges have been redecorated with new carpets fitted and pictures hung on the walls. Some resident’s rooms have also been decorated with new carpet supplied. A new bath chair has been provided in the assisted bathroom and twenty-five hospital style beds have been supplied. The services provided for GP and other health care consultations have improved, with a room dedicated for the purpose. The medications room has been refurbished and decorated with new medicines trolleys provided. Improved services have been provided by the local GP surgery including training for staff. Monthly psychiatrist visits take place. Staffing levels have improved with further qualified nurses and care staff employed. Where it is necessary for an RN to be in charge of the home as opposed to an RMN a competency assessment has been completed by the registered manager. The recruitment procedures have improved with necessary checks made. Staff training has increased and 50 of care staff are now qualified to at least NVQ level 2 in care. Almost all staff have undertaken adult protection training.
Cornwallis DS0000009008.V284466.R01.S.doc Version 5.1 Page 7 The registered manager has qualified as a moving and handling trainer and has provided training for staff who were not up to date. It is hoped that new uniforms will be provided for staff, one carer was wearing the proposed uniform, a tunic with trousers suitable for moving and handling practices. 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.V284466.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.V284466.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 Residents are only admitted to the home following an assessment of their needs to ensure the home can provide adequate care. EVIDENCE: The Registered Manager stated that she or her deputy visit prospective residents to assess their needs prior to any decision being made to admit them to the home. The assessment is undertaken with the resident when possible with the assistance of their family. Other health professionals are involved when necessary. A new format is in use and relevant risk assessments are included. The Registered Manager said she always obtains the Social Services assessment for prospective residents as well. There is evidence of assessments undertaken but the person not admitted, as the home is not suited to meet their needs. Cornwallis DS0000009008.V284466.R01.S.doc Version 5.1 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, 8 and 10 Individual care plans are generated for each resident; the new format when implemented should 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. Systems are in place to ensure that residents are respected and their privacy is upheld EVIDENCE: Staff said all residents have a care plan. Current care plans contain information such as pre admission assessments and specialist assessments. Records of daily occurrences and medical interventions by external professionals are kept. The staff team are in the process of developing new care plans for all residents and the registered manager said these should all be implemented in 4 weeks. She intends to audit the care plans every 2 months. The new format needs to expand coverage of issues such as resident’s likes / dislikes and residents’ social history. Care plans must be updated as changes occur; one resident is receiving treatment for pressure sores which is recorded in the wound file but she has no care plan in respect of pressure area care. Nursing staff complete day-to-day notes and care plans. The inspector spoke to several care assistants who said they could access care plans if required.
Cornwallis DS0000009008.V284466.R01.S.doc Version 5.1 Page 11 One inspector spoke to a general practitioner, and a dentist who were happy with care provided. The general practitioner said he felt there had been significant improvement regarding the care given to residents. A GP visits the home every week and a psychiatrist visits every month, the community specialist nurses are also involved as required. Pressure relieving equipment is in use and 25 adjustable nursing beds, with mattresses, have been purchased. Although individual records regarding wound care are maintained a record must be kept of the incidence of pressure sores. There is equipment for moving and handling purposes and the Registered Manager has recently undertaken a course to be the homes moving and handling trainer. The home has access to an occupational therapist and physiotherapy can be arranged via the GP. Staff were observed knocking on doors prior to entering during the inspection although most residents were in the lounges. Curtain screens are provided in the shared rooms. There is access to a telephone in the office. GP consultations are conducted in a private room specifically for that purpose. Staff said they are aware of the privacy and dignity policy and it had been discussed at recent staff meetings. Cornwallis DS0000009008.V284466.R01.S.doc Version 5.1 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): 12, 13 and 15 Satisfactory activities are provided however the registered manager should ascertain if further opportunities can be made available for recreation / stimulation to meet residents lifestyle needs. 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: A programme of activities is displayed on the notice boards in both lounges. On the day of the inspection there was a singsong. The activity took place in one lounge and lasted approximately half an hour. The inspectors spoke to several care assistants. One care assistant said she was able to support residents to go out to the pub or escort some on a trip into town. This seems excellent practice. One inspector spent most of the day observing care practices in both lounges. A member of staff was always available in each lounge to assist residents, and a satisfactory level of interaction between staff and residents was observed. The registered manager said usually the radio would be on in the morning in both lounges, and the television would be on in the afternoon. Although the television was on in the afternoon, the volume was so low it was doubtful most residents could hear it, and even if they could, many people may lack the skills to understand it. Most of the residents in one lounge did not react at all when
Cornwallis DS0000009008.V284466.R01.S.doc Version 5.1 Page 13 the television was turned off and replaced with some music. The registered manager should reassess current activities, which are provided and ascertain if further opportunities can be made available. The registered manager said opportunities for religious observation are provided. For example a priest from the Church of England visits each Sunday to give Communion. Another religious minister visits the home at least weekly. One inspector enjoyed a meal with residents and observed that most people ate all their meal. Staff provided appropriate support, and the meal was unrushed and relaxed. Suitable refreshments were provided. Three meals are provided each day with drinks and snacks in between. Breakfast is usually served between 0900 and 0930 although this can be flexible. Food is pureed if necessary and special diets are catered for. Some residents have their meals in their bedrooms. Cornwallis DS0000009008.V284466.R01.S.doc Version 5.1 Page 14 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 and 18 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: There is a suitable complaints procedure. There are specific forms for recording complaints and the action taken. Thank you cards and letters are kept. There have been no complaints since the last inspection. Policies regarding abuse and whistle blowing were inspected and seem satisfactory. The registered manager said most staff have now attended training regarding protecting residents from abuse. Copies of certificates were available on staff files. Care practices were observed to be to a good standard. Cornwallis DS0000009008.V284466.R01.S.doc Version 5.1 Page 15 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, 20, 21, 22, 24, 26 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. Communal areas are spacious and provide a comfortable environment. Bathing facilities are provided but need improvement for people who are frail and disabled. Resident’s bedrooms are personalised with their possessions making them feel at home. The home is clean and free from offensive odours making it a pleasant place to live in. EVIDENCE: The décor and the new carpet in the lounges have improved the appearance of these rooms and eliminated the odour that used to be very apparent. The conservatory on the first floor is currently out of use for repairs. The number of bathrooms and toilets is satisfactory, although there is currently no specialist bathing facility / walk in shower. A bath chair is provided in the bathroom that is used most. A lock to one of the bathrooms was broken, but the registered manager said she would arrange for this to be repaired as soon as possible.
Cornwallis DS0000009008.V284466.R01.S.doc Version 5.1 Page 16 Although the two lounges have been decorated in pastel colours, the majority of the interior walls are painted white. Not only does this detract from making the building homely, it must make recognition difficult for many of the residents-particularly those who have dementia. The registered manager said she is beginning to use different colours in different rooms. The process needs to continue, as bedrooms and some communal areas need redecoration. The building seemed clean and hygienic. Bedrooms are personalised to varying degrees according to individual tastes. Furnishings provided are to a good standard. The building was warm and levels of light are satisfactory. There were no unpleasant odours at the time of inspection. Sluice facilities are provided. Laundry facilities seem satisfactory. Cornwallis DS0000009008.V284466.R01.S.doc Version 5.1 Page 17 Staffing
The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission 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 and 30 Staffing levels meet the needs of residents and staff morale appears to be good. Recruitment procedures are robust and offer protection to the residents. Residents are in safe hands and benefit from the number of care staff that have an NVQ qualification. There are some gaps in staff training required by regulation this could put staff and residents at risk. EVIDENCE: Rotas were inspected. There is always a RGN (Registered General Nurse) and RMN (Registered Mental [health] Nurse) on duty from 0800 to 2000. Either an RMN or a competent RGN nurse is on duty between 2000 and 0800, with an RGN always on call. On the day of the inspection one Senior Care Assistant, and four Care Assistants were on duty between 0800 and 2000, with one Care Assistant off sick. Between 2000 and 0800 one senior and three care assistants were on duty. The inspector was able to observe care practices and the number of staff available appeared to be satisfactory. 50 of care staff have achieved at least the NVQ level 2 in care. 4 others are undertaking the course and 2 have enrolled. Staff files contain satisfactory information and show that staff employed have appropriate skills and qualities to work with vulnerable people. For example all they contain a copy of a Criminal Records Bureau (CRB) check, and, as necessary, a Protection of Vulnerable Adults (POVA) check. Two satisfactory references are obtained. The registered provider has a training policy. This needs to be more comprehensive to state what training specific staff grades will receive. Training records were examined for several staff. Some gaps in the training required by
Cornwallis DS0000009008.V284466.R01.S.doc Version 5.1 Page 18 regulation are noted in respect of first aid, infection control and food hygiene training. Manual handling training and fire training, for staff files inspected, appears satisfactory. The registered manager said currently staff receive training in all five areas required by regulation (i.e. manual handling, first aid, food hygiene, infection control, and fire). As long as there are appropriately qualified staff always on duty, all staff may not need to have training in food hygiene and first aid, but the registered provider needs to qualify its position in the training policy. Some staff have received other training such as health and safety, communication, swallowing, and adult protection. The registered manager said the majority of staff are currently undertaking training regarding the needs of people with dementia. Records of induction are satisfactory for staff recently recruited, but missing for others. The registered manager said this was because induction had not been completed for these staff and/ or records were waiting to be signed off. The registered manager said fire training, infection control, food handling and manual handling training is being delivered in house. The inspector said any training delivered in-house must be by an appropriately qualified person. The registered manager said ‘Croners’ had audited the health and safety training provided and said it was acceptable. The registered manager is however advised to check current in-house training programmes meet legal requirements with the appropriate regulatory body (e.g. fire authority and Health and Safety Executive). Cornwallis DS0000009008.V284466.R01.S.doc Version 5.1 Page 19 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 The home is run in the best interest of the residents, however quality assurance systems need to be improved. There is a suitable system in the home for dealing with residents’ money that ensures that the residents’ financial interests are safeguarded. Health and safety precautions are currently unsatisfactory, and could put residents and staff at risk. EVIDENCE: Quality assurance surveys have not taken place for some time, it is recommended that they recommence and a report of the findings be sent to the Commission. Staff meetings take place and minutes are kept. The registered manager said she talks to visitors regularly and comments are recorded in the daily records. The relatives meetings have stopped because of poor attendance. Accidents are audited and the new care plans will be audited. The registered manager said the registered provider would be completing the regulation 26 reports now that the operations manager has left.
Cornwallis DS0000009008.V284466.R01.S.doc Version 5.1 Page 20 There is a policy for the safekeeping of resident’s money; this needs to include the procedure for staff to follow out of office hours. Two signatures are recorded for all transactions and receipts are maintained. The money checked was correct. The organisation’s health and safety policies include a general health and safety policy, and policies regarding COSHH, Legionella and infection control. ‘Croners’ also complete a twice-yearly audit of health and safety standards. The last audit completed in June 2005 outlined a number of areas for improvement. COSHH data sheets for chemicals and cleaning materials appear satisfactory. Accidents appear to be appropriately reported and audited. Staff seem aware of residents who are subject to regular falls, and suitable strategies to minimise these are adopted. Since the last inspection there have been no accidents, which have needed to be reported to the Health and Safety Executive under RIDDOR. Other incidents are recorded in an incident file. Health and safety risk assessments are in place. These were last completed on 04/01/06 and there is a fire risk assessment. Although there is a risk assessment regarding the prevention of Legionella, this does not state what control measures are in place. No records appear to be kept regarding regular checks. However one of the maintenance staff said he believed some checks were completed but he was unable to locate the records. Action must be taken to document checks. Hot water temperatures to prevent scolding are monitored and records are kept of this. Fire call points are tested weekly and a record is kept of this. It is recorded on the weekly checklist that lighting is checked ‘monthly’, although it is unclear what specific tests are completed e.g. visual check, battery run down etc. The registered persons must check with the fire authority what checks, at what frequency, must be completed. These must be implemented and records clearly maintained. A qualified engineer last checked the lift, and moving and handling equipment, in September 2005. The registered manager was not clear at what frequency this work is carried out. It appears before this date the equipment was checked more frequently. The registered persons need to ascertain whether the equipment now needs to be retested, and ensure this is completed according to the manufacturers guidance. There is no record that the home’s electrical hardwire circuit has been tested in the last five years. The registered persons must arrange this, if it has not been done, or alternatively provide the Commission with suitable documentation. Gas appliances and the boiler were last serviced in July 2004. Again appliances must be tested on an annual basis and a gas appliance safety certificate must be obtained on an annual basis. Cornwallis DS0000009008.V284466.R01.S.doc Version 5.1 Page 21 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 X 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 X 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 3 3 X X 3 X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X X 2 X 3 X X 1 Cornwallis DS0000009008.V284466.R01.S.doc Version 5.1 Page 22 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 OP7 15 Standard Regulation Requirement The home must evidence that monthly reviews of care plans, in consultation with service users and their representatives, are undertaken The home must update the care plans as changes occur and consult the service user or representative of the changes The falls risk assessment must outline what staff do to minimise falls Care plans must fully inform and direct staff in the care to be provided A record must be maintained of the incidence of pressure sores 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
DS0000009008.V284466.R01.S.doc Timescale for action 01/07/06 2 OP7 15 01/04/06 3 4 5 6 OP7 OP7 OP8 OP30 13(4) (c) 15 17.1(a) Sch 3(n) 18, 19 01/04/06 01/07/06 01/07/06 01/07/06 Cornwallis Version 5.1 Page 23 7 8 OP38 OP38 13 13, 23 9 OP38 13, 23 must meet legal requirements. Issues identified in the Health and Safety audit must be addressed The registered persons must take satisfactory precautions regarding the prevention of Legionella: • The policy regarding the prevention of Legionella must document what control measures are in place. • Advice regarding control measures must be sought from suitably qualified persons as necessary. • Suitable checks must be documented, and records must be available for inspection. The registered persons must ascertain what checks on emergency lighting must be completed by regulation with the fire authority, and at what frequency. These must be implemented and records clearly maintained. 01/07/06 01/07/06 01/04/06 10 OP38 13, 23 11 OP38 13, 23 12 OP38 13, 23 The registered persons must 01/04/06 ascertain if the lift, and other moving and handling equipment needs to be serviced. Equipment must then be tested at frequencies recommended by the equipments’ manufacturer. Gas appliances and the boiler 01/04/06 must be serviced on an annual basis. A gas appliance safety certificate must be obtained on an annual basis. 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
DS0000009008.V284466.R01.S.doc Version 5.1 Page 24 Cornwallis 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 3 Refer to Standard OP7 OP12 OP24OP22 OP19 Good Practice Recommendations The new care plans need to expand the coverage of issues such as resident’s likes / dislikes and residents’ social history The registered manager should reassess the activities provided and ascertain if further opportunities can be made available. The registered provider should consider a more varied colour scheme throughout the home as rooms and communal areas need redecoration. This will not only make the home more homely, but will assist residents with dementia. Appropriate specialist guidance for people with dementia should be followed. A walk in shower and assisted bath facilities should be provided. 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) There should be a procedure for service user’s money that includes what the staff should do out of office hours. 4 5 6 7 OP21OP22 OP27 OP29 OP30 8 OP35 Cornwallis DS0000009008.V284466.R01.S.doc Version 5.1 Page 25 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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