Inspection on 05/09/05 for Cornwallis

This inspection was carried out on 5th September 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. 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

Cornwallis 11/02/10

Cornwallis 22/10/09

Cornwallis 28/07/09

Cornwallis 23/10/08

Cornwallis 02/11/07

Cornwallis 23/05/07

Cornwallis 22/05/06

Cornwallis 24/02/06

Cornwallis 03/03/05

Cornwallis 20/09/04

Cornwallis 08/03/04

Similar services:

Fairfields Country Rest Home

Trevaylor Manor

Stallcombe House

Stroud Lodge

The Woodmill

Woodland Vale

Bolealler House

Fairfax House

Extracts from inspection reports are licensed from CQC, this page was updated on 08/07/2008.

CARE HOMES FOR OLDER PEOPLE Cornwallis Trewidden Road St Ives Cornwall TR26 2BX Lead Inspector Diana Penrose Unannounced 05 September 2005 09:30 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 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 D52-D04 S9008 Cornwallis V245537 050905 Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Cornwallis Address Trewidden Road St Ives Cornwall TR26 2BX 01736 796856 01736 797143 info@porthiaproperties.com Cornwallis Care Services Limited Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Mrs Sherran Thompson - Manager Designate 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 D52-D04 S9008 Cornwallis V245537 050905 Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: None Date of last inspection 03/03/05 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 service users with a dementia or mental health problem. Service users’ accommodation is spread over three floors. Service users 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 assisted bathing facilities are provided. The garden area is secure and accessible to service users. There are opportunities for socialising and visitors are openly encouraged. Cornwallis D52-D04 S9008 Cornwallis V245537 050905 Stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. Two inspectors visited Cornwallis Nursing Home on the 05 September 2005 and spent six hours at the home. This was an unannounced visit. The purpose of the inspection was to gain an update on the progress of compliance to requirements made by the Commission and to inspect a number of standards. At the last inspection dated 03 March 2005, 37 requirements and 14 recommendations were identified. Due to the number of requirements and recommendations CSCI have been visiting the home approximately monthly to monitor the progress that the home is making. At the last visit on 11 August 2005, 38 requirements and 13 recommendations were identified. An Operations Manager has been appointed to assist the manager in running the home and external assistance has been sought from Social Services and the Primary Care Trust to help improve the standard of care provided. This inspection focused on the progress that the manager has made in the following key areas of care: choice of home, care planning, health care, leisure, complaints, and some environmental and management areas. On the day of inspection 35 residents were living in the home. The methods used to undertake the inspection were to meet with a number of residents, staff and the manager to gain their views on the services that Cornwallis offers. Cornwallis Nursing Home records, policies and procedures were examined and the inspectors toured the building. This report summarises the findings of this inspection. The Manager has complied with 12 requirements and 1 recommendation from the previous inspection visit. However 26 requirements have been re notified at this inspection a further 15 identified. CSCI remain concerned due to the high number of requirements and the amount of work that the managers and registered provider need to achieve to ensure compliance with the national minimum standards. Due to this CSCI will continue to visit the home regularly to monitor the progress that the home is making. What the service does well: The home provides accommodation that is clean, warm, comfortable and well maintained. Strides are being made to ensure it is well furbished and decorated. Residents spoken with said they are happy with their rooms. They said the staff are caring and look after them well. They also said the food is good and that they have enough to eat. Cornwallis D52-D04 S9008 Cornwallis V245537 050905 Stage 4.doc Version 1.40 Page 6 The registered provider, managers and staff at Cornwallis welcome the inspectors and other agencies to the home. They are keen to discuss ways in which to improve standards in the care provided to the residents. What has improved since the last inspection? What they could do better: Immediate requirements were issued in respect of POVA and CRB disclosures. Staff must not commence employment until a POVA disclosure has been obtained and staff awaiting the return of a CRB disclosure must work under constant supervision until the disclosure has been obtained. The recruitment and CRB policies require updating. Although it is recognised that care plans are being reviewed by the deputy manager the care documentation is in need of improvement and five requirements were identified in this area. It has been recommended that one care plan be fully updated so that the inspectors can see what documentation the home intends to have in place. Six requirements were identified in respect of medications, some of which have been identified on previous occasions, met and now identified again. The medicine policy requires reviewing and staff must be aware of the policy. This is particularly relevant to new staff working in the home. There must be a suitable skill mix of staff on duty at all times to care for the residents, especially those with complex mental health needs. There should also be job descriptions for all staff including qualified nurses. Cornwallis D52-D04 S9008 Cornwallis V245537 050905 Stage 4.doc Version 1.40 Page 7 New employees must receive induction training according to legislation; qualified nurses in particular lacked adequate recorded induction training. The manager undertakes supervision of care staff but the records require more information. All staff must be appropriately supervised and this includes the induction period. Issues pertaining to Health and Safety have been identified. An in depth Health and Safety audit has been undertaken by an outside company that identifies risks and potential to residents, staff and visitors. The documentation provided to the home includes timescales for action; the CSCI require an action plan from the registered provider as to how he intends to address this audit and reasonable timescales must be included. 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 D52-D04 S9008 Cornwallis V245537 050905 Stage 4.doc Version 1.40 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 Standards Statutory Requirements Identified During the Inspection Cornwallis D52-D04 S9008 Cornwallis V245537 050905 Stage 4.doc Version 1.40 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 standard(s) 1 Prospective residents are given information about the home but it does not enable them to make a fully informed choice of home. EVIDENCE: The statement of purpose had been sent to the Inspectors prior to this inspection. This document has improved a great deal since the last inspection. A letter is to be sent to the Manager explaining the areas that still require attention. Cornwallis D52-D04 S9008 Cornwallis V245537 050905 Stage 4.doc Version 1.40 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 standard(s) 7,9 and 11 Individual care plans are generated for each resident but do not inform guide and direct staff in their care provision. There are systems in place for dealing with resident’s medicines but they do not assure residents safety. There is a policy for death and dying that assures residents they will be treated with care, sensitivity and respect at the end of their life. EVIDENCE: Each resident has a written care plan; these are at varying stages of review and contain varying levels of information. The Deputy Manager explained that she has started reviewing the care plans and wherever possible she is getting the views and agreement from the resident and or representative. It is recommended that one care plan be fully updated so that the inspectors can review and discuss it on the next monthly visit. There were six requirements identified at the last visit in respect of care planning. It is acknowledged that this area of care is being developed but is in the early stages and further work is required. Therefore five of these requirements are re notified to the registered provider. Risk assessments are included in the care documentation, some are repeated several times. There are forms for consent to the use of restraint such as cot sides but no consent to the use of covert medication. The daily records are Cornwallis D52-D04 S9008 Cornwallis V245537 050905 Stage 4.doc Version 1.40 Page 11 informative and the care staff are now starting to write in these. The care documents are stored securely but not very accessible to care staff. The home has a medicines policy that requires reviewing and updating, this was discussed with the Manager. She is awaiting information prior to including a protocol for the use of creams. The deputy Manager said that creams are dated when opened, however none of the creams seen in use were dated. The Manager said there is a copy of the Royal Pharmaceutical Guidelines for the Administration of Medicines in Care Homes in the home. Staff were not aware of the location of this document. It was observed that all medication was stored safely and the newly refurbished medicines room and new trolley are a definite improvement. A monitored dose system is in use in the home and a qualified nurse administers the medicines at all times. No resident was self administering his or her medicines at the time of the inspection. There is not always a signature recorded for medicines administered or a reason for them being omitted. Transcribing of medicines and instructions onto the MAR charts are not signed or dated. A nurse was asked about the washing of the medicine pots was not aware of the homes policy. A new system for the disposal of medicines is being introduced. Medicines refused or dropped on the floor, for example were not recorded as being disposed. The Manager said she has requested training for the staff, in medications, from the local pharmacist. The home has a policy for the care of the dying and a separate policy for death. There is no reference to outside organisations that may be involved, for example the Macmillan service and counselling services. Cornwallis D52-D04 S9008 Cornwallis V245537 050905 Stage 4.doc Version 1.40 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 standard(s) EVIDENCE: These standards were not inspected on this occasion. Cornwallis D52-D04 S9008 Cornwallis V245537 050905 Stage 4.doc Version 1.40 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 standard(s) EVIDENCE: These standards were not inspected on this occasion. Cornwallis D52-D04 S9008 Cornwallis V245537 050905 Stage 4.doc Version 1.40 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 standard(s) 19 The home and grounds are well maintained however there are areas to be addressed to ensure a safer environment for residents, staff and visitors. EVIDENCE: The layout and decor of the home is not ideal for residents who have a dementia but it is clean, warm and comfortable. The home is in the process of being re-decorated and it is hoped that the colour schemes and environmental design will be addressed and more appropriate for those who have a dementia. No risk assessment has been undertaken in respect of staff and residents during the re-decoration of the corridors, this was discussed with the Manager. It was very noisy and one resident was quite distressed, as she could not go down the corridor by her room. New carpets for the lounges have been ordered and should address the odour problem in the communal areas. Odours in some of the bedrooms still need to be addressed. New beds have been purchased for those requiring nursing care. The carpet outside of rooms 110 and 111 is frayed and worn. Other issues to address are fire exit doors propped open, lights needing repair, tins of paint in the garden accessed by residents, doors open that should be locked and the Cornwallis D52-D04 S9008 Cornwallis V245537 050905 Stage 4.doc Version 1.40 Page 15 conservatory was unlocked while the repair work was going on. There is a lack of grab rails and aids for residents in the en suite facilities in particular. Paper towels are available in most areas and alcohol hand cleansing gel is available for staff use. Cornwallis D52-D04 S9008 Cornwallis V245537 050905 Stage 4.doc Version 1.40 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27, 28, 29 and 30 Staffing levels are suitable but the skill mix is not always appropriate for the needs of the residents accommodated. NVQ training is now provided for care staff, which should assure the residents that they are in safe hands. Recruitment procedures are not robust and do not offer adequate protection to the people living in the home. The home is endeavouring to improve training for staff so they will be more competent in their roles. EVIDENCE: Most of the qualified nurses have left the home but other nurses are being recruited. Agency nurses are employed to compensate for the present shortfall. The manager must ensure there is an appropriate skill mix of staff on duty at all times to care for the needs of the residents accommodated. There were sufficient numbers of staff on duty for the number of people living in the home. One member of staff said she works a lot of extra hours; there is no evidence that this is in compliance with the European working time directive. Residents spoken with said the staff look after them well. Seven personnel files were inspected. In general the documents required by legislation are held. There is little evidence of CRB and POVA disclosures being obtained prior to employment; immediate requirements were issued. Some staff have terms and conditions of employment and some have job descriptions. Photographs of staff should also be on file. There is some evidence of interview records but not for all staff. The Recruitment and CRB policies require review. The home are working towards 50 of their care staff trained to NVQ level 2 in care. An NVQ assessor was in the home during the inspection. She said there Cornwallis D52-D04 S9008 Cornwallis V245537 050905 Stage 4.doc Version 1.40 Page 17 are 16 care staff undertaking NVQ2 training and some doing short courses. The assessors visit every two weeks and the courses are due to complete by March 2006. There is some evidence of induction training for new employees but is lacking for the qualified nursing staff. There are individual training profiles for staff that show that individual needs have been identified. Training provided has improved since the last inspection and staff spoken with acknowledged this and felt supported by the manager in this area. Cornwallis D52-D04 S9008 Cornwallis V245537 050905 Stage 4.doc Version 1.40 Page 18 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 36 and 38 The supervision of staff is not suitable and does not assure residents safety. Some systems in the home need improvement to ensure the health, safety and welfare of the residents, staff and visitors. EVIDENCE: The manager said she is addressing supervision for staff. The supervision records are inadequate and staff appraisals were evident in the past but not now. New staff and those awaiting CRB disclosure are not adequately supervised. An external consultant has undertaken a Health and Safety audit and a comprehensive document has been compiled for the manager to address. The fire risk assessment has not been done. Statutory training is taking place with records maintained. COSHH data sheets were not available to staff. Accident recording and reporting is satisfactory. The accident audit would be more meaningful if undertaken in line with the monthly accident report headings. The number of accidents recorded has reduced over the last two months. Cornwallis D52-D04 S9008 Cornwallis V245537 050905 Stage 4.doc Version 1.40 Page 19 There is no restrictor on the window in the staff office where some records are maintained. The labels on the sharps disposal bins were not completed. Cornwallis D52-D04 S9008 Cornwallis V245537 050905 Stage 4.doc Version 1.40 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score 2 x x x x x HEALTH AND PERSONAL CARE Standard No Score 7 1 8 x 9 2 10 x 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 x 13 x 14 x 15 x COMPLAINTS AND PROTECTION 2 x x x x x x x STAFFING Standard No Score 27 2 28 2 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score x x x x x x x x 2 x 2 Cornwallis D52-D04 S9008 Cornwallis V245537 050905 Stage 4.doc Version 1.40 Page 21 yes Are there any outstanding requirements from the last inspection? 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 1 Regulation 4,6 Requirement The statement of purpose and service users guide must be updated in line with the Care Homes Regulations and National Minimum Standards. A copy of the revised version must be sent to the CSCI. The practice of segregating service users must urgently be reviewed in line with service users individual care needs assessments (previous timescale of 23/05/05 not met) There must be relevant risk assessments for all service users that are fully completed, reviewed, dated and signed. This must include those at risk of falling. The action to be taken must be recorded The home must evidence that monthly reviews of care plans, in consultation with service users and their representatives, are undertaken (previous timescale of 25/07/05 not met) The registered provider must develop service users care plans further. They must address all physical, social, educational and leisure needs and specify what Timescale for action 05/12/05 2. 7 12,15 14/11/05 3. 7, 8 12,13 05/12/05 4. 7 15 06/02/06 5. 7 14,15 18/12/05 Cornwallis D52-D04 S9008 Cornwallis V245537 050905 Stage 4.doc Version 1.40 Page 22 6. 15 7 7. 8. 9. 13 13 13 9 9 9 10. 13 9 11. 13 9 12. 13 9 13. 17, Sch 3 8 14. 12 10 15. 12,16 12 interventions/actions staff are to undertake. Training in this area must be undertaken.(previous timescale of 25/07/05 not met) The home must update the care plans as changes occur and consult the service user or representative of the changes Consent must be recorded in respect of the administration of covert medicines. All medicines for disposal must be recorded appropriately The medicines policy must be reviewed, updated and available to staff along with the Royal Pharmaceutical Society guidelines for care homes The use of creams and lotions must be included in the medicines policy and implemented (previous timescale of 30/08/05 not met) Transcribing of medicines and instructions, by staff, onto the MAR charts must be witnessed with two signatures recorded. There must be a signature recorded for all medicines administered or a reason for them being omitted. There must be a record of the incidence of pressure sores and of the treatment provided to the service users.(previous timescale of 06/06/05 not met) Cornwallis philosophy and the implementation of a policy to ensure that service users privacy, dignity and confidentiality are maintained at all times must be addressed with all members of staff. There must be a full review of service users social and spiritual needs and action must be taken to provide meaningful and stimulating activities(previous D52-D04 S9008 Cornwallis V245537 050905 Stage 4.doc 18/12/05 16/10/05 16/10/05 16/10/05 16/10/05 16/10/05 01/10/05 13/11/05 18/12/05 18/12/05 Cornwallis Version 1.40 Page 23 timescale of 25/07/05 not met) 16. 13 19 A risk assessment must be undertaken in respect of staff and residents during the redecoration of the corridors The conservatory must remain locked while the repairs are undertaken. Paint tins must not be accessible to service users. Suitable aids and equipment must be provided for service users to reduce risks to their safety and maximise their independence Carpets must be replaced where worn and lights repaired where necessary Doors marked keep locked must be locked The home must be kept as far as possible free from odours A copy of the action plan in respect of the environmental audit of the home must be sent to the Commission(previous timescale of 30/08/05 not met) There imust be an appropriate skill mix of staff on duty at all times to care for the needs of the residents accommodated Staff must not commence work without a satisfactory POVA check Staff must work under supervision at all times until a satisfactory CRB disclosure is obtained The recruitment and CRB policies must be reviewed and updated There must be evidence that an appropriate induction programme for all new employees is in place and implemented A Registered Manager must be appointed (previous timescale of 06/06/06 not met) 05/09/05 17. 13 19 05/09/05 18. 13,16 22 06/02/05 19. 20. 21. 22. 13 13 16 13 19 19 26 19,20 06/02/06 05/09/05 05/09/05 23/10/05 23. 18 27 05/09/05 24. 25. 18,19 18,19 29 29 05/09/05 05/09/05 26. 27. 19 18 29 30 31/01/06 16/10/05 28. 8 31 31/10/05 Cornwallis D52-D04 S9008 Cornwallis V245537 050905 Stage 4.doc Version 1.40 Page 24 29. 10,12 33 30. 31. 12,13 12,13 35 35 32. 33. 34. 35. 18 17 13 13,23 36 37 38 38 36. 37. 13 13 38 38 38. 39. 40. 13 13 13 38 38 38 Policies, procedures and practices must be reviewed and updated. All staff must be made aware and relevant training must take place. The procedure for the safekeeping of service users monies must be extended There must be an urgent review of the system for the handling of service users money. Service users money must not be pooled in one account, receipts must be given for all money paid into the account and maintained for all expenditure. Service users or their representatives must receive regular statements of their account. All staff must be appropriately supervised including those on induction programmes Record keeping in the home must be much more comprehensive A fire risk assessment must be undertaken A review of commodes must be undertaken and commodes that are a health and safety/ infection control risk must be disposed of and where necessary replaced. The home must produce and implement a policy in respect of the restraint of service users Fire training sessions must include the opening of fire exit doors and maintaining a safe environment at the fire exits The health and safety audit must be addressed with an action plan produced COSHH data sheets must be available to staff A risk assessment in respect of the need for a window restrictor in the staff office must be D52-D04 S9008 Cornwallis V245537 050905 Stage 4.doc 31/03/06 01/12/05 01/12/05 31/10/05 31/03/06 31/10/05 30/11/05 30/11/05 05/09/05 31/12/05 31/10/05 17/10/05 Cornwallis Version 1.40 Page 25 undertaken. 41. 18 31 The job description for the designated Manager and the organisation and management structure charts must be sent to the CSCI Regulation as agreed with the registered provider on 22/08/05(previous timescale of 02/09/05 not met) 23/09/05 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. 4. 5. 6. 7. 8. 9. 10. 11. 12. Refer to Standard 7 9 9 11 27 27 27 28 29 29 29 30 Good Practice Recommendations One care plan should be fully updated so the inspectors can review and discuss it on the next monthly visit. All drug reference books should be replaced annually. Creams in pots should be disposed of one month from the date of opening, those in tubes three months, unless otherwise directed. The policy for the care of the dying should make reference to any outside agencies involved It is strongly recommended that no more service users with nursing needs be admitted until further notice The domestic staff should work their contracted hours solely in the home and not be responsible for the Porthia offices at the same time Staff working hours should be reviewed in line with the working time directive It is strongly recommended that 50 of the care staff employed achieve the NVQ level 2 in care. All staff should have terms and conditions of employment and a job description Interview records should be maintained for prospective employees There should be a photograph of each member of staff on file It is recommended that arrangements be made for the diabetes nurse specialist to talk to the staff about the rationale for the new directions regarding insulin administration D52-D04 S9008 Cornwallis V245537 050905 Stage 4.doc Version 1.40 Page 26 Cornwallis 13. 14. 15. 16. 17. 18. 31 35 35 35 38 38 The registered managers job description should be reviewed to ensure that it reflects the legal responsibilities that this post holds. The Manager should have a copy of Power of Attorney certificates. Service users or their representative should sign an agreement giving the home permission to handle their money. The home should only hold pocket money for service users if really necessary The accident audit format should be reviewed to be more meaningful The labael on the bins for sharps disposal should be completed Cornwallis D52-D04 S9008 Cornwallis V245537 050905 Stage 4.doc Version 1.40 Page 27 Commission for Social Care Inspection 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 © 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 Cornwallis D52-D04 S9008 Cornwallis V245537 050905 Stage 4.doc Version 1.40 Page 28 - 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. 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