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Inspection on 20/12/05 for Cornwallis Court Residential And Nursing Home

Also see our care home review for Cornwallis Court Residential And Nursing Home for more information

This inspection was carried out on 20th December 2005.

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

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

What follows are excerpts from this inspection report. For more information read the full report on the next tab.

What the care home does well

The aspect of the home that the four residents spoke most positively about was the welcome that Cornwallis gives and the feeling of warmth and caring that is given by all staff, starting from the manager down. Individual staff were named as particularly caring and good at their job. The residents felt very supported by staff. Staff training is highly regarded at the home, starting from induction and supporting care staff through to a qualification and enabling nurses to maintain their qualifications. The home is well looked after and most areas are nicely decorated and bright. Residents are able to move around the home freely and easily. Aids and adaptations for disabilities are appropriate. There are plans for some internal improvements such as a new sluice facility. The variety and option on entertainment and activities suits the needs of the residents. The notice board on the day advertised carpet bowls, hairdressing and a bus trip into town and in Geoffrey Dicker there was a carol concert with the local vicar attending for prayers.

What has improved since the last inspection?

Cornwallis continues to maintain a high standard of care for the three differing types of care it offers, residential, nursing and dementia care. Each of which has its own dedicated staff grouping within the home. The staffing at the home has improved. More nurses have been recruited to the permanent post within the home, thus ensuring more consistency of care, as does the reduction in the use of agency staff. The numbers of care staff working in the main house, Cornwallis has increased during the day. Call bells were seen to be promptly responded too. The inspection of the medication standard (Standard 9) was conducted by Pharmacist Inspector Mr. Andrews. The inspection follows a complaint investigation by Mr. Andrews in August and September 2005 where there were found to be failings in the home`s management of controlled drugs. During this inspection, the inspector found overall that medicine management practice is satisfactory. In addition, there are significant improvements in the way the home are now handling and recording controlled drugs.

What the care home could do better:

The catering at the home has made improvements since that last inspection, but has not reached the previous standard of `commendable` known and come to be expected by residents who have been at the home for some time. Residents should be further consulted on catering matters to try to achieve a more reliable consistent quality of food that meets individual requirements. The Pharmacist Inspector, on conducting an audit of medication against medication records, did find, however, that there were some relatively minor inadequacies in record-keeping practices requiring further remedial action. In addition, several recommendations were made in order to further enhance practice particularly with respect to the safe administration of anti-coagulant warfarin.

CARE HOMES FOR OLDER PEOPLE Cornwallis Court Residential And Nursing Home Hospital Road Bury St Edmunds Suffolk IP33 3NH Lead Inspector Claire Hutton Unannounced Inspection 20th December 2005 10:00 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Cornwallis Court Residential And Nursing Home DS0000024366.V274209.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 Court Residential And Nursing Home DS0000024366.V274209.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Cornwallis Court Residential And Nursing Home Address Hospital Road Bury St Edmunds Suffolk IP33 3NH 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) 01284 768028 01284 700709 arichards@rmbi.org.uk Royal Masonic Benevolent Institution Mr Alan James McMahon Care Home 74 Category(ies) of Dementia - over 65 years of age (10), Old age, registration, with number not falling within any other category (64) of places Cornwallis Court Residential And Nursing Home DS0000024366.V274209.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 1 Maximum of twelve people with nursing needs may be accommodated at Cornwallis Court. 2 Maximum of ten people with dememtia may be accommodated at Geoffrey Dicker House. 29th April 2005 Date of last inspection Brief Description of the Service: Cornwallis Court is situated in very well maintained grounds and gardens and was originally part of the West Suffolk Hospital. Cornwallis Court opened in June 1981 and has provided care for freemasons since that time. The Home can care for up to 74 residents and up to 12 of those beds could be used for nursing care and up to 10 for people with dementia. The accommodation offered residents single bed sitting rooms with en-suite facilities. In the main building there were two main lounges, one on the ground floor and one on the first floor, and a ground floor dining room. There were also other smaller areas for use by residents who may wish to sit on their own or in a small group. All rooms were comfortably furnished to a good standard, with a continuous program of decoration and upgrading. There is also a well-stocked library. There were bathrooms and WCs, which are well equipped to assist residents and staff. There are a number of kitchenettes for use by residents and their relatives to make hot drinks and snacks. There is also a small shop and hairdressing salon for use by residents. Ramps are provided and pathways maintained to enable residents to access the garden and to enable people wishing to walk around the grounds to do so safely. Geoffrey Dicker is a selfcontained home with lounge, dining room and kitchenette. There is a separate entrance to this part of the home. Cornwallis Court Residential And Nursing Home DS0000024366.V274209.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection carried out on a December day by Claire Hutton, Inspector and Mark Andrews, Pharmacy Inspector. The inspection lasted 7 hours. The previous inspection conducted on 29th April 2005 contains the key standards that were met and not inspected during this visit. Requirements made in April were followed up at this inspection along with action taken by the home to resolve concerns raised in a complaint relating to medication practices in November 2005. A group of four residents were met and a discussion about the home was held over coffee, two other residents were met during the visit. Eight staff were also spoken with along with the manager and deputy manager who were both helpful throughout the inspection. A tour of communal areas in the main house and Geoffrey Dicker was undertaken. Records examined included sampling assessments, care plans, medication records, complaints, staff training, rosters, residents finances, quality assurance and certificates of maintenance. What the service does well: What has improved since the last inspection? Cornwallis continues to maintain a high standard of care for the three differing types of care it offers, residential, nursing and dementia care. Each of which has its own dedicated staff grouping within the home. Cornwallis Court Residential And Nursing Home DS0000024366.V274209.R01.S.doc Version 5.1 Page 6 The staffing at the home has improved. More nurses have been recruited to the permanent post within the home, thus ensuring more consistency of care, as does the reduction in the use of agency staff. The numbers of care staff working in the main house, Cornwallis has increased during the day. Call bells were seen to be promptly responded too. The inspection of the medication standard (Standard 9) was conducted by Pharmacist Inspector Mr. Andrews. The inspection follows a complaint investigation by Mr. Andrews in August and September 2005 where there were found to be failings in the homes management of controlled drugs. During this inspection, the inspector found overall that medicine management practice is satisfactory. In addition, there are significant improvements in the way the home are now handling and recording controlled drugs. 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 Court Residential And Nursing Home DS0000024366.V274209.R01.S.doc Version 5.1 Page 7 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 Court Residential And Nursing Home DS0000024366.V274209.R01.S.doc Version 5.1 Page 8 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 People who use this service will find that their needs will be assessed before they move into the home, therefore they can expect to have their needs met. EVIDENCE: Assessments of two new residents were examined. One resident was moving into the main part of the home that day and one person who had recently moved into Geoffrey Dicker. In both cases an assessment before moving to the home had been completed to enable the home to determine that in these cases they could meet the needs of the individuals. The recordings were on the individuals file. In one case the care plan had been developed in the other case the plan was about to be developed as the person had arrived that afternoon. Cornwallis Court Residential And Nursing Home DS0000024366.V274209.R01.S.doc Version 5.1 Page 9 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7 and 9 People who use this service will find they have a plan about their care that is known and followed by staff. Also that their medication is dealt with in a satisfactory manner, therefore they can expect to have their care and health needs met. EVIDENCE: Care plans for two individuals were examined. The first was for a resident who resided in the nursing wing of the home. This resident was very frail and required a great deal of care to maintain their health and well-being. The nurse who was spoken to was very knowledgeable about the individuals needs and was aware of all aspects of the care plan. The care plan had good detail on specific needs of maintaining skin and preventing any pressure sores. The nurse was also knowledgeable about the individual’s appetite and the need in this case to encourage more fluids. The daily statements written by staff reflected the care given throughout each day. Even though the resident was frail their wishes and preferences were being observed. The second care plan to be examined was for a resident in Geoffrey Dicker House. This again was fully completed; the plan developed was based upon the assessment completed before admission. Additional information on social Cornwallis Court Residential And Nursing Home DS0000024366.V274209.R01.S.doc Version 5.1 Page 10 life and past history was gained from a relative. Risk assessments to prevent pressure areas developing was present along with manual handling assessments, falls risk assessment and a night time assessment of needs. The care plan set out the specific care needs for the individual and included elements on bathing, continence and care of the feet. The daily statement written by one senior (on duty that day) was consistently good in the detail of the care given. The inspection of the medication standard (Standard 9) was conducted by Pharmacist Inspector Mr. M Andrews. The inspection follows a complaint investigation by Mr. Andrews in August and September 2005 where there were found to be failings in the homes management of controlled drugs. During this inspection, the inspector found overall that medicine management practice is satisfactory. In addition, there are significant improvements in the way the home are now handling and recording controlled drugs. On conducting an audit of medication against medication records, he did find, however, that there were some relatively minor inadequacies in record-keeping practices requiring further remedial action. In addition, several recommendations were made in order to further enhance practice particularly with respect to the safe administration of anti-coagulant warfarin. A copy of the full pharmacy inspection report has been sent to the registered provider alongside this report and is available subject to request. Cornwallis Court Residential And Nursing Home DS0000024366.V274209.R01.S.doc Version 5.1 Page 11 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 15 People who use this home may find a wholesome and pleasing diet cannot be assured in a consistent manner to meet individual needs and requests. EVIDENCE: Catering was one focus of this inspection as previously there had been complaints around the catering and the standard had slipped from a 4 rating that is commendable and exceeds the standard to a 2 rating that has minor shortfalls at the last inspection. Four residents were met with over coffee and the following statement: ‘At Cornwallis Court I can expect to receive a varied, appealing, wholesome and nutritious diet that is suited to my needs. The setting is congenial and the times of meals flexible,’ was passed around and discussed. More than one person held the view that the catering was the weakest part that the home. There was the view that a slight improvement has been made recently. There were still concerns about the time it took between courses and that on occasions hot drinks were served less than hot. One person said they had never had a bad cup of tea at the home. More than one person stated that they frequently requested a small portion of meat, but always got a large portion. One person recounted how it took a number of weeks to get the catering staff to understand their individual dietary needs, but now this was all okay. Cornwallis Court Residential And Nursing Home DS0000024366.V274209.R01.S.doc Version 5.1 Page 12 A main meal was requested for lunchtime at approximately 9.30am to taste the food and sample the experience of dining in the main dining room as many visitors can do at this home. No option of meal was offered. The dining room is a pleasant setting with tables laid to a high standard. Lunch that arrived was steak and kidney pie with mash potatoes, cabbage, broccoli and sweet corn with gravy added. This was followed by jam sponge pudding and custard. There was no delay between the courses. The meal was rather mediocre with a little too much salt added to the cooking and the vegetables over cooked. Three residents were asked after their meal, if they had received what they had ordered and if they liked it. All three said yes. One member of staff who ate the same lunch did not feel that the meal was satisfactory and left the dessert, as it was too sweet. Cornwallis Court Residential And Nursing Home DS0000024366.V274209.R01.S.doc Version 5.1 Page 13 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 People who use this service can expect that complaints and prevention of abuse will be taken seriously and acted upon. EVIDENCE: The home display their complaints procedure in the entrance hall for all to see and access if needs be. The home keeps a record of all complaints made and their outcome. The records of complaints showed that six complaints had been made since that last inspection in April 2005. Three of these related to the catering, two to care practice and one to agency staff. All these were resolved satisfactorily and the action recorded. There are no outstanding complaints at the home. The home has an appropriate policy on the protection of vulnerable adults and staff were able to locate this promptly. Staff spoken to confirmed they had received training on the subject and staff training records confirmed that this was the case. The lead person on training explained that the policy was gone through with staff and a video was watched with the staff to ensure understanding of protection matters. Two care staff also confirmed that they had a current enhanced criminal records bureau check in place. They were aware that this was not transferable from another job and politely checked out the reasons why. Cornwallis Court Residential And Nursing Home DS0000024366.V274209.R01.S.doc Version 5.1 Page 14 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19 and 26 People who use this service will find that the environment is well maintained and a plan of maintenance in place. People can expect that specialist equipment will be available to meet their care and access needs. EVIDENCE: A tour of most of the communal areas was undertaken including Geoffrey Dicker House. The main communal areas in Cornwallis are well maintained and provide a welcoming and warm atmosphere. There were decorations and Christmas trees to reflect the seasonal celebrations. It was evident from observations that residents are able to use the home as they wish. Example of this was the coffee and mints served after lunch in the main sitting room and visitors being able to be seen in private. In the residential part of the home there are two main lounges, one on the ground floor and one on the first floor, and a large ground floor dining room. There is also one lounge/dining room in the nursing wing used by people who Cornwallis Court Residential And Nursing Home DS0000024366.V274209.R01.S.doc Version 5.1 Page 15 are more dependant in their care needs. The nursing wing had recently been decorated and the décor now looked clean and fresh. There were also other smaller areas for use by service users, including two small conservatories, where service users may wish to sit on their own or in a small group. There were a number of kitchenettes for use by service users and their relatives to make hot drinks and snacks. There was also a small shop and hairdressing salon for use by service users. Geoffrey Dicker is a smaller home at the back with its own entrance and more or less self-contained. Catering is provided from the main kitchen. The facilities included a lounge, dining room, kitchenette, sluice and bathing and toilet facilities. Geoffrey Dicker has its own self-contained garden that was looking very nice for the time of year. The home had a range of aids, adaptations and equipment designed to meet the needs of residents and assist them with mobility and personal care. There are sufficient bathrooms with adapted facilities. All bedrooms had an en-suite facility. One toilet close to the lounge and dining room in the residential wing, was being used by residents, but had two large cardboard boxes close to the wash hand basin that prevent residents from washing their hands. It was explained that these boxes contained fittings for a new sluice room and that there were plans to decommission the toilet. Other plans for changes included an extension of a bedroom. Changes had already been made to one area that now allowed for appropriate storage of hoist when they were not in use. The CSCI had not been notified of the planned changes. All areas of the home seen were very clean and free from any odour. Residents spoken to all spoke highly of the environment both internal and external. Cornwallis Court Residential And Nursing Home DS0000024366.V274209.R01.S.doc Version 5.1 Page 16 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27 and 30 People who use this service can expect to find sufficient staff, with an appropriate skill mix employed to meet their needs. EVIDENCE: Since the last inspection at the home the registered manager Mr Alan McMahon has taken personal responsibility for the staffing rosters within the whole home. He has spoken to each member of staff individually about their roster patterns and now has a full understanding of how the rosters have developed over the years at the home. Mr McMahon stated that the significant aspect to emerge was that the home was overstaffed on weekdays and under staffed at weekends. Previously allocated benefits for working at a weekend were no longer available to care staff. Since the last inspection staffing numbers have increased and the use of agency staff has decreased. The number of staff on shift in Cornwallis has increased by one care assistant on both the early and late shift. The home employs eleven nurses. Four of these are on their relief pool. The home employs five shift leaders, one of whom works in Geoffrey Dicker. The home employs forty-three care assistants, fourteen of which work in Geoffrey Dicker House. In addition the home employs two full time maintenance men, five domestic staff and three laundry assistants – none of which work at a weekend. The home also employs administration support, finance support and a full time activities coordinator. The home operates a manager on call system; thereby ensuring one of the three managers is available for support and advice to staff at the home. Cornwallis Court Residential And Nursing Home DS0000024366.V274209.R01.S.doc Version 5.1 Page 17 A copy of all the rosters for the above posts was given to the inspector along with a list of residents and into which band of dependency they fall. This enabled the residential forum guidance (guidance on staffing levels issued by the Department of Health) to be calculated. The manager of the home was aware of the calculation tool and had being using this to develop staffing levels at the home. The calculations showed that Geoffrey Dicker was comfortably staffed over the required minimum and that the main house in Cornwallis was just within the minimum staffing levels required. In terms of outcomes for the residents, those spoken with felt there was sufficient staff available to care for them. Individual staff were named as particularly caring and good at their job. The residents felt very supported by staff. During the day the response times to the call bell were monitored and these were all responded to promptly with no excessive waiting noted. The home operates a system of training passports. The person responsible for training was met, she explained that she was in the process of updating the training planner. Each member of care staff had a training passport that states what training is required and when it is completed. Evidence of new staff induction and training was assessed as appropriate. Fifty two per cent of staff have NVQ 2. Food hygiene training is planned for January 2006 followed by Infection Control training. Evidence from November 2005 showed that staff underwent training in First Aid and this now means all staff are trained. Cornwallis Court Residential And Nursing Home DS0000024366.V274209.R01.S.doc Version 5.1 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 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 and 38. People who use this service can expect the home to be managed in a way that will safeguard their finances and promote and protect their health safety and welfare. EVIDENCE: The registered manager for this service is Mr Alan McMahon. He started managing the home on 7th January 2004. Alan McMahon has suitable qualifications such as the Managers Award and D32 and D33. Nurses within the home are line managed by an RGN level one in the Care Coordinators role, post currently held by Mrs Ros de Vick. The aspect of the home that four residents spoke most positively about was the welcome that Cornwallis gives and the feeling of warmth and caring that is given by all staff, starting from the manager down. One resident felt that Mr McMahon was an excellent manager for the home. Cornwallis Court Residential And Nursing Home DS0000024366.V274209.R01.S.doc Version 5.1 Page 19 The Inspector found the manager and Care Coordinator helpful and very responsive to the inspection process and keen to resolve any matter that arose. In terms of audits and assuring quality within the home, the manager explained this was an ongoing process and that in the last year every department within the home had been reviewed. This was through an in house survey. A copy of the audit was seen. Where negative feedback appeared Mr McMahon said these were either followed up individually to ensure satisfaction or matters were taken up to be resolved in a residents meeting – which ever was most appropriate. There were no current outstanding matters. The residents meetings are held regularly and well attended and minutes kept and displayed. In addition there is a relatives survey that is generated from the head office and monthly unannounced visits from the organisation to meet the requirements of a regulation 26 visit as prescribed by the Care Homes Regulations. A copy of this is regularly sent to the CSCI office in Ipswich. The Business Coordinator, Mrs Kirk was met with. She is responsible for maintaining and accounting any residents monies. The process was explained and paperwork and money sampled. A clear audit trail for money was available. Money could be accessed freely by the individual resident, but was kept secure. The accounts were audited weekly and allowed for a double signature for cash taken – one of which was usually a residents signature. The Head of Maintenance, Mr Stapleton was met with. He was able to verify and provide evidence of servicing of equipment through out the home, including hoists, lifts, fire alarms, gas safety, water temperatures including checking for legionella. All the safety checks were kept on a yearly computer print out and were available immediately as well as access to the individual certificates and recordings. Mr Stapleton was very knowledgeable about the processes and records kept. The home has devised a disaster plan that can be activated should any significant event take place. During the visit one new member of staff was undertaking individual fire instruction. Cornwallis Court Residential And Nursing Home DS0000024366.V274209.R01.S.doc Version 5.1 Page 20 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 x x 3 x x N/a HEALTH AND PERSONAL CARE Standard No Score 7 3 8 x 9 2 10 X 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 x 13 X 14 X 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 x 29 x 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 x 3 x 4 X x 4 Cornwallis Court Residential And Nursing Home DS0000024366.V274209.R01.S.doc Version 5.1 Page 21 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 OP9 Regulation 13.2,13.4 17.1 sch 3 Requirement The registered person must take steps to ensure full MAR chart records of medicine dosage directions are written in order to enable respective medicines to be safely administered in line with most recent prescribed instructions. The registered person must take steps to ensure records of medicines prescribed with variable doses are completed in full at all times following administration. Residents must have a wholesome, varied, appealing and balanced diet to meet their needs therefore: - Individual dietary requirements must be supplied once assessed without delay. - The quality of catering must be monitored to ensure that the standard is consistently satisfactory. The CSCI must be notified in writing of any significant alterations to the care home. DS0000024366.V274209.R01.S.doc Timescale for action 13/01/06 2. OP9 13.2 13/01/06 3. OP15 16 (2)(i) 29/01/06 4. *RQN 39 (h) 29/01/06 Cornwallis Court Residential And Nursing Home Version 5.1 Page 22 Specifically the change of toilet to sluice room and extension of one bedroom. RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard OP9 Good Practice Recommendations It is recommended that for clarity and in order to assist in ensuring the safe administration of warfarin, scheduled doses are indicated on the MAR chart in advance. It is recommended that the home undertakes a risk assessment of the possibility of adverse incidents arising throughout the Dementia unit where medicines for external application can currently be accessed by service users with dementia. It is recommended that risk assessments for service users self-administering medicines are completed and recorded on a monthly basis It is recommended that steps are taken to ensure that when medicine refrigerator temperatures fall outside the normal range appropriate remedial action is taken by staff It is recommended that a written procedure is developed to provide guidance for nursing staff handling medicines for disposal It is recommended that steps be taken to ensure controlled drugs no longer in use are promptly disposed of (allowing for the seven day period of quarantine following death). Residents should continue to be surveyed about their views on the whole catering experience to agree a strategy of improvements that meet the needs of the individual residents. The home should consider having domestic support available at a weekends to ensure care staff are not taken from their role. 2. OP9 3. OP9 4. OP9 5. OP9 6. OP9 7. OP15 8. OP27 Cornwallis Court Residential And Nursing Home DS0000024366.V274209.R01.S.doc Version 5.1 Page 23 Commission for Social Care Inspection Suffolk Area Office St Vincent House Cutler Street Ipswich Suffolk IP1 1UQ 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 Court Residential And Nursing Home DS0000024366.V274209.R01.S.doc Version 5.1 Page 24 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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