Inspection on 01/09/08 for Fistral House

This inspection was carried out on 1st September 2008.

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

Fistral House 03/09/07

Fistral House 30/05/06

Fistral House 07/03/06

Fistral House 22/09/05

Fistral House 03/03/05

Fistral House 07/09/04

Similar services:

Fairfields Country Rest Home

Poldhu

Queensmount

Trevaylor Manor

Didsbury Court Rest Home

Belma

Hunters Care Centre

Manor Lodge

Extracts from inspection reports are licensed from CQC, this page was updated on 13/03/2009.

CARE HOMES FOR OLDER PEOPLE Fistral House 3 Esplanade Road Pentire Newquay Cornwall TR7 1PY Lead Inspector Melanie Hutton Unannounced Inspection 10:00 1 September 2008 st 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 Fistral House DS0000008927.V367469.R02.S.doc Version 5.2 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. Fistral House DS0000008927.V367469.R02.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Fistral House Address 3 Esplanade Road Pentire Newquay Cornwall TR7 1PY 01637 878423 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) Mr Geoffrey Ernest Dowling Mrs Rita Gladys Dowling Mr Geoffrey Ernest Dowling Care Home 13 Category(ies) of Old age, not falling within any other category registration, with number (13) of places Fistral House DS0000008927.V367469.R02.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. To include accommodation for two named persons only outside of the age range and other category of the home. 3rd September 2007 Date of last inspection Brief Description of the Service: Fistral House is a care home providing personal care and accommodation for up to thirteen older people. The home is located in a residential area of Newquay directly opposite Fistral beach. The home provides a conservatory for service users to enjoy the views. The home has all en suite (toilet and wash hand basin) bedrooms on the ground and first floor. There is a stair lift facility to all the bedrooms on the first floor. Communal accommodation is on the ground floor and consists of a lounge, dining room and conservatory. The home has a spacious level back garden and car parking is available at the front of the home. Fees range from £300 to £500 per week. Fistral House DS0000008927.V367469.R02.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 1 star. This means the people who use this service potentially experience adequate quality outcomes. This was an unannounced inspection at Fistral House, which took place over a period of approximately 7 hours commencing at 10am on 1st September 2008. During this inspection we spent time in the office in discussion with the registered provider and head of care and looking at policies, procedures, records and other documentation. We met with residents, two relatives and staff on the day of inspection. Prior to the inspection we sent out a number of surveys to people who use the service, staff and health care professionals. We received back 5 completed by the staff. Six surveys for residents were returned, two identified that carers had helped the resident to complete these and four people had the support of their relatives. Two surveys intended for health professionals had been completed by relatives of residents. Two further surveys for relatives, carers and advocates were completed and returned. The residents and their relatives were complimentary about the home generally, and the kindness and consideration of the care staff. The Annual Quality Assurance Assessment (AQAA) has been returned to us since the last inspection. The registered provider and the head of care assisted us during the inspection. We looked at records, care documentation, policies and procedures and inspected the environment. Case tracking and direct observation were used. What the service does well: One resident told us “Mrs Dowling and all her staff are caring, considerate and make Fistral House a happy place”. Relatives who completed surveys said “The attitude to the residents is outstanding. All of the staff genuinely care about the residents and respect them”. “The home does everything that is possible to make my mother happy”. Staff we spoke with during the inspection were positive about the care provided and working at the home. The home is well maintained, pleasantly decorated in a homely way and is clean and odour free. Residents and relatives were very positive towards the registered provider and staff and commended the consideration shown to them and the manner in which their privacy and dignity is respected. Fistral House DS0000008927.V367469.R02.S.doc Version 5.2 Page 6 The environment is well decorated in a homely and domestic style, is clean and free from odours. The garden is a well maintained and pleasant place for residents to spend time and provides comfortable seating areas. The home consistently undertakes a robust recruitment procedure for each member of staff before they start work at the care home. What has improved since the last inspection? What they could do better: Some care plans are in more detail than others. All care plans should now consistently inform and direct staff of the action they must take to meet the identified care needs of residents, including personal care and health related tasks. A secure storage facility should be available for residents who self medicate to store their medication. The registered provider should develop a system that helps people to know what their main meal of the day is to be. The training for staff and policy and procedure to safe guard residents need to be improved and updated to ensure people are fully protected. Resident’s monies should not be held in a pooled account as this compromises residents in that they may not receive the interest due on their money. Supervision should be implemented so that it is provided regularly for all staff and the content recorded. Fire training and safety checks relating to fire regulations should be undertaken regularly and within the legal time scales. All training or checks must be recorded to demonstrate that it took place. Fistral House DS0000008927.V367469.R02.S.doc Version 5.2 Page 7 Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Fistral House DS0000008927.V367469.R02.S.doc Version 5.2 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 Fistral House DS0000008927.V367469.R02.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 2, 3 and 6. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The care needs of potential residents are assessed prior to admission. People who are privately funded are issued with a contract that details the terms and conditions within the care home. The home does not provide intermediate care. EVIDENCE: Pre-admission information and detailed care needs assessments were seen to be evident for all residents who have been admitted to the home. Further information is sought from the commissioners of care. One resident has moved to the care home from out of county. This person’s records showed that prior to admission to, verbal conversations had taken place with the hospital they transferred from. Contracts are provided to those residents who are privately funded. These detail the room to be occupied and fees to be paid. Fistral House DS0000008927.V367469.R02.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Not all care plans specifically inform and direct staff of the action they must take to meet peoples care needs. Therefore there is a risk that resident’s care needs may not always be met. Resident’s health care needs are fully met, but they are not fully protected by the agencies policies, procedures and systems for handing medicines. Staff treat the resident’s with respect and ensure their privacy is protected. EVIDENCE: Each resident has a care plan. Residents and their relatives told us that they were aware of their care plan and most people said that they were included in developing this and in the review process. Residents have been asked how frequently they want to be involved in the review process and most residents and / or their relatives, have signed a document stating they wish their care plan to be reviewed every two months. Care plans generally inform staff of the action they must take to meet peoples assessed care needs. Some provide more detail than others in how personal Fistral House DS0000008927.V367469.R02.S.doc Version 5.2 Page 11 care needs are to be met. For example, one care plan did not identify the name of a cream or when it is to be used – this is generally in the Medication Administration Record (MAR) if it is a prescribed cream. Another care plan inspected did not specify full detail of how continence was to be promoted. Other care plans were particularly detailed around personal care and included information on the person’s preferences and choices whilst encouraging and promoting independence. One resident told us “I am not feeling so well today and the staff have completely looked after me, they just know what to do”. Another resident said, “the owner and staff go out of their way to ensure my comfort and make sure all my needs are met”. A relative told us “We are extremely pleased with the care my mother is receiving”. Daily records are factual and evidence the day’s events, including how the assessed care needs have been met. Records clearly identify the involvement of external professionals e.g. community nurses, general practitioner and chiropodist. Residents are assisted by the staff to ensure that their health care needs are met including the contacting of external professionals when needed and transport to appointments. Medicines that the home holds for residents are appropriately stored and administered, in line with the medication policy in use. When people are assessed as being able to self medicate, the registered person should ensure that provision is made available for their medication to be stored securely A record is kept for the return of medication. A Control Drug book is kept and was seen to be in order. Medicine Administration Records were seen to be accurate and current. It is recommended that the MAR sheet is fully completed to identify the medication received into the home. The supplying pharmacist regularly inspects the home’s medicine systems. The residents and relatives spoken with were very positive of the registered provider and staff and commended the consideration shown to them and the manner in which their privacy and dignity is respected. Records are held of the resident’s preferred gender of carer and people told us this is respected. Some residents have their own telephone, but all have access to one. Observation during the inspection confirmed that mail is delivered unopened to residents, though assistance is given as needed. Residents’ preferred term of address is known and used. Fistral House DS0000008927.V367469.R02.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents confirmed that the home meets their social/recreational needs, that they are free to determine their daily lives, and that there is no restriction on receiving visitors. A wholesome, diet is provided, and residents said that the standard of food provided was very good. EVIDENCE: We were told by residents, their relatives and the registered provider that varied activities are provided by the home, and that an activity is offered every day. Three residents made the following comments: “The crafts are very good, we make different things, keep fit is available once a week – sometimes I go if I feel like it”, “I have enough to keep me occupied” and “There is plenty to do here, I join in sometimes if I wish but often I don’t – it is my choice”. We were shown examples of some of the items made during the craft activities by one of the residents. Daily records evidenced activities undertaken by people, e.g. watching a film, reading, external entertainers and the participation and enjoyment of the resident. Some people told us that they preferred their own company and Fistral House DS0000008927.V367469.R02.S.doc Version 5.2 Page 13 liked to read or watch television in their own room. On the day of inspection an exercise class took place in the afternoon, with most resident’s taking part. There is a visitor’s book in the entrance, which shows regular and frequent visitors to the home. Residents and staff confirmed that there are no restrictions on visitors. One visitor told us “There is an open access policy for visitors, although not an unlocked door and the home is welcoming to visitors”. A number of residents have their own telephone lines in their bedrooms, but calls can be made and received in private without this facility. All the residents have relatives or representatives available to act in their interests. Staff were seen to interact with residents in a comfortable, familiar and caring manner. There is a monthly newsletter sent to all the residents with articles about recent or planned events, outings and news. A 2-week menu is used within the home. We were told that this menu has been in place for twelve months. On the day of inspection the menu could not be located and had to be reproduced from the computer. The cook told us that this was not an issue as she was familiar with the menu and knew what was planned for each day. A choice of meals is provided at both lunch and teatime. Since the last inspection there is also a hot choice available to people for their evening meal. On the day of inspection this was cheese on toast. The lunchtime menu on the day of the inspection was cottage pie with two vegetables. This was well presented and looked appetising. Residents said that they had enjoyed their meal. One resident told us “I do not eat much but every day cook discusses with me all my meals and prepares especially for me”. Two resident’s told us that while they liked the food provided at the home, they were not aware of what the lunchtime meal was to be. The cook told us that each resident is advised each afternoon of the next days meals and asked for their choice. Residents did tell us they could always ask for alternatives if they did not like the meal provided. It is recommended that the registered provider develop a system that helps people to know what their main meal of the day is to be. There is a record of food provided to each person. Fistral House DS0000008927.V367469.R02.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. There is a new complaints policy, which will be circulated to residents and their representatives with the new Statement of Purpose in the next few weeks. There is an adult protection policy in place that needs to be developed to ensure that staff are provided with clear guidance on the procedure to follow. All staff must receive safe guarding adults training to fully protect the residents. EVIDENCE: A detailed complaints policy and procedure is available to residents and their representatives. This advises people on how to and to whom to make a complaint. It also references how to contact the Department of Adult Social Care (DASC) and the Commission for Social Care Inspection (CSCI)- although since the policy was distributed the contact details for CSCI have changed. Residents said they were very happy at the home and were seen to enjoy good relations with the staff. Residents told us that they would feel able to voice concerns and three people said that if they had any concerns at all they would discuss them with the registered provider Mrs Dowling. The registered provider told us that there have not been any complaints made to the home. Fistral House DS0000008927.V367469.R02.S.doc Version 5.2 Page 15 There is an adult protection policy in place. The protection of the residents could be improved with a clear adult protection procedure for staff to follow in the event of an allegation of abuse that is in line with local multi agency policies and procedures. Safe guarding adults training is provided to staff within the Induction training using a DVD, handouts and work sheets. Update training is provided using the DVD and some staff have attended external training provided by the County Council. However, some staff have yet to complete safe guarding training. The head of care stated that this is being addressed as a priority. Staff were able to tell us in detail of the action they would take should they witness or suspect that abuse has taken place. Fistral House DS0000008927.V367469.R02.S.doc Version 5.2 Page 16 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. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 21, 22, 23, 24, 25 and 26. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Fistral house is a large domestic dwelling, which is suitable to its stated purpose. The property is generally well maintained and is clean, pleasant, and hygienic. EVIDENCE: The care home is a two storey building. Access to the first floor is by means of the stairs or a stair lift. A tour of the premises showed that the building is well decorated and maintained providing comfortable accommodation for people in a domestic style. The gardens to the rear of the home are well maintained, accessible to residents and provide seating areas. To the front of the property there is a small car parking area, with additional parking available on the road outside. Fistral House DS0000008927.V367469.R02.S.doc Version 5.2 Page 17 There are beautiful views over Newquay beach from some bedrooms and from the main lounge and conservatory. Residents were very happy with the accommodation provided. Communal areas in the home include a spacious lounge, conservatory and dining room. All communal areas were comfortably furnished and decorated in a homely style. Most resident’s bedrooms were personalised with their own possessions. All service user rooms are en-suite, and all but three offer a shower or bath. Some of the ensuite toilets appear small in size. Commodes are also available within the home and were observed in some rooms. The registered provider told us that only one person uses their en suite bathing facility. There is one communal lavatory and one communal bathroom. The communal bathroom is on the first floor. Within this bathroom there was a selection of un-named toiletries. The registered provider told us that the home purchases various toiletries for residents to use if they wish to do so. Care should be taken to ensure that cross infection does not occur e.g. un-named roll on deodorants and razors were observed within the bathroom. The registered provider stated that these would be disposed of if the staff were not able to identify who they belonged to. With regard to the care needs and the number of current residents, there are sufficient toilet and bathing facilities. We were told that the baths have mixing valves to control the supply of hot water and that the plumber employed by the home has tested these to ensure the water is delivered at the correct temperature. There was no written evidence available to support this. The heating is provided through radiators in each room with individual controls and protective guards. There are double-glazed windows fitted throughout the home, including a porch to the front of the building. There are window restrictors fitted to all windows but some were not working. One window could not be opened. The registered provider was aware of this issue and told us that this is an ongoing issue that she is addressing with the company that fitted the windows. No reference is made to the lack of window restrictors within the homes risk assessments. All areas of the home were seen to be clean, and there were no undue odours evident. Two residents were very complimentary about the new cleaner and said “she is lovely to me and does a really good job of cleaning my room” and “we have a new cleaner who is very good, the home is always beautifully clean”. The laundry is located on the ground floor next to the office. Industrial machines are available with the washing machine providing a hot sluice wash. The walls of the laundry are impermeable and a system is in place to prevent cross contamination between soiled and clean laundry. Liquid soap, paper towels and sanitising gel is available throughout the home to promote the control of infection. Fistral House DS0000008927.V367469.R02.S.doc Version 5.2 Page 18 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. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The assessed care needs, of the current resident’s, are met by the staff group. Staff are appointed following a robust recruitment procedure. A programme of training is being developed to ensure that staff are competent and trained to meet residents care needs. EVIDENCE: At the time of the inspection there were 3 care staff, 1 domestic and a cook on duty, with 7 residents. Residents said that they felt well cared for. A duty rota is used, which accurately reflects the care staff on duty. It is not clear from the duty rota of the exact times that the registered provider is available in a management role. When the registered provider is on duty to provide care, this is shown on the rota. Residents’ comments and care documentation show that care needs are well met. There are sufficient waking night staff on duty. The AQAA told us that there are 12 full time and 1 part time care staff employed by the home, of which 10 have achieved NVQ Level 2 or above and 2 Fistral House DS0000008927.V367469.R02.S.doc Version 5.2 Page 19 are working towards this qualification. Staff files inspected did not always provide the evidence of this qualification. The home has developed a training programme and maintains a training matrix that gives an over view of the training undertaken and planned. Some staff are due to undertake training and update previous training and the head of care is currently resourcing and booking training to address these gaps. The home has implemented a Skills for Care compliant induction programme, and all staff are currently undertaking this programme. The home generally enjoys a low staff turnover, which benefits the residents. Four staff personnel files were inspected. These showed that two written references had been obtained and CRB checks obtained prior to the staff commencing work. The application form in use identifies the applicants past work/education history, experience or qualifications. Staff files evidenced that terms and conditions are issued and The General Social Care Council code of conduct is available within the home. One member of staff told us that their recruitment process had been thorough and that references and CRB checks obtained before they could start work. Fistral House DS0000008927.V367469.R02.S.doc Version 5.2 Page 20 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. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 32, 33, 35, 36 and 38 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The registered provider is in day-to-day control, and there is a clear management structure in place at the home. Residents are able to give their views on the running of the home. The health and safety of the residents is compromised by the fire procedures and other health and safety measures in the home. Some residents financial interests are compromised by the pooled account held in the registered providers name. EVIDENCE: The registered provider is in day-to-day control and is supported in her duties by the Head of Care. Residents were aware of who was in charge at the home. The registered provider is well experienced in care and in meeting the needs of the residents. Fistral House DS0000008927.V367469.R02.S.doc Version 5.2 Page 21 A quality survey has been distributed to residents, their representatives and other interested parties. The outcome of this survey was available for inspection and is due to be published in the next newsletter. The home handles only a small amount of money for residents, and this is kept in a pooled bank account. We discussed this with the registered provider who said that the relatives of the residents were aware of the system and satisfied with it. However, this does compromise residents with regard to the interest that could be accumulated on the account. Although there is some evidence of staff supervision, there is limited evidence to show that staff are receiving supervision at least 6 times per year. We were told that supervision is being addressed and taking place regularly – written records should be available for all supervision to evidence that it took place and the areas covered. Of the five surveys we received that were completed by staff members, three said that they regularly / often meet with their manager for supervision and two said that their manager never meets with them to provide support. The home is well maintained, and records of regular maintenance work and other records were inspected, including: • Environmental Health Officer – July 2007 • Gas Safety certificate – April 2008 • Electrical Inspection report – July 2007. Portable appliance tests are due to be undertaken. We were told that the five yearly hard wiring test of the house was undertaken in 2005 but no evidence was available to support this at the inspection. • Hoist inspection – • We were told that a legionella test has been undertaken by no certificate was available to support this. • RIDDOR • COSHH • Accident Book Fire training for staff has not taken place as required for all staff. There were also gaps noted in the weekly fire alarm and fire door testing records. This was discussed with the registered provider who told us that the checks and training had been carried out but omissions had been made in the recording. An annual fire training is provided to staff from an external provider and this is planned to take place within a month of the inspection. Fistral House DS0000008927.V367469.R02.S.doc Version 5.2 Page 22 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 3 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 3 3 3 3 3 3 2 3 STAFFING Standard No Score 27 3 28 2 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 3 X 3 1 X 1 Fistral House DS0000008927.V367469.R02.S.doc Version 5.2 Page 23 Are there any outstanding requirements from the last inspection? Yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP9 Regulation 13(2) Requirement It is required that the registered person shall make arrangements for the safekeeping of all medicines received into the care home. When a resident self medicates, suitable and secure storage facilities must be provided. It is required that the registered provider shall make arrangements, by training staff or by other measures, to prevent service users being harmed or suffering abuse or being placed at risk of harm or abuse. The registered provider must ensure that staff are appropriately supervised. Previous time scale for action – 01/04/08 4. OP38 17(2) Schedule 4(14) It is required that the registered provider keep a record of every fire practice, drill or test of fire equipment (including fire alarm equipment) conducted in the DS0000008927.V367469.R02.S.doc Timescale for action 10/11/08 2. OP18 13(6) 10/11/08 3. OP36 18 10/11/08 06/10/08 Fistral House Version 5.2 Page 24 care home and of any action taken to remedy defects in fire equipment. Clear records must be kept of the training provided to all staff. 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 OP7 Good Practice Recommendations It is recommended that all care plans provide sufficient detail so that staff are informed and directed of the action they must take in order to meet the assessed needs of the residents. It is recommended that the registered provider develop a system that helps people to know what their main meal of the day is to be. It is recommended that the complaints procedure is updated to reflect CSCI’s current address. There is a Protection Of Vulnerable Adults policy in place, though the registered provider should also provide a procedure that includes clear instruction as to the steps to take in the event of an allegation of abuse, relevant contact details (Adult Social Care office), and to show adherence to the Cornwall Protection Of Vulnerable Adults procedure. The registered provider should make arrangements for staff training in adult protection. It is recommended that where the environment provides potential risks to resident’s e.g. broken window restrictors, the registered provider include this within an environmental risk assessment detailing any action that has been taken to reduce the risk and to resolve the situation. 2. OP15 3. 4. OP16 OP18 5. OP25 Fistral House DS0000008927.V367469.R02.S.doc Version 5.2 Page 25 6. OP28 It is recommended that the training programme continues to be developed and implemented to ensure that all staff receive training appropriate to the work they are to perform, and to ensure the safety of themselves and others. It is recommended that the registered provider review the system for holding residents monies, so that they are not held in a pooled account. 7. OP35 Fistral House DS0000008927.V367469.R02.S.doc Version 5.2 Page 26 Commission for Social Care Inspection South West Colston 33 33 Colston Avenue Bristol BS1 4UA National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 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. 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