CARE HOMES FOR OLDER PEOPLE
Little Trefewha Praze-an-Beeble Camborne Cornwall TR14 0JZ Lead Inspector
Diana Penrose Unannounced Inspection 8th November 2007 09:30a 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 Little Trefewha DS0000009097.V350229.R01.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. Little Trefewha DS0000009097.V350229.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION
Name of service Little Trefewha Address Praze-an-Beeble Camborne Cornwall TR14 0JZ 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) 01209 831566 01209 831566 Little Trefewha Limited Mrs Jacquelyn Jane Elliott Care Home 20 Category(ies) of Old age, not falling within any other category registration, with number (20) of places Little Trefewha DS0000009097.V350229.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION
Conditions of registration: 1. To include one named person under 65, outside the category of registration 25th April 2006 Date of last inspection Brief Description of the Service: Little Trefewha is situated in the village of Praze-an-Beeble, close to the towns of Camborne and Helston. It is set in its own spacious, very well tended grounds and has reasonable parking space for staff and visitors. The home is part of a group of homes owned by a locally based company and provides residential care for up to twenty elderly people. The premises consists of a two storey detached building with a ground floor extension at the back. There is adjoining accommodation occupied by the Registered Manager. The upper floor is accessible by a stair lift. There is one shared room, the rest are single. Four rooms have en suite facilities. The home provides ample shared space including a large lounge and a smaller quiet lounge. Meals are prepared in the kitchen on the ground floor and served in the dining room, or individual bedroom if preferred. Outside there is a patio and extensive lawns with seating and tables accessible to residents. Suitably experienced care staff provide personal care within a relaxed, friendly, welcoming atmosphere. Information about the home is available in the form of a residents’ guide, which is available in the home and can be supplied to enquirers on request. A copy of most recent inspection report is also available in the home. The person in charge did not know the range of fees on the day of inspection. Additional charges are made in respect of private healthcare provision, hairdressing and personal items such as newspapers, confectionary and toiletries. Little Trefewha DS0000009097.V350229.R01.S.doc Version 5.2 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. An inspector visited Little Trefewha Care Home on the 08 November 2007 and spent seven and a half hours at the home. This was a key inspection and an unannounced visit. The purpose of the inspection was to ensure that residents’ needs are properly met, in accordance with good care practices and the laws regulating care homes. The focus was on ensuring that residents’ placements in the home result in good outcomes for them. All of the key standards were inspected. On the day of inspection 18 residents were living in the home. The methods used to undertake the inspection were to meet with a number of residents, staff and the person in charge to gain their views on the services offered by Little Trefewha Care Home. Records, policies and procedures were examined and the inspector toured the building. The registered manager has completed an Annual Quality Assurance Assessment and the information provided has also been used. This report summarises the findings of this inspection. The registered manager was on sick leave at the time of this inspection and a senior carer was on duty. She assisted the inspector on this occasion. One of the Company Directors arrived later in the day. Residents expressed satisfaction with the care and services provided at the home and the environment is relaxed friendly. As there are areas in this report that show residents safety may be at risk this inspection indicates that the home is providing a poor quality of service for the residents placed there and improvements must be made. Eight requirements have been notified in this report. Nine recommendations have also been made, some of which are breaches in regulations that the registered providers need to comply with. What the service does well:
The home provides a comfortable homely environment that is very clean and well maintained for residents, staff and visitors. There is ample sitting and dining space and suitable washing and toilet facilities. There are spacious grounds that are accessible to residents. There is a friendly welcoming atmosphere and residents say they are happy living in the home. They say the staff are very kind and caring and work well together. Little Trefewha DS0000009097.V350229.R01.S.doc Version 5.2 Page 6 Residents are only accepted into the home following an assessment of their needs. From this each resident has a written care plan detailing their individual requirements; this directs staff on how best to meet their needs. The plans are compiled with the resident, reviewed regularly and signed. Doctors, nurses and other healthcare professionals visit the home to provide care when necessary. Equipment is provided for moving and handling purposes and for the prevention of pressure sores. Resident’s say their privacy and dignity is respected at all times and this appeared to be so during the inspection. A range of activities are on offer, including a monthly religious service, and residents can join in as they wish, some said they stay in their rooms most of the time and this is accepted. Staff said they try to spend time on a one-to-one basis with residents as well. Residents are able to maintain contact with their family and friends as they wish. Visitors are welcome in the home and some residents go out with their families. All residents spoken with said their individual preferences are respected and they are supported to maintain their independence. They get up and go to bed when they wish and go out according to their ability. All residents’ bedrooms are personalised with their own belongings. One resident said, “It is home from home”. The food served is to a good standard with homemade cooking, fresh fruit and vegetables. Special diets and individual needs are catered for. All residents spoken with said the food is very good. There is an appropriate complaints policy available in the home and there is a method for recording complaints, the action taken and the outcome. Residents said that staff are kind and caring and there are enough on duty during the day. 64.7 of care staff have an NVQ qualification in care. The home employs a registered manager who is competent and experienced to run the home. Staff and residents feel she is approachable and listens to what they have to say. There is a system for the safekeeping of resident’s money however residents are encouraged to manage their own money for as long as possible. What has improved since the last inspection?
A new fire system has been installed. Further decoration has taken place and more new carpets have been fitted. The patio outside the lounge has been upgraded with a ramp so residents can access the garden.
Little Trefewha DS0000009097.V350229.R01.S.doc Version 5.2 Page 7 A lock has been fitted to the resident’s toilet on the upstairs landing. What they could do better:
The statement of purpose was not available for inspection. This is an important document that gives full details of home and the services provided. A copy of the statement of purpose must be accessible in the home at all times and copies available to give to people enquiring about the home. The medicines policy must be easily accessible to staff for reference, a copy of this policy was not available for inspection. There must be a review of the medicine systems to ensure that residents are safeguarded. The medicines fridge must be working correctly and checks must be made of the temperature, staff must be aware of the safe temperatures for storing medicines. Prescribed medicines must not be shared with other residents. Hand written orders on the medicine charts must be witnessed and signed by two staff to ensure the correct instructions are recorded. Staff must ensure the controlled drugs register is maintained appropriately and records are up to date. Staffing during the daytime appears to be suitable for resident’s needs but the nighttime arrangements must be reviewed to ensure there are enough staff. Recruitment procedures must be robust to safeguard the residents and staff. Some files lacked the documents and safety checks required by law. All staff must receive training appropriate to their role to ensure they have up to date knowledge and skills to perform their work. This includes a rigorous induction programme for new employees, abuse training for all staff with annual updates and statutory training required by law, that is fire, health and safety, food hygiene, infection control, first aid and moving and handling. The training records must be kept up to date and available for inspection. Health and safety documentation and records must also be available for inspection. These include the health and safety risk assessments, policies and records to confirm that machinery and equipment has been appropriately checked and serviced. Radiators that are very hot should be thermostatically controlled or covered to prevent the risk of burns to residents. Day and night records should be detailed and written by the person administering the care to ensure the correct information is recorded. There should be a risk assessment in place for all residents with bed rails in situ. Discussion should take place with the resident, relatives and any relevant healthcare professional to ensure this is best for the resident’s needs. The registered manager should ensure that systems are in place and staff are aware of the policies and procedures pertaining to the management of the home if they are left in charge of the home.
Little Trefewha DS0000009097.V350229.R01.S.doc Version 5.2 Page 8 Quality assurance systems need to be put in place to show that the home listens to the residents and staff and aims for continuous improvement. A flow chart or simplified adult protection procedure should be compiled for staff to reference easily. This has probably been done but was not available on the day of inspection. A sluice with a washer disinfector should be provided for infection control purposes. 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. Little Trefewha DS0000009097.V350229.R01.S.doc Version 5.2 Page 9 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 Little Trefewha DS0000009097.V350229.R01.S.doc Version 5.2 Page 10 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): 1 and 3 (6 is N/A) Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home did not have a statement of purpose available in the home. Residents are only admitted to the home following an assessment of their needs to ensure the home can provide suitable care. EVIDENCE: The statement of purpose produced for inspection was incorporated in the resident’s guide. It was only one page and did not contain the detail requires by legislation. One resident said she received good information about the home prior to admission and some said they visited the home prior to making any decisions to move in. The person in charge said that the registered manager or her deputy visit prospective residents or they come to see the home prior to admission. Records show that a thorough needs assessment is undertaken with the resident and their family. There were assessments on file undertaken by the
Little Trefewha DS0000009097.V350229.R01.S.doc Version 5.2 Page 11 department of adult social care and nurses. These help the home to make a decision as to whether they can manage the person’s needs. Little Trefewha DS0000009097.V350229.R01.S.doc Version 5.2 Page 12 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): Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Each resident has an individual care plan; a risk assessment for restraint and more detailed day and night records will help to ensure that individualised care is provided. The home’s medicine policy is not available to staff and although the administration of medicines appears satisfactory some processes could put residents safety at risk. EVIDENCE: Each person using the service has an individual care plan and three were inspected. The plans are detailed and include social and religious needs. They are signed by the resident or their representative when possible and reviewed every three months. There are sheets included for visits by doctors and other health professionals. Daily records are maintained but could contain more information, for example it was recorded that a resident was asking about her GP visit and that the carer would follow it up, there were no further entries to show that this had been done. The night staff do not write in the daily records, a carer said they write notes on a piece of paper for the registered manager to include in the records. It is strongly recommended that those people undertaking the care write in the records.
Little Trefewha DS0000009097.V350229.R01.S.doc Version 5.2 Page 13 Some risk assessments are undertaken for example for pressure sore risks, falls, nutrition and moving and handling. Only one person has bed rails in situ, there is no evidence that a risk assessment has been undertaken or that consent has been obtained from the resident, relatives or health professional. Bumpers were not fitted to the bedrails to help prevent entrapment. This could be a health and safety risk. Resident’s said their healthcare needs are met and that doctors and nurses visit regularly. A nurse visited during this inspection. One person said, “It is not easy getting a doctor to see you”. One resident talked about a hospital appointment and two others about recent admissions to hospital. Suitable equipment is available to staff for moving and handling purposes and pressure relief. No resident’s have pressure sores but two have special mattresses. The home’s medicines policy and the The royal pharmaceutical guidelines for care homes were not available for inspection. There was a UK HCA policy that stated what carers could do in respect of medicines. Medicine reference books and patient information leaflets are available for staff. A monitored dose system is in use. The medicine administration records are complete and up to date and there are records of medicines received. The disposal records could not be found it was thought they might be at the chemist. A photograph of each resident is held with their medicine records. There is a medicine fridge, the temperature has not been recorded since 31/10/07 and it has been running too high, 10ºC. One resident administers his own insulin and has a lockable facility in his room for storage. The unopened insulin is kept in the medicine fridge. The homely remedies list has not been signed as approved by a doctor. Lactulose syrup, prescribed for individuals is being shared between several residents. Handwritten instructions on the charts are not signed or witnessed. Minimal controlled medicines are kept; these must be handled more carefully. There was Oramorph recorded in the controlled drugs register for a deceased resident but the medicine was no longer in the cupboard. Another resident has had tablets recorded as received in the register but the running total has not been updated. Care staff said they have received medicines training. Residents’ privacy appeared to be upheld during the inspection. Residents said they are treated with respect and their privacy is maintained at all times. Residents said they receive their post unopened and the telephone arrangements in the home are satisfactory, direct lines are supplied on request. The shared room is provided with appropriate screens. Little Trefewha DS0000009097.V350229.R01.S.doc Version 5.2 Page 14 Little Trefewha DS0000009097.V350229.R01.S.doc Version 5.2 Page 15 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): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Staff encourage residents to socialise and join in activities, visitors are welcome and efforts are made to ensure that residents choices and preferences are respected. EVIDENCE: Some activities take place in the home, there are posters displaying what’s on. Staff said that more residents do not wish to join in these days. The person who used to provide bingo no longer comes to the home because of resident’s lack of interest, staff said. It was observed that very few people use the lounge; more were in their rooms than at the last inspection. Entertainers come in to the home and some people said they enjoy them. A summer fete took place and residents said it was very good. Records of social activities are kept in the form of an individual sheet for each person, these include visits by family and friends, hairdresser and chiropodist visits. Two residents said they go out on the bus and some said they go out with their families. One man said he doesn’t join in activities, as he prefers his music in his room. Staff interacted well with the people using the service and they said they try to spend 1:1 time with everyone. All staff said they try to make sure residents are encouraged to socialise and join in with activities they enjoy.
Little Trefewha DS0000009097.V350229.R01.S.doc Version 5.2 Page 16 Residents said they could receive visitors at any time they wish or contact them by telephone. Some said they go out with their friends and relatives; one woman went out with her daughter during the inspection. Visitors were in the home during the inspection. All residents spoken with said their individual preferences are respected and they are supported to maintain their independence. They said they are free to go out when they wish and some visit their families. The daily routines are flexible to suit them for example going to bed and getting up in the morning. Most residents control their own money with the help of their families. One resident helps in the kitchen, does her own laundry and goes out shopping. One resident goes into Camborne regularly. All residents have their own belongings in their rooms. One resident said that staff tend to choose her clothes each day and she has expressed that she can do this herself. There is a set menu but records show that alternatives are available the lunchtime meal is written on a board in the dining room. The cook said that Special diets can be catered for. Fresh fruit and vegetables are included and there are homemade cakes at teatime. Likes and dislikes are recorded in each residents file. All residents spoken with said the food is very good and there is enough of it. Pasties seemed to be particularly popular. Little Trefewha DS0000009097.V350229.R01.S.doc Version 5.2 Page 17 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): Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The adult protection policy was not available to staff in the home and not all staff have received appropriate training, this could compromise the safety of vulnerable elderly people in the home. EVIDENCE: There is a suitable complaints procedure; the CSCI contact details need to be updated. There have been no complaints since the last inspection. Residents said there are no barriers to raising concerns with the staff or the manager. There was an adult protection policy and information on local authority procedures at the last inspection but these were not available this time. One of the company directors stated that the adult protection policy has been updated along with a flow chart; these have been seen at the other homes in the group. Some staff said they have attended the ‘No Secrets’ training; all staff must attend training on abuse. Little Trefewha DS0000009097.V350229.R01.S.doc Version 5.2 Page 18 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): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is comfortable, clean and well maintained making it a safe homely place for people to live in. EVIDENCE: There have been no structural changes to the premises since the last inspection. A new fire system has been installed. Some rooms have been redecorated and some new carpets have been fitted. The patio has been upgraded with a ramp to access the garden. New garden furniture has been supplied. A lock has been fitted to an upstairs toilet for resident’s privacy. The bathing facilities have not changed as yet. Some radiators are very hot probably due to the new boiler that has been installed. The home is well maintained, decorated and furnished to a good standard. It is very clean, homely and comfortable. Residents have their own possessions around them and have personalised their rooms. All residents were happy with their rooms; one said, “It is home from home”. The grounds are very tidy and
Little Trefewha DS0000009097.V350229.R01.S.doc Version 5.2 Page 19 accessible. Residents said they are very happy in their home and surroundings. The home has a non-smoking policy; smokers have to go outside and are satisfied with this arrangement. The step inside the front door made it awkward getting a resident in a wheelchair outside as the chair had to be manoeuvred backwards. Staff said the concrete chippings in the drive also make it difficult to push wheelchairs. One of the company directors said there are plans to alter the entrance and to tarmac the driveway. The laundry facilities are suitable and red dissolvable laundry bags are used. Residents had no complaints about the laundry service. There are appropriate hand-washing facilities for staff and alcohol hand cleansing gel is in use. Protective clothing is provided for staff. There is no sluice with a washer disinfector for infection control purposes. Little Trefewha DS0000009097.V350229.R01.S.doc Version 5.2 Page 20 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): Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. There are suitable numbers of staff during the daytime but at night residents may be at risk. Recruitment procedures have deteriorated and there appears to be less training taking place this could also have an effect on the safety of the residents. EVIDENCE: The person in charge said there is one vacancy for a teatime cook otherwise there are sufficient staff. Generally there are three care staff on duty in the mornings and two in the afternoons and evenings. There is also another person in charge of the home, usually the registered manager or her deputy. At night there is one carer with the registered manager living in the adjoining accommodation. This was discussed with one of the company directors as the registered manager is at present on sick leave and should not be working in any capacity. As the people accommodated seem to be more dependent now there must be a full review and risk assessment of the night staffing arrangements in the home to ensure that sufficient staff are on duty. Residents said the staff are very kind and they are well cared for. According to the Annual Quality Assurance Assessment (AQAA) 64.7 of care staff are qualified to at least NVQ level 2 in care. Others are currently studying for an NVQ qualification. Little Trefewha DS0000009097.V350229.R01.S.doc Version 5.2 Page 21 Five staff files were inspected and were disappointing in the information held. Employees had completed an application form and health questionnaire. Only one had interview records. One person had two references on file, two had one reference and the remaining two had no references at all. The three newest staff had no terms and conditions of employment or letter of appointment. One lacked evidence that a POVA and CRB check had been done. Her POVA first check, dated 05/11/07 stated that the CRB had not been received. She commenced work on 15/10/07. Only two had photographs on file and there was very little evidence of training, a few certificates were seen. No induction records were available. There was little evidence of staff training and staff said that not much has taken place. A file titled ‘moving and handling’ had information and a training sheet dated 2004. Staff said they have done fire, moving and handling, first aid and food hygiene training and they said that some staff have had training in palliative care. One member of staff said she would like training in challenging behaviour. The AQAA states that improvements are needed in respect of training and updating. Little Trefewha DS0000009097.V350229.R01.S.doc Version 5.2 Page 22 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): Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. The home is run in the best interest of the residents but there are no quality assurance systems in place to bring about change and improve quality. Systems are not in place for when the registered manager is absent and documentation is missing or unavailable to staff. Policies, training and effective health and safety systems are lacking so the wellbeing of residents, staff and visitors could be at risk. EVIDENCE: The registered manager was on sick leave at the time of the inspection and her deputy was on a day off. The person in charge of the home knew the residents well and how to care for them but did not know where some information and records pertaining to the management of the home were kept. She was courteous and as helpful as she could be, nothing was too much trouble. The registered manager has always been competent in running the home, however
Little Trefewha DS0000009097.V350229.R01.S.doc Version 5.2 Page 23 she must ensure that when she is not there systems are in place and staff are aware of the policies and procedures pertaining to the management of the home. Staff said the manager runs the home well and in the best interest of the residents. Residents spoken with said she is kind and considerate and manages the home very well. There is no annual development plan or other systems, which may assist in bringing about change, and improving quality. A file was found that contained resident/relative surveys. None of them were dated so it was impossible to know how recent they were. There was no report of collated surveys in the file. The surveys and comments were very positive. A report was to be be compiled on completion of the surveys following the last inspection and a copy sent to the Commission, this has not been received. The last resident’s meeting was in May 2007 and the last staff meeting in January 2007 according to the records. Staff confirmed that this was correct. They said there were no staff meetings as the same issues kept coming up. The AQAA has been completed by the registered manager but lacks detail. There is a policy for the safekeeping of residents money, it must be expanded to detail the specific procedures used in the home. The resident’s guide states money is held in a separate account which is incorrect. The home holds cash for six people, it is stored separately in a locked facility. Records are maintained of all transactions and receipts are kept for purchases. Receipts are not number coded and transactions have only one signature recorded. Receipts are not given to families when they hand money to the home. Several health and safety policies were seen; one included a list signed by staff stating they had read it. The health and safety risk assessments were not found nor were the servicing records for equipment and machinery. There were no statutory training records available. The home has few accidents recorded; there is no evidence that audits take place. The reporting system changed from the beginning of October; the reports are now filed individually in resident’s files. They are not copied or recorded elsewhere which makes it very difficult to see how many there are each month or if there are trends. Little Trefewha DS0000009097.V350229.R01.S.doc Version 5.2 Page 24 A new fire system has recently been installed. A fire risk assessment dated December 2006 is kept with the fire records, the records are up to date. The maintenance man said he would check when the battery is run down on the emergency lighting system, he thought the Exco Company did it as he does not do it, there are no records. Records show that fire drills take place each week and staff said they include some teaching. One took place during this inspection, one fire door was wedged open and no one closed it. The maintenance person was advised to talk to the fire authority regarding the fitting of door fixtures that allow doors to be open but will close when the fire alarm is raised. Some radiators are very hot, probably due to the new boiler that has been installed, they must be fitted with appropriate covers to prevent the possibility of resident being burnt. Little Trefewha DS0000009097.V350229.R01.S.doc Version 5.2 Page 25 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 1 X 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 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 2 30 1 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 1 X 2 X 1 2 Little Trefewha DS0000009097.V350229.R01.S.doc Version 5.2 Page 26 Are there any outstanding requirements from the last inspection? No 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 OP1 Regulation 4 Requirement The home must have an up to date statement of purpose that is available in the home. This will ensure that people have the information they require about the home The medicines policy must be accessible to all care staff. This will ensure staff know what is expected of them Medicine systems in the home must be reviewed to include • Management of the medicines fridge • Non sharing of prescribed medicines • Transcribing on MAR charts to be witnessed and signed by two staff • Accurate recording in the controlled drugs register This will safeguard residents A review and risk assessment of the night staffing arrangements must be undertaken to include: • The design of the building • Continence management • Moving and handling arrangements
DS0000009097.V350229.R01.S.doc Timescale for action 31/01/08 2 OP9 13 (2) 19/12/07 3 OP9 13 (2) 19/12/07 4 OP27 12 (1) 18 (1) (a) 19/12/07 Little Trefewha Version 5.2 Page 27 • 5 OP29 19 Sch 4 (6) 17 6 OP35 16 (2) (l) Sch 4 (9) 7 OP38 OP30 13 (5) (6) 17 18 (1) (c) Sch 4 (6) (g) 23 (4)(d) 8 OP38 13 (4) 23 (2) (e) 17 How often people wake at night • How often a staff are summoned • Staff break times and so on This will safeguard residents and ensure sufficient staff are there to care for them Recruitment of new employees must be robust and include the records and checks required by law. Two references and a satisfactory POVA check must be obtained prior to work commencing and staff must be supervised until a satisfactory CRB check has been received. This will safeguard residents and staff The home’s policies must detail the arrangements for the safekeeping of resident’s monies and valuables. This will inform and direct staff All staff must receive appropriate training including: • Induction training • Abuse training • Statutory training, in accordance with legal requirements. Records must be maintained and available for inspection. This will ensure that staff have the knowledge and skills to care for and safeguard the people using the service. Documentation and records pertaining to health and safety must be maintained and available for inspection. These include: • Health and safety risk assessments • Relevant policies • Servicing records for equipment and machinery 08/11/07 31/01/08 31/03/08 31/01/08 Little Trefewha DS0000009097.V350229.R01.S.doc Version 5.2 Page 28 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 There should be a risk assessment in place for all residents with bed rails in situ. Discussion should take place with the resident, relatives and any relevant healthcare professional to ensure this is best for the resident’s needs. Day and night records should be detailed and written by the person administering the care to ensure the correct information is recorded A flow chart or simplified adult protection procedure should be compiled for staff to reference easily A sluice with a washer disinfector should be provided for infection control purposes. The registered manager should ensure that systems are in place and staff are aware of the policies and procedures pertaining to the management of the home if they are left in charge of the home The registered manager should seek the views of relatives and external stakeholders in relation to quality reviews A copy of the quality assurance annual report should be available for inspection to evidence what people think about the home There should be an annual development plan for the home and systems for continuous improvement Radiators should be regulated or covered to prevent the risk of burns 2 3 4 5 OP7 OP18 OP26 OP31 6 7 8 9 OP33 OP33 OP33 OP38 Little Trefewha DS0000009097.V350229.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection Devon Area Unit D1 Linhay Business Park Ashburton TQ13 7UP 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
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