Inspection on 17/08/06 for Trefula House

This inspection was carried out on 17th August 2006.

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

Other inspections for this house

Trefula House 10/09/09

Trefula House 20/09/07

Trefula House 01/12/05

Trefula House 15/06/05

Trefula House 11/01/05

Trefula House 08/07/04

Trefula House 23/03/04

Similar services:

The Vicarage

Fairfields Country Rest Home

7 Hyde Road

5 Seafield Road

Poldhu

Queensmount

Trevaylor Manor

Didsbury Court Rest Home

Extracts from inspection reports are licensed from CQC, this page was updated on 09/07/2008.

CARE HOMES FOR OLDER PEOPLE Trefula House St Day Redruth Cornwall TR16 5ET Lead Inspector Diana Penrose Unannounced Inspection 17th August 2006 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 Trefula House DS0000009152.V299732.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. Trefula House DS0000009152.V299732.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Trefula House Address St Day Redruth Cornwall TR16 5ET 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 820215 01209 822499 Issuemarket Limited Miss Pamela May Davey Care Home 37 Category(ies) of Old age, not falling within any other category registration, with number (37), Physical disability (37), Terminally ill (37) of places Trefula House DS0000009152.V299732.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 1st December 2005 Brief Description of the Service: Trefula Nursing Home is situated on the outskirts of the village of St Day, near Redruth. It is in a quiet secluded area and has extensive views of the surrounding countryside. The home provides nursing and personal care for up to thirty-seven elderly people, there is a Registered Nurse on duty at all times. The home’s registration allows for people with a terminal illness or a physical disability. The home was first registered in 1992 and comprises of a two-storey house with an extension to the rear. Accommodation is provided in two distinct areas. There are hand washbasins in all bedrooms and adequate toilet and bathing facilities. Meals are prepared in a comparatively small kitchen on the ground floor and served in the dining rooms or lounges. Residents can choose to eat in their individual bedrooms if preferred. The home has extensive gardens that are well maintained. Access for residents is restricted in certain areas for safety reasons. There is a large car park at the front of the home. There is a flexible visiting policy and residents can see their visitors in private. Information about the home is available in the form of a residents’ guide, which can be supplied to enquirers on request. A copy of most recent inspection report is available in the home. Fees range from £444.25 to £520.00 per week; this information was supplied to the Commission in the pre inspection questionnaire received on 28/07/06. Additional charges are made in respect of private healthcare provision, hairdressing and personal items such as newspapers, confectionary and toiletries. Trefula House DS0000009152.V299732.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. An inspector visited Trefula Nursing Home on the 17 August 2006 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. It was also to gain an update on the progress of compliance to the requirements identified in the last inspection report dated 01/12/05. All of the key standards were inspected. On the day of inspection 30 residents were living in the home and one attended once a week for day-care. The methods used to undertake the inspection were to meet with a number of residents, relatives, staff and the registered manager to gain their views on the services offered by Trefula Nursing Home. Records, policies and procedures were examined and the inspector toured the building. This report summarises the findings of this inspection. Residents and relatives expressed satisfaction with the care and services provided at the home. Overall the home is providing a high standard of care to the residents placed there and outcomes for them are good. Planning permission has been granted to build a dining facility in the ground floor extension, zone 5. Three double rooms are also to be converted into singles with en suite facilities. The registered providers are applying to the Commission for Social Care Inspection to register 12 rooms, in zone 5, for the accommodation of residents with dementia or a mental disorder. What the service does well: The home provides a warm, clean, homely environment that is well maintained and safe for residents, staff and visitors. The laundry facilities are good and appropriate hand washing facilities are provided for staff in all areas. Care provided is to a high standard and residents are only admitted following a full assessment to ensure the home can meet their needs. Residents have an individual detailed care plan and relevant risk assessments are undertaken. The plans are reviewed every month with the resident or their representative. Residents said their care needs are met and they are very happy living in the home. They said the staff are kind and caring and work very hard. A visitor commented that the home is the best place he has been to, they look after the residents very well and both the staff and residents have smiles on their faces. Trefula House DS0000009152.V299732.R01.S.doc Version 5.2 Page 6 Sufficient numbers and skill mix of staff are on duty to ensure that resident’s needs are met. There is a robust recruitment policy and appropriate training is provided for staff. Residents said there are enough staff and they are always willing to help. Staff were observed to interact well with residents in a very kind, relaxed manner. Care practices observed were appropriate and safe. Medicines are stored safely and securely and only qualified nurses administer the medicines. There are suitable systems for dealing with complaints and abuse. Staff and residents said they could approach the manager if they had a problem. Friends and family are welcome in the home and residents can go out according to their wishes and ability. What has improved since the last inspection? What they could do better: Suitable leisure and recreational activities must be provided for residents. Residents said there were insufficient activities provided although staff did try and find time to chat and spend time when they could. The registered manager must ensure that all areas of the medication system remain consistent with the homes policy, The Royal Pharmaceutical Guidelines for the Administration of Medicines in Care Homes and that there is compliance with legislation at all times Another audit of commodes and bed tables should take place and replacements made as necessary, the replacements previously identified have not been provided. Trefula House DS0000009152.V299732.R01.S.doc Version 5.2 Page 7 The facilities for making drinks in the main kitchen are utilised by all staff and visitors to the home. This needs to be changed for health and safety reasons. Staff should use the facilities in the staff room for making drinks and separate arrangements need to be made for visitors. 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. Trefula House DS0000009152.V299732.R01.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 Trefula House DS0000009152.V299732.R01.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 3 (6 is N/A) Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are only admitted to the home following an assessment of their needs to ensure the home can provide adequate care. EVIDENCE: Evidence was provided in the form of records and discussion with the registered manager and relatives. The registered manager said that she, or another nurse, visits prospective residents whenever possible to assess their needs prior to admission. A specific form is used to record the assessment, which is comprehensive. Relevant information from other healthcare professionals for example, Adult Social Care, GP’s and hospital staff, is obtained where possible. A relative said he gave the manger information about his mother prior to her admission. Trefula House DS0000009152.V299732.R01.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Individual care plans are generated for each resident that inform and direct the staff in their care provision. Service users have access to health care services as necessary to ensure their assessed needs are met. There are systems and policies in place for dealing with resident’s medicines; extra attention in some areas will ensure a safer system. Systems are in place to ensure that residents are respected and their privacy is upheld at all times. EVIDENCE: Evidence was provided in the form of documentation, records, observation, interviews with residents, relatives, staff and registered manager. Each resident has a written care plan that includes health, social and personal care needs. Risk assessments include Waterlow scoring, nutrition, moving and handling, falls and Barthel scoring. The plans are divided into relevant sections and they are very detailed to direct staff in the care to be provided. The plans are signed by the resident or their representative whenever possible. They are reviewed monthly or in between if the need arises. The daily records refer to the care plan and notes are kept to a minimum. Residents, relatives and staff Trefula House DS0000009152.V299732.R01.S.doc Version 5.2 Page 11 said the care provided by the home is of a high standard. One resident said, “The care here is second to none”. Doctors and other healthcare professionals visit residents as appropriate and records are kept. The home has sufficient equipment for moving and handling and pressure relief. Nutritional screening takes place on admission and needs are reviewed monthly. Residents are weighed regularly according to their individual requirements. A monitored dosage system (MDS) of medication is used in the home. Records of the receipt, administration and disposal of medicines are well maintained and there is a photograph of each resident with his or her medication chart. Handwritten medicine details or instructions on the medication charts are not always witnessed with two signatures recorded. The registered manager endeavours to ensure that staff follow this process and it has been recorded in several staff meeting minutes. She said she would continue to reiterate this to the nurses and follow it up. Medicines prescribed for an individual resident must not be administered to anyone else; a bottle of Lactulose was being shared between several residents. This had been resolved by a change in the labelling system but has not been kept up; the registered manager said she would sort this out. Controlled drugs are dealt with appropriately and those checked were correct. The registered manager said she would ensure that money and items of jewellery are removed from the controlled drug cupboard. The lunchtime medicine round was carried out in an orderly and professional manner. The medicines policy has been reviewed and updated; some minor adjustments were discussed with the registered manager. Staff have received training on the MDS system and the pharmacist provides information as required. Care staff receive basic medication training as part of the NVQ course. The registered manager said she is going to include basic medication training for care staff in the induction programme. There is a file for storing patient information leaflets (PIL) and reference books are supplied for staff. The arrangements for ensuring privacy and dignity are specified in the statement of purpose. Staff were observed to respect residents privacy during the inspection and residents said this is always so. Suitable screening is provided in shared rooms and residents are addressed by their preferred name. Trefula House DS0000009152.V299732.R01.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home provides some activities and entertainment; the registered manager hopes to improve this to offer a lifestyle that meets individual residents needs more fully. Links with family, friends and the community are good and allow residents the opportunity to socialise. Residents are helped to maintain control over their lives and staff respect their individual preferences and choice. Dietary needs of residents are well catered for with a varied selection of food available that aims to meet their taste and preference. EVIDENCE: Evidence was provided in the form of documentation, records, observation, interviews with residents, relatives, staff and registered manager. The registered manager has been actively trying to recruit an activities coordinator. At present the care staff provide activities for residents as staffing levels allow. This includes colouring books, manicures, one to one chats and going out around the garden. Both residents and staff said that activities for residents is an area that needs to be addressed. Some residents said they read books and there is a small library of books available in the home. Several said they enjoy watching television although sometimes it is just there in the background. Singers come in to entertain and trips out are organised when Trefula House DS0000009152.V299732.R01.S.doc Version 5.2 Page 13 sufficient people are available to help the wheelchair users. The home held a fete recently; some residents were involved with this and several went outside for this event. Staff and residents said they enjoyed the fete and the money raised will be used to benefit the residents. Social interests and hobbies are recorded in the resident’s records however the provision of suitable leisure and recreational activities is an area that must be developed. There is a record of visitors to the home and there were visitors in the home during the inspection. Residents said they could receive visitors in private and at any time. Visitors spoken with said they are made welcome in the home and can call in when they like. They also take residents out when they wish. One resident said she goes out with her son every Saturday. One is attending her granddaughters wedding and the home has helped with the provision of transport for her. Residents said the telephone arrangements in the home are good. Residents said they have control over their lives as far as possible. They said they are given choices in respect of food, clothes to wear, daily routines and so on. They also said they are addressed by their preferred name; staff reiterated to the inspector the preferred name of one resident as she did not like to be addressed by her Christian name. One resident said she goes out with friends when she likes. All residents have their own possessions in their rooms. Each resident has a nutritional needs assessment and their likes and dislikes are recorded. There is a varied menu with fresh vegetables and fruit available each day. Homemade cakes are served with afternoon tea and drinks and snacks are available as requested. The cook said that each resident has a jug of fresh water every day replenished as required, fruit squash is also provided. A juicer has been purchased and the residents enjoy fresh fruit juices on a daily basis. Meals are served in the dining room, lounges or individual bedrooms. The dining tables have tablecloths and fresh flowers provided, there is special cutlery, plates and plate guards available for those who need them. Everyone spoken with said the food is very good and there was little food waste at lunchtime. A number of residents require assistance with their meals and staff did this in a sensitive manner that was unhurried. Residents said they have a cake made for them on their birthday and there are special celebrations at Christmas and Easter, and so on. Trefula House DS0000009152.V299732.R01.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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home has a satisfactory complaints procedure that ensures complaints are listened to and acted upon. Arrangements are in place for the protection of residents safeguarding them from harm or abuse. EVIDENCE: Evidence was provided in the form of documentation and discussion with the registered manager. There is a suitable complaints policy in the home and a method for recording complaints, the action taken and the outcome. There have been no complaints since the last inspection. Thank you letters and cards are kept and displayed on notice boards. The home has an adult protection policy that includes the Local Authority inter agency procedures, alerters guide and a draft copy of the national framework for safeguarding adults. A flow chart is included for staff to reference easily. There is a secure facility for the storage of money in the home. The Registered Manager said it continues to be difficult getting staff onto the adult protection training days as they are fully booked. In house training takes place and adult protection is included in the induction programme. Trefula House DS0000009152.V299732.R01.S.doc Version 5.2 Page 15 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19 and 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home and grounds are well maintained providing a safe environment for residents, staff and visitors. The home is clean and free from offensive odours making it a pleasant place to live in. EVIDENCE: Evidence was provided in the form of a tour of the premises, observation, interviews with residents, relatives, staff and registered manager. The home is clean, warm, comfortable and well maintained. There has been a great deal of re-decoration and refurbishment since the last inspection and carpets are to be replaced in two of the lounges. Each bedroom refurbished has had a new vanity unit installed. New dining room chairs and tables have been provided and they enhance the dining experience for residents. The tables are a better design for those sat in wheelchairs. Hospital style beds are provided as required and screening is provided in double rooms. Residents spoken with are very happy with their accommodation and surroundings. Trefula House DS0000009152.V299732.R01.S.doc Version 5.2 Page 16 Several commodes and bed tables require replacement and this was acknowledged in the last environmental audit undertaken by the registered providers; 19 commodes and 15 tables were to be purchased. It is recommended that another audit take place and replacements be made accordingly. The grounds are tidy with colourful flowers and garden seating is provided. The laundry facilities are suitable with two washers and three driers. The home deals with personal laundry; sheets and towels are contracted out. There are two sluices with washer/disinfectors in the home. Suitable hand washing facilities are provided for staff. Staff undertake infection control training as part of the NVQ syllabus. Three double rooms are to be converted into singles with en suite facilities and planning permission has been granted for proposed building alterations to zone 5. Trefula House DS0000009152.V299732.R01.S.doc Version 5.2 Page 17 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Staffing levels meet the needs of residents and staff morale appears to be good. Residents are in safe hands and benefit from the 60 of care staff that have achieved an NVQ qualification. Recruitment procedures are robust and offer protection to the residents. The home provides appropriate training for staff to help them be more competent in their roles. EVIDENCE: Evidence was provided in the form of records, observation, interviews with residents, relatives, staff and registered manager. The registered manager said the skill mix of staff was suitable for the residents living in the home. The rota shows sufficient numbers of staff on duty, both staff and residents feel the numbers are sufficient. There are two nurses on duty during the day and one at night. There are on average 5 care staff in the mornings, 4 in the afternoons and 2 at night. Residents said that staff are very kind and caring and they work extremely hard, one said that nothing is too much trouble. Relatives spoke highly of the staff team and one said, “They are all angels”. Staff were observed to interact well with residents, in a very kind, friendly manner, care practices observed were appropriate and safe. Three overseas staff are employed and have settled well into the team. Staff and residents said their English is good and there are no communication problems. Trefula House DS0000009152.V299732.R01.S.doc Version 5.2 Page 18 60 of care staff have an NVQ either at level 2 or 3 and copies of NVQ certificates are kept on file. All new care staff are enrolled on the NVQ level 2 course if they have not already achieved the certificate. The home has a robust recruitment policy and the registered manager ensures that appropriate checks are made prior to employing new staff. An equal opportunities monitoring form is in use. The records required by legislation are maintained. New employees sign for the receipt of various documents and policies, these include the GSCC code of conduct, the employee handbook and the homes emergency procedure manual. There are specific induction programmes for staff in each area; new staff are fully supervised for at least the first two weeks of employment and staff verified this. Each member of staff has an individual training plan and a training record card. There are basic training records of care instruction for care staff that are very useful. Training is identified through the appraisal and supervision system, staff meetings and general conversation and observation. Staff said that training is provided but it is felt that generally there is not so much on offer in the county for nurses. There are e-learning packs for staff on dementia care and person centred care. Trefula House DS0000009152.V299732.R01.S.doc Version 5.2 Page 19 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 and 38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The Registered Manager is a person of good character and fit to run the home. The home is run in the best interest of the residents and they benefit from the Quality Assurance systems in place. There is a suitable system in the home for dealing with residents’ money that ensures that the residents’ financial interests are safeguarded. Appropriate training and safety checks are undertaken to ensure the health safety and welfare of residents and staff. EVIDENCE: Evidence was provided in the form of documentation, records, interviews with residents, relatives, staff and registered manager. The registered manager is competent and experienced to run the home. She is a qualified mental nurse and has achieved the Registered Managers’ Award. Trefula House DS0000009152.V299732.R01.S.doc Version 5.2 Page 20 She keeps herself up to date on current issues by reading relevant magazines, using the internet and attending appropriate training. Recent training includes diabetes, PEG feeding and infection control. Staff said she is a very fair manager and one said she is like a mother to her. All of the staff spoken with said they could approach her about anything and would go to her if they had a problem. They felt supported and regular supervision takes place. Residents said the home is well managed and the manager sees them every day. Quality assurance surveys are sent to relatives to complete with or on behalf of residents every six months and participation is good. The results are collated and necessary action taken, a copy of the results is sent to the Commission for Social Care Inspection annually. Regular meetings take place with residents and all grades of staff, minutes are maintained that show issues are addressed and action is taken. An external consultant undertakes health and safety audits. The registered provider has undertaken an environmental audit and the registered manager audits accidents and care plans. There is a suitable policy for the management of resident’s money. The registered manager holds money for all residents. Resident’s money is held in a non-interest bank account separate to the business account. Pocket money is stored securely in a safe in the form of petty cash and receipts are kept for all money removed from the safe. Appropriate electronic records are maintained of all transactions, the accounts are printed every three months for the resident or their representative. Receipts are kept for purchases and for money received on behalf of residents. There is a book to record purchases from the trolley shop and these are transferred to the individual residents records. There is a system for staff to follow when the registered manager is not in the home and one of the nurses explained this. The registered manager endeavours to ensure that working systems are safe. An external consultant has been employed to assist with health and safety management and training. Statutory training takes place regularly for moving and handling, fire, health and safety and food hygiene. The registered manager said it is difficult to ensure that night staff attend the appropriate number of fire training sessions but she is working on resolving this. Suitable systems are in place for infection control and residents who require hoisting have individual slings that are laundered regularly. All necessary service and equipment checks are undertaken as appropriate. Accidents are few and are recorded and reported appropriately; the Registered Manager audits the accidents each month. COSHH data sheets are available to staff. The cooks have all recently achieved the food hygiene foundation certificate. Staff have their own facility in the staff room for making hot drinks, they should not use the facilities in the kitchen. Staff should not enter the kitchen unless absolutely necessary and with the authorisation of the cook. The kitchen is very small and excess people in this space poses a risk to health and safety, Trefula House DS0000009152.V299732.R01.S.doc Version 5.2 Page 21 the use of kitchen equipment by non-catering staff could create an infection control risk. Visitors should never utilise the home’s kitchen facilities. Trefula House DS0000009152.V299732.R01.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 X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 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 3 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 4 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 3 Trefula House DS0000009152.V299732.R01.S.doc Version 5.2 Page 23 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 OP12 Regulation 16(2) (m) (n) Requirement Suitable leisure and recreational activities must be provided for residents Timescale for action 10/01/07 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 All areas of the medication system in the home should consistently be in line with the home’s policy, The Royal Pharmaceutical Guidelines for the Administration of Medicines in Care Homes and comply to legislation An audit of commodes and bed tables should take place and replacements made as necessary. The registered manager should be allocated a budget • Staff should not enter the kitchen unless absolutely necessary and with the authorisation of the cook, they should use the facilities in the staff room for making drinks. • All staff utilising the kitchen should hold an up to date food hygiene certificate • It is strongly recommended that visitors have a separate facility for making drinks they should not DS0000009152.V299732.R01.S.doc Version 5.2 Page 24 2 3 4 OP19 OP34 OP38 Trefula House utilise the kitchen. Trefula House DS0000009152.V299732.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection St Austell Office John Keay House Tregonissey Road St Austell Cornwall PL25 4AD National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. 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