Inspection on 20/05/09 for Trelawne

This inspection was carried out on 20th May 2009.

CQC found this care home to be providing an Adequate service.

The inspector found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 5 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Trelawne 29/05/08

Trelawne 22/05/07

Trelawne 18/08/06

Trelawne 23/02/06

Trelawne 22/09/05

Trelawne 16/03/05

Trelawne 19/01/05

Trelawne 29/03/04

Similar services:

Claremont House

Oak Ridge

Sun Court Nursing Home

Ashville House

Bilney Hall

Hill Barn

Mabbs Hall Nursing Home

Henrietta House

Extracts from inspection reports are licensed from CQC, this page was updated on 07/08/2009.

Inspecting for better lives Key inspection report Care homes for older people Name: Address: Trelawne 31 Lancaster Gardens West Clacton On Sea Essex CO15 6QG     The quality rating for this care home is:   one star adequate service A quality rating is our assessment of how well a care home, agency or scheme is meeting the needs of the people who use it. We give a quality rating following a full assessment of the service. We call this a ‘key’ inspection. Lead inspector: Helen Laker     Date: 2 0 0 5 2 0 0 9 This is a report of an inspection where we looked at how well this care home is meeting the needs of people who use it. There is a summary of what we think this service does well, what they have improved on and, where it applies, what they need to do better. We use the national minimum standards to describe the outcomes that people should experience. National minimum standards are written by the Department of Health for each type of care service. After the summary there is more detail about our findings. The following table explains what you will see under each outcome area. Outcome area (for example Choice of home) These are the outcomes that people staying in care homes should experience. that people have said are important to them: They reflect the things This box tells you the outcomes that we will always inspect against when we do a key inspection. This box tells you any additional outcomes that we may inspect against when we do a key inspection. This is what people staying in this care home experience: Judgement: This box tells you our opinion of what we have looked at in this outcome area. We will say whether it is excellent, good, adequate or poor. Evidence: This box describes the information we used to come to our judgement. Copies of the National Minimum Standards – Care Homes for Older People can be found at www.dh.gov.uk or bought from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop 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 Our duty to regulate social care services is set out in the Care Standards Act 2000. Care Homes for Older People Page 2 of 30 Reader Information Document Purpose Author Audience Further copies from Copyright Inspection report CSCI General public 0870 240 7535 (telephone order line) Copyright © (2009) Commission for Social Care Inspection (CSCI). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CSCI copyright, with the title and date of publication of the document specified. www.cqc.org.uk Internet address Care Homes for Older People Page 3 of 30 Information about the care home Name of care home: Address: Trelawne 31 Lancaster Gardens West Clacton On Sea Essex CO15 6QG 01255220259 NA Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): Type of registration: Number of places registered: Conditions of registration: Category(ies) : Mrs Monica Roberts care home 13 Number of places (if applicable): Under 65 Over 65 13 old age, not falling within any other category Additional conditions: Date of last inspection Brief description of the care home 0 Trelawne Rest Home is situated in an established area of Clacton-on-Sea, known locally as the Gardens, close to the sea front and within easy walking distance of all local amenities. The home is registered for thirteen older people. The registered person is Mrs Monica Roberts who has managed the home for a number of years. The home provides accommodation on two levels. A passenger lift is provided for access to the first floor. A number of communal areas are available. The home has a large garden area to the rear of the property. The fee range for the home ascertained at the homes last inspection on the 29th May 2008 was between 345.24 pounds - 417.27 pounds per week, additional charges are made for the following: Hairdressing, Chiropody, and Toiletries. The manager was not available at this inspection so the current rate of fees could not be established but can Care Homes for Older People Page 4 of 30 Brief description of the care home be verified by contacting the home directly. Care Homes for Older People Page 5 of 30 Summary This is an overview of what we found during the inspection. The quality rating for this care home is: Our judgement for each outcome: one star adequate service Choice of home Health and personal care Daily life and social activities Complaints and protection Environment Staffing Management and administration peterchart Poor Adequate Good Excellent How we did our inspection: The quality rating for this service is 1 star This means the people who use this service experience adequate quality outcomes. This inspection was carried out as part of the annual inspection programme for this home. The inspection focused on all of the key standards. A tour of the premises was undertaken. Discussions were held with people living at the home and staff on duty, as well as the opportunity to look at most records of how people living at Trelawne were supported and how staff were recruited and trained. Evidence was also taken from the Annual Quality Assurance Assessment (AQAA) completed by the management of the home and submitted to CQC. The AQAA provides an opportunity for the service to tell us what they do well and areas they are looking to Care Homes for Older People Page 6 of 30 improve and/or develop. It is anticipated that some improvement be noted as this contributes to the inspection process and indicates the homes understanding of current requirements, legislation changes and own audited compliance. The judgements made within this report are based upon evidence found on the inspection visit along with information submitted by the service and feedback from service users, staff and other parties since the previous inspection. The previous inspection report was also reviewed and two surveys were returned by service users, one by a relative and two by staff to the CQC. Mrs Monica Roberts, the proprietor/manager of Trelawne, was not available at the inspection visit. We were told by staff that the proprietor/ manager would be back and when it was clear that access to the locked office was not possible as the manager was the only key holder, efforts were made to contact her. However, it was not possible to contact her and they had not returned by the time we completed our inspection. This was disappointing as the majority of records were locked in the managers office and no one else had access. It is expected that all records required for inspection be available and accessible for review at all times. As we were unable to ascertain fully the homes current situation with regard to standards 27 to 38, the judgement and any requirements made at the last inspection have been carried forward and will be followed up at the homes next inspection. What the care home does well: What has improved since the last inspection? What they could do better: It was noted at the homes last inspection that care records had improved with regard to the frequency of reviews, although individual plans did not all show details of all the assessed needs. This had improved at this inspection but there is a need to ensure that greater attention be paid to care plans, daily recordings and assessment recording. Through assessment and consultation with service users the team at the home must ensure that residents individual social care needs are met and that their independence and self worth is promoted. Social histories of residents should be completed and consideration should be given to ensuring residents are provided with appropriate activities that meet their interests and wishes. Improvements need to be made in the range of activities available to people living at Trelawne. Radiators which required covering, in areas where service users may be at risk i.e. some bedrooms, have still to be attended to and should be risk assessed. Although improvements had been made to the training of staff at Trelawne at the last two inspections there was still little evidence of formal inductions for new carers. We were unable to ascertain that progress had been made in this area as all records pertaining to this were not available. Trelawne still needs to develop a robust quality assurance process to demonstrate the home is run in the best interests of those living there, as well as a business plan to show the homes continued financial viability. Since the last two inspections, there has been only slow progress in relation to meeting the requirements made. The requirements made at the last inspection have only Care Homes for Older People Page 8 of 30 decreased marginally, two were met, and one new one was made with five being repeated. Additionally a further five recommendations were made at this inspection. The manager is aware of the importance of ensuring these be met and had assured us at the last inspection that this will be the case by the next inspection, and that has not happened. The manager is again reminded that although the AQAA showed they had an understanding of the home and was slightly more detailed than last year, it still needs much more clarification and detail included to demonstrate this. If you want to know what action the person responsible for this care home is taking following this report, you can contact them using the details set out on page 4. The report of this inspection is available from our website www.cqc.org.uk. You can get printed copies from enquiries@cqc.org.uk or by telephoning our order line –0870 240 7535. Care Homes for Older People Page 9 of 30 Details of our 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) Outstanding statutory requirements Requirements and recommendations from this inspection Care Homes for Older People Page 10 of 30 Choice of home These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People are confident that the care home can support them. This is because there is an accurate assessment of their needs that they, or people close to them, have been involved in. This tells the home all about them and the support they need. People who stay at the home only for intermediate care, have a clear assessment that includes a plan on what they hope for and want to achieve when they return home. People can decide whether the care home can meet their support and accommodation needs. This is because they, or people close to them, have been able to visit the home and have got full, clear, accurate and up to date information about the home. If they decide to stay in the home they know about their rights and responsibilities because there is an easy to understand contract or statement of terms and conditions between them and the care home that includes how much they will pay and what the home provides for the money. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. This judgement has been made using available evidence including a visit to this service. Prospective residents can be assured that their needs will be considered before any agreement to their admission and that they will receive information to enable them to make a positive and informed choice about where they wish to live. Evidence: The home has a published Statement of Purpose and Service User Guide, both of which are made available to existing and prospective residents at Trelawne. Copies of these were seen in residents care plans. The examination of three care records showed that people living in the home had their individual needs assessed and these assessments formed the basis of individual care plans. The care records examined showed that the date of admission in most cases was the day before the pre admission assessment was formulated. This was discussed with the staff on the day of inspection Care Homes for Older People Page 11 of 30 Evidence: as this does not show that service users are being assessed prior to entering the home. The AQAA states The statement of purpose and service users guide promote accurate information. Prospective residents and families are asked to visit and someone will show them around and answer any questions. They can spend a trial session at the home if requested. Three resident surveys returned all stated that they did have enough information about the home to enable them to make an informed choice and the most recent resident admitted to the home confirmed that they had had discussions before coming to the home. A discussion with staff on the day of inspection highlighted that best practice would be for documentation to evidence any assessments made prior to admission, to ensure an accurate audit trail is in place. Discussions with the staff and service users supported the evidence found in care records and indicated that these assessments gained views and insights from the individual, and their families and professionals were involved in the individuals care. The homes AQAA also identifies that The feedback gained from surveys and prospective residents show that the information given is accurate and gives them informed choice. At the last inspection in May 2008 we were informed that improvements to be made were that pre admission visits to the home with service users and their relatives will be a more inclusive process involving all members of the staff team. Discussions with the staff team and service users, combined with survey feedback confirmed this. Trelawne does not provide intermediate care. Care Homes for Older People Page 12 of 30 Health and personal care These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People’s health, personal and social care needs are met. The home has a plan of care that the person, or someone close to them, has been involved in making. If they take medicine, they manage it themselves if they can. If they cannot manage their medicine, the care home supports them with it, in a safe way. People’s right to privacy is respected and the support they get from staff is given in a way that maintains their dignity. If people are approaching the end of their life, the care home will respect their choices and help them feel comfortable and secure. They, and people close to them, are reassured that their death will be handled with sensitivity, dignity and respect, and take account of their spiritual and cultural wishes. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. This judgement has been made using available evidence including a visit to this service. Peoples needs are assessed in a person centred way that enables staff to have a better understanding of each individual, however people must be further assured that the care and support in some areas that they require to meet their needs is planned and recorded sufficiently well to guide staff in promoting their well being and safety. Evidence: At the homes last inspection in May 2008 it was noted that there was an existing care planning system in place consisting of an assessment, care plans and risk assessments. Care plans cover the residents identified needs. They are informative and contain sufficient detail to ensure residents needs can be met. Also at the homes last inspection it was noted that not all paperwork had been sufficiently completed highlighting a support need for staff via training. Progress has now been made in this area and care plans now include information on personal preferences and use a more person centred approach concentrating on strengths, rather than needs and putting Care Homes for Older People Page 13 of 30 Evidence: support in place to optimize residents abilities. Life maps have also been developed which correlate with the residents care plan. The examination of three care records and individual plans of care showed that there had been improvements to the frequency of the reviews of plans, however the quality of daily entries in the evaluations were still somewhat non specific and repetitive. The homes AQAA acknowledges that We could monitor and evaluate more effectively what care staff document on the care plan as documentation needs to reflect changes in a residents care. One staff member said they would be happy to have more care plan training and it was being covered in an NVQ qualification they were currently undertaking. Residents spoken with were positive in their comments relating to staff members understanding of their current needs. It was suggested at the homes previous inspection that the more dependent residents who have limited interaction with staff, may benefit from assessments for signs of well being and feeling ill being developed. There was no evidence at this inspection of development in this area. A monthly review system is in place and undertaken by key workers, and this is generally consistent. Those seen complete show a good staff appreciation of residents needs and changes, however attention is still required to include dates, times and signatures. This was discussed with the staff on duty on the day of inspection. A range of risk assessments are completed that include manual handling, falls, general and environmental and nutrition. Evidence that these are kept under review were on file and in general do contain sufficient detail. Of the care plans reviewed only one person who had mobility issues did not have an assessment in place. A discussion with the staff was held regarding this and short-term goals, and staff should ensure that identified risks are reflected in the care plan so that the management of the risk is clear. The homes general policies and procedures and practices for the storage, administration and recording of medicines were seen to be appropriate and offered sufficient protection to those living at Trelawne. The proprietor was advised at the last inspection that all transcribed medications should have two signatures and this was repeated at this inspection. The AQAA further advises us that over the next twelve months the home plans to Develop strategies to incorporate the values and beliefs of each person in their care The observation of interactions between staff and people living at the home provided evidence that people were treated with respect and their right to privacy was upheld. Staff were seen to knock on doors before entering private bedrooms and address those living at the home in a respectful and caring manner. Care Homes for Older People Page 14 of 30 Daily life and social activities These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: Each person is treated as an individual and the care home is responsive to his or her race, culture, religion, age, disability, gender and sexual orientation. They are part of their local community. The care home supports people to follow personal interests and activities. People are able to keep in touch with family, friends and representatives. They are as independent as they can be, lead their chosen lifestyle and have the opportunity to make the most of their abilities. People have nutritious and attractive meals and snacks, at a time and place to suit them. There are no additional outcomes. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. This judgement has been made using available evidence including a visit to this service. The social care needs of residents in this home are not fully met. Residents continued contact with family and friends is welcomed and encouraged by the home and they are provided with a wholesome, tasty and balanced diet however staff need to be more aware of the need to support residents regarding the choice of daily activity so their lifestyle choices can be met. Evidence: The examination of social care plans within the home showed there were activities on offer to people living at Trelawne. There was a programme displayed on the wall showing tabletop activities on a daily basis and records were maintained detailing how people had participated and whether they had appeared to enjoy the activity. Staff spoken with stated Activity provision is difficult as sometimes residents prefer not to do anything The homes AQAA identifies under what they could do better, We plan to introduce more social activities depending on individuals choice and to value the views of residents as an integral part of this One service user spoken with stated It would be nice if we could do more things like bingo or going out. We used to but it doesnt Care Homes for Older People Page 15 of 30 Evidence: happen so much now One relative survey returned stated It would be good if the TV in the downstairs lounge was on in the morning and tea in bed plus a glass of wine or sherry for Sunday lunch could be considered. On the day of inspection there were no planned activities taking place, music was playing in two lounges, two service users were in their rooms, and one being visited by Age Concern regarding a personal matter. Some people living at Trelawne are more independent and were able to independently pursue activities outside of the home, others can be supported to go to the shops or to the seafront. The home does not have an activities coordinator and care staff therefore undertake any social activity either on a one to one basis or in groups. However staff agreed on the day of inspection that not many activities take place within the home and this could be improved upon. Discussions with staff and with people living at the home generally indicated that the activities when offered were enjoyed and people generally felt there was something to do. Care records showed that people living at Trelawne were encouraged to make decisions about how they lived and how they spent their time. However there were some time gaps in recording. A discussion with the manager at the homes last inspection and also with the staff at this one highlighted the need to be consistent with entries and recording one to one or group activity participation. The homes AQAA identifies the need for the home to research new skills and undertake training to meet all the diverse needs of the service users. It states As the needs of residents change we need to identify this more accurately. We recognise that good communication is essential. This will be followed up at the homes next inspection. The home was open to visitors at any time and people living at Trelawne stated that they had regular contact with relatives and friends. There were some visitors in the home at the time of inspection and all spoke of being made to feel very welcome at Trelawne. People living at the home spoke well of the food offered at Trelawne. Records showed there was a good range of meals provided and snacks and drinks were available throughout the day. The main meal of the day was served at lunchtime. On the day of inspection this consisted of steak pie, mixed vegetables, potatoes and rice pudding. This was seen to be nutritionally balanced and attractively presented. The home generally provide choices on a daily basis and set menus are not in place. The manager/proprietor usually undertakes the cooking duties but on the day of inspection was out and uncontactable so a member of staff took over the task. A discussion was held with staff regarding the appropriateness of them undertaking kitchen duties whilst in a caring role. This is not considered best practice for health and safety cross infection reasons and also because on the day of inspection there were only two members of staff on duty in total for 10 residents. Designated kitchen staff should be available at all times with separate staff undertaking a caring role. Care Homes for Older People Page 16 of 30 Care Homes for Older People Page 17 of 30 Complaints and protection These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: If people have concerns with their care, they or people close to them know how to complain. Any concern is looked into and action taken to put things right. The care home safeguards people from abuse and neglect and takes action to follow up any allegations. People’s legal rights are protected, including being able to vote in elections. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. This judgement has been made using available evidence including a visit to this service. Residents can expect that they will be listened to through the homes complaints and safeguarding adults systems. Residents can also be assured that all carers are trained to safeguard their welfare. Evidence: Trelawne has a robust and accessible complaints procedure and appropriate Protection Of Vulnerable Adults protocols that are understood by staff. Service users spoken with felt safe at the home and indicated that they could raise issues of concern with the proprietor and these would be acted upon. Staff spoken with were aware of whistle blowing procedures and had attended POVA training and were aware of the safeguarding procedures. We have not been made aware of any complaints and one safeguarding referral has been made which was dealt with appropriately by the home. The homes AQAA identifies the need to be vigilant via audit processes. The complaints procedure was noted to require updating with the CQCs new address. Care Homes for Older People Page 18 of 30 Environment These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People stay in a safe and well-maintained home that is homely, clean, pleasant and hygienic. People stay in a home that has enough space and facilities for them to lead the life they choose and to meet their needs. The home makes sure they have the right specialist equipment that encourages and promotes their independence. Their room feels like their own, it is comfortable and they feel safe when they use it. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. This judgement has been made using available evidence including a visit to this service. The home provides a safe, well-maintained environment that is accessible to the people who live there, homely and meets their individualised needs. Evidence: The home employs a handyman and a domestic who maintain Trelawne to a good standard. All areas are generally well decorated, clean and free from offensive odours. There were radiators in some rooms that had not been covered and, although the proprietor/manager believed these to be safe, there was no evidence of risk assessments being conducted. It required that the registered person make sure there are risk assessments conducted to assess the safety of all radiators through Trelawne and take appropriate actions to minimise the risks those present. This has now been attended to in part and most radiators now have covers with a few still outstanding. A discussion with the maintenance man on the day of inspection was held regarding this and he stated he would convey the issues to the proprietor who would systematically deal with them. Risk assessments for this could not be seen on this occasion either as the manager was not available and the office was locked and inaccessible by other staff members. The AQAA states The kitchen is in need of upgrading and risk assessments must be more stringent, checks on water temperatures must be Care Homes for Older People Page 19 of 30 Evidence: enforced. The maintenance person spoken to on the day of inspection stated that water temperatures are tested intermittently but agreed there was no documentation to evidence this. Staff spoken to confirmed the kitchen had been refurbished. The home is furnished in a domestic style and overall met the needs of people living there in a homely fashion. The home is considered fit for its stated purpose, accessible and safe. There were sufficient bathrooms and WCs and all but two bedrooms had en-suite toilets. Individuals spoken with living at the home expressed satisfaction with their environment and were happy to allow us access to their rooms. Rooms were noted to be personalised to individual taste and looked homely and inviting. Care Homes for Older People Page 20 of 30 Staffing These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have safe and appropriate support as there are enough competent staff on duty at all times. They have confidence in the staff at the home because checks have been done to make sure that they are suitable to care for them. Their needs are met and they are cared for by staff who get the relevant training and support from their managers. There are no additional outcomes. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. This judgement has been made using available evidence including a visit to this service. Residents can expect to be protected by the recruitment processes of the home which have sufficient safeguards in place to ensure residents are protected. Improvements in training would ensure residents are supported by knowledgable staff with the skills required to meet their needs. Evidence: These standards were unable to be inspected fully on the day of inspection as the manager was not in and was not contactable, and all documentary records required for inspection were locked away in the office and she had the only key. Evidence was gained through discussions with staff and residents and feedback given on surveys. At the homes last inspection in May 2008 discussions with the manager and the examination of records showed that staff were employed in adequate numbers to meet the needs of those living at the home. At this inspection staff numbers were deemed appropriate for the dependency levels of the current client group. Staff spoken too felt they were able to meet service users needs in full and confirmed that they felt enough staff were employed on each shift. On the day of inspection two staff were on duty for ten residents. Staff recruitment, training and supervision files could not be reviewed at this inspection as they were locked in the office and this was not able to be accessed Care Homes for Older People Page 21 of 30 Evidence: by the staff on duty on the day of inspection. At the homes last inspection in May 2008 two staff files were appropriately maintained and showed the homes recruitment practices generally offered protection to those living at the home by ensuring that all necessary pre-employment checks were undertaken. There was little evidence of staff receiving training to develop their skills further and competences and formal inductions were poor or not evidenced at all. One member of staff spoken with at this inspection could not clarify what their induction had involved, however none of this could be evidenced as documentation was inaccessible. Discussions with those living at the home gave evidence that they felt safe at Trelawne and that they felt staff were able to meet their needs. Duty rotas could not be inspected as they were unavailable to clarify the ratio of staff on duty and in relation to the number of current service users and dependency levels. The AQAA submitted states The staff structure does fluctuate at times however the last year has seen a more stable workforce. There are sufficient numbers for us to meet the needs of the residents. Rigorous recruitment procedures are in place. All staff have attended skills for care induction and 95 percent of staff are training to NVQ level 2 or above. It is expected that all records required for inspection be available and accessible for review at all times. As we were unable to ascertain fully the homes current situation with standards 27 to 30 fully the judgement and any requirements made at the last inspection have been carried forward and will be followed up at the homes next inspection. Care Homes for Older People Page 22 of 30 Management and administration These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have confidence in the care home because it is led and managed appropriately. People control their own money and choose how they spend it. If they or someone close to them cannot manage their money, it is managed by the care home in their best interests. The environment is safe for people and staff because appropriate health and safety practices are carried out. People get the right support from the care home because the manager runs it appropriately with an open approach that makes them feel valued and respected. The people staying at the home are safeguarded because it follows clear financial and accounting procedures, keeps records appropriately and ensures their staff understand the way things should be done. They get the right care because the staff are supervised and supported by their managers. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. This judgement has been made using available evidence including a visit to this service. Residents living at the home can expect to be supported by leadership who have demonstrated their suitability for the role. Service users are generally protected by the home practice, policies and procedures. Evidence: The documentation for these standards was unable to be inspected on the day of inspection as the manager was not in and was not contactable.The records required for inspection were locked away in the managers office and she had the only key. At the homes last inspection in May 2008, it was ascertained that the home is managed by the proprietor who has a number of years experience in caring for the client group. She was undertaking her NVQ level 4 in management and attended the training sessions that are available to the staff group. The AQAA submitted for this key inspection a statement by the manager purports I work most days at the home and Care Homes for Older People Page 23 of 30 Evidence: rely on a small core number of staff to support me. The personal touch is evident and we have a professional relationship with the local GP, Pharmacist and District Nurses. We are also informed in the AQAA that the manager has now completed her learning and management course level 4 and is awaiting certification. Discussions with staff and people living at the home showed that the general ethos of the home is open and understanding. There was no evidence to inspect to support staff or resident meetings being held although it was noted at the homes last inspection in May 2008 that there was an intention to recommence these. Staff spoken with stated that although formal meetings were not always held they were open with the manager about issues and she actively dealt with issues and encouraged them to do further training. We are further informed that views of those living at the home are sought through questionnaires although there was no evidence of a formal quality assurance process being undertaken. A requirement made at the last two inspections was that of a business plan being in place for the home to demonstrate its continued financial viability. This could not be verified at this inspection. Also at the homes last inspection in May 2008 records of staff supervision were poor. In one case evidencing just a brief discussion in eight months. The proprietor agreed and identified in the AQAA that this had been allowed to lapse. Although some staff had received supervision, this was infrequent and insufficient. Staff spoken to at this inspection maintained that supervision had been undertaken but could not verify this with documentation as it was locked in the managers office. Although most records relating to the welfare of people living at Trelawne were in place at the last inspection in May 2008 they were not available for review at this inspection. Photographs as required in Schedule 2 of the Care Home Regulations 2001 were noted to be present on care plans and medication records. At the homes last inspection in May 2008 there were appropriate policies and procedures in place regarding the health, welfare and safety of those living in Trelawne, staff and visitors which included electrical and gas safety checks which had been conducted at appropriate intervals and the home displayed relevant insurance and registration Certificates. Fire procedures were displayed in prominent positions and regular checks of fire alarms and safety equipment had been undertaken. This was confirmed in discussions with the maintenance man. Evidence of fire drills being undertaken was not available and staff spoken with could not confirm when the last drill was. It is expected that all records required for inspection be available and accessible for review at all times. As we were unable to ascertain fully the homes current situation with standards 31 to 38 fully the judgement and any requirements made at the last inspection have been carried forward and will be followed up at the homes next inspection. Care Homes for Older People Page 24 of 30 Are there any outstanding requirements from the last inspection? Yes R No £ Outstanding statutory requirements These are requirements that were set at the previous inspection, but have still not been met. They say what the registered person had to do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. No. Standard Regulation Requirement Timescale for action 1 12 16 (2) m & n (3) Through assessment and 31/07/2008 consultation, the team at the home must ensure that residents? individual social care needs are met and that their independence and self worth is promoted. Social histories of residents should be completed with staff being aware of the content. Consideration should be given to the appointment of an activities officer to help ensure that residents individual and group social needs are met. The registered person must 31/07/2008 ensure that all staff receive formal induction at the point of commencing employment in the home to ensure that people living at Trelawne are protected from the risk of harm and or abuse. The previous timescale of 31/10/06 and the 31/10/07 was not met. 2 30 13 (6) & 18 (c)(i) 3 33 24 The registered person shall 31/07/2008 develop a formal process for assessing the quality of the service provided at Trelawne to ensure the home continues to operate in the Page 25 of 30 Care Homes for Older People best interests of the people living there. The previous timescale of 31/10/06 and the 31/10/07 was not met. 4 34 25 The registered person shall 31/07/2008 develop a business plan for Trelawne to demonstrate the continued financial viability of the home. The previous timescale of 31/10/06 and the 31/10/07 was not met. 5 36 18 (2) Staff must have regular 31/07/2008 supervision and the staff supervision system needs to be developed further to ensure staff are competent to meet service users needs. The previous timescale of 31/10/06 and the 31/10/07 was not met. Care Homes for Older People Page 26 of 30 Requirements and recommendations from this inspection: Immediate requirements: These are immediate requirements that were set on the day we visited this care home. The registered person had to meet these within 48 hours. No. Standard Regulation Requirement Timescale for action Statutory requirements These requirements set out what the registered person must do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The registered person(s) must do this within the timescales we have set. No. Standard Regulation Requirement Timescale for action 1 12 16 Through assessment and 31/08/2009 consultation, the team at the home must ensure that residents individual social care needs are met and that their independence and self worth is promoted. Social histories of residents should be completed with staff being aware of the content. Consideration should be given to the appointment of an activities officer To ensure that residents individual and group social needs are met. 2 33 24 The registered person shall 31/08/2009 develop a formal process for assessing the quality of the service provided at Trelawne to ensure the home continues to operate in the best interests of the people living there. Care Homes for Older People Page 27 of 30 To ensure service users health safety and welfare is promoted 3 34 25 The registered person shall 31/08/2009 develop a business plan for Trelawne to demonstrate the continued financial viability of the home. To ensure service users health safety and welfare is promoted 4 36 18 Staff must have regular 31/08/2009 supervision and the staff supervision system needs to be developed further to ensure staff are competent to meet service users needs. To ensure service users health safety and welfare is promoted 5 37 17 The registered person shall 31/08/2009 ensure all records pertaining to the home for people living at the home contain up to date information and are available and accessible at all times to ensure the persons best interests can be protected. To ensure service users health safety and welfare is promoted Recommendations These recommendations are taken from the best practice described in the National Minimum Standards and the registered person(s) should consider them as a way of Care Homes for Older People Page 28 of 30 improving their service. No. Refer to Standard Good Practice Recommendations 1 2 It is considered best practice that any prospective residents are assessed fully prior to the date of admission to the home and that any documentation accurately reflects that process. Daily evaluation recordings should correlate with the care plan, be specific and non repetitive and be person centred to evidence that staff appreciate the diversity of individual residents. All transcribed medications should have two signatures, to ensure mistakes in administration are avoided and that residents are protected Sufficient kitchen and care staff should be on duty in such ratios to undertake seperate roles and duties so that all residents needs can be met. The registered person shall make sure there are risk assessments conducted to assess the safety of all radiators through Trelawne and take appropriate actions to minimise the risks these present.This will safeguard residents from harm. It is required that staff should have access to the management office at all times in case documentation and records are required by the home or other professionals 2 7 3 9 4 15 5 25 6 37 Care Homes for Older People Page 29 of 30 Helpline: Telephone: 03000 616161 or Textphone: or Email: enquiries@cqc.org.uk Web: www.cqc.org.uk We want people to be able to access this information. If you would like a summary in a different format or language please contact our helpline or go to our website. Copyright © (2009) Commission for Social Care Inspection (CSCI). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CSCI copyright, with the title and date of publication of the document specified. 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