Inspection on 02/11/06 for Trelawney House

This inspection was carried out on 2nd November 2006.

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

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Trelawney House 18/11/08

Trelawney House 21/05/08

Trelawney House 09/07/07

Trelawney House 06/06/06

Trelawney House 17/11/05

Trelawney House 17/05/05

Trelawney House 04/11/04

Trelawney House 14/05/04

Similar services:

Fairfields Country Rest Home

Poldhu

Queensmount

Trevaylor Manor

Didsbury Court Rest Home

Belma

Hunters Care Centre

Manor Lodge

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

CARE HOMES FOR OLDER PEOPLE Trelawney House Polladras Carleen Helston Cornwall TR13 9NT Lead Inspector Ian Wright Unannounced Inspection 10:15 2nd and 3 November 2006 rd 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 Trelawney House DS0000053715.V312860.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. Trelawney House DS0000053715.V312860.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Trelawney House Address Polladras Carleen Helston Cornwall TR13 9NT 01736 763334 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) Christine Anne Gatzianidis Rigas Gatzianidis Care Home 11 Category(ies) of Old age, not falling within any other category registration, with number (11) of places Trelawney House DS0000053715.V312860.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. To include one named service user with dementia which is outside the registered category. 6th June 2006 Date of last inspection Brief Description of the Service: Trelawney Care Home is situated in Polladras, about five miles from the town of Helston. The registered persons provide residential care for up to eleven elderly people. Day-care is also available for people living in the community. The home is set in spacious grounds with seating provided for service users. There is sufficient car parking available. Accommodation is on two floors; the first floor can be accessed by a shaft lift. There is one large lounge and a smaller television lounge. Meals are cooked in a large kitchen and served in the dining room. Trelawney provide a meals on wheels facility and supply around ten meals to people in the community each day. The homeowners live adjacent to the care home and are actively involved in the day-to-day running of the home. Care staff provide personal care and the home has a friendly, atmosphere. There are opportunities for socialising and visitors are encouraged. A copy of the inspection report is not on public display, and it is suggested a copy is requested from management if required. The range of fees at the time of the inspection is £325-£450 per week. There are additional charges e.g. for hairdressing, chiropody, trips out and newspapers etc. Trelawney House DS0000053715.V312860.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This key inspection took place over fourteen and quarter hours over two days. All of the key standards were inspected. The methodology used for this inspection was: • To case track five service users. This included interviewing the service users about their experiences and inspecting their records. • Interviewing four staff about their experiences working in the home. • Informal discussion with other service users and staff. • Observing care practices. • Discussing care practices with management. • Inspecting records and the care environment. Other evidence gathered since the previous inspection, such as notifications received from the home (e.g. regarding any incidents which occurred), were used to help form the judgements made in the report. What the service does well: What has improved since the last inspection? What they could do better: Two service users did not have a care plan and these need to be developed as a matter of priority. All staff still do not have a protection of vulnerable adults check / criminal records bureau check, although these have been applied for. The management should chase these up and need to confirm with the Trelawney House DS0000053715.V312860.R01.S.doc Version 5.2 Page 6 commission when suitable checks have been received. Some improvement is still required to staff training for example staff need to have regular fire training and training regarding infection control. Some staff still need to receive training in food handling and first aid. All staff also still need to have training regarding dementia awareness. Some improvement is still required to recruitment practices for example to ensure all new staff have two references. The electrical (hardwire) circuit still needs to be serviced and the commission requires confirmation from the provider when this is completed. 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. Trelawney House DS0000053715.V312860.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Trelawney House DS0000053715.V312860.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 2, 3 Quality in this area is good. The judgement has been made using available evidence including a visit to the service. Service users are issued with either suitable terms and conditions of residency or a social service contract at the time of admission. This enables service users to be aware of their rights and responsibilities. The pre admission assessment procedure is good and enables the registered persons to ascertain they can meet the needs of service users before admission is arranged. EVIDENCE: Copies of resident contracts (if privately funded) were available for inspection in service user files. Service users funded by statutory authorities only receive a social services contract. Mrs Gatzianidis assesses service users before they are admitted. Service users confirmed they or their relatives visited the home before formal admission was arranged. Service users said an assessment was completed before admission was arranged. Copies of assessments were available for inspection in service user files. The inspector said contemporaneous notes should be retained regarding preadmission assessments. Trelawney House DS0000053715.V312860.R01.S.doc Version 5.2 Page 9 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9,10 Quality in this area is adequate. The judgement has been made using available evidence including a visit to the service. Most service users have a care plan and these are satisfactory. However these need to be developed for all service users. Appropriate care plans ensure staff have consistent guidelines to provide care according to service user needs and wishes. Healthcare support seems appropriate so service users can be assured they will receive suitable support from medical practitioners. The medication system needs improvement to ensure it meets Royal Pharmaceutical Society Guidelines, and so service users can be assured staff handle their medication appropriately. Most service users said staff work with them in a manner which respects their privacy and dignity although an allegation of poor practice must be referred to Cornwall Adult Social Care. Matters regarding the diverse backgrounds of service users appear suitably addressed. EVIDENCE: There is a copy of a care plan in most service users’ files. However these were absent for two service users, and these need to be developed as a matter of priority. Staff said care plans were accessible to them. The care plan format is satisfactory and care plans were last reviewed in September 2006. Care plan review now needs to occur frequently. The section which outlines what care Trelawney House DS0000053715.V312860.R01.S.doc Version 5.2 Page 10 interventions are required for individual service users was only kept in the main office, and the inspector suggested these would be more accessible in the main service user files. The registered provider said she would address this. Service users said they were satisfied with the healthcare support they received. This includes visits from GP’s, district nurses, chiropodists, dentists and opticians. Service users said doctors are called when necessary. The registered providers have a satisfactory medication policy. Medication is administered via the NOMAD system (dossetts packed by the pharmacist). One service user currently self-administers medication and there is a suitable agreement for this. Medication procedures although adequate need some improvement: • A minority of dosages were not signed for, although medication appeared to be administered. • There was excess medication stored for some service users (Gaviscon, E45 cream, Lactulose). • Some medication was not recorded on the medication sheets (Aqueous cream, E45 cream, Gaviscon.) • There was no medication sheet for one service user. Although the person self administers, medication is stored with other service user medication, and there needs to be a correct record of the stock kept for this person. A locked cabinet / lockable could be provided in the service user’s bedroom. Staff have received training regarding the storage and handling of medication from the pharmacist. The majority of service users said they felt staff worked with them in a manner which respected their privacy and dignity. The majority of service users were positive about their care. However one service user and their relatives made an allegation of poor practice / possible abuse by one of the carers. The matter was discussed with the registered provider. An immediate requirement was made for the matter to be referred to Cornwall Adult Social Care. The matter needs to be investigated under their adult protection procedure. The registered provider needs to follow its own adult protection procedure regarding this matter. The registered provider must report back to the commission within the timescale set regarding action taken. The registered provider has appropriate policies regarding equal opportunities and anti discrimination. The registered providers were able to demonstrate suitable knowledge and awareness of equality and diversity issues regarding the care of service users. There are currently no service users from ethnic minorities, although the registered providers stated they would be more than happy to accommodate service users from other cultures. The local population is predominantly Cornish, and from ‘White-UK’ background. Issues regarding sexuality, gender and disability seem to be suitably addressed. Trelawney House DS0000053715.V312860.R01.S.doc Version 5.2 Page 11 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, 15 Quality in this area is good. The judgement has been made using available evidence including a visit to the service. Routines and activities are satisfactory so service users can live a lifestyle according to their wishes and needs. Arrangements to assist service users with their finances are satisfactory so service users can maintain choice and control over their lives. Meals are provided to a satisfactory standard so service users can be assured they will receive an appealing and balanced diet. EVIDENCE: Service users said they could get up and go to bed when they wished. Some spend the majority of their time in one of the lounges, while others choose to spend the majority of their time in their bedrooms. There are only limited organised activities for example occasional entertainers. Service users seemed happy how they spent their time and the registered provider said, despite encouragement, current service users did not wish for any more structured activities. Service users said they could receive visitors when they wished. The registered provider said she looks after small amounts of money on behalf of one service user. Suitable records are kept regarding this. Service users said they either look after their own monies or these are managed by their relatives / legal representatives e.g. via power of attorney arrangements. Service users said they were able to bring small items of furniture and their belongings to the home. Trelawney House DS0000053715.V312860.R01.S.doc Version 5.2 Page 12 The inspector shared a meal with service users on the first day of the inspection. This comprised of quiche, vegetables and potatoes. For sweet, treacle sponge was served. The meal was to a good standard. The vast majority of service users said they enjoyed the food provided, although a small minority said food was variable. The registered provider acknowledged it was difficult to please every body, but emphasised service users were provided with a choice of meals, and effort was made to please everybody. The home is trying to provide more home baked cakes and sweets. Service users said they had a choice of breakfast- and a cooked breakfast was provided some mornings. At tea times a choice was provided e.g. a cooked snack, cakes and / or sandwiches. Drinks are provided throughout the day. Special diets (e.g. pureed meals) are provided as required. Trelawney House DS0000053715.V312860.R01.S.doc Version 5.2 Page 13 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16, 18 Quality in this area is good. The judgement has been made using available evidence including a visit to the service. The registered providers have suitable procedures regarding complaints and adult protection. Service users and their relatives can subsequently be assured there are processes if they have an allegation of abuse, concern or complaint. One service user made an allegation which subsequently has been referred to Cornwall Adult Social Care for investigation. EVIDENCE: The registered provider has satisfactory procedures regarding complaints and adult protection. Staff and service users showed some awareness of the procedures, and were able to say whom they would approach if they had a complaint or were concerned about abuse. The registered provider said all staff were required to read the adult protection policy when they commenced employment. Staff are encouraged to attend courses regarding adult protection although available places are limited. The majority of staff and service users said they had not witnessed any bad or abusive practices. However one service user alleged poor practice, and the registered provider is subsequently investigating this under its adult protection procedure (see earlier section in this report). Criminal Record Bureau / Protection of Vulnerable Adult checks have been applied for and these have been returned for the majority of staff. However some disclosures have not yet been received from the CRB. The commission must be informed of the receipt of outstanding disclosures (e.g. disclosure numbers, any matters which arise from the receipt of the disclosures) when these are received. Trelawney House DS0000053715.V312860.R01.S.doc Version 5.2 Page 14 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 26 Quality in this area is good. The judgement has been made using available evidence including a visit to the service. Trelawney provides a pleasant, homely, clean and well-maintained environment for service users to live and feel at home in. EVIDENCE: The building was inspected. The building appears to be well maintained, clean, pleasantly decorated and homely. The home is situated in a rural area surrounded by beautiful countryside. There is a pleasant garden, which service users can use. A bench is provided outside the back door for service users benefit. All communal rooms are homely and comfortable, and bedrooms are individualised and comfortable. A lift is provided for service users to useunusual for such a small home. Some decoration is required to the lounge and the registered provider said this matter would be addressed. The majority of bedrooms have an ensuite toilet and shower. The showers however offer limited access for people with mobility problems and do not appear to be used. Trelawney House DS0000053715.V312860.R01.S.doc Version 5.2 Page 15 There is a bathroom which has a chairlift to enable access. One bedroom had a slight smell of urine which the registered providers are trying to address. The registered provider is currently refitting the kitchen. This will be a significant improvement, although the current facility is clean and safe. Satisfactory laundry facilities are provided. Trelawney House DS0000053715.V312860.R01.S.doc Version 5.2 Page 16 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29, 30 Quality in this area is adequate. The judgement has been made using available evidence including a visit to the service. There appears to be satisfactory numbers of staff on duty so service users can be assured they will receive satisfactory staff support. Recruitment records are generally satisfactory, although there is an absence of some records required by regulation (e.g. two references and CRB /POVA checks for some staff) and this could put service users at risk. Evidence of training needs some improvement. Staff must receive appropriate training as required by regulation so service users can be assured staff have suitable skills to cater for their needs. Equal opportunities issues regarding recruitment and work practices seem appropriately addressed. EVIDENCE: Rotas show at least two members of staff are on duty from 0800 to 2100. There is a waking night member of staff from 2100 to 0800. Mrs Gatzianidis assured the inspector that on occasions of staff sickness, other absence or staff vacancy one of the registered providers or the assistant manager would cover the shift. The registered provider has a suitable approach to providing National Vocational Qualifications for care staff. Currently 55 of care staff have an NVQ 2 or 3- although other staff are working towards this qualification. Evidence of training has improved since the last inspection in June 2006. However there are still some gaps in training required by regulation. This includes first aid, infection control, food handling and fire instruction. All staff Trelawney House DS0000053715.V312860.R01.S.doc Version 5.2 Page 17 need to receive training in infection control and fire instruction. If staff handle food (e.g. from making a sandwich) they must receive suitable external training e.g. a food hygiene certificate. There must always be at least an ‘approved first aider’ on the premises. Staff should be provided at least with a short course in dementia so they can develop an understanding of these peoples’ needs. The registered provider said two staff would attend a course regarding dementia next year. Recruitment records were also inspected. Records were generally satisfactory, although some records for staff who commenced employment since June 2006 did not contain all the appropriate information as required by regulation. For example a copy of two written references, a copy of a criminal records bureau check, a copy of a protection of vulnerable adults check-including a POVA first check (as applicable), a copy of e.g. a birth certificate to validate the person’s identity needs to be obtained for all employees. A full list of information required is contained in Schedule 4 of the Care Homes Regulations 2002. Staff, the inspector spoke to, said they received an induction when they started work at the home. There is a copy of an induction checklist on staff files for employees recruited since the last inspection. The registered provider has appropriate policies regarding equal opportunities and anti discrimination. The registered providers were able to demonstrate suitable knowledge and awareness of equality and diversity issues regarding the appointment and management of staff. Trelawney House DS0000053715.V312860.R01.S.doc Version 5.2 Page 18 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35, 38 Quality in this area is adequate. The judgement has been made using available evidence including a visit to the service. The registered providers appear to be suitably experienced and qualified to manage the home. This ensures service users receive a service which meets their needs. The registered providers have a suitable policy regarding quality assurance. This ensures there is a suitable system to improve service delivery and to ascertain the views of service users and their representatives. The registered providers approach to handling service users monies is satisfactory, so service users can be assured their financial interests are safeguarded, where the registered providers are involved in this area of their lives. The management of health and safety issues is adequate and although improved since the last inspection, needs further work so service users can be assured they live in a safe environment. EVIDENCE: The registered providers appear approachable, competent and have appropriate qualifications to manage the care home. The staff the inspector spoke to say the providers were good to work for, and provided sufficient guidance and support to help them to do their jobs. Service users found the Trelawney House DS0000053715.V312860.R01.S.doc Version 5.2 Page 19 registered providers supportive and approachable. Satisfactory progress has occurred since the last key inspection in June 2006 regarding requirements made at the last inspection. The registered providers have employed a manager-Mark Thomas. Mr Thomas manages certain aspects of the care home although he is not registered with the commission to manage the home. This is not necessary as long as the registered providers can suitably demonstrate they are responsible for the dayto-day management of the home, which they currently are able to. The registered providers have a quality assurance policy, and a survey of service user and relatives views was completed in August 2006. It is recommended a development plan be developed from survey results. There are also regular staff meetings and a residents’ meeting was held in August 2006. Generally the registered providers said they do not look after service user monies. They said the service user / their representative/ next of kin is invoiced for any agreed expenditure such as hairdressing. The registered provider said some support is provided to look after small amounts of money for one service user, for which suitable records are maintained. The registered provider has a suitable health and safety policy. However records of checks required by regulation need some improvement. There are suitable records that fire equipment is checked. For example records are kept regarding the testing of fire alarm call points and emergency lighting. The accident book is maintained, and there does not appear to have been any issues of concern. The lift was last serviced in August 2006 and this appears to be in satisfactory working order. A new heating system was installed in December 2005. The registered providers have said the company that installed the system said it does not need to be serviced until January 2007. The registered provider said this would be arranged. Health and safety risk assessments were produced in October 2006 and are satisfactory. The registered providers have employed a specialist company to provide advice regarding the prevention of Legionella. A risk assessment has been completed and the company are coming back shortly to complete any work required. Arrangements have been made to test the electrical hardwire circuit and the commission needs to be sent a copy of the certificate when this work is completed. Portable electrical appliances are currently being tested and the inspector saw evidence of this. There are some gaps in health and safety training are highlighted in the ‘Staffing’ section of the report. From discussion with staff the inspector concludes that staff need to be given guidance regarding what to do in the event of a fire as soon as possible e.g. the next staff meeting. Trelawney House DS0000053715.V312860.R01.S.doc Version 5.2 Page 20 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X 2 3 X X X HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 2 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 2 Trelawney House DS0000053715.V312860.R01.S.doc Version 5.2 Page 21 Are there any outstanding requirements from the last inspection? YES STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. 2. Standard OP7 OP9 Regulation 15 13 Requirement All service users must have a care plan. The registered provider must operate a safe system for storing and handling medication. Previous deadline of 01/07/06 not met Second Notification 3. OP10 OP18 12, 13, 37 The registered provider must investigate an allegation made by a service user of abusive behaviour by a carer. The matter must also be referred to Cornwall Adult Social Care for possible investigation under their adult protection procedures. The Commission for Social Care Inspection must be kept informed of developments and outcomes regarding this matter 18, 19 The registered provider must ensure: • All staff receive a satisfactory Protection of Vulnerable Adults check / Criminal Records Bureau check. DS0000053715.V312860.R01.S.doc Timescale for action 01/01/07 01/12/06 17/11/06 4. OP29 OP18 01/01/07 Trelawney House Version 5.2 Page 22 5. OP29 17, 19 Schedule 4.6. The Commission must be informed when outstanding CRB /POVA checks are received, giving detail of disclosure numbers and any issues arising from the disclosures. • Staff must work under supervision at all times until a satisfactory CRB check has been received. Suitable employment records 01/01/07 must be obtained and maintained for all staff for example: • A copy of two written references • A copy of e.g. a birth certificate to validate the person’s identity needs to be obtained for all employees The registered providers must provide staff with suitable training to do their jobs and meet regulatory requirements. Suitable evidence of training must be maintained. Training must include fire training, food handling (if food is handled), infection control, first aid (i.e. there must always be a member of staff qualified to appointed person level on duty). Staff must also have training in dementia awareness. Previous deadline of 01/12/06 extended 01/04/07 • 6. OP30 18 7. OP38 13 The registered providers must ensure health and safety standards are appropriately met. There must be evidence available for inspection that the electrical circuit (hardwire) is tested at least every five years. DS0000053715.V312860.R01.S.doc 01/01/07 Trelawney House Version 5.2 Page 23 Previous deadline of 01/09/06 not met Second Notification 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 2 Refer to Standard OP3 OP33 Good Practice Recommendations Dated contemporaneous notes of pre admission assessments should be retained. A quality assurance development plan should be developed as a result of the annual quality assurance survey. Trelawney House DS0000053715.V312860.R01.S.doc Version 5.2 Page 24 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. Extracts may not be used or reproduced without the express permission of CSCI Trelawney House DS0000053715.V312860.R01.S.doc Version 5.2 Page 25 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!