Inspection on 09/07/07 for Trelawney House

This inspection was carried out on 9th July 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is (sorry - unknown). 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 02/11/06

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 Key Unannounced Inspection 9th July 2007 10:15 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.V340471.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.V340471.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.V340471.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. 2nd November 2006 Date of last inspection Brief Description of the Service: Trelawney Care Home is situated in Polladras, approximately 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 in a very pleasant rural setting. There is sufficient car parking available. Accommodation is on two floors; the first floor can be accessed by a passenger 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 supplies approximately ten meals to people in the community each day. The homeowners live adjacent to the care home and are actively involved in its day-to-day running. A small team of care staff provide personal care and support, and the home has a friendly, atmosphere. There are opportunities for socialising and visitors are encouraged. A copy of the inspection report was not on public display on the day of the inspection. It is suggested a copy is requested from management if required. The range of fees at the time of the inspection is £365-£450 per week. There are additional charges e.g. for hairdressing, chiropody, trips out and newspapers etc. Trelawney House DS0000053715.V340471.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 eight and quarter hours. All of the key standards were inspected. The methodology used for this inspection was: • To case track four people living in the home. This included interviewing them about their experiences and inspecting their records. • Interviewing staff about their experiences working in the home. • Informal discussion with other people living at the home 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: Some improvement is required to the medication system i.e. all prescribed medication must be recorded on medication sheets. Staff recruitment and pre employment checks need improving and must be more rigorous. Staff training still needs some improvement so it meets regulatory requirements. There must be a quality assurance system in place which helps the providers to have a system of continuous improvement. Health and safety precautions need improvement so people who live in the home can be assured they live in a safe environment. Trelawney House DS0000053715.V340471.R01.S.doc Version 5.2 Page 6 Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Trelawney House DS0000053715.V340471.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.V340471.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. JUDGEMENT – we looked at outcomes for the following standard(s): 2, 3 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The registered provider has developed a contract / statement of terms and conditions of residency. However both parties should sign this documentation. The provision of suitable information ensures people who use the service are aware of the services are offered. This information also helps ensure people who use the service are made aware of their rights and responsibilities. The registered provider has a suitable assessment procedure. There is suitable evidence that people who use the service have been assessed appropriately, before admission is arranged. Suitable assessment procedures ensure the registered provider only accommodates people for whom the provider can suitably meet their needs. EVIDENCE: Files for people who live in the home were inspected. Each person has a copy of the home’s statement of terms and conditions of residency / contract. A copy of a contract issued by the Department of Adult Social Care (social Trelawney House DS0000053715.V340471.R01.S.doc Version 5.2 Page 9 services) is on file where applicable. The registered provider said the people who use the service have a copy of appropriate documentation. However if the home does issue its own contacts, both parties need to sign this documentation, so all parties are clear regarding their rights and responsibilities. The registered provider has an assessment policy. There is satisfactory evidence that a senior member of staff has assessed the people who use the service, before admission was arranged (for example copies of pre admission assessments were available for inspection). Some of the people who use the service, who the inspector spoke to, remembered a senior member of staff completing an assessment before they moved to the home. Some people who use the service said they were able to visit the home before moving in, and others said a relative visited on their behalf. In some cases a copy of a social services / health assessment has been obtained by the registered provider. The service does not provide intermediate care. Trelawney House DS0000053715.V340471.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. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9, 10 Quality in this outcome area is generally good although some improvement is required to medication procedures. This judgement has been made using available evidence including a visit to this service. People who use the service have a generally satisfactory care plan for which there is suitable evidence of regular review. Suitable care plans help to ensure people who live in the home, receive the care they need, for example, in a consistent manner. There is suitable evidence that staff ensure health care needs are met. Some improvement is required to the medication system – for example regarding recording of administration, so people who use the service can be assured their medication is managed to a satisfactory standard. People who use the service said they felt staff worked with them in a manner, which respected their privacy and dignity, and this was also evident from the inspector’s observations. EVIDENCE: Care plans for some people who use the service were inspected. These appeared to be satisfactory, and contained suitable information to assist staff Trelawney House DS0000053715.V340471.R01.S.doc Version 5.2 Page 11 to provide care. There is satisfactory evidence that care plans are reviewed regularly. Although some people who use the service did not appear to be aware of their care plans, people the inspector spoke to said the care they received was appropriate, and carried out in a manner according to their wishes and needs. Health care support appears to be satisfactory. People who use the service said they could see a doctor or other medical practitioner when this is necessary. The medication system was inspected. Medication is stored in locked cupboards and administered via a NOMAD dossett system. The operation of the system is generally satisfactory although some errors were noted during the inspection: • Three items for two people who live in the home were not recorded on the medication sheets (Gaviscon for two people, Lactulose for one person). • The instruction for the administration for one item of medication (a sleeping tablet) was different on the bottle and the medication sheet. It was not clear if the pharmacist or the home had made an error, and the registered provider said they would check this. The registered provider said staff that administer medication have received suitable training. The majority of staff training records inspected had a copy of a training certificate regarding the administration of medication, completed in the last two years. New staff (who commenced employment in 2007) have not had formal training, and therefore should not handle or administer medication until this training has been completed. People who use the service spoke positively regarding the attitude of staff, and said staff respected their privacy and dignity. People who use the service said staff always knock on their doors, and post is always received unopened. Trelawney House DS0000053715.V340471.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. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Routines are satisfactory so people who use the service can have a suitable lifestyle. Visiting arrangements are flexible. Arrangements to assist people who use the service with their finances are satisfactory. Meals are provided to a good standard, so people who use the service can receive a wholesome and nutritious diet. EVIDENCE: People who use the service said they could get up and go to bed when they wished. Most of people who use the service spend the majority of their time in one of the lounges or in their bedrooms. There are only limited organised ‘activities’, for example visits from the church minister, visits from the hairdresser and visits to the church. The registered provider said they had tried to organise more activities but people living in the home did not seem interested. The inspector got a similar response when he asked people if they wanted any more structured activities. This matter needs to be kept under review when new people move into the home. People who use the service said they could receive visitors when they wished. The registered provider assists a limited number of people living in the home with the management of money. Records kept seemed satisfactory. Otherwise Trelawney House DS0000053715.V340471.R01.S.doc Version 5.2 Page 13 people who live in the home either look after their own monies or these are managed by their relatives / legal representatives e.g. via power of attorney arrangements. The spending money for one person was paid into the home’s general account, as the person had no relatives locally who could act on their behalf, and the person could not get to the post office / bank. This is not a very satisfactory arrangement, but it is acknowledged there are not really any other options in the circumstances. People who live in the home said they were able to bring small items of furniture and their belongings when they moved in. People living in the home said they enjoyed the food provided. The main meal is provided at lunch time, and a choice of a hot and cold evening tea is offered. Suitable records of menus are maintained. Special diets (e.g. pureed meals) are provided as required. Although a choice of main meal is not provided, people who live in the home said staff were aware of preferences, and an alternative is provided where necessary. The inspector shared a meal with people who live in the home, and this was to a good standard. Support provided at the mealtime was good, and the meal was a sociable occasion. Trelawney House DS0000053715.V340471.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. JUDGEMENT – we looked at outcomes for the following standard(s): 16, 18 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The registered providers have suitable procedures regarding complaints and adult protection. Subsequently people who use the service can be assured there are satisfactory procedures, which should ensure concerns or bad practice are dealt with appropriately. Improvement is required to staff vetting procedures when new staff commence employment. Unless appropriate procedures and checks are in place when recruiting staff, people who live in the home have minimal protection against potentially untrustworthy and abusive people working in the home. EVIDENCE: The registered provider has satisfactory procedures regarding complaints and adult protection. Staff and people who use the service 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. Some staff have attended adult protection training. Most staff and people who live in the home said they had not witnessed any abusive practices. However a relative of a person living in the home made a complaint when the resident’s wallet went missing, and this matter was never fully resolved. There are concerns regarding the registered providers approach to ensuring staff are fit to work in a care home- as outlined in the staffing section. For example not all staff have a valid Criminal Record Bureau check, and a Protection of Vulnerable Adults check. A requirement to improve procedures has been made. Trelawney House DS0000053715.V340471.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. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Trelawney provides a pleasant, homely, clean and well-maintained environment for people who live there to 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 residents benefit. All communal rooms are homely and comfortable, and bedrooms are individualised and comfortable. A lift is provided for people to use-unusual for such a small home. The kitchen has been refurbished, but there is still some work to do to finish this work off. 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. There is a bathroom, which has a bath chair to assist access. The lock on the door is broken and needs Trelawney House DS0000053715.V340471.R01.S.doc Version 5.2 Page 16 replacing. The door kept reopening even when shut so appears to need some adjustment. The registered providers said they would address this matter. Satisfactory laundry facilities are provided. Trelawney House DS0000053715.V340471.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. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29, 30 Quality in this outcome area is generally adequate although recruitment checks are poor. This judgement has been made using available evidence including a visit to this service. Staffing levels in the home are currently satisfactory. Satisfactory staffing levels ensure people who use the service receive appropriate levels of support when they need it. Recruitment procedures, particularly in regard to obtaining references and Criminal Record Bureau checks, need considerable improvement so people who use the service can be assured they are in safe hands and protected at all times. Staff training requires some improvement so staff have appropriate knowledge and skills to support people who use the service. EVIDENCE: On the first day of the inspection the following staffing was provided: • • • One member of staff from 08:00 to 19:45 One member of staff from 14:30 to 21:00 A waking night staff from 21:00 to 08:00 One member of staff was sick on the morning shift. There were two members of staff who were working in the home on ‘work experience’. The registered providers were assisting with care e.g. to cover the member of staff who was sick. According to the rotas there are usually two members of staff on duty from 08:00 to 21:00. Trelawney House DS0000053715.V340471.R01.S.doc Version 5.2 Page 18 People who use the service were positive regarding the support they received from staff, and comments were made that staff were approachable. The registered provider has a suitable approach to enabling staff to have the opportunity to obtain a national vocational qualification (NVQ) in care. Currently 50 of care staff have at least an NVQ 2 in care. Three staff have been employed since January 2007. Of these: • Two have no references. • No Protection of Vulnerable Adults (POVA First) check was completed on these staff • Two staff did not have a Criminal Records Bureau (CRB) check disclosure returned, although these have been applied for. Only a CRB check from the staffs’ previous employers were on file, but these checks are not transferable between employers. • One person had committed a theft while working for a previous employer (non care environment) despite declaring on their application they had no criminal convictions. The registered provider said they had discussed the matter with the person, and felt there was no risk to people living in the home. However no written risk assessment appears to have been recorded, or record of the conversation. • No copy of induction records were available for two of the staff-although one person started in January. • The registered provider should note that a statement by the person, as to her/ his physical / mental health should also be obtained (e.g. self declaration), as part of the recruitment process. This is required by the Care Home Regulations. Recruitment procedures need to be more rigorous so people living in the home can be assured they are in safe hands. In regard to CRB and POVA First Checks the registered provider has now been notified three times regarding breach of compliance with the regulations. Previous reports outline this non-compliance. Failure to comply with this requirement in future could result in the Commission for Social Care Inspection taking enforcement action. Training records were also inspected for eight staff. By law all staff must have: • Regular fire training in accordance with the requirements of the fire authority • There must always be at least one first aider on duty (at least at appointed person level). • All staff must have manual handling training. • All staff must have basic training in infection control. • If staff handle food they must receive training regarding food hygiene. • All new staff must have an induction and there should be a record of this. There are some gaps in training required by regulation. For example from the sample: Trelawney House DS0000053715.V340471.R01.S.doc Version 5.2 Page 19 • • • • • • Fire Training. There were records that five staff received fire training in 2007, one person in 2004 and two people did not appear to have received any training in this area. First Aid. Only two staff appeared to have received this training. Manual Handling. Only five staff appeared to have received this training since March 2006. Infection control. Only five staff appeared to have received this training. Food hygiene. Only four staff appear to have received this training. Induction- there were records that six staff have received an induction. The registered provider said apart from fire training, staff have completed all training required by regulation, or this training had been arranged. The provider said the two people who had no induction record, were completing their induction currently, but the records were not available for inspection. Trelawney House DS0000053715.V340471.R01.S.doc Version 5.2 Page 20 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35, 38 Quality in this outcome area is adequate although health and safety standards are poor. This judgement has been made using available evidence including a visit to this service. The registered providers appear to be suitably experienced to manage the home. Quality assurance processes however need improvement so people who live in the home can be assured there are systems in place to ensure continuous improvement, and regulatory requirements are met. The registered providers approach to handling monies is satisfactory, so people who live in the home 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 needs significant improvement so people who live in the home can be assured they live in a safe environment Trelawney House DS0000053715.V340471.R01.S.doc Version 5.2 Page 21 EVIDENCE: The registered providers appear suitably skilled, experienced and knowledgeable to manage the home. The providers work day to day in the home and have a good knowledge of people who live there. People who live in the home, who the inspector was able to speak to, were positive about the registered providers approach. The Commission does however have concerns regarding the registered providers’ non compliance with the regulations in some areas- and urgent action is required by them to ensure improvement- for example in regard to ensuring staff have appropriate pre employment checks. Quality assurance processes need some improvement. For example there needs to be satisfactory systems in place to ensure regulatory requirements are met. A survey of stakeholder views was last completed in 2007 and was positive regarding care provided. However it may be useful for the provider to have a development plan for example taking into consideration stakeholder views, as well as other plans of action for service improvement. The registered providers look after some monies on behalf of people who live in the home. Suitable records are maintained regarding these as outlined under NMS 14. The registered provider does not act as appointee for any government financial benefits for people living in the home. The registered provider has a health and safety policy. Although satisfactory portable electrical appliances testing has been completed, and accident records are suitably maintained, other checks required by law need significant improvement. For example: • There are records fire equipment testing- but not all tests are being completed at regular intervals as required by the fire authority. • Servicing of the boiler / heating systems are now required as the system was installed in December 2005. • A test of the electrical hardwire circuit was completed in June 2007. However the electrician said the system needed to be upgraded. This work needs to be completed and the system retested. • There is a suitable risk assessment regarding the prevention of Legionella and control measures are in place. However testing is a little haphazard. • Some upgrading is required to the passenger lift so it is compliant with health and safety legislation. • There are some gaps in health and safety training as highlighted in the ‘Staffing’ section of the report. • Health and safety risk assessments are adequate, but these do not adequately cover all relevant issues, otherwise the matters of concern raised above would have been resolved. Trelawney House DS0000053715.V340471.R01.S.doc Version 5.2 Page 22 A requirement has been made for the registered provider to ensure these matters are attended to. Copies of documentation regarding the testing of the boiler, electrical hardwire circuit and upgrading of the passenger lift must be forwarded to the Commission once this work is completed. Other records must be available for inspection. Trelawney House DS0000053715.V340471.R01.S.doc Version 5.2 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X 3 3 X X X HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 1 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 2 X 3 X X 1 Trelawney House DS0000053715.V340471.R01.S.doc Version 5.2 Page 24 Are there any outstanding requirements from the last inspection? YES STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP9 Regulation 13(2) Requirement Timescale for action 01/08/07 2. OP29 OP18 18. 19 The registered provider shall make arrangements for the recording, handling, safekeeping, safe administration and disposal of medicines received into the care home. (For example medication, which is prescribed, must always be recorded on medication sheets, and signed for if/ when administered.) The registered person shall not 01/08/07 employ a person to work at the care home unless the person is fit to do so. Satisfactory checks must be completed on the person to ascertain this. (For example two written references, a Protection of Vulnerable Adults ‘First’ check, a Criminal Records Bureau check etc. as outlined in Schedule 2 of the Care Homes Regulations 2001). Timescale of 01/04/07 not met Third Notification Trelawney House DS0000053715.V340471.R01.S.doc Version 5.2 Page 25 3. OP29 18. 19 The registered person shall 01/01/08 ensure that persons employed to work at the care home receive training appropriate to the work they are to perform. This must include suitable assistance, including time off, for the purpose of obtaining further qualifications appropriate to such work. (For example such training must include training required by regulation such as infection control, food hygiene, first aid, fire training and manual handling training.) The registered person shall establish and maintain a system for evaluating the quality of the services provided at the care home. The registered person shall ensure that— (a) All parts of the home to which residents have access are so far as reasonably practicable free from hazards to their safety; Unnecessary risks to the health or safety of residents are identified and so far as possible eliminated. The premises to be used as the care home are of sound construction and kept in a good state of repair externally and internally; Equipment provided at the care home for use by residents or persons who work at the care home is maintained in good working order; Version 5.2 Page 26 4. OP33 24(1) 01/10/07 5. OP38 13, 23 01/10/07 (b) (c) (d) Trelawney House DS0000053715.V340471.R01.S.doc [For example there must be suitable evidence of: 1. Testing of fire equipment at regular intervals as required by the fire authority. 2. Servicing of the boiler / heating system. (Documentation regarding this must be forwarded to the Commission). 3. Satisfactory results as a consequence of testing the electrical hardwire circuit. (Documentation regarding this must be forwarded to the Commission). 4. Satisfactory evidence of testing to prevent legionella. 5. The passenger lift complying with health and safety requirements. (Evidence of this must be forwarded to the Commission.) ] Copies of appropriate documentation must be forwarded to the Commission within the timescale set. Other documentation must be available for inspection. Trelawney House DS0000053715.V340471.R01.S.doc Version 5.2 Page 27 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 OP2 Good Practice Recommendations The contacts issued by the registered provider should be signed by both the registered provider and the person who lives in the home (or their representative). Trelawney House DS0000053715.V340471.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Ashburton Office Unit D1 Linhay Business Park Ashburton TQ13 7UP National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © 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.V340471.R01.S.doc Version 5.2 Page 29 - 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. 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