Inspection on 27/07/09 for Tremanse Care Home

This inspection was carried out on 27th July 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 9 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Tremanse Care Home 12/08/08

Tremanse Care Home 22/08/06

Tremanse Care Home 26/01/06

Tremanse Care Home 09/08/05

Tremanse Care Home 07/03/05

Similar services:

Trevaylor Manor

Stallcombe House

Stroud Lodge

The Woodmill

Woodland Vale

Bolealler House

Claremont Nursing Home

Althea Park House

Extracts from inspection reports are licensed from CQC, this page was updated on 15/11/2009.

Key inspection report CARE HOME ADULTS 18-65 Tremanse Care Home Fore Street Bodmin Cornwall PL31 2HR Lead Inspector Helen Tworkowski Key Unannounced Inspection 27th July 2009 09:15 Tremanse Care Home DS0000061991.V376751.R01.S.doc Version 5.2 Page 1 This report is a review of the quality of outcomes that people experience in this care home. We believe high quality care should: • • • • • Be safe Have the right outcomes, including clinical outcomes Be a good experience for the people that use it Help prevent illness, and promote healthy, independent living Be available to those who need it when they need it. We review the quality of the service against outcomes from the National Minimum Standards (NMS). Those standards are written by the Department of Health for each type of care service. Copies of the National Minimum Standards – Care home adults 18-65 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 mission of the Care Quality Commission is to make care better for people by: • Regulating health and adult social care services to ensure quality and safety standards, drive improvement and stamp out bad practice • Protecting the rights of people who use services, particularly the most vulnerable and those detained under the Mental Health Act 1983 • Providing accessible, trustworthy information on the quality of care and services so people can make better decisions about their care and so that commissioners and providers of services can improve services. • Providing independent public accountability on how commissioners and providers of services are improving the quality of care and providing value for money. Tremanse Care Home DS0000061991.V376751.R01.S.doc Version 5.2 Page 2 Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report Care Quality Commission General Public 0870 240 7535 (telephone order line) Copyright © (2009) Care Quality Commission (CQC). 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 CQC copyright, with the title and date of publication of the document specified. www.cqc.org.uk Internet address Tremanse Care Home DS0000061991.V376751.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Tremanse Care Home Address Fore Street Bodmin Cornwall PL31 2HR 01208 74717 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) Vivacare Limited Manager post vacant Care Home 15 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (15) of places Tremanse Care Home DS0000061991.V376751.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 12th August 09 Brief Description of the Service: Tremanse is a large older style house situated in the centre of Bodmin. Whilst within walking distance of the town, the access to the home is up a steep hill for vehicles or through the garden for pedestrians, so that anyone with reduced mobility might have difficulties. The home provides rooms on three floors although not all are currently registered to provide care and accommodation. Those that are, are registered for people with mental health problems. There are communal rooms on the ground floor that comprises a large sitting room, conservatory and dining room. The kitchen and utility areas are on the ground floor. The garden in the front of the home has a level patio area, furnished with tables and chairs for people to use in fine weather. The company that owns the home also own a second, unregistered property behind Tremanse. There is limited car parking at the rear of the property. The fees range between £331 and £560, any additional information on charges are to be obtained from the Registered Provider. The Service User Guide and Statement of Purpose, that provides information about the home, are available in the care home office. Tremanse Care Home DS0000061991.V376751.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 1 star. This means the people who use this service experience adequate outcomes. This inspection included an unannounced site visit that took place between 9.15 a.m. and 5 p.m. The Manager was in home throughout the visit. We were shown around the home and saw all of the communal areas and some of the bedrooms. We looked at the care and support received by three people, this included looking at their care plans and talking with them. We also spoke with some of the other people who live at the home. We spoke with cook and a member of staff who was on duty. As part of the visit we looked at records relating to medication, to staff training and recruitment and in relation to keeping people safe. We sent surveys to all of the staff and people who live at the home, two staff returned surveys, one person who lives at the home returned a survey. The Manager sent us information as part of an “Annual Quality Assurance Assessment”. What the service does well: What has improved since the last inspection? What they could do better: Tremanse Care Home DS0000061991.V376751.R01.S.doc Version 5.2 Page 6 Care Plans need to show people are going to be helped to progress in their goals at Tremanse. There is also a need to ensure that there are thorough risk assessments in relation to life at Tremanse, both for individuals and in terms of more general risks- for example fire. We were particularly concerned that the water in the bathroom was so hot that it posed a hazard. The medication system was generally well organised and staff were trained and confident in this area. However, there were some aspects of the system that needed to be improved, such as guidance on when to administer “as required medication”. The recruitment system has significantly improved, though there are a few small areas where it could be tightened. The Manager is aware of the need to improve the training in home. The Manager told us that she was in the process of recruiting further staff, however we were concerned that the staffing may had been very low at times, we have required that this situation is reviewed. We found that a new set of policies and procedures that the home were to implement did not reflect good practice, particularly in relation to people leaving the home or in relation to protecting people from abuse. 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 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. Tremanse Care Home DS0000061991.V376751.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Tremanse Care Home DS0000061991.V376751.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 1 and 2 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. No new people have moved to Tremanse since the last inspection, therefore it was not possible to fully consider the outcome in this area. EVIDENCE: Tremanse is in the process of submitting a new Statement of Purpose and Service User Guide, in relation to changes that are being made in the home. Therefore these documents, which should provide information about the care provided, were not considered as part of this inspection. No new people have moved to Tremanse since the last inspection, although individuals have moved between different rooms in the accommodation. The Manager, has told us in the “Annual Quality Assurance Assessment” (AQAA) that no one will be admitted without a full assessment, and that prospective people will be offered the opportunity to have a trial stay at the home. Tremanse Care Home DS0000061991.V376751.R01.S.doc Version 5.2 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The people who live at Tremanse can be confident that their needs will be known about by staff, and that they will be encouraged to make decisions and take responsibility in their own lives. Information about the risks people experience is not robust, and there needs to be clearer guidance on how people are to kept safe. EVIDENCE: We looked at the Care Plans relating to three people who live at Tremanse. We found that these were generally up to date, and contained information about the help and support people needed. For one person their care plan, included a transition plan, aimed at helping them to move towards a more independent life. However, there was no detailed information about how this was to be achieved or record of particular progress in this area. Information supplied by the Manager in the AQAA confirmed that the people who live at Tremanse are involved in their care planning and that regular reviews are held with each person. Tremanse Care Home DS0000061991.V376751.R01.S.doc Version 5.2 Page 10 We looked at how risks are managed for people at Tremanse. It was very positive to see that individuals were able to make friends and develop relationships within the home. We discussed with the Manager the need to ensure that people have appropriate guidance and support in these areas. We saw that for one person that it was noted that there was a risk that the person might “lash out”, however there was no detailed risk assessment carried out in relation to this situation. We noted that there had been incidents with the individual concerned in July 09. We asked some of the people who live at the home about rules, and we were told that there weren’t any, people could get up and go to bed when they chose. We also saw that some people managed their own monies and medication; others were given support in these areas of their life. The Manager explained how she was trying to encourage people to take more responsibility, for example by asking them to pay for services such as hairdressing or chiropody, rather than the home making the payment out on the individual’s behalf. We saw that “Resident’s meetings” are held every 6 weeks, the most recent one being held on 25th June 09. The Manager told us that residents are encouraged to participate in the running of the home. Tremanse Care Home DS0000061991.V376751.R01.S.doc Version 5.2 Page 11 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): This is what people staying in this care home experience: People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People are given the opportunity to participate in activities and interests. They are provided with choices in their daily lives. EVIDENCE: The people we spoke with at Tremanse told us that they were given the opportunity to participate in a range of activities in the home- these included games such as bingo and “hangman”. One resident told us that he/she was doing regular cooking sessions and found these very beneficial. One person told us that he would like more trips out. At a previous visit to the home we had noted that the call system can be used to call people, and effect works as at “tannoy” system. We were told that whilst the system could still operate in this way, it was no longer used in this way. When staff wanted to talk to a resident they went to their room, and knocked on the door. We saw that one bedroom can only be accessed by Tremanse Care Home DS0000061991.V376751.R01.S.doc Version 5.2 Page 12 going out of the building. The individual concerned must therefore call staff to open the back door, or go to the front door and ring the bell. This must be reviewed. All residents should have ready access to the facilities in the home without having to go through a member of staff in this way. The people at the home told us that they enjoyed the meals at Tremanse. A cook is employed six days a week to prepare the main meals. The cook told us that fresh ingredients from the local area were used. A four week menu had been set up and was kept under review. Concerns were raised at the last visit about the furniture in the dining room and the lack of space. The Manager said that the furniture had been repaired and that they now ate in two sittings, so that there was more space. We were told that the Environmental Health Officer had visited in the last few months, concerns had been raised but these issues were now resolved satisfactorily. Tremanse Care Home DS0000061991.V376751.R01.S.doc Version 5.2 Page 13 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): People using the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People receive the help and support they need with their health and personal care. Some aspects of the management of medication need to be improved so that it is safer. EVIDENCE: Many of the people who live at Tremanse are able to manage their own personal care with a limited amount of support and guidance from staff. The people we met during this visit were all well dressed, and satisfied with the support they received. As part of this visit we looked at the medication system with a member of staff. We found that in general the system was well managed and in good order. There were some areas where improvements must be made. The Medication Administration Record (MAR) sheet needs to show the time the medication is to be given rather that “lunch time”. Where there may be a variable does of medication, such as one or two paracetamol, it needs to be clear how many are administered. Also where there is an “as required medication”, then there must be clear guidance for staff as to when this should Tremanse Care Home DS0000061991.V376751.R01.S.doc Version 5.2 Page 14 be given. We also identified that there was no running total for medication, such as diazepam, that is only required occasionally. It is important that it is possible to readily audit the amount of medication held in the home. Some of the people who live at Tremanse self medicate, however when we looked at individual files there was not self medication risk assessment. Such risk assessments are important as they can identify the sort of help people need, and any variables that need to be taken into account, such as changes in mental health. Some of the ointments and creams had been opened, however there was no dates to show when this was. This is important as some ointments have to be used or disposed of with a set time of opening. We noted that there was no controlled drugs cabinet in the home. We would recommend that there is a system for keeping controlled drugs, so that should any ever be received in the home they could be properly managed. The member of staff who we spoke with said that she had received in house training in relation to medication, and demonstrated a good understanding on how the medication system worked during this visit. Tremanse Care Home DS0000061991.V376751.R01.S.doc Version 5.2 Page 15 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): People using the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The people who live at Tremanse can be confident that any concerns that they have will be listened to. There are’ however, inadequate policies and procedures in place to ensure that people are protected and that their rights are upheld. EVIDENCE: The Commission has received one anonymous complaint regarding staffing levels at this service. The Manager responded to the Commission on this matter. The two members of staff who responded to surveys said that they knew what to do if someone had concerns about the home. People we spoke with at the home said that they had no complaints. The Manager identified three ways that the home has improved in relation to this area of the service in the last 12 months. These are that all of the residents have a copy of the complaints policy, that regular residents’ meetings are now held, and that some of the staff have received training in relation to the protection of vulnerable adults. The Manager told us that she had just received a set of new policies and procedures from the Registered Provider. We looked at a few of these policies. There was a policy on “Absence without Authority”, this policy stated “… clients are entitled to leave the home unaccompanied providing an agreement has been made between the home and the client. This would involve…”. If there are concerns about the safety or well being of a person who lives at Tremanse Tremanse Care Home DS0000061991.V376751.R01.S.doc Version 5.2 Page 16 then consideration must be given to their capacity and best interest, under the Mental Capacity Act. Another of the policies stated that if there is an allegation of abuse then the Manager will conduct an initial investigation into the concern. This is not the case. It is the duty of the Local Authority Social Services to determine who carries out the initial investigation. Tremanse Care Home DS0000061991.V376751.R01.S.doc Version 5.2 Page 17 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): People using the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The people who live at Tremanse benefit from clean and comfortable accommodation. The temperature of the hot water in baths is so hot that people could be at risk of being scalded. EVIDENCE: We were shown around the home by the Manager and saw all of the communal areas and many of the bedrooms. On the top floor we saw that some of the unregistered bedrooms had been renovated and confirmation was awaited from the Commission that these rooms could be used. The home was generally clean and in good order. The bedrooms that we saw reflected the individuals who occupied them. As has already been noted we were concerned that one bedroom has an external entrance. To re-enter the home the individual must either call staff, or go to the front door. We feel that if an individual is considered suited live in such a room then they need to be able to use the lounge or dining room, without having to go through staff. We Tremanse Care Home DS0000061991.V376751.R01.S.doc Version 5.2 Page 18 saw that the people at Tremanse had keys to their rooms, problems with locks that had previously been identified, where a person could be locked in a room, have been resolved. During this inspection we checked the temperature of the hot water in the bathrooms. We found that the water was so hot that it could scald. We asked to see risk assessments in relation to this issue, but none were available. We therefore made an immediate requirement in relation to risk assessing the risk of scalding. We were shown around the garden. This has a large aviary for doves, one of the people who lives at the home cares for the birds. It is very positive to see such an opportunity to follow an interest; however the aviary is particularly unsightly. The garden is overgrown, and what could be a pleasant well used area appears dilapidated and in need of improvement. Tremanse Care Home DS0000061991.V376751.R01.S.doc Version 5.2 Page 19 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): People using the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The people who live at Tremanse can be assured that there are generally robust systems in place for the recruitment of staff. Plans for training staff have been delayed however staff feel well supported in their work. Staffing levels need to be reviewed to ensure that they are kept at an appropriate level, at all times. EVIDENCE: The people who use the service told us that they the staff are “helpful” and that they are “nice”. The Manager told us that a number of staff had left since the last inspection, and that they were trying to recruit staff to fill these vacancies. We spoke with one member of staff who had started in the last six months. The staff member explained that she received a comprehensive induction which she had found very useful. She had found the staff team supportive and had gained confidence in the work. The staff member explained that in addition to the induction she had also done training in relation to the protection of people from abuse and in relation to the Mental Capacity Act. Tremanse Care Home DS0000061991.V376751.R01.S.doc Version 5.2 Page 20 We looked at the recruitment of three people who had recently started at the home. We found that each person had an application form and that two references had been taken for each person. However we found that the references did not always relate to the last employer, including the last time a person worked with vulnerable people. In one case one of the references was a personal reference rather than an employer’s reference. We found that there were proper checks of whether people were suited to work with vulnerable people including a Criminal Records Bureau check. These had been received, as they should be, prior to the individuals starting work. We discussed with the Manager the need to ensure that where an individual has a conviction that a written risk assessment is recorded to clarify if the individual is suited to the work. The Manager explained to us that the plans for training had not been completed as she would have wished. However she is aware of the deficits in this area and is booking training. In the AQAA the Manager has commented that in the next 12 months staff all staff will be up to date with their mandatory training and will be commencing their National Vocational Awards. She also noted that staff will receive training appropriate to their roleincluding training in relation to Food Hygiene, violence and aggression. The Commission received an anonymous complaint that there had been only one member of staff on duty on a weekend day, and this had been insufficient. We received information from the Manager to show that on the day concerned that there were two staff (one of whom was cooking the meal). When we spoke with one of the staff during the inspection the individual confirmed that due to staff annual leave there were occasions when he/she was on duty alone. The two staff who responded to our surveys said that there were usually or always enough staff on duty. The Manager has informed us that she is on call if there are any concerns. We believe that the level of staffing may have been low at times, and require that this is reviewed. Tremanse Care Home DS0000061991.V376751.R01.S.doc Version 5.2 Page 21 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. 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 are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home is well managed on a day to day basis. Documentation that should be in place to ensure that risks are minimised was not in place. EVIDENCE: The Commission has received an application from the Manager to be registered in this role. We are satisfied with the existing management arrangements until this process is complete. We believe that the current manager has the relevant skills and competencies in this interim role. We discussed with the Manager changes that have happened in the home over the previous 12 months. This has meant that the Manager now has a greater range of responsibilities. This is at the same time as having to change the culture of the home, and to recruit, train and induct new staff to appropriate ways of working. We discussed with Tremanse Care Home DS0000061991.V376751.R01.S.doc Version 5.2 Page 22 the Manager whether the current management structure within the home was adequate, and whether additional resources were needed. We looked at checks that had been made in relation to the fire system, and found that the fire alarm had been tested weekly as were the door closers. There was also evidence of fire drills being done. However there was no fire risk assessment. We asked about checks that were made on the water system. As has already been noted we found that some of the bath water was excessively hot (66.5 degrees centigrade). Whilst we found that there was a list of dates and temperatures in relation to checking the water system in relation to Legionella, there was no underlying risk assessment. The Manager told us that she had just received a new set of Policies and Procedures from the Registered Provider. However when we looked at these policies we had concerns at the contents. This issue has been detailed under complaints and protection, earlier in the report. We asked about the quality assurance system and was told that a new system was being implemented and that survey forms had been sent out on 3/7/09. The Manager told us that there had been visits to the home by the Responsible Individual. These visits are to check on the running of the home, however no copies of these reports were available in the home and the manager had not seen these documents. Tremanse Care Home DS0000061991.V376751.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 Adults 18-65 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 X 2 3 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 1 ENVIRONMENT Standard No Score 24 3 25 2 26 X 27 X 28 X 29 X 30 1 STAFFING Standard No Score 31 2 32 X 33 X 34 2 35 2 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 X 2 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 X 3 X 3 2 X 2 X Version 5.2 Page 24 Tremanse Care Home DS0000061991.V376751.R01.S.doc YES Are there any outstanding requirements from the last inspection? 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 YA30 Regulation 13 Requirement Immediate Requirement: Risk Assessments must be immediately carried out in relation to all service users and risk of scalding from hot water. Appropriate action must be taken. Each person who lives at Tremanse must have a detailed care plan that where appropriate specifies goals, for example in relation to learning new skills or moving towards independence. Risk of self-harm, suicide, or aggression should be comprehensively assessed and action taken where appropriate. This requirement was made at the last inspection and has not been met. Risk assessments must be completed in relation to people self medicating. The amount of medication administered, where there is a variable dose, must be recorded. There must be clear protocols for the administration of “as required medication”. There must be a readily auditable account of all DS0000061991.V376751.R01.S.doc Timescale for action 04/08/09 2 YA6 15 01/11/09 4. YA9 4 01/11/09 3 YA20 13 01/11/09 Tremanse Care Home Version 5.2 Page 25 medication held. 4 YA22 13 Policies and procedures, including those relating to protecting people from abuse must reflect good practice. This must include the role of Social Services in taking a lead role in investigations of allegations of abuse. The use of the bedroom with external access must be reviewed. Any one occupying such a room must have ready and independent access to all communal facilities. Staffing levels must be reviewed to ensure that there are sufficient staff on duty at all times to meet people’s physical, psychological and emotional needs. Care staff must have received training where appropriate to ensure that they have the skills and competences to carry out their role. Where appropriate training in relation to mental health, moving and handling, and in relation to managing aggression must be provided. This requirement was made at the last inspection and is still to be met. Risk assessments must be carried out, implemented and available for inspection in relation to risks, including those posed by fire, legionella, and chemicals. 01/11/09 5. YA25 23(2) 01/11/09 6. YA33 12 01/11/09 7. YA35 18 (c)i 01/12/09 8. YA42 13 01/11/09 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. Tremanse Care Home DS0000061991.V376751.R01.S.doc Version 5.2 Page 26 No. 1 2 3 4 Refer to Standard YA24 YA25 YA34 YA39 Good Practice Recommendations The garden and aviary should be properly maintained. The call system should be changed so that it is not possible to listen in on individuals without their consent, or be used as a tannoy system. References for prospective staff should include the most recent employer and the last employer where a person worked with vulnerable people. Reports of Regulation 26 visits by the representative of the provider must be available for inspection in the care home. Tremanse Care Home DS0000061991.V376751.R01.S.doc Version 5.2 Page 27 Care Quality Commission Care Quality Commission Citygate Gallowgate Newcastle Upon Tyne NE1 4PA National Enquiry Line: Telephone: 03000 616161 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) Care Quality Commission (CQC). 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