CARE HOMES FOR OLDER PEOPLE
Tremethick House Meadowside Redruth Cornwall TR15 3AL Lead Inspector
Paul Freeman Unannounced Inspection 13th December 2006 10:00 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information
Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Tremethick House DS0000009095.V324352.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. Tremethick House DS0000009095.V324352.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION
Name of service Tremethick House Address Meadowside Redruth Cornwall TR15 3AL Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 01209 215713 01209 313680 info@anson-care-services.co.uk Mrs Mary Allison Anson Mr John Robert Anson Mrs Barbara Denise Ball Care Home 29 Category(ies) of Dementia - over 65 years of age (10), Old age, registration, with number not falling within any other category (29) of places Tremethick House DS0000009095.V324352.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION
Conditions of registration: 1. Room 22a may be used as bedroom accommodation for one person for the duration of the building works. 16th January 2006 Date of last inspection Brief Description of the Service: The home is owned and run by Mr and Mrs Anson and the providers take an active role in the services and facilities provided. A registered manager Mrs Denise Ball has been appointed to take the lead role in the day to day running of the home. Tremethick is a care home that offers care to twenty-eight older people. The majority of bedrooms are for single occupancy and communal space is provided throughout the home. The majority of the communal space is located on the ground floor and is maintained to a high standard. There is reasonable access outside and inside the home for people who experience a disability. A passenger lift is also provided. The home is located on the edge of Redruth town with pleasant grounds and car parking facilities. The location provides easy access to the town, leisure facilities and health services. The home offers transport to appointments and for outings. The home state they provide care in a manner that meets the individual needs and preferences of residents in a manner that promotes independence, dignity and the rights. At the time of the inspection major works are taking place to extend the facilities and refurbish areas of the care home. Tremethick House DS0000009095.V324352.R01.S.doc Version 5.2 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. A planned key inspection took place on 13 December 2006 and 14 December 2006. The purpose of the inspection was to consider the work that had been undertaken on the requirements set at the last inspection on 16 January 2006 and to inspect other core standards. Therefore some of the key standards considered included care planning, health, staffing arrangements and safe working practices. One of the registered providers, the registered manager, residents, staff and visitors were consulted about the services and facilities provided. The environment, records and documents were also considered. Residents and visitors are very positive about the services provided and the manner in which staff meet care and support needs. Major improvements continue to the environment that will significantly enhance the accommodation available. It is planned the works will be completed during the summer of 2007. The current fee levels at the care home are between £320 and £410. The level of fees is determined by the residents needs and the type of accommodation required. What the service does well:
Each prospective resident is visited before they move to the home for the providers to undertake an assessment of their needs and to determine their individual choices and preferences. The prospective resident is able to fully participate in the assessment process. The views and opinions of relatives or representatives and any professionals involved are also taken into account. Good arrangements are in place to meet health needs and medical services are promptly accessed when required. Suitable arrangements are also in place regarding the storage and administration of medicines. Residents are also able to administer their own medication when it is safe. Residents stated they are very satisfied with the lifestyle they experience. A range of activities is provided at the home and links have also been established with community groups. There are no barriers to residents accessing the community when it is safe to do so. Positive and flexible visiting arrangements are also in place. Residents said that the staff warmly welcomed all visitors. Tremethick House DS0000009095.V324352.R01.S.doc Version 5.2 Page 6 Many of the residents prefer to arrange their own leisure time and residents said they felt in control of their lives. Residents were very complimentary about the food and all said the meals were “good”. A seasonally adjusted menu is in place that takes account of the residents’ preferences and choices. Residents are also provided with a choice at each mealtime and were more than satisfied about the quantity and quality of food they receive. Plans are at the final stage of development to refurbished, improve and upgrade the kitchen area. This will be achieved by a purpose built extension at the rear of the property. The current kitchen equipment meets the required standard and is regularly maintained and serviced. Appropriate standards of hygiene and cleanliness are in place and satisfactory measures have been established to promote a safe and healthy kitchen environment. The providers or the Commission over the last year has received no formal complaints. Positive arrangements are in place to deal with any complaints or concerns that arise. Residents said they had confidence about raising any issues and were sure the matter would be dealt with promptly and resolved in a satisfactory manner. Satisfactory arrangements are also in place to protect residents against abuse. Any allegations or issues or concerns are reported to the statutory authorities. These include whistle-blowing arrangements where staff able to report concerns to a third party. The dedicated housekeeping staff maintains a good standard of cleanliness and hygiene. Sufficient number of staff is on duty to meet the needs of residents. Residents commented they were very pleased with the manner in which the staff provided care and support. The residents said staff were flexible and treated them in a respectful and dignified manner. The staff is appropriately trained and an ongoing programme of training is in operation. This makes sure that staff has the skills and abilities to provide a positive and reliable service to residents. Good arrangements are in place to recruit, select and vet new staff. Newly appointed staff also completes a period of induction. This makes sure they are aware of their roles and responsibilities and have the skills and knowledge to provide the care and support required. Tremethick House DS0000009095.V324352.R01.S.doc Version 5.2 Page 7 The home is well run and managed for the benefit of the residents. The manager takes the lead in the day-to-day running of the home and the providers also play an active role in the provision of the services and facilities. Residents said the providers and manager are very approachable and there are no barriers to raising any issues or concerns. Residents were confidant that any issues raised would be dealt with positively and efficiently. The staff are appropriately supported and stated that advice, guidance and support is always available whenever it is required. Residents are regularly consulted about the services and facilities provided to make sure that every reasonable step in taken to meet their needs, preferences and choices. There are no concerns about the financial viability of the home and arrangements are in place to make sure that residents’ financial interests are safeguarded. The providers have established a range of policies and procedures to promote safe working practices for the residents and staff. Equipment and services are also regularly monitored and maintained. What has improved since the last inspection?
Each resident has a care plan that outlines their needs and provides staff with the information, guidance and direction needed to provide the care and support required. The care plans are regularly reviewed with the residents and their relatives or representatives. Appropriate records of the review are in place to make sure the staff has an up to date picture of the care and support needed. In many parts of the environment an excellent or good standard of furniture and fittings are provided which create a comfortable and safe setting for residents. The providers are in the process of refurbishing other areas that will result in excellent or good standards throughout the home and compliance with the Care Homes Regulations. The plan includes extending the facilities and accommodating more residents. A new kitchen and additional communal areas are included in the plan. Residents their relatives and representatives and staff are being actively consulted about the plans. Residents commented they are satisfied with the facilities provided and they confirmed a reliable programme of maintenance is in place. The arrangements to manage risks individual residents may experience continue to improve. However risk assessments are not always completed
Tremethick House DS0000009095.V324352.R01.S.doc Version 5.2 Page 8 when a situation arises that could compromise the health, safety or welfare of a residents or staff member. This could place residents at risk. What they could do better: 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. Tremethick House DS0000009095.V324352.R01.S.doc Version 5.2 Page 9 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 Tremethick House DS0000009095.V324352.R01.S.doc Version 5.2 Page 10 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): The standards considered were 3 and 6. Quality in this outcome area is good. The providers complete a suitable needs assessment for each prospective resident to make sure they have a clear picture of the care and support required. The assessment also satisfies the providers’ the facilities and services are suitable for the needs of each prospective resident. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The providers assess each prospective resident before they move to the home. The assessment takes account of the views and opinions of the prospective resident and their relatives or representatives. In addition the opinions of any professionals that are involved with the person concerned are also taken into
Tremethick House DS0000009095.V324352.R01.S.doc Version 5.2 Page 11 account. The assessments also provide sufficient information for the registered providers to be satisfied they can meet the needs of the person concerned. Residents that have recently moved to the care home said they were visited and fully consulted about their needs and preferences prior to the move. Residents commented they felt in control of events and were positively welcomed when they first arrived by everyone at the home. The providers do not offer a intermediate care service or rehabilitation service but are committed to maintaining residents independence as far as possible. Tremethick House DS0000009095.V324352.R01.S.doc Version 5.2 Page 12 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): The standards considered were 7, 8, 9 and 10. Quality in this outcome area is good. Satisfactory care planning arrangements are in place that summarise residents’ needs and provide staff with clear guidance and information about the care and support required. Good arrangements are in place to promote residents health and medicines are stored and administered safely. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Each resident have a care plan that summarises their needs, preferences and choices. The care plan provides staff with adequate guidance and direction about the care and support required. The care plans are regularly reviewed
Tremethick House DS0000009095.V324352.R01.S.doc Version 5.2 Page 13 and appropriate records are maintained about each review and any further action required. Residents were positive about the care and support provided and the manner in which staff undertake their duties. It is clearly apparent that good and trusting relationships exist between the staff and residents. The residents also said they felt in control of the care they receive and were confidant they could direct the care required. It is also clear that residents are treated with dignity and respect at all times. It is evident the providers have continued to improve and develop the care planning arrangements. The staff commented they found the plans positively assisted in providing the care and support required and to safeguard residents. The providers do need to be mindful that more detailed information and direction is provided in care plans for residents that have more complex needs. Although the current arrangements are satisfactory further improvements can occur in this area to make sure that staff have good guidance and direction. Residents’ health needs are well met and medical services are promptly accessed when required. The residents said they had confidence in the care and support provided and any issues received prompt attention. The records show that health professionals regularly visit residents and are called in when required. The records of visits provide a comprehensive picture of the contacts that have taken place. Residents are able to administer their medication when it is safe to do so. Where assistance is provided by the staff a suitable policy and procedure is in place and the medicines are stored in a secure facility. The staff responsible for administering medication has been suitably trained and good records are maintained. The Pharmacist safely disposes of any medicines that are no longer required. Tremethick House DS0000009095.V324352.R01.S.doc Version 5.2 Page 14 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): The standards considered were 12, 13, 14 and 15. Quality in this outcome area is good. Residents are provided with a varied and stimulating lifestyle that reflects their needs, preferences and choices. The meals are “good” and offer a varied and nutritional diet that provides choice and variety. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Residents stated they were provided with a varied and stimulating lifestyle and felt in control of their lives. The daily routines are flexible and residents confirmed that staff positively responded to their requests or the routine they required. The residents also said that staff is available and responsive when they required assistance. A range of activities is provided at the home that reflect the residents’ interests and hobbies. Residents are therefore able to participate if they wish. A varied
Tremethick House DS0000009095.V324352.R01.S.doc Version 5.2 Page 15 programme had been put in place leading up to xmas and residents were very pleased with the arrangements. Each care plan also summarises the person’s interests and hobbies and there are no barriers to residents meeting their religious or cultural needs. It would be beneficial for more detailed information to be included in the care plans about residents’ hobbies and interests. This will help the providers to make sure that residents’ needs are met and to further develop the opportunities. Residents said they were generally satisfied with the arrangements in place. There are no barriers to residents accessing the local community when it is safe. In addition a number of community groups regularly have contact with residents at the care home. The residents were also very satisfied and complimentary about the food and menu provided. The menu is seasonally varied and reflects the preferences of residents. A choice is provided at each mealtime and special diets are also provided where required. Residents choose where they take their meals and an attractive well maintained dinning room is provided in a conservatory at the rear of the building. All the residents said the food was “good” and were very satisfied with the arrangements in place. Plans are at the final stage of development to refurbished, improve and upgrade the kitchen area. This will be achieved by a purpose built extension at the rear of the property. The current kitchen equipment meets the required standard and is regularly maintained and serviced. Appropriate standards of hygiene and cleanliness are maintained and satisfactory measures are in place to promote a safe and healthy environment. The Environmental Health Officer inspected the facilities and practises in August 2006 and found the arrangements to be “satisfactory.” Tremethick House DS0000009095.V324352.R01.S.doc Version 5.2 Page 16 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): The standards considered were 16 and 18. Quality in this outcome area is good. Positive arrangements are in place to deal with any complaints or concerns and appropriate arrangements have been established to protect residents from abuse. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The providers or CSCI has received no complaints over that last year. A satisfactory policy and procedure is in place to deal with any complaints or concerns. Residents commented they had confidence in the providers dealing with any issues in a positive and efficient manner. The residents stated there were no barriers to raising any issues or concerns with the providers. Satisfactory arrangements are also in place to protect residents against abuse and a suitable policy and procedure is in place. Any allegations of abuse are formally reported to the authorities and where appropriate are investigated. The providers have also established satisfactory whistle blowing arrangements. Staff are therefore able to report any concerns they have about abuse to a
Tremethick House DS0000009095.V324352.R01.S.doc Version 5.2 Page 17 third party if they feel unable to inform the providers. This provides the residents with further protection. Tremethick House DS0000009095.V324352.R01.S.doc Version 5.2 Page 18 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): The standards considered were 19 and 26. Quality in this outcome area is adequate. The environment is generally maintained to a satisfactory standard. Certain facilities need to be refurbished in order that a good standard is provided throughout the care home. The current building works should therefore provide residents with an excellent or good environment throughout. This judgement has been made using available evidence including a visit to this service. EVIDENCE: There are currently major works taking place to extend the care home and improve the facilities in the current registered premises. This is part of the providers long term plans to improve and develop the facilities provided.
Tremethick House DS0000009095.V324352.R01.S.doc Version 5.2 Page 19 The building works will involve some disruption to residents and will require a minimum number of residents to temporarily be accommodated in other bedrooms. The providers have fully consulted with residents and their relative or representatives about the implications of the current plans. All of the residents were positive about the work that has been completed which has positively impacted on the facilities and services they receive. The residents also said the current building works had not had a major impact on their daily lives. The current works will result in improved garden facilities and easier access for residents. In addition the work already completed on the communal areas has provided residents with excellent accommodation. Residents’ bedrooms are appropriately equipped and furnished and many residents have personalised their rooms. There are also a range of bathrooms and toilets distributed throughout the care home that are within a reasonable distance from communal areas and residents bedrooms. A range of aids and adaptation are provided throughout the home to assist residents to maintain their independence as far as possible. These include a passenger lift and stair lifts where appropriate. A stair lift has recently been installed on the first floor to improve access for residents. In addition residents are individually supplied with aids to assist independence where this is required and following a specialist assessment. Residents commented they were very satisfied with the accommodation and facilities provided. The providers have established reliable arrangements to undertake repairs where this is required. The residents said the maintenance staff was efficient, very competent and reliable about any repairs that are required. The home is maintained to a good standard of hygiene and cleanliness and domestic staff is on duty each day. The residents said they had no concerns about the standard of hygiene which they considered were of a high standard. Tremethick House DS0000009095.V324352.R01.S.doc Version 5.2 Page 20 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): The standards considered were 27, 28, 29 and 30. Quality in this outcome area is good. Sufficient numbers of suitably qualified, experienced and competent staff are on duty each day and night. Good arrangements are in place to recruit new staff that safeguard residents. New staff also complete an induction programme to make sure they have the knowledge and skills to meet the residents needs. This judgement has been made using available evidence including a visit to this service. EVIDENCE: One of the registered providers plays an active role in the provision of care to the residents. In addition there are sufficient numbers of staff on duty during the waking hours and each night to make sure that residents are safeguarded and their needs are met. Additional staff is also provided when required. All the residents’ commented the staff were, “very good” and they were very satisfied with the manner in which the staff provided the care and support they require. Residents said they felt in control of the care they received and found the staff to be flexible in their approach and available when required.
Tremethick House DS0000009095.V324352.R01.S.doc Version 5.2 Page 21 Visitors were also positive about the care staff and had confidence that good standards were maintained at all times. The staff is suitably trained and the providers have established an annual programme of training for all staff. This makes sure the staff has up to date knowledge and the appropriate skills to maintain a good standard of care and support. In addition a number of staff are trained to NVQ 2 and NVQ 3 standard. Good arrangements are in place to recruit select and vet new staff to make sure that staff have the required skills and abilities and that residents are safeguarded. Each newly appointed staff member also completes an induction programme that ensures they are aware of their roles and responsibilities. The providers are currently taking steps to make sure the current induction arrangements meet the guidelines recently established by Skills for Care. Tremethick House DS0000009095.V324352.R01.S.doc Version 5.2 Page 22 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): The standards considered were 31, 33 and 38. Quality in this outcome area is good. The home is well run for the benefit of residents and one of the registered providers and the registered manager provide a well-organised and competent service. Residents are regularly consulted about the quality of the services and facilities provided to meet their needs. A range of measures is in place to promote safe working practices but the risk assessment and risk management arrangements continue to require improvement to make sure residents are safeguarded. This judgement has been made using available evidence including a visit to this service. Tremethick House DS0000009095.V324352.R01.S.doc Version 5.2 Page 23 EVIDENCE: Residents commented the home is well run and there are no barriers to raising any issues with the providers or registered manager. The registered manager coordinates the day-to-day services and facilities and the providers also play an active role in the running of the home. In addition a Deputy Manager is in post who operationally assists the Registered Manager. The providers and registered manager are experienced in social care and Mrs Anson is also a qualified nurse with an active pin number. The registered manager has also obtained the registered managers award. The evidence indicates that residents’ financial interests are safeguarded and there are no apparent concerns about the financial viability of the home. The providers have established a range of methods to consult residents and visitors about the quality of the services and facilities provided. The measures include individual consultations, annual resident’s survey and carers meeting. The findings are generally positive although a number of residents commented the laundry service required improvement. The providers consider the new laundry facilities that are part of the building works will address any shortfalls. The providers have also established a range of measure and policies and procedures to promote safe working practices. The equipment and services are regularly monitored and maintained and the staff group are appropriately trained. Residents said they felt safe and were positive about the measures in place to promote their health and wellbeing. The arrangements to assess and manage risks that individual residents encounter continue to improve. However there continue to be occasions where risk assessments have not been undertaken following an incident or accident a resident has experienced. In addition risks are not always taken into account as part of the assessment of needs arrangements. Staff regularly undergoes fire training and the fire equipment is monitored on a regular basis. Tremethick House DS0000009095.V324352.R01.S.doc Version 5.2 Page 24 A policy and procedures to guide direct and inform the staff about the fire arrangements is in place. It is recommended the policy is reviewed to make sure it is robust and comprehensively addresses the issues and actions required. It would also be beneficial for the policy to detail the roles and responsibilities of the fire warden. This will further develop and strengthen the arrangements in place. Tremethick House DS0000009095.V324352.R01.S.doc Version 5.2 Page 25 SCORING OF OUTCOMES
This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from:
4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable
CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 4 X 3 X 3 X X 2 Tremethick House DS0000009095.V324352.R01.S.doc Version 5.2 Page 26 Are there any outstanding requirements from the last inspection? No STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. 2. Standard OP19 OP38 Regulation 23 Requirement Timescale for action 30/07/07 28/02/07 The environment and facilities provided must meet the required standard s. 13(4)(a-c) The registered person shall ensure that— (a) all parts of the home to which service users have access are so far as reasonably practicable free from hazards to their safety; (b) any activities in which service users participate are so far as reasonably practicable free from avoidable risks; and (c) unnecessary risks to the health or safety of service users are identified and so far as possible eliminated, Therefore risk assessments and risk management plans must be Tremethick House DS0000009095.V324352.R01.S.doc Version 5.2 Page 27 in place where any situation arises that could potentially compromise the health, wellbeing or safety of a service user. 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 OP38 Good Practice Recommendations The policy and procedures regarding fire should be reviewed and improved so that staff is given clear direction about their roles and responsibilities. Tremethick House DS0000009095.V324352.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection St Austell Office John Keay House Tregonissey Road St Austell Cornwall PL25 4AD 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
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