Inspection on 15/10/07 for Tremethick House

This inspection was carried out on 15th October 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. 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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Tremethick House 13/12/06

Tremethick House 16/01/06

Tremethick House 18/07/05

Tremethick House 28/02/05

Tremethick House 23/09/04

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 Tremethick House Meadowside Redruth Cornwall TR15 3AL Lead Inspector Stephen Baber Unannounced Inspection 15th October 2007 10:00a 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.V349763.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.V349763.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 42 Category(ies) of Dementia (10), Old age, not falling within any registration, with number other category (42) of places Tremethick House DS0000009095.V349763.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category of service only: Care home providing personal care only- Code PC to service users of either gender whose primary care needs on admission to the home are within the following categories: Old age, not falling within any other category- Code OP- maximum 42 places 2. Dementia - Code DE- maximum 10 places The maximum number of service users who can be accommodated is 42. 13th December 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. The new extension has been completed and provides a very high standard of accommodation. The new fourteen bedrooms have ensuite facilities aand are finished to high specifications. The new spacious lounge overlooks the front of the home and car park. Tremethick is registered to offer care and accommodation to forty-two older people. Overall the majority of bedrooms are for single occupancy and communal space is now 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. Two passenger lifts are 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 their rights. . Current weekly charges are £335 to £540. Tremethick House DS0000009095.V349763.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The Commission for Social Care Inspection (CSCI) have made changes to the way we inspect services. Known as Inspecting for Better Lives (IBL). We are now more proportionate when reporting our findings, and more focused on the experience of people using services. The purpose of the inspection was to ensure that resident’s needs are appropriately met, with good outcomes provided to them. We carried out the key inspection on the 15th and 17th October 2007. The inspection lasted for approximately 10 hours. The purpose of the inspection was to ensure that residents’ needs are properly met, in accordance with good care practices and the laws regulating care homes. The focus is on ensuring that residents’ placements in the home result in good outcomes for them. The inspection included interviews, some held privately in residents’ rooms and some in the communal area of the home, with residents and visiting relatives. Several members of staff were interviewed and there were opportunities to directly observe aspects of residents’ daily lives in the home and staff interaction with them. Other activities included an inspection of the premises, examination of care, safety and employment records and discussion with the manager and provider who were present throughout the inspection. The provider explained that the major improvements to build on a large extension to improve the service s and facilities for residents are complete apart from some tidying up. The principle method of inspection was “case tracking”. This involves interviews with a select number of residents; staff caring for them and/or their representatives, and examination of records relating to their care. This provides a useful impression of how the home is working overall. At this inspection three residents files were case tracked, with particular reference to their individual and diverse needs relating to their age, culture and ethnicity, religion, gender, sexual orientation and disabilities. What the service does well: Tremethick House provides a comfortable, safe and well-maintained home for older people. The service provides well-presented written information about the home to enable people to make a decision about whether the home can Tremethick House DS0000009095.V349763.R01.S.doc Version 5.2 Page 6 meet their needs and suits their preferences. The residents I spoke with said “they were very comfortable and well cared for”. The manager carries out detailed assessments and considers carefully if the home can meet the needs of prospective residents. There is an attention to detail in care planning and risk assessment with individual residents and in responding to their preferences and choices. The residents’ healthcare needs are effectively monitored and addressed. Residents report that they are well cared for and they have confidence in the manager and registered providers. The staff are kind and skilled and respect their privacy and dignity. Residents said that staff give them prompt attention and advice when they were unwell.Other comments such as “ Exceptional care and kindness”, “Staff very nice and supportive” and “I cannot praise the owners and staff too highly”. The management of the home is effective and ensures that the aims and objectives as set out in the statement of purpose are met. The home is kept in good decorative with a continuing programme of maintenance and refurbishment of the premises and equipment. The manager and providers actively consult residents individually and obtain their views about the services provided. They regularly evaluate the service provided and follow this up with planned improvements. There is a structured training programme, which covers induction, required statutory training and NVQ at levels 2 and 3. Staff report that they are well supported and supervised. There are arrangements in place to ensure compliance with health and safety legislation and promote the health and safety of staff and residents. What has improved since the last inspection? The new extension has been completed and provides a very high standard of accommodation. The maintenance of the rest of the home building has continued with new carpeting, redecoration for some areas of the ground floor, and new carpets and redecoration in a number of residents’ bedrooms. A brand new shaft lift has been provided in the new extension and provides access from ground to first floor. Care plans are more consistent and comprehensive in providing detailed directions and information for care staff so that residents can be confident that their needs are effectively met. The staff group has a high level of qualification, so that residents receive care from trained and competent staff. Staff are committed to delivering a high quality of care. The introduction of the key worker system will enable staff to have more time in assisting residents with personal care during the busy mornings and at times when residents would like to have a chat. The manager makes time to see residents daily and she continues to review and improve the arrangements for care and activities in the home. Tremethick House DS0000009095.V349763.R01.S.doc Version 5.2 Page 7 What they could do better: The manager and provider were given detailed feedback throughout the two days and open and frank discussion took place on the findings of the inspection. An immediate requirement was left which draws management’s attention to the current method of administration of medication. The current system is secondary dispensing and should cease forthwith. It constitutes a risk to residents and staff are vulnerable to allegations of negligence. Management agreed and said that they are currently reviewing medication in a process of continuous improvement. We also discussed the improvements necessary to the residents and staff files. At present the files are altogether in loose leaf which makes the retrieval of information difficult. Policies and procedures regarding adult protection require updating and the contact details of the Cornwall Department of Adult Social Care should be included in the complaints procedure. A system for recording details regarding staff’s CRB details should be set up. The guidance states that CRB’s should not be kept longer than six months. The manual handling assessments inspected do not guide and inform the staff because it is a tick box exercise. The manager should give staff information that informs and directs them. Please contact the provider for advice of actions taken in response to this Tremethick House DS0000009095.V349763.R01.S.doc Version 5.2 Page 8 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.V349763.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.V349763.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): Standard 3 was assessed. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The needs of prospective residents are assessed so that they can be assured that the home can provide adequate care EVIDENCE: Three files were case tracked. The manager had recorded an admission assessment, which forms the basis for the care plan. The care plan records detailed directions and information for staff, so that the resident’s needs could be met. The manager is very aware of the need to complete thorough assessments of prospective residents to ensure that the home is able to meet their needs and preferences. The residents we spoke with reported that assessments had been carried out and they also said the home was comfortable, clean and tidy, and the staff had been very kind in helping them feel at home. Tremethick House DS0000009095.V349763.R01.S.doc Version 5.2 Page 11 Tremethick House DS0000009095.V349763.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): Standards 7,8,9, and 10 were assessed. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Written care plans direct and inform staff in detail about the residents’ health and personal care needs so that these can be met. The manager is very attentive in monitoring the changing healthcare needs of residents and ensuring that these are addressed. The arrangements for the management of medicines do not protect residents EVIDENCE: We case tracked three residents’ records. These records all had written care plans and monthly summarries. The plans cover the residents’ personal, health and social care needs. Each plan sets out a stated objective, the action to be taken and regular dated evaluations. The care plans provide detailed and specific directions for staff to meet the residents’ care needs. Residents sign their care plans. Care staff record daily notes consistently; these are factual, legible and signed. The care plans contained regular reviews and evaluations. They documented the actions that had been taken to meet the changing needs Tremethick House DS0000009095.V349763.R01.S.doc Version 5.2 Page 13 of residents. Residents reported that staff were ‘kind’, knew what they were doing in the delivery of care, and respected their privacy and dignity. Residents were very satisfied with the quality of the care they receive. Residents see GPs and community nurses in their own rooms. Residents are registered with local surgeries. The residents’ records detail health care contacts and appointments. Residents stated that the staff were very good at monitoring their health and well being and obtained medical attention and advice when this was required. The community nurses visit the home regularly to carry out required nursing interventions, for example dressings, and tissue viability assessment and monitoring. A nurse visited a resident during the inspection. The resident reported that she had found the prompt response reassuring. The chiropodist visits the home at six weekely intervals and provides attention to a number of residents. Moving and handling information is going to be reviewed and instead of a tick box exercise detailed instructions are going to recorded that inform and direct staff, so that care is delivered safely The medication policy and procedure does not comply with the standard and is not based on the Royal Pharmaceutical Society guidance. An immediate requirement was left and management agreed that they would review the medication and improve on the current system. Staff check and book in all medicines received into the home. Staff receive training in the management of medicines from the local Penwith College. Tremethick House DS0000009095.V349763.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): Standards 12,13,14 and 15 were assessed. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are supported in a lifestyle, which accords as far as possible with their own expectations and preferences. There are regular activities and the manager is reviewing these so that they meet residents’ needs and preferences. The diet provided is varied and nutritious with attention to individual preferences. EVIDENCE: The manager records the residents’ preferences in food, drink and care arrangements at admission. Care plans set out the residents’ preferred activities and interests, and guide staff in supporting people in these. Residents felt that the routines were relaxed and allowed them to pursue their own lifestyle and preferred pattern of life. Breakfast and tea are flexible in timing and offer a choice of menus to suit individual preferences. Some residents said that they were able to follow their preferred routine and were supported by staff to achieve their goals. Residents discussed their interests Tremethick House DS0000009095.V349763.R01.S.doc Version 5.2 Page 15 and were observed engaged in enjoying listening to Radio Cornwall, reading books and newspapers, and conversation. A religious service takes place in the home every other month. The manager is currently reviewing and developing the range of indoor activities provided by the home. Activities are organised almost daily for residents. The Age Concern takes residents out once a month if they wish.. The manager has introduced sessions with musical entertainers, inhouse bingo, weekly hairdresser and keep fit sessions. The manager has a clear intention to continue to review and improve the activities provided. The manager welcomes family and friends visiting at any time as long as this accords with the wishes of the resident. Visitors were coming to the home throughout the inspection. Residents can receive visitors in their own rooms or the communal rooms. The new lounge or small quiet areas provides a quiet area for receiving visitors. Residents reported that the arrangements for visiting were satisfactory and the manager was helpful in this. The home provides three meals daily, and a drink and a snack for supper. Residents were generally very satisfied with the quality of meals and catering arrangements. The menu records a varied and nutritious diet. Care plans detail, where required, individual needs in relation to nutrition. All the residents I spoke with said the meals were very good and they could have portions size that suited their needs. The dining room is spacious, light and airy and tables have linen tablecloths, napkins and flowers. On the day of the inspection there was a choice of meal. The food was appetising and well presented. The residents were not rushed. Staff provided unobtrusive and appropriate individual support. Some residents choose to eat in their rooms. A choice of savouries is available for tea. Fresh fruit was available if requested. Staff cut up the food for residents where they need this assistance with particular menu items. Tremethick House DS0000009095.V349763.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): Standards 16 and 18 were assessed. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home has a satisfactory complaints procedure that would ensure that complaints are listened to and acted upon. The manager has established arrangements to protect residents from abuse EVIDENCE: The complaints procedure complies with the standard. The manager and providers actively consult residents individually and obtain their views about the services provided. The residents we spoke were very satisfied with the service and none had felt the need to make a complaint. They stated that they found the manager and providers approachable and helpful. It is recommended that the contact details of the Cornwall department of Adult Social Care be recorded on the complaints procedure. The home’s policy and procedure on the prevention of abuse complies with the standard. The manager has a copy of the recently issued multi agency Cornwall Adult Protection Policy. Staff receive training in the protection of vulnerable adults during induction. Several staff have attended the multiagency training on adult protection, and the manager intends for more staff to attend this training. Staff were aware of their responsibilities in relation to adult protection. The manager needs to review the provision of regular refresher training for staff in this area and update the policy to the Commission For Social Care Inspection and not NCSC. Tremethick House DS0000009095.V349763.R01.S.doc Version 5.2 Page 17 The home provides a secure storage facility for small amounts of residents’ cash. There is a policy statement on financial relationships with residents Tremethick House DS0000009095.V349763.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): Standards 19 and 26 were assessed. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is well maintained and safe. The premises are clean and hygienic providing a pleasant environment and reducing risks to residents EVIDENCE: The home is situated in a residential area near Redruth town centre. Information about the accommodation is provided in the Statement of Purpose. The access at the front has a number small granite steps to the main door. Inside the building handrails, provide access from the hall to various parts of the building. The second entrance to the new lounge also has a series of steps, which would make it difficult for the more dependent residents who require level access. There are two passenger lifts, which serve ground, and first floor throughout the building. Tremethick House DS0000009095.V349763.R01.S.doc Version 5.2 Page 19 The home is comfortable and homely. The providers have continued their programme of maintenance and refurbishment. Areas of the ground floor in the main house are currently being upgraded. The providers are going to provide new carpets and some new furniture to improve the overall standards and make Tremethick a home to be proud of. The communal space comprises a small sitting room, lounge and large lounge dining room as well as the dining room. This allows ample space for those residents who wish to have greater privacy and time to reflect. Furniture is domestic in style and of good quality. The home is centrally heated. Lighting is domestic in nature and appears adequate. The garden is being upgraded, with areas for residents to sit. With reference to smoking the manager stated that this arrangement has changed with the introduction of legislation on 1st July 2007. Under the legislation, smoking in care homes will be restricted to designated rooms, which meet the requirements of the regulations. The new laundry is very impressive. There is a procedure setting out control measures for the transfer of laundry, which has been agreed with the environmental health officer. The laundry equipment comprises one washing machine, one industrial grade, and two dryers. There are hand washing facilities for staff with liquid soap. Residents reported that their clothes were laundered with a good standard of care. Staff reported that there were always plenty of gloves and aprons. The baths, showers, toilets, commodes and basins that we inspected were clean and hygienic. Bathrooms and toilets were in good decorative order. Hand washing facilities and alcohol hand rubs are situated around the home. Residents reported that their rooms were kept clean and fresh. There are detailed written cleaning procedures with specified tasks for staff. Tremethick House DS0000009095.V349763.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): Standards 27,28,29 and 30 were assessed. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The staffing and training arrangements ensure that the needs of residents are met. There is a high level of qualified staff. Recruitment procedures and practice support and safeguard the residents. EVIDENCE: Tremethick enjoys a stable core of staff that have worked at the home for many years. The staff group seems to have settled down to a well-qualified and enthusiastic team. The roster shows that there are five care staff on duty until after lunch, three care assistants on duty in the afternoon, two care assistants in the evening and two waking care assistants through the night. This is in addition to the manager and support staff daily. Of 18 care staff 15 staff hold NVQ level 2. This gives an overall level of qualification of 83 . Four staff are currently completing level 3 and two recently appointed staff have registered for their NVQ level 2. Recruitment records for recently appointed staff were inspected. These contained the required information and documents, including application forms, references, Criminal Records Bureau disclosures and POVA first checks. Tremethick House DS0000009095.V349763.R01.S.doc Version 5.2 Page 21 Advice was given to the manager about the guidance issued by the CRB department, in that staff’s CRB’b should not be retained for longer than Six months. The provider issues staff with statements of terms and conditions of employment. Staff receives copies of the General Social Care Council Code of Conduct. The home has a structured programme for Skills For Care induction training. The induction training is tailored to the level of qualification and previous experience of new staff. Staff reported that they received a thorough introduction to their job and sound support and supervision through a lengthy induction period. Records of induction training were on file, appropriately signed and dated. Staff have individual training records which detail regular supervision. Staff showed a sound awareness of good care practices in discussing their work. Tremethick House DS0000009095.V349763.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): Standards 31,32,33,35,36 and 38 were assessed. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The registered providers and manager are experienced and qualified, and fit to run a care home. The providers and manager use a range of methods to obtain the views of residents and their representatives. The providers operate a system for safeguarding residents’ spending money. The health and safety of residents and staff are promoted and protected. EVIDENCE: The registered manager has completed the Registered Manager’s Award and exceeds the experience requirement for a registered manager. She is an Tremethick House DS0000009095.V349763.R01.S.doc Version 5.2 Page 23 assessor for NVQ awards and has worked at the home for 23 years. She regularly completes training to keep her knowledge and skills up to date. The home’s information pack sets out the arrangements for quality monitoring which will include the views of other stakeholders. The manager and providers employ a number of quality assurance systems. These include: - a quarterly menu survey; - a regular recorded review with residents and their representatives of their views on the care and services provided; - a satisfaction survey form for visitors and relatives; - monthly care plan reviews and monthly summaries on the health, welfare and well being of each resident. The majority of residents have delegated the management of their financial affairs to family and representatives The provider’s ‘Health and Safety Policy’ sets out the responsibilities of the employer and employees, and the arrangements for managing health and safety. There are hazard analyses and risk assessments for a range of activities and equipment. The most recent Fire Building Control and Kerrier District Council environmental health officer health and safety inspection took place on registration of the new extension. Staff felt that the providers were attentive to health and safety matters, and that, for example, moving and handling was well managed. Accidents records were appropriately completed and closely monitored by the manager. The records regarding fire, fire training, electrical appliances, service documents required maintenance and safety checks were sampled and confirmed against the original documents. The records show regular required checks of the fire alarm systems, emergency lighting and equipment. Tremethick House DS0000009095.V349763.R01.S.doc Version 5.2 Page 24 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 X HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 1 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 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND3 ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 3 X 3 3 X 3 Tremethick House DS0000009095.V349763.R01.S.doc Version 5.2 Page 25 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. Standard OP9 Regulation 13(2) Requirement The registered persons must make suitable arrangements for the recording, handling, safekeeping, safe administration and disposal of medication in the care home. Timescale for action 28/02/08 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2 3 Refer to Standard OP16 Good Practice Recommendations The registered person should include the contact details and telephone number of the Cornwall Department of Adult Social Care in the complaints procedure. The Adult Protection policy and procedure should be updated to reflect accurate information. The registered person should set up a system to record the details of staff CRB disclosures. OP18 OP29 Tremethick House DS0000009095.V349763.R01.S.doc Version 5.2 Page 26 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 Tremethick House DS0000009095.V349763.R01.S.doc Version 5.2 Page 27 - 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. 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