Inspection on 15/08/06 for Trevern

This inspection was carried out on 15th August 2006.

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

Trevern 22/10/07

Trevern 11/01/06

Trevern 04/07/05

Trevern 20/01/05

Trevern 01/07/04

Similar services:

Fairfields Country Rest Home

Poldhu

Queensmount

Trevaylor Manor

Didsbury Court Rest Home

Stallcombe House

Belma

Hunters Care Centre

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

CARE HOMES FOR OLDER PEOPLE Trevern 72 Melville Road Falmouth Cornwall TR11 4DD Lead Inspector Richard Coates Key Unannounced Inspection 15th August 2006 09:15 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Trevern DS0000008922.V296818.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. Trevern DS0000008922.V296818.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Trevern Address 72 Melville Road Falmouth Cornwall TR11 4DD 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) 01326 312833 01326 210196 Cornwall Care Limited Mrs Bridget Irene Varney Care Home 40 Category(ies) of Dementia - over 65 years of age (21), Mental registration, with number Disorder, excluding learning disability or of places dementia - over 65 years of age (11), Old age, not falling within any other category (13) Trevern DS0000008922.V296818.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 4. 5. Service users to include up to 13 adults of old age (OP) Service users to include up to 21 adults over 65 with dementia (DE{E}) Service users to include up to 11 adults over 65 with a mental disorder (MD{E}) Service users to include one named person only outside of the normal age category of the Home Total number of service users not to exceed a maximum of 40 Date of last inspection 11th January 2006 Brief Description of the Service: Trevern is one of eighteen care homes owned by Cornwall Care Ltd. It is situated on Melville Road in Falmouth. The home provides care and accommodation for up to forty older people, twenty-one of who may have a degree of dementia on admission. There are service user bedrooms in the original house and, adjoining this, flatlets for more able and independent residents. Sixteen rooms are provided in the recent extension to the home. Bedrooms in the flatlets and ‘house’ are on the ground floor and first floor with a lift at each end of the building. The new wing is on one level. All units have sufficient communal rooms and bathrooms and toilets. All rooms have call bells. Meals are prepared in a kitchen on the ground floor and served in three dining rooms, accessible to all residents. The grounds are tidy and there are outside areas with seating and tables, accessible by residents. A secure garden area has also been developed next to the new extension of the home. Limited car parking space is provided at the front of the home. The range of fees is currently from £290 to £450 weekly at August 2006. The Registered Manager identified above has recently moved to another post within Cornwall Care Ltd, and, at the time of inspection, the commission was processing a registration application for a new manager. Trevern DS0000008922.V296818.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was a planned unannounced key inspection. The purpose of the inspection was to follow up the provider’s compliance with the requirements and recommendations set in the last inspection report dated 11 January 2006, and to focus on the key national minimum standards as identified by the commission. The inspector was on the premises over two days. The methods used were discussion with the manager, staff, residents, their relatives and visitors, inspection of records and documents, observation of the daily life of the home and inspection of the premises. The manager submitted a preinspection questionnaire. The inspectors are grateful to the providers, staff and residents for their assistance in completing the inspection. What the service does well: Service users and their representatives stated that Trevern provides good quality care and accommodation. Comments about staff made by residents included ‘There are always enough staff’, ‘The manager knows her job’, ‘Kind polite and attentive’ and ‘The staff do a good job’. Residents commented that they felt that they were consulted about their care needs. They reported that their health needs are monitored and appropriate professional advice and assistance are obtained when necessary. Staff record needs assessments for prospective residents and draw up care plans with the resident and their representatives. Residents are supported to take part in a mix of organised group activities and individual activities with staff on their wing. Residents felt their visitors were welcomed to the home and visiting relatives were positive about the welcome they received. Residents, relatives and staff felt able to approach the registered manager with any concerns and issues. The home is well maintained, tidily decorated and kept clean and hygienic. There are pleasant accessible outside areas. The staff team has a number of staff who have worked at the home for some years. This allows staff and residents to get to know each other and promotes consistent care delivery. Residents were positive about the skills and attitudes of staff. Staff receive regular supervision. Cornwall Care has a structured training programme and supports and encourages staff in their training and development so that residents and their representatives can have confidence in a well trained and supervised staff team. Staff were satisfied with the training they receive and with the support from the management team. Trevern DS0000008922.V296818.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. Trevern DS0000008922.V296818.R01.S.doc Version 5.2 Page 7 The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Trevern DS0000008922.V296818.R01.S.doc Version 5.2 Page 8 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 Trevern DS0000008922.V296818.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 3, Trevern does not provide intermediate care (standard 6) Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to this service. The needs of service users are assessed so that they can be assured that the home can provide the care required. EVIDENCE: Managers complete needs assessments for prospective residents and obtain assessments from the commissioning authority. Cornwall Care Ltd has a standard format for assessment and care planning which, when completed in sufficient detail, covers all the issues specified in the standard. All the residents’ records case tracked contained written needs assessments. Copies of assessments, and admission information from health and adult social care were on file. The home’s assessments consistently stated who was present, providing evidence that the prospective resident and their family were involved in the assessment. Trevern DS0000008922.V296818.R01.S.doc Version 5.2 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10 Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to this service. Written care plans direct and inform staff about how to meet the residents’ health and personal care needs. The health and well being of residents are monitored and addressed so that their healthcare needs are met. With one exception detailed below, the arrangements for the management of medicines protect service users. EVIDENCE: All the residents case tracked had written care plans. Cornwall Care Ltd has a standard single format for assessment and care planning. Staff here have not drawn up a ‘Care Profile’ - a summary of the care plan used as a working document in some Cornwall Care homes. The recently appointed manager is introducing this. The care plans directed and informed care staff on meeting the health, personal and social care needs of residents. There were good examples of individual care planning. However, some care plans, or parts of care plans, were not consistent in providing adequate detailed directions and information for staff on meeting the diverse care needs of residents. Care plans had evidence of regular reviews. Each resident has a key worker. The Trevern DS0000008922.V296818.R01.S.doc Version 5.2 Page 11 Personal Routines and Preferences records detail residents’ lifestyle preferences and choices, their dietary preferences and needs, their religious beliefs and choices in other areas. All residents case tracked had a moving and handling assessment. Falls risk assessments were included as a small part of the moving and handling assessment. Where a resident is at risk of falling, there should be a separate and detailed risk assessment to direct staff in reducing the risk and safeguarding the resident. Daily records were generally adequately detailed, although some individual records lacked a daily entry. The daily records may not reflect all the activities that go on in the home. Staff keep separate records in respect of bathing, and other specific individual care needs. Residents are all registered with local GP practices. Residents and their representatives felt that their health care needs were well-monitored and appropriate attention obtained. Resident records detailed medical contacts for each resident. The community nurses visit the home regularly. A community nurse visiting the home reported that the care staff work well with them, follow instructions and feed back effectively. An assistant manager reported that one resident currently has pressure area. This was acquired in hospital and is being treated by the community nurses. The deputy manager discussed how the home met the needs of one resident with a specific health condition. Medicines for the house and flatlets are stored in a locked trolley in a locked room. The new wing has its own storage area, which was not inspected on this occasion. The room and trolley were tidy and well organised. There is a small medicines refrigerator and the temperature is checked daily. The monitored dosage system is in use. Some residents administer their own medication. Residents sign an agreement to the administration of medicines. Cornwall Care has a corporate policy and procedure on the handling of medicines which includes guidance on the use of homely remedies. Identified staff, who have completed training, have responsibility for the administration of medicines. The administration records were well maintained. A second member of staff should check and sign hand written medication records, for example for residents admitted for respite. Samples of stocks were checked against the medicine administration record and found to be accurate. Controlled drugs are stored in a separate locked cabinet. There is a controlled drug register and each administration is signed and witnessed. A sample of controlled drugs was checked against the record and found to be accurate. A record of medicines returned to the pharmacist is kept as a duplicate book. The pharmacist last made a visit for advice on 27 April 2006. A number of residents have a prescription for the same common liquid medicine; the home was using individual bottles in turn as a supply for all. The use of ‘community medicines’ like this is not acceptable. Trevern DS0000008922.V296818.R01.S.doc Version 5.2 Page 12 Residents provided positive comments on the skills and caring qualities of staff. They felt that staff worked sensitively with them when assisting with personal care and respected their privacy and dignity. Examples of staff delivering appropriate and sensitive care were noted during the inspection. Residents stated that staff listened to them and took notice of their requests and comments. Trevern DS0000008922.V296818.R01.S.doc Version 5.2 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15 Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to this service. Residents are supported to follow a lifestyle which accords as far as possible with their own choices and preferences. The diet provided is varied and nutritious with attention to individual preferences. EVIDENCE: Residents felt that they had control over their daily lives and choices in their routines. The home provides some regular programmed activities including arts and crafts, hairdressing, and a regular Christian service. Residents discussed their interests and activities with the inspector. Individual interests are recorded in service user admission information and care plans. Residents are supported to continue their own preferred individual activities and interests. Staff were engaged in one to one and small group activities with residents. The manager commissions additional staff to provide one to one activities inside and outside the home. There is a flexible visiting policy and residents choose where they meet their guests. Residents felt that their visitors were made welcome. Visitors confirmed that the home’s visiting arrangements suited them and staff make Trevern DS0000008922.V296818.R01.S.doc Version 5.2 Page 14 them welcome. They may be offered, for example, a cup of tea, or invited to use the facilities provided to make themselves and their relative a drink. The Registered Manager stated that she does not act as appointee for any residents for their benefits or manage any savings. The home does act as agent to collect benefits for a small number of residents. There is a record of the amount paid to the home as fees and the personal allowance paid to the resident. This record should be signed by the resident or witnessed by a second member of staff. A minority of residents manage their own finances. Other residents’ finances are managed with informal assistance from relatives or through Power of Attorney arrangements. Residents can bring in possessions and furniture by agreement with the provider. An Age Concern advocate is involved with one resident currently. The manager reported that she has also activated the ‘Care Aware’ advocacy service commissioned by Cornwall Care for some residents. The manager was keen to introduce Cornwall Care ‘appetite for life’ initiative to ensure that a varied and appealing diet is provided to residents in a relaxed atmosphere. The kitchen is currently being completely refitted and a kitchen has been set up in a temporary building in the car park. Staff were working effectively to minimise disruption to the lives of residents. Breakfast is served flexibly according to individual preferences. The choices include cereal, toast, fruit, prunes, a cooked breakfast and drinks. There are two main choices each day at lunch, with further choices available. The home is currently providing diabetic diets and one low fat/low dairy food diet. One resident has liquidised meals and a specific dietary need. An additional worker has been introduced to assist her to eat and provided this care with warmth, sensitivity and skill. Residents made positive comments about the quality of food provided. They can choose to have their meals in their room or in the dining area for their wing. The inspector joined residents for lunch. This was a relaxed and sociable occasion with staff providing appropriate and effective support. Residents enjoyed a glass of wine or a non-alcoholic drink with their choice of meal. Residents reported that they had a good choice at breakfast, and a range of savouries and puddings and cakes at tea. Drinks are served between meals. Trevern DS0000008922.V296818.R01.S.doc Version 5.2 Page 15 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to this service. The home has a satisfactory complaints procedure that would ensure that complaints are listened to and acted upon. There are arrangements to protect service users from abuse. EVIDENCE: Cornwall Care Ltd has a corporate complaints procedure. Trevern has received no formal complaints since the last inspection. Residents and visitors told the inspector that they felt that they could approach the managers at the home with their concerns and these would be addressed. Cornwall Care Ltd has an adult protection policy and procedure. The policy and procedure have been recently revised to comply with the local Multi-Agency Adult Protection Guidelines. Staff do not receive refresher training in adult protection following their induction. The Registered Manager stated that she had nominated staff for the Cornwall multi-agency alerter’s training, but has not been successful in obtaining any places. It was recommended to the Registered Manager that she ensure that she has a copy of the Cornwall MultiAgency Adult Protection Guidelines. Trevern DS0000008922.V296818.R01.S.doc Version 5.2 Page 16 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19 and 26 Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to this service. The home is generally well maintained and provides a safe environment. The premises are clean and hygienic providing a pleasant environment and reducing risks to residents. EVIDENCE: The residents’ accommodation at Trevern is in three areas. The original house provides accommodation on two floors with a lift. The flatlets were added some years ago and are also on two floors with a lift. The recently commissioned new wing is on one level. Each wing is a self-contained unit with bedrooms, dining area, lounge, toilets and bathrooms. Each unit has access to a tidy and attractive outside area accessible to residents. There is one double room and this is occupied as a single at present. The bedrooms in the house tend to be smaller than those on the new wing. All rooms inspected were pleasantly decorated and furnished. There is a detailed maintenance record. Trevern DS0000008922.V296818.R01.S.doc Version 5.2 Page 17 A complete refit of the kitchen was taking place at the time of the inspection. This will meet one of the requirements set in the last inspection report. Trevern is situated in a residential area of Falmouth not far from the facilities and services of the town. The car park is close to the entrances which are suitable for wheelchair users. Cornwall Care Ltd continues to maintain and refurbish the home’s décor and furnishings. The house and flats are generally decorated to a good standard; there are some chips and scuffs on the paintwork around doors. The new wing is very well presented. Residents and their representatives, and staff all commented that they are satisfied with the home’s cleanliness, presentation and the quality of furnishings. Residents reported that their rooms were kept clean and fresh. The rooms were personalised and service users had the option to lock their rooms. The laundry complies with the standard. The washing machines and tumbler driers are industrial standard. Residents commented that the laundry service is ‘good’. Residents’ clothes looked smart and well cared for. The bathing and toileting facilities in the home comply with the standard, providing assisted baths. Hot water was supplied at a safe temperature. The new wing has a level entry shower. Toilets are suitably close to communal areas. All the bathrooms and toilets inspected were clean and hygienic. Facilities for hand washing with hand wash, paper towels and alcohol rub were situated throughout the home. Aids and adaptations were evident to assist with mobility and transfers. Trevern DS0000008922.V296818.R01.S.doc Version 5.2 Page 18 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30 Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to this service. The staffing and training arrangements ensure that the needs of residents are met. Recruitment procedures support and protect the service users. EVIDENCE: Residents commented that they felt staffing levels were sufficient. There are seven care staff, adequate domestic and catering staff, and an assistant manager across the three units during the waking day. At night there are 3 waking staff and an on call manager. The home has a deputy manager. The registered manager stated that the home employs agency workers where required to supplement staffing. Residents were positive about the skills, kindness and qualities of the staff team. Just over 50 staff have completed their NVQ in care at level 2 or level 3. Further staff are currently engaged on their NVQ level 2. The provider recruited a number of new staff following the commissioning of the new wing and this has reduced the overall proportion of qualified staff. However, the Cornwall Care Ltd training structure ensures that all new staff are registered promptly for their NVQ level 2. Posts are advertised through the Job Centre and local press. Cornwall Care Ltd has standard corporate recruitment procedures. Two managers interview with set questions. The records of three recently recruited staff showed that the Trevern DS0000008922.V296818.R01.S.doc Version 5.2 Page 19 required employment checks had been properly completed. One recent record lacked a photograph. Staff records for established staff contained the required documents and information. Staff receive a statement of terms and conditions of employment. Cornwall Care Ltd provides a structured corporate training programme for staff. Training records showed that staff had completed required training in moving and handling, dementia care, food hygiene and health and safety. Recently appointed staff had begun their inductions. Staff were satisfied with the training they received to do their jobs. Cornwall Care Ltd should review the use of the Personal Profile staff training record. These were not completed and up to date, but the staff member’s training history information was generally recorded on other documents. Trevern DS0000008922.V296818.R01.S.doc Version 5.2 Page 20 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35, 36 and 38 Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to this service. The provider has recently appointed an experienced and qualified manager who is determined to ensure that it meets its stated purpose and objectives, and provides the highest quality care. Arrangements for safekeeping of residents’ money safeguard their interests. The health and safety of residents and staff are promoted and protected. EVIDENCE: Cornwall Care has recently appointed a new manager to Trevern. The manager has applied for registration as the registered manager and the commission is currently processing the application. There are clear lines of accountability from the manager through the deputy and assistant managers, who each have specific areas of responsibility, and supervise one of the wings Trevern DS0000008922.V296818.R01.S.doc Version 5.2 Page 21 and staff. Staff were positive about the support and supervision that they received from the manager. Cornwall Care Ltd has corporate policies for the management of service users’ monies and the home provides safekeeping for small amounts of money. Each resident has a record detailing payments in and out, and a running balance. Each resident’s balance is not held as an individual amount of cash – for 40 residents this would amount to a large sum for the home to hold. The cash is held in a specific bank account with a float available for daily transactions. A separate cash book details all payments in and out of the cash float. The administrator has systems in place for checking and reconciling the amount of cash, the bank account balance, and the individual resident’s recorded balances. Cornwall Care Ltd has previously sought the views of residents and their representatives, and other stakeholders through questionnaires. The manager stated that the annual quality assurance survey this year is being carried out by an external organisation. The surveys will be distributed to residents and all other stakeholders with a stamped envelope so that they can be returned directly to the external organisation for analysis. The staff records showed that all staff received regular supervision sessions. Each assistant manager is responsible for supervising the staff on an identified wing of the home. The deputy manager supervises the night staff. The frequency of supervision had increased recently, but had not achieved the six sessions a year recommended in the standard. Staff receive annual appraisals. Staff valued the regular opportunity to talk with their manager. Staff were satisfied that informal and formal supervision supported them to do their jobs well. Cornwall Care Ltd has comprehensive policies for health and safety. The preinspection questionnaire detailed required maintenance and safety records. A sample were checked against the original records and found to be accurate. Staff have attended relevant health and safety training. Staff reported that Cornwall Care Ltd promotes safe working and manages health and safety well. The accident record for both residents and staff was completed satisfactorily. The records showed weekly tests of the fire alarm system and the emergency lighting and regular fire training for all staff. There is a written fire plan/procedure. The home’s fire risk assessment has been completed but it was not evidenced if the fire service has seen it and provided feedback. The refrigerators and freezers display their temperatures, but a daily record is not being made. Trevern DS0000008922.V296818.R01.S.doc Version 5.2 Page 22 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 2 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 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 3 X 3 X 3 X X 3 Trevern DS0000008922.V296818.R01.S.doc Version 5.2 Page 23 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 OP8 Regulation 13 Requirement The Registered Person must complete a separate individual falls risk assessment for all service users at risk of falls. The registered person must not using an individual resident’s prescribed medicine as a communal supply for all residents who are prescribed the same medicine. Timescale for action 30/11/06 2 OP9 13 25/08/06 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 OP7 Good Practice Recommendations Care plans should provide sufficient specific detail to direct staff in meeting each resident’s diverse needs and individual preferences. Handwritten medication administration records should be checked and signed by a second member of staff. The registered person should ensure that the home has a DS0000008922.V296818.R01.S.doc Version 5.2 Page 24 2 3 Trevern OP9 OP18 4 5 OP18 OP35 copy of the local multi-agency adult protection guidelines. The registered person should review the provision of refresher training for staff in adult protection. The resident or a second member of staff, should sign to confirm the payment of a resident’s personal allowance. Trevern DS0000008922.V296818.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection St Austell Office John Keay House Tregonissey Road St Austell Cornwall PL25 4AD National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Trevern DS0000008922.V296818.R01.S.doc Version 5.2 Page 26 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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