Care Home: Trengrouse House

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What the care home does well Trengrouse provides a safe and comfortable home for older people. Residents and their representatives stated that Trengrouse provides good quality care and accommodation. Comments made by residents included `The home has a nice atmosphere`, `The staff do care well` and `The staff are very kind`. Residents and their representatives felt that that their health needs were well monitored and appropriate referrals made promptly. The provider obtains assessment information from the appropriate authorities before admission and carries out its own needs assessment. Some residents reported that the home and local community provided a varied programme of activities and there was enough for them to do. Residents felt their visitors were welcomed to the home. Residents, relatives and staff felt that they could approach the manager with any concerns and issues. Residents were particularly satisfied with the quality of the meals provided. The home is well maintained, tidily decorated and kept clean and hygienic. 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 made positive comments about the staff`s kindness, skills and attitudes. Staff stated that the informal and formal supervision supported them to do their jobs. Cornwall Care has a sound training programme for staff. The provider 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. What has improved since the last inspection? The previous report listed a number of recommendations. The new management team have worked hard to ensure that these recommendations have been addressed. Detail to the content of care planning has improved. New care plans have been drawn up and put in place. Residents` daily records are now generally satisfactory. Refresher training for staff in safeguarding adults is underway. New staff are promptly receiving their induction training. Risk assessments are being given more attention The Statement of Purpose has been amended to reflect recent changes. A program of improvement and redecoration is underway. What the care home could do better: A second member of staff should check and countersign hand written medication records. In many cases this is achieved but consistency is necessary. The supervision of all staff has to be conducted at least 6 times per year. This target has not always been met in the past 12 months. CARE HOMES FOR OLDER PEOPLE Trengrouse House Trengrouse Way Helston Cornwall TR13 8BA Lead Inspector Mike Dennis Unannounced Inspection 18th December 2007 09:30 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 Trengrouse House DS0000009139.V352913.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. Trengrouse House DS0000009139.V352913.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Trengrouse House Address Trengrouse Way Helston Cornwall TR13 8BA 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 573382 01326 563917 Cornwall Care Ltd Vacant Care Home 44 Category(ies) of Dementia - over 65 years of age (42), Mental registration, with number Disorder, excluding learning disability or of places dementia - over 65 years of age (2), Old age, not falling within any other category (6) Trengrouse House DS0000009139.V352913.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 4. Service users to include up to 6 adults of old age (OP) Service users to include up to 42 adults aged over 65 with dementia (DE[E]) Service users to include up to 2 adults aged over 65 with a mental illness (MD[E]) Total number of service users not to exceed a maximum of 44 Date of last inspection 6th October 2006 Brief Description of the Service: Trengrouse House is one of eighteen homes owned by Cornwall Care Ltd. It is registered to accommodate forty-four older people in need of personal care who may have a degree of dementia and are over retirement age. The previous double bedrooms are now used for single occupation. They would only accommodate two people where two partners or two individuals wished to share. Trengrouse House is on one level and is fully accessible for service users who have mobility difficulties or use a wheelchair. There is a secure sensory garden that all service users are able to access. Trengrouse House has close links with Age Concern and the local community. The home is located near to the town centre of Helston and offers day care for up to seven local people. The weekly fees at December 2007 were given as from £350 to £450 Trengrouse House DS0000009139.V352913.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 6 October 2006, and to focus on the key national minimum standards as identified by the commission. We were on the premises for one full day. The methods used were discussion with the manager, staff, residents, and their relatives, inspection of records and documents, observation of the daily life of the home and inspection of the premises. The Manager completed the Annual Quality Assurance Assessment document prior to this inspection. We are grateful to the providers, staff and residents for their assistance in completing the inspection. What the service does well: Trengrouse provides a safe and comfortable home for older people. Residents and their representatives stated that Trengrouse provides good quality care and accommodation. Comments made by residents included ‘The home has a nice atmosphere’, ‘The staff do care well’ and ‘The staff are very kind’. Residents and their representatives felt that that their health needs were well monitored and appropriate referrals made promptly. The provider obtains assessment information from the appropriate authorities before admission and carries out its own needs assessment. Some residents reported that the home and local community provided a varied programme of activities and there was enough for them to do. Residents felt their visitors were welcomed to the home. Residents, relatives and staff felt that they could approach the manager with any concerns and issues. Residents were particularly satisfied with the quality of the meals provided. The home is well maintained, tidily decorated and kept clean and hygienic. 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 made positive comments about the staff’s kindness, skills and attitudes. Staff stated that the informal and formal supervision supported them to do their jobs. Cornwall Care has a sound training programme for staff. The provider supports and encourages staff in Trengrouse House DS0000009139.V352913.R01.S.doc Version 5.2 Page 6 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. What has improved since the last inspection? What they could do better: A second member of staff should check and countersign hand written medication records. In many cases this is achieved but consistency is necessary. The supervision of all staff has to be conducted at least 6 times per year. This target has not always been met in the past 12 months. Trengrouse House DS0000009139.V352913.R01.S.doc Version 5.2 Page 7 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. Trengrouse House DS0000009139.V352913.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 Trengrouse House DS0000009139.V352913.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. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 3, 5. People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Prospective residents receive the information they require in order to make an informed choice about residing at Trengrouse and their needs are assessed so that they can be assured that the home can provide the care required. EVIDENCE: The Statement of Purpose has been revised to reflect changes in the management of the home. Contracts and/or statements of terms and conditions of the home are in place in respect of each resident. Trengrouse House DS0000009139.V352913.R01.S.doc Version 5.2 Page 10 Managers visit prospective residents and complete a needs assessment. Cornwall Care Ltd uses a standard format for assessment and care planning. When completed in sufficient detail, this record covers the assessment issues specified in the standard and the diverse needs of prospective residents. All the residents’ records case tracked contained needs assessments completed by the home’s managers. The records contained summaries of social work assessments, and joint assessments from local health agencies and Cornwall Department of Adult Social Care. The assessment records for recently admitted residents recorded their assessed needs in detail and included their views and preferences. The home’s assessments state who was present at the assessment. This provides evidence that the prospective resident and their family, or representatives, were involved in the assessment to ensure that their diverse needs were recorded. Relatives felt that the home involved them in the resident’s care arrangements. Residents and relatives informed us that they were given the opportunity to visit the home prior to moving in. Trengrouse House DS0000009139.V352913.R01.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9, 10. People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Residents health, personal and social care needs are set out in individual plans of care which are regularly reviewed and amended. Medication procedures are appropriately followed EVIDENCE: All the residents case tracked had written care plans. Cornwall Care Ltd has a standard single format for assessment and care planning. These care plans were dated and signed, with dated records of regular reviews. The records for residents include a written life story. The care profile summarises the interventions required from staff. The care profiles directed and informed care staff in detail in meeting the health, personal and social care needs of residents. Residents’ preferred social activities and interests are included in the written Occupational Profile and Plan. The Personal Routines and Trengrouse House DS0000009139.V352913.R01.S.doc Version 5.2 Page 12 Preferences records detail residents’ lifestyle preferences and choices, their dietary preferences and needs, and their religious beliefs. There were good examples of individual care planning. Each resident has an identified key worker with a photograph of each resident’s key worker in his or her bedroom. All residents case tracked had a moving and handling assessment. Cornwall Care use a standard format for this. These assessments had been reviewed regularly. Where a resident is at risk of falling, there was a separate and detailed risk assessment to direct staff in reducing the risk and safeguarding the resident. The examples of falls risk assessments inspected were completed in detail with clear strategies for managing the risks. The managers carry out regular audits of falls as part of a strategy to reduce the incidence of falls and support an appropriately active lifestyle. The daily records for residents detailed the care delivered, visitors, health care matters, occurrences and activities. Staff keep separate records in respect of bathing, and other specific individual care needs. The contents of the residents’ records met regulatory requirements. Residents are registered with local GP practices. Residents felt that their health care needs were monitored and attention obtained promptly when needed. Care staff record each resident’s medical contacts and appointments. There are also written plans where required for eye care, foot care and dental and oral care. Residents are weighed regularly. Medicines are stored in a locked medicines trolley and a locked cupboard in the managers’ office. There is a secure controlled drug cabinet, but two of the storage areas are not steel medicines cabinets to the required industry standard. The cupboards 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. Residents sign an agreement to the administration of medicines. Some residents may self administer their own medication from time to time and rooms have a lockable storage area. Cornwall Care has a corporate policy and procedure on the handling of medicines, which includes guidance on the use of homely remedies. Specific named staff, managers or care coordinators, complete training and have responsibility for the administration of medicines. The administration records were well maintained. Two staff check in stocks of medicines delivered from the pharmacist. Two staff must always check and sign hand written medication records, drawn up, for example, when residents are admitted for respite. The home has a controlled drug register and each administration is signed and witnessed. A check of stock of one drug against the record showed this to be accurate. A record of medicines returned to the pharmacist is kept on the pharmacy standard format. Residents made positive comments on the skills and caring qualities of staff. They felt very well cared for and reported that staff delivered care sensitively Trengrouse House DS0000009139.V352913.R01.S.doc Version 5.2 Page 13 and respected their privacy and dignity. Residents made statements like, “wonderful” and “would not like to go anywhere else”. Residents felt safe when, for example, staff were transferring them and providing personal care in the assisted baths. Examples of staff providing skilled and sensitive care were observed during the inspection. Trengrouse House DS0000009139.V352913.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): 12, 13,14, 15 People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. 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 routines. The home provides some regular planned activities including arts and crafts, hairdressing, and musical entertainment. Residents also have the opportunity to join in the day centre activities. Some staff have had hand and foot massage training. Staff support residents in their own preferred individual activities and interests. The visiting arrangements are flexible and residents choose where they meet their guests. If visitors call at meal times it is preferred that they have a meal with the person they are visiting. Residents felt that their visitors were made Trengrouse House DS0000009139.V352913.R01.S.doc Version 5.2 Page 15 welcome. Visitors confirmed that the home’s visiting arrangements suited them and staff make them welcome. The Manager stated that she does not act as appointee for any residents for their benefits or manage any savings. 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. The Manager was very positive about the Cornwall Care ‘appetite for life’ initiative for residents to receive a varied and appealing diet in a relaxed atmosphere. Breakfast is served flexibly according to individual preferences. The choices include cereal, toast, fruit, juices, a cooked breakfast and drinks. Residents were very happy with the choice at breakfast. There are two main choices each day at lunch. Further choices are available to individual residents who would prefer something different. Tea is a choice of savouries and home made cakes. The cook discusses the menu choices with residents. 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. There was a relaxed and unrushed atmosphere during lunch 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 the meals were very good with appetising choices and sufficient portions. Meals were well prepared and presented. Drinks are served between meals. Trengrouse House DS0000009139.V352913.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): 16, 18. People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home 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. Trengrouse has received no formal complaints since the last inspection. There is a record for complaints and compliments. This contained a number of expressions of appreciation and thanks. Residents and representatives had confidence 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 revised to comply with the local Multi-Agency Adult Protection Guidelines. Staff receive training in adult protection following their induction and as part of their NVQ level 2. All senior staff have had refresher training in safeguarding vulnerable adults. The Manager stated that the majority of care staff had received the Cornwall multi-agency alerter’s training. Staff were aware of their responsibilities to report concerns about the Trengrouse House DS0000009139.V352913.R01.S.doc Version 5.2 Page 17 protection of vulnerable adults. The Manager has a copy of the Cornwall Multi-Agency Adult Protection Guidelines. Trengrouse House DS0000009139.V352913.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): 19 to 26 People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home is generally well maintained and provides a safe environment. The premises are clean and hygienic providing a pleasant environment and reducing risks to residents. EVIDENCE: Trengrouse is situated in a residential area of Helston not far from the facilities and services of the town. The car park is close to the entrance which is suitable for wheelchair users. The home is on one level. It is set out as four wings around a central hub and enclosed garden area. The wings do not accommodate residents according to specific identified levels of need and residents have freedom of movement around the home. Cornwall Care Ltd Trengrouse House DS0000009139.V352913.R01.S.doc Version 5.2 Page 19 continues to maintain and refurbish the home’s décor and furnishings. The communal rooms and residents rooms inspected were pleasantly decorated and furnished. There is a record of repairs and maintenance. Residents and their representatives commented that they are satisfied with the home’s cleanliness and presentation. Residents reported that their rooms were kept clean and fresh. The quality of furniture is generally good, and several armchairs have been replaced. Various carpets have also been replaced. Ongoing redecoration was occurring during the inspection. The laundry complies with the standard. The washing machines and tumbler driers are industrial standard. Clothes and linen for laundry is transported through the home in sealed red bags or covered containers. Residents and their representatives 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, with six assisted baths. Hot water was supplied at a safe temperature. Toilets are suitably close to communal areas. All the bathrooms and toilets inspected were tiled on the lower half of the wall, pleasantly decorated and clean and hygienic. Facilities for staff hand washing, with hand wash and paper towels, were situated throughout the home. Staff reported that there were good supplies of gloves and aprons. Aids and adaptations were evident to assist with mobility and transfers. We were impressed with the cleanliness and organisation of the kitchen areas. Trengrouse House DS0000009139.V352913.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): 27, 28, 29, 30. People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Recruitment procedures support and protect the service users. Staff are trained and competent to meet the needs of residents. The staffing levels are generally satisfactory. EVIDENCE: Residents commented that they felt staffing levels were sufficient. The manager stated that minimum staffing levels are intended to be seven care staff, adequate domestic and catering staff, and a care coordinator. This ratio reduces to five care staff during the afternoon and then six in the evening, again with a care coordinator and ancillary staff. At night there are 2 waking staff and an on call manager. In addition the manager and/or deputy are also on site. Residents were positive about the skills, kindness and qualities of the staff team. Over 75 staff have completed their NVQ in care at level 2. and three other staff are currently undertaking the course. The Cornwall Care Ltd training structure ensures that all new staff are registered promptly for their NVQ training. Trengrouse House DS0000009139.V352913.R01.S.doc Version 5.2 Page 21 Posts are advertised through the Job Centre and local press. Cornwall Care Ltd has standard corporate recruitment procedures including equal opportunities. The records of the most recently recruited members of staff showed that the required employment checks had been properly completed. 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, which covers required areas of training. Training records showed that staff had completed training in moving and handling, dementia care, food hygiene and health and safety. Recently appointed staff had begun their inductions. In fact three new staff were receiving their initial induction on the day of inspection. Staff were satisfied with the training they receive to do their jobs. Trengrouse House DS0000009139.V352913.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): 31, 32, 33, 35, 36, 37, 38 People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The provider has appointed an experienced and qualified manager who maintains the care delivery to meet the homes stated purpose and objectives. The health and safety of residents and staff is promoted. EVIDENCE: The manager is newly appointed, having been in post since the 2nd.October 2007. She is an experienced manager having been a registered manager at another Cornwall Care home. She has made an application to become the Registered Manager at Trengrouse. Her qualifications include NVQ4 and the Trengrouse House DS0000009139.V352913.R01.S.doc Version 5.2 Page 23 Registered Managers Award. She is supported by the deputy manager and three care coordinators. There are clear lines of accountability from the manager through the other senior staff, who each have specific areas of responsibility. Staff were positive about the support and supervision that they received from the manager. Residents felt that the Manager would listen to and address any concerns that they might have. Cornwall Care Ltd has corporate policies for the management of residents’ 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, with receipts for all expenditures. Each resident’s balance is not held as an individual amount of cash as this would amount to a large sum for the home to hold. The money 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 was carried out in August. The staff records showed that staff received supervision sessions, some as individual sessions and some as small group wing meetings. Each member of the senior staff team is responsible for supervising a number of staff. The frequency of supervision has consistently achieved the six sessions a year recommended in the standard. Staff were satisfied that informal and formal supervision supported them to do their jobs well. They stated that if they sought guidance and information, this was always provided. Staff felt that they worked well together to ensure the well being of residents. Cornwall Care Ltd has comprehensive policies for health and safety. The Annual Quality Assurance Assessment 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 inspected. Completed accident records should be kept on the individual residents file. 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. The home’s fire risk assessment has been completed. Trengrouse House DS0000009139.V352913.R01.S.doc Version 5.2 Page 24 Trengrouse House DS0000009139.V352913.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 3 3 3 X 3 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 3 3 3 3 3 3 3 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 3 3 3 3 3 3 3 Trengrouse House DS0000009139.V352913.R01.S.doc Version 5.2 Page 26 Are there any outstanding requirements from the last inspection? None 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. Standard Regulation Requirement Timescale for action 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. Refer to Standard OP9 OP36 Good Practice Recommendations A second member of staff should check and countersign hand written medication records. Maintain the supervision of all staff at approximately 2 monthly intervals. Trengrouse House DS0000009139.V352913.R01.S.doc Version 5.2 Page 27 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 Trengrouse House DS0000009139.V352913.R01.S.doc Version 5.2 Page 28 - 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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