Care Home: Trewartha House

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What the care home does well Trewartha House provides a safe and comfortable home for older people. Service users and their representatives reported that Trewartha House provides good quality care and accommodation. Comments made by residents included `they listen to me` and `good as gold`. Residents and their representatives felt that that their health needs were well monitored and appropriate assistance sought when required. The managers ensure that they have obtained a sufficiently detailed assessment to determine if the home can meet the prospective resident`s needs. Residents felt that they were supported to follow their preferred daily routine. They reported that there were sufficient activities and enough to do. The home has a recently appointed activities worker. Residents felt their visitors were welcomed to the home. Residents, relatives and staff said that they were confident that they could approach the registered manager with any concerns and issues. Residents expressed satisfaction with the quality and quantities of the meals provided. The home is well maintained, generally tidily decorated and clean and hygienic. Residents made positive comments about the staff`s kindness and caring qualities. Staff stated that the informal and formal supervision supported them to do their jobs well. Cornwall Care has a well-established training programme for staff which covers required areas. The company supports 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 statutory requirement listed at the last inspection has been complied with. The content and review of care planning has improved. The home is about to change the recording format for pre-admission assessments and care planning and it is hoped that this will further improve these important areas of work. 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. What the care home could do better: CARE HOMES FOR OLDER PEOPLE Trewartha House Trewartha Estate Carbis Bay St Ives Cornwall TR26 2TQ Lead Inspector Mike Dennis Unannounced Inspection 10:00 22 January 2008 nd 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 Trewartha House DS0000009134.V347184.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. Trewartha House DS0000009134.V347184.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Trewartha House Address Trewartha Estate Carbis Bay St Ives Cornwall TR26 2TQ 01736 797183 01736 797287 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) Cornwall Care Limited Mrs Christine Muxlow Care Home 40 Category(ies) of Dementia - over 65 years of age (40), Mental registration, with number Disorder, excluding learning disability or of places dementia - over 65 years of age (40) Trewartha House DS0000009134.V347184.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 16th January 2007 Brief Description of the Service: Trewartha House is one of eighteen homes for which Cornwall Care Ltd is the registered provider. It is registered to accommodate and provide personal care for forty older people with dementia and mental illness. The provider endeavours to plan all admissions, and to avoid emergency admissions whenever possible. The accommodation for residents at Trewartha House is on one floor with four wings radiating out from a central communal area. Each wing has its own bedrooms, toilets and bathrooms and is decorated in a distinctive colour scheme. The wings are arranged in pairs, each pair with a shared dining area and sitting rooms. The garden area is secure with a large paved area, seating and a wooden summerhouse. The majority of residents’ bedrooms are single. There are four shared bedrooms. Trewartha House is accessible for people who have mobility difficulties or use a wheelchair. The home is close to community facilities in the immediate area and is a short distance from St Ives. Trewartha House has developed relationships with local agencies including the Alzheimers Society. Trewartha House DS0000009134.V347184.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 2 star. This means the people who use this service experience good quality outcomes. 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 16th.January 2007. We were on the premises for 6 hours and focused on the key national minimum standards as identified by the commission. The methods used were discussion with the manager, staff, residents, and their relatives and visitors, inspection of records and documents, observation of the daily life of the home and inspection of the premises. We are grateful to the Management team, staff and residents for their assistance in completing the inspection. What the service does well: Trewartha House provides a safe and comfortable home for older people. Service users and their representatives reported that Trewartha House provides good quality care and accommodation. Comments made by residents included ‘they listen to me’ and ‘good as gold’. Residents and their representatives felt that that their health needs were well monitored and appropriate assistance sought when required. The managers ensure that they have obtained a sufficiently detailed assessment to determine if the home can meet the prospective resident’s needs. Residents felt that they were supported to follow their preferred daily routine. They reported that there were sufficient activities and enough to do. The home has a recently appointed activities worker. Residents felt their visitors were welcomed to the home. Residents, relatives and staff said that they were confident that they could approach the registered manager with any concerns and issues. Residents expressed satisfaction with the quality and quantities of the meals provided. The home is well maintained, generally tidily decorated and clean and hygienic. Residents made positive comments about the staff’s kindness and caring qualities. Staff stated that the informal and formal supervision supported Trewartha House DS0000009134.V347184.R01.S.doc Version 5.2 Page 6 them to do their jobs well. Cornwall Care has a well-established training programme for staff which covers required areas. The company supports 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? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. Trewartha House DS0000009134.V347184.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. The summary of this inspection report can be made available in other formats on request. Trewartha House DS0000009134.V347184.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 Trewartha House DS0000009134.V347184.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. 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 Trewartha 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. Trewartha House DS0000009134.V347184.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. The residents’ records case tracked contained completed needs assessments. The home staff carry out an assessment for both private purchasers and those commissioned by the local authority. All the residents’ records case tracked contained a written assessment and care plan. 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. The records for a resident case tracked included the assessment and commissioning documents from the local authority. The assessment part of the care planning records were completed in reasonable detail. Trewartha House DS0000009134.V347184.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 Trewartha House DS0000009134.V347184.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 a secure room. 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 Trewartha House DS0000009134.V347184.R01.S.doc Version 5.2 Page 13 and respected their privacy and dignity. Examples of staff providing skilled and sensitive care were observed during the inspection. Trewartha House DS0000009134.V347184.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: are recorded. There are two dining areas. In addition to the main kitchen, each pair of wings shares a small kitchen for serving breakfast and drinks. Residents were positive about the quality of food provided, reporting that the meals were very good with appetising choices and sufficient portions. Residents have their breakfast, with a hot choice available, in one of the dining areas or in the resident’s room. The cooks have approached residents about their choices and preferences, and have introduced a four-week rotating menu for lunch. There are two main choices each day for lunch, with further individual choices available. Tea is a choice of savouries and home made cakes. The daily menu is displayed in each dining room. The food was Trewartha House DS0000009134.V347184.R01.S.doc Version 5.2 Page 15 appetising and well presented. Residents were relaxed and unrushed with staff providing appropriate support to residents to make choices and eat their meals. Hot and cold drinks are served between meals. Residents felt that they were helped to make choices about their daily lives and routines. They felt that there was enough to do. There is a notice board displaying information and a recently introduced newsletter. The home provides a range of planned activities, supported by the activities co-ordinator. During the inspection, the activities c0-0rdinator was observed working with residents. Residents and visitors reported that they found the visiting arrangements open and flexible. They felt that visitors were made welcome and they were offered a drink. Residents choose where they meet their guests. The Registered Manager reported that she is not appointee for any residents for their benefits. Relatives or representatives manage the residents’ finances, a high proportion being recorded as through Power of Attorney arrangements. Residents can bring in possessions and furniture at admission by agreement with the provider. The staff record an inventory of belongings at admission. Many residents and their families had personalised their bedrooms to a high degree. Cornwall Care has introduced the ‘appetite for life’ initiative for residents to receive a varied and appealing diet in a relaxed atmosphere. Each resident’s preferences and choices Trewartha House DS0000009134.V347184.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 that complies with the standard and regulation. Trewartha has received no formal complaints since the last inspection. There is a record for complaints and compliments containing a number of expressions of appreciation and thanks. Residents and representatives had confidence that they could approach the managers and they would listen to any concerns. Cornwall Care Ltd has a corporate adult protection policy and procedure. The policy and procedure complies and is compatible with the Cornwall MultiAgency Adult Protection Code of Practice. Staff receive training in adult protection following their induction and as part of their NVQ level 2. Cornwall Care also provides staff with refresher training in safeguarding vulnerable adults. The home had a copy of the Cornwall Multi-Agency Adult Protection Guidance and the Alerters’ Guidance. Trewartha House DS0000009134.V347184.R01.S.doc Version 5.2 Page 17 Trewartha House DS0000009134.V347184.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: Trewartha is situated in a residential area of Carbis Bay in its own grounds. The main entrance is accessible for wheelchair users. The residents’ accommodation is on one level. One area of the building has further floors used as offices, training room and a sleeping-in room for duty managers. The entrance hall leads to a central activity and sitting area. The four wings are arranged in two pairs, each pair with their own dining and sitting areas. Trewartha House DS0000009134.V347184.R01.S.doc Version 5.2 Page 19 Cornwall Care Ltd continues to maintain and refurbish the home’s décor and furnishings. Some areas of the home are in need of redecoration. The wing corridors are painted in very bright colours. The manager explained that these areas are to be redecorated using more pastel shades. This work has already commenced. The paintwork of the outside of the metal window frames is peeling and scruffy, and needs attention. This was reported in the last inspection report. Furniture is of good quality and in good condition. Residents and their representatives commented that the home is kept clean and fresh. The garden is accessed through two sets of doors. One of these is a new set of patio doors leading to an extensive paved area with garden furniture. The grounds were tidy and appeared safe. Residents reported that their rooms were comfortable and pleasant, and kept clean and hygienic. The home has two laundries. A domestic scale laundry deals with the household linen such as tablecloths. The main 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 were satisfied with the laundry service. Residents’ clothes appeared well cared for. The bathing and toileting facilities in the home comply with the standard. There are five assisted baths and one level entry shower. The toilet and bathroom doors have clear signs and suitable locks. Hot water was supplied at a safe temperature. Toilets are situated throughout the home. All the bathrooms and toilets inspected were fully tiled, 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. Equipment and adaptations were in place to assist with mobility and transfers. Trewartha House DS0000009134.V347184.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: A written roster details the deployment of staff. Generally five or six care staff are on duty during the day; the domestic staff assist with meals and drinks. There are two cooks and ancillary kitchen staff. A care coordinator is on duty during the day and on call at night. At night there are 2 waking care staff. Residents were positive about the staff’s kindness and caring qualities. Cornwall Care Ltd has standard corporate recruitment procedures including an equal opportunities policy and procedure. Posts are advertised through the Job Centre and local press. Two people interview applicants and use a recording and rating system. The records for two 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 Trewartha House DS0000009134.V347184.R01.S.doc Version 5.2 Page 21 information. The company issues staff with a statement of terms and conditions of employment. Cornwall Care Ltd provides a structured training programme for staff which covers induction, NVQ and other required training. Staff and the employer sign up to a Contract for Training and Development. Records for recently appointed staff detailed planned inductions to the Skills for Care standard. Staff had individual well maintained training records which showed that staff had completed training in moving and handling, first aid, dementia care, health and safety and other training courses. Cornwall Care Ltd ensures that all new staff are registered promptly for their NVQ training. Currently approximately 80 staff have completed their NVQ in care at level 2, with other staff working towards their qualification. The cook has a City and Guilds qualification and an NVQ level 3 qualification, and an intermediate food hygiene certificate. Staff said that access to training was good. Trewartha House DS0000009134.V347184.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, 33,34, 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 registered manager, Mrs Christine Muxlow, exceeds the experience requirement in caring for older persons and has completed her registered manager’s qualification. Mrs Muxlow has attended recent courses to update her knowledge and skills. There are lines of accountability from the manager Trewartha House DS0000009134.V347184.R01.S.doc Version 5.2 Page 23 through the deputy manager and care coordinators, who have identified areas of responsibility. Managers and staff were positive about the support and supervision that they received from the registered manager. Residents had confidence in the registered manager and felt that she would listen to and address any concerns that they might have. The registered manager does not act as agent or appointee for any resident in the collection of benefits. Cornwall Care Ltd has a corporate policy and procedure for the safekeeping of small amounts of residents’ money. The person managing the resident’s finances pays in money for the resident to spend. A standard record for each resident details the 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 to retain. The home runs a specific bank account, with a float available for daily transactions. The administrator has systems in place for reconciling the cash held, the bank account balance, and the residents’ individual recorded balances. The registered manager carries out regular checks on these records. Cornwall Care Ltd has obtained the views of residents and their representatives, and other stakeholders through questionnaires. The registered manager felt that the supervision structure with the deputy and care coordinators having an identified team of staff contributed to quality assurance. There are regular management team meetings and training days. The manager has found that discussions with small groups of residents are effective in gaining their views. There are regular staff meetings. The maintenance person carries out regular planned checks of the building and facilities. The records showed that staff receive regular supervision. Staff reported that informal and formal supervision supported them to do their jobs well and they had confidence in the management. Staff felt that the home provided a high quality of care and they worked well as a team to achieve this. 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. The accident record for residents was inspected. This does not record a high level of incidents. The records showed regular tests of the fire alarm system and the emergency lighting. The fire procedure is displayed at strategic points in the home. The home’s fire risk assessment has been completed. There are records of regular fire drills and fire safety training for staff. Trewartha House DS0000009134.V347184.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 3 3 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 3 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 Trewartha House DS0000009134.V347184.R01.S.doc Version 5.2 Page 25 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. Refer to Standard OP19 Good Practice Recommendations The registered person should review the condition of the metal-framed windows and plan for their redecoration. Trewartha House DS0000009134.V347184.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 Trewartha House DS0000009134.V347184.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. 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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