Inspection on 01/12/05 for Priory Manor [formerly Trebursye Manor]

This inspection was carried out on 1st December 2005.

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

Priory Manor [formerly Trebursye... 24/02/09

Priory Manor [formerly Trebursye... 02/04/08

Priory Manor [formerly Trebursye... 25/07/07

Priory Manor [formerly Trebursye... 10/01/07

Priory Manor [formerly Trebursye... 04/07/06

Priory Manor [formerly Trebursye... 27/06/05

Priory Manor [formerly Trebursye... 12/10/04

Priory Manor [formerly Trebursye... 07/06/04

Priory Manor [formerly Trebursye... 01/10/03

Priory Manor [formerly Trebursye... 26/06/03

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

CARE HOMES FOR OLDER PEOPLE Trebursye Manor Trebursye Launceston Cornwall PL15 7ES Lead Inspector Philippa Cutting Unannounced Inspection 1st December 2005 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 Trebursye Manor DS0000044111.V254319.R01.S.doc Version 5.0 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. Trebursye Manor DS0000044111.V254319.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Trebursye Manor Address Trebursye Launceston Cornwall PL15 7ES 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) 01566 774752 0207 5159993 HealthCare Trust Limited Mr Robert Edward Rotchell Care Home 54 Category(ies) of Dementia - over 65 years of age (29), Mental registration, with number Disorder, excluding learning disability or of places dementia - over 65 years of age (29), Old age, not falling within any other category (29) Trebursye Manor DS0000044111.V254319.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 4. Service users in the category of MD may be admitted at age 55 years and over. Service users to include one named individual under the age of 55 years. Service users to include one named individual aged 53 years from 1 November to 15 November 2004, suffering from a mental disorder. Total number of service users not to exceed a maximum of 54. Date of last inspection 27th June 2005 Brief Description of the Service: Trebursye is an older property situtated in a rural landscape approximately five miles from Launceston. Over the years the main house and annexe have been adapted and extended. The present owners are undertaking further necessary renovations to improve the structure and facilites offerred. Trebursye is now specialisng in caring for people with mental health difficulties and provides care and accommodation for three groups of people. It has created three separate units with in the building. These are for older people with dementia; people over the age of 55 years with mental health problems and older people not falling within any other category. Trebursye Manor DS0000044111.V254319.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection that took place between 9.45am and 4.45 pm. The time was spent looking at service users’ files and notes, an inspection of the premises, discussion with staff and service users. The home has improved considerably over the last two years under the direction of the present registered manager and now presents as an environment that has a focus specialising in mental health. The Commission had concerns that whilst the improvement was due to the skills of the registered manager and his knowledge of mental health issues, it had become too dependent on this, leaving a potential void if he were to be away. The home has now appointed a deputy to the registered manager who is also experienced in the field of mental health. She was present during this inspection, the registered manager being on leave. Staff with whom the inspector spoke appeared to be working together as a team. Some are employed in designated areas whilst others work in various parts of the home. There is some more thought needed for night staffing as the building is a difficult one to cover due to its layout. What the service does well: What has improved since the last inspection? Staff morale has improved and recruitment has stabilised. Care plans for service users are more detailed in identifying problems and goals. They are being regularly reviewed with good daily recording. Trebursye Manor DS0000044111.V254319.R01.S.doc Version 5.0 Page 6 What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Trebursye Manor DS0000044111.V254319.R01.S.doc Version 5.0 Page 7 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 Trebursye Manor DS0000044111.V254319.R01.S.doc Version 5.0 Page 8 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): 1,2,3,4,5 Information is gathered on prospective service users prior to offering them accommodation and details of the services provided by the home is available. Contracts for service users are in place. EVIDENCE: The home’s statement of purpose & service users guide is available but it was not possible to determine from service users whether they had read these documents or whether they had viewed the home prior to moving in. They were either too frail to be able to comment or were disinclined to do so. All prospective service users are visited by the registered manager to assess their needs, in order to ascertain if Trebursye can meet these. A random selection of service users’ records was sampled and contracts from the purchasers were seen to be in place. One of the files sampled had additional funding agreed. It was not entirely clear from the contract what services were to be provide for this. The deputy manager undertook to look into it to ensure that the home was delivering what it had undertaken. Trebursye Manor DS0000044111.V254319.R01.S.doc Version 5.0 Page 9 The home has established contacts with various external agencies who help provide specialist help when the need is identified. This ranges from community nurse support to psychiatric input. The staff in the home are receiving regular training on topics of relevance to their roles so that they can meet the service users’ needs or identify when extra help is needed. Trebursye Manor DS0000044111.V254319.R01.S.doc Version 5.0 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): 7,8,9,10 Service users’ care needs are set out clearly with strategies in place to meet them. Staff have received training to promote the correct administration of medication. EVIDENCE: Care plans are in place for all service users, set out in individual files with problems and goals identified. There has been a marked improvement in these with a consistent format, which is regularly reviewed, being established. A sample of care plans noted good examples of recording and new problems added to the care plan. Staff who are responsible for administering medication have been on courses to promote awareness and safe handling. Medication administration record sheets were seen to be fully completed. Audits for controlled drugs (CDs) have been undertaken and were clearly recorded. CDs were signed and witnessed correctly in the CD register, numbers tallied. Staff promote dignity amongst the service users, sometimes having to intervene to ensure this where peoples’ own awareness has become Trebursye Manor DS0000044111.V254319.R01.S.doc Version 5.0 Page 11 compromised. Some service users were seen to be wearing what appeared to be insufficient clothing – especially footwear – given the temperature. When asked, staff said that this was the service users’ choice. They had suggested socks etc would be appropriate but the suggestion had been rejected. Staff had observed that the same service users did put on additional clothing sometimes, so they therefore respected the decisions that people made for themselves if advice was ignored. Trebursye Manor DS0000044111.V254319.R01.S.doc Version 5.0 Page 12 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 Opportunities for service users to pursue social activities and family contacts are provided and encouraged but the take up is variable according to peoples’ wishes and preferences. EVIDENCE: The three groups of service user vary considerably in age, expectation and ability; therefore social contact and activities have to vary accordingly. The home is actively seeking to recruit an activities organiser to plan and oversee this role. With the older group in Lakeside staff are involved in providing stimulation and activity. Where concentration spans are limited this can involve one:one activity as well as group sessions. Staff encourage people to go out, weather permitting, for short walks in the grounds. Opportunities are provided for the younger service users but the response can be less enthusiastic as many prefer their own company or spend much of their day in the smoking room. Visits into the local town are arranged on a regular basis for those who wish to go; one such had been arranged on the day of this inspection. Trebursye Manor DS0000044111.V254319.R01.S.doc Version 5.0 Page 13 Everyone is invited and encouraged to attend the periodic outside entertainment that is arranged. Families and friends are welcomed and help can be given to maintain any previous community contacts etc. Service users are encouraged to make their own arrangements with families or a trusted person to manage their finances but where this is not possible the home will hold monies for service users and has set up individual bank accounts for them where needed. Trebursye Manor DS0000044111.V254319.R01.S.doc Version 5.0 Page 14 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): 16,17,18 Service users’ well being is taken seriously. Complaints are investigated and staff awareness of abuse issues was in evidence. EVIDENCE: The complaints procedure is readily available throughout the home although some service users are unlikely to be able to read or initiate it if they had a problem. For some any concerns would be displayed through their body language or behaviour. The Commission for Social Care Inspection has been involved in one complaint and one protection of vulnerable adults (PoVA) meeting since the last inspection. Staff have had, and are receiving, on going training with regard to PoVA. Information regarding the action that should be taken should any abuse be suspected is displayed clearly at several points in the home. Documents concerning peoples’ access to postal votes etc. were seen in files. Trebursye Manor DS0000044111.V254319.R01.S.doc Version 5.0 Page 15 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): 19,20,21,22,23,24,25,26 The service users who chose to comment said they were satisfied with their accommodation. There is sufficient space in all units for people to associate with others or remain on their own as they wish. An area in the older part of the house needs to be checked for structural safety. EVIDENCE: All parts of the home were inspected. The units are fitted with keypads for security and to divide the annexe (Trelawney & Lansye) into distinct areas. The walls and carpets are colour coded for increased orientation. LAKESIDE – Unit for elderly frail with dementia – 25 beds. The premises were seen to be clean and warm although there was a slight smell permeating the ground floor. The stairs are not now used regularly by staff or service users; they have been fitted with locks approved by the fire department, to be used in an emergency. Trebursye Manor DS0000044111.V254319.R01.S.doc Version 5.0 Page 16 The access to the first and second floors is via the lift. Staff told the inspector that the Fire Safety Officer had approved this. Rooms contained personal mementoes and pictures and were generally well presented. The service users are encouraged to spend their days downstairs in the communal areas. Half the chairs in the sitting room were arranged in rows; staff said that they frequently moved them in small ‘friendly’ groups but one service user liked to rearrange them uniformly. As the other service users did not appear to object, this was not made into an issue. It was noted in one room, identified to the deputy manager, that there was a gap between the walls and floorboards. Given the past structural defects in the main house, this should be checked out. There are also a number of old metal window frames left in some rooms that are difficult to open and shut properly. These should be assessed for replacement in the refurbishing schedule for the building. It was noted that one room does not have an opening window although, due its poor fit, air could be felt coming into the room. Ventaxias need to be included in the cleaning schedule as a build up of fluff can create a fire hazard. The use of colour on the upper floors should be considered in order to help the service users find their way around. At present the walls and doors are all white. There are notices directing people to the lift and toilets etc but these could be bolder or toilet doors could be painted a distinguishing colour etc. There is sufficient space in the communal areas for people to be able to wander between rooms as they wish or have a choice of where to sit. At present there is no easily accessible garden area for service users unless they are accompanied by staff. The inspector was told that a project to create a safe space is in hand and will be finished by in time for next summer. TRELAWNEY – unit for older people -10 beds. The sitting room & dining room were redecorated recently and still look in good order. There are facilities for people to make themselves tea or coffee if they wish; all those within the unit who wish to do so are felt to be able to undertake this safely at present. Rooms were satisfactory and contained varying amounts of personal possessions according to the service users’ wishes. Two rooms in this unit are away from the main area and involve going up stairs or passing the ‘wash up’ area. The current service users are able to manage this but future occupants would have to be assessed carefully. Five service users had opted to stay in their rooms for the day and those who wished to speak to the inspector said that they were well cared for and content. Trebursye Manor DS0000044111.V254319.R01.S.doc Version 5.0 Page 17 LANSYE - unit for people with mental health problems -18 beds - includes a number of younger, more mobile people. The accommodation is generally satisfactory. There have been difficulties in one room that the home has had to address. A smoking room has been made for the service users. It appeared to be well used and efforts are made to prevent the smell of cigarette smoke permeating the rest of the unit. The service users were disinclined to converse with the inspector on this occasion. It was noted later when checking records that there is problem with the fire alarms being set off by a service user. LAUNDRY The laundry area has been made safer by the erection of a partition and door to prevent service user access, as the laundry stairs are very steep and potentially hazardous. The registered manager needs to consider how anyone working in the laundry would attract attention if he or she had accident/needed help and was unable to leave the room. The floor looked as though it needed a thorough clean as there was fluff and dirt around the edges. One of the machines had a broken switch and the way this machine was being turned on, as described, did not sound safe. The problem of clothes being returned to the wrong service user seems to have been overcome. A spot check of service users’ clothes showed that they were named and in the correct cupboards and drawers. The grounds surrounding the home are extensive. They have been partially redeveloped which has resulted in the lower part leading to the stream and ponds becoming wild. This area has been fenced off. The driveway to the home is trimmed and gives a positive first impression. Trebursye Manor DS0000044111.V254319.R01.S.doc Version 5.0 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): 27,28,29,30 The on going staff training programme is promoting knowledge and awareness. The recruitment process is satisfactory, recruitment appears to have stabilised in recent months. EVIDENCE: A sample of staff files were inspected. These are maintained securely in individual files that were seen to contain the necessary information including written references and Criminal Records Bureau checks. A training matrix is displayed showing the topics and sessions available. Staff are expected to be active participants in the training programmes. Those staff with whom the inspector spoke, especially those in Lakeside, were very positive about the programme. The night staffing in the home needs more thought as the layout of the home means that if there are four people on duty and something occurs that needs the intervention of two staff, people have to be prepared to cover all units. Also break times must be taken separately to maintain minimum cover at all times. Trebursye Manor DS0000044111.V254319.R01.S.doc Version 5.0 Page 19 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): 31,32,33,34,36,37,38 The registered manager has a clear view of the service that he wishes the home to offer. He has made big improvements in all aspects of the organisation. He is experienced and competent but needs to ensure that his specialist knowledge does not cause the home to offer accommodation to people whose needs are too demanding or are outside the home’s registration. EVIDENCE: The registered manager was absent at the time of this inspection. He is a qualified nurse with considerable experience in a care setting. Discussions have been held with him about his level of expertise & knowledge, as it is this that has enabled the home to accept the current group of service users with mental health problems, especially those in Lansye. There were concerns that the home would become too reliant on the registered manager. It is therefore helpful to find that a deputy has been appointed. Trebursye Manor DS0000044111.V254319.R01.S.doc Version 5.0 Page 20 Under the present registered manager Treburyse Manor has ceased to be a failing home. Staff morale has improved and a stable workforce, that includes non-UK nationals, is being established. However, the inspector noted that there are four service users in the home who are outside the age limits of the registration and only one of them has been agreed with the Commission. This is not satisfactory. A questionnaire relating to the quality of services offered at Trebursye was seen. It was not clear whether this had taken place or was about to be distributed to service users and relatives but it will form part of the home’s quality assurance audit. Service users’ money is managed for those who need help - see comments in section on Daily Life & Social Activities. Staff said they were receiving supervision and several commented that they found the opportunity to discuss matters helpful. The records required by statute are maintained. The registered manager needs to ensure that all matters that can affect the health & welfare of a service user are forwarded to the Commission for Social Care Inspection under Regulation 37. Following a review of records, the inspector felt there were situations covered by regulation 37 that should have been notified. Health & safety audits have been undertaken by an external consultant. Trebursye Manor DS0000044111.V254319.R01.S.doc Version 5.0 Page 21 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 3 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 X COMPLAINTS AND PROTECTION Standard No Score 16 3 17 3 18 3 2 3 3 3 3 3 3 2 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 X X 3 2 3 Trebursye Manor DS0000044111.V254319.R01.S.doc Version 5.0 Page 22 Are there any outstanding requirements from the last inspection? no STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP1 Regulation 4 (1)(c) Schedule 1 Requirement Service users under the age specified on the registration certificate may not be admitted to the home unless prior permission has been agreed with the Commission for Social Care Inspection. The registered manager must advise the Commission for Social Care Inspection of anyone currently falling into this category and provide details of their needs so that their continued placement can be considered. The structural safety of the main house must checked in the vicinity of room 20 The registered manager must inform the Commission of all events that affect the health & welfare of a service user. Timescale for action 12/12/05 2 3 OP19 OP37 23(2)(b) 37 01/01/06 01/01/06 Trebursye Manor DS0000044111.V254319.R01.S.doc Version 5.0 Page 23 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 2 3 4 5 6 Refer to Standard OP19 OP23 OP25 OP26 OP26 OP26 Good Practice Recommendations The use of colour on the first and second floor of Lakeside should be considered. Ventaxias should be cleaned regularly to prevent a build up of fluff. A programme to replace old metal windows in the main house should be included as part of the refurbishment programme Cleanliness in the laundry – the floor in particular – should be reviewed The safety of washing machine controls must be checked. A means of summoning help in the laundry should be considered. Trebursye Manor DS0000044111.V254319.R01.S.doc Version 5.0 Page 24 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 Trebursye Manor DS0000044111.V254319.R01.S.doc Version 5.0 Page 25 - 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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