Inspection on 10/01/07 for Priory Manor [formerly Trebursye Manor]

This inspection was carried out on 10th January 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. 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 found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

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... 04/07/06

Priory Manor [formerly Trebursye... 01/12/05

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 Antonia Reynolds Unannounced Inspection 10th January 2007 1:45pm 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.V321151.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. Trebursye Manor DS0000044111.V321151.R01.S.doc Version 5.2 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 01566 775559 www.healthcare-trust.com 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.V321151.R01.S.doc Version 5.2 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 three named individuals under the age of 55 years in Lansye. Service users to include one named individual under the age of 65 years in Lakeside. Total number of service users not to exceed a maximum of 54 Date of last inspection 4th July 2006 Brief Description of the Service: Trebursye Manor is a care home providing personal care and accommodation for fifty four people, over the age of 55, who may have dementia or mental health needs. The home does not provide intermediate care. The home is privately owned by Healthcare Trust Ltd, and the directors also own other care homes in the South West of England. The fee levels are between £370 and £750 per week but vary depending on the individual needs of service users. Information about the home and copies of inspection reports can be obtained from the Registered Manager, Robert Rotchell. Trebursye Manor has been a care home for many years and was purchased by the present owners in 2003. It is in a rural area approximately two miles from the centre of Launceston. It consists of a large detached three-storey building, with a connecting two-storey annex, separated into three units – Lakeside, Lansye and Trelawney - with twenty-six, eighteen and ten service users respectively. The home stands in its own grounds and is approached by a long drive off a side road from the main A30. The only public transport is taxis, therefore the home has its own car for service users. The bedrooms are on each floor with a shaft lift in the main house (Lakeside). Fifty bedrooms are single and two are double, many of which have en suite toilets with some having en suite baths/showers. Bathing/showering and toilet facilities are available on each floor, close to bedrooms and communal rooms. Each unit has lounge and dining rooms on the ground floor and Lakeside has an additional lounge room on the 1st floor. Lansye and Trelawney have separate smoking rooms for service users. The home has a call bell system installed throughout most of the home. Trebursye Manor DS0000044111.V321151.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This key inspection consisted of three unannounced visits between 1.45pm and 5.20pm on Wednesday, 10th January 2007, 2.15pm and 4pm on Friday, 12th January 2007, 6.15am and 11.30am on Tuesday, 30th January 2007; and an announced visit between 10.05am and 5.50pm on Wednesday, 17th January 2007. Colin Lloyd, Regulation Manager from the Commission for Social Care Inspection, was also present for part of the visit on the 30th January 2007. The Registered Manager, Robert Rotchell, was present and available for consultation throughout each visit. A tour of the premises took place and records/documents relating to the care of the service users, staff and the home were inspected. A pre-inspection questionnaire had been completed by the Registered Manager, which contained information relevant to the inspection. Most of the service users were observed during the visits and thirteen service users were spoken with at length. Survey forms were sent to twenty-two relatives and twelve were returned. Twelve staff members were spoken with during the visits and others were observed in the course of their normal duties. Survey forms were sent to ten staff members and three were returned. Survey forms were sent to six health and social care professionals and three were returned. Verbal information had been received from a health care professional prior to the first visit. What the service does well: What has improved since the last inspection? The parts of the environment that were of particular concern at the last inspection have been repaired. Rotting fire doors, windows and a floor in an en suite toilet have been replaced. Repairs to the dishwashing room have Trebursye Manor DS0000044111.V321151.R01.S.doc Version 5.2 Page 6 been carried out. A new heated trolley for transporting food from the kitchen to the dining rooms has been purchased. The renovation of Lakeside has started and all the new radiators have low temperature surfaces to reduce the risk of burning. The home has employed a gardener so there has been some improvement in the state of the grounds. What they could do better: The home has been admitting service users who are not covered by their present conditions of registration, therefore service users under the age specified on the Certificate of Registration must not be admitted to the home unless this is agreed with the Commission for Social Care Inspection. The Registered Manager must apply for a variation to the conditions of registration, including details of the needs of service users, so that their continued placement can be considered. This is a breach of the Care Standards Act 2000 and is the second time this type of breach has occurred as it was also identified during the inspection conducted on 1st December 2005. Due to concerns about the state of the premises the Registered Provider needs to provide evidence to the Commission for Social Care Inspection that the property is of sound construction and being kept in a good state of repair. This is the second inspection where this requirement has been made. If fire doors need to be kept open for a particular reason, appropriate ‘hold open’ devices must be provided. The fire alarm system must be checked to make sure it is working properly and the broken call points repaired. Coded locks that prevent service users from leaving the building must be connected to the fire alarm system so that they are released should a fire occur. Where fire doors are fitted with bolt locks that require a key to open them, the keys must be replaced at a height that they can be reached, or alternative locking devices installed that can easily be opened/released should a fire occur. Records must be kept of the checking/testing of call points, fire extinguishers and fire blankets to ensure that they are in the correct position and not been tampered with. Where service users smoke in bedrooms, precautions must be taken to reduce the risk of fire, such as providing fire retardant furnishings, following consultation with the home’s fire safety contractor. A risk assessment must be carried out and documented to include what action has been taken. This is the second inspection where the fire precautions were found to be inadequate. All electrical items, including portable appliances, must be checked and tested to ensure they are safe. This is the second inspection where this requirement has not been met. There does not appear to be any effective co-ordination and communication between the staff team and contractors who are carrying out building work at Trebursye Manor DS0000044111.V321151.R01.S.doc Version 5.2 Page 7 the care home. This is essential to ensure the safety of the service users and staff who are having to live and work in a building site. The windows in the main house only open at the top and, in many cases, this is very high, therefore the Registered Provider needs to carry out risk assessments on the opening of windows and provide appropriate equipment so that neither service users, visitors, or staff climb on furniture to open them. There are various items in the home that need repairing, replacing or refurbishing such as a torn carpet, a broken electrical socket, en suite facilities, cracked wash hand basins and the lounge room in Lansye. All parts of the building must be kept warm enough for service users, particularly for those who are less active. The use of free standing radiators must be risk assessed to ensure that they are working properly, are not a trip hazard and will not burn service users. Locks need to be fitted to all bathroom, toilet and bedroom doors that are suited to service users’ capabilities and accessible by staff in an emergency. The locks that have been fitted to new bedroom doors in Lakeside must be reviewed to ensure that they can be unlocked from the outside should a key be left in the lock on the inside of the door. This is to ensure service users privacy and security of their belongings if they are away from the home. Coverings need to be provided on all windows, glass doors and en suite facilities to ensure that the privacy and dignity of service users is protected. External areas around the house must be kept clean and tidy, particularly those areas that are not being refurbished, such as the courtyard. The Registered Provider must provide a suitable telephone system in the home so that the staff in Lakeside do not have to leave their posts to use the telephone and so that relatives or social and health care professionals can ring in at night The Registered Provider must install a call bell system with an accessible alarm facility in every room so that service users, visitors or staff can summon assistance if needed. The premises must be kept clean, hygienic and free from offensive odours. The dust and debris in Lakeside must be kept to a minimum and the smell of urine removed. Smoking rooms, extractor fans and radiators must be cleaned and kept free from debris. Enough domestic staff need to be employed to maintain the home in a clean and hygienic state. The staffing complement in Trelawney needs to be reviewed so that staff from Lansye are not required to leave their own posts and staff have time to complete the required paperwork as well as care for the service users. Trebursye Manor DS0000044111.V321151.R01.S.doc Version 5.2 Page 8 A person designated by the company must visit the care home unannounced, at least once a month. This person must produce a written report on the conduct of the care home and supply a copy to the Registered Manager and the Commission for Social Care Inspection. This is the second time this type of requirement has been made. The previous time was at the inspection carried out on 12th October 2004. There must be an effective quality assurance system put into place to review the quality of care provided at the home. A report of the review must be sent to the Commission for Social Care Inspection and made available to service users. This is the second time this type of requirement has been made. The previous time was at the inspection carried out on 12th October 2004. If service users’ money is held in an account administered by the Company, service users and/or their relatives/representatives should be consulted and give their written permission for money to be held in this account. If requested or required service users should be assisted to make telephone calls to relatives, relatives should be informed about changes in health needs and about events/activities taking place in the home. The type of information to be shared with relatives should be agreed when a service user is admitted to the home and documented within the service user’s care plan. A record needs to be kept of all unused medication that is returned to the pharmacy so that there is a clear audit trail in the home of medication being received, administered and returned. The grounds around the home should be altered to provide level access from the care home, so that people with mobility difficulties, or those who use wheelchairs, can access at least part of the grounds. The smoking room in Lansye should have level access, so that it is easily accessible by service users with mobility difficulties. The dishwasher and hot water boiler/urn should be repaired or replaced with items suitable for the size of the care home. Servicing contracts should be considered for essential equipment such as refrigerators and freezers so that there is no delay in repairing or replacing these items. Consideration needs to be given to providing new flooring in the kitchen, as it is showing signs of wear and tear, and cracked tiles should be replaced. The quantity and choice of food provided in the home should be reviewed, as well as the catering budget, to ensure that service users are receiving a healthy, varied and nutritional diet. A suitably qualified person, for example, an occupational therapist, should carry out an assessment of the premises to ensure it is suitable for the service users who live there. Trebursye Manor DS0000044111.V321151.R01.S.doc Version 5.2 Page 9 Consideration should be given to installing a call bell system that can be used by people with dementia. A better use of pressure pads/mats connected to the call bell system should be considered, to alert staff that they need to attend to a service user, particularly if that person is prone to falls. Additional coverings should be placed between mattresses, particularly where these are covered with plastic, and sheets to provide additional comfort for service users. The large washing machine in the laundry should be repaired or replaced. Consideration should be given to purchasing a washing machine with a sluice facility. The laundry needs to be renovated or moved so that it is more accessible for staff and service users should they wish to do their own laundry. Two written references, rather than testimonials, should be obtained for all staff members, including one from the last employer, particularly if the person was employed in a caring role. There should also be confirmation in the home that Criminal Record Bureau checks have been carried out. All staff should receive training in dementia awareness and adult protection. All staff members responsible for laundry and/or cleaning should receive infection control training. A risk assessment relating to first aid training for staff should be carried out to establish which staff need to attend first aid training and at what level that should be. Night staff should complete first aid training. A qualified first aider should be on duty at all times. All staff who prepare food for service users should complete training in food hygiene. All staff should receive manual handling training in relation to the moving and handling of service users and carrying heavy loads. This training would enable staff to carry out their role more effectively and protect the health and safety of service users. The Registered Manager needs to provide documentary evidence of his qualification in management to the Commission for Social Care Inspection. Advice was given to: - ensure that the staff are clear about what action to take regarding an adult protection issue, should a member of the organisation’s management team not be available for advice - the Registered Manager to document any interviews carried out with staff in relation to criminal convictions. Trebursye Manor DS0000044111.V321151.R01.S.doc Version 5.2 Page 10 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. Trebursye Manor DS0000044111.V321151.R01.S.doc Version 5.2 Page 11 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.V321151.R01.S.doc Version 5.2 Page 12 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): Standards 3, 4 and 5 Quality in this outcome area is good. The home’s admissions procedure ensures that prospective service users and their relatives/representatives know that the home will meet their needs. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The pre-admission assessment process ensures that the needs of prospective service users are identified. Service users and their relatives/representatives are welcome to visit the home prior to admission to have a look around the home and meet service users and staff. Service users also have opportunities for extended trial periods if this is required to enable them to settle into a new environment. Discussions with service users, staff and the management team, as well as observation, show that staff are aware of the needs of the service users. The home does not provide intermediate care. Trebursye Manor DS0000044111.V321151.R01.S.doc Version 5.2 Page 13 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 7, 8, 9, 10 and 11 Quality in this outcome area is good. Service users can be confident that they will be treated with respect and that personal and health care needs will be met. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Service users said that they are very well looked after by staff and staff were observed treating all the service users with kindness, consideration and respect. It was observed that staff addressed service users by their preferred name, and were also heard to call people ‘sweetheart’ or ‘darling’, but this did not appear to give offence and the service users responded positively. Three service users’ files were inspected and these contained care plans and risk assessments relating to health and personal care needs that are regularly reviewed. Feedback from health care professionals confirmed that they are invited to multi-disciplinary reviews by the Registered Manager or care staff, where a concern has been raised about an individual’s care. For safety Trebursye Manor DS0000044111.V321151.R01.S.doc Version 5.2 Page 14 reasons, most service users are not allowed to hold their own cigarette lighters and/or matches and smoking is only permitted in specified areas. Discussion with service users, staff and the Registered Manager, as well as observation, confirmed that personal care is maintained, service users can bathe/shower when they choose to and are encouraged to be as independent as possible. Information contained in care plans, written feedback from health care professionals, discussions with service users and District Nurses, as well as observation showed that service users have access to health care services such as doctors, district nurses, opticians, chiropodists, dentists and the mental health team. District Nurses visit the home twice a day although they have not been able to use the home’s treatment room recently due to the refurbishment that is taking place. Discussions with service users and feedback from health care professionals confirmed that referrals are made to other relevant professionals when required. Privacy is respected and staff were observed knocking on doors before entering private rooms. The home has two pay ‘phones for service users but, if they wish to make a private telephone call, they may use the office ‘phone, for which no financial charge is levied. Service users may also have private telephones installed in their bedrooms at their own expense. As part of the refurbishment programme, all bedrooms will have telephone points. Written feedback from health care professionals said that care staff give medication to service users in a respectful way and are aware of the rights of service users to refuse medication. Should this occur staff keep records and contact the relevant health care professional for advice. Medication is stored securely and a monitored dosage system is used for the majority of medicines. Controlled drugs are stored appropriately and records kept. Staff confirmed that the home has a refrigerator specifically for storing medicines that need to be kept at low temperatures. A staff member demonstrated the procedures for administering medication and all medication received or returned to the pharmacist is recorded. At the time of inspection unused tablets were stored in a bottle (in Lakeside) to return to the pharmacist and there were no records of what medication the bottle contained. The senior staff member on duty and the Registered Manager agreed that this would be changed immediately and all medication returned to the pharmacist would be documented. This is to ensure that there is a clear audit trail in the home of medication being received, administered and returned. Service users with terminal illnesses can remain in the home as long as their needs can be met by the staff and the community health team, and service users’ wishes were documented. Trebursye Manor DS0000044111.V321151.R01.S.doc Version 5.2 Page 15 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 12, 13, 14 and 15 Quality in this outcome area is good. The routines in the home are relaxed, relatives and friends can be confident that they are welcomed and social activities are arranged. Dietary needs of service users are catered for with a balanced and varied selection of food that meets service users’ tastes and choices. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Discussions with service users, staff and the Registered Manager, as well as pre inspection documentation, confirmed that various activities take place for service users, either individually or in groups. These include trips out to the pub, garden centres or for personal shopping. Service users can go for walks in the grounds but this is impractical for those people with mobility difficulties, or who use wheelchairs, as the ground is either gravelled or rough. The home has visits from external entertainers such as local musicians and in-house activities include arts and crafts, board games, bingo and horticulture. Special activities are arranged where requested, for example, horse riding, swimming and yoga. The home employs a staff member with specific responsibility for co-ordinating and arranging various activities. Feedback from relatives and Trebursye Manor DS0000044111.V321151.R01.S.doc Version 5.2 Page 16 the staff confirmed that visitors are actively welcomed into the home and may visit whenever they like. However three relatives said that they would appreciate better communication from the home such as helping service users to make telephone calls, being informed of changes in health needs and about what is happening in the home, for example, by a quarterly newsletter sent out to relatives. The home owns a car to transport service users to appointments and social events if required but service users are also encouraged to use public transport if they are able to. Meals are prepared in the home’s main kitchen, transported around the home using a heated trolley and served in the three dining rooms. Service users said that they liked the food provided in the home and can choose what they want. Personal preferences and special diets are known and catered for, with records kept of meals provided. A discussion took place with the Cook and Registered Manager about the potential usefulness of recording which vegetables are served each day, so that detailed nutritional information is available should this be needed. Written feedback from staff indicated that the quantity and choice of food has reduced over the last few years, which they attribute to a low catering budget. Meal timings are flexible and both service users and staff said they are able to enjoy their meals in an unrushed and sociable atmosphere. There are limited opportunities for service users to use the home’s kitchen due to health and safety reasons, therefore facilities are provided in each of the units, where service users can prepare their own drinks and snacks if they are able to. Trebursye Manor DS0000044111.V321151.R01.S.doc Version 5.2 Page 17 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 16 and 18 Quality in this outcome area is good. Service users can be confident that any concerns or complaints will be listened to and addressed. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home has a written complaints procedure, that is also available in large print, and service users know how, and to whom, to make a complaint should they need to. Service users said that they had confidence in the Registered Manager and staff team to resolve any issues as soon as they arise. However, service users also said they have no complaints about the home or the care they receive. Some staff members spoken with said that all staff are expected to attend training related to the protection of vulnerable adults, however written feedback from staff indicated that there are some staff who have not completed this training. The home has an adult protection procedure to follow if necessary and staff are aware of this. A discussion took place with the Registered Manager about ways of ensuring that staff are clear about what action to take, should a member of the organisation’s management team not be available for advice. There is a visitor’s book in the front hallway to record dates, times and names of all visitors to the home. Trebursye Manor DS0000044111.V321151.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 19, 20, 21, 22, 23, 24, 25 and 26 Quality in this outcome area is poor. The home is undergoing extensive refurbishment due to its state of disrepair but there are many areas that are not being maintained properly. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Due to the poor state of the premises identified at the last inspection, the Registered Provider was required to produce evidence, by the 31st August 2006, that the property was of sound construction and kept in a good state of repair. This evidence has not been forthcoming. The parts of the environment that were of particular concern at the last inspection have been repaired. Rotting fire doors, windows and a floor in an en suite toilet have been replaced. Repairs to the dishwashing room have been carried out. A new heated trolley for transporting food from the kitchen to the dining rooms has been purchased. Trebursye Manor DS0000044111.V321151.R01.S.doc Version 5.2 Page 19 The Registered Manager confirmed that there are plans to renovate the entire property and this has started in the main house, Lakeside. However, discussions with the Registered Manager and staff indicated that there is no co-ordination or effective communication with the contractors who are carrying out the building works. This is vital to ensure the safety of the service users and staff who are having to live and work in a building site. When the renovation is complete, the standard of accommodation should be much improved including new plumbing, electrical wiring and radiators with low temperature surfaces. However, there are some aspects of the refurbishment that need to be considered more carefully. These include the new double glazed windows that can only open at the top and, in many cases, these windows are very high. Therefore neither service users nor staff would be able to open them without having to climb on something to do this, and accidents may occur. The Registered Provider needs to carry out risk assessments and provide any necessary equipment to ensure that the safety of service users and staff is not compromised. Locks that have been fitted to the new bedroom doors in Lakeside lock with a key from both inside and outside, therefore may not be accessible by staff in an emergency, should the key be left in the lock on the inside. The communal rooms consist of a large lounge room in Lakeside that is almost completely refurbished and what has been done so far looks very good. There is a smaller lounge on the 1st floor which is unuseable at present due to the building works. There is a dining room on the ground floor. Each of the other units, Trelawney and Lansye, have separate lounge and dining rooms and Lansye and Trelawney have smoking rooms for service users. The lounge room in Lansye looked institutionalised as it was rather bare with strip lighting, although service users’ artwork was on display on the walls. Whilst most of the care home was clean, there were areas in Lakeside that smelt of urine, the stairs were covered in debris and dust from the builders and it was difficult for kitchen staff to keep catering items and equipment clean and free from dust. Whilst recognising that, with the amount of building work going on, there is likely to be dust and debris around, more efforts need to be made to keep dust and debris to a minimum. There were also other areas that needed cleaning, most notably the smoking rooms in Lansye and Trelawney and the courtyard accessible via the smoking room in Lansye. All the radiators were guarded but some of these needed to be cleaned and debris/rubbish removed from the top of them. At the time of inspection the radiators in the lounge and dining rooms in Lansye were not very hot and the rooms were rather cool. A free standing heater had been placed in the lounge room in Trelawney indicating that the room was not warm enough. Extractor fans in en suite facilities and smoking rooms were dirty and need to be cleaned. A pair of double doors in Lansye were dirty and this was pointed Trebursye Manor DS0000044111.V321151.R01.S.doc Version 5.2 Page 20 out to the Registered Manager on the first day of inspection but had still not been cleaned by the last day of inspection. There was also a broken electrical socket near the floor beside these doors, which had been taped over by the last day of inspection but not repaired/replaced. The smoking room in Lansye has a ridge with a sliding door and this ridge creates a trip hazard, particularly for people with mobility problems. The carpet on the stairs to rooms 39 and 40 is torn, or worn through, and needs replacing. Each service user has a single bedroom, although there are two double rooms available should service users wish to share. All the bedrooms contain wash hand basins and many have en suite toilets and some also have en suite baths/showers. En suite facilities inspected in Lansye/Trelawney are in need of refurbishment and redecoration, including replacement of cracked wash hand basins. The bedrooms are located on every floor of the building and there is a shaft lift between the floors in Lakeside. There is a small flat, consisting of a lounge/kitchen, bedroom and bathroom on the 1st floor of Trelawney presently accessible by a stair lift. Bedrooms are individually furnished and contain many personal possessions. The Registered Manager confirmed that, wherever possible, service users choose the colour of their bedrooms and the colour of communal rooms. The bedrooms are all personalised by or for the service users, depending on their wishes. The type and quantity of furniture varies dependant on the wishes and needs of service users. Bedrooms did not have appropriate locks fitted and this needs to be addressed. All bedrooms must be fitted with a lock that can be locked from the inside to ensure the privacy of the service user and from the outside with an individual key to ensure the security of the service user’s personal belongings. All of these locks should be supported by a single master key to enable ease of access in an emergency or there should be a logical system of finding the right key quickly. Some locks have been fitted to new bedroom doors in Lakeside but these are lockable both from the inside and outside with a key. This needs to be reviewed to ensure that they can be unlocked from the outside should a key be left in the lock on the inside of the door. Three bedrooms have glass paned doors and windows opening onto a corridor. Two of these had curtains but, if the curtains are open, anyone can see into the rooms. One room did not have any coverings on these windows. An en suite toilet on the ground floor had windows to the outside of the building and, whilst the window panes were frosted glass, there was no other covering to protect the privacy of the service user, which is particularly important at night when the light is on. One bedroom in Lakeside was not very warm and the service user said she was cold. A staff member had provided a free standing heater but it did not work and was unstable as it had a foot missing. This was reported to the Registered Manager. Whilst service users are actively discouraged from smoking in bedrooms, at least one service user continues to do so. A discussion took place with the Registered Manager about making sure that this person’s bedroom is made as safe as possible, such as providing fire Trebursye Manor DS0000044111.V321151.R01.S.doc Version 5.2 Page 21 retardant furnishings, following consultation with the home’s fire safety contractor. Some mattresses were found to be in need of replacing but the Registered Manager confirmed that beds and mattresses are being replaced as part of the refurbishment. Some mattresses had plastic covers and there were no additional coverings between the mattresses and the sheet, which would provide additional comfort for service users. Some bathroom and toilet doors were not fitted with locks of any kind. All toilet and bathroom doors must be fitted with suitable locks that give service users’ privacy but are accessible by staff from the outside in an emergency. The kitchen was clean with stainless steel fittings but the floor is showing signs of wear and tear and consideration should be given to providing new flooring, as well as repairing any cracked tiles. Whilst the dishwashing room has been renovated, the staff said that the dishwasher has not been working for some months, so all washing up is being done by hand. Also, the hot water boiler/urn has not been working for some time, which means the staff have to use domestic kettles to make hot drinks. This is time consuming for kitchen staff making hot drinks for the number of people who require them. The issue of summoning help from the laundry was discussed, as there has been no action despite this being raised in reports on previous occasions. This is particularly important at night as there are few staff on duty and they are expected to go to the laundry to collect washing. The laundry is accessed via a steep, narrow flight of stairs and could be hazardous for staff, particularly when carrying laundry. The home has a large washing machine but this was out of order on the day of inspection (17th January), therefore the staff were using a smaller domestic type machine, which had a broken door handle and staff were using a knife to open it. There was no sluice facility in the laundry room, apart from an old toilet. The staff member responsible for laundry said she did not use this, which is probably advisable due to the potential risk of airborne infection. There were also two tumble dryers that were working. Infection control was discussed with the staff member responsible for laundry, who did know what to do, but had not received any formal training. Whilst there are some aids and adaptations, such as pressure mattresses, sliding sheets, hoists, grab rails and a shaft lift, more thought needs to be given to meeting the needs of service users with dementia and those at risk of falls. A discussion took place with the Registered Manager about using more items, such as pressure pads/mats, to alert staff when a service user gets out of bed, particularly when it is known that this person has sustained falls in the past. Also, whilst there is a call bell system in the home, this is not always used by service users with dementia as it relies on service users having to request assistance when needed, which they may not be able to do because of their dementia. The call bell system is not present in every room, for example, Trebursye Manor DS0000044111.V321151.R01.S.doc Version 5.2 Page 22 the lounge and dining rooms in Trelawney, although discussion with staff indicated that the rooms used to have call bells until they were redecorated. The home has a main telephone number and, when this is rung during the day, is usually answered by office staff. At night this number is connected to Lansye and Trelawney offices but not to Lakeside. In Lakeside the only available telephone for staff to use is a pay ‘phone, therefore they can make calls to the emergency services. However, if they need to make any other telephone calls, for example, to a doctor or a relative, they have to leave the unit to use a telephone in one of the other units, thus leaving only one staff member on duty. Also, unless relatives and health and social care professionals/agencies are aware of the number for the pay ‘phone, they may find it very difficult to get an answer from the main telephone number at night. Discussions with the staff team indicated that Lakeside had been connected to the main telephone number but there was a problem with the connection that has never been rectified. The building stands in its own large grounds and the Registered Manager said that this will be re-organised in due course to provide horticultural activities for service users. The Registered Manager confirmed that plans for the garden will be discussed and agreed, as service users have requested a small holding to grow vegetables and would like to keep some animals, such as hens. The home has employed a gardener so there has been some improvement in the state of the grounds. At present the grounds are uneven and difficult to use for those with any kind of mobility difficulty, which also means that some service users may not have any access to sunlight. There was a great deal of rubbish lying around the outside of the home, such as building materials and beds/mattresses amongst other items. The Registered Manager said that they were waiting for a skip to be delivered but this had not materialised by the last day of inspection. The area by the storage sheds is particularly untidy and service users’ bedrooms look out towards these sheds, which is a particularly unattractive view. It was also noted that the building in which the Registered Manager and administrative staff are expected to work is in a poor condition. Toilet facilities are basic and involve negotiating a storage area. Trebursye Manor DS0000044111.V321151.R01.S.doc Version 5.2 Page 23 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 27, 28, 29 and 30 Quality in this outcome area is adequate. The management and staff team strive to provide a stimulating, safe environment where service users are respected and rights are upheld. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Observation and discussion with service users and staff confirmed that the staff team are respectful, polite, attentive and responsive to service users’ needs. One relative said that “the staff obviously care about doing a quality job and have affection for those they care for.” Another relative said “the carers do a wonderful job…” and commented on the kindness that most of the staff show to service users. Care staff are supported by catering, laundry, domestic, maintenance and administrative staff, as well as the Registered Manager and an activities co-ordinator. Discussions with service users, the staff on duty and the Registered Manager confirmed that there are usually enough care staff on duty to meet the needs of the service users. The Registered Manager and staff confirmed that staffing is flexible depending on the needs of the service users. There are usually at least three care staff on duty during the day in Lakeside, three in Lansye and one in Trelawney. Staff from Lansye cover for the staff member in Trelawney during break times, leaving Lansye with one fewer staff member. Also two of the rooms in the Trelawney unit are away from the rest of the accommodation, which means Trebursye Manor DS0000044111.V321151.R01.S.doc Version 5.2 Page 24 that the one member of staff can be away from the main body of eight service users. The staff in Trelawney said they find it difficult to complete the required paperwork as well as care for the ten service users. At night there are four waking night staff altogether, with two in Lakeside and two in Trelawney/Lansye. The staff said that most of them work twelve hour shifts and they are happy with this arrangement. The Registered Manager said that he tries to be as flexible as possible with staff hours. The staff members on duty were aware of service users’ needs and how to support them. Staff confirmed that some of them are expected to participate in various training sessions and courses including health and safety, first aid, manual handling, fire safety, food hygiene and National Vocational Qualifications (NVQs). One staff member is a qualified NVQ Assessor. However the three night staff spoken with said they have not completed either first aid or food hygiene training. Senior staff have attended training in working with older people with dementia, and it would be beneficial for all staff to attend dementia awareness training, so that they are better informed about the needs and behaviours of people with dementia. Designated staff undertake medication training and all staff are supervised on a regular basis. The Registered Manager confirmed that recruitment processes are robust in that two written references are obtained as well as a Criminal Records Bureau (CRB) check for all employees. However, six staff files were inspected and two of these did not contain the required information relating to CRB checks, although the Registered Manager confirmed they had been obtained. Also, one of them contained two testimonials, rather than references, and no reference had been obtained from the previous employer, although the staff member concerned had only worked there for a short time. The Registered Manager confirmed that new staff are supervised until all the checks are obtained and there is an induction programme which is presently under review. Advice was given to the Registered Manager to document any interviews carried out with staff in relation to criminal convictions. Due to the amount of work going on in the home, staffing levels need to be reviewed, particularly in relation to keeping the premises clean and free from offensive odours, as this is a constant job during any refurbishment of a property inhabited by service users at the same time as the refurbishment is going on. Trebursye Manor DS0000044111.V321151.R01.S.doc Version 5.2 Page 25 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 31, 32, 33, 35, 36, 37 and 38 Quality in this outcome area is poor. Inadequate fire safety precautions are placing service users at risk. The Registered Provider is not carrying out regular visits to the home and there is no effective quality assurance system in place. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The Registered Manager has several years experience of managing care services and staff. He is a qualified nurse, specialising in mental health, who has kept up his registration with the Nursing and Midwifery Council. He confirms that he has attained a Diploma in Supervisory Management and the Commission for Social Care Inspection is awaiting documentary evidence. Discussion with the Registered Manager confirmed that he is knowledgeable, Trebursye Manor DS0000044111.V321151.R01.S.doc Version 5.2 Page 26 competent, committed and dedicated to providing the best care for the service users. The staff said that the Registered Manager provides positive and clear guidance and leadership to the staff team and that they like working with him. Information provided by the Registered Manager showed that there are five service users under the age of 55 living in the home and only three have been agreed with the Commission for Social Care Inspection. This is a breach of the Care Standards Act 2000. This is the second time this type of breach has occurred as it was also identified during the inspection conducted on 1st December 2005. The Registered Manager confirmed that a variation to the conditions of registration will be applied for, including details of the needs of service users, so that their continued placement can be considered. The home’s administrator, as well as information in pre-inspection documentation, confirmed that most service users or their families/representatives manage their financial affairs. The home does manage small amounts of spending money on behalf of nine service users. The records relating to this money were up to date with two signatures against all expenditure and were regularly checked by the home’s administrator. The Registered Manager and administrator confirmed that, if the amounts of cash start to accrue, then money is sent to Head Office, where it is banked in an account set up specifically for this purpose. However, the Registered Manager did not know the details of this account or how service users’ money is managed when it leaves Trebursye Manor. The Director of the company has supplied information regarding this account to the Commission for Social Care Inspection. If service users’ money is being held in an account managed by the organisation, consultation with service users and/or their relatives/representatives should take place and written permission obtained from service users and/or their relatives/representatives. Pre-inspection documentation and discussions with the Registered Manager confirmed that safety checks have been carried out including gas appliances, hoists and the shaft lift. The Registered Manager confirmed that portable electrical appliances were in the process of being checked at the time of inspection although this had not been completed. At the last inspection the Registered Provider was required to arrange for all electrical appliances to be tested by 31st August 2006. There are no service contracts for electrical equipment such as the refrigerators and freezers and feedback from staff indicated that there are often delays in repairing or replacing essential items if they break down. All accidents and incidents are documented at the time of the event. These are monitored by the Registered Manager to establish whether any patterns emerge and to decide whether other health and social services professionals need to be involved to provide advice, guidance or assistance. Hazardous substances are locked away safely. The home had a visit from the Environmental Regulation Service on 9th January 2007 to check that the issues Trebursye Manor DS0000044111.V321151.R01.S.doc Version 5.2 Page 27 raised at the last inspection have been addressed and to look at the ongoing building work. Discussions with staff confirmed that some of them have received training in health and safety, fire safety, first aid, food hygiene and manual handling. However, the night staff spoken with said they had not completed a first aid course, care staff had not completed food hygiene courses and written feedback from staff said that some staff had not completed manual handling training. The Registered Manager confirmed that the fire service visited on 10th August 2006 and a local fire safety contractor on 11th August 2006 to check the home’s fire precautions and fire safety systems. The fire logbook confirmed that a local contractor serviced the system on 13th September 2006. However, the fire safety precautions are still not adequate. Inspection of the fire logbook indicated that the required weekly and monthly tests/checks of the fire alarm system/equipment are carried out. However the thoroughness of these checks is questionable as the following issues were found during the inspection: • Several fire doors were being held open with wedges, fire extinguishers and other items of furniture. If fire doors need to be kept open for a particular reason, appropriate ‘hold open’ devices must be provided. The Registered Provider should also consider fitting appropriate hold open devices during renovation of Lakeside so that doors are easily opened by frail, older people. The fire panel in the main house indicated a ‘system fault’ on 17th January that was attributed by staff to the presence of workmen in the building. However it still indicated a ‘system fault’ at 0620 on the morning of 30th January when there were no workmen in the building. This must be rectified to ensure the fire alarm system is working correctly. Some external and internal fire doors are fitted with coded locks that are not connected to the fire alarm system, therefore are dependent on staff being present to open them. Locks that prevent service users from leaving the building must be connected to the fire alarm system so that they are released should a fire occur. Several external fire doors are fitted with bolt locks that require a key to open them. Whilst key boxes were present, three of these did not contain a key and were at such a height that some staff and service users may not be able to reach them. The keys must be replaced at a height that they can be reached, or alternative locking devices installed that can easily be opened/released should a fire occur. The glass in one call point was broken and the glass was missing from another call point. These must be repaired or replaced. • • • • Trebursye Manor DS0000044111.V321151.R01.S.doc Version 5.2 Page 28 • • No records could be found on the 17th January relating to the checking/testing of call points and these must be kept. No records could be found on the 17th January relating to the checking of fire extinguishers and fire blankets to ensure that they are in the correct position and not been tampered with and these must be kept. All the radiators seen were guarded. The new radiators in the main house have low temperature surfaces, thereby reducing the risk of service users being burned by hot radiators. The Registered Manager confirmed that all hot water outlets accessible by service users are thermostatically controlled to ensure that hot water is kept to a temperature where service users will not be scalded. The Registered Manager confirmed that, where needed, restrictors are fitted to all windows above the ground floor and the windows inspected did have restrictors fitted. There was a broken electrical socket in Lansye on the first day of inspection and this had not been repaired by the last day, although it had been covered with tape. Discussions with staff confirmed that some of them had not completed an emergency first aid course, and none were qualified first aiders. This is of particular concern at night, where three (out of four) night staff spoken with said they had not completed any kind of first aid course. Staff in Lakeside do not have access to a telephone, other than a pay ’phone and this is a health and safety issue as they have to leave Lakeside to make and receive telephone calls, unless they are emergency calls. The Registered Manager said that the home has a quality assurance system that obtains feedback from service users, relatives and professionals from health and social care services. However, this has not yet incorporated an internal audit, which would have identified the issues raised in this report, had it been carried out. The Registered Provider was previously required to put an effective quality assurance and monitoring system in place during the inspection carried out on the 12th October 2004. These issues would also have been identified if the Registered Provider had carried out, or arranged for a representative to carry out, monthly visits, which is a legal requirement. The Commission for Social Care Inspection has not received any such reports for 2006, neither were there any available in the home. This is the second time this type of breach has occurred as it was also identified during the inspection conducted on 12th October 2004. Trebursye Manor DS0000044111.V321151.R01.S.doc Version 5.2 Page 29 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 1 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 3 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 10 3 11 3 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 1 1 2 1 2 1 1 1 STAFFING Standard No Score 27 2 28 3 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 1 X 2 3 1 1 Trebursye Manor DS0000044111.V321151.R01.S.doc Version 5.2 Page 30 Are there any outstanding requirements from the last inspection? Yes 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 OP19 Regulation 23(2)(b) Requirement Timescale for action 31/03/07 2. OP19 13(4)(a) (c) 3. OP19 13(4) The Registered Provider must provide evidence to the Commission for Social Care Inspection that the property is of sound construction and kept in a good state of repair. (Original timescale of 31st August 2006 not met). The Registered Provider must 28/02/07 arrange for effective coordination and communication between the staff team and the contractors who are carrying out the building work, to ensure the safety of the service users and staff who are having to live and work in a building site. The Registered Provider must 30/04/07 carry out risk assessments on the opening of windows and appropriate equipment must be provided to ensure neither service users, visitors, or staff climb on furniture to open them. The torn carpet on the stairs to rooms 39 and 40 must be replaced. The Registered Provider must DS0000044111.V321151.R01.S.doc 4. OP19 16(2)(a)( 30/04/07 Page 31 Trebursye Manor Version 5.2 b) 5. OP20 16(2)(c) 6. OP20 23(2)(o) 7. OP21 23(2)(d) 8. OP22 23(2)(n) 9. OP24 12(4)(a) 16(2)(c) provide a suitable telephone system in the home so that the staff in Lakeside do not have to leave their posts to use the telephone and so that relatives or social and health care professionals can ring in at night. The Registered Provider must refurbish the lounge room in Lansye to remove the institutionalised appearance and fit more suitable and attractive light fittings. The Registered Manager must ensure that external areas around the house are kept clean and tidy, particularly those areas that are not being refurbished, such as the courtyard. The Registered Provider must refurbish and redecorate en suite facilities, including replacement of cracked wash hand basins. The Registered Provider must install a call bell system, with an accessible alarm facility, in every room, so that service users, visitors or staff can summon assistance if needed. To protect the privacy and dignity of service users the Registered Provider must fit locks to all bathroom and toilet doors that are accessible by staff in an emergency. Locks must be fitted to all bedroom doors that are suitable to service users’ capabilities and accessible by staff in an emergency. The locks that have been fitted to new bedroom doors in Lakeside must be reviewed to ensure that they can be unlocked from the outside should a key be left in the lock on the inside of the door. 31/07/07 31/03/07 30/01/08 31/07/07 31/07/07 Trebursye Manor DS0000044111.V321151.R01.S.doc Version 5.2 Page 32 10. OP25 11. OP26 12. OP27 13. OP27 14. OP31 Appropriate coverings must be provided on all the doors and windows of bedrooms and en suite facilities, that are suitable for the needs of the individuals in those rooms, to ensure that the privacy and dignity of service users is protected. 23(2)(p) The Registered Provider must ensure that all parts of the building are kept warm enough for service users, particularly for those who are less active. Where free standing radiators are used, the Registered Manager must ensure they are working properly, are not likely to be a trip hazard and will not burn service users. 16(2)(k) The Registered Provider must 23(2)(d) ensure that the premises are kept clean, hygienic and free from offensive odours. The dust and debris in Lakeside must be kept to a minimum and the smell of urine removed. Smoking rooms, extractor fans and radiators must be cleaned and kept free from debris. 18(1)(a) The Registered Provider must employ enough domestic staff to ensure that the home is maintained in a clean and hygienic state, free from debris, dust, dirt and unpleasant odours. 18 (1)(a) The Registered Provider must review the staffing complement in Trelawney so that staff from Lansye are not required to leave their own posts and staff have time to complete the required paperwork as well as care for the service users. Care The Registered Manager must Standards not admit service users under Act 2000 the age specified on the Section 24 Certificate of Registration unless this is agreed with the DS0000044111.V321151.R01.S.doc 28/02/07 28/02/07 30/04/07 30/04/07 28/02/07 Trebursye Manor Version 5.2 Page 33 Commission for Social Care Inspection. The Registered Manager must apply for a variation to the conditions of registration, including details of the needs of service users, so that their continued placement can be considered. (This is the second time this type of breach has occurred as it was also identified during the inspection conducted on 1st December 2005). The Registered Provider must 31/03/07 establish and maintain a system for reviewing the quality of care provided at the home. A report of the review must be sent to the Commission for Social Care Inspection and made available to service users. (This is the second time this type of requirement has been made. The previous time was at the inspection carried out on 12th October 2004). The Registered Provider must 28/02/07 arrange for the care home to be visited unannounced, at least once a month, by the Responsible Individual, another of the directors, any other person responsible for the management of the organisation or an employee who is not directly concerned with the conduct of the care home. This person must produce a written report on the conduct of the care home and supply a copy to the Registered Manager and the Commission for Social Care Inspection. (This is the second time this type of requirement has been made. The previous time was at the DS0000044111.V321151.R01.S.doc Version 5.2 Page 34 15. OP33 24 16. OP37 26 17(2)(3) Trebursye Manor 17. OP37 17(2)(3) 18. OP38 23(4) inspection carried out on 12th October 2004). The Registered Provider must ensure that records relating to fire safety checks are maintained, accurate and up to date. The Registered Provider must take adequate precautions against the risk of fire: Fire doors must not be held open with wedges and other items of furniture. If fire doors need to be kept open for a particular reason, appropriate ‘hold open’ devices must be provided. The fire alarm system must be checked to ensure it is in working order. Coded locks that prevent service Users from leaving the building must be connected to the fire alarm system so that they are released should a fire occur. Where bolt locks are fitted to fire or exit doors, the means to open them must be easily available to everyone in the building, including service users and visitors, or alternative devices fitted that automatically open should the fire alarm go off. Broken fire call points must be repaired or replaced. Records relating to the checking/testing of call points must be kept. Records relating to the checking of fire extinguishers and fire blankets to ensure that they are 28/02/07 28/02/07 Trebursye Manor DS0000044111.V321151.R01.S.doc Version 5.2 Page 35 in the correct position and not been tampered with must be kept. Where service users smoke in bedrooms, precautions must be taken to reduce the risk of fire, such as providing fire retardant furnishings, following consultation with the home’s fire safety contractor. A risk assessment must be carried out and documented to include what action has been taken. The Registered Provider must 28/02/07 arrange for all electrical items, including portable appliances, to be checked and tested to ensure they are safe. (Original timescale of 31st August 2006 not met). The broken electrical socket in Lansye must be repaired or replaced. 19. OP38 13(4)(a) 13(4)(c) 23(2)(c) 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 OP9 Good Practice Recommendations The Registered Manager should ensure that a record is kept of all unused medication that is returned to the pharmacy so that there is a clear audit trail in the home of medication being received, administered and returned. The Registered Manager should ensure that, where requested, service users are assisted with making telephone calls to relatives and relatives are informed about changes in health needs and about events/activities taking place in the home. The type of information to be shared with relatives should be agreed when a service user is admitted to the home and documented within the DS0000044111.V321151.R01.S.doc Version 5.2 Page 36 2. OP13 Trebursye Manor 3. OP15 4. 5. OP18 OP19 service user’s care plan. The Registered Provider should review the quantity and choice of food provided in the home, as well as the catering budget, to ensure that service users are receiving a healthy, varied and nutritional diet. The Registered Manager should ensure that all staff members receive training related to the protection of vulnerable adults. The Registered Provider should alter the grounds to provide level access from the care home, so that people with mobility difficulties, or those who use wheelchairs, can access at least part of the grounds. The Registered Provider should ensure that the smoking room in Lansye has level access, so that it is easily accessible by service users with mobility difficulties. The dishwasher and hot water boiler/urn should be repaired or replaced with items suitable for the size of the care home. Consideration should be given to providing new flooring in the kitchen and cracked tiles should be replaced. The Registered Provider should arrange for a suitably qualified person, for example, an occupational therapist, to carry out an assessment of the premises to ensure it is suitable for the service users who live there. The Registered Manager should consider making better use of pressure pads/mats connected to the call bell system to alert staff that they need to attend to a service user, particularly if that person is prone to falls. The Registered Provider should consider installing a call bell system that can be used by people with dementia. The Registered Manager should ensure that additional coverings are placed between mattresses and sheets to provide additional comfort for service users. The Registered Provider should repair or replace the large washing machine and also consider purchasing a washing machine with a sluice facility. The laundry should be renovated or moved so that it is more accessible for both staff and service users should they wish to do their own laundry. A system should be provided in the laundry so that staff can summon assistance if they need to. The Registered Manager should ensure that two written references are obtained for all staff members, including one from the last employer, particularly if the person was DS0000044111.V321151.R01.S.doc Version 5.2 Page 37 6. OP22 7. 8. OP24 OP26 9. OP29 Trebursye Manor 10. OP30 employed in a caring role. There should also be confirmation in the home that Criminal Record Bureau checks have been carried out. The Registered Manager should arrange for all staff to receive training in dementia awareness. All staff members responsible for laundry and/or cleaning should receive infection control training. The Registered Manager should acquire documentary evidence of his qualification in management and provide a copy to the Commission for Social Care Inspection. The Registered Manager should consult with service users and/or their relatives and representatives and gain written permission to hold service users’ money in the bank account administered by the company. The Registered Manager should carry out a risk assessment relating to first aid training for staff to establish which staff need to attend first aid training and at what level that should be. Night staff should complete first aid training. A qualified first aider should be on duty at all times. All staff who prepare food for service users should complete training in food hygiene. All staff should receive manual handling training in relation to the moving and handling of service users and carrying heavy loads. The Registered Provider should consider servicing contracts for essential equipment such as refrigerators and freezers so that there is no delay in repairing or replacing these items if they break down. 11. 12. OP31 OP35 13. OP38 Trebursye Manor DS0000044111.V321151.R01.S.doc Version 5.2 Page 38 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 Trebursye Manor DS0000044111.V321151.R01.S.doc Version 5.2 Page 39 - 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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