Inspection on 25/07/07 for Priory Manor [formerly Trebursye Manor]

This inspection was carried out on 25th July 2007.

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... 10/01/07

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 10:50 25th July 2007 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.V334308.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.V334308.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.V334308.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 10th January 2007 Brief Description of the Service: Trebursye Manor is a care home registered to provide personal care and accommodation for fifty-four people, over the age of 55, who may have dementia or mental health needs. Occasionally the home also accommodates some younger people with 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 Trebursye Manor DS0000044111.V334308.R01.S.doc Version 5.2 Page 5 smoking rooms for service users and there is an outside smoking area at the rear of Lakeside. The home has a call bell system installed throughout most of the home. Trebursye Manor DS0000044111.V334308.R01.S.doc Version 5.2 Page 6 SUMMARY This is an overview of what the inspector found during the inspection. This key inspection consisted of an unannounced visit from 10.50am and 3.30pm on Wednesday, 25th July 2007 and two further visits between 11.30am and 3.50pm on Thursday, 26th July 2007 and 10.30am and 2pm on Tuesday, 31st July 2007. The Registered Manager, Robert Rotchell, was present and available for consultation throughout each visit. The organisation’s Operations Manager, Christine Hanwell, was also present during the first visit. A visit was made to the organisation’s Head Office on Friday, 10th August 2007 to inspect records relating to service users’ finances. A tour of the premises took place and records/documents relating to the care of the service users, staff and the home were inspected. An annual quality assurance assessment had been completed by the Registered Manager, which contained information relevant to the inspection. All of the service users were observed during the visits and fourteen service users were spoken with at length. Survey forms were sent to twenty-four relatives and twelve were returned. Eleven staff members were spoken with during the visits and others were observed in the course of their normal duties. Survey forms were sent to twenty-three staff members and seven were returned. Survey forms were sent to seven health and social care professionals and four were returned. Verbal information had been received from a health care professional prior to the first visit. What the service does well: 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. One relative said that the staff provide physical help and emotional support to service users and promote independence so service users do not feel institutionalised. Another relative said “Rob and the staff are doing a wonderful job”. Health and social care professionals are very supportive of the service offered by the home and by the flexibility of the staff to respond to the changing needs of service users. One professional said the staff “care in appropriate and understanding ways for those with mental health issues.” Another said that the home “copes with very variable patient needs remarkably well.” Service users said that the meals are very good, there are always alternatives to the main choices and a menu is available in the dining rooms so that service users know what meals are being served each day. Trebursye Manor DS0000044111.V334308.R01.S.doc Version 5.2 Page 7 What has improved since the last inspection? What they could do better: The recruitment procedure in the home must be followed with two written references obtained for all staff members. New staff must not carry out unsupervised personal care with service users until two satisfactory references and a Criminal Records Bureau check have been received. This is to ensure that service users are protected from risk of harm. The home is accruing large amounts of one particular medication and arrangements should be made to reduce the amount of this medication being Trebursye Manor DS0000044111.V334308.R01.S.doc Version 5.2 Page 8 kept on the premises. This is because the home should only keep enough medication to meet the needs of service users. The home needs to improve communication with relatives, particularly those who are not able to visit regularly, so that they are kept up to date with changes to service users’ needs and what is happening in the home. This should include assisting service users to make telephone calls or write letters if required. Relatives who want active communication should be kept 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. The fire exit from the laundry needs to be cleared of moss and overhanging plants to reduce the risk of accidents to staff. 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.V334308.R01.S.doc Version 5.2 Page 9 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.V334308.R01.S.doc Version 5.2 Page 10 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 People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including visits to this service. The home’s admissions procedure ensures that prospective service users and their relatives/representatives know that the home will meet their needs. EVIDENCE: Discussions with the Registered Manager and the Operations Manager confirmed that the Statement of Purpose and Service User Guide are being updated to reflect changes in the service user group. A discussion took place with the Registered Manager about making sure that any additional charges, such as escorting a service user to hospital, need to be stated clearly in contracts, statements of terms and conditions as well as in the Statement of Purpose and Service User Guide. 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 Trebursye Manor DS0000044111.V334308.R01.S.doc Version 5.2 Page 11 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.V334308.R01.S.doc Version 5.2 Page 12 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 and 10 People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including visits to this service. Service users can be confident that they will be treated with respect and that personal and health care needs will be met. 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. Information from social/health care professionals also said that the dignity of service users is maintained. Six 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 four social/health care professionals confirmed that service users’ health care needs are usually met and care staff usually have the skills and experience necessary to support people’s needs. One professional said the staff “care in appropriate and understanding ways for those with mental health issues.” Another said that the home “copes with very variable patient needs remarkably well.” For safety reasons, most service users are not allowed to hold their own cigarette Trebursye Manor DS0000044111.V334308.R01.S.doc Version 5.2 Page 13 lighters and/or matches and smoking is only permitted in designated 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, 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. Discussions with service users and feedback from health care professionals confirmed that referrals are made to other relevant professionals when required. Discussion with service users and information from social/health care professionals confirmed that privacy is respected and staff were observed knocking on doors before entering private rooms. The home has two pay ‘phones for service users in Lakeside and Trelawney but service users may also use the home’s ‘phone if they wish to make a private telephone call, for which no financial charge is levied. Service users may also have private telephones installed in their bedrooms at their own expense. Discussions with service users and feedback from health care professionals showed that care staff support service users with their medication in a respectful way. Discussion with staff confirmed they 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 in each of the three units in the home demonstrated the procedures for administering medication and all medication received or returned to the pharmacist is recorded. The Operations Manager has identified that some medication is being given covertly to service users and is arranging for this procedure to be reviewed. A discussion took place with the Registered Manager about the need to reduce the stock of one particular medicine as the home should only keep what service users need on the premises and all additional stock should be returned to a pharmacy. Trebursye Manor DS0000044111.V334308.R01.S.doc Version 5.2 Page 14 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 12, 13, 14 and 15 People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including visits to this service. 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. EVIDENCE: Discussions with service users, staff and the Registered Manager, as well as the annual quality assurance assessment, confirmed that various activities take place for service users, either individually or in groups. The home has recently employed an experienced activities co-ordinator who arranges various activities and service users said they liked participating. These include walks in the grounds and trips out to the pub, garden centres or for personal shopping in Launceston or Plymouth. Three service users visited Newquay Zoo recently and said they thoroughly enjoyed themselves. The home has visits from external entertainers such as local musicians and in-house activities include arts and crafts, board games, bingo, karaoke and horticulture. Special activities are arranged where requested, for example, horse riding, swimming and yoga. Service users also have opportunities to participate in educational Trebursye Manor DS0000044111.V334308.R01.S.doc Version 5.2 Page 15 courses, for example, horticulture. Discussion with service users and feedback from relatives and the staff confirmed that visitors are actively welcomed into the home and may visit whenever they like. However four 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. A menu for each day is available in the dining rooms to remind people what is on offer for that day and service users said they found this useful to refer to. Personal preferences and special diets are known and catered for, with records kept of meals provided. 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 wish to. Trebursye Manor DS0000044111.V334308.R01.S.doc Version 5.2 Page 16 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 16 and 18 People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including visits to this service. Service users can be confident that any concerns or complaints will be listened to and addressed. 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. The Commission for Social Care Inspection has received three complaints about the home since the last inspection. These have all been investigated thoroughly by the Operations Manager and any issues arising have been addressed. Staff members spoken with said that all staff are expected to attend training related to the protection of vulnerable adults and procedures were displayed in the home. Written feedback from six staff confirmed that they are aware of adult protection procedures. The Registered Manager is undertaking a trainer’s course, so that he will then be able to train the staff in the home. 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.V334308.R01.S.doc Version 5.2 Page 17 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, 23, 24 and 26 People who use the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including visits to this service. Parts of the home have been refurbished to a very high standard but there are many areas that still require attention. EVIDENCE: The refurbishment of Lakeside is almost complete and discussion with the Registered Manager confirmed that there is a good level of communication with the contractors who are carrying out the building works. The ground and first floors are finished and the refurbishment is of a very high standard with good quality furnishings, fittings and décor. The organisation has an action plan in place to address all other areas that need refurbishment and redecoration, including Lansye, Trelawney, the kitchen, dishwashing room and the laundry, therefore any defects in those areas will not be itemised in this report. A new office for the Registered Manager and reception area for the home’s administrator are in the process of being prepared for occupation. Trebursye Manor DS0000044111.V334308.R01.S.doc Version 5.2 Page 18 The Operations Manager confirmed that a safe method of opening the new double glazed windows, that only open at the top, is being sought from the manufacturers. In the meantime, staff have been provided with equipment to reach the windows to ensure that the safety of service users and staff is not compromised. She also confirmed that appropriate telephone systems are being sought that will meet the needs of both service users and staff. At present there is a problem with reception for mobile/portable telephones in some parts of the building. The communal rooms consist of a large lounge room in Lakeside, a smaller lounge on the 1st floor and a dining room on the ground floor. The dining room has a small kitchen area where service users can make their own drinks and snacks if they wish to. There is a designated smoking area outside the back of Lakeside. 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 has been improved since the last inspection with new lighting and furniture. Service users’ artwork was on display on the walls. Observation, as well as feedback from relatives, indicated that the home is kept clean and there were no unpleasant odours. The Registered Manager confirmed that there has been an increase in domestic staff to cope with the debris and dust from the builders. Areas identified at the last inspection as being in need of cleaning have been tidied and cleaned and there was a significant improvement in the environment. There was a significant smell of smoke on entering Trelawney and the Registered Manager agreed to look into the reason for this. 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. Staff in Lansye and Trelawney said that all the toilets, bathrooms, showers and en suite facilities were in working order and any maintenance jobs are addressed immediately by the builders on site. 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. When the refurbishment is complete, all bedroom, bathroom and toilet doors will be fitted with appropriate locks that can be Trebursye Manor DS0000044111.V334308.R01.S.doc Version 5.2 Page 19 accessed by staff in an emergency. Where bedrooms have glass paned doors and windows opening onto a corridor, the glass has been etched to prevent people from looking in, so that privacy is enhanced. Kitchen and laundry facilities are satisfactory at present as they are included in the plan to be refurbished in due course. A bell has been installed in the laundry room so that staff can summon assistance should they need to. 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 this is gradually being cleared away. Trebursye Manor DS0000044111.V334308.R01.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 27, 28, 29 and 30 People who use the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including visits to this service. The management and staff team strive to provide a stimulating, safe environment where service users are respected and rights are upheld. Recruitment practices are not robust enough to protect service users from risk of harm. EVIDENCE: Observation and discussion with service users and staff confirmed that the staff team are respectful, polite, attentive and responsive to service users’ needs. Feedback from relatives said that service users are supported to live as they choose and most relatives say that the service users are happy and the staff team do a good job. One relative said that the staff provide physical help and emotional support to service users and promote independence so service users do not feel institutionalised. Another relative said “Rob and the staff are doing a wonderful job”. 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 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. The staff members on duty were aware of service users’ needs and how to support them. Trebursye Manor DS0000044111.V334308.R01.S.doc Version 5.2 Page 21 Staff confirmed that they are expected to participate in various training sessions and courses including adult protection, health and safety, first aid, manual handling, fire safety, food hygiene, infection control, dementia awareness and National Vocational Qualifications (NVQs). One senior staff member is a qualified NVQ Assessor. Two staff members have recently achieved a Certificate in Community Mental Health. Designated staff undertake medication training and all staff are supervised on a regular basis. The files of two recently recruited staff members were inspected. One of these contained only one written reference and, although a Criminal Records Bureau (CRB) check had been applied for, it had not been received in the home. Discussion with this staff member indicated that he was carrying out unsupervised personal care tasks with service users. Trebursye Manor DS0000044111.V334308.R01.S.doc Version 5.2 Page 22 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 31, 33, 35, 36, 37 and 38 People who use the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including visits to this service. The management approach is open and positive, providing clear leadership and guidance. Service users’ rights are promoted but their welfare is not always protected due to proper recruitment practices not being followed. 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 does not hold a relevant management qualification but confirms that he keeps himself up to date with current practices in mental health, for example, attending a meeting regarding the Mental Capacity Act. Discussion with the Registered Manager confirmed that he is knowledgeable, competent, Trebursye Manor DS0000044111.V334308.R01.S.doc Version 5.2 Page 23 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. Discussion with service users and the Registered Manager, as well as records in the home, confirmed that most service users or their relatives/representatives manage their financial affairs. The home does manage small amounts of spending money on behalf of some of the 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 and audited by staff in the organisation’s Head Office. 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. The Director of the company has supplied information regarding this account to the Commission for Social Care Inspection and the records were provided. The Operations Manager confirmed that written permission is obtained from service users and/or relatives/representatives to administer money in this way. Pre-inspection documentation and discussions with the Registered Manager confirmed that safety checks have been carried out including gas appliances, portable electrical appliances, hoists and the shaft lift. Whenever new electrical equipment is purchased, such as refrigerators and freezers, the organisation is ensuring that these come with servicing contracts so that there is no delay in repairing or replacing these 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 raised at a previous were addressed and to look at the ongoing building work. Discussions with staff confirmed that they are expected to undertake training in health and safety, fire safety, first aid, food hygiene, infection control and manual handling. The Operations Manager confirmed that first aid training is being arranged for all the staff who need it. Following the last inspection, the fire service visited the home and issued improvement notices. Since then a new up-to-date fire alarm system has been installed and inspection of the fire logbook indicated that the required weekly and monthly tests/checks of the fire alarm system/equipment are carried out. A discussion took place with the Registered Manager about the usefulness of numbering all the call points as a practical way of being able to record which ones are tested each week. The Registered Manager and staff members confirmed that the new coded door locks are connected to the fire alarm Trebursye Manor DS0000044111.V334308.R01.S.doc Version 5.2 Page 24 system and will open automatically should the fire alarm go off, so that service users and staff are able to evacuate the premises quickly. The steps of the fire exit from the laundry were covered in moss and overhanging plants and this should be kept clear to reduce the risk of accidents to staff. 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, however one window inspected did not have a restrictor fitted. The Registered Manager said he would address this immediately. The Registered Manager has started the quality assurance process by obtaining feedback from service users about the care they receive, through questionnaires and meetings, and sending out questionnaires to relatives and professionals from health and social care services. He confirmed that an internal audit will take place and the results of the audit will be made available to service users, relatives and other people/agencies that have an interest in the home. The organisation’s Operations Manager visits the home several times a month and, once a month, provides a written report on the conduct of the care home to the Registered Manager and to the Commission for Social Care Inspection. Trebursye Manor DS0000044111.V334308.R01.S.doc Version 5.2 Page 25 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 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 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 3 3 X 3 3 X 3 STAFFING Standard No Score 27 3 28 3 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 3 3 3 Trebursye Manor DS0000044111.V334308.R01.S.doc Version 5.2 Page 26 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 OP29 Regulation 19 Requirement The Registered Manager must obtain two written references for all staff members. New staff must not carry out unsupervised personal care with service users until two satisfactory references and a Criminal Records Bureau check have been received. This is to ensure that service users are protected from risk of harm. Timescale for action 12/09/07 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 make arrangements to reduce the amounts of one particular medication being kept on the premises. This is because the home should only keep enough medication to meet the needs of service users. The Registered Manager should ensure that, where requested, service users are assisted with making telephone calls to relatives and relatives are informed DS0000044111.V334308.R01.S.doc Version 5.2 Page 27 2. OP13 Trebursye Manor 3. OP38 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. This is to ensure that relatives are kept up to date with changes to service users’ needs and what is happening in the home. The steps of the fire exit from the laundry should be kept clear of moss and overhanging plants to reduce the risk of accidents to staff. Trebursye Manor DS0000044111.V334308.R01.S.doc Version 5.2 Page 28 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.V334308.R01.S.doc Version 5.2 Page 29 - 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. 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