Inspection on 04/07/06 for Priory Manor [formerly Trebursye Manor]

This inspection was carried out on 4th July 2006.

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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

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

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

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

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

Priory Manor [formerly Trebursye... 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 Philippa Cutting Unannounced Inspection 4th July 2006 09:45 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.V298216.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.V298216.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 0207 5159993 HealthCare Trust Limited Mr Robert Edward Rotchell Care Home 54 Category(ies) of Dementia - over 65 years of age (29), Mental registration, with number Disorder, excluding learning disability or of places dementia - over 65 years of age (29), Old age, not falling within any other category (29) Trebursye Manor DS0000044111.V298216.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 1st December 2005 Brief Description of the Service: Trebursye is an older property situated in a rural landscape approximately five miles from Launceston. The property is approached by a long drive off a side road from the main A30. Over the years the main house and annexe have been adapted and extended. Further renovations are now needed to improve the structure and facilities offered. Trebursye provides care and accommodation for three groups of people: older people with dementia, people over the age of 55 years with mental health problems and older people not falling within any other category. The latter group are becoming an increasing minority as the home is specialising in caring for people with mental health difficulties. The registered manager has created separate areas to accommodate the groups. Trebursye Manor DS0000044111.V298216.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced key inspection of the complex that makes up Trebursye Manor. It was conducted over two days initially but the flaws and deficits that were found in the premises meant that a third day was required to inspect records. The owner was asked to attend on the second day in order that the deficiencies could be discussed. The annexe, which is divided into the Trelawney unit and Lansye, was found to be in a very poor state of repair with rotten doors, floors and water leaks. The condition in one area – the wash up/pot room - was so poor that the Environmental Health Officer (Health & Safety) was contacted for urgent advice. The grounds were, apart from the entrance drive, derelict. Photographs were taken as a record of evidence. The main house (Lakeside) will, the inspector was told, be the subject of a major overhaul starting on September 1st 2006. No plans for the annexe were detailed. The premises as a whole caused the inspector sufficient concern that an immediate requirement was left requiring the registered provider to provide evidence by means of a survey from a qualified surveyor as to the condition of the building. Staff commented that they found it extremely frustrating that although they were pursuing their training and keeping records in good order they were unable to deliver all the care they wanted as maintenance problems in the building confounded them. The registered manager’s comment was that he no longer had any budgetary control so any work or supplies that were needed now had to go via the Healthcare Trust Ltd’s central office. The home found that this incurred considerable delays, some of them unacceptable; examples were quoted. Fees in the home range from £375.00 – £742.00 per week, What the service does well: Staff training has resulted in staff being aware of people’s needs and meeting these as well as they are able with good recording to support this. The staff team appears to have gelled into an able working group. Trebursye Manor DS0000044111.V298216.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Trebursye Manor DS0000044111.V298216.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Trebursye Manor DS0000044111.V298216.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 2,3,5, These standards were assessed as being good. The inspector has confidence in the home’s procedures whilst the current registered manager is in post. All prospective service users are visited and fully assessed prior to admission. There was evidence that extended trial periods are given where someone takes longer to settle but the home will end the placement of any service user whose needs it cannot meet. It was a concern for the inspector that admission to Lansye is very dependent on the registered manager’s assessment skills & knowledge of mental health. His absence or departure could create a major problem here. EVIDENCE: Lansye: This unit is for younger people (over the age of 55 years) with a mental heath problem. The registered manager has built up good links with the mental health team who understand the problems that the home can deal Trebursye Manor DS0000044111.V298216.R01.S.doc Version 5.2 Page 9 with. He reported that he has good support from them and they respond quickly if a situation arises where further intervention is needed. The registered manager assesses prospective service users for the Lansye unit having first gathered information from the mental health team. He then visits them several times & invites them to the home before offering accommodation. All placements are on month’s trial, reviewed at the end of this time and extended if necessary. Trelawney: The inspector and registered manager discussed admissions to this part of the home. There have been no new admissions for a long time as the registered manager said he envisaged people from Lansye who no longer needed such close supervision moving to Trelawney. There are instances of where this has already occurred. Trelawney is adjacent to Lansye so whilst any such move may mean changing their room, it would not be a major disruption for service users. Lakeside: Lakeside is the unit in the main house for older people with dementia or mental health problems. It covers three floors but the majority of service users spend their day in the communal areas on the ground floor. People seeking admission are visited and assessed by either the registered manager or a team leader. Prospective service users are welcome to visit when making a decision about admission but in reality is more likely to be families who do this on behalf of their relative. Respite care is offered but not intermediate care or rehabilitation. A statement of purpose & service users guide are available. Fees are specified in contracts and based on a breakdown of the services provided in the units. Trebursye Manor DS0000044111.V298216.R01.S.doc Version 5.2 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9,10,11 The outcome for this group of standards is assessed as being good. They standards are well met with the way that health and personal care is delivered and recorded having improved in the last two years. Staff complete care plans and conduct reviews with daily recording being informative. The training that staff have received is shown in this improvement. They do however need to be alert to the need for risk assessment of specific problems for specific service users. People were treated with respect by the staff although some service users had difficulty in responding in like measure. The administration of medication, as seen, was satisfactory. EVIDENCE: All service users had a care plan drawn up detailing their needs and action to meet these. Advice or intervention from other agencies and professionals is Trebursye Manor DS0000044111.V298216.R01.S.doc Version 5.2 Page 11 sought as required. The local GP practice visits service users as needed and the mental health team responds to requests for help. Care plans are reviewed for all service users but few were signed either by the service user or a relative to show their agreement and understanding of any problems identified and the care needed. Care plans on Lansye had good care guide lines. Staff were trying some extra recording to note a person’s mood. For safety reasons, service users are not allowed to hold their own cigarette lighters and/or matches and smoking is only permitted in specified areas. The staff who administer medication have received in house training and when this was discussed they appeared to be aware of the correct procedures and were alert to instances where contra indications were apparent. The registered manager is looking to put all senior carers on an accredited training course approved by the British Pharmaceutical Society. All medication is stored in locked areas. It is supplied in monitored dose systems with medication administration record sheets being fully completed and colour coded to match the blister packs. Medication that is received or returned to the pharmacist is recorded. No controlled drugs were being used at the time of the inspection. Senior staff on Lansye said that the medication regimes had been altered so that it was administered at set times, rather than waiting for a person, who might choose to stay in bed, to appear. This has the benefit that doses are correctly spaced throughout the day, especially important where a person is diabetic. It was noted that staff addressed service users by their preferred name - ‘John’ or ‘Liz’ in some cases, ‘Miss X’ or ‘Mr Y’ in others. Staff were also heard to call people ‘sweetheart’ or ‘darling’ but this did not appear to give offence. The day of this inspection was hot. People appeared to be dressed appropriately whereas, at the previous inspection, service users were observed to be wearing thin clothes or be barefoot during a cold spell. There have been few deaths at the home. Two people were admitted to hospital where they subsequently died but the home would usually expect to care for service users until their lives’ end. Trebursye Manor DS0000044111.V298216.R01.S.doc Version 5.2 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14,15 The outcome for this group is judged as being good as opportunities are provided for service users to participate in activities and options to improve the quality of their lives. The staff realise that service users need encouragement to utilise these situations and that some will choose not to do so. There is scope for further development here. Trebursye Manor is home to a group of service users who are not easy to motivate. Staff spend time with them and try to respond to their mood. Where a particular interest is known the home attempts to encourage this. Contact with families and friends is encouraged but this does not exist for all service users. EVIDENCE: Lansye: It was difficult to ascertain how well the home met peoples’ aspirations as most were disinclined to comment. People in Lansye spend a lot of time in the smoking room although they had decorated the sitting room with flags etc. as part of following the World Cup football series. Those who did comment were satisfied with their accommodation and care. One person in particular had started an outside project and, with staff encouragement, was pleased with progress towards getting fitter and losing weight. Trebursye Manor DS0000044111.V298216.R01.S.doc Version 5.2 Page 13 Organised activities depend largely on the service users’ mood. Staff are aware that activity is more likely to be on short 1:1 spells rather than regular group sessions. Visits from families and friends are encouraged but some have very few people with whom they are still in contact. People have opportunities to go to Launceston on a weekly basis. The registered manager said there were plans to recommence swimming sessions, although this would have to wait until the schools re started as the home was not able to book a dedicated slot during holiday times. It was noted that special activities are arranged where appropriate e.g. horses riding. Trelawney: Here people were more talkative. Some go out regularly – with a risk assessment being in place where they prefer to go alone – others were sitting outside reading or listening to music as they chose. A wish to remain in their room is respected although people are asked to come to the dining room for main meals as part of general socialisation. People seemed content. Lakeside: Staff spend time with the service users and a new activities organiser had started that week. She was focussing her attention in Lakeside whilst getting to know the home. As well as simple activities staff take service users for walks (usually short) outside. A trip with in a wheel chair would be difficult as the ground is either gravelled or rough which makes pushing a chair impractical. Staff have more contact with the families of service users in this unit and were able to talk about or reassure anyone who was worried about their children or spouses. Meals are served in the three dining rooms. Few people have meals in their in rooms unless they are unwell. Personal preferences are known and catered for, as are any special diets. Both the catering staff and care staff complained that they had difficulties in taking the food from the kitchens to the dining areas as the wheels on the ‘hot trolleys’ used for this purpose had collapsed and could no longer be replaced. Drinks and snack facilities are available in all parts of the home, some being accessible to service users to use independently. Staff were encouraging the frailer people to drink as it was hot. All service users are invited and encouraged to attend any outside entertainment that is organised or join in a general bingo session for example. Trebursye Manor DS0000044111.V298216.R01.S.doc Version 5.2 Page 14 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16,18 The outcome group is judged as being adequate. The home has a complaints procedure and any issues are handled on an individual basis rather than a ‘complaints’ record book. The policy is displayed but the majority of service users would not be able or would be unlikely to make a complaint on their own behalf, therefore ways in which the complaints policy could be made more easily available to service users or other parties should be consider by the use of a different format or larger print etc. The prevention of abuse is taken seriously by the registered manager and staff. EVIDENCE: The registered manager has had to address a complaint from a relative. This has been given time and attention but there have been difficulties in dealing with it because the complainant has intruded into private areas and made offensive comments of a racial nature. Staff have received training with regard to the protection of vulnerable adults and in speaking with staff, they were alert to all aspects of abuse. The trainer has since left and to date there appears to be no arrangements for the continuation of this awareness training. Trebursye Manor DS0000044111.V298216.R01.S.doc Version 5.2 Page 15 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19,20,21,22,23,24,25,26 These standards were not met and are assessed as poor. The home was in a state of disrepair due to a lack of maintenance and there were areas that gave serious concern for the safety of the staff and service users. Requirements were left for the most urgent matters to be dealt with immediately and proof of the building’s suitability for its purpose made. EVIDENCE: The environment was found to be quite unsatisfactory and the inspector formed the impression that some areas if the home had deteriorated significantly since the last visit with little or no maintenance being carried out. When the home first came under the management of the Health Care Trust Ltd it had a full time gardener and three maintenance men. Now there was one person to cover the care of the grounds and maintenance but he had given notice leaving the home without any cover. Externally apart from the front drive that had been recently mown, the grounds were totally neglected with knee high grass, weeds and saplings in Trebursye Manor DS0000044111.V298216.R01.S.doc Version 5.2 Page 16 evidence. There were some building materials left lying around and the area by the storage sheds was dismal. There were no views of interest for service users to look over from any part of the home. Rotting eternal doors and windows were noted, there was evidence of water leaks, failed lights, poor décor and soiled floor coverings. The floor in the ensuite WC in one room had collapsed making it impossible for the service user to use the lavatory. Photographs were taken of various areas. The owner was invited to visit the home the following day whilst the inspector was there to discuss the deficiencies. The inspector had particular concerns about the state of the ‘pot room’ where washing up is done. The floor was awash and appeared to be hazardous as it was so slippery. The member of staff working there said that the sink surround had become so sodden and rotten that water spilled onto it and then ran down through the unit underneath and over the floor. The drain outside also flooded with foul water. A call was made to the Environmental Health Officer (Health& Safety) to report these concerns. In the main house the inspector was told that a room that had given cause for concern following the last inspection because of the ‘bounce’ in the floor, had been repaired and dry rot found. It seems unlikely that dry rot would have confined itself to one room in a property of this age and in view of other parts where concerns were noted, a requirement was left that the owner should provide evidence by means of a survey that the building was sound and stable. The inspector made an inventory of the rooms & deficits, noting that there were 48 outstanding reported items requiring maintenance in Lansye alone. Unaddressed concerns were listed for Lakeside as well. The issue of summoning help from the laundry was discussed, as there has been no action despite this being raised in reports on various previous occasions. The owner said he was unaware of this. The cook said that there was outstanding work from the last Environmental Health inspection that had not yet been done. The inspector had the clear impression that it has been a long time since the owner visited the home and walked around it. Neither has there has been any activity from the responsible individual in this regard. This is reprehensible as the service users are a group of people who do not think to complain and in some cases appear unaware of their surroundings. It therefore behoves on the company to take extra care. The registered manager stated that whereas he used to have a budget and could arrange for work to be done in the home, especially that of an urgent nature, this has been removed and now if he wants any work done or any Trebursye Manor DS0000044111.V298216.R01.S.doc Version 5.2 Page 17 supplies bought for the home, he has to request this from the company’s office. He said that all requests take an inordinate amount of time. He cited instances where the home had needed new crockery and stationery that had incurred a delay of several weeks. He said his comments and concerns regarding repairs and maintenance had been voiced at company meetings but had not elicited a response. Staff expressed their opinions very strongly about how the lack of maintenance was hampering their work and preventing them from delivering care as they wished. The inspector also discovered that the fire panel was not working properly and an immediate requirement was left for this to be serviced and rectified within seven days. On the second day of the inspection workmen arrived. They replaced the collapsed WC floor and were in the throes of replacing fire doors. It was observed that it took six hours to replace one window as, on removal of the glass, the frame was found to be rotten. The owner said that he intended to send a team of workmen to refurbish the main house in sections starting in September. This would involve the removal and replacement of floors and ceilings. New windows had been ordered. Such works will mean considerable disruption to everyone in Lakeside and a plan to minimise this is essential as well as keeping families informed about what is happening. Refurbishment of Lansye and Trelawney did not appear to programmed in. It was also noted that the building in which the registered manager and administrative staff are expected to work are poor. Toilet facilities are basic and involve negotiating a storage area. Trebursye Manor DS0000044111.V298216.R01.S.doc Version 5.2 Page 18 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,20,30 The outcome for these standards generally was assessed as good but the present policy of the Health Care Trust Ltd to centralise staff records and employment details means that the records that the home keeps are only part of a persons’ employment details. The centralisation also prevented the inspector from checking all aspects of the recruitment process. Details of Criminal Records Bureau checks relating to any new staff are forwarded to the registered manager and were available for inspection that indicated that this process is satisfactory. The staff have been encouraged to take up training opportunities and they have stabilised as a group. Staff records relating to training are still held in the home as are records of staff supervision. Those with whom the inspector spoke were positive about their work and said that they appreciated the support that the registered manager provided. EVIDENCE: LANSYE: By day Lansye is staffed by three carers but one person has to cover Trelawney during break periods for the member of staff on that unit. TRELAWNEY: Two of the rooms in the Trelawney unit are away from the rest of the accommodation. This means that the one member of staff working in Trelawney can be away from the main body of eight service users. Staff on Trebursye Manor DS0000044111.V298216.R01.S.doc Version 5.2 Page 19 both Lansye & Trelawney said they felt this situation did not create a problem as they had radio speaker contact with each other. LAKESIDE: There are several empty beds on the unit at present so it is staffed by three persons in the morning and either two or three in the afternoons, depending on availability. Staff said that when there were three staff on in the afternoons they could spend time with the service users encouraging them with various activities. The staffing numbers may need to be reviewed whilst major alterations are in progress. Staff have their preferred areas of work but can and do at times work in other parts of the home. All are encouraged and expected to work towards National Vocational Qualifications. Staff working primarily in Lansye include mental health components into their National Vocational Qualifications. The home had a robust training programme but the trainer left three months ago and the arrangements for continuing this are not yet clear. The new induction programme ‘Skill for Care’ needs to be overseen for new staff. On the day of this inspection staff were undertaking a manual handling and moving course. One senior member of staff passed her examination to become an accredited assessor for the home. The registered manager interviews for new staff and a list was available showing who had had Criminal Records Bureau checks. The remainder of the staffs’ records are held centrally so the home has become somewhat divorced from the recruitment process. During a recent crisis in the home the registered manager commented on how all the staff had reacted positively and effectively. Trebursye Manor DS0000044111.V298216.R01.S.doc Version 5.2 Page 20 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31,32,33,36,37,38 Overall these standards are assessed as adequate because the positive atmosphere promoted by the registered manager amongst the staff has to be set against the failure to keep the fire records and equipment in good order. The registered manager’s skills are good and whilst he is in post the care provided to service users will remain in safe hands. Service users could become very vulnerable if he were not there and no suitable deputy appointed. The standard fails where the responsibility for overseeing some managerial responsibilities such as fire safety have been taken over by the company’s office team. They must be more vigilant in attending to this role, especially where the safety of service users, by prevention of fire or other health & safety matters, is concerned. Trebursye Manor DS0000044111.V298216.R01.S.doc Version 5.2 Page 21 EVIDENCE: The registered manager is a registered mental nurse with many years experience. He has the skills and knowledge to oversee the care that the service users, especially those in Lansye, need. The home has yet to be successful in appointing a deputy for him; therefore it is a concern as to what would happen if he were no longer in post. The staff like working with him and realise that the care in the home has improved under his leadership. They were less enthusiastic about the role played by the owner. An effective quality assurance and monitoring system needs to be introduced as this is going to play an increasing and regular role in inspection in the future. Money is held on behalf of the majority of service users for safekeeping. The amount is not allowed to accrue and written records are kept. Staff supervision is taking place. Its purpose is now understood and people take the opportunity to raise issues that they wish to discuss. Some members of staff have moved from night duties to day time, as it was felt that they had good skills that could be better utilised by day. The records required by statute were inspected. The fire records were not up to date. The last entries dated from April 2006 & May 2006 and it must therefore be presumed that testing of the fire bells and emergency light etc. had not taken place. There were records for another home found in the fire file. After the specialist contractor had serviced the fire service user system following the inspector’s requirement for this to be done urgently, the service sheet stated that the system was not, in the engineer’s opinion, satisfactory. This comment has been passed to the Fire Safety Officer at the local brigade. There was no evidence of PAT testing for electrical appliances. A service engineer who inspected a bathroom hoist left the comment that the hoist could work properly until the floor was repaired, damage having been caused by water penetration. Trebursye Manor DS0000044111.V298216.R01.S.doc Version 5.2 Page 22 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 3 3 X 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 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 2 17 X 18 3 1 1 1 1 1 1 1 1 STAFFING Standard No Score 27 3 28 3 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 4 3 1 x X 3 2 2 Trebursye Manor DS0000044111.V298216.R01.S.doc Version 5.2 Page 23 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 OP19 Regulation 23 (4)(a)(c) Requirement Timescale for action 12/07/06 2 OP19 17(2) 14 3 OP19 23(2)(b) 4 OP38 23(2)(c) An immediate requirement was left to require the registered provider to arrange for a full fire safety check of the home’s fire system An immediate requirement was 12/07/06 left to require the registered provider to arrange that fire training, equipment and alarm testing was undertaken and recorded An immediate requirement was 31/08/06 left to require the registered provider to provide evidence that the property is of sound construction and kept in a good state of repair. The registered provider must 31/08/06 make arrangements for all electrical items to be PAT tested RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. Trebursye Manor DS0000044111.V298216.R01.S.doc Version 5.2 Page 24 No. 1 2 3 Refer to Standard OP7 OP15 OP26 Good Practice Recommendations Risk assessments should be included for specific individuals where this is indicated. The provision for transporting food to the dining rooms safely needs to be addressed. A means of summoning help in the laundry should be considered. Trebursye Manor DS0000044111.V298216.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection St Austell Office John Keay House Tregonissey Road St Austell Cornwall PL25 4AD National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. 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