Inspection on 11/10/05 for Trevarna

This inspection was carried out on 11th October 2005.

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

Trevarna 20/08/07

Trevarna 03/07/06

Trevarna 16/05/05

Trevarna 16/11/04

Trevarna 19/05/04

Similar services:

Fairfields Country Rest Home

Poldhu

Queensmount

Trevaylor Manor

Didsbury Court Rest Home

Stallcombe House

Belma

Hunters Care Centre

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

CARE HOMES FOR OLDER PEOPLE Trevarna 4 Carlyon Road St Austell Cornwall PL25 4LD Lead Inspector Mike Dennis Unannounced Inspection 11th October 2005 12.01p 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 Trevarna DS0000009242.V256302.R01.S.doc Version 5.0 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Trevarna DS0000009242.V256302.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Trevarna Address 4 Carlyon Road St Austell Cornwall PL25 4LD 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) 01726 75066 Cornwall Care Limited Ms Carol Ruth Mogford Care Home 54 Category(ies) of Dementia - over 65 years of age (46), Mental registration, with number Disorder, excluding learning disability or of places dementia - over 65 years of age (46), Old age, not falling within any other category (8) Trevarna DS0000009242.V256302.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. To include two service users under the age of 65 yrs for respite care only Total number of service users not to exceed a maximum of 54 Date of last inspection 16th May 2005 Brief Description of the Service: Trevarna is a purpose built care home situated close to the residential centre of St. Austell with the local library next door. The home provides residential care for up to 54 elderly people, including up to thirty with a dementia. Accommodation is provided on one floor and service users can access all areas` easily. The building consists of five wings, each having a sitting room, dining room, kitchenette and bedrooms. Meals are prepared in a large kitchen and served in the dining rooms of each wing. Assisted bathing facilities are provided and all rooms have call bells. The home has a hairdressing salon, which is well utilised by service users. There is also a day care facility at the home providing a service for up to twelve elderly people with a dementia. The grounds are kept tidy and there are patios with bench seating. Ramps provide easy access for service users. There is adequate car parking space at the front of the home. There are opportunities for socialising and visitors are openly encouraged. Trevarna DS0000009242.V256302.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place on the 11th. October 2005 over a five hour period. The inspector met with an Assistant Manager and the Administrator. A selection of staff from all departments were observed and spoken with. Five service users had conversations with the inspector on an individual basis and groups of service users conversed with the inspector throughout the lunch period. During the course of the day the inspector observed groups of service users engaged in a number of activities. Staff were observed to be tending to service user needs whilst respecting their dignity. Various records, policies and procedures were inspected. The inspector visited all parts of the building, including the day centre, and noted a satisfactory standard of hygiene and maintenance. Service users commented favourably on the overall service received, and acknowledged the improvements being made. Positive outcomes were noted What the service does well: What has improved since the last inspection? On the day of inspection it became apparent that a service user was nearing the end of her life. Staff are to be commended for the care and attention she was receiving. Care plans continue to be reviewed in a professional and thorough manner. Induction of new staff is being undertaken promptly and thoroughly. Trevarna is undergoing a programme of refurbishment and improvement Trevarna DS0000009242.V256302.R01.S.doc Version 5.0 Page 6 What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Trevarna DS0000009242.V256302.R01.S.doc Version 5.0 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Trevarna DS0000009242.V256302.R01.S.doc Version 5.0 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 3 and 5 Prospective service users are provided with the information they require in order to make an informed decision about admission to the home. Each service user has a written contract/statement of terms and conditions. Service users are fully assessed prior to admission to the home. Service users and or family members visit the home prior to admission EVIDENCE: A comprehensive Statement of Purpose and Service User Guide is available. These documents are regularly reviewed. Service users informed the inspector that they had knowledge of these documents. Four service user files were inspected and case tracked. All contained information pertaining to pre-admission assessment. The information provided included :- continence assessment, pain assessment, risk assessments and general details of daily care requirements, medication and health care requirements. Service users files contained signed contracts/ terms and conditions of the home. Trevarna DS0000009242.V256302.R01.S.doc Version 5.0 Page 9 Relatives informed the inspector they were able to visit the home prior to admission of their relative. On the day of inspection the inspector observed two families being shown around the home prior to them making a decision for their family member to take up residence. Staff spent considerable time answering questions etc. As a result one person was booked in for a weeks taster visit. Trevarna DS0000009242.V256302.R01.S.doc Version 5.0 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9, 10 and 11. The health care needs of service users are identified, planned for and met. Comprehensive policies and procedures for dealing with medicines are available. Service users are treated with dignity and respect. Staff are especially diligent and caring at the time of death. EVIDENCE: Four Individual Plans of Care were inspected. They were seen to contain full and relevant information, to include Risk Assessments, pertaining to the health, personal and social care needs of that individual. In addition information is gathered regarding the service users past life experiences and interests. This information will be used to promote an Active Care programme for that individual. Appropriate professionals from other disciplines frequently visit the home to provide for general health care, ie. G.P’s, Community Nurses, Opticians, Dentists etc. Service users have the opportunity to receive aromatherapy and massage. This service is offered on a regular basis. The home’s medication policies are adhered to by all staff. The manager and assistant managers are the nominated persons who administer medication. Trevarna DS0000009242.V256302.R01.S.doc Version 5.0 Page 11 The majority of the drugs are in blister packs. An error recently occurred whereby an excess of medication was administered to a service user. Upon investigation the cause was due to a gap in procedural polices rather than negligence by any particular staff member. The manager has amended the policies and procedures to ensure a similar incident does not re-occur. During the course of the inspection, it became apparent that one service user was failing and close to death. Staff were continuously in attendance. Management were considerate of the emotional effect on certain staff members and offering them support at the same time. Trevarna DS0000009242.V256302.R01.S.doc Version 5.0 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 13 and 15 Service users receive visitors at any reasonable time throughout the day. Service users were satisfied with the food provided. EVIDENCE: The visitors book indicated that visitors visit on a daily basis and several were observed in the home during the course of the inspection. The inspector talked to groups of service users during the lunch time. All expressed satisfaction with the food provided. Trevarna DS0000009242.V256302.R01.S.doc Version 5.0 Page 13 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): 17 Service users legal rights are protected. EVIDENCE: Service users informed the inspector that staff will facilitate and arrange for an advocacy service if requested. They also stated that they were able to vote at elections. Trevarna DS0000009242.V256302.R01.S.doc Version 5.0 Page 14 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): 20, 21, 23, 24 and 26 The location and layout of the home is suitable for it’s stated purpose and provides a safe and well maintained environment. The home was clean, hygienic and generally free from offensive odours providing an attractive and homely place to live. EVIDENCE: Service users have access to safe and comfortable communal facilities. There are plans to improve and refurbish certain areas of the home. In fact this programme has already commenced with one lounge area almost complete. It was noted that the new radiators installed in this area have exposed pipe work. Covers will need to be provided on health and safety grounds. Sufficient and suitable lavatories and washing facilities are provided in each area. Bedrooms are suitable for purpose and all individually personalised by the occupant. Service users expressed satisfaction with their living accommodation. Some staff were enthusiastic with the improvements already made and those planned. Trevarna DS0000009242.V256302.R01.S.doc Version 5.0 Page 15 The home was generally free from offensive odours, clean and hygienic. Trevarna DS0000009242.V256302.R01.S.doc Version 5.0 Page 16 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 An appropriate number of staff were on duty during this inspection. EVIDENCE: The inspector visited all parts of the building and noted that a sufficient number of staff were present in each group living area. A number of staff were spoken with and observed going about their tasks. In general they were quite enthusiastic about their work and demonstrated a solid understanding of their collective roles. Trevarna DS0000009242.V256302.R01.S.doc Version 5.0 Page 17 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): 36 Staff supervision is not occurring at the required time intervals. EVIDENCE: Some staff informed the inspector that they were not receiving the six supervisions per year. The records confirmed this. It is acknowledged that the home is currently carrying some management vacancies. It is nevertheless important that staff are given the opportunity for supervision. This deficit needs to be addressed. Trevarna DS0000009242.V256302.R01.S.doc Version 5.0 Page 18 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 3 3 x 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 x 13 3 14 x 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 x 17 3 18 x x 3 3 x 3 3 x 3 STAFFING Standard No Score 27 3 28 x 29 x 30 x MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score x x x x x 2 x x Trevarna DS0000009242.V256302.R01.S.doc Version 5.0 Page 19 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 33.2 Regulation 18(2) Requirement Ensure that all supervision is fully recorded. Extended time scale Timescale for action 31/12/05 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 OP20 Good Practice Recommendations Ensure new radiator pipe work is covered Trevarna DS0000009242.V256302.R01.S.doc Version 5.0 Page 20 Commission for Social Care Inspection St Austell Office John Keay House Tregonissey Road St Austell Cornwall PL25 4AD National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Trevarna DS0000009242.V256302.R01.S.doc Version 5.0 Page 21 - 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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