Inspection on 03/07/06 for Trevarna

This inspection was carried out on 3rd July 2006.

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

Trevarna 20/08/07

Trevarna 11/10/05

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 Key unannounced Inspection 3rd July 2006 10:00 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.V302423.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. Trevarna DS0000009242.V302423.R01.S.doc Version 5.2 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.V302423.R01.S.doc Version 5.2 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 11th October 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.V302423.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place on the 3rd. and 4th. July 2006 over a twelve and a half hour period. The inspector met with the manager, assistant managers. 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 inspection. During the course of the inspection 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, 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? The staff complement has now come back to near full strength enabling more staff to be on duty at any one time. Staff training continues and the home can show that more than 60 of the staff team have now achieved an NVQ award ranging from level 2 to level 4. A further 4 staff have all but completed their NVQ award and a further 5 are now enrolled. Supervision of staff had been slightly below par, as reported in the last report. Evidence produced would indicate that this important function is now back on track. Trevarna DS0000009242.V302423.R01.S.doc Version 5.2 Page 6 Service users and relatives all reported satisfaction with the care and services being provided. 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.V302423.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 Trevarna DS0000009242.V302423.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): 1, 2, 3, 4, 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. A copy of these documents is to be found in each service user’s bedroom. 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. Trevarna DS0000009242.V302423.R01.S.doc Version 5.2 Page 9 Service users files contained signed contracts/ terms and conditions of the home. Service users and relatives confirmed they had knowledge of these documents and processes. Relatives informed the inspector they were able to visit the home prior to admission of their relative. The home caters for those suffering from dementia and all staff receive relevant training to a good standard. Intermediate Care is not provided at this home. Trevarna DS0000009242.V302423.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. 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. 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. The inspector spoke with a visiting District Nurse who expressed satisfaction with the working relationship she had with the home. From her point of view there were no problems arising from the care of her patients. Service users have the opportunity to receive aromatherapy and massage. This service is offered on a regular basis. Trevarna DS0000009242.V302423.R01.S.doc Version 5.2 Page 11 The home’s medication policies are adhered to by all staff. The manager and assistant managers are the nominated persons who administer medication. The majority of the drugs are in blister packs. An audit trail was conducted in respect of the ‘controlled drugs’ held on the premises and found to be correct. Medication records were efficiently maintained. Staff handling medication have been trained to do so by an external accredited trainer. The inspector observed staff treating service users with respect, addressing them in a polite and friendly way whilst respecting dignity and privacy. Service users and relatives confirmed that this was the case. Trevarna DS0000009242.V302423.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 Service users and relatives confirmed that the lifestyle they experience in the home meets their expectations and preferences. Visitors are welcome at all times. A steady flow of visitors were observed to be in the home during the course of the inspection. Service users are helped to exercise choice and control over their lives. The food prepared was varied, wholesome and well received. EVIDENCE: The service users individual care plan has a detailed section regarding their interests and choice, and activities are planned to encompass these interests. The home arranges and facilitates visiting entertainment and in-house activities. Life story books are being collated to enable social profiling and active care. Planned activities are displayed on a notice board. Flexibility is achieved throughout all aspects of daily living. The management ‘buy in’ facilitators for aromatherapy, hand massage, drama therapy, ‘pat a dog’ etc. Service users were given the opportunity to vote at the recent elections and evidence was presented to demonstrate that some service users had had contact with solicitors and advocates. Relatives, service users and staff gave examples of the lifestyle, interests etc. relating to individual service users. Trevarna DS0000009242.V302423.R01.S.doc Version 5.2 Page 13 The inspector spoke with two of the cooks and evidenced that they were well experienced and qualified. A variety of choices and menus are available on a day to day basis and in some cases special/individualised diets are catered for. Service users confirmed that the food presented was to a high standard and that it met with their approval. Trevarna DS0000009242.V302423.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 registered persons ensure that service users are protected from all forms of abuse The complaints procedure is well publicised and used when required. with staff having knowledge through training of Adult Protection issues which helps to protect service users EVIDENCE: A comprehensive complaints policy and procedure is kept within the home. This procedure includes timescales and who will deal with the complaint. The home also keeps a complaints log for ease of reference. Service users indicated that they were aware of the procedures. The home has a comprehensive policy and procedure in place to protect service users from abuse. Policies are also available in regard to physical and / or verbal aggression from service users, physical intervention and restraint. Staff are made aware of these procedures during the induction period. The registered manager is also aware of the local social services procedure within “No Secrets” to investigate any complaints regarding the suspected abuse of any service user. CRB and POVA checks are undertaken, with Cornwall Care being the umbrella body to obtain these checks. Trevarna DS0000009242.V302423.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, 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. A program of redecoration and refurbishment is ongoing. Sufficient and suitable lavatories and washing facilities are provided in each area. Sluicing facilities are available. 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. The home was generally free from offensive odours, clean and hygienic. Trevarna DS0000009242.V302423.R01.S.doc Version 5.2 Page 16 Seating areas are arranged in the gardens with one area designated to become a sensory garden. Some areas present as a little tired, of which the manager is well aware but overall the premises present to a good standard. Management are considering the replacement of the call bell system to provide a more up to date system. Trevarna DS0000009242.V302423.R01.S.doc Version 5.2 Page 17 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28,29,30 Robust recruitment policies and procedures are implemented. All staff are supported and Inducted through good training opportunities. A positive number of staff are on duty to meet the service user’s needs. EVIDENCE: The staff team shows a positive regard for service users and appears very organised. Additional staff are on duty at peak times of activity during the day. In addition to care staff there are 2/3 domestics and 1 laundry staff member on duty each morning. The duty rota indicates that 8/9 care staff are on duty during the mornings, 8 throughout the afternoon and evenings. Waking night staff number 3. In addition managers, domestic and catering staff are on duty Staff recruitment is conducted in line with the home’s policies and procedures. Evidence obtained from staff files indicates that references, CRB and POVA checks are taken up prior to interview. All staff undertake Induction Training. . NVQ training is encouraged. At present at least 60 of staff hold NVQ certificates with a further 4 staff about to complete their courses and a further 5 staff have been enrolled. Individual training profiles for staff are kept up to date with accurate information of progress made. Staff are receiving supervision and an appraisal system is in place. Staff morale appeared high resulting in an enthusiastic workforce that works positively with service users to improve their quality of life. Trevarna DS0000009242.V302423.R01.S.doc Version 5.2 Page 18 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, 33, 36, 38 The registered manager is qualified, competent and experienced to run the home. The home is run in the interests of service users. Professional, independent quality assurance systems are in place. Staff receive appropriate training and supervision. The health, safety and welfare of service users is taken seriously. EVIDENCE: 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. The manager has successfully completed the registered managers award. She is currently studying for the Institute of Leadership and Management Diploma. Trevarna DS0000009242.V302423.R01.S.doc Version 5.2 Page 19 The manager is able to demonstrate that she has undertaken periodic training i.e. the dementia care certificate in order to keep herself updated. The manager stated that her job description enables her to take responsibility to fulfil her duties. Staff and service users commented that they were happy with the current style of management The Manager is provided with a budget for the home. There is a five-year financial plan for the home. The accounts clerk at the home sends the invoices and financial details to the head office where records of all financial transactions are maintained. Annual business and financial plans are produced. Relevant insurance cover was in place and the certificate was displayed. Employment policies and procedures adopted by the home are entirely satisfactory. Staff are now receiving regular supervision. Quality assurance audits are carried out by an independent organisation, analysed, and findings published. The inspector observed and inspected a number of documents relating to health and safety issues and was satisfied that policies and procedures, training, checks and balances are in place to protect the welfare of service users. Trevarna DS0000009242.V302423.R01.S.doc Version 5.2 Page 20 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 3 3 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 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 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X X 3 X 3 Trevarna DS0000009242.V302423.R01.S.doc Version 5.2 Page 21 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. Standard Regulation Requirement Timescale for action RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Trevarna DS0000009242.V302423.R01.S.doc Version 5.2 Page 22 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.V302423.R01.S.doc Version 5.2 Page 23 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!