Inspection on 11/09/07 for Trevaylor Manor

This inspection was carried out on 11th September 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Excellent. 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

Trevaylor Manor 09/11/06

Trevaylor Manor 22/02/06

Trevaylor Manor 19/09/05

Trevaylor Manor 02/12/04

Trevaylor Manor 02/06/04

Similar services:

The Vicarage

Fairfields Country Rest Home

7 Hyde Road

5 Seafield Road

Queensmount

Poldhu

Didsbury Court Rest Home

12 Orchard Mews

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

CARE HOMES FOR OLDER PEOPLE Trevaylor Manor Newmill Road Gulval Penzance Cornwall TR20 8UR Lead Inspector Stephen Baber and (Expert) Mrs Fiona Thomas Unannounced Inspection 11th September 2007 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 Trevaylor Manor DS0000009137.V347036.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. Trevaylor Manor DS0000009137.V347036.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Trevaylor Manor Address Newmill Road Gulval Penzance Cornwall TR20 8UR 01736 350856 01736 360370 trevaylor@swallowcourt.com 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) Swallowcourt Limited Mrs Janet Prela Care Home 73 Category(ies) of Dementia - over 65 years of age (24), Mental registration, with number Disorder, excluding learning disability or of places dementia - over 65 years of age (24), Old age, not falling within any other category (73), Physical disability (24) Trevaylor Manor DS0000009137.V347036.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. Dementia over 65 years of age, excluding learning disability or mental disorder, (DE(E)) Maximum 24 The Home may accommodate up to 5 service users aged between 50 65 years for respite or permanent care. These service users may be across the registered categories, depending on need. 9th November 2006 Date of last inspection Brief Description of the Service: Trevaylor Manor is large detached manor house standing in spacious landscaped grounds approximately two miles outside of Penzance. It is registered under the terms and conditions set out in the Care Standards Act 2000 and Care Homes Regulations to provide nursing and residential care to 73 people in need of nursing and personal care (24 of whom have a dementia or a mental disorder past or present and are accommodated mainly on the lower ground floor of the home.). Resident’s rooms are spread out over three floors with a shaft lift to access all floors. Resident’s bedrooms are a mixture of single and double with most of the rooms having ensuite facilities. Bathrooms and toilets with aids and adaptations are located on each floor. Communal facilities consist of a spacious lounge dining room with a decked area adjacent to this room. The home has its own mini-bus and on Tuesdays and Thursdays will pick up family members from their private homes if they dont have transport. There are extensive landscaped gardens around the home, which are much enjoyed by all with a tarmac drive that leads to a sun house for the residents to enjoy. Medical cover is provided by several general practitioners practices from Penzance. There is ample parking to the front and rear of the home. There are qualified nurses on duty throughout the twenty-four hour period and the staffing ratios are determined to meet the range of needs of the residents that are accommodated. Management have established a very successful carers group for the dementia wing. The manager describes the aims, services and facilities clearly in the Statement of Purpose. The home sets out to provide a high quality service that responds to individual needs and preferences. Fees range from £600.00 to £650.00 nursing continuing care and £700.00 to £750.00 per week for dementia continuing care. Additional charges are made for, hairdressing, private chiropody. The homes mini bus, which accommodates 15 residents, provides daily outings or trips to the town. There is no extra charge for this service. Trevaylor Manor DS0000009137.V347036.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The Commission for Social Care Inspection (CSCI) have made changes to the way we inspect services. Known as Inspecting for Better Lives (IBL). We are now more proportionate when reporting our findings, and more focused on the experience of people using services. This was the homes fourth inspection and noticeable improvements have been made since the last inspection. The purpose of the inspection was to ensure that resident’s needs are appropriately met, with good outcomes provided to them. The Commission have introduced Experts By Experience. This project was developed to improve social care services by involving people we can use in our inspections. Areas covered by the expert included talking with the residents and staff, observations of daily life and relationships between staff and people who use services and a look around the premises. Mrs Fiona Thomas-Lambourn (the Expert by Experience) spent over 5 hours in the home and gave very comprehensive feedback to management at the end of her visit. This was a key inspection, which was unannounced. It took place on 11th and 13th September 2007 and lasted for approximately 16 hours. The purpose of the inspection was to ensure that residents’ needs are properly met, in accordance with good care practices and the laws regulating care homes. The focus is on ensuring that residents’ placements in the home result in good outcomes for them. The inspection included interviews, some held privately in residents’ rooms and some in the communal area of the home, with residents and visiting relatives. Several members of staff were interviewed and there were opportunities to directly observe aspects of residents’ daily lives in the home and staff interaction with them. We also carried out a Short Observational Framework for Inspection, which has been developed by CSCI in conjunction with Bradford University Dementia Group. It is a tool based on dementia care mapping principles and enables inspectors to sample the outcomes for people who use services where direct communication is not possible or effective. The tool is based upon person centred principles of care and incorporates a 2 hour detailed observation period. It has been piloted in both dementia care and learning disability settings and has been proved to generate invaluable information for assessing the quality of care being provided. Other activities included an inspection of the premises, examination of care, safety and employment records and discussion with the manager and managing director who were present throughout the inspection. The managing Trevaylor Manor DS0000009137.V347036.R01.S.doc Version 5.2 Page 6 director explained that the company are making major improvements throughout the home and would like us to see the improvements already made. The principle method of inspection was “case tracking”. This involves interviews with a select number of residents; staff caring for them and/or their representatives, and examination of records relating to their care. This provides a useful impression of how the home is working overall. At this inspection five residents on the nursing wing and two residents on the dementia wing were case-tracked, with particular reference to their individual and diverse needs relating to their age, culture and ethnicity, religion, gender, sexual orientation and disabilities. The Expert By Experience said in her report “On arrival at Trevayor Manor I was introduced to staff members, including the Head of Nursing and one of the directors (also a qualified senior nurse) who is at Trevaylor Manor every day where possible. Everyone working at the home was most welcoming, friendly and open”. What the service does well: The statement of purpose provides clear information on the services and facilities offered, including short-term and respite care so that prospective residents have good information as to whether the home will be suitable to meet their needs. The manager, senior nurse and managing director carryout comprehensive assessments with prospective residents prior to their admission. This ensures that prospective residents and their representatives can be confident the home will be suitable for them. The manager has drawn up excellent care plans and supporting documentation, which give a really full picture of each persons preferences, choices and particular needs. The care plans inform and direct the staff and give clear guidance to staff on how these should be met. There is a really good schedule of activities on offer and throughout the home there are notice boards with pictures of outings and forthcoming events. The activities coordinator explained that activities could be on a one-to-one basis or small and large group activities. Residents said to us that they enjoy going to the local supermarket and trips out in the homes mini coach. Residents are given lots of opportunities to maintain interests and hobbies of their choosing. One resident said to us that she would never like to leave the home. because she is very happy there. She explained to the expert and I that she had bad experiences when she lived in the community and now feels safe and well cared for. Trevaylor Manor DS0000009137.V347036.R01.S.doc Version 5.2 Page 7 The company are committed to equalities and diversity and the manager with the support of the managing director leads by example in that they harness the different perspectives and skills of all staff, make use of them in their work and provide a working environment that is free from discrimination, harassment or victimisation. The company and the manager are mindful to promote equality for residents and staff and they embrace diversity and ensure full inclusion for people who use and work in the service. They promote equal opportunities, preventing discrimination and valuing diversity, which the manager and managing director explained is fundamental to building a strong service. Throughout the inspection the manager was able to provide examples of what she and the staff have carried out to improve the quality of life for all the residents. Residents were very pleased with the catering arrangements and said that they can choose what they want to eat every day. Both the expert by experience and I were given very positive feedback from the relatives who visited throughout the two days. One person told us that she preferred to travel a long distance from her home to visit her relative because she knows that they are well cared for at the home. What has improved since the last inspection? The manager has reviewed the assessments and care plans. The new documentation is very professionally presented, detailed, comprehensive and clearly inform and directs the staff on the action they need to take to ensure that all aspects of the health, personal and social care needs of the residents are met. Those residents living at Trevaylor Manor said to us that they feel confident that staff do all they can to meet individual needs and preferences and respect their daily routines, which are important to them. The manager also submitted the annual quality assurance assessment (AQAA) self audit tool. It was clear and gave us all the information we asked for. We received the annual quality assurance assessment (AQAA) before the date the manager had to send it to us. We got good information from the AQAA. It was very detailed with clear evidence of how the home has improved since the last key inspection in November 2006. The home are able to think of new and creative ways to make sure that their service is able to do the things that matter to people. For example the home gave us a lot of evidence that showed that people and their representatives that use their service are fully involved in the assessment and care planning Trevaylor Manor DS0000009137.V347036.R01.S.doc Version 5.2 Page 8 process. This has meant that people agree to the care they receive and know that the home is able to meet their needs. We looked at the information in the AQAA and our judgement is that the home is still providing an excellent service and that they continue to improve on their service to the residents. The view of the expert by experience and inspector is that the quality rating of the home is excellent and this has been backed up with very positive comments from residents, relatives, and improved care planning which informs and directs the staff. 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. The summary of this inspection report can be made available in other formats on request. Trevaylor Manor DS0000009137.V347036.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 Trevaylor Manor DS0000009137.V347036.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 1,2,3,4 and 5 were assessed. Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Prospective residents have the information they need to make an informed choice about where to live. Each resident is provided with a contract at the point of moving into the home so that they know the services and facilities that will be on offer to them. There is a full and detailed admission process at Trevaylor Manor to ensure that the prospective needs of residents can be met. This whole process is thoughtfully and sensitively carried out. EVIDENCE: The home has a detailed statement of purpose and a service users guide which contain all of the required information in order that individual’s can make an informed choice as to whether the services and facilities provided at the home are sufficient to meet their needs. Trevaylor Manor DS0000009137.V347036.R01.S.doc Version 5.2 Page 11 We spent some time with the administrator and looked at resident contracts with the home. The contracts inspected were found to be very clear and stated the services and facilities on offer to residents. The home has developed comprehensive person centred care plans based on wishes and choices from the information provided by the resident’s and information gathered during the assessment process. The new comprehensive assessments evidence that a full pre-admission assessment prior to a new resident moving into the home is carried out. Seven files were case tracked and all contained evidence of clear assessments that formed the basis for the working care plans. Clear information was in place to show the involvement of specialist services and professionals, ensuring a multi-disciplinary approach. We have received on more than one occasion positive feedback from other professionals on how well the manager and staff work with them. The AQAA submitted by the home states How we have improved in the last 12 months “It is our aim throughout Swallowcourt to constantly internally and externally audit, maintain and improve our standards. An internal audit is carried out every 3 months. Large sums of money have been invested to constantly upgrade the home. Further investment has been made towards staff training and development. All recommendations from previous inspections have been addressed”. Our plans for the next twelve months “To be constantly investing in the structure and refurbishment of the home. To constantly invest in staff training and development. To look for new innovations and equipment so that our care homes are at the forefront using modern equipment and up-to-date methods. To address any areas of concern that arise quickly and efficiently. To address any areas arising from inspections or visits from CSCI”. Trevaylor Manor DS0000009137.V347036.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 were assessed. Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. The home operates with a good person centred care planning for all residents. Care plans, are extremely detailed and are regularly reviewed and updated to reflect the resident’s currently changing needs and choices to ensure that the correct level of support is given. Residents can feel secure in that their health care needs will be fully met. The manager and staff work professionally with all healthcare professionals to provide a high standard of health care. EVIDENCE: Seven files were case tracked. All resident files are in the process of being updated with the very comprehensive assessments such as manual handling, Tullamore Falls risk assessment, nutritional screening, waterlow, mobility, emotional wellbeing, eating and drinking, social and recreational activities and maintaining a safe environment. Trevaylor Manor DS0000009137.V347036.R01.S.doc Version 5.2 Page 13 All care plans case tracked evidenced a clear understanding of the individual needs of residents and they informed and directed staff. As part of person centred care each resident has a life story, which they contributed to or information was freely offered by their representatives. The care plans covered areas of identified need such as communication, social needs and emotional wellbeing, these recorded individual’s progress and any actions, which have been taken. Comprehensive care plans and daily records were in place for all seven residents. The documentation looked at was found to be recorded with a high level of information and it was clear that the information had been gathered over a long period of time with the individual involved being central to the whole process. The information in place recorded the individual’s preferred routines and an overview of an individual’s day and well-being. These are reviewed and updated monthly. We observed staff talking and assisting residents in a reassuring, calm, friendly and unhurried manner. They appeared responsive to individual needs and we noted that residents were respected and reassured at all times Tasks were observed such as lifting with the hoist and this was carried out with full dialogue and respect fro privacy and dignity Comments from the residents confirmed that these important principles of care are being met. The home operates the Boots monitored dosage system. The nurses in line with the homes policies and procedures administer the medication. Storage, administration, recording satisfies the guidance stipulated by legislation and regulation. Clinical Waste is disposed of via a contractor. A physical count and check of the medication system confirmed the security and safety of all prescribed medication to be satisfactory. It is recommended as part of the upgrading programme that the clinical room be redecorated and refurbished It is also recommended that if medication is not being taken it should be returned to the pharmacist. A stock of medication for one resident was being reordered when it was only being taken occasionally. In summary the SOFI exercise evidenced that the three people observed showed that staff were on hand to offer the appropriate intervention and for two people experienced good engagement with their environment and the other person had a lot of staff contact because of her unsettled manner. The AQAA submitted by the home states How we have improved in the last 12 months “Funding has been made available for more specialist equipment to support the residents’ needs. A communal wet room has been added to the dementia care unit to enable residents to access showers more easily. Evidenced throughout is the companies commitment to improve. Other tests are used which reflect Trevaylor Manor DS0000009137.V347036.R01.S.doc Version 5.2 Page 14 the principles that underpin all that goes on in the home. Our performance can be judged in relation to governing philosophy, against national minimum standards and regulation. More staff have achieved their NVQ Level 2 and 3.”. Our plans for the next twelve months “To maintain the high standard of care provided at the home. To improve the facilities further with more wet rooms and specialist equipment.”. The Expert By Experience in her report said “Accompanied by the Head of Nursing I visited the lower ground floor where residents have level of dementia (approx 24 residents) or a mental disorder needing constant personal care and nursing. This secure unit requires a very high level of highly trained nurses and care staff. There is a lift with access to all three floors. One lady shadowed us around the unit needing constant tactile contact. I was told she constantly walks and cannot/will not sit to eat a meal so her food needs are all by hand, mainly through sandwiches The home maintains files on each resident showing their life’s history and families are very much involved and asked to participate writing entries relating to family and the jobs they have done. This gives a marvellous insight into the resident and helps with communication for staff. It was very obvious to me how caring and concerned the staff in this unit were towards the residents I went alone to the sitting room to speak to the residents: one gentleman tried hard to communicate with me, indicating his appreciation of the care he is getting, but not happy with his situation. Some residents were dozing or unable to communicate at all. A younger woman gave me a wonderful smile and showed me a little china fairy that she had tucked into the folds of her cardigan; she apparently carries this everywhere and it is her companion. In this secure unit the residents were allowed freedom to wander. However, their room doors are kept shut to try and maintain privacy and respect for each resident. I was shown a few of the rooms which are nicely but simply furnished. There was such a good feeling in this unit, with residents in their own clothes, looking clean and fresh. All areas had a nice fresh smell which is a great achievement since most of the residents are incontinent”. Trevaylor Manor DS0000009137.V347036.R01.S.doc Version 5.2 Page 15 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 12,13,14 and 15 were assessed. Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. The activities coordinator plans routines and activities of the home in a way, which meets the choice, and wishes of the residents with meaningful activities being arranged for those residents who wish to participate on a one to one basis, small and large groups. Residents are given the opportunity to exercise some choice and control over their daily lives. The food in the home is of a high quality, well presented and meets the dietary needs of the residents. EVIDENCE: The activities coordinator, management and staff support resident’s to become part of, and participate in, the local community in accordance with assessed needs and individual plans. Staff enable resident’s integration into the community life through knowledge and support to enable individual’s to make Trevaylor Manor DS0000009137.V347036.R01.S.doc Version 5.2 Page 16 use of services, facilities and activities in the local community, such as shops, pubs, and church. Evidence provided and confirmed by the activities coordinator showed that those living at the home are offered a variety of social, leisure and educational activities. Individuals are able to participate if they wish and the manager and staff are mindful of the great ages, and general infirmity of some residents and facilitate more suitable activities. Information seen in recording logs evidenced that individuals regularly are supported to visit places of local interest and local community groups. The activities coordinator picks up residents relatives in the homes mini bus on Tuesday’s and Thursdays. This is a much-appreciated service by the relatives. The home has open visiting arrangements and residents can entertain their family and friends in their own room. Staff supports individuals to maintain family links and friendships inside and outside of the home and staff assisting individuals with correspondence and telephone calls. The home also provide a number of ‘in house’ activities such as weekly arts and crafts sessions, quiz afternoons, bingo and armchair exercise. On the day of the visit the residents on the dementia wing were playing floor noughts and crosses, which they appeared to enjoy. A relative spoken with said of the home, ‘its standards of care, support, and understanding of individuals needs is excellent’. Residents are also supported to follow their faith in or outside the home. Three trained chefs and three kitchen porters are employed in the kitchen. The kitchen was in good order, well organised, clean and tidy. Emphasis is placed on good plain cooking with choices available at all times. The chefs take great pride and pleasure in providing meals of quality, in sufficient quantity and of nutritional value. Special diets are catered for. We shared a meal with the residents at lunchtime. The dining area is well lit airy and spacious. Tables were decorated with linen tablecloths and tablemats. Cold drinks and hot drinks were offered. The meal was a choice of roast lamb, vegetarian or salad. Condiments were provided; the pudding was ice cream or fruit and cream, yogurt followed with a cup of tea or coffee. The mealtime was seen to be unhurried, and discreet support was available for individuals if needed. The atmosphere was relaxed. There were good-natured interaction between staff and residents. The managing director joined us for lunch with the residents. It was a pleasant dining experience. The AQAA submitted by the home states How we have improved in the last 12 months “The Company is constantly investing in all aspects of the home to improve the daily life for our residents. Improvements to the property as referred to in the section ‘What we do well’ have been made.”. Our plans for the next twelve months Trevaylor Manor DS0000009137.V347036.R01.S.doc Version 5.2 Page 17 “The combination of internal audits, quality assurance audits will continue to enable us to meet and surpass our residents’ needs.”. The Expert By Experience in her report said Activities: “I met the person who is head of entertainment for the home. He drives the mini-bus, taking residents out shopping, for a pub lunch or other outings. Twice a week he picks up residents’ family visitors (there is no public transport). While I was there he was encouraging and helping those residents who were able to plant bulbs in pots, and in the spring, planting the hanging baskets. One resident was doing this; handling the bulb fibre and sitting in the shade within the secure fenced area next to the house. I also spoke to a resident who was proud to tell how she helps the two full-time gardeners with flower-bed weeding, which she loves. She calls Trevaylor Manor her home, as I heard another resident say later, and the staff, her family. She appeared happy and relaxed and enjoyed chatting. The garden also has a large summer house (accessible through a locked gate) where relatives or friends can visit. There is also a decking area with comfortable outside chairs and shade umbrellas available for residents, their families and friends to use. While I was there, there was entertainment in the first floor sitting room, where a gentleman was playing an organ and singing. Later in the afternoon there was a sing-song which was attended by visitors as well as the residents. One visitor tells me that she encourages her husband, now in the secure unit, to attend these entertainment afternoons so they can sit together and hold hands. I spoke to two visitors who said that although the home was some distance from their home they wouldn’t dream of moving their mother to somewhere closer because she is happy at Trevaylor and her care is so good. Later I saw this lady’s room where she had her personal effects making it ‘her space and her home”. Meals “Breakfast was still in progress when I arrived at 9.45am. Choices included eggs and bacon or different cereals according to resident’s preferences. The dining room was sunny, light and roomy with large windows looking out over a hard surfaced area of garden, made secure by a tasteful metal fence, flower beds and with further views over the extensive lawns, shrubs and trees which are part of the lovely grounds I joined the residents for lunch, which consisted of roast lamb with roast potatoes, broccoli and gravy or a prawn salad. I chose the lamb, which was Trevaylor Manor DS0000009137.V347036.R01.S.doc Version 5.2 Page 18 very good, and I noticed that the helpings were proportionate to elderly residents. Dessert was rice pudding or strawberry ice cream. The chef caters for approximately 74 residents and up to 60 staff each day. The dining room is spacious and light with comfortable chairs. Residents sat at tables of 4. Residents needing help sat at a table with staff attending to them. I asked residents if they enjoyed the food and they said that they did and there was variety”. Trevaylor Manor DS0000009137.V347036.R01.S.doc Version 5.2 Page 19 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 were assessed. Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. The home has a complaints procedure that meets national minimum standards and regulations, the procedure is available with in the home and residents and relatives understand how to make a complaint. The policies and procedures regarding the protection of residents are comprehensive and regularly reviewed and updated by the company. The service is clear when incidents need external input and who to refer the incident to. Residents can feel safe in the home. EVIDENCE: The complaints policy and procedure shows a clear timeline and action to be taken in event of a complaint. It also directs the complainant to the contact details of the Cornwall Adult Social Care department. The residents we spoke with said they knew how to make a complaint and said the manager was always available to discuss any concerns they had. During the last twelve months the Commission had received one concern which was investigated and a number of requirements were made and have since been complied with. Staff spoken to showed an awareness of the policies and procedures in place to protect vulnerable adults. The home also has a clear whistle blowing policy in Trevaylor Manor DS0000009137.V347036.R01.S.doc Version 5.2 Page 20 place. Staff have undertaken training in protection of vulnerable adults through the company training manager. Recruitment practices carried out in the home protect residents from abuse, criminal records bureau and protection of vulnerable adults checks are carried out, and two written references are obtained before staff commence employment. The AQAA submitted by the home states How we have improved in the last 12 months “We have updated our policies on complaints. Have achieved training to all our appropriate staff with regards to the protection of vulnerable adults. Our quality assurance questionnaire returned with positive comments from residents, relatives and visitors to the home. Evidence of staff training is detailed in individual staff training portfolios.”. Our plans for the next twelve months “To carry out research into the topic of restraint which affects residents on the dementia care unit. To monitor each area of restraint such as medication, cot sides and reclining chairs. To train staff to be aware of the freedom of liberty, at which point we need to be considering the Bournewood principles for which there is a draft code of practice available, formally due for implementation in Autumn 2008. To continue to have consent from G.P, relatives and friends for residents who are suffering severely from dementia. To always evidence this in our care plan.”. Trevaylor Manor DS0000009137.V347036.R01.S.doc Version 5.2 Page 21 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 19,29,24,25 and 26 were assessed. Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. The home has a well-maintained environment, which provides aids and equipment to meet the care needs of the residents. It is a very pleasant place to live with rooms that have been personalised by its occupants. The management has a good infection control policy with advice sought from external specialists E.g. infection control and the manager encourage her staff to work to the homes policy to reduce the risk of infection. The home is well lit, clean and tidy and smells fresh. EVIDENCE: The accommodation is well used and the residents looked relaxed and comfortable. The premises are detached and set in their own spacious Trevaylor Manor DS0000009137.V347036.R01.S.doc Version 5.2 Page 22 grounds, which are carefully maintained and provide a welcoming and interesting feature to the house. Internally the home provides a good standard of furnishings and is well maintained and decorated. Residents are provided with accommodation in addition to their individual bedrooms and have a choice in this respect, of a spacious, comfortable and nicely furnished lounge or a dining room. In addition the home has spacious grounds, which are very well maintained and are enjoyed by some of the residents. Staff assist those residents with impaired mobility to access the grounds. There accessible toilets for the residents near to the main communal areas. Bathing and toilet provision within the home is satisfactory. These areas are well maintained. Appropriate equipment and adaptations have been provided based upon individual assessed need throughout the home there are aids and adaptations to meet resident’s needs. There is a shaft lift that serves three floors. Storage areas are also provided for equipment and there is a call bell system throughout the home for residents to use. Rooms have been personalised by their occupants and very much reflect the individuality of the resident. Special locks have been fitted to resident doors on the dementia unit. To give greater privacy in the shared rooms curtains are provided. Advice has been sought from the appropriate professionals on the management of Legionella. Systems have been set up to test the hot water systems. The home complies with the requirements of the health and safety officer in that all radiators have been covered, thermostatic valves have been fitted to hot water outlets where body immersion takes place have been fitted and restrictors have been fitted on windows. Comprehensive systems are in place to control the spread of infection. The inspector noted the good work the domestics were doing in keeping the home clean and tidy. There are two laundress’s employed who launder all the resident’s personal laundry. Sheets go out to contract cleaners. Protective clothing is provided and the infection control officer gives regular training opportunities to the staff. The AQAA submitted by the home states How we have improved in the last 12 months “We have achieved the redecoration and refurbishment of 25 Rooms. We have provided a wet room and a separate dining room for the dementia care unit. We have provided new boilers for the central heating in the home. We have replaced the kitchen flooring.”. Our plans for the next twelve months Trevaylor Manor DS0000009137.V347036.R01.S.doc Version 5.2 Page 23 “We run a continuous programme of refurbishment. When bedrooms become vacant they are redecorated and new carpets provided as required. Evidenced throughout is the commitment to providing high standards of accommodation which matches individual preferences and needs.”. The Expert By Experience said in her report “After lunch I visited some rooms on the first and second floors. Some refurbishing is going on with many rooms having new pine chests of drawers, hanging cupboards, bedside cabinets, new carpets and curtains. This is not all completed yet, but the upgrading is good. Corridors and rooms are kept very clean and tidy. Beds and mattress coverings are washed when necessary . I spoke briefly to the cleaners who told me they work continuously throughout the day. The entire home has a very high standard of cleanliness and freshness. Most are single rooms, but some are occupied by couples. On feedback to the inspector and management of the home I indicated that I was very pleased with what I had observed on my visit.” Trevaylor Manor DS0000009137.V347036.R01.S.doc Version 5.2 Page 24 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 were assessed. Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. The service ensures that all staff within the home receives relevant training that is targeted and focussed on improving outcomes for residents. The company employ a training manager to work with the home to deliver the training. External training is also undertaken if the manager feels that they have not got the appropriate skills within the home. The residents said that staff working with them are very skilled in their roles and are consistently able to meet their needs. Residents have confidence in the staff that care for them. All staff are clear regarding their role in what is expected of them. Recruitment practices safeguard the residents. EVIDENCE: Guidelines on dependency levels are being met and these are kept under constant review to accommodate the changing levels of resident dependency. Staff on duty on the days of the inspection were on the nursing wing manager plus 3 qualified nurses and 8 care assistants, dementia wing senior nurse plus Trevaylor Manor DS0000009137.V347036.R01.S.doc Version 5.2 Page 25 2 nurses and 5 care assistants. In addition to this there were chefs, domestics, maintenance personnel, laundress, and secretary. The company have introduced clear, written recruitment policies and recruitment documents are asked for by the home when staff are offered employment E.g. C.R.B. and P.O.V.A.first are carried out for all staff, photographs are obtained, proof of I.D. for example. It iIs recommended that all prospective staff record the last ten years of employment. There is a comprehensive policy to ensure that staff are recruited on the basis of equal opportunities. Residents stated they were extremely well looked after by the staff that approached their work in a caring manner. The company are committed to well-trained staff. Training is provided to all staff and leads on to NVQ 2 or above. Training commences from Skills for Care Induction and is ongoing. The training is planned according to the individual needs of the staff and this helps to meet the varied needs of the residents. The company employ a training manager who works closely with the manager. A major area of improvement has been completed on individual staff files and training records. The files are very professional and makes for the quick retrieval of information. Courses are conducted in house and through local colleges and independent training providers. I talked with staff who said that they are provided with good access and support to undertake training to develop their knowledge and skills for the benefit of the residents. The AQAA submitted by the home states How we have improved in the last 12 months “60 of care staff have now obtained NVQ 2 and 3. The Corporate Training Manager has two Training Officers within Trevaylor who support her in the delivery of training from induction to ongoing training. Staff have been encouraged to take ownership for their own development. Identifying what training days they wish to attend. Through the supervision of staff appraisals they will be encouraged by the Registered Manager and Training Manager to achieve their goals.”. Our plans for the next twelve months “It has been identified that some staff are working long shifts which are tiring and not necessarily productive. Trevaylor will be recruiting sufficient staff and have the ability to draw from the Swallowcourt bank to enable this practise to be eradicated. The company value its staff and the contributions they make.”. The Expert By Experience said in her report “Some of the staff are recruited as care assistants and go on to train further, attaining more NVQs; some are trained in-house, while others attend courses and training days outside the home. Commercial companies such as Johnson and Johnson have their own training officers who visit and demonstrate to staff how to use their products” Trevaylor Manor DS0000009137.V347036.R01.S.doc Version 5.2 Page 26 Trevaylor Manor DS0000009137.V347036.R01.S.doc Version 5.2 Page 27 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 31,32,33,36,37 and 38 were assessed. Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Residents and staff benefit from the home being well managed. There is clear leadership and a strong focus on the outcome for residents in all management and development decisions. The home ensures that individual’s interests and rights are promoted and protected by a knowledgeable and experienced staff team EVIDENCE: The registered manager is highly qualified and experienced in management and nursing. The manager has created clear lines of accountability and delegation throughout the home. The manager discharges her duties with honesty and professionalism. The managing director offers her support, Trevaylor Manor DS0000009137.V347036.R01.S.doc Version 5.2 Page 28 guidance and supervision on a daily basis and gives added strength to the management team. We were impressed by their commitment to the company and high quality care with a well-trained staff. We evidenced from discussions with residents and staff that residents benefit from her ethos, leadership and management approach of the home. The manager’s style is one of openness and she enables staff and residents to affect the way the service is delivered. The inspection was a very positive one with open and honest discussion taking place. The manager has implemented means of determining the views of residents and their representatives on the quality of the services provided. This year residents and their relatives, other stakeholders will be asked to complete a quality assurance exercise. The manager will have all the necessary elements to draw up an annual development plan for the home. The home only has responsibility for resident’s personal allowance. Appropriate provision is made for the safekeeping of personal monies and valuables. A non-interest account has been opened to facilitate this. However the administrator needs to meet with the company accountant to discuss policies and procedures that would inform and guide her particularly when deceased residents have a debit or credit balance. Also the policies and procedures should record a maximum ceiling for individual’s personal allowance. Large amounts of money should be put in an interest account for that person. The manager advised that supervision takes various forms from supervised practice; hand over periods, formal meetings, supervision and appraisal. Individual records are maintained for each member of staff. Staff are well supported by the management of the home with sound systems in place to support and guide staff practice in order to ensure that all staff are providing a good quality service to those who live at Trevaylor Manor, these include personal development and supervision sessions and overall review of staff performances. Records inspected and required by regulation were in sufficient detail and upto-date. The home has a written policy in respect of data protection and confidentiality and records are kept securely in a locked office in the care home. All the appropriate certificates and servicing takes place at regular intervals. Fire training to day and night staff takes place at the recommended intervals. The home displays a current certificate of Employer’s Liability Insurance. The AQAA submitted by the home states How we have improved in the last 12 months Trevaylor Manor DS0000009137.V347036.R01.S.doc Version 5.2 Page 29 “We have updated the quality questionnaire sent them to residents and their families. This is to gain a more advanced understanding of how the service is meeting the resident’s needs. Better control of the budget provided to run the home. More staff meetings for all departments to improve standards and communication”. Our plans for the next twelve months “To continuously update the company policies and procedures introducing legislative training. To work closely with the Health and Safety company that advises Swallowcourt and Trevaylor Manor and provides the policies in this important area.”. Trevaylor Manor DS0000009137.V347036.R01.S.doc Version 5.2 Page 30 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 4 3 4 4 4 N/A HEALTH AND PERSONAL CARE Standard No Score 7 4 8 4 9 3 10 4 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 4 14 4 15 4 COMPLAINTS AND PROTECTION Standard No Score 16 4 17 X 18 4 4 3 X X X 3 4 4 STAFFING Standard No Score 27 4 28 3 29 4 30 4 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 4 4 x x 3 3 4 4 Trevaylor Manor DS0000009137.V347036.R01.S.doc Version 5.2 Page 31 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. OP2 9 1. Refer to Standard OP9 Good Practice Recommendations The registered person should include the redecoration and refurbishment of the medical room as part of the upgrading programme and medication should not be allowed to accumulate but should be disposed of. The registered person should ask all prospective staff to record the last ten years of employment. The registered person should arrange a meeting for the administrator of the home and company accountant to agree policies and procedures that would inform and guide her and agree what to do regarding some financial situations such as large amounts of money and debit and credit balances for deceased residents. 2. 3. OP29 OP35 Trevaylor Manor DS0000009137.V347036.R01.S.doc Version 5.2 Page 32 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. 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