Inspection on 19/09/05 for Trevaylor Manor

This inspection was carried out on 19th September 2005.

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

Trevaylor Manor 11/09/07

Trevaylor Manor 09/11/06

Trevaylor Manor 22/02/06

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 TR20 8UR Lead Inspector Stephen Baber Announced 19 September 2005 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 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 D52-D04 S9137 Trevaylor Manor V231487 190905 Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Trevaylor Manor Address Newmill Road Gulval Penzance TR20 8UR 01736 350856 01736 360370 Telephone number Fax number Email 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 Ltd 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), Terminally ill (28) Trevaylor Manor D52-D04 S9137 Trevaylor Manor V231487 190905 Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: None Date of last inspection December 2004 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 separately on the lower ground floor of the home.). Residents rooms are spread out over three floors with a shaft lift to access all floors. Residents bedrooms rooms 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 new 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 homes if they don’t 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 and Marazion.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. Trevaylor Manor D52-D04 S9137 Trevaylor Manor V231487 190905 Stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was the unannounced inspection as part of the homes annual inspection programme. The inspection took place over two weekdays on the 16th and 19th September 2005 and 13 hours was spent over the two days talking with residents, relatives and staff. I also focused on the following key areas of care, care planning, assessments activities, medication and policies and procedures, discussion with the manager of the home on how it operates on a day-to-day basis, inspection of the building and observation of the daily life of the home. . The inspection report shows that the management and staff continue to manage a well run home. Residents said that they felt that they are well cared for and the service was responsive and flexible to their needs at all times. What the service does well: Management makes every effort to meet the requirements and recommendations set by this authority and have always worked professionally with me giving her full and cooperation. The manager visits all prospective residents prior to admission and has delegated this to other senior members of staff. She is also thinking of extending this opportunity to care assistants to broaden their skills and expertise. Prospective residents and their representatives are provided with opportunities to visit the care home as part of their decision making process. Each prospective resident is also provided with written information about the care home. The standard of health care provided is to a high standard. The current residents stated that they are very satisfied with the care provided and the manner in which the staff undertake their duties. Care planning and dependency scoring tools and risk assessments processes are in operation on a day-to-day basis. High standards are maintained in the administration of medication. A new recreational coordinator is in place and he organises a full itinery for the residents, which includes trips out, reminiscence therapy, individual and group activities but he could improve this service by providing detailed evidence of what he carries out. Visitors are given every hospitality and a husband of a recent admission to the home to stays with his wife and takes meals with her. Residents were very complimentary about the food provided and residents can choose to eat in their own rooms if they wish. Special diets and puréed meals are also catered for. The premises are maintained both internally and externally to a very high standard and a programme of redecoration and refurnishing is about to take place. Throughout the home there was evidence of appropriate equipment for staff to use and aids and adaptations for the more dependant residents. Trevaylor Manor D52-D04 S9137 Trevaylor Manor V231487 190905 Stage 4.doc Version 1.40 Page 6 This inspection was positive and Swallowcourt Ltd is an organisation that wants to establish the corporate approach and to achieve a high quality of care to all its residents. What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by Trevaylor Manor D52-D04 S9137 Trevaylor Manor V231487 190905 Stage 4.doc Version 1.40 Page 7 contacting your local CSCI office. Trevaylor Manor D52-D04 S9137 Trevaylor Manor V231487 190905 Stage 4.doc Version 1.40 Page 8 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 Standards Statutory Requirements Identified During the Inspection Trevaylor Manor D52-D04 S9137 Trevaylor Manor V231487 190905 Stage 4.doc Version 1.40 Page 9 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 standard(s) 1,2,3,4,5,6. Prospective residents are provided with information that enables them to make an informed choice about where they wish to live. Contracts are issued to all residents or their representatives at the point of moving into the home. Residents are admitted to the home only after receiving an assessment of their needs by qualified and experienced staff. Prospective residents and their representatives are satisfied their needs will be met in a manner that reflects individual choice EVIDENCE: The statement of purpose tells prospective residents about the services and facilities that the home will provide. The service users guide is being updated and will be ready at the next inspection. Contracts are given to all residents and specify the services and facilities to be offered including the room to be occupiede. The records of residents who had moved to the care home following the last inspection evidenced that an assessment of their needs had been undertaken. In some instances the records confirmed that the views of specialist workers involved with the prospective residents had also been taken account of. Trevaylor Manor D52-D04 S9137 Trevaylor Manor V231487 190905 Stage 4.doc Version 1.40 Page 10 The assessments were detailed and addressed certain key areas of the individuals needs. The records reflected the choices and preferences of the residents concerned about the most appropriate way to provide the care and support required. In order to demonstrate transparency the prospective residents or their relatives should be encouraged to sign and agree the care to be given. Prospective residents and their families or representatives are able to visit the care home to help them decide if it is a suitable setting to live in. The visiting arrangements are flexible and are detailed in the homes statements of purpose and service users guide. Trevaylor Manor D52-D04 S9137 Trevaylor Manor V231487 190905 Stage 4.doc Version 1.40 Page 11 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 standard(s) 7,8,9,10,11. Individual care plans are in place for all residents and fully direct and inform the staff in the care to be given. Medication is well managed to ensure the safety of residents. The principle on which the home’s philosophy of care is based ensures that residents are treated with dignity and respect and that their privacy is preserved at all times. Policies and procedures and training for all staff assure residents who are unwell that they and their family will be treated to care and sensitivity. EVIDENCE: As evidenced from the documentary evidence the care plans are constantly being improved. Further development should take place by trying to encourage the residents or their representative to sign the care plan or the reason why they cannot. The daily recording on all residents covers the twenty-four hour period and was in sufficient detail and up to date. Reviews take place monthly and as noted where an outcome has been recorded an action should follow it. Risk assessments and dependency scoring assessments take place and guide and inform staff on the individual needs of the residents. Medication is well managed and a physical count and check of the medication room proved to be satisfactory. There are suitable arrangements for ensuring the privacy and Trevaylor Manor D52-D04 S9137 Trevaylor Manor V231487 190905 Stage 4.doc Version 1.40 Page 12 dignity. Staff were observed to be responsive to the needs of the residents and the residents told me that they were comfortable and well cared for. Trevaylor Manor D52-D04 S9137 Trevaylor Manor V231487 190905 Stage 4.doc Version 1.40 Page 13 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 standard(s) 12,13,14,15. The home provides a wide range of activities and aims to provide an individualised or group programme that meets resident’s needs. Every effort is being made to maintain links with family; friends and the local community to ensure the residents live as normal a life as they are able. EVIDENCE: The company employ a recreation coordinator to organise individual and group activities in and outside the home. The residents said how much they enjoy going out to the local supermarket and having a cake and cup of tea. Group activities are organised and consist of Bingo, reminiscence therapy, art and craft, tea dances and individual trips out. The mini bus also collects and takes home the relatives who cannot get to the home to see their family. It is recommended that all this good work be comprehensively recorded in individual files. There is an open door policy to visitors and they are given a welcome and hospitality by the management and staff. Trevaylor Manor D52-D04 S9137 Trevaylor Manor V231487 190905 Stage 4.doc Version 1.40 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 standard(s) 16,17,18. There is a detailed complaints procedure with time scales for the resolution and types of complaints that can be made. This ensures that the residents know that their complaint will be taken seriously and acted upon. There are measures in place to protect vulnerable residents from abuse but these should be strengthened and improved to protect vulnerable residents. EVIDENCE: The Company have established a satisfactory policy and procedure for dealing with complaints in a manner that complies with the national minimum standards and Care Home Regulations 2001. Residents commented they are aware of the arrangements to register complaints and any issues of concern. Residents said they have confidence in the senior nursing staff and there are no barriers to raising complaints or concerns with the senior staff employed at the home. The Company have received no formal complaints since the last inspection Relatives of their representatives largely deal with Resident’s financial affairs The home has a written policy for the protection of vulnerable adults from abuse, which is in the process of being updated, as the current version is now several years old and is out of date. The manager should also obtain copies of local multi-agency procedures and those of the various placing authorities in respect of residents who have been placed there from out of county. Staff are provided with guidance by management as part of their induction training prior to working in the home, but should also be given access to external, multiagency training. Trevaylor Manor D52-D04 S9137 Trevaylor Manor V231487 190905 Stage 4.doc Version 1.40 Page 15 The arrangements are designed to safeguard residents against any form of abuse. A suitable whistle blowing policy is also in place. This enables staff to report concerns regarding abuse to a third party if they feel unable to report the matter to the Company or senior staff. This provides additional protection for residents. Trevaylor Manor D52-D04 S9137 Trevaylor Manor V231487 190905 Stage 4.doc Version 1.40 Page 16 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 standard(s) 22,25,26. Trevaylor provides a good standard of décor and furnishings creating a comfortable and safe environment for those living there and visiting. Improvements to the home continue to be made and more improvements are planned. This will improve the accommodation for the residents and add to their comfort and well being. EVIDENCE: As evidenced throughout the home there are aids and adaptations to make life easier for residents and staff. Residents have the specialist equipment they require to maximise their independence. Shared bedrooms are provided with suitable screening. Residents are able to bring personal items with them on admission to the home and rooms had been personalised by the residents. Trevaylor Manor D52-D04 S9137 Trevaylor Manor V231487 190905 Stage 4.doc Version 1.40 Page 17 Radiators are guarded in the home and bathrooms have thermostatic control valves fitted where total body immersion takes place. The home was clean and hygienic on the day of the inspection except for one bedroom, which was discussed at the time of the inspection. Trevaylor Manor D52-D04 S9137 Trevaylor Manor V231487 190905 Stage 4.doc Version 1.40 Page 18 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27,29,30. Staffing levels appeared to meet the needs of the residents and staff morale appears to be good. Residents are in safe hands and the number of staff with NVQ level 2 exceeds the 50 ratio. Selection and recruitment procedures are in place to protect vulnerable residents from abuse but these should be strengthened and improved. Satisfactory arrangements are in place to select suitable staff in order that a quality service can be provided to residents. EVIDENCE: Staffing levels were flexible to meet the needs of the residents. Normally there are 9 care assistants on duty in the mornings, 5 in the afternoons and 4 at night. There are registered nurses on duty at all times. This ensures are the residents are safe and well cared for. Staff files were sampled and evidenced that required information was not always in place. A review of the recruitment and selection policies and practice must take place to ensure that residents are supported and protected by the homes recruitment practices. CRB and POVA were discussed with the manager and the Internet connection must take place immediately so that business support can operate these checking procedures. The manager is mindful of the magnitude of the job of ensuring that all staff training, development and supervision is taking place. She is currently reviewing this area of her responsibility and will be discussing it with the Trevaylor Manor D52-D04 S9137 Trevaylor Manor V231487 190905 Stage 4.doc Version 1.40 Page 19 managing director and agreeing a way forward. Each member of staff has an individual portfolio and all staff training is recorded in this portfolio, which commences from induction. Trevaylor Manor D52-D04 S9137 Trevaylor Manor V231487 190905 Stage 4.doc Version 1.40 Page 20 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31,32,35,36,38. The home is well run and organised for the benefit of the residents. Residents are encouraged to contribute and comment on the manner the home is run on a regular basis. This provides residents with the opportunity to improve the services and facilities provided. The systems in place for residents’ money safeguard their interests. Staff are well managed and supported in their duties by the management, which results in an enthusiastic workforce who work positively with residents to provide a positive quality of life. EVIDENCE: I have worked with the home for several years and note that that the residents benefit from the management style, ethos and her leadership approach. The manager’s style is one of openness and she enables staff and residents to affect the way the service is delivered The managing director supports the manager and visits nearly every day. Her support to the management team and staff is commendable and her open manner encourages residents and their relatives to contribute and comment to Trevaylor Manor D52-D04 S9137 Trevaylor Manor V231487 190905 Stage 4.doc Version 1.40 Page 21 the management and running of the service. Residents commented about the confidence they have in the management and the manner in which the home is organised to take account of their views, preferences and choices. The Responsible Individual submits a monthly report about the services and facilities provided as required by regulation 26. With reference to Health and Safety systems of control including risk management and operational controls, these should be reviewed in line with the corporate approach and be reflected in up to date policies and procedures. Records held by the home are stored in a confidential manner and in line with The Data Protection Act 1998. Trevaylor Manor D52-D04 S9137 Trevaylor Manor V231487 190905 Stage 4.doc Version 1.40 Page 22 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score 3 3 3 3 3 x HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION x x x 3 x x 3 3 STAFFING Standard No Score 27 3 28 x 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 3 2 4 4 x x 3 3 x 2 Trevaylor Manor D52-D04 S9137 Trevaylor Manor V231487 190905 Stage 4.doc Version 1.40 Page 23 No Are there any outstanding requirements from the last inspection? 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 18 Regulation 13(6) Requirement The Adult Protection policies and procedures must be reviewed to reflect current practice and all staff must receive ongoing training in adult protection to protect residents from harm. The recruitment and selection arrangements must be developed to be more robust and meet the requirements of 2 New staff must not commence care duties until the manager has recived a staisfactory POVA check. All helath and safety policies and procedures must be reviewed, updated and revised in line with the corporate approach. Timescale for action 28th February 2006 2. 29 18-19 sch 2 19 sch 2 28th february 2006 Immediate 3. 29 4. 38 12-13-23 28th february 2006 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 1 Good Practice Recommendations The Service User Guide should be up to date and avialable to residents and their representatives. D52-D04 S9137 Trevaylor Manor V231487 190905 Stage 4.doc Version 1.40 Page 24 Trevaylor Manor 2. 3. 4. 3 7 12 Agreement should be reached with the resident or their represenative on the care to be given by signing assessments and care plans. Outcomes recorded as a result of a review should have an action plan. Evidence of Leisure and social activities provided would further enhance the service. Trevaylor Manor D52-D04 S9137 Trevaylor Manor V231487 190905 Stage 4.doc Version 1.40 Page 25 Commission for Social Care Inspection John Keay House Tregonissey Road St Austell 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 Trevaylor Manor D52-D04 S9137 Trevaylor Manor V231487 190905 Stage 4.doc Version 1.40 Page 26 - 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. 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