Inspection on 22/02/06 for Trevaylor Manor

This inspection was carried out on 22nd February 2006.

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 found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Trevaylor Manor 11/09/07

Trevaylor Manor 09/11/06

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 Unannounced Inspection 22nd February 2006 09:00 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.V270610.R01.S.doc Version 5.0 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Trevaylor Manor DS0000009137.V270610.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Trevaylor Manor Address Newmill Road Gulval Penzance Cornwall TR20 8UR 01736 350856 01736 360370 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), Terminally ill (28) Trevaylor Manor DS0000009137.V270610.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 19th September 2005 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.). 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 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 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 twentyfour 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. Trevaylor Manor DS0000009137.V270610.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspector visited Trevaylor Manor Nursing Home on the 22nd and 23rd February 2006 and spent eleven and half hours at the home. This was an unannounced visit. The purpose of the inspection was to gain an update on the progress of compliance with the requirements that were identified in the last inspection report dated September 2005. In addition the inspector focused on the following key areas of care: choice of home, assessment and care planning, medications, leisure, complaints, environment, staffing and management areas and discussion with the service users and their relatives. The methods used to undertake the inspection was to meet with a majority of service users, visiting relatives and staff to enable me to gain an overall picture on the care and services the home is offering. Trevaylor Manor’s records, policies and procedures were inspected and time was spent looking around the home and observing the daily routine. This report summarises the findings of this inspection. It must be noted at the outset that the company are spending a considerable amount of money upgrading the home for the benefit of the service users. The following is not an exhaustive list but an example of what is going on, E.g. Redecoration, recarpeting, new equipment and new heating system. What the service does well: The service provides clear written information to enable people to make a decision about whether the home can meet their needs and suit their preferences. The home provides comfortable, well-maintained and homely accommodation, which meets the needs of the service users. The manager carries out detailed assessment of needs and considers carefully if the home can meet the needs of prospective service users. There is attention to detail in care planning and risk assessments with management and staff respecting the service users lifestyle preferences and choices in every thing they do. Residents report that they are well cared for, they have confidence in the registered manager and her staff who are kind and skilled and respect their privacy and dignity. The manager and staff monitor the healthcare needs of service users and are skilled at ensuring access to appropriate community healthcare professionals. Residents reported that they were satisfied with how their healthcare needs were met. With a very large staff group the manager is Trevaylor Manor DS0000009137.V270610.R01.S.doc Version 5.0 Page 6 constantly evaluating the service provided and taking action to secure improvements. What has improved since the last inspection? What they could do better: The care plan is the end point of the assessment of the service user. It is therefore fundamentally important that the plan is drawn up with the involvement of the service user or their representative. This ensures that the care to be given is agreed. The manager should set up a system whereby all the care plans are reviewed at least once a month, updated to reflect changing needs and current objectives for health and personal care. A shower room on the dementia wing would greatly assist staff to carry out the duties more efficiently especially in times of mishaps. Staff recruitment should be more robust with all required details as set out in Schedule 2 regulation 7,8,9. Please contact the provider for advice of actions taken in response to this Trevaylor Manor DS0000009137.V270610.R01.S.doc Version 5.0 Page 7 inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Trevaylor Manor DS0000009137.V270610.R01.S.doc Version 5.0 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 Outcomes Statutory Requirements Identified During the Inspection Trevaylor Manor DS0000009137.V270610.R01.S.doc Version 5.0 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 the following standard(s): 1,2,3,4,5,6. Prospective service users are given information about the home enabling them to make an informed decision about where they wish to live. Contracts are provided to service users with a statement of terms and conditions at the point of moving into the home. Service users are only admitted to the home following an assessment of their needs to ensure the home can meet the needs of all individuals. The Statement Of Purpose fully explains the importance of all prospective service users and their representatives visiting the home prior to making a decision to come and live there. No intermediate care is offered. EVIDENCE: The records for service users on the nursing and dementia wings were case tracked. The assessment included a general needs assessment on a standard format for the assessment of older persons, separate assessments for nutritional needs, moving and handling, and the risk of falls, activities of daily living, waterlow, eating and drinking, communication, orientation and behaviour, wound management and maintaining a safe environment were all in Trevaylor Manor DS0000009137.V270610.R01.S.doc Version 5.0 Page 10 place. The manager had also recorded the service users preferences and choices in a number of areas and these could be found on various documents. The service users and relatives I spoke with said they were satisfied with the way the admission had been managed. However the manager could take this one step further by agreeing and discussing the care plan with the service user or their representatives. The representatives who I spoke with stated that their relative was unable to visit the home so they visited for them to assess the quality, facilities and suitability of the home. The home does not specialise in intermediate care provision and does not have separate facilities for this. There are facilities for short-term respite care for service users who intend to return to their own homes following an admission to hospital. Each service user is provided with a statement of terms and conditions at the point of moving into the home. The statement of terms and conditions includes room to be occupied, overall care and services covered by the fee fees payable and rights and obligations of the service user and company and who are liable if there is a breach of contract and period of notice. Trevaylor Manor DS0000009137.V270610.R01.S.doc Version 5.0 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 the following standard(s): 7,8,9,10 and 11. All service users have detailed care plans, which direct and inform staff. The healthcare needs of service users are well monitored and addressed by the trained staff group. There are suitable systems in place for dealing with service users medicines and policies and procedures that inform and direct staff and ensures service users safety. Systems are in place to ensure that service users are respected and their privacy is upheld with service users benefiting from this. EVIDENCE: All service users have detailed care plans, which are drawn up as specific plans for each area of care need, risk and activity. Attention is also given to making specific directions and information accessible to staff for service users with more complex needs. The records of service users were case tracked. Each plan is dated and signed, and details the area of care, the objectives and the interventions required but monthly reviews are not routinely carried out. With 73 service users living at the home the reason for this maybe the magnitude of the task. The manager is currently reviewing this area of her responsibility and is going to set up systems wherby staff can on a daily basis review the specific Trevaylor Manor DS0000009137.V270610.R01.S.doc Version 5.0 Page 12 goal and reference it in the daily record when it requires attention by the nursing team. The keyworker nurse will follow up this intervention and new goals will be set. The records evidence that the healthcare needs of service users are monitored with the manager and staff being very good at accessing all community healthcare professionals with the aim of providing a good standard of healthcare to the service users. Service users felt that they were well supported to make decisions about their care, others were too ill to make decisions and that staff respected their dignity and wishes. The service users plans meet relevant clinical guidelines produced by the relevant professional bodies concerned with the care of older people and include risk assessments, with particular attention to prevention of falls. It is recommended that further work is undertaken on the greater involvement of the service users or their representatives so that agreement on the care to be given is agreed. Where it is not possible to obtain the signature of the service user or representative to agree a care plan, the reason should be recorded. The daily records are informative with all care staff contributing to the daily record. This improves their skills in recording. There is a suitable medicines policy and system in place for the administration of medicines. Storage is safe and secure. All medicines received into the home are recorded on the MARS sheets. Medicines are suitably disposed of through a waste company and the new Doom Kit was in operation. A physical check and count of the controlled medication confirmed the security and safety of all prescribed medication to be satisfactory. The are suitable arrangements for ensuring the service users privacy and dignity. Staff were observed to respect service users privacy during the inspection. The home has a policy and procedure on the care of dying service users. There is evidence that service users’ wishes and preferences in respect of care and death are recorded. The manager’s aim is for service users who are dying to be cared for in their own room, with support from staff, other agencies and for family to be involved where this is the service user’s wish. Trevaylor Manor DS0000009137.V270610.R01.S.doc Version 5.0 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 the following standard(s): 12,13,14,15. Service Users are supported in a lifestyle accords with their expectations and preferences. Family and friends are encouraged and made welcome when they visit which enables the service users to retain contact with their loved ones. The availability, quality and style of presentation of food along with the way in which staff assist service users ensures that service users receive a wholesome, appealing and nutritious diet. EVIDENCE: The Statement Of Purpose clearly sets out the aim of the home to provide an environment where service users will have the opportunity to maximise their choice to exercise personal autonomy and choice to experience a fulfilling residential experience. The home provides transport to take service users on outings and the home also picks up and takes home family members on Tuesday and Thursday who do not have any transport to visit their relatives. Service users informed the inspector that they enjoy the outings and activities and were pleased that transport is provided free to their relatives. The company employ an activities assistant for taking service users to appointments, reminiscence and activities of the choosing This member of staff demonstrated an awareness of the needs of the service users in relation to Trevaylor Manor DS0000009137.V270610.R01.S.doc Version 5.0 Page 14 activities and daily life. The manager and staff welcome family and friends at any time as long as this accords with the wishes of the service user. This is stated in the statement of purpose. Service users can entertain visitors in their own rooms or the communal rooms. Service users reported that they were pleased with the arrangements for visiting and the staff always made their visitor welcome. Service users made consistently positive comments about the quality of meals and catering arrangements. The menu records a varied and nutritious diet. Breakfast consists of a choice of cereals, toast, fruit, eggs and drinks and anything of the service users choosing. The main meal is taken at midday. The dining room is spacious, light and airy and tables have linen tablecloths and napkins and flowers. The meals observed were appetising and well presented. The service users who required help were not rushed and received appropriate individual support from the staff. Special diets are presented in a manner, which are attractive and appealing in terms of texture, flavour and appearance in order to maintain appetite and nutrition. Trevaylor Manor DS0000009137.V270610.R01.S.doc Version 5.0 Page 15 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): 16,17,18 The home has a comprehensive complaints procedure that ensures complaints are listened to and acted upon. Arrangements are in place to protect service users and respond to all concerns in a positive manner to ensure the safety of service users. EVIDENCE: There is a robust complaints policy, which details the types of complaint that can be made and the timescales for the resolution for the complaint. The service users, relatives and friends that I spoke with said they would know how to make a complaint and who to complain to. Staff recruitment records show that they are employed on the basis of their fitness and suitability to work with vulnerable adults. There are detailed written procedures to guide them on how to recognise when abuse is taking place and what to do when this happens. Staff have access to the homes policy and procedure on Aduilt protection, which details the role of the local multi-agency, and are provided with in-house training. Trevaylor Manor DS0000009137.V270610.R01.S.doc Version 5.0 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 the following standard(s): 22,25,26. The home is well appointed, comfortable, safe and well maintained. The premises are clean and hygienic providing a pleasant environment and reducing risks to service users. EVIDENCE: The home is situated on the outskirts of Penzance. Information about the accommodation is provided in the statement of purpose. Trevaylor Manor is set in spacious landscaped grounds with parking to the front. Entry to the home is diabled friendly with ramped areas. Inside the home equipment and facilities are provided to assist service users to get around the home easily. There is a passenger lift to all which is serviced at regular intervals. The home is comfortable and homely and the company maintains the premises to a high standard. The service users rooms have been personalised by them and reflects the individuality of the occupant. All personal and the homes washing are laundered on the premises. The company has provided commercial washing and drying machines. Protective gloves, aprons and Trevaylor Manor DS0000009137.V270610.R01.S.doc Version 5.0 Page 17 appropriate hand washing facilities with paper towels have also been provided. The baths, showers, toilets, commodes and all basins were clean and hygienic. Service users reported that their rooms were kept clean and tidy. There are detailed cleaning procedures with specified tasks for staff. There are hygiene procedures. Infection control information is available to staff. It is recommended that consideration be given to creating a shower facilty on the dementia wing. The benefits of this would mean that if a mishap occurred the service user could be given immediate attention by the staff. Trevaylor Manor DS0000009137.V270610.R01.S.doc Version 5.0 Page 18 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27,29,30 Staff are employed on the basis of fair, safe and effective recruitment policies and practices to ensure that they are suitable to work with service users. They are well trained to ensure that service users benefit from good care practices. EVIDENCE: Guidelines on dependency levels are being met and these are kept under constant review to accommodate the changing levels of dependency. Staff on duty on the days of the inspection was on the nursing wing manager plus 3 qualified nurses and 8 care assistants, dementia wing senior nurse plus 2 nurses and 5 care assistants. In addition to this there were chefs, domestics, maintenance personnel and laundress and secretary. The company have introduced clear, written recruitment policies and recruitment documents. Further work should be carried out to provide evidence that this is adhered to in practice. Some staff files inspected lacked the full information e.g. Photograph, proof of I.D. for example. There is a comprehensive policy to ensure that staff are recruited on the basis of equal opportunities. Service users stated they were extremely well looked after by the staff that approached their work in a flexible manner. Training is provided to all staff and the majority hold NVQ 2 or above. The training is planned according to the individual needs of the staff and this helps to meet the varied needs of the service users. The company employ a training officer who works closely with the manager. Trevaylor Manor DS0000009137.V270610.R01.S.doc Version 5.0 Page 19 The company are committed to well-trained staff. Training commences from induction and is ongoing. Further work should be done on the individual staff files to fully record all training and supervision that has taken place. Courses are conducted in house and through local colleges and independent training providers. I talked with staff that said that they are provided with good access and support to undertake training to develop their knowledge and skills for the benefit of service users. Trevaylor Manor DS0000009137.V270610.R01.S.doc Version 5.0 Page 20 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31,32,35,38. 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 discharges her responsibilities fully. The systems in place for residents’ money safeguard their interests. Appropriate training in Health and Safety is provided and safety checks are undertaken to ensure the health safety and welfare of service users and staff. EVIDENCE: The home is managed in an open manner and service users are encouraged to contribute and comment upon the management and running of the service. Service users said to me that they have confidence in the management and Trevaylor Manor DS0000009137.V270610.R01.S.doc Version 5.0 Page 21 the manner in which the home is organised to take account of their views, preferences and choices. Where possible, service users control their own finances or have delegated this to family and representatives. The administrator maintains a balance sheet for each of the service users who personal allowance she manages. This details the personal allowance, the balance of money held, and any expenditure and cash taken by the service user. The Statement of Purpose asks families to record inventories of belongings for each service user at admission and requests that the manager is informed when money and belongings are brought into the home. The manager endeavours to ensure that working practices are safe. Relevant service checks take place as required. Staff receives statutory training regularly which includes fire training, health and safety, food hygiene and first aid. Accident reporting complies with data protection and the Manager audits accidents in the home at regular intervals. Staff are supported by the manager and nursing team and the manager has an open door policy and encourages staff and representatives of service users to discuss any issues they have with her in an open and fair manner. The Managing Director visits the home every day to offer her support and guidance and she also submits a regulation 26 reports to the Commission every month on the conduct of the home. The managing director’s input is pivotal to the success of the company. Trevaylor Manor DS0000009137.V270610.R01.S.doc Version 5.0 Page 22 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 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 Standard No Score 16 3 17 3 18 3 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 4 4 x x 3 x x 3 Trevaylor Manor DS0000009137.V270610.R01.S.doc Version 5.0 Page 23 Are there any outstanding requirements from the last inspection? Yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP29 Regulation 18-19 sch 2 Requirement The recruitment and selection arrangements must be developed to be more robust and meet the requirements of Schedule 2. “2nd Notification Timescale for action 30/08/06 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 OP3 Good Practice Recommendations Agreement should be reached with the resident or their representatives on the care to be given by signing assessments and care plans. 2nd notification A shower room should be considered for the dementia wing to enable the staff to have an additional bathing facility for the service users. POVA first checks should be carried out before employment is offered. Individual staff training files should be incorporated in the staff files to represent one file one staff. 2 3 4 OP22 OP29 OP30 Trevaylor Manor DS0000009137.V270610.R01.S.doc Version 5.0 Page 24 Commission for Social Care Inspection St Austell Office John Keay House Tregonissey Road St Austell Cornwall PL25 4AD National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. 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