CARE HOMES FOR OLDER PEOPLE
Trevaylor Manor Newmill Road Gulval Penzance Cornwall TR20 8UR Lead Inspector
Stephen Baber Key Unannounced Inspection 9th November 2006 09:30 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.V305825.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.V305825.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), Terminally ill (28) Trevaylor Manor DS0000009137.V305825.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION
Conditions of registration: Date of last inspection 22nd February 2006 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 on the lower ground floor of the home.). Service users rooms are spread out over three floors with a shaft lift to access all floors. Service users 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 service users 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 service users 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 £562.00-£650.00 per week. Additional charges are made for, hairdressing, private chiropody. Daily outings organised by the home are free to all service users. Trevaylor Manor DS0000009137.V305825.R01.S.doc Version 5.2 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. The Commission are making changes to the regulations and inspection of social care agencies. Inspecting for Better Lives (IBL). We are modernising the way we inspect all social care services and will be more proportionate, more focus on the experience of people using services and focus on providers to ensure quality. This was an annual key inspection, which took place over two days and was unannounced. It lasted for approximately 17 hours. The Commission did not receive information about the home prior to the inspection in the form of a pre inspection questionnaire. This information was lost in the post and has now been forwarded to the Commission. The purpose of the inspection was to ensure that service users’ needs are appropriately met in the home, with particular regard for ensuring good outcomes for them. Throughout the two-day inspection interviews with service users and observation of the daily life and care provided were undertaken. There was an inspection of the home’s premises and of written documents concerning the care and protection of the service users and the ongoing management of the home. Staff were interviewed and observed in relation to their care practices and there was a discussion with the home’s manager. The principle method used was case tracking. This involves examining the care notes and documents for a select number of service users and following this through with interviews with them and/or their relatives and staff working with them. This provides a useful, in-depth insight as to how service users needs are being met in the home. At this inspection, three of the service users on the nursing wing and two on the dementia wing were case tracked. Overall there was evidence of ongoing improvement in care standards at this inspection and work is continuing to improve it further to provide service users with a safe and comfortable home in which service users can feel comfortable and safe. This was evident on the dementia wing where additional communal space has been provided with pleasant views of the gardens for all service users. The manager has decided that two beds will be integrated in the home with service user accommodation spread out over two floors. What the service does well:
The home’s policy is for prospective service users to undergo assessment of their needs prior to their admission. The registered manager or senior nurses
Trevaylor Manor DS0000009137.V305825.R01.S.doc Version 5.2 Page 6 undertakes this with the prospective service users and/ or their representatives, including relatives and health or social care professionals if they are involved. Assessments consider service users individual and complex health, personal and social care needs so they can be confident the home will be suitable for them. The statement of purpose provides clear information on the services and facilities offered, including short-term and respite care so that prospective service users have good information as to whether the home will be suitable to meet their needs. Service users interviewed at the time of the inspection said that they are satisfied that their healthcare needs are being met. Healthcare professionals visit the home and contribute and work with management and staff to the quality service the service users receive. Records evidence that this takes place regularly. There are facilities to ensure that service users can receive personal care in private and service users said that there are suitable arrangements to ensure they are treated with respect. Family and friends were observed to be visiting and they confirmed that they are able to visit when they wish and can meet with their relatives in private. The home has a range of communal facilities and a spacious garden, which service users can make use of with the support of family or staff. The service users I spoke with said the facilities and lifestyle the home provides is good. Outings are arranged daily and there are entertainers and different therapies taking place daily. The recreational Coordinator showed me the daily activities and records of those service users who attended. There are no restrictions on visitors and service users are able to maintain relationships with friends and relatives if they wish. The nurse in chage and staff very well manages the complex needs of the service users on the dementia wing. I observed service users making choices over issues that were important to them at the time. Rooms were personalised but on the dementia wing they had to be locked because of the behaviours of some service users. The home appears comfortable, well maintained and safe so that service users can enjoy attractive and homely surroundings. It was clean and tidy throughout at the time of the inspection, which was unannounced and service users said that it is always kept clean and that they were very comfortable.. All of the service users interviewed said that they are very satisfied with the care and services provided to them in the home and would feel confident that any complaints would be taken seriously and acted upon by the manager and staff.. There are systems in place to protect service users from harm and abuse, including written guidance for staff on what they should do if they Trevaylor Manor DS0000009137.V305825.R01.S.doc Version 5.2 Page 7 suspect abuse of a service user and recruitment practices to ensure that staff are suitable to work with vulnerable adults in a care setting. Staff are employed in different capacities and sufficient numbers to meet service users needs. The nurses are very well qualified and the care staff are provided with training that is recognised Nationally (NVQ) Staff are recruited on the basis that they are suitable to work with vulnerable adults in a care setting. The home provides service users and staff with a safe environment to live and work in. There are satisfactory systems in place including staff training, written policies and procedures, accident records, regularly reviewed risk assessments and equipment tests and checks by suitably qualified people What has improved since the last inspection? What they could do better:
Throughout the report the manager and staff have demonstrated through evidence, discussion with service users and observations of daily life that they have substantial strengths and a sustained track record of delivering performance and managing improvement. Where weaknesses have emerged in the area of recording staff training, supervision and quality assurance the service recognises this and manages them well. The key National Minimum Standards under outcomes groups are generally met but the areas detailed
Trevaylor Manor DS0000009137.V305825.R01.S.doc Version 5.2 Page 8 above require improvement and I am confident the manager will put them right. 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. Trevaylor Manor DS0000009137.V305825.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.V305825.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 3,6. Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to this service. Admissions are not made to the home until a full needs assessment has been undertaken. The home are then able to confirm that they can meet the needs of the individual through the service they deliver as detailed in the Statement of Purpose. Evidence confirms that the assessment is conducted professionally and sensitively and has involved the family or representative of the service user. EVIDENCE: The manager, managing director or senior nurse complete detailed assessments on service users prior to admission. Service users I spoke with said that the manager arranged to meet them and discussed their needs. The manager would also involve and seek out the views of other community health care professionals and family and relatives. Assessment formats include consideration of prospective service users diverse needs relating to their cultural and ethnic backgrounds, religion, age, gender, abilities and some consideration of their sexual orientation. There was assessment information relating to all the service users who were case tracked on their personal files
Trevaylor Manor DS0000009137.V305825.R01.S.doc Version 5.2 Page 11 and comprehensive risk assessments covering the holistic needs of service users. Intermediate care is not provided by the home. Trevaylor Manor DS0000009137.V305825.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9,10. Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to this service. The care plan is used as a working tool and is understood by all staff. It is written in a clear language and can be used in an emergency by people who are not familiar with its content. Each care plan includes a comprehensive risk assessment. Management of risk takes into account the needs of service users balanced with their aspirations for independence and choice. There is evidence of current reading and learning, including training, that the home keeps up to date with professional research and literature, in both the social and clinical fields and ensures that care plans are informed by the social and clinical guidance. Quality monitoring systems include gathering the views and experiences and satisfaction of service users in relation to their involvement in developing the care plan and in the review process. The home acts upon the outcomes of consultation with service users and their families. EVIDENCE: Trevaylor Manor DS0000009137.V305825.R01.S.doc Version 5.2 Page 13 Service users with whom I spoke varied from people who were quite ill to people who lead a full life at the home with the support and help of the staff. Some service users did not wish to be concerned with their care plan because of their age, general dependency and frailty, whilst others I spoke with said that they knew about their care plan. Records of their care plans were inspected and evidenced that regular reviews take place. The manager stressed the importance of user and family or representatives involvement in the process. It is recommended that the signatures of service users or their representatives are recorded to evidence has been reached on agreement to the care plan. Risk assessments and dependency scoring assessments take place that guide and inform staff on the individual needs of the service users. Medication is well managed and a check of the medication room proved to be satisfactory. There are suitable arrangements for ensuring the privacy and dignity of service users. Staff were observed to be responsive to the needs of the service users and the comments from the service users confirmed that these important principles of care are being met. Records inspected were legible, well written and up to date. Trevaylor Manor DS0000009137.V305825.R01.S.doc Version 5.2 Page 14 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. Quality in this outcome area is excellent. This judgement has been made from evidence gathered both during and before the visit to this service. Food and mealtimes is treated as an occasion and something to be looked forward to. Experienced chefs are responsible for providing quality nutritional meals that meet the cultural and dietary needs of the service users. Care staff and the nurses are sensitive to the needs of those service users who find difficulty to eat and give assistance with feeding. The staff are aware of the importance of feeding at the pace of the service users, making them feel comfortable and unhurried. Tables are set attractively with the necessary good quality cutlery and aids to help individuals during meal times. Birthdays and celebrations are made special for individual service users A great deal of thought is given to arranging social life within the home including the opportunities to take part in activities. The service works hard to meet the varying needs of the individual service users. EVIDENCE: This is an area that has greatly improved with management and staff accepting that know service users are at a later stage of life this does not mean that their social, cultural, recreational and occupational characteristics which have taken a lifetime to emerge have know diminished. I discussed at length with the recreational coordinator the lifestyle of individuals within the home and the social life that is organised within the home along with the range of activities
Trevaylor Manor DS0000009137.V305825.R01.S.doc Version 5.2 Page 15 available. It was noted that throughout the home some service users want an active well organised social life, in contrast, others will want a level of privacy and independence from others and look to the home for more passive activities such as religious observance. Detailed records were provided of what individual service users would like to do and the management and staff respected this. Another improvement is on the dementia wing where additional communal space has been provide for the service users with very pleasant views of the grounds. 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.V305825.R01.S.doc Version 5.2 Page 16 Complaints and Protection
The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16,18. Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to this service The service has a complaints procedure that is up to date, very clearly written, and is easy to understand. The service users demonstrated a good understanding of how to make a complaint and they are very clear of what can be expected to happen if a complaint is made. Unless there are exceptional circumstances the service always responds within the agreed timescales. The policies and procedures regarding the protection of service users 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. 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. Most of the service users who were interviewed at the time of the inspection stated that they are satisfied with the care and services provided to them at the home. Some said that they had confidence in the home’s manager to address their concerns. 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
Trevaylor Manor DS0000009137.V305825.R01.S.doc Version 5.2 Page 17 procedure on Adult Protection, which details the role of the local multi-agency, and are provided with in-house training. Trevaylor Manor DS0000009137.V305825.R01.S.doc Version 5.2 Page 18 Environment
The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19,26. Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to this service The home has a well-maintained environment, which provides aids and equipment to meet the care needs of the service users. It is a very pleasant place to live with rooms that meet the national minimum standards or are larger and some have ensuite facilities. Service users are encouraged to personalise their rooms to meet their needs. 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 home provides a high standard of accommodation and is well decorated and attractively furnished throughout. The home appeared clean and tidy throughout at the time of the inspection, which was unannounced. Staff and
Trevaylor Manor DS0000009137.V305825.R01.S.doc Version 5.2 Page 19 service users confirmed that it is kept clean. The staff undertake training in infection control and there are written policies and procedures in place to guide staff on how to prevent infection from spreading in the home. Staff are provided with protective clothing and bactericidal hand gel and were observed making use of, suitable equipment to maintain hygiene in the home. Trevaylor Manor DS0000009137.V305825.R01.S.doc Version 5.2 Page 20 Staffing
The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29,30. Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the 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 service users. The service users its own in-house training officer and expertise within the home to deliver this training. External training is also undertaken if the manager feels that they have not got the appropriate skills within the home. The service users report that staff working with them are very skilled in their roles and are consistently able to meet their needs. EVIDENCE: For varying reasons several care staff have left the home recently to pursue different occupations or left to go up country. The manager has put out advertisements for care assistants and is currently recruiting. 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 were 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 are asked for by the home when staff are offered employment
Trevaylor Manor DS0000009137.V305825.R01.S.doc Version 5.2 Page 21 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. 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 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 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 service users. The company employ a training officer who works closely with the manager. It is recommended that the homes induction training is compared to The Skills For Care Induction and an action plan is drawn up to introduce this induction training in line with Skills For Care 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 who 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.V305825.R01.S.doc Version 5.2 Page 22 Management and Administration
The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31,33,35,36,38. Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to this service. The manager has the required qualifications and experience and is competent to run the home. She works to continuously improve services and provide an increased quality of life for the service users. The manager is service user focused and leads and supports a professional nursing and care staff team whom she has recruited herself. The manager is aware of current developments both nationally and by C.S.C.I. and plans the service accordingly. EVIDENCE: The home is managed in an open and transparent 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 the manner in which the home is organised to take account of their views, preferences and choices.
Trevaylor Manor DS0000009137.V305825.R01.S.doc Version 5.2 Page 23 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 in her office. 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. There are currently formal systems in place to take service users views on the quality of the services provided into account in the ongoing planning and development of the service. This may be through the care planning process, carers groups, service users meetings, anonymous questionnaires and compliments cards, for example. The manager has introduced a formal quality assurance questionnaire in June 2006 but has not collated the information to provide an annual development plan for the home based on a systematic cycle of planning, action, review, reflecting aims and outcomes for service users. It is recommended that this be completed. New nursing staff interviewed said that there is good induction training and they have regular contact with the manager. The manager is also a practitioner and works alongside staff offering them supervision, guidance and support, but needs to arrange formal 1:1 supervision with staff so that they have opportunities to reflect on and develop their practice. There are written environmental and fire safety risk assessments in place but these were completed in 2004. It is recommended that the fire plan is brought up to date and the Pac Master is downloaded to record when the electrical appliances were last tested. Detailed records were maintained of the ongoing work the maintenance staff are doing. Trevaylor Manor DS0000009137.V305825.R01.S.doc Version 5.2 Page 24 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 X X 3 X X N/a HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 4 14 4 15 4 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 4 X 3 X 3 3 X 3 Trevaylor Manor DS0000009137.V305825.R01.S.doc Version 5.2 Page 25 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. 1. Refer to Standard OP7 Good Practice Recommendations The registered person where appropriate and, unless it is impracticable to carry out such consultations, after consultation with service users or a representative of his, revise the service users plan and notify the service users of any such revision and encourage the service user or their representative to sign the care plan to evidence that agreement has been reached on the care to be given. The registered person compares the current induction programme to Skills For Care Induction and draws up an action plan in line with the requirements for the recognised induction training and all staff training should be recorded in their training profiles. The registered person shall establish and maintain a system for reviewing at appropriate intervals the quality of care provided at the care home, including the quality of nursing. The registered person shall ensure that all staff receive
DS0000009137.V305825.R01.S.doc Version 5.2 Page 26 2. OP30 3. OP33 4. OP36 Trevaylor Manor 5 OP38 formal 1:1 supervision so that they have opportunities to reflect on and develop their practice The registered person ensures that the fire risk assessment is updated and that the detail is downloaded from the Pac Master electrical appliance to evidence that all the electrical equipment throughout the home has been tested and is safe to use. Trevaylor Manor DS0000009137.V305825.R01.S.doc Version 5.2 Page 27 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
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