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We are carrying out a review of quality at Trevern. We will publish a report when our review is complete. Find out more about our inspection reports.
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Inspection report

Date of Inspection: 16 January 2015
Date of Publication: 20 February 2015
Inspection Report published 20 February 2015 PDF | 77.77 KB

People should get safe and appropriate care that meets their needs and supports their rights (outcome 4)

Not met this standard

We checked that people who use this service

  • Experience effective, safe and appropriate care, treatment and support that meets their needs and protects their rights.

How this check was done

We looked at the personal care or treatment records of people who use the service, carried out a visit on 16 January 2015, observed how people were being cared for and checked how people were cared for at each stage of their treatment and care. We talked with people who use the service, talked with carers and / or family members and talked with staff.

Our judgement

Some of the people who used the service were not able to comment in detail about the service they received due to their healthcare needs, so we spent two hours observing care provided both before and during lunch in a dining area of one of the units. People were asleep or watching the TV. There were no activities going on for people to occupy their time. The registered manager told us there were pre planned activities including arts and crafts from external providers and church groups attending every other week in the main house. The staff in the laundry told us they encouraged some people to help fold laundry as an activity.

We saw staff placing clothing protectors over two people’s heads without explaining to them first what they were about to do. Although we observed some caring and sensitive interactions between staff and people who lived at the home, we also saw staff move two people without any explanation. One person had their wheelchair moved from behind without any warning by the staff. This did not respect the person.

Staff supported people with their meal. Staff spoke to people when they gave them their meal but did not actively engage the person in conversation during the meal and sat largely in silence. Lunch was not a social occasion for others who were able to eat independently, people ate without conversation. The television was on in the room and there was also quiet music in the background. Staff left the people sitting in the dining area alone. Following lunch one person requested to be moved to a more comfortable chair. This person asked four times before staff arrived to move them. This person felt unwell following this transfer and told staff they were about to be sick, staff were unsure where to locate a bowl for this person and there was a considerable delay in this person being supported. This did not help to maintain this person’s dignity.

During our inspection we walked around the three units which made up the home. We found unnamed continence products in all the bathrooms and toilets in the home. We were told staff used these for anyone who needed a pad change when in the toilet with staff. This did not ensure people would be provided with the correct product they had been assessed as requiring to meet their individual needs. However, we were shown the storage cupboard where there were individually named continence products, which were then transferred as needed in to people's rooms. One of the units was a dementia care unit. There was no clear signage in this unit to support people’s needs and encourage independence. Doors were not personalised to aid recognition. There were two rooms marked ‘bathroom’ one of which was the only operational bathroom for this unit, and contained a large amount of unnamed toiletries. The registered manager told us, “don’t know whose those are.” Communally used toiletries did not respect peoples’ dignity. There was one assisted bathroom and a shower/wet room in this part of the home.

We looked at three care plans. One person had not been able to have a bath or shower for eleven months due to the home not obtaining the appropriate bathing equipment to meet the person’s needs. This person’s family told us “they keep saying they are looking into it, but nothing happens. Hopefully something will come soon.” The care plan for this person did not provide clear guidance and direction for staff as it stated,“(the person) is able to be bathed and showered if they would like.” The care plan also stated the person was, “to have full bed bath to occur 3-4 (times) weekly and hair wash.” Staff did not record the care they provided every day, there were gaps in these records for 12 and 13 January 2015, with the last entry made at 2.20pm on 14 January 2015. Staff had not recorded that this person had received regular full bed baths. This person’s health care needs had changed recently and the home had appropriately requested the support of the Acute Care at Home team wh

Reasons for our judgement

Care and treatment was not planned and delivered in a way that ensured people’s safety and welfare.