Trevaylor Manor

Updated 5 April 2023

The inspection

We carried out this inspection under Section 60 of the Health and Social Care Act 2008 (the Act) as part of our regulatory functions. We checked whether the provider was meeting the legal requirements and regulations associated with the Act. We looked at the overall quality of the service and provided a rating for the service under the Health and Social Care Act 2008.

Inspection team

The inspection was carried out by three inspectors and an Expert by Experience. An Expert by Experience is a person who has personal experience of using or caring for someone who uses this type of care service.

Service and service type

Trevaylor Manor is a ‘care home’. People in care homes receive accommodation and nursing or personal care as a single package under one contractual agreement. The Care Quality Commission (CQC) regulates both the premises and the care provided, and we looked at both during this inspection.

Registered Manager

This provider is required to have a registered manager to oversee the delivery of regulated activities at this location. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Registered managers and providers are legally responsible for how the service is run, for the quality and safety of the care provided and compliance with regulations.

At the time of our inspection there was a registered manager in post.

Notice of inspection

This inspection was unannounced.

What we did before the inspection

We reviewed information we had received about the service since the last inspection. We also reviewed information that we held about the service such as notifications. We used information sent to us by the provider in their PIR. A PIR is information providers send us to give some key information about the service, what the service does well and improvements they plan to make.

We used all of this information to plan our inspection.

During the inspection

We reviewed 6 people's care plans and risk assessments. We reviewed staff training and supervision. We also reviewed other records relating to the management of the service. We spoke with the 9 people who lived at Trevaylor Manor,12 staff, the registered manager, the human resources manager, the business manager, and the quality manager. We spoke with 4 relatives. Following the inspection visit we spoke with 6 relatives and a visiting healthcare professional on the phone to gather their views.

Updated 5 April 2023

About the service

Trevaylor Manor is a residential care home providing personal and nursing care to up to 81people. The service provides support to older people and people living with dementia. At the time of our inspection there were 59 people using the service.

Trevaylor Manor is part of the Swallowcourt Limited group of services.

People’s experience of using this service and what we found

We toured the premises and found a few doors marked ‘fire door keep shut’ which were propped open. Doors to staircases and to rooms containing items which could be of risk to people were not always secured. We have made a recommendation about this in the safe section of this report.

The provider had effective safeguarding systems in place and staff knew what actions to take to help ensure people were protected from harm or abuse.

People received their prescribed medicines in a safe way. An electronic medicines management system was being used. Regular medicine audits were taking place to identify any areas for improvement.

There were enough staff to meet people's needs and ensure their safety. However, staff told us of short notice staff absences which had led to pressure on staffing, especially at weekends. Some agency staff were being used. However, these were mostly consistent and knew people well.

Many staff members had worked at Trevaylor Manor for years. One staff member told us, “We would not stay if we were not happy. It is a good place to work.”

The service had some vacant posts at this time. Recruitment of new staff was in progress. Processes in place helped ensure safe recruitment.

People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible and in their best interests; the policies and systems in the service supported this practice.

Staff worked within the principles of the Mental Capacity Act (MCA) and sought people's consent before providing personal care and assistance. Guidance in care plans guided staff to help build independence wherever possible.

Identified risks were assessed and monitored. Care plans contained guidance and direction for staff on how to meet people’s needs.

Food looked appetising and there were staff available to support people where needed. Specific staff were allocated to people who required additional nutritional support. People, relatives and staff told us they enjoyed the food.

Relatives told us, “Since (Person’s name) came here they are so much better, almost like the dementia has decreased. They have confident staff that know how to handle (Person’s name),” “There are always staff around to talk to if you need to. They have worked hard to get (Person’s name) to eat, they are fussy and reluctant to eat,” “My standards are high, and I am happy. I am completely listened to, they communicate well” and “We are always told if anything happens or any changes in their health.”

The registered manager and the provider had effective oversight of the service. There was a robust audit programme in place to help identify any areas of the service that may require improvement.

A visiting healthcare professional told us, "I could not be more supportive of Trevaylor Manor as everything is so much better now than a few years ago. They are quick to ring me and follow any advice I give."

Staff and relatives were asked for their views and experiences at meetings held by the registered manager. Feedback about the registered manager was positive. Relatives were kept informed of any changes in people’s needs or incidents that occurred.

The registered manager understood their responsibilities under the duty of candour.

The registered manager and staff worked closely with local health and social care professionals to meet people’s needs.

For more information, please read the detailed findings section of this report. If you are reading this as a separate summary, the full report can be found on the Care Quality Commission (CQC) website at www.cqc.org.uk

Rating at last inspection

Rating at last inspection was good (published 12 June 2021). At this inspection the rating remains good.

Why we inspected

This inspection was prompted by concerns received by CQC about this service. Concerns were regarding staff shortages, lack of equipment, poor mealtime support and medicine errors.

We looked at infection prevention and control measures under the Safe key question. We look at this in all care home inspections even if no concerns or risks have been identified. This is to provide assurance that the service can respond to COVID-19 and other infection outbreaks effectively.

Recommendations

We have made a recommendation in relation to fire door checks and securing rooms containing items that could pose a risk to people.

Follow up

We will continue to monitor information we receive about the service, which will help inform when we next inspect.