Inspection on 26/06/07 for The Trio House

This inspection was carried out on 26th June 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. 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

The Trio House 22/06/09

The Trio House 16/05/06

The Trio House 07/11/05

The Trio House 22/06/05

The Trio House 19/02/05

The Trio House 15/09/04

The Trio House 18/03/04

Similar services:

Polesworth Group Friary Road

Polesworth Group Pooley Heights

Polesworth Group 32 Station Road

Polesworth Group 70 Long Street

Breme

Polesworth Group 64 Long Street

Polesworth Group 68 Long Street

10 Whitfield Avenue

Extracts from inspection reports are licensed from CQC, this page was updated on 09/07/2008.

CARE HOME ADULTS 18-65 Trio House The 15 Abbotsmead Road Belmont Hereford Herefordshire HR2 7SH Lead Inspector Christina Lavelle Key Unannounced Inspection 26th June 2007 5.45- Trio House The DS0000024794.V337826.R01.S.doc Version 5.2 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 Trio House The DS0000024794.V337826.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 Adults 18-65. 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. Trio House The DS0000024794.V337826.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Trio House The Address 15 Abbotsmead Road Belmont Hereford Herefordshire HR2 7SH 01432 342416 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) Miss Margaret Clark Stevenson Miss Margaret Clark Stevenson Care Home 3 Category(ies) of Learning disability (3) registration, with number of places Trio House The DS0000024794.V337826.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. Residents may also have a physical disability in addition to a learning disability 16th May 2006 Date of last inspection Brief Description of the Service: The Trio House is home to three adults who require care due to severe learning disabilities. The service users are all men who are aged in their thirties and forties. The home was set up just for them in 2001 when the care home they were living in closed. The provider and manager of this home (Miss Stevenson) was also manager of their former care home and so they have all known each other for years. Miss Stevenson is referred to as the manager in this report. The property is a detached family house, which is situated on a large, modern housing estate on the outskirts of Hereford city. There are local shops and facilities nearby, such as a superstore with a café and a park. The home has a suitable vehicle to provide transport for outings to town or further afield. The home has a fairly small and secure garden, which can be accessed through the conservatory from the living area. There is a good-sized lounge and a brick built conservatory with seating, a television and music centre so providing an extra sitting room. The house has a kitchen/dining area, a utility room, office and a staff sleeping-in room. Service users all have single upstairs bedrooms. One bedroom has an en-suite toilet and bath and another an en-suite toilet and shower facilities. There is a separate bathroom and ground floor cloakroom. The current fee for the service is £1103.00 per week for each service user. Additional charges are specified in the homes Terms & Conditions of Residence document, and include holidays, clothing, individual personal needs, renewing personal goods, funeral expenses and transport. Trio House The DS0000024794.V337826.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This is a key inspection of The Trio House. This means the inspector checked all the Standards that can be most important to people who live in care homes. During this visit to the home time was spent with service users in their lounge, observing their activities and interactions with each other and staff. It is not possible to discuss the home with them directly because of their disabilities. Survey forms were sent to service users’ families and to health and social care professionals involved with them, asking their views of the service. Although only two responses were received, their feedback is mentioned in this report. The manager discussed how the home is run, service users and their care and staffing. An annual self-assessment form had also been completed before this visit (as is now required). This asks providers to say what they think their care home does well, any changes they’ve made and plans to improve the service. One care worker was spoken with privately about her experience, training and the support staff receive. Service users care and lifestyles were also discussed. Various records about service users, staff and that show how the home is kept safe were checked and the premises looked at. All other information received by the Commission about the home since the last inspection is also considered. What the service does well: The Trio House offers a stable and comfortable home to service users. It is an “ordinary” house, which has helped them become part of the local community. The home feels homely and relaxed and service users and staff seem to get on well together. The home has good links with the service users’ families. One relative says that the care is good and their son is safe and happy. Service users are supported to go out a lot and on holidays. They take part in various activities outside the home, which makes their lives more interesting. Staff make sure that all the service users’ personal and health care needs are met. The home also manages their medicines safely for them. The house is well kept, decorated and furnished. Service users’ bedrooms are personal and this all makes the home a nice and homely place for them to live. Staff receive training so they know how to keep service users safe in the home and when they are out in the community. The small, stable staff team work together to make sure service users are well cared for. Trio House The DS0000024794.V337826.R01.S.doc Version 5.2 Page 6 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 contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Trio House The DS0000024794.V337826.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Trio House The DS0000024794.V337826.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 2&5 Quality in this outcome area is good. This judgement has been made using available evidence including this visit to the service. The home was set up for current service users and there have not been (and is unlikely to be) any new service users. Consequently Standards relating to the assessment and admission of prospective service users do not apply. Service users each have a contract agreed between the provider and their funding authority and the home provides a statement of terms and conditions. EVIDENCE: It was previously confirmed that a statement of purpose, service users guide and a terms & conditions of residence documents are provided for the home. There is also a contract agreed by the provider and the service users’ funding authority (Herefordshire Council), for the provision of the service. The home was set up for the current resident group and so there has not been a need for prospective service users to be given information about the home. Therefore key Standard 2 and other Standards relating to the assessment of prospective service users’ needs and aspirations and the arrangement of visits and trial stays at the home as part of an admission process, are not applicable. Trio House The DS0000024794.V337826.R01.S.doc Version 5.2 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 & 9 Quality in this outcome area is adequate. This judgement has been made using available evidence including this visit to the service. Each service user has a care plan showing their physical care needs, likes & dislikes and some goals that have been identified by staff. Plans help staff know their needs and how to meet them. However they need to be reviewed and updated with staff, service users and relevant people involved, to show how decisions are made on their behalf and their personal goals ascertained. Service users make some choices in their lives and daily routines. Risk assessments are also in place to minimise risks to their safety, but should focus positively on supporting them to develop their life and social skills. EVIDENCE: The service users’ care files were looked at and each person has a needs assessment and a care plan. Records include a personal profile (written in the first person) by staff with some life history information. Fairly detailed daily reports are made of their activities, GP & health care appointments and any other significant events, so providing useful information about their lives. Trio House The DS0000024794.V337826.R01.S.doc Version 5.2 Page 10 Plans are not very detailed but do cover relevant areas of personal, health and social needs and some information about each service users’ strengths and wants. Most plans were drawn up in 2005 and, as service users’ care needs have not changed significantly, staff have signed and dated them as being reviewed at regular intervals since. Although the care plan format does now include some new activities and goals, and how to help achieve them, further development of this more “person centred” approach to care planning is needed and their plans and risk assessments reviewed and updated accordingly. Although service users may not be able to openly express what they want plans should reflect how choices and goals are made on their behalf and why, with outcomes. The manager reports their relatives are reluctant to provide much direct input, however when staff identify goals etc this should be stated and could also be discussed in annual placement reviews or with other professionals involved, such as staff at the day service. The manager and care worker confirm they try to encourage service users to make choices about such as food and activities to the extent possible. Staff are able to interpret their body language and facial expressions and so get to know what they like and want to do. However plans do not show how this communication is facilitated and how staff are supporting them to develop their self help and daily living skills. Risk assessments have been carried out for each service user including for managing behaviours, advising staff to offer reassurance and use distraction. Others relate to environmental hazards such as guarding radiators or general risks such as falling, choking, bathing, swimming and support required when out in the community. They therefore focus on keeping service users safe. Whilst acknowledging service users’ potential to have an independent lifestyle is limited due to their disabilities, risk assessments should also be reviewed as part of developing their life skills and to show when decisions about their lives are made on their behalf. Trio House The DS0000024794.V337826.R01.S.doc Version 5.2 Page 11 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, 15, 16 & 17 Quality in this outcome area is good. This judgement has been made using available evidence including this visit to the service. Service users are supported to participate in various leisure and other activities within the wider community. The home also helps them to maintain links with their families and provides wholesome meals they like. EVIDENCE: Service users are not able to develop work related skills and so have a job or work placement. They all spend one day a week at a local day service, go horse riding and have group outings and holidays. Having lived in the same care home for years they are used to this and seem to get on well together. However additional funding was agreed last year to enable them to have more individualised activities. This involves designated staff time during weekdays to provide 1 to 1 support with activities out in the community. Each person has an activity plan which shows they go out for drives, shopping, swimming, walking, to Tescos etc. Today they had all been to Kenchester water gardens. Trio House The DS0000024794.V337826.R01.S.doc Version 5.2 Page 12 When at home service users spend most evenings watching TV, going out for walks or to the pub. They now also have music therapy sessions. This evening service users seemed happy and relaxed and sat in the lounge or conservatory, some watching TV. They had recently returned from a nine day holiday in Spain and more weekends away are planned. The care worker confirms service users do go out a lot and take part in activities and clearly understands the expectation that staff facilitate their activities. The manager has adjusted rotas so staff are deployed more flexibly for this reason. Issues of equality and diversity, and how the service promotes, them were discussed with the manager (and included in the self-assessment information). Service users are all men of a similar age with severe learning disabilities who are physically able. There are also no ethnic or cultural differences amongst them. The manager says that therefore that The Trio House offers an ordinary home to service users and that staff understand their different, individual needs and support them to feel confident out in the community. It was also discussed that the staff team are currently all women. However the manager does not feel there are any gender issues in respect of personal or social care. All service users either have regular contact and/or go to their family homes for visits. Relatives are invited to annual placement review meetings and the manager says the home is also trying to involve them more in care planning and service development. However they are happy with the current service provided and do not wish to have more direct input. One relative says she always receives enough information about her son and is kept up to date. She feels staff have the right skills and experience and has never had to complain. Her comments include that “All the residents are severely handicapped and the care home does everything possible to make their lives happy”. This family are very satisfied with present arrangements and say the service user is safe and happy at the home. Regarding food provided by the home the manager draws up weekly menus. Menus show a range of wholesome meals with plenty of fresh vegetables, fruit, pasta, salad etc. and few less healthy options. Breakfast is flexible and comprises of bran, cereals and toast. Lunches are such as omelette and salad with a main cooked meal each day. The staff member said that meals are freshly prepared and include fresh vegetables. Also that staff know service users’ food preferences and there is a list of their likes & dislikes. They can offer an alternative when a service user wants one or refuses a meal. None of the service users need a special diet but some plans show when any assistance is needed e.g. food cut up. Service users have their main meal together. Trio House The DS0000024794.V337826.R01.S.doc Version 5.2 Page 13 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 & 20 Quality in this outcome area is good. This judgement has been made using available evidence including this visit to the service. Service users receive appropriate support with their personal and health care and their medicines are managed safely on their behalf. It would ensure that all service users’ health care needs are being monitored, preventative steps taken and their good health promoted if they each have a Health Action Plan. EVIDENCE: Service users were observed to be clean and dressed in suitable clothing for spending the evening at home in summer. Their plans reflect that their selfhelp & daily living skills are limited and their personal care needs are described as “all care needed”. Staff complete daily hygiene records and toileting charts showing when and who has given support. The care worker confirms service users need a lot of support with personal care but staff encourage them to do as much for themselves as they can, such as washing and cleaning their teeth. Care records include some details of service users’ medical history, condition and health related issues. They show regular, routine health care checks and records kept of relevant physical checks, such as weight and body charts for any injuries, marks etc. However the Department of Health now recommends Trio House The DS0000024794.V337826.R01.S.doc Version 5.2 Page 14 that people with learning disabilities should have an individual Health Action Plan (HAP). These HAPs help to make sure that their physical and emotional health are being closely monitored, any problems identified and their good health promoted. This includes that service users’ special needs have been recognised and understood and that they are being supported to stay healthy through preventative, as well as routine and specialist health care input Regarding the management of service users’ medication none are able to self medicate and so staff do so on their behalf. Their medicines are suitably and safely stored and administration records are being maintained appropriately. The home provides a policy & procedures and staff had undertaken training on safe handling of medicines and receive in-house instruction from the manager. Trio House The DS0000024794.V337826.R01.S.doc Version 5.2 Page 15 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22 & 23 Quality in this outcome area is good. This judgement has been made using available evidence including this visit to the service. Although service users are unable to express their views directly the home has a system for complaints and they all have relatives to raise concerns for them. It would help to ensure staff are clear about their responsibility in relation to adult protection, and know when and how to refer any incidence or suspicion of abuse or neglect of service users, if they had received relevant instruction. EVIDENCE: The home has a complaints procedure, although in view of service users’ disabilities they are not able to express their concerns or views verbally. It is essential therefore that their families, staff and other people would do so on their behalf. Feedback from a relative (and other relatives previously) confirm they have never needed to make a complaint. One professional comments the manager is approachable and the home usually responds appropriately to any concerns. There have not been any complaints made to the home or to the Commission about the service, since the last inspection. However one issue has arisen in relation to the conduct of the manager. This has been referred under adult protection procedures and is not yet resolved. There is information in the home about abuse which staff go through during their induction. However it is recommended that staff working in care services should attend a training session taken by the co-ordinator for the Protection of Vulnerable Adults. This would ensure that they know about the multi-agency procedures and understand their responsibility for protecting service users and when and how they must report any suspicion or incidence of abuse or neglect. Trio House The DS0000024794.V337826.R01.S.doc Version 5.2 Page 16 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24 & 30 Quality in this outcome area is good. This judgement has been made using available evidence including this visit to the service. The Trio House provides accommodation that suitably meets service users’ needs and offers them a safe, clean and comfortable home. EVIDENCE: The Trio House is at the end of a cul-de-sac on a large, modern, residential housing estate. There is a park next to it and a superstore with a café within walking distance. It is an ordinary detached house and so fits in well with the local community. The house is decorated, furnished and equipped to a good standard and is well maintained. The self-assessment states that necessary health & safety and fire safety checks and risk assessment are being carried out and staff receive relevant training. The electrical circuits had been checked recently and the heating and gas installations serviced. The manager also said that the kitchen flooring had been replaced since the last inspection. The inspector spent time in the lounge, which is comfortable and service users clearly felt at home there, one watching the TV with their legs up on the sofa Trio House The DS0000024794.V337826.R01.S.doc Version 5.2 Page 17 and as it was a sunny day the door to the patio was open and one person was sat in the conservatory. All areas were seen to be clean and tidy. There is a policy and procedures in place relating to infection control and disposable gloves and aprons provided for staff. There are also arrangements in place for disposing of soiled waste. Trio House The DS0000024794.V337826.R01.S.doc Version 5.2 Page 18 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 33, 34 & 35 Quality in this outcome area is good. This judgement has been made using available evidence including this visit to the service. Service users are supported effectively by a more stable staff team. This is good for consistency of care and should mean they all know each other well. Improved recruitment procedures should also help safeguard service users. Staff receive support and complete necessary health & safety training. Their knowledge and skills would be enhanced with more training in relation to service users’ special needs and when more achieve a care qualification. This should help them understand and be able to meet service users needs better. EVIDENCE: The staff team comprises the manager and eight care staff. This is two extra two care workers since the last inspection, although necessary checks were awaited before one person could start work. Two staff are always deployed during the day, with a third most weekdays to facilitate activities, and one on at night sleeping in. There are no staff changes since the last inspection and rotas were more flexible to accommodate service users’ activities and holidays. Trio House The DS0000024794.V337826.R01.S.doc Version 5.2 Page 19 Regarding recruitment the records of the two new staff were checked. They had completed application forms and where one person had a gap in their employment, an explanation was obtained. Suitable written references had been taken up, including the most recent employer and a college tutor for one person who had just left college. Their staff files included copies of required documents such as a birth certificate and driving license. The home had introduced the Learning Disability Award Framework (LDAF) induction training programme for new staff, which is accredited especially for staff working in care with people who have learning disabilities. Although two staff have completed LDAF two others still need to undertake it, and should be enrolled on the course as soon as possible. The home also has an induction checklist for new staff and they work shadow shifts with the manager to familiarise themselves with care practices, service users and their needs and all the home’s policies & procedures. There is a training plan to make sure that staff complete mandatory health & safety training, with regular refreshers. This should include LDAF, care related topics (e.g. person centred planning) and other training that relates to service users’ special needs such as effective communication and epilepsy. Three staff have an NVQ qualification in social care and another two staff are doing the course currently. Once they achieve NVQ this will meet with the Standard that specifies at least half the staff team should be qualified. The manager and staff member feel that there is good communication within the staff team. Staff make and always read the service users’ daily reports, shift handovers take place and staff meetings held regularly. Staff receive individual supervision and new staff have an appraisal. Trio House The DS0000024794.V337826.R01.S.doc Version 5.2 Page 20 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. 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 are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 & 42 Quality in this outcome area is good. This judgement has been made using available evidence including this visit to the service. The home is being run by a suitably experienced manager and this inspection confirms compliance with relevant legislation that includes appropriate policies, procedures and practices in place to keep the home safe for service users. The system to review and assure the quality of the service should result in a plan for the home’s continual development. This should reflect improvements for service users, based on what they want and/or views of stakeholders and other people involved with them and help to make decisions on their behalf. EVIDENCE: The evidence obtained from this inspection indicates overall that the service provides good outcomes for service users. Whilst this is so the manager should ensure that the service continues to develop. Also that care practices, and her own and staff training, are up to date and reflect currently accepted Trio House The DS0000024794.V337826.R01.S.doc Version 5.2 Page 21 good practice guidelines and approaches, including person centred planning and effective communication techniques. There is now an onus on providers to monitor and assure the quality of care services, based on the views of service users and other stakeholders. More work is needed to develop these processes, although some audits are being undertaken. The manager says questionnaires have also been sent by the home to service users’ families and the intent is to invite them to a meeting to obtain their views and try to involve them more. The views of staff will also be sought and an annual plan for the continual development of the service drawn up reflecting all their views and improvements for service users. This plan should be made available to relevant people and a copy sent to the Commission. Regarding health & safety staff undertake relevant training and the information obtained indicates that risk assessments and necessary servicing and checks are being undertaken. There were also no safety hazards noted during this visit and so it is apparent that the safety of service users is being promoted, for their protection. Trio House The DS0000024794.V337826.R01.S.doc Version 5.2 Page 22 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 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 X 2 N/A 3 X 4 X 5 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 2 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 2 33 3 34 3 35 2 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 2 X 2 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 3 15 3 16 2 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 2 3 X 2 X 2 X X 3 X Trio House The DS0000024794.V337826.R01.S.doc Version 5.2 Page 23 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 meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The registered provider 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 to consider carrying out. No. 1 Refer to Standard YA6 & YA9 Good Practice Recommendations Service users’ plans and risk assessments should be reviewed and updated using a person centred approach. They should reflect how decisions are made on their behalf and involve relevant people in this process & to set goals. Each service user should have a Health Action Plan set up (as recommended by the Department of Health for people with learning disabilities). All staff should receive instruction in respect of abuse and adult protection and the multi-agency procedures for the Protection of Vulnerable Adults (POVA) taken by the local Adult Protection co-ordinator. The programme of NVQ training should continue to ensure that at least half the staff team achieve this qualification. Care staff should receive training in topics relevant to care practice and to the special needs of service users, such as LDAF, person centred planning and epilepsy. An annual plan should be produced with aims and action needed for the continual development of the service. This should reflect improvements for service users and their views and those of relevant other people and stakeholders. 2 3 YA19 YA23 4 5 6 YA32 YA35 YA39 Trio House The DS0000024794.V337826.R01.S.doc Version 5.2 Page 24 Commission for Social Care Inspection Worcester Local Office Commission for Social Care Inspection The Coach House John Comyn Drive Perdiswell Park, Droitwich Road Worcester WR3 7NW National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 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 Trio House The DS0000024794.V337826.R01.S.doc Version 5.2 Page 25 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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