Inspection on 25/01/07 for Three Trees

This inspection was carried out on 25th January 2007.

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

Three Trees 16/02/09

Three Trees 28/02/06

Three Trees 12/10/05

Three Trees 15/02/05

Three Trees 14/09/04

Similar services:

Larch Avenue

Alderson Road 12

Cranworth Close Registered Care Home

The Cornerstone

John Street Nursing Home

Pennine Camphill

Muston Road (70)

Grayling

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

CARE HOME ADULTS 18-65 Three Trees 24 St Johns Avenue Bridlington East Yorkshire YO16 4NG Lead Inspector Mr M. A. Tomlinson Unannounced Inspection 25th January 2007 09:30 Three Trees DS0000019764.V325044.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 Three Trees DS0000019764.V325044.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. Three Trees DS0000019764.V325044.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Three Trees Address 24 St Johns Avenue Bridlington East Yorkshire YO16 4NG 01262 601626 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) Mr Barrie Stephen Gosland Mrs Christine Alma Gosland Mrs Christine Alma Gosland Care Home 21 Category(ies) of Learning disability (21) registration, with number of places Three Trees DS0000019764.V325044.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 28th February 2006 Brief Description of the Service: Three Trees registered to provide care and accommodation for up to 21 younger adults is a comfortable well maintained domestic style home that is situated in a residential area of the seaside town of Bridlington in East Yorkshire. It is conveniently located for all of the main community facilities including the public transport network. The care home has a number of communal/lounge areas two of which are designed to provide selected service users with an opportunity to experience semi-independent living. There is a mix of single and shared bedrooms. The home does not have a passenger lift and consequently is only considered suitable for service users who are reasonably ambulant. The home has its own transport for taking residents to day centres or on outings in the surrounding countryside and has good access to the local bus service and railway station. Residents who are supported by well-trained and competent staff team have access to a range of educational, social and leisure activities through day centres, work experience and different clubs and forums. The current fee for service users is £317 a week. Three Trees DS0000019764.V325044.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection visit formed an integral part of the annual key inspection of Three Trees undertaken by the Commission for Social Care Inspection (CSCI). The inspection focussed on what the Commission considers to be ‘key areas’ that directly affect the safety, welfare and quality of life of the service users. Information contained in this report was obtained through discussions with the registered manager, the staff and the service users. Telephone discussions were also held with representatives of social services who had direct involvement in the home and the relatives of several of the service users. Survey comment cards were sent to a several social and health care professionals. The inspection visit also included an examination of several statutory records and an inspection of the premises. This report incorporates information received by the CSCI relating to the care home since the previous inspection visit. What the service does well: What has improved since the last inspection? The registered manager continues to encourage the staff to undertake both statutory and professional training courses. The premises continue to be updated including the installation of doubleglazing. The management team continue to look at ways of improving the service in particular the quality of life of the service users. Three Trees DS0000019764.V325044.R01.S.doc Version 5.2 Page 6 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. Three Trees DS0000019764.V325044.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 Three Trees DS0000019764.V325044.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 Quality in this outcome area is good. Prospective service users can be assured through the use of a comprehensive admission and assessment process that their needs can be met by the home. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Three service users’ care records were examined. These included the record of the most recently admitted service user. The records contained documentary evidence that the service users had been assessed prior to their admission into the care home. From discussions with the Registered Manager it was evident that these assessments were in addition to any assessment provided by a Placing Authority. The home’s assessments were, however, compatible with the assessment undertaken by the Placing Authority but had specific elements expanded for the benefit of the care home’s staff. The Registered Manager presented as having a sound understanding of the need for a comprehensive pre-admission assessment to ensure that the home was capable of meeting a service user’s needs. The Registered Manager had also made several additional assessments of a service user after their admission so that a full and accurate picture was obtained of the individual. She said that when a person changed their environment it often changed their assessed Three Trees DS0000019764.V325044.R01.S.doc Version 5.2 Page 9 needs and consequently several assessments were required. The assessments identified any limitations to a service user’s abilities and level of understanding. Where possible a ‘phased’ admission process was undertaken to ensure that admission into the home was as problem free as possible for the service user concerned. A service user confirmed this admission process and said that they had made the decision to be admitted into the home with the help of a relative. At the time of the inspection visit, the Local Authority had placed all of the service users in the home. Many of the service users had lived at Three Trees for a considerable number of years. Three Trees DS0000019764.V325044.R01.S.doc Version 5.2 Page 10 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 and 9 Quality in this outcome area is good. The service users are provided with good standards of care planning that enable the staff to meet their assessed needs. This judgement has been made using available evidence including a visit to this service. EVIDENCE: All of the service users had been provided with care plans developed and implemented by the home. These were in addition to, but complimentary with, care plans provided by the service users’ placing authority. Three care plans were examined in detail as part of the Case Tracking process. It was evident that the service users’ care plans had been based on their initial assessments. They were clear, meaningful and took into account the literacy skills of the staff. The involvement of the service users and/or their families in the development of the care plans was evident from the fact that the plans had been signed in agreement. The care plans identified the service users’ Three Trees DS0000019764.V325044.R01.S.doc Version 5.2 Page 11 primary needs and the actions to be taken by the staff to address them. Every service user had been risk assessed. Not, according to the Registered Manager, to eliminate a risk but to minimise it. The Registered Manager stated, “Risk is essential for achieving independence”. The home used a system of ‘key workers’ in order to monitor the service users’ needs. The key workers provided a written report on the respective service users each month and this was used as the basis of a review. A copy of the report had also been sent to the respective Social Service’s Care Coordinator. These reports were available in the service users’ care records. The key workers reports were also used as input for the reviews held by the service users’ placing authority. Other people involved with service user, such as their relatives and medical practitioners, were also invited to these reviews. Some of the service users did not wish to attend their reviews and the staff had respected this. The care staff spoken to had a sound understanding of the service users’ needs and saw the care plans as a useful tool by which they were able to meet those needs. One member of staff stated, “ The key worker’s main role was to endeavour to promote the personal development of the service users”. They provided examples on how this was achieved. They said that they had a flexible approach to the provision of care to take into account the service users’ needs and wishes at any particular time. They confirmed that they had tried pictorial communication techniques for certain service users but this had only had limited success. They said that they found a combination of communication techniques the most successful approach. It was apparent from discussions with the staff and observation of the service users that emphasis was placed on the promotion of the service users’ independence and their ability to make choices. This was undertaken regardless of a service user’s level of disability thereby promoting equality and diversity within the service. The care records also included a profile of each service user, a weight chart as part of their nutritional screening process and an inventory of their personal belongings. There was also recorded evidence to confirm that service users’ meetings were held on a regular basis. A member of staff, but not the registered provider, attended these meetings. It was apparent that the registered provider addressed the outcomes of these meetings. Three Trees DS0000019764.V325044.R01.S.doc Version 5.2 Page 12 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): 11, 12, 13, 14, 15, 16 and 17 Quality in this outcome area is excellent. The service users are provided with a range of opportunities to develop their social and educational skills thereby enhancing their independence. This judgment has been made using available evidence including a visit to this service. EVIDENCE: The service users presented as having a wide range of needs. At one end of the needs spectrum were service users who were relatively independent and therefore required only minimal input from the staff, to other service users who were relatively dependent on staff support and guidance. Whilst there was not a set programme of social activities, the majority of the service users had day placements. These had been planned in conjunction with the service user concerned and their Care Coordinator and took into account the service user’s needs, wishes and abilities. Some of the older service users had decided to ‘retire’ from attending day placements and spent more time in the Three Trees DS0000019764.V325044.R01.S.doc Version 5.2 Page 13 care home. One of the more independent service users said that they went to see Hull City Football Club play at home. They were able to get the coach from the end of the street and did not require staff supervision. Another service user said, “I like to go shopping in Boyes’. I do a lot of things and I’m always busy. They’re (staff) my friends”. Another of the more able service users had obtained part time employment in Boyes’ general store. It was apparent that social and educational activities had been tailored to the assessed needs of the service users and that this had led to them having high levels of motivation. The service users were encouraged to make maximum use of the community facilities. For example, they regularly visited cafes, shops and places of entertainment. According to the staff the service users were extremely well known locally. The promotion of the service users independence was dependent upon their level of ability and was an integral part of their risk assessment. It was noted, however, that the staff did not ‘fuss’ over the service users but allowed them to live their lives at their own pace. It was apparent from observation of the service users that they had unrestricted access to all parts of the care home and were able to use their bedrooms as and when they wished. They also confirmed that they had retained good contact with members of their families and several service users were able to visit or even stay with their family. Surveys received from relatives of the service users confirmed that they were able to visit the home whenever they wished and were always made to feel welcome by the staff. The meals were based on pre-planned menus that had been discussed at the service users’ meetings. These indicated that a reasonable balance had been achieved between healthy eating and use of convenience food often preferred by some of the service users. Those service users on day placements took packed lunches with them and those remaining in the care home had a snack type of meal at lunchtime. The main meal of the day was provided in the evening. This was a social affair with all of the service users eating in the dining room. Whilst the home could provide special diets none were required at the time of the inspection visit. Those service users spoken to expressed satisfaction at the standard of the meals. One said, “There’s always plenty to choose from”. The home had not had a dedicated cook for some time and the staff had undertaken responsibility for preparing and cooking the meals. A new cook was due to commence employment in the home the day after the inspection visit. Three Trees DS0000019764.V325044.R01.S.doc Version 5.2 Page 14 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 and 20 Quality in this outcome area is good. The service users personal and health needs are met with good input from health and social care professionals. This judgement has been made using available evidence including a visit to this service. EVIDENCE: It was apparent from an examination of the service users’ care records that the service users had good access to health and social care professionals. The service users had been registered with local medical practices and had good access to associated healthcare services such as chiropody. A comment card received from a General Practitioner indicated that they were totally satisfied with the service provided by Three Trees. The service users had all been allocated a representative by their placing authority who regularly monitored and reviewed the respective service users. The service users’ health and personal care needs were clearly identified in their care plans. Three Trees DS0000019764.V325044.R01.S.doc Version 5.2 Page 15 From discussions with, and observation of, the staff, it was evident that they had established an excellent relationship with the service users and had achieved a good balance between informality and formal professionalism. I was observed that they spoke to, and assisted, the service users in a patient and empathetic manner thereby providing the service users with respect. The ‘banter’ between the service users and the staff was natural and friendly in approach. It was evident that a sense of humour was an important aspect of the care provided by the staff. It was also observed that the staff encouraged the service users to do as much as possible for themselves thereby promoting their independence. For example, they encouraged the service users to answer questions put to them even if the service user concerned had communication difficulties. On the day of the inspection visit the service users were all dressed in clean and appropriate clothing. Several confirmed that they used local hair dressing facilities. It was also evident from an inspection of the service users’ rooms that they had ample good quality clothing. Several of the service users stated that they enjoyed buying their clothes. The service users’ medication was appropriately stored and secured in a dedicated cabinet. The key to the drugs cabinet was carried by the member of staff on duty responsible for administering the medication thereby minimising the possibility of unauthorised access to the drugs cabinet. Nominated staff trained to an appropriate standard were responsible for the administration process. This process was overseen and monitored by the deputy manager. The medication records were complete and up to date. No controlled drugs were in use at the time of the inspection although facilities were available for their storage and administration should the need arise. None of the service users, except one who had an inhaler, were assessed as being capable of safely administering their medication. A medication administration procedure was available to the staff. This was based on a more traditional approach to the administration of medication as the home’s management had decided against the use of a Monitored Dosage System for safety reasons. The current procedure involved the member of staff placing the medication in pots, for reasons of hygiene, and administering the medication directly to the service user concerned. It was emphasised that it was the same person who placed the medication into the pot that administered it. This consequently complied with the guidance provided by the Royal Pharmaceutical Society. Three Trees DS0000019764.V325044.R01.S.doc Version 5.2 Page 16 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 and 23 Quality in this outcome area is good. The service users are protected by good levels of internal and external support. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home had an appropriate complaints procedure in place that was readily available to the service users and visitors to the home. Several of the service users had no, or limited, literacy skills and consequently relied on a third party to submit a complaint on their behalf. The staff confirmed that attempts had been made to provide the more disabled service users with a pictorial formatted complaints procedure but this had only had limited success. Reliance was therefore placed on the service users’ key workers, their relatives and representatives of their placing authority to act in an advocacy role. The registered manager provided confirmation that the service users had access to an advocacy scheme if it was considered necessary. The staff records provided evidence that the staff had been provided with training in Adult Protection. From discussions with the staff on duty at the time of the inspection visit, it was evident that they had a sound understanding of the types and indications of abuse and the action they should take should possible abuse be identified. Three Trees DS0000019764.V325044.R01.S.doc Version 5.2 Page 17 It was concluded that due to the good standards of internal and external support provided for the service users that any concern relating to a service user would be quickly identified and acted upon. Three Trees DS0000019764.V325044.R01.S.doc Version 5.2 Page 18 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, 25, 28 and 30 Quality in this outcome area is good. The service users’ accommodation meets their needs and provides them with a comfortable and pleasant environment. This judgement has been made using available evidence including a visit to this service. EVIDENCE: On the day of the inspection visit the home warm and very clean. The service users confirmed that the high standard of cleanliness was the norm. It presented as an informal domestic environment that provided the service users with a choice of communal areas. It was decorated and furnished to a high standard. The home did not have a passenger lift and consequently was only deemed suitable for service users who were reasonably ambulant. Those service users who had mobility problems were accommodated on the ground floor. There were a relatively high percentage of shared bedrooms but from discussions with the staff it was apparent that those service users sharing had Three Trees DS0000019764.V325044.R01.S.doc Version 5.2 Page 19 done so for a considerable length of time. The service users who shared bedrooms expressed their satisfaction at doing so. Privacy screening was available for the shared bedrooms although some of the service users had chosen not to use it. All of the bedrooms inspected were furnished and decorated to a good standard. It was evident that the service users had been able to individualise their rooms by furnishing them with their personal belongings. In the majority of cases the bedrooms tended to reflect the personality and interests of the occupant. Several of the service users had displayed certificates of educational and skills achievements. It was evident that the service users had unrestricted access to their bedrooms and that the staff respected the service users’ right to privacy by not entering their bedrooms unless they had obtained permission of the occupant. The home also had two ‘group’ living areas for the use of those service users who had been assessed as benefiting from a degree of independence. These areas had a dedicated kitchen/dining area and laundry facilities. The service users living in these areas were able to make snacks and hot drinks for themselves. The laundry facilities were of a good standard and there an effective and efficient process in place for the collection and distribution of the laundry. It was apparent that the service users had a good range of clothing that had been, where possible, chosen and bought by the service user concerned. A number of the radiators did not have safety guards fitted and the bathroom on the top floor did not have the hot water thermostatically controlled. These had been made the subject of a risk assessment in order to minimise the risk to the service users. The registered manager was, however, encouraged to err on the side of safety particularly with regard to the control of hot water. There were sufficient numbers of baths, showers and toilets available to the service users. The main kitchen was of a commercial standard and on grounds of safety the service users had restricted access. From the home’s records it was apparent that the premises met the specific requirements of the Fire and Environmental Health Departments. A programme of maintenance and refurbishment was in place. Since the previous inspection double-glazing had been installed and the central heating system upgraded. Three Trees DS0000019764.V325044.R01.S.doc Version 5.2 Page 20 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): 31, 32, 33, 34, 35 and 36 Quality in this outcome area is excellent. The service users are supported by a competent and well trained staff team who have a sound understanding of the service users’ needs and the actions required to meet those needs. This judgement has been made using available evidence including a visit to this service. EVIDENCE: From an examination of the staff roster and discussions with the staff, it was apparent that the level of staffing was appropriate for the needs of the current service users. The staffing level also took into account the fact that the majority of the service users attended day placements during the week. The staff confirmed that they had time to support the service users to meet their social needs both within and external of the home. It was evident that the staff had a sound understanding of the service users’ needs and in particular those elements of care such as the promotion of independence and choice that go to provide them a good quality of life. They provided several examples as to how this was achieved. It was also evident that a good relationship existed between the staff and the services users with conversations and banter being Three Trees DS0000019764.V325044.R01.S.doc Version 5.2 Page 21 natural and spontaneous. The night staff had communication facilities available to enable them to summon assistance without having to necessarily leave the scene of an incident/accident. The staff had received a range of training courses in statutory and professional subjects. They demonstrated a sound understanding of Adult Protection procedures including identification of the types and indications of abuse. Less than 50 of the staff had achieved a National Vocational Qualification (NVQ) and from discussions with the staff on duty it was evident that they had chosen not to undertake an NVQ as it entailed working with external trainers and involved time-consuming course work. The registered provider was aware of this and had consequently introduced an internal staff training programme that equated to NVQ at level 2. At the time of the inspection visit the care staff were involved in a Care Plan Training Programme. This was based on a task-analysis approach and was written in a clear and meaningful format to take into account the abilities of the staff. The staff had previously undergone training on Risk Assessment on the same basis. The home’s records confirmed this. The home employed a ‘key worker’ system to ensure that the service users were appropriately monitored and their needs met. Each key worker had been allocated one or two service users. The key worker reports were used as part of the service user assessment and review process. The staff had demonstrated an excellent understanding of the aims of the home and how they contributed in achieving them. There was evidence in the records of staff supervision that emphasis was placed on the staff knowing these aims. They also demonstrated a sound understanding of Equality and Diversity (E&D) and provided examples as to how E&D had been addressed. The senior staff had received training on this subject. This helped in ensuring that all of the service users were provided with similar opportunities to develop their educational and social skills regardless of their disability. The home had implemented a good staff selection and recruitment procedure. This included all prospective staff undergoing a formal interview (interview notes were available), completing an application form and undergoing a full vetting procedure before taking up a post. The interview process took into account Equal Opportunity by providing a consistent approach. A training and development plan had been developed for all new staff that included a formal induction training programme. The staff member concerned had signed the induction form at the successful completion of each training element. Three staff records were examined including the most recently employed member of staff. It was confirmed that staff meetings took place on a regular basis. A representative of the service users was also invited to this meeting. Minutes of Three Trees DS0000019764.V325044.R01.S.doc Version 5.2 Page 22 the staff meetings were available. There was recorded evidence that the staff received regular personal supervision. Three Trees DS0000019764.V325044.R01.S.doc Version 5.2 Page 23 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, 38, 39, 41 and 42 Quality in this outcome area is excellent. The service users and staff are well supported by a competent and experienced management team. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Both the registered manager and the deputy manager had a National Vocational Qualification at level 4 and had amassed considerable experience of working with people with a learning disability. It was evident that they worked closely as a team and both had specific responsibilities within the home. They both held common aims for the home and it was evident that they had achieved a good balance between ‘hands on care’ and their management Three Trees DS0000019764.V325044.R01.S.doc Version 5.2 Page 24 duties. The deputy manager primarily conducted the inspection. Feedback at the conclusion of the inspection was provided for the registered providers and the deputy manager. A Quality Assurance process was in place that incorporated the use of questionnaires to obtain the views of those involved with the home such as the relatives of the service users and healthcare professionals. This was used along with information obtained at staff supervision, staff and service users’ meetings and a management audit of the service to form the basis of an annual appraisal of the service. Confirmation was provided that the staff had been directly involved in this process and that any weaknesses identified in the service provision had been acted upon. The home’s management demonstrated a sound understanding of Quality Assurance and Quality Control. The home had satisfied the criteria of the local authority to be awarded their Quality Development rating. From an examination of the health and safety documentation including the servicing certificates, it was apparent that the registered manger had taken appropriate action to ensure a safe environment for both the service users and the staff. A number of statutory records were examined including the accident, fire and medication records. These were all maintained up to date. There was evidence that regular fire safety checks, including fire drills, had been undertaken. Three Trees DS0000019764.V325044.R01.S.doc Version 5.2 Page 25 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 3 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 4 25 3 26 X 27 X 28 3 29 X 30 4 STAFFING Standard No Score 31 3 32 4 33 4 34 3 35 3 36 4 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 4 X LIFESTYLES Standard No Score 11 4 12 4 13 4 14 4 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 4 3 X 4 4 3 X 3 3 X Three Trees DS0000019764.V325044.R01.S.doc Version 5.2 Page 26 Are there any outstanding requirements from the last inspection? 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 YA24 Good Practice Recommendations Consideration should be given to fitting safety guards to all of the radiators and a thermostatic control valve to the bath on the top floor of the property. The home should continue with its training programme to ensure a minimum of 50 of the care staff achieve NVQ at level 2 or 3. 2. YA32 Three Trees DS0000019764.V325044.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Hessle Area Office First Floor, Unit 3 Hesslewood Country Office Park Ferriby Road Hessle HU13 0QF 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 Three Trees DS0000019764.V325044.R01.S.doc Version 5.2 Page 28 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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