CARE HOMES FOR OLDER PEOPLE
Tree Tops Residential Homes 27-29 View Road Rainhill Prescot Merseyside L35 0LF Lead Inspector
Mrs Elaine White Key Unannounced Inspection 7th September 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 Tree Tops Residential Homes DS0000022416.V295807.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. Tree Tops Residential Homes DS0000022416.V295807.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION
Name of service Tree Tops Residential Homes Address 27-29 View Road Rainhill Prescot Merseyside L35 0LF 0151 426 4861 0151 431 1080 treetopsreshomes@btconnect.com www.treetopsresidentialhomes.co.uk Tree Tops Residential Homes 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) Kate Joanne Lashwood Mr David Beattie Care Home 43 Category(ies) of Dementia - over 65 years of age (13), Old age, registration, with number not falling within any other category (30) of places Tree Tops Residential Homes DS0000022416.V295807.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION
Conditions of registration: 1. 2. Service users to include up to 30 OP and up to 13 DE(E) The service should employ a suitably qualified and experienced manager who is registered with the CSCI 23rd January 2006 Date of last inspection Brief Description of the Service: Tree Tops Residential Homes is located in the Rainhill area of Prescot. The home is easily accessible to bus, road and rail links. The home is owned by a family partnership. The manager is Kate Joanne Lashwood. There are two homes within the complex, Tree Tops, which accommodates thirty service users in the older age category, and Delphlands, which accommodates thirteen service users who are elderly mentally infirm. Neither home provides nursing care. The homes both offer passenger lifts and stair access and both homes share kitchen facilities. Communal facilities in Tree Tops include two lounges, one smoking and one non - smoking, a dining room, conservatory and large well maintained gardens. Delphlands has a communal lounge, dining room and a small-enclosed garden. The weekly charge for the service is from £385.00 to £435.00. This includes Elderly Mentally Infirm (EMI). Tree Tops Residential Homes DS0000022416.V295807.R01.S.doc Version 5.2 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. The site visit took place over one day duration of ten hours. It was an unannounced visit and conducted as part of the regulatory requirement for care homes to be inspected at least twice a year. A tour of the two buildings was conducted, both Delphlands and Treetops. A selection of care staff and home records were also viewed. During the inspection six residents were case tracked (their care files were examined and their views of the home were obtained). This process was not carried out to the detriment of other residents who also took part in the inspection process. The Manager, Kate Lashwood, Managing Director, David Beattie, six staff members, six of the forty three residents and two relatives were spoken with and their views obtained of the home. Survey forms ‘Have your say about….’ were also given to residents to complete. Comments received from the surveys and discussions, which took place, are incorporated within this inspection report. What the service does well:
The home provides a welcoming, detailed statement of purpose and service user guide, which outlines the service provided, staffing structure, qualifications and terms and conditions. This is continually updated to and made available to all prospective residents and those accommodated. A copy of the most recent inspection report and comments from residents and relatives about the home is available to view. A web site is also available to obtain information on the service. The home maintains a high level of occupancy and has a waiting list for admissions. The home has an ongoing training programme, which provides the staff with the necessary skills to deliver the care and support to meet the needs of the residents. The staff are kept up to date with all the statutory training required, which includes moving and handling, first aid, fire safety, food hygiene and health and safety. A training room is available to provide ‘in house’ training for staff. External courses are also available in specialist areas and the home has a number of links with agencies that provide this i.e. challenging behaviour, nutrition and dementia care. The home is committed to providing NVQ (National Vocational Qualifications) for their employees. 59 of the care staff are qualified in at least NVQ Level2. Staff receive regular supervision to discuss their roles and development. The home has an established group of staff with a low staff turnover and many have worked at the home for years. Comments. Staff are sufficient in numbers to meet the needs of the residents and include management, care staff,
Tree Tops Residential Homes DS0000022416.V295807.R01.S.doc Version 5.2 Page 6 domestics, cooks, maintenance person and laundry assistants. Staff spoken with were very positive regarding the support and direction given by the management. An ‘open door’ policy is in place and relatives and residents commented on how approachable the management and the staff are. “They are always there to help if I need them. Kate (Manager) is lovely”, (Relative). During the inspection the staff and management chatted freely with the residents and their visitors and a pleasant atmosphere was in place. Relatives and visitors called in at all times during the inspection and were made welcome by the staff and offered drinks and snacks. Relatives spoken to provided positive comments on the care and support, cleanliness of the home and pleasant approach of the staff. “They always keep me up to date with how my mum is”. The home provides a very clean, pleasant, homely, relaxed and comfortable atmosphere. A full maintenance programme is in place and a maintenance person is on site to respond to repairs where needed. The management responded to improvements identified during the visit immediately. The home is resident focused and relatives and residents are encouraged to comment on the care provided via questionnaires and regular reviews. Annual quality assessments are undertaken annually by the manager to improve good practice and develop the service to meet the needs of the residents. The home uses good quality ‘branded’ products and fresh fruit, vegetables and meat is purchased locally. Menus are displayed and alternatives always available. The majority of surveys received and comments made by residents and relatives during the visit were positive regarding the food provided. “The food is excellent and I enjoy it” (Resident). The chef is qualified in both intermediate and advance food hygiene awards and is to progress to a higher award. All new residents are assessed for their likes, dislikes, allergies and cultural preferences on admission. Risk assessments are in place for each resident and are reviewed when their needs change. Environmental risk assessments are provided for the building. Fire records are maintained up to date and all service certificates in place to promote the health, safety and welfare of the residents and staff. Records are very organised, easy to follow and kept up to date. Policies and procedures are reviewed annually and made available to all staff. No requirements or recommendations were made at the last inspection. Tree Tops Residential Homes DS0000022416.V295807.R01.S.doc Version 5.2 Page 7 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. Tree Tops Residential Homes DS0000022416.V295807.R01.S.doc Version 5.2 Page 8 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 Tree Tops Residential Homes DS0000022416.V295807.R01.S.doc Version 5.2 Page 9 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): 1,2,3,6. The quality in this outcome area is excellent. This judgement has been made using available evidence and visit to this service. Detailed information is provided for prospective residents. Full assessments are carried out prior to admission to ensure the home can meet the needs. Contracts of terms and conditions are in place. EVIDENCE: The home does not provide intermediate care as outlined in Standard 6. The home provides a detailed, up to date statement of purpose and service user guide, which fully outlines the service, staff employed, and their qualifications. A copy of the most recent inspection report, surveys and comments from residents is also available. These documents are available to all prospective service users, residents and relatives to view. Enquiries for admission are recorded and the manager prior to any admission undertakes a full assessment of need. An admissions checklist in place ensures that the home obtains the necessary information on each resident to enable the staff to meet their needs. These include personal profiles, medication, moving and
Tree Tops Residential Homes DS0000022416.V295807.R01.S.doc Version 5.2 Page 10 handling needs, risks identified, nutritional screening, continence and preferences and choice. Contracts of terms and conditions are in place and include fees and additional charges i.e. hairdressing. A sample of case files viewed in both Tree Tops and Delphlands demonstrated this. Comments from a survey – “The family were shown around the entire premises and Ms. Lashwood (Manager) was very helpful and thorough and answered all our questions. Tree Tops Residential Homes DS0000022416.V295807.R01.S.doc Version 5.2 Page 11 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. The quality in this outcome area is good. This judgement has been made using available evidence and visit to this service. Care plans are detailed, easy to read and drawn up with the residents and relatives. Residents’ are treated with dignity and respect and their health care needs are fully met. Medication policies and procedures are in place and staff are trained in this area. EVIDENCE: Care plans viewed in both units show each resident to have an individual plan of care, which is drawn up with the residents, their relative and the manager. Care plans are reviewed monthly to reflect changing needs Reasons for change is recorded and action to be taken by the staff. The plans contain detailed information on the health care needs of each resident to enable the home to provide the care required. These include – nutritional screening, continence, sleep patterns and physical, mental, mobility needs. Should further assistance be required i.e. district nurse, continence advisor, access to health care professionals is available and all visits are recorded. Weight, personal care and bathing records are maintained. The bathing needs of one resident did not fully demonstrate the care practice in place and this was discussed with the deputy
Tree Tops Residential Homes DS0000022416.V295807.R01.S.doc Version 5.2 Page 12 manager during the visit and immediate action taken to ensure the records reflect the care provided. Residents and relatives interviewed and feedback from surveys received provided positive comments on the care and support provided. “The staff are very supportive and attentive” (Resident). “I have total confidence in the judgement of the staff when my father took ill. They always seek a second opinion if they are unsure. Put my father first and contact his doctor”, (Relative). “On a few occasions mum has needed to see a doctor and this was arranged quickly and efficiently”. Care staff spoken to confirmed that the information provided in the care plans is easy to follow and outlines the tasks to be done. Observation and discussion with staff and residents during the inspection confirmed that dignity and respect is upheld at all times. The home has a treatment room, which is available for use by health care professional visits i.e. district nurses. This was observed to take place during the visit with a resident and the nurse attending to provide health care treatment. Treatment can also be provided in the resident’s own private room if they wish. Medication policies and procedures are in place and senior staff responsible for administration are trained. All medication is securely stored. The system of recording showed to be organised and accurate. All administrations made are signed for, sample signatures are in place for staff and written records on the MAR (medication administration record) are countersigned. The pharmacist conducts an annual review of medication. Tree Tops Residential Homes DS0000022416.V295807.R01.S.doc Version 5.2 Page 13 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. The quality in this outcome area is good. This judgement has been made using available evidence and visit to this service. Wholesome, well-balanced meals are provided. The residents are encouraged to exercise choice and control over their lives. Activities are in place and relatives/friends/visitors are encouraged to maintain contact with the residents. EVIDENCE: Care plans viewed outlined the needs, choice, social and cultural interests of the residents. An activity programme is in place in both units, which provides a range of activities from dominoes to day trips, bingo and entertainers. Recent trips to Chester Zoo and Martin Mere have taken place and residents spoken with commented that they had enjoyed the trip. Residents have the choice to take part in activities if they wish. Those who choose not to, their wishes are respected. A number of comments were received regarding the activities in place and these were discussed with the management who confirmed that this is an area, which is continually reviewed, as it can be difficult to suit all tastes and not all residents wish to take part. This was observed during the bingo session during the afternoon of the visit. A number of residents took part, whilst others preferred to sit in the small lounge. There are a number of communal areas available where residents can sit and chat, watch TV, take part in activities or go to their own room for privacy.
Tree Tops Residential Homes DS0000022416.V295807.R01.S.doc Version 5.2 Page 14 Comments from surveys received – “Mum will not join in. But I have seen the activity board” (Relative). “We feel the residents could be more stimulated. The home would benefit from outside help in this area” (Relative) “I wish I could go to the betting shop more often” (Resident) “Activities are arranged although I don’t always take part” (Resident) Relatives and residents are encouraged to comment on the service provided via meetings and questionnaires, which are left at the front entrance. A wholesome, appealing, varied, balanced diet is provided, served in pleasant surroundings and alternatives are always available. The chef conducts a ‘food profile’ on each resident and records food preferences, likes and dislikes. Records are maintained for reference and menu planning. A tour of the kitchen took place and was found to be very clean, well equipped, organised and fully stocked with ‘branded’ products. The fruit, vegetables and meat are purchased locally. The home is conducting a pilot for the Food Standard Agency. To ‘raise awareness of food safety’ and is completing a diary on food preparation. The chef is also working in cooperation with the CIEH (Chartered Institute of Environmental Health to monitor food safety and kitchen management. The majority of comments received from surveys completed and those spoken to were positive regarding the food provided. “Appear to provide a well balanced diet” (Relative) “Staff do provide chopped up or finger food for my relative if he is struggling to eat” (Relative) “My mum has put weight on since staying at Tree Tops. She was underweight and now looks well” (Relative). “I enjoy all the meals” (Resident) “The food is excellent” (Resident) “Mum likes to complain about most things but she always compliments the meals” (Relative) The routines in the home are flexible and residents choose when they go to bed and where to eat their meals i.e. dining room or own room. Tree Tops Residential Homes DS0000022416.V295807.R01.S.doc Version 5.2 Page 15 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. The quality in this outcome area is good. This judgement has been made using available evidence and visit to this service. Policies, procedures, training and recruitment systems in place help protect residents from abuse. A complaints procedure is in place and relatives and residents are confident they will be listened too. EVIDENCE: The statement of purpose and service user guide outlines the complaints procedure and is available for access to relatives, visitors and residents. The home has a ‘grumbles book’ for any comments made, which evidences the ‘grumble’, investigation and outcome. Surveys completed and residents and relatives spoken with confirmed they are aware of how to complain. “Mum has been at Tree Tops for twelve months. If we have been unhappy the problems have been very small and sorted out quickly” (Relative) Abuse policies and procedures are in place and staff interviewed demonstrated their awareness of identifying abuse and the action required. The staff-training programme confirmed that POVA (protection of vulnerable adults) awareness training is provided and the majority of staff have completed the course. Financial policies and procedures are in place. Records and receipts are obtained for all financial transactions made. Tree Tops Residential Homes DS0000022416.V295807.R01.S.doc Version 5.2 Page 16 Several staff files viewed showed that the homes recruitment and selection process ensures all staff are only employed on receipt of a satisfactory CRB (Criminal Record Bureau Check) and two written references. Files viewed were found to be very organised and contained the necessary recruitment information and training records. Tree Tops Residential Homes DS0000022416.V295807.R01.S.doc Version 5.2 Page 17 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): 19,20,21,22,23,24,25,26. The quality in this outcome area is good. This judgement has been made using available evidence and visit to this service. The home provides a safe, wellmaintained, pleasant and hygienic environment for the residents to live. EVIDENCE: An ongoing maintenance programme ensures that repairs and decoration are conducted to maintain the standard. A number of improvements have been made since the last inspection. These include – a number of resident’s rooms have been decorated, the strip lighting has been replaced in a number of rooms, the lounge and dining room in Delphlands has been refurbished and the hallways in Tree Tops decorated. Work was in progress to provide a walk in shower facility on the first floor to replace a bathroom. The home has very well maintained grounds, which surround both units. All areas are accessible for residents and used in the summer months. The home employs a full time gardener and maintenance person.
Tree Tops Residential Homes DS0000022416.V295807.R01.S.doc Version 5.2 Page 18 A number of resident’s rooms were viewed and were found to be comfortably furnished and clean and contained their own possessions. Residents spoken to commented they are satisfied with the accommodation provided. “It is always clean as far as I am concerned” “Tree tops is home from home” Relatives’ comments include – “The bedroom is always clean and tidy”. “Both the lounge and dining room in Delphlands need brightening up with pictures and fresh flowers. Dining room chairs are in need of refurbishing or replacing” “I chose this home after looking at many others. I would not have moved my mum in if I had not been happy”. Residents on both units have access to communal areas. In Tree Tops these include a dining room, a conservatory and two lounges. Whilst in Delphlands there is a lounge and a dining room. All were viewed during the inspection and were found to be comfortable and clean. Discussion took place with the management regarding attention required to one of the resident’s rooms in Delphlands. David Beattie, managing director, acted upon this immediately. Environmental risk assessments are in place. Radiator covers are fitted in some areas and risk assessments are provided for residents who do not have this facility. An organised laundry service is in place, which ensures that each resident has an individual storage basket for his or her clothing. Policies and procedures are in place for infection control. The laundry was found to be very clean and well equipped. Tree Tops Residential Homes DS0000022416.V295807.R01.S.doc Version 5.2 Page 19 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 The quality in this outcome area is excellent. This judgement has been made using available evidence and visit to this service. A robust recruitment and selection procedure is in place. An ongoing training plan ensures that staff are equipped with the necessary skills to provide care and support to the residents. Risk assessments are in place. EVIDENCE: Viewing of duty rotas, training records and staff files demonstrated that the residents are supported by sufficient, suitably appointed, trained and competent staff. Staff files are very organised and contained all the information required. Staff are employed following a Protection of Vulnerable Adults check (POVA) and two written references. A full training programme confirmed that staff are offered a range of training, which meets the statutory requirements. Staff spoken to confirmed that the training is ongoing. The home employs an established group of staff that maintain continuity of care to the residents. Residents spoken to provided positive comments regarding the care and support provided. “The staff are very caring”. Relatives commented, “The staff are very approachable”. Staff are encouraged to obtain NVQ qualifications and over 59 are qualified in at least NVQ Level 2. The staff were observed to be attentive to the residents needs during the visit and a pleasant atmosphere was in place. Tree Tops Residential Homes DS0000022416.V295807.R01.S.doc Version 5.2 Page 20 Environmental and residents risk assessments are in place and updated to reflect changing need. Radiator risk assessments are completed, as there are no radiator covers in place. Tree Tops Residential Homes DS0000022416.V295807.R01.S.doc Version 5.2 Page 21 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): 31,32,33,35,36,37,38. The quality in this outcome area is excellent. This judgement has been made using available evidence and visit to this service. Financial policies and procedures are in place. The home is run in the best interest of the residents and their health, safety and welfare is promoted. The home is well managed and organised. EVIDENCE: A pleasant relaxed atmosphere was present throughout the inspection. Staff and residents chatted freely and visitors were made welcome. Relatives commented, “They are always there to help if I need them. Kate (Manager) is lovely” Tree Tops Residential Homes DS0000022416.V295807.R01.S.doc Version 5.2 Page 22 “I take comfort that Tree Tops is run well and professionally. My wife and I can take peace of mind that my father is well looked after in all aspects. I have every confidence in Tree Tops”. The home is well managed. The records are organised and easy to read. All policies and procedures are reviewed annually. The staff spoken to feel supported, well trained and are happy in their jobs. The residents spoken to say they feel safe and comfortable. And relatives said they are satisfied with the care and support provided. “I have worked here for ten years and wouldn’t work anywhere else”. (Staff) Financial policies and procedures are in place and records and receipts maintained of all financial transactions. Risk assessments are in place and regularly reviewed. Fire records are kept up to date and all certificates for services are in place. The home’s ongoing maintenance programme ensures that repairs are attended to and the standard is maintained. Up to date certificates are in place for all services i.e. Gas, electricity. Quality assurance audits are conducted annually on areas of care and the environment, which identifies areas in need of improvement and attention. A full up to date training programme provides the staff employed with the skills to carry out the jobs safely and meet the needs of the residents. The manager is qualified in NVQ Level 3 and both the manager and deputy manager are working towards their NVQ Level 4 in management. Tree Tops Residential Homes DS0000022416.V295807.R01.S.doc Version 5.2 Page 23 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 4 3 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 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 3 3 3 3 3 3 3 STAFFING Standard No Score 27 3 28 4 29 3 30 4 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 4 4 X 3 3 3 3 Tree Tops Residential Homes DS0000022416.V295807.R01.S.doc Version 5.2 Page 24 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 2 3 4 Refer to Standard OP8 OP15 OP19 OP31 Good Practice Recommendations Records of personal hygiene for residents to be kept up to date and recorded in Delphlands. Activity programmes and meals should receive ongoing reviews to continue to meet the needs of the residents in view of the comments made within the surveys received. The fire escape should be repainted and the carpet in room 7 Delphlands replaced. The manager should obtain a qualification in NVQ Level 4, which she is working towards. Tree Tops Residential Homes DS0000022416.V295807.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection Knowsley Local Office 2nd Floor, South Wing Burlington House Crosby Road North Liverpool L22 0LG National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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