Inspection on 05/11/07 for Treehaven

This inspection was carried out on 5th November 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

Treehaven 08/11/06

Treehaven 18/01/06

Treehaven 07/09/05

Treehaven 08/02/05

Treehaven 05/07/04

Similar services:

Coopers Mill Ltd

Bramley Avenue (73)

Paradise Lodge

Grangewood

Upaya Ananda

Newton Court (1-2)

Kings Lane (32)

Pemdale

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

CARE HOME ADULTS 18-65 Treehaven Sandy Lane West Runton Cromer Norfolk NR27 9LT Lead Inspector Mr Jerry Crehan Unannounced Inspection 5th November 2007 09:30 Treehaven DS0000027391.V354330.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 Treehaven DS0000027391.V354330.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. Treehaven DS0000027391.V354330.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Treehaven Address Sandy Lane West Runton Cromer Norfolk NR27 9LT 01263 837538 01603 279529 t.jeesal@virgin.net www.jeesal.org Jeesal Residential Care Services Limited 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) Jennifer Jonas Care Home 12 Category(ies) of Learning disability (12) registration, with number of places Treehaven DS0000027391.V354330.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: None Date of last inspection 8th November 2006 Brief Description of the Service: Treehaven is a large detached house situated on the edge of the village of West Runton. There is a large secure garden and an area set aside for horticultural work. There are workshops to the rear of the Home with one of these having been converted to house a small gym. The Home provides a service for up to twelve adults who have autistic spectrum disabilities. Accommodation is provided on the ground and first floors that is separated into five areas. All service users have a single bedroom. There are several communal rooms including activities and sensory rooms on site. The Home is owned and managed by Jeesal Residential Care Services Ltd Treehaven DS0000027391.V354330.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. Care services are judged against outcome groups, which assess how well a provider delivers outcomes for people using the service. This report gives a brief overview of the service and current judgements for each outcome group. Six comment cards were received from relatives of people who use the service. These reflected largely good views about the home and the service it provides to people who live there. Although no comment cards were received from people who use the service they made positive expressions at the time of the inspection visit. Six comment cards were received from staff who work at the home. These expressed a general view that the training and support available to them is good or better than good. Records held by the Commission and previous inspection reports were checked. This key inspection comprised an unannounced visit to the home that took place over 7.5 hours on 5th November 2007. Opportunity was taken to tour the premises, look at care records and policies, observe care delivery to people who use the service, communicate with people who use the service, speak with care staff and the Manager. The inspection report reflects regulatory activity since the last inspection and evidence from inspection of Key Standards. The range of fees for the home is £973 to £2,555. What the service does well: • • The service undertakes excellent assessments of the aspirations and needs of prospective tenants, and tenants are involved in this process. Every tenant has an individual care plan that tenants can contribute to. They set out individuals care needs clearly, and reflect their goals or aspirations. Most of the tenants relatives indicate a view that the care home always gives the support or care to their relative that they expect. Tenants are provided with choice and variety their lifestyle, and supported by the home to maintain family relationships. Staff are knowledgeable and enthusiastic about their roles. They show sensitivity and respect in their work with tenants. Staff are supported through the availability of good induction and ongoing training, and the support of an experienced and competent manager. DS0000027391.V354330.R01.S.doc Version 5.2 Page 6 • • • • Treehaven What has improved since the last inspection? • Risk management guidelines are improved and clearly set out guidelines for staff to follow. Guidelines for the management of challenging behaviour in particular provide a clear description of the behaviour, how and when it may be presented, clear strategies or techniques for staff to follow to manage the behaviour in a way that protects both the tenant and staff at the home. The environment at the home has been significantly improved. The proprietor’s and staff have worked hard over the past year to adapt the home to provide an improved environment for tenants. As a consequence tenants benefit from smaller, more homely living environments suited to their individual need. There is a new staff training room on the home’s site that can be used for other purposes such as meetings or care reviews. The manager stated that an activities room sited at the rear of the home would be extended to incorporate toilet facilities for staff and visitors to the home. These facilities will be welcome, as at present facilities in tenants accommodation have to be used. • • • What they could do better: • Four comment cards received from relatives indicate a general view that tenants are supported to live the life they choose at the home. Two comments suggest this could be better promoted through staff with the skills to better support and encourage tenants potential. A recommendation has been made that staff receive refresher training regarding the use of non-prescribed medication or ‘homely remedies’ in line with the home’s policy and procedure. A recommendation that monthly medication administration records (MAR) include a record of any medication carried forward to the next/new MAR chart. This practice will support easier audits of the accuracy of medication administration practices at the home. A recommendation has been made concerning extending NVQ 2 training for more care staff. • • • Treehaven DS0000027391.V354330.R01.S.doc Version 5.2 Page 7 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. Treehaven DS0000027391.V354330.R01.S.doc Version 5.2 Page 8 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 Treehaven DS0000027391.V354330.R01.S.doc Version 5.2 Page 9 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 People who use the service experience excellent quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Prospective people to use the service have a comprehensive assessment of their needs undertaken, and access to all of the information they need about the service they may choose. EVIDENCE: There have been several new admissions to the home since the last inspection visit. One tenant was admitted in October to their own independent accommodation at Treehaven. Senior staff undertook a comprehensive preadmission assessment. Assessments from the tenants previous care setting were obtained with their consent. These included healthcare and social care assessments. The prospective tenant was visited on two occasions by Jeesal senior staff including the manager of the home. They had the opportunity to visit Treehaven on three occasions prior to their eventual move to the home, enabling them to make an informed decision about the move, and for the home to respond to their needs and wishes concerning care and accommodation. Treehaven DS0000027391.V354330.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 & 9 People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People who use the service are involved in decisions about their lives, and play a role in planning the care and support they receive within their capacities. Individual care plans ensure staff have the information to know the support that is needed by the people living at the home. EVIDENCE: Several care files were looked at during the site visit. Each person has an individual care plan that was detailed and comprehensive. Those reviewed also provided evidence of the participation of the tenants and evidence of regular review. One tenants review recently undertaken included their thoughts and wishes about Christmas shopping and family contact over the Christmas period. Individual care plans seen set out care needs clearly, reflect goals or aspirations for tenants, and cover areas such as healthcare, autism, and independent living skills. Treehaven DS0000027391.V354330.R01.S.doc Version 5.2 Page 11 Risk management guidelines are improved and clearly set out guidelines for staff to follow. Those seen provided a very clear analysis of individual risk and corresponding management guidelines, for example in risk management plans for management approaches to challenging behaviour. They provide a clear description of the behaviour, how and when it may be presented; they provide clear strategies or techniques for staff to follow to manage the behaviour in a way that protects both the tenant and staff at the home. Regular meetings take place at the home, where tenants and care staff consider issues of relevance, such as concerns, achievements, the home’s environment and visitors to the home. There is also a wider tenants forum involving tenants from other homes and a tenant representative from Treehaven. This is a forum for discussion and decision making regarding common issues in each of the homes owned by the proprietor. The manager indicated that over the next twelve months she plans to develop joint staff/tenant meetings and to develop policies and procedures with tenant involvement. Six comment cards were received from relatives and visitors to the home prior to the inspection visit. Four respondents indicated that the care home always gives the support or care to their relative that they expect, with supporting comments such as ‘excellent care standard overall’, ‘my relative is very contented with the care they receive, this gives me peace of mind, so my thanks go to all staff at Treehaven’. Two respondents indicated that this was sometimes the case and that the quality of care can be dependent on which staff are on duty. Staff observed at the time of the inspection visit had a good approach to care and an awareness of the individual needs of tenants. Treehaven DS0000027391.V354330.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): 12, 13, 15, 16 & 17 People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People who use the service are provided with choice and variety their lifestyle, and supported to maintain family relationships. Links with the community are supported where possible. EVIDENCE: Tenants have daily living schedules setting out the routines and activities that the tenant prefers. These are communicated for many tenants through visual schedules using symbols to communicate the next part of the plan for the day. The manager stated that, at present, there are no tenants involved in adult education courses though some have in the past. In information provided prior to the inspection visit, the manager indicated that they are considering the development of a resource to enable tenants who choose not to (or are unable to) access adult education resources such as a woodwork shop, or an I.T room. Tenants were observed to go to and from their chosen activities during the inspection visit. Staff are enabled to support tenants in their chosen activities Treehaven DS0000027391.V354330.R01.S.doc Version 5.2 Page 13 through carefully detailed ‘session plans’ for each activity. These included trips on foot to local facilities in the village, and trips further afield using the home’s transport or public transport. Tenants attend facilities such as the local social club on Tuesdays and Fridays, make shopping trips and spend time on household tasks such as cleaning bedrooms and undertaking laundry. Comment cards received from relatives indicate a general view that tenants are supported to live the life they choose at the home. Two comments suggest this could be better promoted through staff with the skills to better support and encourage tenants potential. Staff and tenants were planning a fireworks party on the evening of the day of the inspection visit. This was a topic of discussion and communication among a small group of staff and tenants who were participating in some artwork together in the main activities area. The dedicated activities area now accommodates the sensory room, which has been moved to enable access by all tenants without disrupting other tenants personal accommodation. The home has a gymnasium with some newly purchased equipment to reflect the needs of some tenants. Use of this facility evidently provides a beneficial physical release of energy for some tenants. Contact between tenants and their relatives is well supported by the home, this includes supporting tenants visits home to parents or other relatives, and providing the transport for contact. Family members also attend reviews of care plans where they are able. Relatives of a tenant had returned them to the home following a weekend visit home. A good rapport was observed between visiting relatives and staff at the home. All of the comment cards received from relatives prior to the inspection visit were complimentary about the home’s effort’s to keep them involved and support contact, one card indicated that ‘the home maintains a high level of contact with me through weekly visits’. The manager indicated that arrangements for supporting contact between tenants and their families could be further improved by the provision of somewhere private to meet outside of the tenant’s bedroom accommodation. She stated that the service is considering developing such a facility. All bedroom doors at the home are lockable to support privacy if required. Staff were observed talking to and interacting with tenants throughout the inspection visit. First names are used as the preferred form of address for staff, and service users with verbal communication. Staff prepare all of the meals at the home, tenants may assist in meal preparation at times, though these are generally snack meals. The main meal is generally taken in the evening. Meals were not seen at the inspection visit. Individual preferences and dietary need were evidently catered for. Meals for the next day are communicated to some tenants by means of symbols; alternative symbols are available if the suggested option is not preferred/desired. Treehaven DS0000027391.V354330.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 & 20 People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The health and personal care that people receive is based on their individual needs. Care staff provide good healthcare support to people who use the service. EVIDENCE: Staff spoken with during the inspection visit were very well informed about the health care needs of tenants. They have access to training in health care matters including first aid and medication. Staff are also aware of the complex mental healthcare needs of some tenants. The care they provide is supported by appropriate health and personal care advice in care plans. Each tenant has an individual health profile that includes their medical history, how they may communicate illness, medication requirements, and interventions from health care professionals such as the G.P and dentist. Personal care is provided to tenants so as to ensure their privacy and dignity. A relatives comment card indicated that one of the things the care home does well is ‘respect my relatives right to privacy’. The home uses a monitored dosage system for the majority of medication. Medication seen is stored securely and there are generally good records for the Treehaven DS0000027391.V354330.R01.S.doc Version 5.2 Page 15 receipt of medication into the home and its administration. Some tenants use non-prescribed medication and staff were less certain about recording arrangements for this. It is recommended that staff receive refresher training regarding the use of non-prescribed medication or ‘homely remedies’ in line with the home’s policy and procedure (See Recommendation 1). A recommendation was made at the last inspection that medication to be returned to the pharmacy be kept separate from medication stock held by the home to reduce the risk of it becoming mixed. This recommendation is repeated. It is recommended that monthly medication administration records (MAR charts) include a record of any medication carried forward to the next/new MAR chart (See recommendation 2). This practice will support easier audits of the accuracy of medication administration practices at the home. Treehaven DS0000027391.V354330.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 & 23 People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Arrangements for responding to the concerns and complaints of tenants and staff are good. People who use the service are protected from abuse. EVIDENCE: The home has a detailed complaints procedure and information on how to make complaints is detailed in the service users guide, this is also made available in symbol format. From information provided by the manager a total of four complaints have been received in the last twelve months. The manager has kept a record of these complaints, three of which have been investigated and resolved within the 28 days indicated in the home’s policy. The fourth complaint is still ongoing. Each of the six comment cards received from relatives of tenants indicate that they know whom they would speak and how to make a complaint if necessary. A procedure for responding to allegations of abuse is in place. It is evident from discussion with staff that they are aware of this and that there is good staff understanding of abuse and of arrangements for reporting suspected abuse. The home has experience of making appropriate adult protection referrals through the joint Norfolk ‘Safeguarding’ protocol. Treehaven DS0000027391.V354330.R01.S.doc Version 5.2 Page 17 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 People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The environment at the home has been significantly improved. It is reasonably maintained and better designed to support the needs of people who use the service and their carers. EVIDENCE: There have been substantial changes to the home to improve the living environment for tenants over the past year. The home has been divided into smaller self-contained units. There are two units that can accommodate four or five people and three annexe’s offering single accommodation. Each area (including single accommodation) has their own patio/garden areas. There is a new staff training room on the home’s site and an activities room for tenants where computer, music and art and craft activities take place, and this area incorporates the sensory room mentioned earlier. The manager stated that this would be extended to incorporate toilet facilities for staff and visitors to the home. These facilities will be welcome, as at present facilities in tenants accommodation have to be used. Treehaven DS0000027391.V354330.R01.S.doc Version 5.2 Page 18 The interior accommodation is in a reasonable state of repair, with adequate furnishings and fittings. Some areas require finishing off and re-decorating following the division of the home into separate units, and the manager stated that this is planned. Other areas have benefited from the installation of new window units. The manager stated that the home will be recruiting a part time maintenance engineer to keep on top of the maintenance and repairs needed on an ongoing basis. There are better arrangements for staff supervision with their manager, and improved arrangements for senior staff ‘handovers’ in the new training room. The home was clean and hygienic. Treehaven DS0000027391.V354330.R01.S.doc Version 5.2 Page 19 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 People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Staff at the home are trained, skilled and deployed in sufficient numbers to support the specialist needs of people who use the service. EVIDENCE: There were eleven tenants accommodated at the home at the time of the inspection visit. Usually between five and eight care staff work throughout the day until four o’clock when staffing numbers may reduce by three carers. From records seen during the inspection visit staffing numbers at weekends are sometimes reduced, including a recent episode when there were four care staff on duty. This would be insufficient to meet the needs of the tenant group and be particularly problematic given the new layout of tenants accommodation. It is recommended that here should not be fewer than four care staff on duty during the day (See Recommendation 4). Each shift is lead by a senior support worker, with a system of on call back up from the manager and other senior staff outside office hours. The total care staff group was 17.5 at the time of the inspection visit. However, the manager stated that she would be making two more full time appointments, bringing the establishment to 19.5. This may be adequate to meet the needs of the desired staff rota and to cover staff leave and sickness. Treehaven DS0000027391.V354330.R01.S.doc Version 5.2 Page 20 There has been some staff turnover since the last inspection visit. The manager indicated that three staff have left the home, and that they have been replaced by new staff. Four care staff have a qualification at NVQ 2 or above, a further five staff are currently undertaking the training. There are a further five care staff currently undertaking NVQ training or awaiting verification of their completed work and the successful completion of this training by these staff will see the home exceed the minimum requirement. However, at present the home falls below the recommended numbers of staff who have undertaken the NVQ 2 training and it is recommended that the manager ensure that a minimum of 50 of care staff undertake this training and update their skills (See Recommendation 3). Care staff spoken with indicated that they had access to appropriate induction training when newly employed, and the opportunity to work in a supernumerary capacity observing more experienced colleagues. Staff have accessed a variety of appropriate training, including manual handling, health and safety, first aid, medication, food hygiene, fire safety and adult protection. The majority of staff have also undertaken more specialist training in areas such as autism awareness, dealing with challenging behaviour and dementia. A senior staff member has received specialist training in ‘Total Communication’. This enables them to assess and enhance the quality of communication with tenants and to develop improved communication strategies with staff and tenants. This emphasises that there is an understanding at the home of the critical importance of communication in achieving good care and wellbeing outcomes for tenants. From discussion with staff and from comment cards received prior to the inspection visit it is evident that as a group they are still developing, but work well as a team and are supportive of each other. An improved staff compliment has meant the need to work fewer extra hours. Staff say that they are well supported by their management. Observation of, and discussion with staff provided evidence of their enthusiasm and knowledge for their roles. It was clear that they understand and share the aspirations of tenants, and that they have the commitment to support tenants to achieve them. From discussion with care staff and a review of staff files, it was evident that tenants are protected by good recruitment practices. Evidence of obtaining enhanced CRB checks, references, and proof of identity prior to appointment were seen. Treehaven DS0000027391.V354330.R01.S.doc Version 5.2 Page 21 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 People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The management and administration of the home promotes the health and care of people who use the service, and has developed effective quality assurance systems. EVIDENCE: The manager has four years experience of managing a learning difficulty care service, and five years as deputy manager prior to this. She holds the City In Guilds Advanced Management in Care, and a Certificate of Disability Study. She is currently in the process of undertaking NVQ 4 in Care toward achieving the RMA, though her training provider has caused her delays in undertaking and completing the training within the timescale she anticipated. The home has a quality assurance process in place, which involves a variety of ways of gathering information about the quality of the service provided. For Treehaven DS0000027391.V354330.R01.S.doc Version 5.2 Page 22 example, staff meetings, monthly care plan reviews, daily discussion/communication with tenants, quarterly ‘Quality Forum’ meetings for tenants run by the Directors, an Annual Development Plan (that identifies where improvements are required and how the proprietor and manager can address them) and annual questionnaires for relatives and health/social care professionals. Copies of relevant survey information are provided to the Commission. The home demonstrates good practices ensuring service users health, safety and welfare. Relevant health and safety training for staff, training in moving and handling, first aid, food hygiene training, medication, and fire training support practices. There is communication and referral to relevant community health care professionals. There is also access to specialist training that reflects the specialist needs of some of the tenants living at the home. Treehaven DS0000027391.V354330.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 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 4 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 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 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 3 X 3 X X 3 X Treehaven DS0000027391.V354330.R01.S.doc Version 5.2 Page 24 No 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. 2. Refer to Standard YA20 YA20 Good Practice Recommendations It is recommended that staff receive refresher training regarding the use of non-prescribed medication or ‘homely remedies’ in line with the home’s policy and procedure. It is recommended that monthly medication administration records (MAR charts) include a record of any medication carried forward to the next/new MAR chart. This recommendation is repeated. It is recommended that the manager ensure that a minimum of 50 of care staff undertake this training and update their skills. It is recommended that here should not be fewer than four care staff on duty during the day. 3. 4. YA32 YA33 Treehaven DS0000027391.V354330.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection Norfolk Area Office 3rd Floor Cavell House St. Crispins Road Norwich NR3 1YF 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 Treehaven DS0000027391.V354330.R01.S.doc Version 5.2 Page 26 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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