Inspection on 05/09/07 for Treehaven Bungalows

This inspection was carried out on 5th September 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 Bungalows 20/09/06

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 Bungalows Sandy Lane West Runton Cromer Norfolk NR27 9LT Lead Inspector Mr Jerry Crehan Unannounced Inspection 5th September 2007 09:00 Treehaven Bungalows DS0000066873.V350415.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 Bungalows DS0000066873.V350415.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 Bungalows DS0000066873.V350415.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Treehaven Bungalows Address Sandy Lane West Runton Cromer Norfolk NR27 9LT 01263 837538 01263 838414 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) Application In Process Care Home 10 Category(ies) of Learning disability (10) registration, with number of places Treehaven Bungalows DS0000066873.V350415.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: None Date of last inspection 20th September 2006 Brief Description of the Service: Treehaven Bungalows are two linked bungalows situated on the site of the Treehaven service on the edge of the village of West Runton. The bungalows have separate secure garden areas. The Home provides a service for up to ten adults who have learning disabilities and autistic spectrum disorder. Accommodation is provided on the ground floor and in first floor flats. All tenants have a single bedroom, and there is a variety of communal space available. The Home is owned and managed by Jeesal Residential Care Services Ltd. Treehaven Bungalows DS0000066873.V350415.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. Three comment cards were received from relatives of people who use the service. These reflected almost exclusively positive views about the home, in particular the care and consistency provided to tenants by the service. Records held by the Commission and previous inspection reports were checked. This key inspection compromised an unannounced visit to the home that took place over 8.5 hours on 5th September 2007. Opportunity was taken to tour the premises, look at care records and policies, and communicate with care staff and the Manager. Although some tenants were spoken with during the inspection, all of them have some difficulties with communication, meaning that it was difficult to gather information about their views of the home. Reliance is therefore put upon information from staff, records, observation and the Manager. The inspection report reflects regulatory activity since the last inspection and evidence from inspection of Key Standards. The range of fee’s for the home is £967 to £2,500. 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. Staff are good at writing about the care that people need in ‘care plans’. Tenants are involved in developing their care plans so they are able to communicate their views and express how they would like to be supported. Tenants living at the home are supported by staff to do the things that they enjoy, both at the home and in the community. The health and personal care that people receive is good and based on their individual needs. The way that staff order, looks after and administers medication is good. Staff are knowledgeable and enthusiastic about their roles. They show care and respect for the tenants. Staff are supported through the availability of good induction and ongoing training. The service is well managed by a competent and experienced manager whose priority is addressing and meeting the needs of tenants. DS0000066873.V350415.R01.S.doc Version 5.2 Page 6 • • • • Treehaven Bungalows What has improved since the last inspection? What they could do better: • A recommendation is made that the practice of storing medication to be returned to the pharmacist with currently prescribed medications cease, to reduce the risk of it being wrongly administered. Two recommendations are made in respect of updated infection control training for staff (though practices observed were satisfactory), and extending NVQ 2 training for more care staff. The increase in the staff group currently in progress should assist in sustaining shift patterns and staff allocation required at the home. It is acknowledged that this process takes time, particularly to identify people with the qualities necessary. • • 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 Bungalows DS0000066873.V350415.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 Treehaven Bungalows DS0000066873.V350415.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): Standards 1 & 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 has been one new admission to the home since the last inspection visit. This person was admitted to the home shortly after the last inspection visit and following approximately a year in planning. A wide range of assessment information had been collected including social work, nursing and the proprietor’s own assessment. The home’s own assessment pro-forma and ‘application form’ is used by the manager or other senior and trained staff when collecting information. These documents are well designed to ascertain the level of support required by, and aspirations of, any prospective tenant. The assessment and admission process included evidence of comprehensive involvement with tenants, their relatives and relevant professionals. The service provides prospective tenants with the opportunity to visit the service as often as necessary prior to admission, and tenants observed at the time if the visit appeared appropriately placed. The admission procedure is supported by the home providing suitable information to prospective tenants in formats appropriate to the needs of the individual. Treehaven Bungalows DS0000066873.V350415.R01.S.doc Version 5.2 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 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. EVIDENCE: Each tenant has a personal care plan and a sample of these were reviewed. Those seen were detailed and comprehensive and provided evidence regular review. They set out care needs clearly, reflect goals or aspirations for tenants, and cover areas such as healthcare, autism, and independent living skills. Risk management guidelines are also clearly set out 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 absconding and for management approaches to challenging behaviour. They provide a clear description of the behaviour, how and when it may be presented; it provides clear strategies or techniques for staff to follow to manage the behaviour. Treehaven Bungalows DS0000066873.V350415.R01.S.doc Version 5.2 Page 10 Evidence was seen of a monthly summary of risk management information, and of more comprehensive six monthly review of care plans and risk management information. These (and annual reviews) involve tenants, relatives and placing authorities where appropriate. There was evidence seen of the participation and the contribution of tenants in reviews. The manager stated that tenants are involved with support workers when they prepare their written ‘hand-overs’ of information for colleagues at the beginning of a shift. This way service users are aware, on a daily basis, of what is being recorded or said about them. Treehaven Bungalows DS0000066873.V350415.R01.S.doc Version 5.2 Page 11 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 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 well maintained. EVIDENCE: Sample care plans seen contain individual ‘activity schedules’ that set out the preferred routines and activities of tenants over the course of the day. Activity schedules clearly set out the type of activities preferred, the aims of the activity for the tenant, and a clear process for the staff member to follow in order to support the tenant. A tenant shared their daily activity plan, which contained symbols to illustrate what activities were planned for the day ahead. After each activity is completed the symbol is removed, this helps to support clear communication about what will be happening next. Treehaven Bungalows DS0000066873.V350415.R01.S.doc Version 5.2 Page 12 Tenants have the opportunity to be part of the local community, to use local shops, pubs, restaurants, the gym and swimming facilities, and to attend local clubs. Tenants were observed coming and going to their activities at the time of the inspection visit. The home has access to a car, a mini bus and people carrier. However, tenants often walk to local facilities, and use taxi services and the train for longer trips. The manager stated that tenants families have a significant level of contact with tenants at the home, and that the service supports contact by taking tenants to visit relatives where necessary. The manager confirmed that relatives and other visitors visit tenants regularly, can meet privately, and are made welcome by the home. A comment card from a relative of a tenant indicates that the home always helps the tenant to keep in touch with them, and that they are able to visit when they wish. All bedroom doors at the home are lockable. Support workers were observed talking to and interacting with tenants throughout the inspection visit. First names are used as the preferred form of address for support workers, and tenants with verbal communication. The daily routines of the home are designed to encourage tenants to be as independent as possible. Consequently tenants are involved in undertaking their own personal care tasks, laundry, cooking and cleaning their own bedrooms with appropriate levels of support and supervision. Staff generally prepare all of the meals at the home, with the main meal usually taken in the evening. However, some tenants who lead more independent lives are supported to carry out food preparation and cooking with significantly less staff intervention. Tenants are offered choice of what they would like for lunch or supper, and there is evidently attention to the promotion of a healthy diet with access to fresh and home cooked foods. All tenants have access to the kitchen area with supervision. The home is commended for ‘opening up’ kitchen areas to tenants and managing potential risks from this. If managed properly there will continue to be significant practical and personal benefits to tenants. Tenants choose were they wish to take their meal, some preferring to eat on their own. Treehaven Bungalows DS0000066873.V350415.R01.S.doc Version 5.2 Page 13 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 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. Well trained staff provide good healthcare support to people who use the service. EVIDENCE: Personal care was provided to tenants so as to ensure their privacy and dignity. Staff are supported by the clarity of information available within individual tenants care plans. Each care plan contains a ‘health profile’ for the tenant that includes a range of health information. These contain information such as medication currently prescribed, epilepsy observation, weight monitoring and health care interventions such as the dentist, optician or G.P. There are no tenants accommodated at the home who have responsibility for their own medication. Storage arrangements are improved from the last inspection visit, they are tidy and secure. The bulk of medication is available via the Monitored Dosage System (MDS), though there is also packet and bottled medication. Medication Administration Record (MAR) charts reviewed were well kept, and an audit trail for sample medicines carried out identified no discrepancies. Appropriate records are kept for the receipt of medication into Treehaven Bungalows DS0000066873.V350415.R01.S.doc Version 5.2 Page 14 the home, its administration and any medication returned to the pharmacy. Medication administration practice observed during the visit was good. There are very clear protocols for staff to follow when considering the administration of PRN (when required) medicines. These protocols help to ensure that other means are explored to address the presenting problem or anxiety before the administration of a medicine. This is good practice. There is still a practice of storing medication to be returned to the pharmacist in the medication cabinet with currently prescribed medications, albeit in a bag. This increases the risk of these medicines being wrongly administered. It is recommended that the practice of storing medication to be returned to the pharmacist with currently prescribed medications cease, and alternative arrangements made for its storage (See Recommendation 1). Responses from returned comment cards indicate that people feel that their healthcare needs are met. Treehaven Bungalows DS0000066873.V350415.R01.S.doc Version 5.2 Page 15 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22 & 23 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 service users 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. The manager stated that no complaints had been received since the last inspection of the home. She stated that she tries to make herself available to tenants and their relatives in order that they may discuss any concerns at an early stage. Returned comment cards to the Commission for Social Care Inspection showed that people are aware of how to complain. The service keeps records relating to incidents of behaviours that challenge the service. The manager stated that these are used as a monitoring tool to make judgements about whether any tenant may be experiencing a particular difficulty. Treehaven Bungalows DS0000066873.V350415.R01.S.doc Version 5.2 Page 16 The procedure and practice for handling tenant’s personal allowance monies was reviewed and was satisfactory. Every tenant has a financial care plan setting out the arrangements for their financial management and support. Staff spoken with were clear about the action they would take if concerned about the possibility of abuse taking place and were confident that their manager would deal with this appropriately. Staff are also aware of the home’s ‘Whistle-blowing’ procedure and its function. Staff have received training in the protection of vulnerable adults. Evidence of this was seen in their training schedules. There is good staff understanding of abuse and of arrangements for reporting suspected abuse. Treehaven Bungalows DS0000066873.V350415.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): Standards 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 is safe, suitably maintained and designed to support the needs of people who use the service and their carers. EVIDENCE: The premises are suitable for the homes stated purpose. The interior accommodation is in a good state of repair, with good quality furnishings and fittings. The garden area is also well kept and accessible for tenants, with grassed and patio areas. There have been improvements to aspects of the environment including the creating of an office area for records and medication storage. This also provides an area for staff to meet and to ‘hand over’ at the end of their shift. There is also a new designated ‘sleep in’ area for staff. Improvements to a communal area were in progress at the time of the inspection visit, with new flooring being laid. Tenants were evidently looking forward to the completion of this work so that they could access the area. Treehaven Bungalows DS0000066873.V350415.R01.S.doc Version 5.2 Page 18 There is now an exterior fence with keypad door at the front of one of the bungalows to provide additional security for service users. The bungalows are accessible to the solitary tenant who uses a wheelchair to mobilise. Tenants bedrooms are well furnished and decorated. Each of the bedrooms seen during the visit reflected the personality and interests of the individual tenant. Tenants can have a very heavy impact on the environment, and this was evident in dining furniture in one area of the home. However, there were plans in place to address this and the furniture, fixtures and fittings are generally very robust and of good quality. Premises were safe, clean and hygienic throughout, with evidence of an understanding of infection control practices to deal with situations during the inspection visit. Although there are suitable procedures in place for infection control (that staff are evidently aware of) there is no specific infection control training. It is recommended that infection control training be provided to staff (See Recommendation 2). Treehaven Bungalows DS0000066873.V350415.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): Standards 32, 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 ten tenants accommodated at the home at the time of the inspection visit. Usually eight care staff are working throughout the day until six o’clock when staffing numbers reduce to four carers. Each shift is lead by a senior carer or ‘senior support worker’. There is one waking night staff member and one staff member who ‘sleeps in’ each night. The manager confirmed that she has the authority to provide extra care if required. Staff observed and spoken with have a good understanding of their role and respect the tenants they support. An illustration of this is a comment made ay a staff member to describe their role ‘supporting tenants to do things in their own way, from personal care to social activities’. From observation it is also evident that tenants have confidence in their care staff. Treehaven Bungalows DS0000066873.V350415.R01.S.doc Version 5.2 Page 20 The total care staff group is seventeen. This would fall short of sustaining shift patterns and staff allocation indicated above. The manager stated that the desired staff compliment in 21 and the home is in the process of recruiting to these posts. However, it is acknowledged that this process takes time, particularly to identify people with the qualities necessary. Three care staff have a qualification at NVQ 2 or above, a further five staff are currently undertaking the training. The home falls below the recommended numbers of staff who have undertaken the NVQ 2 training and it is recommended that the manager encourage care staff to 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 experienced carers. Staff have accessed a variety of appropriate training, including manual handling, health and safety, first aid, behaviour analysis, medication, food hygiene, fire safety and adult protection. The majority of staff have also undertaken more specialist training in areas such as autism awareness, epilepsy awareness, and in specialist communication methods such as ‘Signalong’ (the manager is qualified as a Signalong tutor). The manager stated that the speech and language therapist also provides training for staff in particular communication systems. The manager and the proprietor are pursuing the possibility of further enhancing the quality of communication (and communication strategies) through undertaking further specialist training in ‘Total Communication’. If successful the home would have someone trained as a communication coordinator, and able to provide this training to other staff. 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 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, two references, and proof of identity prior to appointment were seen. Treehaven Bungalows DS0000066873.V350415.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): Standards 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 eight years of experience as a registered manager of similar care settings for adults with a learning disability, and several years experience as a carer prior to this. She is in the process of applying to register as manager for Treehaven Bungalows, having taken over the service in November 2006. She is awaiting the result of her recently completed Registered Managers Award training. A comment card received from a tenants relative states that ‘the care home has always put the care of its residents first’. Treehaven Bungalows DS0000066873.V350415.R01.S.doc Version 5.2 Page 22 Staff speak favourably about the manager, indicating that they feel well supported and clear about what they should be doing to support tenants. 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 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 Bungalows DS0000066873.V350415.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 3 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 X 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 Bungalows DS0000066873.V350415.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. Refer to Standard YA20 Good Practice Recommendations It is recommended that the practice of storing medication to be returned to the pharmacist with currently prescribed medications cease, and alternative arrangements made for its storage. It is recommended that infection control training be provided to staff. It is recommended that the manager encourage care staff to undertake NVQ 2 training and update their skills. 2. 3. YA30 YA32 Treehaven Bungalows DS0000066873.V350415.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 Bungalows DS0000066873.V350415.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. Re-publishing this information is in breach of the terms of use of that website. 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