Inspection on 07/07/06 for Treetops

This inspection was carried out on 7th July 2006.

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

Treetops 19/07/07

Treetops 14/12/05

Treetops 29/06/05

Treetops 01/02/05

Treetops 19/07/04

Similar services:

Trevaylor Manor

Stallcombe House

Stroud Lodge

The Woodmill

Woodland Vale

Bolealler House

Claremont Nursing Home

Althea Park House

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

CARE HOMES FOR OLDER PEOPLE Treetops St Clements Road Keynsham Bath & N E Somerset BS31 1AF Lead Inspector Andrew Pollard Key Unannounced Inspection 7th July 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 Treetops DS0000020257.V303069.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. Treetops DS0000020257.V303069.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Treetops Address St Clements Road Keynsham Bath & N E Somerset BS31 1AF 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) 0117 9869700 0117 9860063 treetops@shaw-carehomes.co.uk Shaw healthcare Limited Mr M Gleave (pending fitness assessment). Care Home 24 Category(ies) of Dementia (24), Dementia - over 65 years of age registration, with number (24), Mental disorder, excluding learning of places disability or dementia (24), Mental Disorder, excluding learning disability or dementia - over 65 years of age (24) Treetops DS0000020257.V303069.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 4. The total number of people who may be accommodated in the home at any one time shall not exceed 24. Staffing Notice dated 23/04/1999 applies Manager must be a RN on parts 3 or 13 of the NMC register The home may accommodate people aged 55 years and over. Date of last inspection 14th December 2005 Brief Description of the Service: Treetops is registered as a Care Home for a maximum of 24 residents with dementia and or mental disorder requiring nursing care. The Home is situated in the grounds of Keynsham hospital, which easy access to local community facilities and is within easy access to Bristol and Bath. It can be accessed by car or by bus with a short walk. The Home is purpose built, providing a mix of single, double and en-suite rooms. Care is offered on the ground floor only, which is divided into 3 units. Each unit offers bedrooms, lounge-dining room and bathroom facilities. There is a communal common room and open plan smoking area. There are also pleasant gardens to the rear and side of the property. All parts of the home are accessible to wheelchair users as well as the able-bodied. Treetops DS0000020257.V303069.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The following methods of evidence gathering has been used in the production of this report; observation, discussion with residents a relative and staff, and a tour of the home and sampling policies, records, care plans and viewing meals. One relative and the GP returned comment cards. The resident group are unable to complete survey documents. A very limited number of residents are able to engage in conversation due to advanced dementia. This report has been written using all available evidence including a visit to the home. What the service does well: What has improved since the last inspection? The manager is setting up formal reassessment and rewriting of care plans using a model of care adapted from Orem and Essential Life style planning to establish more holistic care for residents. Fuller records of resident’s participation in recreational activities are made. Residents are offered alternative choices to the main meal menu. A new system for the disposal of medication is in place. Treetops DS0000020257.V303069.R01.S.doc Version 5.2 Page 6 What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Treetops DS0000020257.V303069.R01.S.doc Version 5.2 Page 7 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 Treetops DS0000020257.V303069.R01.S.doc Version 5.2 Page 8 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): 1,3,4,6. The outcome in this quality area is adequate. Prospective residents and their families are given relevant information in written or verbal form about the home. An admission was not found to have been related to staff skills to meet needs. The assessment process will provide sufficient detail of residents needs. Contracts and terms and conditions of services are provided to all residents. EVIDENCE: The statement of purpose (SOP) and service user guide (SUG) documents give appropriate information, meet the regulatory requirements and are comprehensive and written in plain English. Minor amendments have been made a full review will be undertaken by the new manager in due course with the help of any residents wishing or able to. Treetops DS0000020257.V303069.R01.S.doc Version 5.2 Page 9 The home caters for older people with continuing social, mental health and physical health care and nursing needs. The majority of the current residents have organic dementias. The 24 beds at Treetops are contracted via the PCT and placements co-ordinated by Dr N Moore, Dr Jelley and Dr Hewitt consultant psycho geriatricians who manage all referrals. Admissions are taken on a priority of needs basis. When a vacancy arises Dr More liaises with the manager who with a support worker will visits prospective residents prior to admission to assess if their needs can be met and the implications for the current resident group. All residents have a medical and care management assessment completed and available to the home prior to admission. There have been no admissions since Mr Gleave was appointed. A resident admitted during the period no manager was in post had needs that the staff were ill prepared to meet which has caused continuing difficulties. Mr Gleave has a clear understanding about the poor management of this admission so it is unlikely that the situation will be repeated. The manager states he will decline admissions that he considers are outside the homes admission criteria or where the skill mix of the staff is not sufficient to manage the care needs of an individual. Overall the staff have the range of skills and training relevant to meet the needs of the remaining resident group. Treetops DS0000020257.V303069.R01.S.doc Version 5.2 Page 10 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 outcome in this quality area is adequate. One resident’s care needs have not fully been met although active measures are being taken to rectify the situation. The staff provide appropriate personal and nursing care to maintain the remaining residents health and well being. Proper arrangements are in place for residents to access primary healthcare services. The staff properly manages and administers medication for residents. Detailed care plans are written relevant to residents care needs. Risk are properly identified and managed to keep residents safe. Treetops DS0000020257.V303069.R01.S.doc Version 5.2 Page 11 EVIDENCE: None of the current residents have special cultural needs. All residents can remain registered with their own GP if they wish, however at present all are registered at the local St Augustine’s practice. Dr Blackwell visit the home every week or upon request and is considered to provide a good service to the residents. Dr Blackwell returned a comment card in which he gave all positive responses about the conduct of the home. A consultant psycho geriatrician also visits the residents at Treetops. A multidisciplinary meeting including Dr’s Moore, Dr Jelley and the GP, nursing staff, social workers and relatives is held roughly quarterly to review resident’s care and to provide advice and support. A special multidisciplinary team meeting including a nurse specialist, speech therapist, dietician and relative is being held on the 19th July to determine a single care strategy for a residents with specialist care needs. The manager wishes to facilitate arrangements for residents to attend local community dentists or opticians where possible. Domiciliary optical services and dental reviews are provided on request for those who are unable to access the community facilities. All other specialist services are by GP referral if there is an assessed need. The existing Care plan documentation, assessments and evaluations are based on the Activities of Daily Living. Individual files, were prescriptive of care but did not put much emphasis on mental health issues. Several case files were reviewed and they were found to be otherwise comprehensive and detailed. There was evidence of evaluation and updating, however some of the assessments/care-plan elements had not been re written in detail, which should be done annually but just had signatures and dates recorded. One resident had a small pressure sore for which there were minimal records until the most recent entries which where much more informative. A lot of old documentation is held in case files and would be better back filed. The aim is to use a person centred approach to care in the home. A 14-day observation period after admission informs the care plan development including where possible the wishes of the residents and taking account of relatives views. Mr Gleave intends to reassess all residents and rewrite care plans using an adapted form of the Orem and Essential Life style planning models to establish more holistic care for residents encompassing their mental health needs. Treetops DS0000020257.V303069.R01.S.doc Version 5.2 Page 12 There are individual risk assessments for moving and handling, pressure sore development, falls and nutritional risks and continence that have been reviewed and some updated. There was little recorded evidence of resident consultation / involvement. This is due in the main to the advanced dementias and cognitive impairment of the residents. Daily reports are written and countersigned by the registered nurse in charge. Privacy and dignity issues are discussed during induction. Staff were observed to be knocking on doors before entering resident rooms. Resident and staff interactions were seen to be courteous and friendly. The residents able to express an opinion liked the staff and had no complaints. The home uses an individual blister pack drug administration system and nursing staff have responsibility for its management. No residents are safe or able to self-medicate. The resident’s drug profiles are part of the case file. The storage, receipt, administration and Controlled Drug (CD) records were up to date and in order. The GP endorses changes to the administration record. The disposal records being made are completed en-mass rather than at the time items are discontinued and the storage arrangements for drugs awaiting disposal is not in a secure container. CD de-naturing kits are available. Temperature recordings for the drug’s fridge are monitored and recorded. Treetops DS0000020257.V303069.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 outcome in this quality area is good. The recreational arrangements in the home are varied and residents have opportunities to take part in leisure activities. There is evidence of family inclusion and consultation where possible. The menus offer a varied and balanced diet. EVIDENCE: The resident’s ability to exercise choice or make decisions is significantly diminished due to their cognitive impairment, however the manager wishes to include residents in the relative forum and revision of care-plans where they are able and wish to. Relatives or staff often advocate on residents behalf. No residents returned comment cards and those spoken with did not have strong views about decision-making but one person felt they could make choices and one person said, “I do what I want”. The activity organiser works full time and arranges a programme of recreational activities every week for each unit. There is also a programme of Treetops DS0000020257.V303069.R01.S.doc Version 5.2 Page 14 suggested activities for the unit staff to engage with, however this seems limited by general workload. The laundry assistant works as informal activities volunteer. The home has ‘thumbnail biographies” included in the care documentation for each person which gives relevant information about past history, social preferences etc and is utilised by staff in planning activities. The records of resident participation in recreational activities are made in case files. Overall the activity budget is under spent and the manager is to meet with the organiser and staff to look at new ideas for outings, recreation and holidays. Local community entertainers attend the home on a regular basis and include a Hawaiian dancer, musicians and singers. Staff escort residents into the local high street to go to shops, cafés and other community facilities. No residents are safe to go out of the home unescorted. The home has access to mini bus transport owned by the organisation; a number of outings have taken place. Checks had been undertaken on staff’s ability/legality to drive. The local Cof E an RC clergy attends the home for pastoral visits and hold services for major festivals; some residents have also attended a local church. One of the staff conducts a simple Christian service each week. There are no residents from other faith backgrounds or seeking alternative spiritual support. The home has an open visiting policy. Family and friends are welcome to visit. Visits can be made in people’s rooms or the conservatory areas. A number of residents have regular contact with family members or friends including home visits, however in some cases residents have lost contact with family or do not wish to have contact. The relative/residents forums are to be reinstated the first such being on the 14th July. Relatives are encouraged to contribute to care reviews and care planning. The residents spoken with who were able to express an opinion enjoyed their meals, and the quantity was sufficient. The chef transferred from a care role to the chef position and having worked in a care position for several years had a good knowledge of resident likes and dislikes. The menus are a four-week rotation, which do not have formal choice. Residents are asked each morning if they would like an alternative, which is always provided upon request. The menus offer a varied and balanced diet. The food budget is currently overspent and the manager, administrator and chef are meeting to resolve the matter. Treetops DS0000020257.V303069.R01.S.doc Version 5.2 Page 15 Treetops DS0000020257.V303069.R01.S.doc Version 5.2 Page 16 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 outcome in this quality area is good. There are robust and comprehensive policies in place to prevent or manage complaints or allegations of abuse. There are good arrangements in place for staff training and awareness of “Protection of Vulnerable Adults” (POVA) matters for the protection of residents. EVIDENCE: The complaints policy and procedure contained all the required information and is available in the service user guide. There have been no complaints since the last inspection. Previous matters have been concluded and appropriate action taken. One matter of concern has arisen relating to a care management issue concerning a single resident previously referred to above. All the relevant parties including those raising the concerns have agreed the best way forward is to have a case conference to determine a clear strategy and care regime to be followed based on the expert advice. The meeting is scheduled for 19th July. In the meantime a log of concerns is to be maintained including a record of action taken to resolve the issues. No allegations of abuse have been received. Treetops DS0000020257.V303069.R01.S.doc Version 5.2 Page 17 The home has the Local Authority POVA “Inter-agency reporting procedure” and internal written procedures for adult protection; whistle blowing, management of aggression and the management of resident’s money/valuables. The majority of staff have undergone in house and National Vocational Qualification (NVQ) based training in understanding and dealing with verbal and physical aggression, abuse and management of challenging behaviours including breakaway training. Most staff have attended Bath and North East Somerset (BANES), POVA “First Response” training and further training is booked for the 12th of July. All care staff have been issued with the GSCC code of practise. Treetops DS0000020257.V303069.R01.S.doc Version 5.2 Page 18 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): 19,20,23,26 The outcome in this quality area is good. The home is fit for its purpose and suitable for the current resident group. Bedrooms suit the needs and tastes of the residents. The home is generally well furnished, maintained, clean, safe and comfortable. EVIDENCE: The home was purpose built to care for elderly people and has three individual units within the building Each individual unit provides one double bedroom, single bedrooms and a communal lounge/dining area, conservatory and access to the secure garden. The units are centred on the communal reception area, which accommodates an open plan area and enclosed common room. The home is at ground level, which ensures level access to all areas. Resident areas are fitted with appropriate aids such as grab rails, mobile and fixed Treetops DS0000020257.V303069.R01.S.doc Version 5.2 Page 19 hoists. Many rooms have adjustable Kings Fund beds. Pressure relieving equipment is available when required. A suction machine is to be kept on the unit for emergency use for use with a resident at high risk of choking. The bedrooms were appropriately furnished and decorated. Residents able to express an opinion liked their rooms and were able to personalise them as they wished. There are 3 shared bedrooms; people who share make a positive choice to do so as part of the admission process if only a double room is available. Where possible residents can be offered single rooms when they become available on their unit. All rooms have a telephone point from which residents can make and receive private calls. All rooms have a call system that is linked to an audible alarm facility. The lounges and dining areas are well furnished and the décor is in good order. A redecoration and refurbishment programme is ongoing. The home was in good general order, the standard of cleanliness was good and no mal odours were evident. An air purifier system has been installed in the three units. When last inspected by an Environmental Health Officer the kitchens were found to be clean and in good order. However the flooring is due to be replaced in the near future. Sluice areas included a sluicing disinfector on each unit. The laundry had two washing machines and two tumble dryers with appropriate programmes to ensure disinfection of foul linen. One of the dryers is awaiting servicing. There are arrangements in place for the service and maintenance of plant and equipment. Maintenance staff are employed by the organisation. A new handyman has been appointed for 15 hours a week Treetops DS0000020257.V303069.R01.S.doc Version 5.2 Page 20 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): 27,29,30 The outcome in this quality area is good. The home is adequately staffed with a combination of regular, bank staff. Good training arrangements are in place. The recruitment procedures and records are in good order for the protection of residents. Appropriate training arrangements are in place for care staff to provide quality care to residents. EVIDENCE: Mr Gleave has been recently appointed as manager and the CSCI is processing his fitness assessment. The staffing levels were in accord with the staffing notice issued by Avon Health Authority. A Registered Mental Nurse (RMN) is on duty 24hrs a day and the manager works five days a week supernumerary. Six care staff work the day shifts and two the night shift. There is a reduced use of agency most extra duties being covered by bank staff and in general continuity of supply is maintained. There are 55hrs housekeeping staff, 20hrs laundry and 75hrs catering staff on duty each week. Treetops DS0000020257.V303069.R01.S.doc Version 5.2 Page 21 There are no vacancies at present as three nurses and three support workers have recently been appointed. The home operates an equal opportunities employment policy. All staff are issued with written terms and conditions. The recruitment procedure is actioned and coordinated at Shaw Homes head office, including all recruitment paperwork, which remains stored at head office; copies are available in the home. The files seen were in good order. The NMC validations of RN qualifications were up to date an in order. CRB checks had been completed through the personnel office for all staff. A log record of these checks is sent to the manager and was checked. All new staff are enrolled on a formal induction programme, mentorship is arranged and all complete of an induction file, although some are not fully completed. Care staff do a foundation programme obtaining a ‘certificate in care practice’, so can then progress to the NVQ programme. Mandatory training records for food hygiene, first aid, load handling, fire and health and safety infection control and POVA were recorded for all staff. Update sessions have been booked for staff due updates in May/June. Eight care staff have NVQ level 3 and four have level 2. The RN clinical training records had been updated. The records seen previously indicated that in general RN’s are maintaining their learning in accord with PREP. The Huntington’s Disease Association care advisor to meet a particular learning need has recently delivered specialist training. Treetops DS0000020257.V303069.R01.S.doc Version 5.2 Page 22 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): 31,33,35,36,38 The outcome in this quality area is good. There are various methods and systems in place to monitor the quality of care and facilities for the benefit of residents The manager is qualified and experienced for the post. The management structure provides clear lines of accountability and support. The home has good Health and Safety and maintenance arrangements to protect residents EVIDENCE: Mr Gleave is a Registered Mental Nurse with previous experience of managing a nursing home; he expects to complete the NVQ level 4 managers programme later this year. It is hoped that a deputy manager will be appointed in the near future. Treetops DS0000020257.V303069.R01.S.doc Version 5.2 Page 23 The manager is accountable to Mr Tooze the area manager who carries out supervision sessions and conducts the regulation 26 visits on behalf of the organisation. Detailed reports are submitted to the commission each month. The resident forum is a vehicle for residents and more often relatives to raise issues of concern or praise and discuss the manner in which the home operates. It is hoped this group will meet bi-monthly. Due to the impaired cognitive ability of the residents only limited information could be gained in discussion with them. Three residents were able to comment, one person saying, “They are lovely” another that “I get well looked after, I love it here. and felt well looked after. Four people said the food was good. There were no complaints and in the general impression given was that the residents were calm well kempt. A relatives comment card said “ staff and managers are dedicated, kind and very helpful, 10 out of 10”. A quality audit based on components of good care has been conducted recently and although the sample was small the outcomes were in general good or very good. The home has been accredited with the ‘Investor in People’ award. Resident’s allowances and valuable are held in the office safe; records of receipt and expenditure are maintained and two signatures are recorded for all transactions. Each person has his or her own wallet and ledger sheet and a number have Building Society accounts. Three balances were checked and were in order. Only the manager and administrator have access to the safe keys. The accounts were subject to an audit in April and all was found to be in order. Residents or their families are encouraged wherever possible to manage their own finances. At present only one person manages has some independence in managing his or her own allowance. The home is seeking advice from the Court of Protection regarding one person’s financial arrangements. All residents have individualised risk assessments. A number of residents require limited restraint for their own protection from falls. Consent to restrictions such as bed rails, lap straps and Quantic chairs are formally recorded and kept under review. OT and the nursing team assess use of theses item. Regulation 37 notices are submitted as required, accident forms were completed with details of the incident but some required follow up or concluding statements. The fire logbook, drills and training records were up to date and in order. Ms Carpenter has delegated responsibility for H&S matters and is the trainer for load handling two RN’s are also to complete the trainers/assessors course. Treetops DS0000020257.V303069.R01.S.doc Version 5.2 Page 24 Regular H&S audits and environmental risk assessments are carried out to protect the residents from injuries. Hot water outlet temperatures are monitored and recorded. The gas safety certificate was in date. Load testing and hoist maintenance certificates were in order. Testing of portable electrical equipment had been carried out. Treetops DS0000020257.V303069.R01.S.doc Version 5.2 Page 25 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for 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 3 x 3 2 x 3 HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 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 X X 3 X 3 3 STAFFING Standard No Score 27 3 28 X 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 3 X 3 Treetops DS0000020257.V303069.R01.S.doc Version 5.2 Page 26 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. 1. Standard OP4 Regulation 14 Requirement Ensure that the home is able to meet assessed needs including (specialist needs) of individuals admitted to the home. Devise a secure method to store drugs awaiting disposal and make records of such at the time taken out of use. Timescale for action 31/07/06 2. NU9 13.2 31/07/06 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 OP37 OP7 Good Practice Recommendations Old documentation should be removed from case files and back filed. Carryout at least annual reassessments of need and risk and re-write the documentation. Treetops DS0000020257.V303069.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Bristol North LO 300 Aztec West Almondsbury South Glos BS32 4RG National Enquiry Line: 0845 015 0120 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 Treetops DS0000020257.V303069.R01.S.doc Version 5.2 Page 28 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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