Please wait

Please note that the information on this website is now out of date. It is planned that we will update and relaunch, but for now is of historical interest only and we suggest you visit cqc.org.uk

Inspection on 03/01/06 for Treetops Care Home

Also see our care home review for Treetops Care Home for more information

This inspection was carried out on 3rd January 2006.

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

What follows are excerpts from this inspection report. For more information read the full report on the next tab.

What the care home does well

The Commission for Social Care Inspection had received a letter commending the home for the speed and efficiency of the staff members` actions when a small fire broke out in the home. The home was evacuated swiftly and service users experienced no ill effects. Service users` monies maintained by the home were clearly documented and securely stored.

What has improved since the last inspection?

The previous inspection raised a requirement for the registered person to ensure the home was conducted in a manner that respected the privacy and dignity of service users. Discussion with service users and staff and direct observation on the day of the inspection indicated that good progress had been made. The registered manager had developed the complaints monitoring system resulting in a clear audit trail to evidence actions taken to address complaints. The previous three inspection reports had identified a lack of staff training in the Protection of Vulnerable Adults from abuse (POVA). At time of this inspection 50% of the care staff had received PoVA training from an external provider, the registered manager was awaiting further course dates for the remaining staff members. This has been a positive move and efforts need to continue to ensure all staff members receive annual PoVA training. The previous inspection identified that staff supervision sessions had not routinely taken place and that where they had occurred the recording was in bullet point format with no detail of actions to be taken forward from the supervision. The registered manager had put in place regular supervision sessions for all staff however the standard of recording had not improved.

What the care home could do better:

Care plans did not provide sufficient detail to ensure that care staff were fully informed of residents` individual needs and choices. Reviews of the care plans and risk assessments need to be undertaken regularly in order to provide clear instruction for staff. Care plans did not provide evidence of residents, their relatives or representatives involvement. The residents would benefit from all staff members receiving training and attending annual refresher courses in the Protection of Vulnerable Adults from abuse. Whilst the home appeared clean tidy and warm on the day of the inspection the environment was not comfortable, welcoming and homely. Floor coverings need to be replaced to reduce the odours, paintwork was chipped and large areas of the home, such as the lounge, bedrooms, bathrooms and communal areas were in need of decoration and some capital investment. Domestic staffing hours did not provide the residents with a clean, fresh and hygienic environment to live. Residents` safety and well being would be further protected if the home`s recruitment policies and procedures were adhered to. Residents would benefit from all staff members undertaking the NVQ level 2 qualification in care. The home`s Quality Assurance system did not include residents` views and opinions. Staff supervision recording did not include detail of actions to be taken such as training and development and detail of the topics discussed unless of a private and personal nature not related to the health, safety or well being of the residents.

CARE HOMES FOR OLDER PEOPLE Treetops Care Home 23/25 Station Road Epping Essex CM16 4HH Lead Inspector Jane Greaves Unannounced Inspection 3rd January 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 Care Home DS0000017984.V273826.R01.S.doc Version 5.0 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 Care Home DS0000017984.V273826.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Treetops Care Home Address 23/25 Station Road Epping Essex CM16 4HH 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) 01992 573322 01992 570241 Essex Residential Care Homes Limited Mrs Vivienne Lesley Clancy Care Home 52 Category(ies) of Old age, not falling within any other category registration, with number (52) of places Treetops Care Home DS0000017984.V273826.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. Persons of either sex, aged 65 years and over, who require care by reason of old age only (not to exceed 52 persons) 1st September 2005 Date of last inspection Brief Description of the Service: Treetops is a large detached property set in a residential area within five minutes walking distance of the town centre of Epping. The home is owned by Essex Residential Care Homes Limited and the registered manager is Mrs Vivienne Clancy. Treetops is located close to the railway station and a bus service runs regularly. Local shops, banks, post office, library and other facilities are within easy reach in Epping Town centre. This is an adapted property that provides accommodation for older people on four levels, which are serviced by passenger lifts. The home provides a residential care service for older people. Treetops Care Home DS0000017984.V273826.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This routine unannounced inspection was undertaken on 3rd January 2006 by two inspectors. 25 of the 38 National minimum Standards were assessed with 14 being met. During the course of the inspection documents were sampled, practice observed, a tour of the premises undertaken, views of the home and the care provision were gathered from service users, staff members and visiting health care professionals. On the day of this inspection the registered manager had just returned from annual leave. What the service does well: What has improved since the last inspection? The previous inspection raised a requirement for the registered person to ensure the home was conducted in a manner that respected the privacy and dignity of service users. Discussion with service users and staff and direct observation on the day of the inspection indicated that good progress had been made. The registered manager had developed the complaints monitoring system resulting in a clear audit trail to evidence actions taken to address complaints. The previous three inspection reports had identified a lack of staff training in the Protection of Vulnerable Adults from abuse (POVA). At time of this inspection 50 of the care staff had received PoVA training from an external provider, the registered manager was awaiting further course dates for the remaining staff members. This has been a positive move and efforts need to continue to ensure all staff members receive annual PoVA training. The previous inspection identified that staff supervision sessions had not routinely taken place and that where they had occurred the recording was in bullet point format with no detail of actions to be taken forward from the Treetops Care Home DS0000017984.V273826.R01.S.doc Version 5.0 Page 6 supervision. The registered manager had put in place regular supervision sessions for all staff however the standard of recording had not improved. What they could do better: Care plans did not provide sufficient detail to ensure that care staff were fully informed of residents’ individual needs and choices. Reviews of the care plans and risk assessments need to be undertaken regularly in order to provide clear instruction for staff. Care plans did not provide evidence of residents, their relatives or representatives involvement. The residents would benefit from all staff members receiving training and attending annual refresher courses in the Protection of Vulnerable Adults from abuse. Whilst the home appeared clean tidy and warm on the day of the inspection the environment was not comfortable, welcoming and homely. Floor coverings need to be replaced to reduce the odours, paintwork was chipped and large areas of the home, such as the lounge, bedrooms, bathrooms and communal areas were in need of decoration and some capital investment. Domestic staffing hours did not provide the residents with a clean, fresh and hygienic environment to live. Residents’ safety and well being would be further protected if the home’s recruitment policies and procedures were adhered to. Residents would benefit from all staff members undertaking the NVQ level 2 qualification in care. The home’s Quality Assurance system did not include residents’ views and opinions. Staff supervision recording did not include detail of actions to be taken such as training and development and detail of the topics discussed unless of a private and personal nature not related to the health, safety or well being of the residents. Treetops Care Home DS0000017984.V273826.R01.S.doc Version 5.0 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. Treetops Care Home DS0000017984.V273826.R01.S.doc Version 5.0 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Treetops Care Home DS0000017984.V273826.R01.S.doc Version 5.0 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 3 and 4 No resident moved into the home without having their needs assessed and being assured these will be met. Residents know the home they enter will met their needs. EVIDENCE: The registered manager undertook pre-admission assessments, visiting the prospective residents in their own homes or in hospital. Families and social workers were involved in this process. The home’s pre-admission assessment forms were comprehensive covering all aspects of personal, social and physical care. The registered manager reported using observation and discussion with residents/families and social workers to gather detail about the resident. The completed pre admission assessment formed the basis of the care plan together with the Social Services COMM5. This assessment process assisted the residents and their families to make an informed decision as to whether Treetops could meet their assessed needs. The home’s Statement of Purpose and Service User Guide clearly outline the care and facilities provided. Treetops Care Home DS0000017984.V273826.R01.S.doc Version 5.0 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 and 10 Overall the care plans used in the home were insufficient and did not provide a full range of information to the staff. There were systems in place to ensure that residents’ health care needs were met, however, the home was not meeting all of individual residents’ identified needs. The administration of medication was safe and reflected the homes policies and procedures. The home provided a service that treated the residents with respect, staff engaged positively with residents and demonstrated a good understanding of their needs. EVIDENCE: 6 care plans were examined on the day. Overall they contained some information regarding the resident’s need, the action to address this need, and the long-term outcome of the care given. The care plans did not cover all aspects of a resident’s physical, mental and social needs, and were not Treetops Care Home DS0000017984.V273826.R01.S.doc Version 5.0 Page 11 reviewed on a monthly basis. The care plans did have a risk assessment however these were not regularly updated to reflect the current situation. There was no evidence that residents or relatives signed care plans or were involved in the planning process. Residents spoken with confirmed that the staff in the home provided them with a good level of support and assistance. They commented that the staff knew “the things that I need” and that staff “do a very good job to look after all of us”. Staff were observed treating residents with care and sensitivity, one resident who became distressed received calming re-assurance from staff. The care files examined did not contain a sufficient range of additional assessments based on the healthcare needs of the residents. Personal care tasks were not fully recorded, although it was clear that the staff promoted independence in personal care where possible. Mental health needs were identified in the care plan but the action to address these needs was not recorded. The assessments had not been regularly reviewed or updated to include a change in need. From discussion with the staff it was clear that they had an awareness of the action required to meet these needs, but the recording in care plans was not sufficient to guarantee the safe delivery of care. None of the residents in the home were able to self medicate. The home had a clear and comprehensive medication policy and procedure. The medication administration records of all medication used in the home was accurate and up to date, as were the records of receipt and disposal. All medications were stored safely, and controlled drug records were accurate and well maintained. The staff spoken with confirmed that they had received appropriate training and support, and were confident that they ensured the safety of the residents when giving medication. During the inspection the staff working in Treetops were observed giving a friendly and respectful service to residents. The staff spoken with confirmed the importance of privacy and dignity and discussed how they maintained these issues in their daily care practices. Residents spoken to report that staff were “patient and kind,” they assisted residents to preserve their dignity and assisted them with their personal care needs in a professional manner. One resident confirmed that they had made a choice regarding who they wanted to assist them with their personal care needs and that this choice had been supported by the staff. Treetops Care Home DS0000017984.V273826.R01.S.doc Version 5.0 Page 12 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 and 14 Overall the home provided the residents with flexibility and choice with regard to their daily lives. EVIDENCE: The manager confirmed that the home did not act as appointee for any of the residents living there. The residents spoken with on the day were not aware of the advocacy service, as this information was not displayed in the home. The manager confirmed that arrangements for residents to bring in possessions were discussed prior to admission, and records of possessions were available. Routines observed in the home were flexible and residents’ individual choices were addressed. The care plans did not contain any information regarding the choices made by residents and how these had been addressed. The staff spoken with confirmed that they encouraged residents to maintain relationships with relatives and friends. Treetops Care Home DS0000017984.V273826.R01.S.doc Version 5.0 Page 13 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 and 18 Residents and their families and representatives could be confident that their complaints would be listened to, taken seriously and acted upon. Residents were not adequately protected from abuse. EVIDENCE: The home operated a clear and comprehensive complaints policy and procedure including the stages and the timescale for the process. The previous inspection had highlighted the reporting and documenting of complaints as an area for improvement. The registered manager had included a ‘log’ of complaints so that any patterns or trends may be easily and speedily identified. Two complaints had been received since the previous inspection. Records confirmed these had been responded to and actioned within appropriate timescales. Some PoVA training had been provided for the staffing team since the previous inspection however 50 of the staff PoVA training was still outstanding at this visit. The registered manager reported that the remaining staff would be booked on the next available course. The manager was reminded of the need for annual refresher training in the Protection of Vulnerable Adults from abuse to be provided for all staff. Treetops Care Home DS0000017984.V273826.R01.S.doc Version 5.0 Page 14 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): 20, 21, 23, 24 and 26 Residents had access to safe and comfortable indoor and outdoor communal facilities. Residents had sufficient lavatories and washing facilities but would benefit from these areas being refurbished. Residents’ own rooms suited their individual needs. Residents lived in safe and comfortable bedrooms with their own possessions around them. The residents would benefit from the home being free from unpleasant odours. EVIDENCE: The communal areas of the home were large and airy with wheelchair access to all areas. The home appeared to be clean, tidy and warm on the day of the inspection although various areas of the home including bathrooms, bedrooms and communal areas appeared to be in need of decoration and some capital investment. Large areas of the home looked tired and tatty, paintwork was chipped and the environment was not comfortable or homely. When touring the home it was apparent that some areas of the home had an offensive smell. The registered manager agreed that floor coverings should be replaced to Treetops Care Home DS0000017984.V273826.R01.S.doc Version 5.0 Page 15 reduce the smell and make the home more welcoming and comfortable for residents. The garden was accessible although most residents needed the assistance of a carer to access the outdoor areas of the home. Lighting in communal areas was domestic in character and sufficiently bright. Bathrooms and lavatories were of a good size to accommodate residents with wheelchairs and care staff to assist. Facilities were distributed throughout the home and situated close to communal lounge and dining areas. These facilities were functional, tired and gave a ‘cold’ appearance. Residents would benefit from the bathing and toilet facilities being updated and refurbished to give a more homely and domestic appearance. Residents’ bedrooms were safe, comfortable and suited their individual needs. Some residents had personalised their rooms with their own possessions. The majority of the residents’ beds at Treetops were nursing beds, whilst this facilitated the delivery of care and the use of hoists it did not contribute to a homely feel. An unpleasant odour was apparent in the building on the day of this inspection, this was an area highlighted in the previous inspection report. Treetops is a substantial and large building providing care for up to 52 residents in accommodation arranged over four floors. Three domestic staff were employed for 2 shifts of 6 hours each week amounting to a total of 36 domestic hours. The registered manager needed to undertake a domestic staffing needs review and make appropriate arrangements to provide the residents with a clean and odour free environment. Treetops Care Home DS0000017984.V273826.R01.S.doc Version 5.0 Page 16 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28, 29 and 30 Staffing levels (number and competence) met the needs of current residents. Overall the recruitment procedure in the home was robust and provided the safeguards to ensure that appropriate staff were employed. Overall the home provided appropriate training to give staff the skills necessary to do their job. EVIDENCE: The staff rota examined confirmed that the home was providing the agreed levels of staff. The home had an appropriate number of day care and night care staff and additional numbers were on duty during busy periods. Staff absence and sick leave are covered by the permanent staff team, bank staff, and the home occasionally uses agency staff. Records confirmed that 10 of the 35 members of staff employed in the home had achieved the NVQ Level 2 qualification, while the remaining 25 members of staff were waiting to undertake this award. The manager had not made arrangements to undertake the required NVQ Level 4 Registered Manager Award. The three staff personnel files examined contained information necessary to ensure the safety of residents through the recruitment process. All of the files contained the two required references, however the references found on one file were poor in content and did not contain enough information regarding the Treetops Care Home DS0000017984.V273826.R01.S.doc Version 5.0 Page 17 skills and knowledge of the individual. All staff files contained a Criminal Records Bureau check. One of the recruited staff had started work without their CRB but this had been received by the time this inspection took place. This issue was discussed on the day, and the manager was reminded that staff must not commence employment until all of the appropriate documentation was in place. One of the application forms seen did not provide clear and comprehensive details of the skills and experience of the applicant. Treetops Care Home DS0000017984.V273826.R01.S.doc Version 5.0 Page 18 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 32, 33, 35, 36, and 38 Overall the manager is competant and able to fulfil her duties, however, the home was not always run in the best interests of the service users. Residents’ financial interests were safeguarded. Records did not provide evidence of appropriate staff supervision sessions. The health, safety and welfare of service users and staff were promoted and protected. EVIDENCE: The manager confirmed that she had many years of experience in the health and social care industry. She had not applied to undertake the NVQ 4. Many of the residents spoken with on the day were not able to identify the manager and two residents stated that they ”did not know who the manager was”. The manager’s training records confirmed that she undertook regular refresher training. The registered manager had a system of quality assurance in place involving surveying relatives and representatives of residents twice per year. Residents at treetops were not formally consulted for their opinion regarding the care and Treetops Care Home DS0000017984.V273826.R01.S.doc Version 5.0 Page 19 facilities provided at treetops. The registered manager reported regularly chatting informally with residents about their views of the home, however this was not documented or confirmed by residents. Results of the quality assurance surveys and consequent action plans to address areas highlighted by the surveys had not been forwarded to the Commission for Social Care Inspection as required by this standard. Money looked after by the home on behalf of the residents was securely maintained in a safe in the registered provider’s office. The home’s account manager was responsible for the maintenance of the financial records; these were clearly documented with receipts available for monies spent. Any excess funds held by the home on behalf of the residents were placed in a bank account titled ‘Pocket Money A/C’. The registered provider was sole signatory for this account. Interest accrued was divided up pro rata between the individual residents. The bank account was reconciled monthly and cash balances were checked monthly by the account manager and registered manager. The previous inspection visit identified the lack of formal supervision sessions for the staff team. The registered manager had re-introduced regular staff supervisions however the documentation still only identified bullet points discussed and does not provide detail of what actions were to be taken resulting from the supervision, such as staff training, care plan reviews, rota changes etc. The registered manager was able to demonstrate through production of certificates that all relevant safety checks were regularly undertaken. Treetops Care Home DS0000017984.V273826.R01.S.doc Version 5.0 Page 20 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 X X 3 3 X X HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 X 14 3 15 X COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 X 3 2 X 3 3 X 2 STAFFING Standard No Score 27 3 28 2 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 2 2 X 3 2 X 3 Treetops Care Home DS0000017984.V273826.R01.S.doc Version 5.0 Page 21 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. 1 Standard OP8OP7 Regulation 15(2) Timescale for action The registered person must 31/03/06 ensure that care plans contain information on all aspects of individual need. The care plans must be reviewed on a regular basis. The care plans must confirm that residents and or relatives have been involved in the care plan process. The registered person must ensure that care plans contain appropriate and comprehensive information. Risk and associated assessments must be completed and updated to reflect a change in individual need. The registered person must 31/03/06 ensure that care plans are updated to contain information on choices that are made and the action to address these needs. 31/03/06 The registered person must make arrangements, by training staff or by other measures, to prevent service users being harmed or suffering abuse or being placed at risk of harm or abuse. DS0000017984.V273826.R01.S.doc Version 5.0 Page 22 Requirement 2 OP14 12(2) 4. OP18 13 (6) Treetops Care Home 5 OP21 23(2) The registered person must ensure that all parts of the care home are kept clean and reasonably decorated. This specifically refers to the odour and institutional feel of the bathing and toilet facilities. The registered person must make suitable arrangements by training staff or by other measures to keep the care home free from offensive odours. The registered person must ensure that odorous carpets are replaced. The home’s level of hygiene must be assessed and any shortfalls addressed. Various areas in the home would benefit from redecoration, new furnishings and carpets. The registered person must ensure that all staff members are appropriately trained. The registered person must ensure that the information gathered at the point of recruitment is clear and comprehensive. The registered person must ensure that all staff receive comprehensive and relevant training. The registered manager must ensure that they review their qualifications and undertake up to date and appropriate training. The registered person must establish a system for reviewing the quality of care provided at the care home in consultation with service users and their representatives. The registered person must supply the commission a report in respect of any review of the quality of care provided at the care home. DS0000017984.V273826.R01.S.doc 30/06/06 6 OP26 16 (2) (k) 31/03/06 7 8 OP28 OP29 18(1)(a) 19 31/03/06 03/01/06 9 OP30 18(c)(1) 31/03/06 10 OP31 9(2)(b)(i) 31/03/06 11 OP33 24(4) 31/03/06 12 OP33 24(2) 31/03/06 Treetops Care Home Version 5.0 Page 23 13 OP36 18 (2) The registered manager must ensure care staff members receive appropriate formal supervision and this is documented appropriately. 31/01/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Treetops Care Home DS0000017984.V273826.R01.S.doc Version 5.0 Page 24 Commission for Social Care Inspection Colchester Local Office 1st Floor, Fairfax House Causton Road Colchester Essex CO1 1RJ 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 Care Home DS0000017984.V273826.R01.S.doc Version 5.0 Page 25 - 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. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!