Inspection on 08/01/07 for Treetops Residential Home

This inspection was carried out on 8th January 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 found no outstanding requirements from the previous inspection report, but made 2 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Treetops Residential Home 03/12/08

Treetops Residential Home 07/01/08

Treetops Residential Home 25/01/06

Treetops Residential Home 30/06/05

Treetops Residential Home 07/02/05

Treetops Residential Home 14/09/04

Similar services:

Coopers Mill Ltd

Bramley Avenue (73)

Paradise Lodge

Grangewood

Upaya Ananda

Newton Court (1-2)

Kings Lane (32)

Pemdale

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

CARE HOME ADULTS 18-65 Treetops Residential Home Old Ipswich Road Claydon Ipswich Suffolk IP6 0AE Lead Inspector Julie Small Key Unannounced Inspection 8th January 2007 11:00 DS0000024514.V326209.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 DS0000024514.V326209.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. DS0000024514.V326209.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Treetops Residential Home Address Old Ipswich Road Claydon Ipswich Suffolk IP6 0AE 01473 830829 01473 833057 sheila@cephas-care.co.uk 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) Mrs Jane S Hewson Mrs Sheila Mildred Gillians Care Home 7 Category(ies) of Learning disability (7) registration, with number of places DS0000024514.V326209.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 25th January 2006 Brief Description of the Service: Treetops provide care and support to seven adults with learning disabilities whose behaviour can be challenging. The home was first registered in March 1996 and is owned by Mr. and Mrs. Hewson under the name of Cephas Community Care. Mr. and Mrs. Hewson jointly own a number of residential homes for people with learning disabilities within Suffolk. Treetops is a detached two-storey dorma style bungalow, set well back from the road and situated at one end of the village of Claydon. Service users can easily access the amenities within the village and the home is also a few minutes from the A14 allowing easy access to the other main towns within the east of Suffolk. All service users are provided with single room accommodation, which is furnished and decorated to individual tastes and needs. The home has the advantage of an indoor heated swimming pool. Treetops provides day services to the service users which is created around personal interests and learning skills. The home has its own transport and all service users are therefore able to access local community facilities in the east Suffolk area. The manager reported that at the time of the inspection charges at Treetops was £750 to £1,500 per week. DS0000024514.V326209.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The unannounced inspection took place on Monday 8th January 2007 over a period of approximately five and half hours. The inspection was a key inspection which focused on the core standards relating to younger adults and was undertaken by regulatory inspector Julie Small. The homes manager Mrs Sheila Gillians facilitated the inspection process. The report has been written using accumulated evidence gained prior to and during the inspection. A staff member said that service users were referred to as clients at the home, this term will be used throughout the report. A tour of the building, which was facilitated by a client and a staff member, observation of medication storage and records and observation of work practice was undertaken during the inspection. Five clients were met, three were spoken with as much as their abilities allowed and four staff members were spoken with. A range of records were viewed which included fire records, four staff records, three client records, quality assurance records and complaints records. Further records viewed can be found in the main body of this report. The staff and clients welcomed the inspector to the home and information requested was provided promptly and in a friendly and open manner. What the service does well: What has improved since the last inspection? There were records of staff supervision which were undertaken regularly. Staff spoken with confirmed that they were satisfied with the support they received. DS0000024514.V326209.R01.S.doc Version 5.2 Page 6 Medication procedure and recording was appropriate. The home had updated the care planning documentation. There was an allocated staff member who took responsibility for quality assurance within the home. The home had received some areas of redecoration and staff reported further areas of planned redecoration in the home. 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. The summary of this inspection report can be made available in other formats on request. DS0000024514.V326209.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 DS0000024514.V326209.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): 2 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Prospective users can expect that their individual aspirations and needs are assessed. EVIDENCE: Three clients records viewed included assessments of their needs which had been undertaken prior to them moving into the home by the placing authority. The homes manager had completed one viewed. Each client had a care plan which identified what care and support should be provided to each client to meet their needs. DS0000024514.V326209.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): 6, 7, 9 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users can expect that their assessed and changing needs are reflected in their personal plan, they make decisions about their life with assistance required and they are supported to make risks as part of an independent lifestyle. EVIDENCE: Three client’s records were viewed and included detailed care plans which identified care and support they should be provided with to meet their assessed day to day living needs. The care plans included aims and objectives for each activity, such as using public transport, independence, abilities, education, personal care and cleaning their bedroom, resources required to achieve the aims and the time to complete. There was a date of the last update of the care plan, however, there was no record of what changes had been made, the date of each update and the reason for any changes. A staff member spoken with confirmed that the care plans were used to inform the staff of the care they should provide to each client. They said that the client’s DS0000024514.V326209.R01.S.doc Version 5.2 Page 10 key worker was responsible for updating the care plans which were done regularly. The manager said that the care plan format had recently been updated and provided increased detail. Each record had a sheet of paper which staff should sign to state that they had read the records. There were records of behaviours which clients may exhibit, possible triggers for the behaviours and guidelines which provided ways that staff must work with them to assist to calm and divert client’s behaviours. The homes manager confirmed that client’s families and clients were consulted on the provision of care. One client who did not have regular contact with their family had an advocate who visited them regularly. During the inspection staff were observed to provide choice to clients for all activities including what they were going to eat and activities they were participating in. Care plans viewed identified methods of communication that each client used and how they should be supported in making decisions about their day to day life, such as clothing they would wear. Daily records viewed evidenced that clients were supported in making decisions. Arrangements for each client’s finances were recorded in their records, which included the bank or building society they used, if their families held responsibilities and monies which were available to clients. Their abilities with regards to budgeting and their recognition of currency. Three clients records viewed included detailed risk assessments on their day to day living activities which included bathing, going out for a walk, being in the community and using the homes vehicles. The risk assessments included the activity, the risk and methods of preventing or minimising the risk. DS0000024514.V326209.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): 12, 13, 14, 15, 16, 17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users can expect that they take part in appropriate activities, are part of the community, they have appropriate relationships, their rights are respected and that they are offered a healthy diet. EVIDENCE: There were no clients who attended educational or occupational placements during the day. A staff member spoken with said that there were no services available for the clients living at the home and those who had previously attended services had been asked to leave due to their behaviours. They said that they compensated by facilitating activities from the home. Records viewed evidenced that clients had previously attended various training and educational courses. They were provided with regular opportunities to participate in one to one or two to one activities in the local community. Activities included walks round a local lake, visits to neighbouring towns and villages and shopping. One client was observed going out for a walk in the village with a staff member DS0000024514.V326209.R01.S.doc Version 5.2 Page 12 during the inspection. The home had two vehicles which clients could use to go out with. There was a good range of activities within the home which clients could participate in which included using the homes swimming pool, watching television, listening to music, assisting with the domestic duties in the home, keeping their bedrooms tidy and helping with cooking meals. During the inspection a client was observed helping a staff member in the preparation of lunch and a client assisted a staff member in showing the inspector around the home. The manager said that some clients used the local hairdressers and those who were not able used a resident hairdresser at another of the services homes. They said that they were pursuing educational and occupational provision for clients, this was confirmed in clients records viewed, including that their placing officer was also pursuing such day placements. The manager said that clients attend coffee mornings at a service in Ipswich. Client’s records viewed included risks of discrimination that clients may face in the community and how staff should support clients. The manager explained contact arrangements for each client, some had regular home visits, some had visits from their family at the home and some had limited contact with their family. One client had visits from their advocate. Contact arrangements were detailed in clients care plans which were viewed and dates of all contacts were documented. During the inspection a staff member asked all clients for their permission to show the inspector their bedrooms. The staff member knocked bedroom doors and asked permission to enter when clients were in their rooms. Staff were observed asking clients for their choices on what they wanted to eat and if they wanted to participate in activities during the inspection. What each client had eaten each day was included in their daily record and evidenced that they were provided with a balanced and nutritious diet. During the inspection clients were observed enjoying a meal of fish and chips in the dining area. The meal looked and smelled appetising. During a tour of the building it was noted that there was a large bowl of fresh fruit in the kitchen and there was a range of fresh vegetables in the fridge. There was a good stock of a range of food in the kitchen. DS0000024514.V326209.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): 18, 19, 20 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users can expect that they receive personal support in the way they prefer, that their physical and emotional needs are met and that they are protected by the homes medication procedures. EVIDENCE: Clients records viewed included their daily routines and ways of communicating their wishes and needs. There was records of the homes review of their care provision with input from the client and their representatives, their key worker and other professionals involved in their care. Records include what support each client needs in their personal care and methods of ensuring their dignity and independence was respected and supported. Staff spoken with had a clear knowledge of the client’s needs and preferences. A staff member was observed to assist a client when they had used the toilet during a tour of the building. They ensured that their privacy and dignity was respected. DS0000024514.V326209.R01.S.doc Version 5.2 Page 14 Records evidenced that clients were provided with regular health, dental and optical checks. Appointments and their outcomes were recorded. Client’s specific health needs were documented with directions of support they required. There were no clients who self medicated at the home. The homes medication storage was viewed and noted to be safe and secure. Treetops used a MDS (monitored dosage system) and all medicines were well documented. One clients MAR chart had the code ‘D’ which was that they were on social leave. However, all administration times were not accounted for, there were two gaps noted. The manager confirmed that this client was on home leave. There was a clear record of medication which had come into and left the home. There were guidelines for each clients PRN (pro re nata – as needed) medication, and their administration were recorded and reasons for administration was recorded on the back of the MAR chart. Training records evidenced that staff had been provided with medication training. Two staff members spoken with confirmed that they had received medication training, however, they did not administer medication in the home because this was a senior duty. DS0000024514.V326209.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 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users can expect that their views are listened to and acted upon and that they are protected from abuse, neglect and self harm. EVIDENCE: The manager reported that there had been no complaints received since the last inspection. The homes complaints records confirmed this. The home had a complaints procedure. Staff members spoken with confirmed that they knew how to make a complaint at the home. They reported that they were aware of support they should provide to clients and their representatives wished to make a complaint. Which included reporting to a senior member of staff, however, a staff member clearly explained what they would report it to another senior member of staff if the concern was about them. Staff said that they had been provided with POVA (protection of vulnerable adults) training. Two newly employed staff members were complimentary on the POVA training they had received. Training records viewed evidenced that all staff working at Treetops had received POVA training. There had been one incident which had been reported regarding an allegation about a staff member. Records were viewed and the incident was discussed DS0000024514.V326209.R01.S.doc Version 5.2 Page 16 with the manager. It was noted that the incident had been handled appropriately, and that the individual no longer works at Treetops. Staff spoken with explained methods of diversion when working with individuals who were displaying aggressive behaviours. They said that physical intervention would be used as a last resort. Staff spoken with and training records viewed confirmed that all staff had been provided with Unisafe training. The manager reported that the home had their own trainer and updates were regularly provided. DS0000024514.V326209.R01.S.doc Version 5.2 Page 17 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users can expect to live in a homely, comfortable, safe environment which is clean and hygienic. EVIDENCE: A tour of the building was undertaken, which was facilitated by a client and a member of staff. The home was clean, homely and well maintained and provided appropriate furnishings throughout. The manager said that staff and clients took responsibility for ensuring that the domestic upkeep of the home was maintained, it was noted that they did a good job. Client’s records viewed evidenced that they participated in keeping their bedrooms clean and duties in the general housekeeping, which also maintained their independence. There was a maintenance staff member observed painting the outside of the home at the time of the inspection. A bedroom had been redecorated and the staff member reported the plans for the redecoration of all areas of the home. DS0000024514.V326209.R01.S.doc Version 5.2 Page 18 The home was warm and well lit. There were no offensive odours detected during the inspection. The home was situated in a residential area and was accessible to the local village and public transport. The home had an indoor swimming pool, which clients could enjoy and there was a snoozlem, which had been redecorated. The laundry was viewed and was clean and tidy. There was sufficient hand washing facilities in the home which provided hand wash gel and disposable paper towels. There was a good stock of disposable gloves and aprons available for staff use in bathrooms. The home had policies and guidelines on infection control. DS0000024514.V326209.R01.S.doc Version 5.2 Page 19 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34, 35, 36 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users can expect that they are supported by competent, well trained, supervised and supported staff. They can expect that they are protected by the homes recruitment procedures, however, not all records were available in the home. EVIDENCE: Staff spoken with were friendly, professional and they provided information requested in an open manner. They were knowledgeable about their role and the needs of the clients living at the home. Interaction observed between staff and clients during the inspection was positive, relaxed and respectful. Clients responded positively to staff. The manager said that the home had met the target of at 50 of staff to have achieved a minimum of NVQ (National Vocational Qualification) by 2005. However, there had been staff who had transferred to other Cephas homes, staff who had left the home and newly employed staff which had affected the numbers of qualified and unqualified staff. There was one staff who had level 2 and one who had level 3, one was working toward their level 2 and three DS0000024514.V326209.R01.S.doc Version 5.2 Page 20 working toward their level 3 and six staff who had not yet achieved their award. One staff member was attending college undertaking a nursing qualification. When the staff working towards their awards had achieved them the home would have met the 50 target. Training records viewed evidence the qualification status of each staff member. The manager said that recruitment was undertaken centrally by the service and records were kept in the head office as well as in the home. Four staff recruitment records were viewed. All had an application form, POVA first check, CRB check, interview notes, declaration of health, terms and conditions of employment. There was a CRB check for a visiting chiropodist. Three records had two written reference and one had one written reference. The checklist on the title page stated that two references had been received. The checklists stated that each staff members proof of identification had been viewed, however, only one held a copy of their driving licence which had a photograph. No records had a photograph of the staff member. There were photographs of each staff member displayed in the entrance area of the home. The manager was spoken with and said that the service’s human resource department made the appropriate checks and they telephoned to ask for this information to be sent to the home. Each staff member was provided with an identity badge, for which they were required to provide proof of identification. The last inspection report noted that the home had an excellent training programme. Training records and discussions with staff confirmed this. There was a good range of core and specialist training which staff were provided with. Two newly appointed staff members were complimentary about the range and quality of the training which had been provided to them, which included Skills for Care induction. They stated that they shadowed experienced staff as part of their induction period at the home and that they did not escort clients outside the home alone. The manager reported that they encouraged staff to maintain continuous professional development (CPD) files and the home maintained a training matrix regarding each individual’s attendance for training. Records viewed and discussions with the manager and staff members evidenced that staff were provided with regular one to one supervision and team meetings. Staff reported that they were satisfied with the levels of support they were provided with at the home and were complimentary about the levels of team work. DS0000024514.V326209.R01.S.doc Version 5.2 Page 21 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39, 42 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users can expect that they live in a well run home, that their views underpin self monitoring in the home and that their health, safety and security is promoted and protected. EVIDENCE: The manager had achieved the RMA (registered manager) award and they evidenced with training records that they regularly updated their knowledge. A staff member was spoken with who had responsibility for quality assurance exercises in the home, which had recently been undertaken at the home. The staff member explained the process and provided the inspector with documentary evidence to support this. Satisfaction questionnaires had recently DS0000024514.V326209.R01.S.doc Version 5.2 Page 22 been sent to and received from staff and clients families. They were working on collating the responses, they said that they had not received any adverse comments, but that they would speak to the quality assurance manager and service manager if there were concerns regarding the service provided, and they would find methods of improving the service. The staff member was working on developing a user friendly questionnaire for clients. They confirmed that findings of the exercise would be reported to clients and their representatives and to prospective service users. The home provided clear health and safety policies and procedures. Staff spoken with said that they were directed to read the documents in their induction period. The home had a clear fire risk assessment and regular fire checks and drills were undertaken. Staff training records evidenced that staff were provided with health and safety related training such as fire safety, manual handling, food hygiene and first aid. There were environmental risk assessments which were viewed which included using the swimming pool. A staff member reported that the temperature of water temperatures was regulated and that staff checked the temperatures of the baths before clients got into the bath. Accident records were viewed. There was an accident book for reporting RIDDOR (reporting incidents, disease and dangerous incidents regulation) incidents and non-reportable accidents were reported on accident forms which were stored in client’s records. It is recommended that a central record of accidents be maintained which can be cross-referenced to each report form. Records were viewed which evidenced where repairs, checks and services had been undertaken on items such as the swimming pool, gas tumble dryer and electrical items. There were first aid boxes in the home which were well stocked, a staff member confirmed that they were regularly audited and restocked when necessary. DS0000024514.V326209.R01.S.doc Version 5.2 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 X 2 3 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 3 32 X 33 X 34 2 35 4 36 3 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 3 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 DS0000024514.V326209.R01.S.doc Version 5.2 Page 24 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 YA20 Regulation 13(2) Requirement The registered manager must make arrangements for the recording of when clients are on home leave and medicines are not administered. Record must be available for inspection at the home as required in Schedule 4, 6. Timescale for action 31/01/07 2. YA34 19 sch 4 28/02/07 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 YA42 YA6 Good Practice Recommendations It is recommended that a central record of accidents be maintained which cross references to accident report forms. It is recommended that changes to clients care plans be documented. DS0000024514.V326209.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection Suffolk Area Office St Vincent House Cutler Street Ipswich Suffolk IP1 1UQ 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 DS0000024514.V326209.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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