Inspection on 01/11/07 for Trelawn House

This inspection was carried out on 1st November 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is (sorry - unknown). 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 1 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Trelawn House 16/11/05

Trelawn House 30/06/05

Similar services:

Charis

Brook Drive, 124

Rugby House Project

City Roads Crisis Intervention

Oak Lodge

Hope House

Consensa Care Ltd, 67 - 69 Highbury Gardens

Hope House

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

CARE HOME ADULTS 18-65 Trelawn House 30 Russell Hill Purley Croydon CR8 2JA Lead Inspector Michael Williams Key Unannounced Inspection 1st November 2007 10:00 Trelawn House DS0000062556.V350698.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 Trelawn House DS0000062556.V350698.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. Trelawn House DS0000062556.V350698.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Trelawn House Address 30 Russell Hill Purley Croydon CR8 2JA 0208 660 4586 0208 763 0979 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) www.cranstoun.org. Cranstoun Drug Services Mr Melvyn Higgs Care Home 15 Category(ies) of Past or present drug dependence (15) registration, with number of places Trelawn House DS0000062556.V350698.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 25th September 2006 Brief Description of the Service: Trelawn Addiction Centre has changed registered owners and is now part of the organisation ‘Cranstoun Drug Services’, which, as the name indicates, specialises in the rehabilitation of people with drug and alcohol problems. Trelawn is a large traditional brick built domestic style property situated near the Purley crossroads (A22/A23) and the Purley shopping centre. The property has a number of lounges including a combined lounge/dining room on the ground floor, a meeting room and a small quiet lounge on the first floor. There are 2 shared and 11 single bedrooms situated on the three floors of the house. None of the bedrooms have en-suite facilities other than wash-hand basins. There are toilets and bathrooms throughout the home. The home has as its Statement of Purpose to provide rehabilitation for people with drug and alcohol problems and adults recovering from abuse Trelawn can also admit people with mental health problems as a secondary issue. This is a rehabilitation unit, not a detoxification unit. It is expected that residents will move on after a 16 week programme of intensive support and the ethos of the service is that residents will take responsibility for their own actions, so they have a considerable degree of autonomy in the home but are expected to engage in the therapeutic programme at all times. This programme is unusual in having a ‘relapse’ option in certain restricted situations where re-integration into the programme can be managed after a relapse. Fees as at November 2007 were from £628 to £715. Trelawn House DS0000062556.V350698.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This key, unannounced inspection commenced at mid morning on 1st November 2007 when a site visit was made to the home. In addition to this inspection visit, which latest approximately 5 hours, a number of questionnaires were distributed to interested parties; including the residents, relatives/friends, care managers, health professionals and to staff working in the home. In compiling this inspection report the CSCI also noted information received into the commission including details of complaints (if any), untoward incidents and general correspondence. During the course of this inspection visit residents were given the to opportunity to speak to the inspector if they wished and staff were interviewed, in addition to this the premises were toured and documentation, including records, were checked. What the service does well: What has improved since the last inspection? The owners of Trelawn are introducing a wider range of therapeutic programmes; for example all staff are now working with a new programme of counselling groups called “choosing to change” and this is available as one of the several group counselling and support services they offer. The ‘survivors group’ has also proved an important arena for reflecting on long-standing emotional effects of abuse – often dating back to a resident’s childhood. The premises have been upgraded and are now of a very much higher standard which is appreciated by residents even though their stay is timelimited. Three requirements were issued by the Commission when we last Trelawn House DS0000062556.V350698.R01.S.doc Version 5.2 Page 6 inspected in 2006 and these have been addressed by the home and were identified as fully met on this occasion. 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. Trelawn House DS0000062556.V350698.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 Trelawn House DS0000062556.V350698.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): NMS 1, 2, 3, 4 and 5: Quality in this outcome area excellent This judgement has been made using available evidence including a visit to this service. Prospective residents are being assessed prior to admission so as to assure their needs, including their specialist needs associated with their addictive behaviour, can be met when admitted. EVIDENCE: During the course of this inspection a sample of residents’ case files were examined in some detail; residents were interviewed and the manager and staff were invited to comment upon the pre-admission process. The inspector also observed how staff deal with enquiries and on this occasion we had the opportunity to speak to a new resident being admitted to Trelawn on the day of the inspection. Assessments are in place for each resident and form the basis of the initial care plan and risk assessments and this includes analysis of their particular rehabilitation needs. It is made clear from the outset that residents are to participate in the rehabilitation programme and this condition forms the basis of their admission and their care contract. Also included in the pre-admission assessment are any court orders such as compulsory drug testing orders (DTO or DRR), tagging, curfews and bail conditions. Prospective residents can apply directly to Trelawn and will therefore they will of course be fully involved in ascertaining information about Trelawn and what Trelawn House DS0000062556.V350698.R01.S.doc Version 5.2 Page 9 is has to offer and this gives Trelawn the opportunity test the timeliness and readiness of the applicant for admission. The Resident Guide is a very detailed and useful document and is given to each new resident. Areas of strength include the well planned admission process that includes assessment interviews and obtaining information from referring agencies and no matters requiring improvement arise this section, about choice of home, is assessed as excellent. Trelawn House DS0000062556.V350698.R01.S.doc Version 5.2 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): NMS 6,7 and 9: Quality in this outcome area excellent. This judgement has been made using available evidence including a visit to this service. The care planning process and responsible decision-making about risks are central tenets of the work in this home; residents not only know that their care plans reflect their needs they are also expected to assist in drawing up their own plans, so this ensures their specific needs can be addressed and will assist residents achieve their potential. EVIDENCE: From the outset, even before admission or the ‘entry date’ is agreed prospective residents must engage with the service to demonstrate readiness for the programme. This includes confirmation that they are ‘dry’ which may require a period in a detoxification unit prior to admission. They must then demonstrate an understanding of the care planning process and the programme of group and individual counselling sessions that will help them towards recovery. The home also ensures it has assessments from other agencies that worked with or supported the resident so that risks are identified and catered for. This helps the home gauge when and what risks will be acceptable during their stay. This may include for example restrictions during Trelawn House DS0000062556.V350698.R01.S.doc Version 5.2 Page 11 the first weeks leading to a more open approach including local excursions and home visits with all the potential for relapse. Decision-making about their own lives is crucial to the success of this unit and not all residents are able to make decisions that will lead towards recovery – many relapse more than once but as the manager explained each rehabilitation session will bring them closer to an improved lifestyle. Care planning involves the resident at each stage, including the original objectives and goals and subsequent action and review processes. This will involve residents confronting issues in their life they have so far ignored or ‘buried’ including for example bereavement and loss, abuse and failure in many aspect of their life, financial, social and relationships. All residents are expected to fully engage with and take part in the running of the home, in particular domestic task such as cleaning, shopping and cooking as well as the therapeutic groups that residents must fully engage with. Areas of strength include the full involvement of residents in care planning and the process of residents taking responsibility for their own behaviour and recovery and as there were no matters identified on this occasion that require improvement this section, about needs and choice, is assessed as excellent. Trelawn House DS0000062556.V350698.R01.S.doc Version 5.2 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): NMS 11, 12, 13, 15, 16 and 17: Quality in this outcome area good. This judgement has been made using available evidence including a visit to this service. A range of appropriate activities is provided so as to enable resident rehabilitation. Residents are free to make use of the local community resources and are free to maintain personal relationships that do not affect their rehab’ programme but allows them to still have contact with the community. The staff assist residents in preparing their own meals and staff monitor their wholesomeness and in particular that they are taken in a communal setting as part of their programme of care. EVIDENCE: To assess this standard we spoke to several of the residents as well as talking to support staff and checking care plans. We were also able to observe the day to day activities in the home and this includes the running of therapeutic groups and as well as domestic routines. Standard 12 is about the home providing opportunities for person development and this is a key part of the work of this addiction centre. Residents in this home will have in most instances succumbed to their addiction and their addictive behaviour has become maladapted. The home therefore provide each Trelawn House DS0000062556.V350698.R01.S.doc Version 5.2 Page 13 resident with the opportunity to change their way of life and this central role impacts upon all sections of this report. Social and recreational activities are less important in this home but nevertheless the home seeks to support residents is relearning skills and helps the to engage in purposeful social activities and two popular choice for residents are swimming and gym exercises, many bedrooms have weightlifting and other equipment; it is evident many residents want to improve their physical health as well as their well being. Whilst residents have free access to community resources such as shops, cinema, fitness suites the main emphasise is in group and individual meetings. Contact with family and friends is inevitably constrained by the overall programme of Trelawn. In some instances contacted might be discouraged, for example if such contact will inhibit progress, whilst in other instances the home may be able to help residents re-establish family links and more healthy friendships. Trelawn emphasises that each resident must take responsibility for their own progress and which require active participation in groups and meetings as well as individual work - when residents spend time alone reflecting upon their past life, which has often been quite traumatic, and their future aspirations. In respect of meals and dining arrangements, service users, with the support of the care workers, prepare all their own meal. The quality of the meals is therefore dependent upon the skills of residents themselves and there opinion is that this system works well and helps them build confidence in shopping and cooking. The evening meal is taken en-masse as part of the programme. Service users who have lived in other units compare catering in Trelawn favourably because the home provides, or the residents shop for, fresh food throughout the week – it is not bought in bulk. The dining room was recently redecorated and the furniture re-arranged and is an agreeable area to dine. Areas of strength are the full involvement of residents in all aspects of the home so as to improve their personal skills and as there are no matters requiring improvement in this section, about lifestyle, it is assessed as good. Trelawn House DS0000062556.V350698.R01.S.doc Version 5.2 Page 14 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): NMS 18, 19, 20: Quality in this outcome area excellent. This judgement has been made using available evidence including a visit to this service. Residents are receiving support in the manner they require to help them rebuild their lives. In all cases the medication for residents is held in the office and administered with the support of staff for reasons of safety but residents are expected to share in the responsibility for their own medicines including the arrangements for prescriptions. EVIDENCE: In recent years Trelawn has introduced a number of support programmes such as “choosing to change” and the “survivor’s group”. The latter is proving to be an important series of meetings. It is an elective group meeting when many other sessions are compulsory. This group recognises that some residents will have experienced serious traumatic events in their lives and may never had had the opportunity or inclination to address these matters. Some might think their addictive behaviour stems from such trauma and therefore confronting rather than hiding from such historic issues will help them make the personal development defined in standard 11. The home ensures each resident has access to a local General Practitioner and maintains contact with any specialist health consultants treating them. As part of the programme residents are expected to address their own health care Trelawn House DS0000062556.V350698.R01.S.doc Version 5.2 Page 15 needs which may have been somewhat neglected as their addiction took hold. The psychological support provided by this home is critical to its success; residents will have arrived in the unit ‘dry’ – they have that is stopped taking drugs and/or alcohol and at this stage need to rebuild their lives which often requires them to explore issues in their past that they have failed to adjust to such as a significant bereavement or abuse. Residents frequently need to relearn, with the help of staff, how to express their emotions in a constructive way rather than retreat into addictions. The residents themselves and exresidents affirm the success of this programme – but not in all cases - there is a high drop out rate that is apparently not unexpected for this type of work. The care manager we spoke tells us that Trelawn is held in high regard by his local authority team and anecdotally they have the impression Trelawn is proving effective in changing lives and reducing the impact of addictive behaviour. The home now reflects upon its success rates through the TOP audits [Treatment Outcome Profile], which is a new national audit of all such treatment centres. Areas of strength include the proven success rate for their work and as there are no matters requiring improvement so this section, about personal and healthcare is assessed as excellent. Trelawn House DS0000062556.V350698.R01.S.doc Version 5.2 Page 16 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): NMS 22 and 23: Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The arrangements and procedures that are in place ensure residents and their representatives are either able to complain about or compliment the service. Residents can be confident that these procedures are adequate to deal with any complaints and will ensure that they dealt with fairly and in a timely manner. Policies, procedures and staff training that are in place regarding abuse protect the residents but not all staff were aware of the need to refer matters of abuse to the local authority Social service Department without delay and before initiating a full investigation. EVIDENCE: The home has a clear and simple procedure for dealing with complaints so residents’ are confident their concerns will be dealt with promptly and effectively. To ensure vulnerable residents are safeguarded from abuse the home has written policies and procedures about the protection of residents and their property; this includes procedures for passing on concerns to the relevant authorities including the CSCI but in 2006 not all staff were able to demonstrate that the first step in dealing with allegations of abuse is to refer the matter to the local Social Service Department before initiating investigations. All staff must be mindful that the police may wish to take make their own enquiries and check forensic evidence without delay so staff have since been instructed on how to correctly refer allegations of abuse in its various forms. Areas of strength include the home’s openness to comment and complaints by residents and also the support provided to residents in asserting their rights. No matters requiring improvement arise and the requirements to update the guidance to resident has been done and each member of staff has brief summary of the referring suspicion of abuse to the local authority. So this section, about complaints and protection, is assessed as good. Trelawn House DS0000062556.V350698.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): NMS 24 and 30: Quality in this outcome area good. This judgement has been made using available evidence including a visit to this service. Since the last inspection much of the house has been refurbished and now looks much fresher and is again a homely, safe and comfortable place to live in. EVIDENCE: This care home provides for residents who will not be living there for more than a few months and in each case have their own accommodation to which they can return and the Commission is mindful of this point. During the previous inspection the residents in told us that the condition of some rooms and in particular the communal facilities (toilets and bathrooms) were in a poor state of repair and decoration. During a tour of the premises it was evident the environment is much improved, with painted walls and new furniture the home is now decorated to a much better standard. The home also tried to address the residents’ wish for a small gym - but this has not proved possible because of planning laws. Nevertheless the home has provided equipment that is used throughout the home and on the patio. The kitchen was reasonably clean and tidy for such a Trelawn House DS0000062556.V350698.R01.S.doc Version 5.2 Page 18 busy area. The staff ensure residents comply with catering standards including food storage and safe cooking. There are still some areas that need improving including the laundry area. We also note that one shower is not fully functioning and another has broken light and a toilet is not being properly vented. Areas of strength include the ratio of single rooms, this is something residents say they appreciate; residents also commend the general homeliness of the place and they appreciate the improvements to the environment. A requirement is made to address the maintenance issues and ensure showers and toilets remain in good working order. So this section, about the environment is assessed as good. Trelawn House DS0000062556.V350698.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): NMS 32, 34, 35: Quality in this outcome area excellent. This judgement has been made using available evidence including a visit to this service. Staff recruitment, staffing levels, staff qualifications and training appeared adequate to meet the needs of current residents. The Police checks [CRBs] were not available for inspection previously but are now in place. EVIDENCE: As residents in this project are physically mobile and independent fewer staff are needed than in homes catering for more dependent residents. During the day there are usually two or three support workers and never less than two plus the manager and an administrator. At night just one support worker is required. The owners have established a training programme for staff including an off-site training course in therapeutic group work called ‘Choosing to Change’, which is now being introduced to residents as part of the therapeutic programme run by staff. No new staff, other than a volunteer administrator, have been employed since the previous inspection indicating a stable and well established staff team. A member of staff confirmed that he was required to undergo a thorough recruitment process including references, police checks, and other checks he also received induction training and under the auspices of the new owners ongoing support and supervision is provided. A check of staff documentation confirmed good practice. This includes supervision from an Trelawn House DS0000062556.V350698.R01.S.doc Version 5.2 Page 20 independent agency – this provides an opportunity for the whole staff team to reflect upon their practice and the tensions that arise in this intensively therapeutic regime. Areas of strength include a stable and well trained staff team that includes exresidents who might be regarded as ‘experts by experience’ and contribute enormously to the success of the unit. No matters requiring improvement arise on this occasion, so this section, about staffing, is assessed as good. Trelawn House DS0000062556.V350698.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): NMS 37, 39, 41, 42: Quality in this outcome area excellent. This judgement has been made using available evidence including a visit to this service. Residents are involved in a great many aspects of the running of this service as part of their rehabilitation. As they progress through the rehab’ programme, the residents form part of the support team for the newer residents in the early stages of the programme. No hazards were identified during this inspection other than the condition of the bathrooms and toilets and this appears to be a well managed service thus ensuring the safety and wellbeing of residents. EVIDENCE: Based upon a series of inspections with positive outcomes for residents it is clear they benefit from a well run home. The admission process; the rehab’ programme and the relapse programme plus the clear boundaries set for residents makes this an effective and well managed facility. No health and safety hazards were identified during the course of this inspection – which included a tour of the premises. Residents participate in the running of the Trelawn House DS0000062556.V350698.R01.S.doc Version 5.2 Page 22 home and in doing so receive support and guidance in the safe handling of chemicals, how to reduce hazards and how to maintain a safe environment. A range of statutory records were examined including residents’ case files, staff files, complaints, accidents, and incident reports (which are forwarded to the Commission as required). The home also provided confirmation of other records and checks being in place including kitchen records, maintenance of equipment plus the home’s policies and procedures. Since the previous visit the home has received funding which has enabled to improve physical standards. The home was also at full occupancy on the day of inspection although the home is dependent upon referrals to keep occupancy high and few local authorities appear to be in a position to make such referrals to a residents unit, instead people with drug and alcohol addiction appear to be supported in other ways. Residential rehabilitation appears to be a ’last resort’ and Trelawn is therefore at the end of the (rehab’) line. In order to expand the range of services it can provide the home is again in a position to offer support and rehabilitation to people with mental health problems as secondary issues to the primary addictive condition. The national audit TOP [Treatment Outcome Profile] will help the home monitor outcome for its residents over a longer period of time. Areas of strength include a stable staff team; a well established programme of rehabilitation; positive feedback from residents and a success rate (as judged by residents completing the programme and visiting care managers) and as no matters requiring improvement are identified this section, about management and administration, is assessed as excellent. Trelawn House DS0000062556.V350698.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 4 2 4 3 3 4 3 5 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 4 33 X 34 3 35 4 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 4 X 4 x LIFESTYLES Standard No Score 11 4 12 3 13 3 14 X 15 3 16 4 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 4 4 3 X 4 X 4 X 3 3 x Trelawn House DS0000062556.V350698.R01.S.doc Version 5.2 Page 24 Are there any outstanding requirements from the last inspection? No STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard YA19 Regulation 23(2)c Requirement Premises: the home must keep equipment such as showers, toilets and lighting in good working order for the benefit of all residents. Timescale for action 30/12/07 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. Refer to Standard YA9 Good Practice Recommendations Risk assessments: It is recommended that the home ensure old risk assessments are confirmed as no longer posing a risk or included in new and reviewed risk assessments so that residents will be assured the home is aware of potential risks whilst living in the home. Trelawn House DS0000062556.V350698.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection Croydon, Sutton & Kingston Office 8th Floor Grosvenor House 125 High Street Croydon CR0 9XP 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 Trelawn House DS0000062556.V350698.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. 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!