Inspection on 16/10/06 for Trevayler Residential Care Home

This inspection was carried out on 16th October 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Trevayler Residential Care Home 07/08/07

Trevayler Residential Care Home 03/01/06

Trevayler Residential Care Home 12/09/05

Trevayler Residential Care Home 16/02/05

Trevayler Residential Care Home 22/06/04

Trevayler Residential Care Home 30/09/03

Similar services:

Thornham Grove

Thistle Hill Hall

Conifer Lodge

Westwood Lodge

Egerton Lodge Care Home

Alfred Minto House Care Home

St Matthews Unit

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

CARE HOME ADULTS 18-65 Trevayler Residential Care Home 309 Burton Road Derby Derbyshire DE23 6AG Lead Inspector Steve Smith Unannounced Inspection 16th October 2006 11:00 Trevayler Residential Care Home DS0000002003.V313558.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 Trevayler Residential Care Home DS0000002003.V313558.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. Trevayler Residential Care Home DS0000002003.V313558.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Trevayler Residential Care Home Address 309 Burton Road Derby Derbyshire DE23 6AG 01332 348080 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) 2 Care Christine Helen Lawrence Care Home 23 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (23) of places Trevayler Residential Care Home DS0000002003.V313558.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 3rd January 2006 Brief Description of the Service: Trevayler Care Home provides care for 23 people recovering from mental health problems. The level of care available is dependent on Service Users’ difficulties and is provided on three levels: that available for dependent Service Users, semi-independent Service Users and independent Service Users. Independent Service Users live in a separate property next door to the main house, and is fully self-contained. All Service Users have a room of their own. There are two lounges in the main house, with one being much larger that the other. One lounge is available to those Service Users who wish to smoke. There is also one dining room and one kitchen area. The Home operates a rota for Service Users to assist staff in preparing meals. Service Users also take turns to assist with cleaning and maintaining the Home, again on a rota basis. The ‘work’ carried out by Service Users is part of the rehabilitation process operated by the Home. The charges made for a room at Trevayler range from £580.00 to £990.00 a week, dependent on the needs of the Service User. Trevayler Residential Care Home DS0000002003.V313558.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place in just over 6.5 hours. Discussion was held with two Service Users, whose records were also ‘case tracked’, the Manager and staff. A number of records were examined, and the bedrooms of two Service User were looked at and all public areas of the Home were examined. The Commission’s pre-inspection questionnaire, sent to the Manager, and the Commission’s questionnaire sent out to a selection of Residents, had been completed, and were available prior to the inspection. Three Residents choose to complete the questionnaire. What the service does well: The issues mentioned in these next three sections of the report were the items inspected on this visit to the Home. A statement of purpose and a very good quality Service Users Guide are available in the Home. All new Service Users moving to the Home were appropriately assessed. Good records were maintained on each Service User staying at the Home, and these were reviewed at six monthly intervals. Service Users interviewed were extremely pleased with the assistance provided by staff of the Home. They said that they could help with providing educational courses, obtaining jobs and the management of money. They also were supportive of Service Users dealing with day-to-day issue in their lives and in organising social activities. A good complaints procedure was provided and good protection policies and procedures were also provided. The Home was well maintained and Service Users were encouraged to keep their bedrooms clean and tidy. Good quality staffing and appropriate numbers of staff were provided at all times. The Registered Provider and Manager ensured that the Home was run to a very good standard at all times. Trevayler Residential Care Home DS0000002003.V313558.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? 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. Trevayler Residential Care Home DS0000002003.V313558.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 Trevayler Residential Care Home DS0000002003.V313558.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 1 & 2. The quality in this outcome group was ‘Good’. This judgement was made using available evidence including a visit to the Home. The Registered Provider’s statement of purpose and Service User’s Guide were well completed, so that prospective Service Users would be adequately informed of the operation of the Home prior to deciding to move there. All new Service Users moving to the Home were appropriately assessed prior to their admission, so that they were reassured that their needs would be met. EVIDENCE: The Home’s statement of purpose and Service User’s Guide were reviewed during this inspection. The Service User’s Guide was found to be a large document of over 30 pages in length, covering all issues likely to confront a Service User staying in the Home. Both documents were well constructed and copies of the Service User’s Guide were found in Service Users’ bedrooms. The Home received referrals of new Service Users via the Care Management teams of Social Services Depts or Health Authorities, mainly from the east midland region. The Manager said that placing authorities always provided adequate information when Service Users were placed in the Home. Currently, only one Service User was self-funded. The Manager had conducted her own assessment of this Service User. All Service Users referred through Social Trevayler Residential Care Home DS0000002003.V313558.R01.S.doc Version 5.2 Page 9 Services Depts or Health Authorities were assessed by the Manager prior to the beginning of their placement. Trevayler Residential Care Home DS0000002003.V313558.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 6, 7, 8 & 9. The quality in this outcome group was ‘Good’. This judgement was made using available evidence including a visit to the Home. The Manager and staff enabled Service Users to take risks, ensuring that the risks were appropriate to their abilities. EVIDENCE: To help assess Standard 6, the Service User’s Plan of Care, the records of two Service Users were examined, for the purpose of case tracking. All of the basic information, concerning each Service User, was found to be in the files examined. Copies of the initial assessment completed by the Social Services Care Manager, where one was involved, were available, and the staff in the Home had completed their own initial assessment of needs for both of the Service Users. There were also good care plans and risk assessments available in each record examined, providing staff with information to met Service User’s needs. Trevayler Residential Care Home DS0000002003.V313558.R01.S.doc Version 5.2 Page 11 The files showed that extensive records of events affecting each Service User were kept. The Service User’s formal reviews of care, undertaken on a six monthly basis, had been signed by each Service User. Service Users also signed many of the other entries found in the files, and the Manager was complemented on this. Service Users records were easy to read and were very detailed. Both of the files contained a confidential section, and both of the files seen were well organised and regularly completed. Each file was found to be very full, with lots of information completed by staff. Again, the Manager was complemented on this very positive standard. Two Service Users were interviewed, at length during this inspection. They both said that staff respected their right to make decisions about their lives, and would advise them when necessary – ‘Staff advise, but don’t make you.’ They also said that staff supported them to make decisions in their lives – ‘(my keyworker) prompts me’. ‘They ask you what you want from life.’ Staff also helped one Service User to join support group. Staff also supported the Service Users with financial issues - ‘She helped me sort out my benefit problems’. Self-harm can sometime be an issue within this Home and Service Users said that staff were very helpful concerning this difficulty – ‘(Service Users) sometimes will tell me they are suicidal and I can tell staff or tell them to contact staff about this’. ‘I can tell staff, if I think it is serious…they are good at helping with this.’ Service Users help with the day-to-day running of the Home. The two Service Users spoken said that they were on rotas to provide cooking, and cleaning in the kitchen, cleaning in the public areas of the Home and in the bathrooms and toilets. They said that all Service Users help with these tasks. The Manager said that a Service User is present in all staff meetings, and Service Users also take part in the national representation meeting held by 2Care. The Manager said that staff informed the Service Users of risk assessment strategies used in the Home prior to their moving in, which was also noted within each file. She also said that staff would respond promptly to any unexplained absence of each Service User from the Home. Risk assessments were undertaken for both Service Users interviewed. They said that – ‘an assessment was done with me and my social worker.’ ‘They decided with me on the areas we would be working on.’ Trevayler Residential Care Home DS0000002003.V313558.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 12, 13, 14, 15, 16 & 17. The quality in this outcome group was ‘Good’. This judgement was made using available evidence including a visit to the Home. Links with the local community were good and supported and enriched Service Users social opportunities. Service Users were offered varied meals which met their dietary needs. EVIDENCE: Service Users were able to say that staff assisted them in finding and participating in fulfilling activities – ‘I assist in shopping for the Home, as well as myself, I also attend an interior design course at (a local) collage. The Manager said that the Home had links with a number of charities to help some Service Users find fulfilling employment. Service Users also said that, if they choose they could take part in swimming groups, sports groups, and dog walking groups. All activities were planned by staff, with the assistance of Service Users. On occasions staff would involve appropriate professional support for an activity. An activities programme was seen during the Trevayler Residential Care Home DS0000002003.V313558.R01.S.doc Version 5.2 Page 13 inspection that involved the activities already mentioned and the following activities: an art group, creative writing, healthy living, gardening and wildlife, cookery, camera group, and sports and leisure group. However, other groups were also arranged by staff from time to time. Staff enabled Service Users to make use of shops, cinemas, leisure centres etc. The Service Users were also enabled to obtain bus passes, and were provided with transport to facilities, when appropriate. One of the Service Users was aware that staff had arranged for her to be placed on the electoral role and so to vote in national and local elections, if she chose. Service Users said that videos and DVDs were provided by the Home. Service Users also said that they had taken part in a week’s holiday to Great Yarmouth, financed by the Home. Staff encouraged Service Users to maintain links with family and friends – ‘Every weekend I go home, and staff will pick me up and drop me off.’ Family and friends can also visit the Home when planned by the Service User, and can be seen in the Service User’s room, again if planned by the Service User. Staff only entered Service Users bedrooms with the invitation of the Service User, unless ‘fire checks’ where being undertaken. Each Service User had a key to their bedroom and to the main door of the Home. Service Users spoken to were also very aware of the rules in the Home on smoking, alcohol and drugs taking. Service Users undertook cooking on a rota basis, assisted by staff. Service Users chose the menu for each week, which involved a choice of two main dishes each day. Special diets could be arranged if necessary, although the Manager said that a Service User could choose something else if what had been provided was actively disliked. The Manager also said that if a Service User had an eating disorder that special attention would be paid by the staff to that Service User’s needs. Trevayler Residential Care Home DS0000002003.V313558.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 18,19 & 20. The quality in this outcome group was ‘Good’. This judgement was made using available evidence including a visit to the Home. Service Users personal needs were well met, ensuring that their privacy, dignity and independence were maintained. The system of administering medication was good, and arrangements were in place to ensure Service Users medication needs were met. EVIDENCE: Service Users were able get up and go to bed at times of their own choosing. However, if they were due to carry out the various jobs necessary in the Home, these had to be done at the specified time. Baths and showers could be taken whenever the Service User wished. Service Users said that staff needed to encourage some Service Users to carry out personal hygiene tasks, when this was necessary. However, Service Users were expected to choose their own clothes and style of appearance. Each Service User was allocated two keyworkers, although Service Users did say that it was possible to change a keyworker, if they failed to get along. Trevayler Residential Care Home DS0000002003.V313558.R01.S.doc Version 5.2 Page 15 Initially, Service Users said that their medication was managed by staff, but as they moved through the Home, into semi-independent living and then independent living, the responsibility for managing medication moved to each Service User. The Manager said that any potential health complication was referred to the Service User’s medical team whenever necessary. The medication procedures followed within the Home were examined, and a good system was found to be in operation. The Manager said that a weekly check was made of the Medication Administration Record sheets, and any errors in administration or recording were discussed with the relevant member of staff. Trevayler Residential Care Home DS0000002003.V313558.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 22 & 23. The quality in this outcome group was ‘Good’. This judgement was made using available evidence including a visit to the Home. Complaints made to the Registered Providers were appropriately addressed to meet Service Users needs. The protection policies and procedures provided by the Home meant that Service Users were well protected. EVIDENCE: The Service Users spoken to were aware of the complaints procedure, both pointed out that it was detailed in the Service Users Guide. A check was made, and the Manager was able to confirm, that she addressed all complaints, whether written or verbally passed on. She also said that Residents were regularly reminded of the complaints procedure in the community meetings, which were held at least weekly. The Commission had not received any notice of complaint since the last inspection of the Home in January 2006. The Safeguarding Adults procedure was seen, and the Manager said that an internal procedure was also in place to ensure that Service Users were protected from abuse. The Manager also had a Whistle Blowing policy and had the relevant information on the Public Interest Disclosure Act of 1998, and on the Dept of Health guidance ‘No Secrets’. She said that all allegations and incidents of abuse would be followed up and action would, if necessary, be taken. She also said that any incidents of abuse by her staff would be passed on to the Protection of Vulnerable Adults register, but to date this had not been Trevayler Residential Care Home DS0000002003.V313558.R01.S.doc Version 5.2 Page 17 necessary. The policies and practices within the Home ensured that physical or verbal aggression by Service Users was understood by staff and that staff would only intervene as a last resort to protect Service Users, other Service Users or staff. Satisfactory policies and procedures were in place to deal with Service Users money and financial affairs. The Manager said that the Home had a policy to inform staff that they could not benefit, in any way, from Service Users wills. Trevayler Residential Care Home DS0000002003.V313558.R01.S.doc Version 5.2 Page 18 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 24, 25, 26, 27, 28, 29 & 30. The quality in this outcome group was ‘Good’. This judgement was made using available evidence including a visit to the Home. Service Users were provided with a safe, comfortable environment in which to live. EVIDENCE: The premises of the Home were judged to be suitable for caring for Service Users. They were found to be safe and well maintained. Improvements had been made to aspects of the Home, which was positive to observe. On this visit only the bedrooms of two Service Users were examined, and these where found to be satisfactory. Bedrooms did not always contain the correct amount of furniture required by the Regulations. However, the Manager said that this had been discussed with Service Users, on an individual basis, and that after deciding on the quantity of furniture they wanted within their bedrooms, Service Users had signed to say that this was satisfactory. This was noted within the two files examined during this inspection. Trevayler Residential Care Home DS0000002003.V313558.R01.S.doc Version 5.2 Page 19 Residents said that they were encouraged by staff to keep their bedrooms clean and tidy, and they were seen to be so during the inspection. Trevayler Residential Care Home DS0000002003.V313558.R01.S.doc Version 5.2 Page 20 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 32, 33, 34 & 35. The quality in this outcome group was ‘Good’. This judgement was made using available evidence including a visit to the Home. Adequate staffing was provided consistently within the Home to meet the needs of Service Users. EVIDENCE: At the time of this inspection it was found that well under 50 of care staff had a qualification of at least NVQ level 2 in Care; 3, out of a total of 11 care staff, had an NVQ level 3 in Care. However, a further 5 care staff were in the process of completing their NVQ level 3 qualification, and the Manager said that the courses ended in November 2006. Staffing provided in the Home was compared with the details provided by the Residential Forum. This showed that during the two weeks of the 18 September and 2 October 2006, the Home was providing more than sufficient staffing, for 23 Service Users, with 12 Service Users judged to be at the Low Dependency and 11 Service Users with Medium Dependency needs. These figures were calculated without the Manager’s working time included, as recommended by the Residential Forum. Therefore suitable amounts of staff time were provided within the Home to meet Service Users needs. Trevayler Residential Care Home DS0000002003.V313558.R01.S.doc Version 5.2 Page 21 The records of two new staff, employed during the past 12 months, were examined to see whether the Manager had obtained all relevant information about them. It was found that all information had been obtained. Staff induction and foundation training was provided for all new staff that came to work in the Home. Records of this training were seen. The Manager also said that all care staff were provided with at least three paid days training a year. All staff also had an individual training and development assessment and profile. Trevayler Residential Care Home DS0000002003.V313558.R01.S.doc Version 5.2 Page 22 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 37, 39 & 42. The quality in this outcome group was ‘Good’. This judgement was made using available evidence including a visit to the Home. The Registered Provider ensured that the Home received monthly ‘inspections’ to ensure that Service Users needs were being continually met. The Manager also addressed the Quality Assurance issues to ensure Service Users care was maintained at a positive standard. EVIDENCE: The Manager said that she had completed her training at NVQ level 4 in Management and Care, but had not received notification of her pass result at the time of this inspection. A representative of the Registered Provider regularly visited the Home, on a monthly basis, and reviewed its operation. The representative interviewed Service Users and staff, and examined various documents to ensure that the Trevayler Residential Care Home DS0000002003.V313558.R01.S.doc Version 5.2 Page 23 details of Regulations 26 were met. Reports of these visits were seen during the inspection. The Manager ensured that effective quality assurance measures were used within the Home. An annual development plan was provided together with surveys of Service Users opinions on the operation of the Home. These documents were reviewed by a representative of the Registered Provider at regular intervals during the year. The views of family and friends of Service Users, and of professionals, such as GPs and CPNs, were obtained during the formal 6 monthly reviews of care. The training provided for staff was examined. This showed that the training required by the Commission on Moving and Handling, Fire Safety, First Aid, Food Hygiene and Infection Control had been provided. However, three staff were still in need of Infection Control training. The Manager was also able to show that training was also provided in Violence and Aggression, Working with Mental Health Problems, Dealing with Resistance and Low-Motivation, Key Working and Care Planning, Group Work, Listening Skills, Equal Opportunities and Anti Discrimination Practice, Alcohol and Substance Misuse and Report Writing and Communication. Evidence was also seen of the extensive additional training provided for the Manager and Deputy Managers of the Home. The questionnaire sent to the Manager by the Commission, prior to the inspection, showed that the Registered Provider and Manager had provided all policies and procedures required. The Registered Providers had complied with all necessary legislation, such as the Health and Safety at Work Act 1974, and the Manual Handling legislation of 1992. The Manager was able to show that she had provided risk assessments on the working conditions of staff; and had provided a written statement of the policy, organisation and arrangements for maintaining the safe working practices in the Home. The Manager was also able to confirm that all accidents, injuries and incidents of illness or communicable disease were recorded and reported to the relevant government bodies. She also confirmed, that with the assistance of the Fire Service, that fire safety notices were posted in relevant places around the Home. Trevayler Residential Care Home DS0000002003.V313558.R01.S.doc Version 5.2 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 3 2 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 3 26 3 27 3 28 3 29 3 30 3 STAFFING Standard No Score 31 X 32 3 33 3 34 3 35 3 36 x CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 3 3 X LIFESTYLES Standard No Score 11 3 12 X 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 Trevayler Residential Care Home DS0000002003.V313558.R01.S.doc Version 5.2 Page 25 Are there any outstanding requirements from the last inspection? No STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. Standard Regulation Requirement Timescale for action RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. Refer to Standard YA32 No. 1. Good Practice Recommendations The Registered Provider should ensure that at least 50 of care staff are trained to at least NVQ level 2 in Care as soon as possible. The Manager needs to obtain a qualification in Management and Care at NVQ level 4 by 31 December 2006. The three care staff in need of Infection Control training should receive this as soon as possible. 2. YA37 3. YA42 Trevayler Residential Care Home DS0000002003.V313558.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Derbyshire Area Office Cardinal Square Nottingham Road Derby DE1 3QT 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 Trevayler Residential Care Home DS0000002003.V313558.R01.S.doc Version 5.2 Page 27 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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