Inspection on 07/08/07 for Trevayler Residential Care Home

This inspection was carried out on 7th August 2007.

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

Trevayler Residential Care Home 16/10/06

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 Key Unannounced Inspection 7th August 2007 11:15 Trevayler Residential Care Home DS0000002003.V341776.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.V341776.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.V341776.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.V341776.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 16th October 2006 Brief Description of the Service: Trevayler provides care for 23 people recovering from mental health problems. The level of support available is dependent on Service Users difficulties and is provided in three ways: that available for dependent Service Users, semiindependent Service Users and independent Service Users. Independent Service Users live in a separate property next door to the main house, which 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 £610.00 to £1080.00 a week, dependent on the needs of the Resident. A copy of the Commission’s inspection report is available from within the Home. Trevayler Residential Care Home DS0000002003.V341776.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 under 6 hours. Discussion was held with one Resident, and the needs of two Service Users were ‘case tracked’. The Manager was spoken with, and one member of staff was also seen. A number of records were examined, and the bedrooms of two Service Users were looked at and all public areas of the Home were examined. The Commission’s Annual Quality Assurance Assessment, sent to the Manager, was completed and reviewed. The Commission’s questionnaire sent out to ten Service Users, had been completed and returned by four Service Users. These were examined and all were found to comment very favourably on the operation of the Home. What the service does well: What has improved since the last inspection? Since the last inspection of the Home, in October 2006, the Registered Providers have ensured that at least 50 of care staff were trained to at least Trevayler Residential Care Home DS0000002003.V341776.R01.S.doc Version 5.2 Page 6 NVQ level 2 in Care. The Manager’s level 4 NVQ qualification in Management and Care had also been confirmed. At the time of the last inspection three staff were awaiting training in Infection Control, which had now been provided. 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. Trevayler Residential Care Home DS0000002003.V341776.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.V341776.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): Standards 1, 2 & 4. The quality in this outcome area was Excellent. This judgement was made using available evidence including a visit to this service. All new Service Users moving to the Home were appropriately assessed prior to their admission, so that they and their families were reassured that their needs would be met. EVIDENCE: The Home’s statement of purpose and Service Users Guide were reviewed during this inspection. The Service Users Guide was found to be a large document, covering all issues likely to confront a Resident staying in the Home. Both documents were well constructed and copies of the Service Users Guide were found in Service Users bedrooms. The Residents Guide contained information on how contact could be made with the Commission, the local Social Services Dept and local Health Authority. 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. All Service Users referred through Social Services Depts or Health Authorities were assessed by the Manager prior to the beginning of their placement. Trevayler Residential Care Home DS0000002003.V341776.R01.S.doc Version 5.2 Page 9 Prior to moving to the Home, Service Users were invited to visit and to talk to other Service Users staying in the Home and to talk with staff. A Resident commented on how useful this was in helping to make the decision to move to the Home. Trevayler Residential Care Home DS0000002003.V341776.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): Standards 6, 7 & 9. The quality in this outcome area was Excellent. This judgement was made using available evidence including a visit to this service. The staff ensured that Service Users needs were met, allowing for their differing abilities. They also enabled Service Users to take risks, ensuring that the risks were appropriate to their abilities. EVIDENCE: To help assess Standard 6, the Service Users Plan of Care, the records of two Service Users were examined, for the purpose of case tracking. All of the basic information, concerning the Service Users, was found to be in the files examined. Copies of the initial assessment completed by the Social Services Care Managers were available, and the Manager had completed her own initial assessment of needs for the Service Users. There were also good care plans and risk assessments available in the records examined, providing staff with information to met the Service Users needs. Trevayler Residential Care Home DS0000002003.V341776.R01.S.doc Version 5.2 Page 11 The files showed that extensive records of events affecting each Resident were kept, and entries were seen to be made at least twice a day. The Service Users formal reviews of care, undertaken on a six monthly basis, had been signed by each Resident. Service Users also signed many of the other entries found in the files. Each Resident was also provided with a keyworker from the Home. 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. A Resident spoken with said that staff respected Service Users rights to make decisions about their lives, and would advise them when necessary – ‘Staff will talk things through with me, but don’t make me do anything.’ Staff said that Service Users were encouraged to talk about their wishes for their lives, particularly by their Keyworkers. Staff also encouraged Service Users to join advocacy groups outside the Home – ‘I’ve been told about a women’s group I could join, and also about a representative from ‘Mind’ who calls at the Home who might be able to help me.’ Staff helped Service Users to manage their benefits appropriately – ‘Staff look after my money, but we have planned that I get so much each day.’ Staff were found to encourage Service Users to tackle areas in their lives that were problematic (‘areas of risk’) – ‘Staff encourage me to go out and do things I am scared to do.’ Staff also said that they did things with Service Users to help provide the confidence to tackle difficult areas in Service Users lives. However, procedures were available, in the Home, to ensure that Service Users wellbeing was addressed should they fail to return to the Home at the agreed times. Staff said that should this occur – ‘A report would be made to the duty manager, followed by contact with the police and Service Users family, when appropriate.’ Trevayler Residential Care Home DS0000002003.V341776.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): Standards 12, 13, 14, 15, 16 & 17. The quality in this outcome area was Excellent. This judgement was made using available evidence including a visit to this service. Links with the local community were good and supported and enriched Service Users social opportunities. Varied meals were also provided to all Service Users. EVIDENCE: Staff encouraged Service Users to take part in regular activities – ‘Staff did go with me to the shops to buy toiletries and cigarettes, but now I can go on my own.’ Activities were also provided within the Home. A Resident said that such things as – ‘Cookery, creative writing, gardening, bingo, music are all provided within the Home. But you could also go to college and do maths and English. I guess these things help you get into work if that’s what you want.’ Staff said that Service Users were also encouraged, when appropriate, to visit job centres and take up paid employment. However, much more time is spent assisting Service Users with benefit entitlement – ‘They help me manage my benefit and my saving, which are going up!’ Trevayler Residential Care Home DS0000002003.V341776.R01.S.doc Version 5.2 Page 13 The Home also ran cinema, swimming and gym groups, where Service Users were accompanied initially, but where they eventually went alone, or with other Service Users. Access to the cinema, swimming pool or gym was initially provided by taxis, but eventually buses were used, often with a free pass. Staff said that to facilitate this, the Manager expects them to be available in the evenings and weekends when such activities were usually carried out. Where appropriate, staff said that use was made of the multi-cultural centre for appropriate Service Users. Examples of leisure activities were provided by staff and Service Users, including entertainment brought into the Home; videos and DVDs. A Resident also said that some Service Users had been away for a four day holiday to Butlins, in Skegness, which was largely paid for by the Home. These events were chosen by the Service Users – ‘We can chose going to the cinema, on shopping trips; we have been to Burton to see beer making, and also to Blackpool.’ Service Users were encouraged to maintain links with family and friends, when this was found to be important to the Resident – ‘My sister and my nephew come to see me, and my daughter will also visit me here. Staff always make them very welcome.’ However, staff said that this was only done when it was clear that this was in the Resident’s best interests and with the Resident’s agreement. Staff were clear that they would never enter a Service Users bedroom without permission from the Service Users (unless the Resident was judged to be at risk) – ‘Staff always knock and wait for me to invite them in.’ Service Users also said that they had a key to their bedroom door, and could lock the door from both the outside and inside of the bedroom. Mail addressed to a Resident was always only opened by the appropriate Resident – ‘Staff do not open my letters.’ A Resident said that the rules on smoking meant that – ‘Smoking is only allowed in the smoking lounge.’ Meals are provided by both staff and Service Users working together, in rota. A Resident said that – ‘We vote for what we want for each main meal of the day. If you don’t like what is chosen you can always have a sandwich or something else.’ A Resident said that - ‘You can have your meal in the dinning room, or in the lounge or in your bedroom. The choice is yours.’ Staff said that the needs of Service Users with anorexia or obesity were regularly reviewed to ensure that the right approach was always made by staff to these difficulties. Trevayler Residential Care Home DS0000002003.V341776.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): Standards 18, 19 & 20. The quality in this outcome area was Excellent. This judgement was made using available evidence including a visit to this service. Service Users’ personal needs were well met, ensuring that their privacy, dignity and independence were maintained. The system of administering medication was good, and ensured Service Users medication needs were met. EVIDENCE: A Resident said that she was able to get up and go to bed at times of her choosing. However, if Service Users were due to carry out the various jobs necessary in the Home, these had to be done at the specified times. This Resident also said that baths and showers could be taken whenever the Resident wished. Staff said that some Service Users needed to be prompted to wash and bath at appropriate times, and this was supported by one of the Service Users. However, Service Users were expected to choose their own clothes and style of appearance. A Resident said that Service Users were able to discuss their keyworkers with senior staff if they didn’t get on, and that usually a change would be made, and this view was supported by the Manager. Trevayler Residential Care Home DS0000002003.V341776.R01.S.doc Version 5.2 Page 15 From the records seen in Service Users files, Service Users Social Workers and Community Psychiatric Nurses were found to be in regular contact with Service Users, which was also supported be the comments made by Service Users and staff. Service Users were supported to maintain good health. When staff and a Resident judged it appropriate the responsibility for managing medication was passed from staff to the Resident. Should a GP need to visit the Home, they saw the Resident in private, although supported by staff, with the Resident’s agreement. During this visit to the Home the Medication Administration Record sheets were examined and all was found to be very well managed and maintained. Trevayler Residential Care Home DS0000002003.V341776.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): Standards 22 & 23. The quality in this outcome area was Excellent. This judgement was made using available evidence including a visit to this service. Complaints made to the Manager were addressed to meet Service Users needs. The protection policies and procedures provided meant that Service Users were well protected. EVIDENCE: The Service Users spoken with were aware of the complaints procedure, and pointed out that it was detailed in the Service Users Guide. The Manager was able to say that she had addressed all complaints, whether written or verbally passed on. She also said that Service Users were regularly reminded of the complaints procedure in the community meetings, which were held at least weekly, which was also confirmed by a Resident. A member of staff said that Service Users sometimes used her to discuss possible complaints, and that she would enable the Service Users to make a complaint, if that was their wish. The Commission had not received any notice of complaint since the last inspection of the Home in October 2006. Good procedures were seen for both written and verbal complaints. The Registered Providers complaints procedure detailed that all complaints would be responded to by the Registered Providers or Manager within at least 28 days. The Registered Providers had a Safeguarding Adults procedure that included a ‘Whistle Blowing’ policy. The Manager said that a copy of the Public Interest Disclosure Act of 1998, and of the Dept of Health’s policy called ‘No Secrets’ were available in the Home. The Manager also confirmed that all allegations Trevayler Residential Care Home DS0000002003.V341776.R01.S.doc Version 5.2 Page 17 and incidents of abuse would be promptly followed up and that all actions taken would be recorded. The policies and practices laid down by the Registered Provider ensured that all staff understood physical and verbal aggression by Service Users. The Manager said that a policy was available to staff stating that they could not benefit from Service Users wills, which was also understood by the staff, with whom discussions were held. Trevayler Residential Care Home DS0000002003.V341776.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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 24, 25, 26, 27, 28, 29 & 30. The quality in this outcome area was Good. This judgement was made using available evidence including a visit to this service. The Home was well maintained throughout, providing all Service Users 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. Following the visit made to the Home in October 2006, improvements had been made to various aspects of the Home, which was positive to observe. During 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.V341776.R01.S.doc Version 5.2 Page 19 The Home was attractively decorated throughout, and the lounges and dining room were pleasant to sit in, and were provided with appropriate items for the Service Users. In the dinning room fresh fruit was seen on the dresser. Toilets were easily available to all Service Users, and were clearly marked. All bedroom doors were provided with locks, which most Service Users chose to use. All radiators were appropriately guarded, and could be controlled within each bedroom. The Home had an appropriate laundry and clothing was washed at appropriate temperatures. A public telephone was seen within its own kiosk. However, the following issue needed attention: In the ‘independent living home’, wallpaper was seen to be coming away from the wall on the stairwell to the first floor. Trevayler Residential Care Home DS0000002003.V341776.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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 32, 33, 34 & 35. The quality in this outcome area was Good. This judgement was made using available evidence including a visit to this service. Overall, adequate staffing was provided within the Home to meet the needs of Service Users. EVIDENCE: At the time of this inspection it was found that more than 50 of care staff had a qualification of at least NVQ level 2 in Care. The staffing level provided during July 2007 was reviewed. This showed that for three of the four weeks more than appropriate levels of staffing were provided. However, for the week beginning 9 July 2007 the staffing level was found to be much lower. Therefore, staffing levels should be reviewed to ensure that appropriate levels of staffing could always be provided. 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. Trevayler Residential Care Home DS0000002003.V341776.R01.S.doc Version 5.2 Page 21 Staff induction and foundation training was provided for all new staff that came to work in the Home. Records of this training was seen. The Manager also said that all care staff were provided with at least five paid days training a year, although a member of staff said that at least 6 to 7 paid days training was provided. All staff also had an individual training and development assessment and profile. Trevayler Residential Care Home DS0000002003.V341776.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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 37, 39 & 42. The quality in this outcome area was Excellent. This judgement was made using available evidence including a visit to this service. Management arrangements at the Home were in place to ensure that Service Users care was maintained at a positive standard. EVIDENCE: The Manager was appropriately qualified to manage the Home, having an NVQ level 4 qualification in Management and Care. The records of the monthly ‘inspections’ of the Home, carried out by a senior manager, were examined and found to be in good order. The Manager and Registered Providers 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 throughout each year. The views of Trevayler Residential Care Home DS0000002003.V341776.R01.S.doc Version 5.2 Page 23 family and friends of Service Users, and of professionals, such as Social workers and CPNs, were obtained during the formal 6 monthly reviews of care, and were recorded. Staff interviewed, during this visit to the Home, were able to say that they completed a review of the Service Users progress, for whom they were keyworker, at three monthly intervals. Copies of these reviews were seen within the files examined. 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. This was also confirmed by a member of staff spoken with during the visit to the Home. From copies of the Home’s maintenance schedule, forwarded to the Commission prior to the inspection, it was found that all necessary maintenance and repairs were being appropriately addressed. 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.V341776.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 4 2 4 3 X 4 4 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 4 23 4 ENVIRONMENT Standard No Score 24 3 25 4 26 4 27 4 28 4 29 4 30 4 STAFFING Standard No Score 31 X 32 3 33 3 34 4 35 4 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 4 4 X 4 X LIFESTYLES Standard No Score 11 X 12 4 13 4 14 4 15 4 16 4 17 4 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 4 4 4 X 4 X 4 X X 4 X Trevayler Residential Care Home DS0000002003.V341776.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. 1 Standard YA24 Regulation 23(2)(d) Requirement The wallpaper in the stairwell of the ‘independent living home’ must be replaced or repaired to make an attractive appearance. Timescale for action 31/10/07 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 YA33 No. 1 Good Practice Recommendations Good levels of staffing should always be provided within the Home. Trevayler Residential Care Home DS0000002003.V341776.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: 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 Trevayler Residential Care Home DS0000002003.V341776.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. 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!