Inspection on 10/07/07 for Trevi House

This inspection was carried out on 10th July 2007.

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

The inspector found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 3 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Trevi House 07/01/09

Trevi House 09/07/08

Trevi House 29/01/07

Trevi House 02/03/06

Trevi House 28/06/05

Trevi House 18/01/05

Trevi House 16/06/04

Similar services:

Clouds House

Closereach

Westcliffe House

Hilldales

Longreach

Chandos House

Cherry Orchards Camphill Community Ltd

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

CARE HOME ADULTS 18-65 Trevi House 2/6 Endsleigh Gardens Mutley Plymouth Devon PL4 6DR Lead Inspector Antonia Reynolds Unannounced Inspection 10th July 2007 13:30p 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 Trevi House DS0000003558.V340659.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. Trevi House DS0000003558.V340659.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Trevi House Address 2/6 Endsleigh Gardens Mutley Plymouth Devon PL4 6DR 01752 255758 01752 255758 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) Trevi House Project Vacancy Care Home 13 Category(ies) of Past or present alcohol dependence (13), Past or registration, with number present drug dependence (13) of places Trevi House DS0000003558.V340659.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. Female Only Age18 to 60 years Date of last inspection 29th January 2007 Brief Description of the Service: Trevi House is registered as a care home providing ongoing treatment and support for a maximum of thirteen women, between the ages of 18 and 60, who are undergoing rehabilitation from alcohol/drug addiction. All the women have young children, under the age of 8, who are also accommodated with them at the centre. The centre has a nursery for the children, which is regulated by Ofsted, and children of school age attend a local school. Service users are expected to abstain from taking drugs and/or alcohol throughout their stay except those involved in drug reduction programmes. The home is owned by The Trevi House Project, a ‘not for profit’ organisation. Fees start at £900 per week for a service user and one child over the age of 2. Detailed information about fees and the project, as well as copies of inspection reports, can be obtained from the centre. Trevi House was established in 1994 and is situated in the residential area of Mutley, very close to the centre of Plymouth. It consists of five two-storey houses, three of which are terraced, that are arranged as a cul-de-sac. The centre has been physically enclosed from the surrounding area for security and there is an intercom system at the main gate. There are bedrooms in every house and each one is designed to accommodate one adult as well as their children, although there are also separate bedrooms for children if this is required. Four of the bedrooms have en-suite toilets and baths. Other bathing/showering and toilet facilities are available in every house, close to bedrooms and communal rooms. There are communal lounge and dining rooms, where service users are expected to socialise, and each house has kitchen facilities for the service users. Smoking is not permitted inside any of the buildings but people may smoke in a designated outside area. Trevi House DS0000003558.V340659.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was unannounced and undertaken over three days. Visits to the home took place between 1.30pm and 4pm on Tuesday, 10th July 2007; 12.30pm and 4.15pm on Wednesday, 11th July 2007 and 11am and 1pm on Friday, 27th July 2007. The interim managers, Jane Filby and Brian Moore of Filby Moore Associates, were present on the first and third days; the residential service manager, Angela Drake, was present on the second day. A tour of the premises took place and records/documents relating to the care of the service users, staff and the home were inspected. An annual quality assurance assessment had been completed by the residential services Manager, which contained information relevant to the inspection. Nine service users and four staff members were spoken with during the visits. Other staff members were observed going about their normal duties. Postal surveys were sent out to seventeen staff members and five were returned. Nine postal surveys were sent out to social care professionals and three were returned. What the service does well: What has improved since the last inspection? The Trustees have appointed Filby Moore Associates to manage the home on an interim basis until a permanent Manager is recruited. The interim Trevi House DS0000003558.V340659.R01.S.doc Version 5.2 Page 6 management team have devised an action plan to address all the issues that were identified at the last inspection. The Statement of Purpose has been reviewed and updated to reflect the aims, objectives and philosophy of the home. Care plans have been reviewed and updated to include more information relating to treatment and rehabilitation. A training plan has been put into place to include a structured induction programme for new staff and ongoing training for all staff. Staff meetings and individual supervision sessions have been started and will include all staff in due course. 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. Trevi House DS0000003558.V340659.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 Trevi House DS0000003558.V340659.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, 3, 4 and 5 People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including visits to this service. Prospective service users are provided with sufficient information to enable them to make an informed decision to live at this home. The admissions procedure ensures that prospective service users know that the home will meet their needs and aspirations. EVIDENCE: The Statement of Purpose has been reviewed and updated to include the aims, objectives and philosophy of the home. Service users confirmed that they received detailed information about the home prior to admission, which enabled them to make an informed decision about whether the service could meet their needs. Discussion with service users, as well as information contained in the Statement of Purpose, indicated that, wherever possible, service users and their representatives are welcome to visit the home prior to admission to have a look round and meet other service users and staff. The files of four service users were inspected and these contained pre-admission assessments, which is part of the process to ensure that the needs of prospective service users are identified. Discussions with service users and staff, as well as observation, showed that staff are aware of the needs of the service users. Service users said that they were informed of the terms and conditions of residency, including the restrictions of liberty within the first two Trevi House DS0000003558.V340659.R01.S.doc Version 5.2 Page 9 weeks, as part of the pre-admission process before they arrived at the home. The management team confirmed that all the service users are funded by the local authority and have contracts, as well as an individual statement of terms and conditions, with the home. Trevi House DS0000003558.V340659.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, 8, 9 and 10 People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including visits to this service. Service users can be confident that they will be enabled and supported to make choices and decisions about their lives through active participation in the rehabilitation programme. EVIDENCE: Four service users’ files were inspected and these contained care plans and risk assessments relating to health and personal care needs that are regularly reviewed. The care planning documentation has been updated to include more information relating to treatment and rehabilitation and how the care needs of service users should be met by the staff team. Service users are involved in developing and reviewing their care plans and are encouraged to reflect upon their life’s events and how these have affected them. Service users keep a diary of significant events and these are shared through group work. Service users said they understood why their movements and freedoms were initially restricted and had agreed to these before entering the programme for rehabilitation. Some of the service users also said that these restrictions made Trevi House DS0000003558.V340659.R01.S.doc Version 5.2 Page 11 them feel safe and were grateful for them. Observation and discussion with service users showed that they are involved in the running of the home and meet weekly as a group to plan the following week’s menus, domestic tasks and other activities, as well as to discuss any issues of concerns. Service users said that they feel confident to share their experiences with staff who always respect their privacy. With regard to service users’ money, the management team confirmed that this is administered by the home for all the service users. Service users are supported to claim for all relevant state benefits and pay off any outstanding debts. Each service user receives the personal allowance element of income support each week and records show that they sign for this money. The finances relating to one service user were inspected in detail and found to be accurate. Service users confirmed that any child tax credits they are entitled to are kept safely by the home, on their behalf, so that they accrue some money to pay for large items they may need and for when they move into the community. As part of the transition process before moving into the community, service users are assisted with opening bank or building society accounts. Ongoing assistance, advice and guidance are provided for service users to manage their financial affairs should they need this. Trevi House DS0000003558.V340659.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 11, 12, 13, 14, 15, 16 and 17 People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including visits to this service. Service users can feel confident that they will have opportunities for personal development, various activities are available, and independence and choice are promoted. EVIDENCE: The women and their children stay at Trevi House for approximately six to nine months. During this time they undergo a programme of rehabilitation and therapy to support them to overcome their addictions, develop the necessary life skills in order to live independently and to care appropriately for their children. This is achieved by group and individual counselling as well as physical therapies/activities such as Indian head massage, swimming and visits to a gym. Emphasis is given to providing a structured environment in which the women are able to enjoy quality time with their children with the support of the nursery staff. Service users said they are encouraged to make decisions about their future plans and staff assist with accessing the relevant state Trevi House DS0000003558.V340659.R01.S.doc Version 5.2 Page 13 benefits and appropriate housing. Service users said they go out regularly to use community facilities/services (apart from the first two weeks) and are encouraged to support each other to develop social and leisure interests. A timetable of community activities is developed each week at the house meeting. Service users are expected to eat together at lunchtimes on weekdays, as part of the rehabilitation programme and to encourage socialisation, and clear away/wash up afterwards on a rota basis. This meal is prepared by a cook employed by the home and service users were very complimentary about the food and meals provided. Service users are expected to make breakfast and tea for themselves and their children on weekdays and cook all their meals at weekends. Kitchen facilities are available for service users at all times. Families and partners of the service users are able to visit by agreement. In the latter stages of the programme, service users are able to move to a selfcontained part of the centre where they can further develop independent living skills to prepare for independent living when they leave Trevi House. Trevi House DS0000003558.V340659.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 and 20 People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including visits to this service. Service users can be confident that personal support promotes and respects their dignity and independence. EVIDENCE: Service users said they feel very well supported and that the staff are always approachable and friendly. Service users manage their personal care needs and that of their children independently and may just need occasional prompting or encouragement from staff. Four service users’ files were inspected and these contained information relating to service users’ healthcare needs, and that of their children, as well as addressing physical and emotional well-being. The home keeps detailed records to monitor an individual’s progress and these are maintained thoroughly and consistently. External professional advice and guidance is sought when necessary from local drug/alcohol addiction services, health care professionals or social services, including psychiatric services and consultants if required. Feedback from one social care professional said that they are not consulted, provided with progress reports or kept informed about treatment relating to particular service users. Trevi House DS0000003558.V340659.R01.S.doc Version 5.2 Page 15 Because the service provides rehabilitation from drug/alcohol addiction, none of the service users manage their own medication. A staff member demonstrated the medication administration process and this showed that the procedures for receiving, storing, administering and returning medication are safe and audited weekly. The Residential Service Manager confirmed that she trains staff in the administration of medication until they are competent and feel confident to carry out this task. Two staff members confirmed that they have also received medication training from the local pharmacist. Trevi House DS0000003558.V340659.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 and 23 People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including visits to this service. Service users can be confident that any concerns or complaints will be listened to and addressed. EVIDENCE: Discussion with the service users, staff and the management team, demonstrated that the open culture of the home and the recognition of service users’ rights ensure that service users are protected from harm. Service users said that they feel safe and protected by the staff team. The home has a written complaints procedure and all the service users are well aware of how and to whom to make a complaint should they need to. Observation showed that service users could raise any issue at any time with the staff and management team. Service users said that they were encouraged to speak about any concerns relating to group living within the group counselling sessions and identify a solution together. The management team confirmed that all staff members are expected to attend training in the protection of children and vulnerable adults. The home has a copy of the Local Authority’s Alerter’s Guidance available for staff with a procedure for notifying any alleged incidents of abuse or concern. Information obtained from staff members showed that they are aware of child and adult protection procedures. Trevi House DS0000003558.V340659.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): Standards 24, 25, 26, 27, 28 and 30 People who use the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including visits to this service. Service users live in a pleasant, clean, safe and comfortable home with sufficient facilities to meet the everyday living needs of the women and children living at the home. EVIDENCE: The premises are leased from Devon & Cornwall Housing Association (who are responsible for maintenance and décor) and consist of five two-storey houses, three of which are terraced. The buildings form a sheltered complex around a landscaped courtyard that has been physically enclosed from the surrounding area for security and there is also a children’s nursery within the premises. There is plenty of outdoor space although one of the service users commented that it would be nice if there were a grassy area for the children to play. The home is comfortable, safe and clean but some areas are in need of redecoration/refurbishment. Feedback from a social care professional said that the counselling rooms do not seem conducive to the purpose and would benefit Trevi House DS0000003558.V340659.R01.S.doc Version 5.2 Page 18 from refurbishment. The management team confirmed that redecoration is due to take place in the near future. The home has a large lounge and dining room that are shared by all the service users and each house has kitchen facilities. Service users carry out all the domestic tasks within the home, usually on a rota basis, and said that the laundry facilities are suitable. Smoking is not permitted inside any of the buildings but there is a designated outside area for smoking. There are bedrooms in every house and each one is designed to accommodate one adult as well as their children, although there are also separate bedrooms for children if this is required. Bedrooms are individually furnished and personalised by the service users. The type and quantity of furniture varies dependant on the wishes and needs of service users. Whilst most bedroom doors are fitted with appropriate locks, none of the service users have been given a key to their own room. Discussions with various staff members showed that they were not aware of any specific reason why service users were not given their own keys. However, discussions with the service users confirmed that they had no concerns about locking bedroom doors and perceived this openness as an element of trust between service users and staff. One service user commented that she had never experienced this level of mutual trust and support before and liked the fact that she did not have to lock her bedroom door. Most of the bedrooms contain wash hand basins and four of the bedrooms have en-suite toilets and baths. Other bathing/showering and toilet facilities are available in every house, close to bedrooms and communal rooms. Trevi House DS0000003558.V340659.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): Standards 31, 32, 33, 34, 35 and 36 People who use the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including visits to this service. Service users benefit from an experienced, enthusiastic and dedicated staff team who work positively with service users to improve their quality of life. However recruitment practices have not been sufficiently robust to protect service users. EVIDENCE: Discussions with service users, various staff members and the management team confirmed that there are always enough staff on duty to support the needs of the service users. The number of staff on duty is flexible and may vary depending on the needs and activities of the service users and their children. At night there are two staff members who sleep in but, if required, additional staff will be provided. There is an ‘on call’ system at night so that members of the management team can be contacted should the staff on duty need assistance. Staff are very committed to the service users and are aware of service users’ needs and how to support them. Service users confirmed that they find the staff team to be skilled, competent and very approachable. Staff were observed interacting in a positive and enabling way with service users Trevi House DS0000003558.V340659.R01.S.doc Version 5.2 Page 20 and it was evident that there was a good rapport between service users and staff. Three staff files were inspected but one of these only contained one written reference, did not have an appropriate Criminal Records Bureau (CRB) check and checks relating to the protection of children were not being carried out for all the staff. However, no new staff have been recruited since August 2006 and the new management team are aware of the correct recruitment processes, including volunteers. A discussion took place with Mr Moore about ensuring that Trustees who have access to the premises also have CRB checks carried out. The management team have carried out a training needs assessment with all staff members and have devised an action plan. This plan includes a structured induction programme for new staff, child and adult protection, first aid, fire safety, food hygiene, health and safety, medication, drug and alcohol awareness, motivational interviewing, supervision, teamwork skills and equality and diversity issues. There has been inconsistency with supervision in the past but a programme of individual supervision sessions has now been started and these meetings are documented. The home has good working links with other local services for people with drug and/or alcohol dependencies, and staff are able to access specialist services for advice and information if required. Trevi House DS0000003558.V340659.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): Standards 37, 38, 39 and 42 People who use the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including visits to this service. Service users and staff can be confident that previous concerns regarding the management of the home are being resolved. Service users’ rights, health, safety and welfare are protected and promoted. EVIDENCE: The home does not have a Manager registered with the Commission for Social Care Inspection at present as the previous Registered Manager resigned in March 2007. The Trustees have appointed a consultancy firm, Filby Moore Associates, to manage the home through this period of change and have advertised for a General Manager who, in due course, will apply to be registered with the Commission for Social Care Inspection. Trevi House DS0000003558.V340659.R01.S.doc Version 5.2 Page 22 Health and safety practices are satisfactory in that equipment is maintained in good working order and there is a plan in place for staff to receive training in health and safety, fire safety, first aid and food hygiene. There are safe infection control practices in place to dispose of contaminated items such as used needles and nappies. Discussions with service users and staff confirmed that fire drills take place at least once a month and everyone spoken with was aware of what to do in the event of a fire. However, inspection of the fire logbook indicated that the required weekly and monthly tests/checks of the fire alarm system/equipment, and the names of staff who have attended fire safety training, are not being documented. The home has not yet introduced a quality assurance system that focuses on service users’ views and obtains feedback from service users, relatives and professionals from health and social care services. Trevi House DS0000003558.V340659.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 3 2 3 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 2 25 3 26 2 27 3 28 3 29 X 30 3 STAFFING Standard No Score 31 3 32 3 33 3 34 3 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 3 3 3 LIFESTYLES Standard No Score 11 3 12 3 13 3 14 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 2 3 1 X X 2 X Trevi House DS0000003558.V340659.R01.S.doc Version 5.2 Page 24 Are there any outstanding requirements from the last inspection? Yes 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 YA34 Regulation 19 Requirement The home must operate a thorough recruitment process for all staff members and volunteers by obtaining two written references and Criminal Record Bureau checks relating to both adults and children. This is to ensure the protection of service users and their children. The Registered Person must introduce a system for reviewing and improving the quality of care provided at Trevi House, that seeks the views of service users, staff and all other stakeholders. This is the second inspection where this requirement has been made. Previous timescale of 1/5/07 not met. Checks and tests of fire safety equipment must be documented to evidence that it is working properly and is in the correct position. The names of staff members attending fire safety training must be documented to ensure that all staff attend training as required by the home’s fire risk assessment. Timescale for action 08/09/07 2. YA39 24 08/12/07 3. YA42 23 08/09/07 Trevi House DS0000003558.V340659.R01.S.doc Version 5.2 Page 25 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. 3. 4. 5. Refer to Standard YA18 YA24 YA24 YA26 YA26 Good Practice Recommendations The home should provide regular updates on the progress of service users to relevant professionals to ensure consistency and continuity of support. Redecoration and refurbishment should be carried out where required to make the environment more comfortable, bright and cheerful. Counselling rooms should be refurbished to make them more pleasant and relaxing so that they are more suited for their purpose. All the bedrooms should contain wash hand basins to promote the privacy and dignity of service users. All bedroom doors should be fitted with appropriate locks that can be accessed from the outside in an emergency. Risk assessments should be carried out and service users consulted about whether or not they would like a key to their bedroom doors to enhance privacy and security of belongings. This process and the outcome should be clearly documented. Trevi House DS0000003558.V340659.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Devon Area Unit D1 Linhay Business Park Ashburton TQ13 7UP 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 - 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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