Inspection on 29/01/07 for Trevi House

This inspection was carried out on 29th January 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 no outstanding requirements from the previous inspection report, but made 7 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 10/07/07

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 Tina Maddison Unannounced Inspection 29th January 2007 10:00 Trevi House DS0000003558.V320831.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 Trevi House DS0000003558.V320831.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.V320831.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 Mrs Elizabeth Angela Brooks 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.V320831.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 2nd March 2006 Brief Description of the Service: Trevi House is made up of a cul- de- sac of terraced houses. The centre has been physically enclosed for security, from the surrounding area. The unit is situated between Mutley Plain shopping precinct and the city centre of Plymouth. The centre provides second stage treatment for a maximum of 13 women, between the ages of 18 and 65, who are pursuing rehabilitation from alcohol / drug addiction, while supporting their young children who are also accommodated with them at the unit. The service has stated that no more than 16 children, under the age of 8, will also be present at any one time, with the service users retaining full parental responsibility during their stay at Trevi. An Ofsted registered nursery is provided on site and children of school age attend a local school whose teaching staff have the necessary skills to support children who may have had an unsettled childhood prior to their mother being admitted to Trevi House. Treatment is by means of counselling and mutual support. The service requires total abstinence from all service users throughout their stay except for those involved in drug reduction programmes. Restrictions on personal choice are agreed with all prospective service users in advance of their admission to the unit. Trevi House DS0000003558.V320831.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 over one day on the 29th January 2007. Prior to the inspection a pre inspection questionnaire,completed by the Registered manager was received. Following the inspection sixteen staff surveys were returned. There were five residents and their children present in the service during the inspection. The Registered manager, Mrs Angela Brooks was present during the inspection. A lunchtime meal was observed, and a tour of the entire inside and outside of the service, including the nursery provision for the children was undertaken. During the Inspection, three members of staff and two residents were spoken with at length. What the service does well: Service users praised the staff and the service that is offered at Trevi House. One service user said that thanks to the staff at Trevi House “I now have the strength to manage my life.” The Manager believes that the ethos and purpose of the service are positive and have helped many women to care for their children appropriately and stop their dependency on drugs or alcohol. The Manager stated that she believes that approximately 67 of women who finish the programme offered at Trevi House do not relapse into drug or alcohol dependency. The children of the women receiving the service at Trevi House are well cared for in the purpose built nursery by qualified staff and have their own play area. They appeared happy and content on the day of the inspection. The service provides a package of resettlement help following discharge from the service that includes housing and benefits advice, and an individual after care package. Trevi House DS0000003558.V320831.R01.S.doc Version 5.2 Page 6 Staff are skilled and experienced and are commended for their dedication to promote the service users well being and independence. What has improved since the last inspection? What they could do better: The Registered Manager has introduced a new range of therapies, and these should be evidenced as effective and professionally validated interventions, that includes counselling and therapy for service users in treatment and recovery programmes and this must be documented in the statement of purpose. On the 12th February a vote of no confidence in the Registered Managers Management style was proposed and signed by seventeen members of staff. Trevi House DS0000003558.V320831.R01.S.doc Version 5.2 Page 7 This is currently being investigated by the Registered Individual and the Board of Trustees. The concerns include a lack of Confidential supervision and an unapproachable and dismissive manner by the Manager towards staff. Records evidenced that some staff have not received appropriate induction training when they were first employed by Trevi House. There is concern from staff regarding the Managers alleged inconsistency when giving them directions for working with the service users, and they are confused about their roles and responsibilities. It was found that there is not a training programme for staff. There was not a formal quality assurance system in place, and the Registered Individual must find a way of gathering staff views regarding the home. A member of staff informed the inspector that he was reviewing the format of the care plans. This is needed, as the care plans are not currently clearly informing the staff about the women and childrens’ care needs and how these should be met at Trevi House. The fire prevention records were not up to date and there was not evidence that staff had received fire safety training or that the fire prevention equipment was regularly serviced. Please contact the provider for advice of actions taken in response to this inspection. Trevi House DS0000003558.V320831.R01.S.doc Version 5.2 Page 8 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.V320831.R01.S.doc Version 5.2 Page 9 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.V320831.R01.S.doc Version 5.2 Page 10 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): 1,2,3,4,5. Quality in this outcome area is poor because the current statement of purpose does not clearly detail the interventions and specialist treatment that a service user will receive whilst at Trevi House. Pre admission assessments are satisfactorily carried out. This judgement has been made using available evidence including a visit to this service. EVIDENCE: There is a statement of purpose and service users guide available at Trevi House. Due to an apparent change in the philosophy and treatments that are now offered at Trevi House, the statement of purpose must be amended to reflect these. A service user confirmed that she had seen a copy of the service users guide, and was aware of the restrictions placed upon service users within the first two weeks of rehabilitation. Following a referral from a care manager, a preliminary assessment is undertaken by the Manager of Trevi house that includes inviting prospective service users to visit Trevi House and further information is gathered to ascertain whether Trevi House is able to meet the service users assessed needs. Trevi House DS0000003558.V320831.R01.S.doc Version 5.2 Page 11 Part of the assessment procedure is for women to state their wishes for the future and that of their children. Two care workers are identified to work with the individual during their assessment. Prior to entering Trevi House for the six to nine months agreed rehabilitiation, women have to sign to say that they have read and agree to abide by the homes policies and procedures. Each service user has an individual written contract and statement of terms and conditions with the home. Trevi House DS0000003558.V320831.R01.S.doc Version 5.2 Page 12 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7,8,9. Quality in this outcome area is adequate. Care plans would benefit from being updated and reviewed to concisely reflect service users assessed care needs and personal goals, and how staff will meet these. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Each service users is provided with a “welcome pack” which provides further information about living at Trevi house, including a statement about service users rights and responsibilities. The individuals care plan is drawn up with the service user, using information gained from the pre admission process, information from the care manager and from the service user. The care plans are currently being reviewed and are to be produced in a new format that was shown to the Inspector by a member of staff who is developing these. The current care plans will be improved in this new format, as currently they are not clear about identifying the service users Trevi House DS0000003558.V320831.R01.S.doc Version 5.2 Page 13 care needs, and how these will be met by staff and there was no evidence that they are regularly reviewed. Part of the nine months programme is about service users taking control of their lives with assistance from the staff and becoming aware of how to meet their childrens care needs. Service users who were spoken to during the inspection said that since they had been on the programme they were managing their life better, and hoped that their dependence on drugs or alchohol would be overcome with help from the staff at the home. Service users said that they understood the restrictions on their freedom and movements that were initially restricted, and had to agree to these before starting on the programme of rehabilitation. Service users spoken with felt that they were fully involved with the day to day running of the home, and met to discuss menus, domestic tasks and any issues or concerns. Risk assessments are completed for each service users upon their admission to the home for a variety of activities. These would benefit from being documented in a more concise and clear format with details for staff to follow, and risks to be identified and instructions to staff about how these are to be safely managed. Trevi House DS0000003558.V320831.R01.S.doc Version 5.2 Page 14 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): Quality in this outcome area is adequate because service users are able to participate in appropriate leisure activities and are offered a healthy diet. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The women and their children stay at Trevi House for 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. The current aim is to achieve this currently by group and individual therapy, and 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. 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 self contained part of the house where they can further develop their independent living skills in order to be prepared for independent living when they leave Trevi House DS0000003558.V320831.R01.S.doc Version 5.2 Page 15 Trevi House. There is a full time resettlement officer who is employed to assist the service users with housing and benefits in preparation for when they move on. Service users confirmed that each afternoon following time spent with their children after lunch, they are able to visit the gym and other facilities at a nearby day centre free of charge. A range of healthy meals are provided by the home, where a cook is employed. The service user said that they enjoyed these, and also had the opportunity to cook for themselves and their children. Lunch time was observed to be a social occasion shared with the children by their mothers and the staff. Trevi House DS0000003558.V320831.R01.S.doc Version 5.2 Page 16 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18,19,20. Quality in this outcome area is adequate, because service users healthcare needs are met at Trevi House, and medication is appropriately managed by staff. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Service users said that they felt well supported, and that the staff were 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. Personal files evidenced that service users heath care needs were addressed as were their childrens. Service users are registered with a general Practitioner. The home has good working links with Broadhaven, which is a Plymouth based service for people with drug or alchohol dependencies, and staff are able to Trevi House DS0000003558.V320831.R01.S.doc Version 5.2 Page 17 access drug and alchohol dependency specialist services for advice and information if required. Medication was found to be appropriately stored, and there were robust procedures in place for the dispensing of medication. The four key workers are responsible for administering medication and all have received appropriate training. Trevi House DS0000003558.V320831.R01.S.doc Version 5.2 Page 18 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22,23. Quality in this outcome area is adequate. Complaints and concerns from service users are treated seriously. Service users are listened to and issues resolved promptly. A lack of clear direction from the Management to staff on occasion has resulted in a lack of clear direction for the service users. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Service users said that the staff were very approachable and they were confident that any issues of concern would be listened to and dealt with. 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 home has received no complaints since the previous inspection. A copy of the complaints procedure is displayed on the notice board. The two service users who were spoken with said that they felt able to complain if they needed to. There is a complaints book, where any complaints and concerns are logged, but there had been no recent complaints logged. Staff spoken with were aware of the homes adult and child protection procedures. Staff had received child and adult protection training. 14 out of 16 staff who returned their staff survey form stated that they were aware of adult and child protection procedures. Trevi House DS0000003558.V320831.R01.S.doc Version 5.2 Page 19 Physical and verbal aggression is understood by staff at Trevi House and physical intervention is only ever used as a very last resort. There were no incidents of physical restraint logged in the last twelve months. There was concern from staff that there was a lack of consistency and mixed messages given to the service users from the Manager with regard to programmes to be followed by the service users, and staff then felt that they had been undermined and the lack of clear direction given to the service users was not helpful. Trevi House DS0000003558.V320831.R01.S.doc Version 5.2 Page 20 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24,25,26,27,28,30. Quality in this outcome area is adequate because service users live in a pleasant, clean and warm home that is comfortable and warm and provides sufficient facilities to meet the everyday living needs of the women and children living at the home. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The house is divided into two living areas, both of which contain single bedrooms that are suitable for a service user and their child/children. There are adequate communal areas within the home, with specified areas for smoking. The service users share the domestic tasks and the home was clean and tidy on the day of the inspection. Since the previous inspection, the dining room and kitchen have been refurbished, and there is a new dining table and chairs. The building is owned and managed by Devon and Cornwall Housing Association who are responsible Trevi House DS0000003558.V320831.R01.S.doc Version 5.2 Page 21 for the maintenance inside and outside of the home. There is planned redecoration due in May/June this year, for the inside and outside of the home. There are appropriate numbers of bathrooms/toilets available for the service users use. The nursery area is a pleasant, brightly decorated and child friendly area. The children have the use of a small enclosed outside play area that has outdoor play equipment. Service users spoken with said that they were happy with their bedrooms and the facilities in the home, but two did feel that the home would benefit from redecoration as some areas were looking tired. Trevi House DS0000003558.V320831.R01.S.doc Version 5.2 Page 22 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): 31,32,33,34,35,36. Quality in this outcome area is poor because although the staff team are committed and caring they are inadequately supported, trained and supervised by the Management to effectively do their jobs. Roles and responsibilities of the staff team are not clear. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Four staff survey forms sent prior to the inspection were not returned, but following the inspection twenty staff survey forms were sent to all staff members at Trevi House, and 16 staff surveys were returned. During the inspection two members of staff were interviewed. Thirteen of the sixteen staff stated in the survey forms that they believed that the home did not provide funding and time for them to receive appropriate training. Records evidenced that most of the staff were qualified to NVQ level and had qualifications in drug and alcohol dependency counselling. There was not a training plan available for staff. Trevi House DS0000003558.V320831.R01.S.doc Version 5.2 Page 23 Staff said that there was some inconsistency with staff roles and responsibilities and they were not clear about their roles and responsibilities. Supervision was inconsistent and not always given by the Manager on a regular basis. Staff supervision records evidenced that some supervision was given, but not on a regular basis. Six staff stated in the survey forms that they did not feel that supervision with the Registered Manager was confidential. One member of staff stated that they had sought their own regular external supervision after a request for the home to fund external supervision was refused. Staff appeared to be very committed to the service users, and service users confirmed that they believed that the staff team were skilled, and competent and very approachable. All staff are qualified to NVQ level, and the majority are trained in working with people who have a drug or alcohol dependency. The manager informed the Inspector that staff have to undertake a six month induction, but there was not any documented evidence to confirm this, and one staff member said that they had not received an induction. Staff survey forms returned said that six out of sixteen staff said that they had not received full induction training. Four staff records were examined, and evidenced that all appropriate documentation including two references and a CRB check was on file. Staff spoken with confirmed that they felt able to deal with physical and verbal aggression from service users in an appropriate manner. Any incidents of this nature are recorded. Staff were observed interacting with the service users, and the Inspector was impressed with the positive and enabling manner in which this happened. Service users confirmed that the staff were always helpful and approachable, and were very supportive. During the day there are four counsellors on duty, plus an administration assistant, a resettlement worker, a development manager and the Registered Manager. At night there are two out of hours counsellors and a senior worker. Fourteen staff out of the sixteen survey forms returned stated that they did not receive enough support from the home to do their job well. Trevi House DS0000003558.V320831.R01.S.doc Version 5.2 Page 24 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37,38,39,40,41,42,43 Quality in this outcome area is poor because there are serious concerns regarding the management of the home. There is no formal quality assurance system in place at Trevi House. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Mrs Brooks has been the Registered Manager for three years at Trevi House. She is a qualified drug and alcohol counsellor and She worked at the home for ten years prior to this. Staff Confidence in the management of the home was very low. A vote of no confidence in the management that was signed by seventeen members of staff has been sent to the board of trustees of Trevi House who are currently Trevi House DS0000003558.V320831.R01.S.doc Version 5.2 Page 25 investigating claims that the management style of Mrs Brooks is unacceptable for a number of reasons including allegations of an authoritarian and undermining method of management and misuse of supervision. Seven survey forms completed by staff mentioned that they thought that the outcomes for the service users were being affected by what they see as the poor management of the home. Staff views are not sought, and they confirmed that they did not feel that they were listened to when they had any concerns. There is not a formal quality assurance system in operation in the home, although there was evidence that service users are encouraged to document their views of the staff. Two service users were spoken with during the inspection, and both said that they thought that the home was efficiently run. Policies and procedures are in place and available to staff and service users. Fire safety records were not up to date and the last recorded fire training/drills/appliance testing was in July 2006. Records to evidence appropriate gas and electrical systems are regularly tested and maintained were in place. Accident records were up to date and in place. Records were available to evidence that gas and electrical systems are regularly serviced. Windows are restricted on upper floors. The premises are secure with the operation of an intercom system at the main gate. Appropriate insurance cover is in place. Trevi House DS0000003558.V320831.R01.S.doc Version 5.2 Page 26 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 1 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 3 25 3 26 3 27 3 28 3 29 x 30 3 STAFFING Standard No Score 31 1 32 3 33 2 34 3 35 1 36 1 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 3 2 x LIFESTYLES Standard No Score 11 2 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 1 1 2 2 2 2 Trevi House DS0000003558.V320831.R01.S.doc Version 5.2 Page 27 no Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard YA1 Regulation 4 Requirement The statement of purpose for Trevi House must be reviewed to be clear about the aims, objectives and philosophy of the home. The Registered Person must ensure that staff employed at the home receive training appropriate to the work they are to perform. The Registered Manager must ensure that all staff receive structured induction training (within six weeks of appointment) to sector skills specification. The Registered Person must make arrangements to enable staff to inform the registered person and the Commission of their views regarding the care home. The Registered Manager must ensure that staff working at Trevi House are appropriately supervised and supported. The Registered Person must introduce a system for reviewing and improving the quality of care provided at Trevi House, that DS0000003558.V320831.R01.S.doc Timescale for action 01/04/07 2. YA35 18 01/04/07 3. YA35 18 01/04/07 4. YA39 21 01/04/07 5. YA36 18 01/04/07 6. YA39 24 01/05/07 Trevi House Version 5.2 Page 28 7. YA42 23 seeks the views of residents, staff and all other stakeholders. Fire safety drills and training must take place at the appropriate intervals. Fire safety equipment must be recorded as receiving regular maintenance tests. 01/03/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard YA6 Good Practice Recommendations Care plans should be further improved to document treatment and rehabilitation, and how staff will meet current and changing needs and aspirations and achieve goals. Trevi House DS0000003558.V320831.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection Ashburton Office 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 Trevi House DS0000003558.V320831.R01.S.doc Version 5.2 Page 30 - 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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