Inspection on 17/05/05 for Two Trees

This inspection was carried out on 17th May 2005.

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

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

Other inspections for this house

Two Trees 17/11/08

Two Trees 07/12/06

Two Trees 24/11/05

Two Trees 16/12/04

Two Trees 24/06/04

Similar services:

2 Perhaver Park

The Vicarage

7 Hyde Road

St George`s

5 Seafield Road

Credence House

Radfords

Trevaylor Manor

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

CARE HOME ADULTS 18-65 Two Trees 33 Milehouse Road Milehouse Plymouth PL3 4AF Lead Inspector Brendan Hannon Announced 17 May 2005 th 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 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 Stationary 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. Two Trees D52-D04 S3510 Two Trees V214725 170505 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Two Trees Address 33 Milehouse Road, Milehouse, Plymouth, Devon, PL3 4AF Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 01752 561189 01752 558181 Mr Roger Festin Gliddon, Mrs June Ann Gliddon, Mrs Paula Marie Pillage Mrs Paula Pillage Care Home 28 Category(ies) of Learning disability (28), Physical disability (28) registration, with number of places Two Trees D52-D04 S3510 Two Trees V214725 170505 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: 5 residents maybe over the age of 65yrs Learning disabled adults some of whom may have a physical disability Date of last inspection 16/12/04 Brief Description of the Service: The home is located in three combined large terraced houses, on the end of a terraced row of houses, in the Milehouse area of central Plymouth. A full range of amenities and facilities are within walking distance though, the home has its own vehicles and the central shopping area of Plymouth is easily accessible by bus. The home can accomodate up to twenty eight residents. The home has one main entrance from which all parts of the home may be accessed. There are residents bedrooms on the ground floor and the home is partially wheel chair accessible. There are five communal bathrooms and one communal shower. There are no shared bedrooms. Due to the age of the building all the ceilings are reasonably high giving an additional feeling of space in the home. There are seven communal areas in the home including lounges, dining areas and activity rooms. There is a large area of patio space to the rear of the building that has been made accessible to all the residents. This area can be accessed either from the lane to the rear of the building or from the rear of the ground floor. The service offered by the home is for men and women with a learning disability over the age of 18 and perhaps over the age of 65. The present group of residents are of a mixed range of ages and abilities but are in the main very active within the home and in the community. Two Trees D52-D04 S3510 Two Trees V214725 170505 Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was announced. Preparation for the inspection included analysis of the pre inspection questionnaire, the previous inspection report, relatives and residents comment cards and correspondence with the home over the last 12 months. An inspection plan was developed from this information. The inspector was in the home over two days from 9.45am to 4.30pm on the first day and 9.00am to 10.30am on the second. The inspector spent time with or spoke to twenty of the twenty eight residents, with particular attention being given to three residents whose care was looked at closely. The whole of the building was inspected. The registered providers, the registered manager, assistant manager and four care staff were spoken to during the inspection. The registered manager and deputy manager were spoken to at length. Care planning files, care delivery records, medication records, communication books, and health and safety records were inspected. A thorough inspection was carried out covering all areas of service delivery in order to gain an overview of the home for the Regulation Inspector who had not inspected the home before. What the service does well: The home management and staff team seek to provide a homely and comfortable place for the residents to live. The home provides good information about the service to potential new residents, and their representatives, so that they can make an informed choice about whether to use the service. The service has exceeded the required standard for leisure activity by providing an activity centre and activity coordinator as well as supporting leisure activity outside the home. Residents receive enough, varied, good food. Residents’ personal care needs are met and medication is well managed. Records in general in the home are of excellent quality which helps to support the provision of personal care, medication administration and support the provision of health care by healthcare professionals. The residents benefit from a homely, comfortable, clean and well maintained building that has been appropriately adapted to meet their needs. The service was commended for the physical adaptations and equipment that had been put in place to support residents with physical disability needs. There are comfortable communal areas outside the building for residents to use as well as extensive communal facilities within the building. Resident’s needs are met by enough competent, qualified, vetted and trained staff. The staff team is led by effective management team that is consistently working to improve the quality of residents’ lives. Two Trees D52-D04 S3510 Two Trees V214725 170505 Stage 4.doc Version 1.30 Page 6 What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Two Trees D52-D04 S3510 Two Trees V214725 170505 Stage 4.doc Version 1.30 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 Standards Statutory Requirements Identified During the Inspection Two Trees D52-D04 S3510 Two Trees V214725 170505 Stage 4.doc Version 1.30 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users’ know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 1,2,3,4 The home provides adequate information about the service to allow a new resident, and their representatives, to make an informed decision to use the service. The home supports new residents to make a successful move into the home. EVIDENCE: Both the service users guide and the homes statement of purpose were available. The information in these documents would enable potential new residents and their supporters to understand the service provided by the home. Residents and care staff were observed and spoken to throughout the inspection. Through this observation, through the care plans, and through records there was good evidence to show that resident’s needs are being met. A pre admission assessment is carried out by the home using a standard format for all prospective residents to ensure that the service provided can meet their needs. There were records of initial visits to the home. The policy on trial visits states that prospective residents may come for visits and overnight stays. This was seen in practice for a recently admitted resident who had stayed overnight and visited on weekends before deciding to move into the home. These initial visits will help to inform potential new residents and make their move into the home an easier transition. Two Trees D52-D04 S3510 Two Trees V214725 170505 Stage 4.doc Version 1.30 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate, in all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 6,7,8,9 The delivery of resident’s care is good but is hampered by limited care planning and resident risk assessment. Improvements in these areas will support further progress in the delivery of consistent, high quality support to the residents. EVIDENCE: Resident’s care plans were sampled. All the residents’ files had a care plan and risk assessments in place and these were being appropriately reviewed. However the information held in the care plan document should be comprehensive to cover all the issues affecting the resident and should also be more detailed. The home has developed a new care plan format, which it was agreed, would be brought into use during 2005. When a detailed and comprehensive care plan has been developed for each resident the quality of their care support will be further improved and this should therefore improve the resident’s quality of life. There was little detail in the care plan on leisure and/ or valued activities participated in by the resident. The manager was advised to introduce a plan of regular and irregular activities to help the staff to be consistent in there support during activities. Some residents have behaviours that challenge the service. It was advised that in these circumstances there should be clear behaviour management plans in the individuals care plan to ensure that staff Two Trees D52-D04 S3510 Two Trees V214725 170505 Stage 4.doc Version 1.30 Page 10 always intervene in a consistent planned manner. This may help residents to adapt their behaviours and will help them have a better quality of life. There were individual risk assessments in resident’s care plans. However they were generally limited to specific issues and were not comprehensive. They did not identify all the risks and agreed restrictions affecting the resident and they also did not address the identified risks in enough detail. Individual residents risk assessments should be comprehensive and detailed to identify all the risks and agreed restrictions affecting the resident and the measures in place to reduce these risks to an acceptable level. Throughout the inspection there were numerous examples of the service working hard to be creative and successfully support each resident to establish and maintain a good quality of life. Activities ranged from traditional day care, through activity centre groups, to one to one supported activities with staff members. Such enablement and support has given the residents independence and freedom. Two Trees D52-D04 S3510 Two Trees V214725 170505 Stage 4.doc Version 1.30 Page 11 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12,14,17 Residents have enough appropriate activity to ensure a good quality of life while living at the home. Residents receive enough, varied, good food. EVIDENCE: The manager described at length the activities that were enjoyed by the residents. This information was supported to some extent by care planning, residents’ daily diaries, the homes communication book and a log held by the activity centre. Additional weekly activity planning was advised under standard 6. The home has an area of the home specifically identified as an activity centre and a separate kitchen area for work with development of daily living skills, such as cooking. The home employs an activity coordinator to manage the centre and support the residents’ use of it. At the time of the inspection a group of ten residents were involved in a complex arts and craft session. The residents involved were spoken to individually. They explained what they were doing and expressed how much they were enjoying this activity. The centre keeps a log of the activities that have been participated in by residents and how successful they have been for the individual residents. The availability of both the facility and the activity centre coordinator have made a real difference to the quality of the residents lives and is commended in this report as exceeding the standard required by standard 12. Two Trees D52-D04 S3510 Two Trees V214725 170505 Stage 4.doc Version 1.30 Page 12 Similarly it could be seen from the menu plans, food provided records and from the various stocks of food and drink in the home, that the residents are supplied with enough, good quality food of a type that they like. There was a four week menu plan, the residents food likes and dislikes and a record of the choices made by the residents regarding their meals all present in the main kitchen. Two Trees D52-D04 S3510 Two Trees V214725 170505 Stage 4.doc Version 1.30 Page 13 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 18,19,20,21 Residents’ health is maintained by; meeting the residents’ personal care needs, through the thorough administration of their medication and by supporting the residents’ access to health services. EVIDENCE: Many of the residents living in Two Trees at the time of the inspection were seen. There was no observable evidence of any personal care issue not being met. Weight records are being well maintained for all the residents. Some of the residents in the home have complex health needs and the home is successfully meeting these needs. Individual chart records relating to personal and health care needs were in use wherever they were required to monitor progress, and these records were being maintained thoroughly and consistently. Where there is frequent involvement from health professionals this information helps the delivery of better health care and helps to maintain the residents health. These records will also help to inform the homes management early of any issues that arise. The resident files sampled showed that health service input was actively being sought and then supported by the home. This support ensures that the residents receive their right to a full health care service from the national health system. Due to the number and complexity of health needs of some residents in the home the medication system is a considerable undertaking for the home. Two Two Trees D52-D04 S3510 Two Trees V214725 170505 Stage 4.doc Version 1.30 Page 14 Trees have a substantial system of medication which they manage effectively and safely. The home uses a monitored dosage blister pack system. The record of medication administration was well maintained. A complete and up to date list of each resident’s medication (medication profile) is kept with the Medication Administration Record. The management was advised to obtain a controlled drug record book should the home need in the future to administer controlled drugs. The medication storage was clean and ordered. Two Trees D52-D04 S3510 Two Trees V214725 170505 Stage 4.doc Version 1.30 Page 15 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 22,23 Complaints are properly managed by the home protecting the welfare of the residents. EVIDENCE: There is an adequate complaints procedure and this is clearly displayed in the home. The contact details for the CSCI are given within the procedure. The management of the home were advised to simplify the complaints procedure and display the new document at the main entrance of the home to make it as accessible as possible. The home has all the required adult protection policies in place and members of the staff team have attended adult protection training. Two Trees D52-D04 S3510 Two Trees V214725 170505 Stage 4.doc Version 1.30 Page 16 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 24,25,26,27,28,29,30 The residents benefit from a homely, comfortable, clean and well maintained building that has been appropriately adapted to meet their needs. EVIDENCE: The home was looked at closely and only a few minor repairs were noted. The quality of the living environment and the standard of decoration throughout the home, including communal areas and the residents bedrooms, was generally good. There were a wide variety of communal areas with unusual rooms such as the activity centre and a music room. There was juke box, disco lighting and a dance floor in the music room. In the lounge areas and dining rooms there was good quality seating and furnishing. To the rear of the building is a large patio area, which has been made as accessible as possible to allow its use by all of the residents in the home. Garden furniture was placed around the area and barbecue facilities had been built into the scheme. The bedrooms varied in the level of personalisation depending on the wishes of the resident. The quantity of furniture also varies dependant on the wishes and needs of the resident who uses the room. There is a system of star key locks on bedroom doors giving privacy and security to the room. Some residents make use of the offer of lockable storage facilities in their room. Two Trees D52-D04 S3510 Two Trees V214725 170505 Stage 4.doc Version 1.30 Page 17 The laundry had been newly renovated to provide plenty of room, easily washable surfaces and space for an industrial washing machine and dryer. The home was clean and hygienic. The bathrooms and toilets were in good condition and there are enough facilities to meet the needs of the residents. However some of these facilities were either without a working lock or had an internal bolt lock in place. It was recommended that there should always be a working lock to provide privacy for residents and that the locks should preferably be of an override type to allow access from the outside in the event of an emergency, thereby supporting the health and safety of the residents. The needs of the present residents have required the service to change to meet much greater physical disability needs. Impressive developments and alterations had been made to meet the needs of specific residents. Three ceiling track hoists had been fitted in the building as well as shower facilities. The level of concern, design and implementation that had been carried out to meet physical needs is commended in this report as exceeding the standard required under standard 29. Two Trees D52-D04 S3510 Two Trees V214725 170505 Stage 4.doc Version 1.30 Page 18 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 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 32,33,34,35,36 Resident’s needs are met by enough competent, qualified, properly vetted and trained staff. EVIDENCE: The homes record of the hours worked was checked and this showed that there is always an adequate number of staff on duty to meet the needs of the residents. Personnel records were sampled. A large staff team is necessary to meet the needs of the residents. The personnel records, including CRB checks were sampled and met the required Care Homes Regulations. Residents are asked for their opinion of potential new staff and the views expressed are taken into account as part of the interview process. The appropriate checking of new staff ensures the safety of the residents. More than half of the staff team are NVQ2 qualified, or above. A substantial training programme is delivered to the staff at Two Trees to ensure that the level of qualification of the staff team is maintained. The required basic trainings as required by the National Minimum Standards are maintained thoroughly. Due to the ongoing needs of the residents the home has made training in dementia care a core training need. As staff have moved on from the home over time the number of care staff trained in this area has declined and is now approximately half of the staff team. It was advised that further training in this area become a priority to return the number of dementia care trained staff to the former level. In general the care staff team at the home are Two Trees D52-D04 S3510 Two Trees V214725 170505 Stage 4.doc Version 1.30 Page 19 well trained ensuring that the care staff are competent to meet the needs of the residents. A simple induction regime is in place for new members of staff. This system is basic and does not comply with the National Training Organisation (NTO) specification for induction. The home should develop a new induction format that is compliant with NTO specification, meets the needs of the home and ensures that new staff can meet the needs of the residents early in their work at the home. The management of the home have been carrying out observation of staff practice but not individual minuted staff supervision sessions, as envisaged within standard 36. The design of a practical system was discussed during the inspection. This type of monitoring would help to ensure that staff practice and staff training are regularly reviewed enabling staff to further improve their practice. Two Trees D52-D04 S3510 Two Trees V214725 170505 Stage 4.doc Version 1.30 Page 20 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 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 37,39,40,41,42 The management of the home is effective and continues to ensure that the needs of the residents are met. EVIDENCE: A Registered Manager of the home is Paula Pillage. She has completed both her NVQ 4 in care and the Registered Managers Award. The registered manager is supported by an assistant manager and a senior care officer. The registered manager and staff were seen to be working well together. Good working relationships amongst the staff promote better quality support for the residents. The homes management has developed a new quality assurance system. However it was agreed that this should be reviewed to develop a system that is more focussed on the residents views and wishes. A new system should seek to gain feedback on the service provided not only from the residents but also relatives and professionals linked to the home. Any new system should seek to identify what is of value in the present service for the residents and what might be improved to provide them with a greater quality of life. Two Trees D52-D04 S3510 Two Trees V214725 170505 Stage 4.doc Version 1.30 Page 21 Records were observed throughout the inspection. All were well maintained and the use of charts to monitor health related issues were particularly impressive. The recording of medication administration was well managed. In addition the record of food provided demonstrated not only, what was on offer, but also the choice made by the residents. The quality of the record keeping in the home is very good and this reliable consistent information gives a strong basis for the successful delivery of care to the residents. The quality of the recording in the home is commended in this report as exceeding the standard required by standard 41. Health and Safety is generally well managed in the home. Hygiene and infection control are well managed in the home. This could be observed both in the cleanliness of the home but also in the availability of appropriate facilities and equipment to manage these issues. The Environmental Health Officer’s last report found no problems. Fire protection and accident records are well maintained. Fire training is carried out regularly but a procedure should be written to clearly state the topics that are covered in the ‘in house’ fire training. The residents are encouraged to join in fire protection training so that they are aware of the fire evacuation procedure. Hot water temperatures have been turned down at the boiler but this cannot ensure that the temperature at the tap is not more than the recommended temperature of 43 degrees centigrade. The home has thermometers to test and record the temperature of baths before they are used by the residents. However the home is advised to consider installing fail-safe valves at the baths and showers in the home to prevent the risk of scalding from hot water. Where the hot water taps available to residents have not been adapted to reduce the water temperature a risk assessment should be in place for each hot tap. Similarly where radiators have not been covered, and a possible risk of pressure burn remains, each radiator should be risk assessed to identify that the present situation is safe. None of the windows above ground floor level have had their opening restricted. The management are happy that the situation is safe but while a potential risk remains each unrestricted window should be individually risk assessed to identify that the residents are safe. Comprehensive safety checks have been carried out, as noted in the pre inspection questionnaire, including gas appliances and electrical equipment. Two Trees D52-D04 S3510 Two Trees V214725 170505 Stage 4.doc Version 1.30 Page 22 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score 3 3 3 3 x Standard No 22 23 ENVIRONMENT Score 3 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 2 3 3 2 x Score Standard No 24 25 26 27 28 29 30 STAFFING Score 3 3 3 2 3 4 3 Standard No 11 12 13 14 15 16 17 x 4 x 3 x x 3 Standard No 31 32 33 34 35 36 Score x 3 3 3 3 2 CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Two Trees Score 3 3 3 x Standard No 37 38 39 40 41 42 43 Score 3 x 3 3 4 2 x D52-D04 S3510 Two Trees V214725 170505 Stage 4.doc Version 1.30 Page 23 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 Regulation Requirement Timescale for action RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. Refer to Standard 6 9 Good Practice Recommendations All the residents should have a careplan in place which is comprehensive and detailed. All the residents needs should be identified and how the staff are to meet these needs. Each resident should have a comprehensive and detailed individual risk assessment. This assessment should include all restrictions of choice or personal freedom agreed to be in the residents best interests. All bathroom and toilet doors should have functioning locks preferably of a type that can be overriden from the outside. A structured induction in line with the National Training Organisation specification should be developed. Care staff should receive six recorded, one to one, supervision meetings per year. The quality assurance system should be redeveloped to be resident focussed and based on gaining extensive comment from residents,relatives and professionals regarding the quality of the service. The building risk assessment should be expanded to include an individual risk assessment of each radiator that D52-D04 S3510 Two Trees V214725 170505 Stage 4.doc Version 1.30 Page 24 3. 4. 5. 6. 27 35 36 39 7. 42 Two Trees has not been covered, each unadapted hot water outlet, and each unrestricted window opening above ground floor level. A procedure should be written identifying the topics covered within fire training carried out by the home. Two Trees D52-D04 S3510 Two Trees V214725 170505 Stage 4.doc Version 1.30 Page 25 Commission for Social Care Inspection Unit D1 Linhay Business Park Ashburton TQ13 7UP National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Two Trees D52-D04 S3510 Two Trees V214725 170505 Stage 4.doc Version 1.30 Page 26 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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