Inspection on 07/12/06 for Two Trees

This inspection was carried out on 7th December 2006.

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

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

Other inspections for this house

Two Trees 17/11/08

Two Trees 24/11/05

Two Trees 17/05/05

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 Devon PL3 4AF Lead Inspector Antonia Reynolds Unannounced Inspection 7th December 2006 1:50pm Two Trees DS0000003510.V290520.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 Two Trees DS0000003510.V290520.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. Two Trees DS0000003510.V290520.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Two Trees Address 33 Milehouse Road Milehouse Plymouth Devon PL3 4AF 01752 561189 01752 558181 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) Mr Roger Festin Gliddon Mrs June Ann Gliddon, Mrs Paula Marie Pillage Mrs Paula Marie Pillage Care Home 28 Category(ies) of Learning disability (28), Physical disability (28) registration, with number of places Two Trees DS0000003510.V290520.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 5 residents may be over the age of 65yrs Learning disabled adults some of whom may have a physical disability Date of last inspection 24th November 2005 Brief Description of the Service: Two Trees is a care home providing personal care and accommodation for twenty-eight people with a learning disability, who may also have physical disabilities. The age range is mainly 18 to 65 but there are a few service users over the age of 65. The home is privately owned by Mr and Mrs Gliddon, and Mrs Pillage, who is also the Registered Manager. The fee levels are between £313 and £789, although these may vary depending on the individual needs of service users. Information about the home and copies of inspection reports can be obtained from Mrs Pillage. The original home was opened in 1978 and is now comprised of three interlinked, three-storey terraced houses, with one main entrance, situated in the Milehouse area of Plymouth. It is within walking distance of local shops and amenities, central Plymouth is easily accessible by public transport, and the home has its own vehicles. All the bedrooms are single and are located on each floor. Over half of the bedrooms have en suite toilets, with many having en suite showers or baths, some of which are adapted to meet the specific needs of individual service users. There are also communal bathrooms, showers and toilets throughout the home. The home is partially wheel chair accessible and has a shaft lift as well as a stair lift. The home has two through lounge/dining rooms, two conservatories, a music/relaxation room and a room for the specific use of a visiting hairdresser. There is a large area of patio space at the rear of the building that has been made accessible to all the service users. This area can be accessed either from the lane to the rear of the building or from the rear of the ground floor. On street parking is available at the front of the home. Two Trees DS0000003510.V290520.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This key inspection consisted of an unannounced visit between 1.50pm and 6.30pm on Thursday, 7th December 2006 and a further visit between 10am and 1.30pm on Monday, 11th December 2006. The Registered Provider, Roger Gliddon and the Registered Manager, Paula Pillage, were present on the first day of inspection and Paula Pillage was present throughout the second visit. A tour of the premises took place and records/documents relating to the care of the service users, staff and the home were inspected. A pre-inspection questionnaire had been completed by the Registered Manager, which contained information relevant to the inspection. Survey forms had been completed by five service users, eight service users were spoken with at length and a further ten service users were observed during the visit. Feedback was obtained from three relatives and four social and health care professionals. What the service does well: What has improved since the last inspection? The management of the home has worked hard to develop and improve the detail contained in service users’ care plans and risk assessments, and these Two Trees DS0000003510.V290520.R01.S.doc Version 5.2 Page 6 are regularly reviewed. The Registered Providers have reviewed the way in which service users’ personal money is managed by the home and have reached agreements with service users and/or their relatives/representatives that each service user will contribute £16.50 a week for transport. There has been ongoing investment in the home, continually improving the quality of the living environment for the service users. Covers have been fitted to all the radiators to reduce the risk of burns to service users, a bathroom has been refurbished and an en suite bathroom added to a service user’s bedroom. Twenty of the bedrooms have been fitted with appropriate key locks, with the rest to be completed in the near future. The Registered Manager has devised a comprehensive induction programme for new staff, which complies with national training requirements. 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. Two Trees DS0000003510.V290520.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 Two Trees DS0000003510.V290520.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 2, 3 and 4 Quality in this outcome area is good. The home’s admissions procedure ensures that prospective service users and their relatives/representatives know that the home will meet their needs and aspirations. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The pre-admission assessment process ensures that the needs of prospective service users are identified. Service users and their relatives/representatives are welcome to visit the home prior to admission to meet other service users, staff and have a look around the home. There are also opportunities for prospective service users to have a meal or stay overnight should they wish to. Discussions with service users, staff and the Registered Manager, as well as observation, show that staff are aware of the needs of the service users. Two Trees DS0000003510.V290520.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 6, 7, 8 and 9 Quality in this outcome area is good. Service users can be confident that they will be encouraged and supported to make choices and decisions about their lifestyles. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Five 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 and contains comprehensive and detailed information about how the care needs of service users should be met by the staff team. Discussion with service users and staff confirmed that personal care is maintained, service users can bathe/shower when they choose to and are encouraged to be as independent and make as many choices as possible. A local advocate was visiting on the second day of inspection, demonstrating that service users have access to advocacy services should they need them. Two Trees DS0000003510.V290520.R01.S.doc Version 5.2 Page 10 With regard to service users’ money, the Registered Manager confirmed that the home operates a bank account for residents’ money only. State benefits are paid into this account and care home fees and personal money are immediately paid out, therefore no money is stored in this account. All the service users are expected to make a financial contribution towards the cost of transport, which is presently the lower rate of the mobility component of Disability Living Allowance (£16.50 per week). For this money, the service uses have the use of two minibuses owned by the home and all public transport costs are covered by the home. The Registered Manager confirmed that each service user has their own bank/building society account into which personal monies are paid to ensure that large amounts of money are not kept on the premises. Service users are enabled to access their accounts by individual staff support. Two Trees DS0000003510.V290520.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 11, 12, 13, 14, 15, 16 and 17 Quality in this outcome area is good. Service users can feel confident that they will have opportunities for personal development, various activities are available to fulfil their aspirations, and independence and choice are promoted. This judgement has been made using available evidence including a visit to this service. EVIDENCE: All the service users living in the home attend a range of regular work and leisure activities and educational opportunities are available if required. The unannounced inspection started at the end of the afternoon, therefore the inspector was able to meet and see service users arriving home from work, day placements and various activities. This was a very cheerful, noisy and welcoming time for everyone. The home has set up an activity centre in a house attached to the residential home and several of the service users participate in activities and events that take place there. The home employs a staff member with specific responsibility for co-ordinating and arranging Two Trees DS0000003510.V290520.R01.S.doc Version 5.2 Page 12 various activities. Service users confirmed that they have regular holidays to a large static caravan that belongs to the home and is located at Butlins in Minehead. The home owns two minibuses, one with a tail lift, to transport service users to appointments and social events. Service users are also encouraged to use public transport if they are able to and this is funded by the home. Each service user has his/her own building society account and is provided with assistance, advice and guidance to manage their financial affairs should they need this. Each service user contributes £16.50 a week (the lower rate of the mobility component of Disability Living Allowance) towards the cost of transport. Service users said that they liked the food provided in the home and can choose what they want to eat. There are limited opportunities to cook meals in the home, but service users can prepare their own packed lunches if they wish to. The activities centre also has a kitchen where service users can bake and cook their own meals if they wish to. Service users are able to enjoy their meals in an unrushed and sociable atmosphere. Two Trees DS0000003510.V290520.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 18, 19, 20 and 21 Quality in this outcome area is good. Service users can be confident that personal support is provided in the way, and at the time, that they want and need. Health care needs are monitored and advice is sought when necessary. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Service user plans provide information about personal, emotional and health care needs. Where service users have complex health needs, the management and staff team work hard at meeting those needs with support from local health care professionals. 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 health care professionals or social services and visits to the doctor, dentist and other health appointments are recorded in individual files. Through observation it is clear that timings are flexible and the choice of the service user. Each service user has a designated key worker and service users said they could discuss any personal issues with their key worker or other members of staff. Two Trees DS0000003510.V290520.R01.S.doc Version 5.2 Page 14 Records pertaining to the administration of medication are up to date and a staff member demonstrated the medication administration practices in the home, which are satisfactory. Two Trees DS0000003510.V290520.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 22 and 23 Quality in this outcome area is good. Service users can be confident that any concerns or complaints will be listened to and addressed. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Discussion with the service users, staff and the Registered Manager, demonstrated that the open culture of the home and the recognition of service users’ rights ensure that service users are protected from harm. The home has a written complaints procedure. Service users are well aware of how and to whom they can make a complaint and feel free to do so. They each have a designated key worker and said they could speak to this person, the Registered Manager or any other member of staff. The Registered Manager confirmed that all staff members are expected to attend training in the protection of 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. Two Trees DS0000003510.V290520.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 24, 25, 26, 27, 28, 29 and 30 Quality in this outcome area is good. Service users live in a clean, safe, comfortable and well-furnished home that has been adapted to meet their needs. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home is spacious, comfortable, safe and clean with a good standard of décor and furnishings. The home employs a full-time person responsible for maintenance and the Registered Manager confirmed that repairs, maintenance and redecoration are ongoing projects. Service users confirmed that they are responsible for cleaning their own bedrooms if they wish to and the staff clean the communal areas. There are a wide variety of communal rooms including two large through lounges/dining rooms, two conservatories, and a music/relaxation room with juke box, disco lighting and a dance floor. The home also has a room specifically for hairdressing and an activity centre in another house attached to the care home. The home has a pay ‘phone that service users may use. Two Trees DS0000003510.V290520.R01.S.doc Version 5.2 Page 17 Each service user has a single bedroom, most of which are large rooms, with plenty of space for individual needs and lifestyles. The bedrooms are located on every floor of the building. The home has a shaft lift and a stair lift to the 1st floor so that service users with a physical disability can get upstairs easily. All the bedrooms contain wash hand basins and over half of them have en suite toilets, with most of these also having en suite baths or showers. Bedrooms are individually furnished and contain many personal possessions. Service users and the Registered Manager confirmed that, wherever possible, service users choose the colour and décor of their bedrooms. The bedrooms are all personalised by or for the service users, depending on their wishes. The type and quantity of furniture varies dependant on the wishes and needs of service users. The home is fitting locks to bedroom doors that can be locked from the inside by using a knob, and locked from the outside by using a key. At the time of inspection the Registered Manager confirmed that twenty bedrooms now have appropriate locks, although observation demonstrated that service users tended to continue using the star key locks that were previously fitted. The home keeps a master key to all the key locks so that they can be opened if an emergency should occur. The bathrooms and toilets are in good condition and discussions with service users, as well as observation, indicated that there are enough facilities to meet the needs of the service users and staff. All bathroom and toilet doors are fitted with locks that can be opened from the outside by staff in an emergency. The Registered Manager confirmed that, wherever possible, a service user’s en suite facility is used for personal care tasks. Due to the changing needs of the service users, the owners have made many adaptations and alterations to meet those needs, particularly for those service users with physical disabilities. The home has mobile hoists, bath lifts/hoists, overhead ceiling tracks for hoists and adapted/specialised baths and showers. Discussion with the Registered Provider confirmed that they are willing to adapt any area to meet specific needs of service users. The level of innovation, design and implementation that has been carried out to meet physical needs is excellent and worthy of commendation. At the rear of the building is a large patio area, with garden furniture and a built in barbecue, which has been made as accessible as possible for all the service users in the home. The laundry has recently been renovated and is large with easily washable surfaces and space for an industrial washing machine and dryer. Service users confirmed that they can their own laundry if they wish to. The kitchen is large and the Registered Manager confirmed that, due to health and safety reasons, service users do not prepare or cook meals in this kitchen. However they may prepare their own packed lunches and a kitchen is available in the activity centre attached to the home where service users may cook meals or bake. Two Trees DS0000003510.V290520.R01.S.doc Version 5.2 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 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 Quality in this outcome area is good. Service users benefit from a competent, experienced, well-supported and supervised staff team. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Discussions with service users, the staff on duty and the Registered Manager confirmed that there are always enough staff on duty to meet the needs of the service users. There are usually at least three care staff on duty during the day and evening, as well as an activities co-ordinator and a member of the management team. At night there are two waking night staff but, if needed, additional staff will be provided. In addition to the care staff, the home also employs ancillary staff, including a handyman, gardener, cleaners, cooks and housekeepers. The staff members on duty were aware of service users’ needs and how to support them. Service users confirmed that the staff team are very good and it was evident that there was a good rapport between service users and staff. Two Trees DS0000003510.V290520.R01.S.doc Version 5.2 Page 19 Four staff files were inspected and the information in them show that the organisation has a robust recruitment procedure. The Registered Manager confirmed that two verbal references are always obtained and the information is recorded. Two of the files contained only one written reference and the Registered Manager confirmed that the second references are being pursued. Criminal Record Bureau (CRB) checks are made for every new staff member and the Registered Manager and members of staff confirmed that new staff are never left unsupervised until all the checks and references are returned. Service users are asked for their opinion of potential new staff and the views expressed are taken into account as part of the interview process. The staff team at Two Trees is expected to participate in a substantial training programme to ensure that the level of qualification is maintained. All training and supervision meetings are documented in staff files. The staff members spoken with were confident that they receive enough training and supervision to enable them to do their jobs. Staff are expected to complete training in adult protection, first aid, health and safety, fire safety, medication, food hygiene, National Vocational Qualifications (NVQs) and several courses related specifically to working with service users with learning and physical disabilities. These include topics such as advocacy, social role valorisation, communication, mental health, epilepsy, challenging behaviour, sight and hearing impairments and manual handling amongst others. Due to the ongoing needs of the service users the home has made training in dementia care a core area. The home has recently devised a structured induction training that complies with the Skills for Care requirements and this will be put in place for all new staff. Two Trees DS0000003510.V290520.R01.S.doc Version 5.2 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 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 37, 38, 39, 41 and 42 Quality in this outcome area is good. The management of the home ensures that the needs of the service users are met by providing clear leadership and guidance. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The Registered Manager, Mrs Paula Pillage, has been managing this home for several years and has gained appropriate qualifications, being the NVQ 4 in Care and Registered Manager’s Award. Discussions with the service users and staff confirmed that the ethos of the home is very good. This is because the management approach is open and inclusive with the home being organised to meet the needs and aspirations of the service users. The quality of care provided is continually being monitored and reviewed by the Registered Manager as she spends a great deal of time at the home talking with service Two Trees DS0000003510.V290520.R01.S.doc Version 5.2 Page 21 users, their relatives/representatives and staff. Service users and staff confirmed that they are consulted and included in all decisions regarding the running of the home. Comments received from relatives were complimentary about the care provided. The home has 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. A discussion took place about pulling all this information together with everything the home has achieved in each year and writing a short annual report on progress to be made available to all interested parties. The record keeping in Two Trees is excellent as all records are well maintained and the use of charts to monitor health related issues are particularly detailed. The recording of medication administration is well managed. The record of food provided in the home demonstrates not only what is on offer, but also the choice made by the service users. Reliable consistent recorded information gives a strong basis for the successful delivery of care to the service users and the staff team is commended for their efforts to ensure that detailed information is documented. Records and documents relating to health and safety issues are up to date. Tests and checks of fire safety equipment are carried out as required and the service users and staff are aware of fire safety procedures. Records show that the staff receive regular fire safety training and a discussion took place about devising a system to ensure that all staff receive the level of training required in the home’s fire risk assessment. All radiators are guarded to reduce the risk of burns to service users. The Registered Provider confirmed that the home uses combination boilers for its hot water system and that the temperature of the hot water is regulated at the boiler to reduce the risk of scalding service users. The Registered Provider and Manager said that they had tried using individual fail safe devices on the taps to control the hot water temperature but these had not worked properly. Therefore the staff team always test the temperature of hot water when giving baths/showers to service users following advice from a health and safety consultant who said that these precautions are adequate for service users’ safety. The Registered Manager confirmed that restrictors are fitted to all windows above the ground floor and the windows inspected did have restrictors fitted. Discussions with staff, as well as training records, confirmed that all staff are expected to attend training in health and safety, emergency first aid, food hygiene and fire safety. Pre-inspection documentation and discussions with the Registered Manager confirmed that comprehensive safety checks have been carried out including gas appliances, electrical equipment, hoists and lifts. All accidents and incidents are documented at the time of the event. Two Trees DS0000003510.V290520.R01.S.doc Version 5.2 Page 22 Two Trees DS0000003510.V290520.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 X 2 3 3 3 4 3 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 4 26 3 27 4 28 3 29 4 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 X LIFESTYLES Standard No Score 11 3 12 4 13 3 14 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 3 3 3 3 X 4 3 X Two Trees DS0000003510.V290520.R01.S.doc Version 5.2 Page 24 Are there any outstanding requirements from the last inspection? No STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. Standard Regulation Requirement Timescale for action RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Two Trees DS0000003510.V290520.R01.S.doc Version 5.2 Page 25 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 Two Trees DS0000003510.V290520.R01.S.doc Version 5.2 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. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!