Inspection on 30/12/05 for Talbot Court

This inspection was carried out on 30th December 2005.

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

The inspector found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 19 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Talbot Court 04/09/07

Talbot Court 15/01/07

Talbot Court 10/05/06

Talbot Court 22/02/05

Talbot Court 22/06/04

Talbot Court 03/03/04

Similar services:

Polesworth Group Friary Road

Polesworth Group Pooley Heights

Polesworth Group 32 Station Road

Aston Court Nursing Home

Polesworth Group 70 Long Street

Breme

Ravenhurst

Polesworth Group 64 Long Street

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

CARE HOME ADULTS 18-65 Talbot Court 1-3 Jervoise Street West Bromwich West Midlands B70 9LU Lead Inspector Mr Patrick Wright Unannounced Inspection 30th December 2005 11:30 Talbot Court DS0000004780.V275709.R01.S.doc Version 5.1 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 Talbot Court DS0000004780.V275709.R01.S.doc Version 5.1 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. Talbot Court DS0000004780.V275709.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Talbot Court Address 1-3 Jervoise Street West Bromwich West Midlands B70 9LU 0121 525 3508 0121 525 3508 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) Milbury Care Services Limited Mrs Emma Doran Care Home 10 Category(ies) of Learning disability (10), Physical disability (10) registration, with number of places Talbot Court DS0000004780.V275709.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. Service users to include up to 10 PD and up to 10 LD Date of last inspection 25/8/05 Brief Description of the Service: Talbot Court is a purpose built bungalow that originally operated as two units, each for five service users. More recently the unit has been operating as one, with the occupants of the home sharing a communal lounge and separate dining area. Internally the two areas are linked. The home provides nursing care for up to ten people with learning and physical disabilities. The unit also offers kitchen, laundry and bathing facilities. The bathrooms have been adapted to offer sensory stimulation. The bungalow comprises of ten single rooms in total, three of which offer an en-suite shower facility. An adapted minibus is available, at an extra cost. This is charged in addition to the weekly fees with the intention of enabling service users to access wider community facilities. Talbot Court DS0000004780.V275709.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was conducted by two inspectors from the Commission for Social Care Inspection, and was a statutory unannounced inspection. The purpose was to assess progress and compliance in meeting the National Minimum Standards and towards addressing issues identified as needing attention at previous inspection visits. A range of inspection methods was used to make judgements and obtain evidence, which included a tour of the premises, including some of the service users bedrooms. Other inspection methods used included introductions with some of the service users, discussion with the Deputy Manager, and a number of records and documents were also examined. The inspection was conducted with the full co-operation of the Registered Manager, staff and service users. The discussion and atmosphere throughout the inspection was constructive and those involved interacted positively as part of the process. Service users were at home during the inspection, but formal interviews were not appropriate. Therefore the inspectors relied upon observations of body language, eye contact, gestures, responses and other observations of interaction between staff and service users. Service users appeared relaxed and comfortable in their surroundings. There are ten service users currently living at Talbot Court. There has been one admission to the home since the last inspection. Based on the information available to the inspectors at the time of this visit, the service is showing signs of improvement and there are indicators of some stability and continuity of care. As at the last inspection, it is acknowledged that there is evidence of progress in areas, which have previously been identified as shortfalls. It is expected that improvements continue to be made and the management can evidence further advancements and innovation at the home to reach minimum standards. Where progress has been made on the previous requirements, these will continue to be outstanding until evidence is produced at future inspections or until fully met. What the service does well: The Registered Manager is working productively with the local Community (Learning Disabilities) Team and all of the service users needs are being reassessed through reviewing the care packages in place. Some evidence of individual preferences was available through examination of a sample of service users files and discussion with staff and Management. Talbot Court DS0000004780.V275709.R01.S.doc Version 5.1 Page 6 Some staff were also observed to consult with service users when making decisions. Daily life at Talbot Court is reasonably flexible in terms of general routines of daily living. Service users at this home are offered a good choice of meals from a balanced menu, which recognises individual preferences. The communal premises are comfortable and homely. The home offers furniture and fittings, which are domestic in style and comfortable. The staff duty rota was examined and showed that the home continues to meet its minimum staffing requirements. The Registered Manager is experienced and qualified to run the home and meet its stated aims and objectives. What has improved since the last inspection? What they could do better: Talbot Court DS0000004780.V275709.R01.S.doc Version 5.1 Page 7 The Registered Manager is hindered and staff morale restricted, by some of the organisations systems and processes. Issues around securing training and progress with regard to improving parts of the premises, affect the overall service delivery and impact on some safe working practices. There are some issues that need attention with regard to general maintenance, décor, food hygiene/safety and infection control. The Registered Manager is aware of the maintenance jobs and redecoration issues. Staff require training updates or initial instruction, to ensure all of the staff team are appropriately trained and the service benefits from a planned training and development programme. The organisations training plan has not progressed recently and shortfalls have been identified are in the provision of staff training development opportunities. The Registered Manager must continue to ensure that vacant carers posts are actively recruited to and shortfalls in staffing provision are addressed as soon as practically possible. The home must continue to demonstrate how individual choices are made, and instances when others make decisions. The home must ensure that structured activity/plans are implemented for all of the service users and demonstrate that other opportunities for day care and education have been explored. Through a shortfall in assessment documents and record keeping it is not possible to confirm that personal support is received in the way service users wish. Care staff should be made aware of the value placed on the content of the records being produced and evaluated, as part of their role. The Registered Manager must ensure that staff understand their own and other’s roles and responsibilities. The company must evidence an effective system for quality assurance is in place at this home, in which standards and indicators to be achieved are clearly defined and monitored on a continuous basis. The Registered Manager should involve the service users and staff at Talbot Court in the quality assurance process and explore ways and methods of demonstrating the quality of service is appropriate. 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. Talbot Court DS0000004780.V275709.R01.S.doc Version 5.1 Page 8 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 Talbot Court DS0000004780.V275709.R01.S.doc Version 5.1 Page 9 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 the following standard(s): 3 Current records, documentation and practice do not demonstrate the home is meeting the needs of the people who live there. However, there has been headway since the last inspection. EVIDENCE: Based on the information available to the inspector at the time of this visit, (i.e. the content and quality of records and documentation, plus observations and discussion of practice issues) it is not possible to evidence that services offered are fully meeting the needs of the people who live there. However, there is an acknowledgement by the inspector that improvements have been made. The Registered Manager is working productively with the local Community (Learning Disabilities) Team and all of the service users needs are in the process of being reassessed through reviewing the care packages in place. This should assist the Registered Manager, who is aware of the need to demonstrate the homes capacity to meet the assessed needs (including specialist needs) of individuals living at the home. In addition, improvements noted in care planning and risk management and in continuity of care are favourable. Unfortunately, the Registered Manager is hindered and staff morale restricted, by other obstacles. Issues around securing training and progress with regard to improving the premises affect the overall service delivery and impact on some safe working practices Requirements from previous inspections were also monitored. Where applicable, these will remain outstanding until fully met. Talbot Court DS0000004780.V275709.R01.S.doc Version 5.1 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7 The home is not able to demonstrate how individual choices have been made and where applicable, why others make these decisions. However, support is being given to staff and service users to help progress with this issue. EVIDENCE: Some evidence of individual preferences was available through examination of a sample of service users files and discussion with staff and Management. Some staff were also observed to consult with service users when making decisions. Records kept on file provided some indication, although limited, that service users are consulted with and are involved in the assessment process. Where appropriate, relatives are also part of the assessment process. The home must continue to demonstrate how individual choices are made, and instances when others make decisions. Key-workers should support service users in achieving the individual’s personal aims. The Registered Manager is advised that the care staff should be made aware of the value placed on the content of the records being produced and evaluated, as part of their role. Talbot Court DS0000004780.V275709.R01.S.doc Version 5.1 Page 11 The Registered Manager is not an agent or appointee for any of the service users. The home manages and holds in safekeeping personal allowances for all of the service users. The Registered Manager also has access to the funds of service users on their behalf when required. This is monitored by internal audits from Milbury, with support provided by the Appointee-ship unit of Sandwell MBC and assistance from the Community (Learning Disability) Teams. Information is available at the home, with regard to independent advocacy services. Requirements from previous inspections were also monitored. Where applicable, these will remain outstanding until fully met. Talbot Court DS0000004780.V275709.R01.S.doc Version 5.1 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 16 and 17 The home is pressing ahead with helping service users find out about and take up opportunities, for further education and training. Daily life at Talbot Court is reasonably flexible in terms of general routines of daily living. However, the home must continue to evidence that daily routines promote individual choice and recognise service users rights and responsibilities. Service users at this home are offered a good choice of meals from a balanced menu, which recognises individual preferences. EVIDENCE: Service users at Talbot Court do not currently utilise any external day care facilities or educational establishments. All of the service users remain at home during the day. Educational activities are arranged by care staff. The Registered Manager discussed how the home has begun working with the Open College Programme/Network and seven of the service users have enrolled and are currently participating in the programme. One of the service users is Talbot Court DS0000004780.V275709.R01.S.doc Version 5.1 Page 13 shortly visiting a `supported` college with a view to commencing an educational programme of her choice. The home must ensure that structured activity/plans are implemented for all of the service users and demonstrate that other opportunities for day care and education have been explored. Records of consultation and outcomes should be available and opportunities for service users at the home to take part in valued and fulfilling activities should be in place. Observations and discussions with staff and management identified there has been some improvement in that routines are more flexible to suit the needs of individual service users. There is some flexibility in terms of leisure and social activities, food and meal times and general routines of daily living. Service users likes and dislikes are being identified, and are spoken to using a preferred term of address. Service users privacy and dignity, was observed to be respected with regards to personal care, entering toilets and bathrooms. Service users bedrooms can offer privacy locks. The home must continue to evidence and demonstrate that service users rights are respected. Service users are offered three meals a day, plus drinks/supper. Meals are taken from a four-week rotational menu that offers a varied and balanced diet. A choice of meal is recorded for breakfast and lunch, but not for teatime. A pictorial menu is being designed to assist some of the service users. Others can make their preferences known either verbally or otherwise. The Deputy Manager told the inspector that an alternative is available, and that the menu is not strictly adhered to and is used as a guideline. Alternatives accepted by service users are recorded. Service users are not generally involved in meal preparation, although opportunities can be managed as requested. Service users identified as having specific dietary or religious/cultural needs are offered a choice of meal. Portion sizes are not consistently documented. Menus state the specific requirements of the resident and indicate that a choice is offered at each meal. There were some gaps in the recording of foods accepted by those on special diets. Nutritional risk assessments have been conducted for each service user. Food stocks were good and included a range of fresh, frozen and non-perishable items. Fridge and freezer temperatures are being recorded appropriately. Requirements from previous inspections were also monitored. Where applicable, these will remain outstanding until fully met. Talbot Court DS0000004780.V275709.R01.S.doc Version 5.1 Page 14 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18 The home is attempting to demonstrate how personal support routines are provided flexibly and are enabled/encouraged to exercise control over such matters. Through a shortfall in assessment documents and record keeping it is not possible to confirm that personal support is received in the way service users wish. EVIDENCE: Through records, observations and discussions with Management, it was identified that the service is trying to ensure that personal support is provided which ensures that principles of privacy, dignity and independence are adhered to. Service users can within reason get up/go to bed when they choose, withdraw to their room for privacy, choose their own clothing, etc. Registered Nurses deliver all of the nursing care within the home, and other specialists are utilised as needed. For example one of the service users has been referred to a Diabetic nurse specialist through the home liaising with the community nurse and GP. The home operates key worker system, and through the stability being offered by having a permanent qualified staff group, the named nurse structure will compliment the overall process. Service users were said to receive personal care/support in the way they prefer/require, although this may not be fully evident from the personal records being maintained. Talbot Court DS0000004780.V275709.R01.S.doc Version 5.1 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 the following standard(s): N/A EVIDENCE: No standards from this section were assessed at this inspection. Talbot Court DS0000004780.V275709.R01.S.doc Version 5.1 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 the following standard(s): 24, 30 The premises are comfortable and homely, but there are some issues that need attention with regard to general maintenance, décor, food hygiene/safety and infection control. EVIDENCE: At this inspection the home appeared more organised and presentable whilst retaining a homely atmosphere. The home offers furniture and fittings, which are domestic in style and comfortable. The home offers an attractive sensory/relaxation bathroom that the Registered Manager said she hoped to develop further with funds from the Open College Programme. The Registered Manager is aware of the maintenance jobs and redecoration issues. She is advised to include these in correspondence with the provider. A programme of redecoration/refurbishment was included in a previous action plan from the `Millbury`. However there are a number of issues that remain outstanding or currently require attention. For example, within the food preparation area one of the worktops is damaged, the extractor fan was dirty and the florescent light cover contained dust and dead insects, the flooring is not being cleaned properly and is harbouring dirt around the skirting board, two drawer units are broken, one door unit is broken, the dishwasher was not Talbot Court DS0000004780.V275709.R01.S.doc Version 5.1 Page 17 working and had not been in use since for over a week, and one of the oven doors was broken. The overall condition of the fitted kitchen is poor. Some of the service users bedrooms were viewed with the individuals consent. Rooms were attractive and had been personalised by the occupants. Two of the rooms had badly stained carpets that need attention or replacing. The corridor carpet is also stained. The rear garden has been cleared and made accessible. Handrails have been fitted to assist service users. A cupboard and damaged fridge/freezer need to be removed from the garden. The laundry equipment has been relocated from two small areas to one large room. Two washing machines that provide appropriate sluicing facilities are installed. One was broken and had been for over a week. The condition of the rest of the room is not conducive to good infection control measures being practiced. It is required that the laundry floor finishes must be impermeable and these and wall finishes need to be readily cleanable. In addition, the location of the designated hand-washing sink in this area should be made clear, the paper towel dispenser moved nearer to the sink and it is recommended that a hand-washing poster and laundry procedures are displayed. A range of floor mops were noticed to be drying in this room. These should be left drying inverted not in buckets. One of the staff told the inspector that they were washed in the machine after each time they are used. However this has little consequence if staff are not aware of the temperatures the mops need to be washed at. One member of staff told the inspector the temperature that the mops were washed at was in “reasonably hot water”. This area should have a stock of disposable gloves and aprons available, rather than being stored in a cupboard in the adjacent corridor. The use of a communal plastic jug (stored in the bathroom) for rinsing service users hair when bathing should cease. It is proposed to relocate the medication/treatment room to a larger space within the home. The inspector was told this is due to be completed by 31st January 2006. The existing area where medication is stored does not provide a hand-washing sink. This will be required should the above timescale not be met by the provider. Requirements from previous inspections were also monitored. Where applicable, these will remain outstanding until fully met. Talbot Court DS0000004780.V275709.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32,33 and 35 The number of staff currently trained to at least NVQ level 2 trained staff will not meet the proposed target set by the Commission for Social Care Inspection and `Skills for Care`. The home has a `core` group of experienced staff to support the service users and the use of agency workers has decreased. Staff will require training updates or initial instruction, to ensure all of the staff team are appropriately trained and the service benefits from a planned development programme. EVIDENCE: Five of the sixteen support workers have achieved an NVQ 2, with a further three carers having enrolled for training and one carer due to commence the award in July 2006. Two members of staff have been enabled to access Learning Disability Award Framework (LDAF) training. The staff duty rota was examined and showed that the home continues to meet its minimum staffing requirements. The Registered Manager told the inspector that the use of agency staff increased over the Christmas period but this has since been reduced. Overall the use of agency staff has decreased. Existing part time and bank staff are covering shortfalls in the staffing rota. This should be monitored closely to ensure staff are not working excessively Talbot Court DS0000004780.V275709.R01.S.doc Version 5.1 Page 19 long hours or shifts without adequate breaks. At the time of this inspection the home had vacancies for five whole time equivalent care staff, with one full time post having been offered to an applicant who was awaiting clearances. Registered Nurses for people with Learning Disabilities, Mental Health problems and General Nurses provide the day-to-day nursing care within the home. One part time, (15 hrs) post remains vacant. However a suitable person, (a Registered Nurse -Learning Disability), has been recruited and is awaiting clearances. The home operates at staffing levels of one qualified nurse and six support workers, (including one senior support worker) during wakeful hours, and one qualified nurse and two support workers during the night time. These staffing levels are the minimum the home must operate at. The Registered Manager is advised of the need to monitor and adjust staffing levels, as needed, to ensure the needs of service users are being met. A new position has been created for an `activity co-ordinator`. The hours of employment for this post (35 hrs per week) are included in the overall allocated care hours for the home. Whilst this initiative and the creation of such a position is supported, the role of the post-holder should be clarified. The hours of work for the `activity co-ordinator` cannot be included in the care staffing ratios if the post is solely for the purpose of activities and recreational pursuits. The organisations training plan has not progressed recently and shortfalls have been identified are in the provision of staff training development opportunities. For example, seven staff need of training and direction in Basic Food Hygiene, ten staff in Health and Safety and seven staff in First Aid. Thirteen of the staff require training in Adult Abuse Awareness. This was raised with the Registered Manager and Associate Regional Director, who was present for part of the inspection. By the end of this visit it was encouraging to note, that two separate training days had been arranged in January 2006 for all of the staff team in the subject of Abuse Awareness. In addition, six staff have been nominated to attend Adult Protection training with Sandwell MBC in February 2006. Training in Infection Control is also needed and staff should be enabled to access the Learning Disability Award Framework accredited training, (LDAF). Other staff will shortly require training updates, or initial instruction, to ensure the staff team are appropriately trained and the service benefits from a well trained and supported workforce. Talbot Court DS0000004780.V275709.R01.S.doc Version 5.1 Page 20 The Registered Manager has reviewed the imminent mandatory training needs of the staff team and produced an updated matrix. The Registered Manager was advised to ensure night workers are enabled to attend relevant training, in particular fire safety awareness/drills. Each of the staff should have a training needs analysis conducted through a system of appraisal. This will ensure the Registered Manager has sufficient information to inform the homes Training and Development plan and ultimately the organisations training department. The revised induction system for new staff is provided through an in house system that is referenced to the `Skills for Care` induction standards. Requirements from previous inspections were also monitored. Where applicable, these will remain outstanding until fully met. Talbot Court DS0000004780.V275709.R01.S.doc Version 5.1 Page 21 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 and 42 The Registered Manager is experienced and qualified to run the home and meet its stated aims and objectives. The home operates the organisations Quality assurance system, but this needs to be strengthened within the service to ensure the outcomes for service users are reinforced. The Registered Manager is aware that as far as reasonably practicable the home must ensure the health, safety and welfare of service users and staff. However, practice issues, staff training and record keeping need to improve. EVIDENCE: The Registered Manager has appropriate qualifications and experience for the post, and undertakes periodic training and development to maintain her knowledge and skills. She is a Registered Nurse (Learning Disability) and is currently working towards the NVQ level 4/Registered Managers Award qualification. Talbot Court DS0000004780.V275709.R01.S.doc Version 5.1 Page 22 Milbury Care Services need to consider reinforcing the quality assurance policy and procedure for this care home. The company must evidence an effective system for quality assurance is in place based on the outcomes for service users, in which standards and indicators to be achieved are clearly defined and monitored on a continuous basis. The company complaints procedure is available to all service users and their representatives, and is in suitable formats. Regular reviews of care plans and systems are held, and policies and procedures are available in the practice manual. In addition, various audits take place in the establishments, for example, monthly quality audits. The Registered Manager is aware of the need to involve the service users and staff at Talbot Court in the quality assurance process, but should explore ways and methods of demonstrating the quality of service is appropriate, and include other stakeholders. The Registered Manager has produced an annual development plan for the home. This document should detail a system of planning, action and review for the establishment. It needs to reflect a self-monitoring tool that includes the Regulation 26 visits and the internal audits. The actual plan needs to incorporate other documents such as the homes aims and objectives, (subject to review), the maintenance and redecoration plan, the staff training and development plan, and details of outcomes from the quality assurance system, including any new or reviewed policies and procedures. A random sample of maintenance and service records was examined. Certification was available for routine servicing and testing etc, with the exception of the fixed electrical wiring test that had been conducted recently. The Registered Manager told the inspector that it appeared the certification for this issue had not yet been issued to the home from the Milbury head office. The temperature readings of cooked food are not being consistently monitored/recorded and the food probe is not being calibrated according to relevant guidance. The staff could not locate a written Food Hazard Analysis and the cleaning schedule for the kitchen was not being completed. Overall there are a number of issues with regard to safe working practices that raise concerns about the service, as detailed in the various sections of this report. For example, staff training in safe working practice issues, (food hygiene, infection control etc), and associated routines in the home, in addition to deficiencies about the premises. It is recommended that the home is enabled to access and use e-mail and web site facilities to assist with communication and researching current good practice and guidance. Requirements from previous inspections were also monitored. Where applicable, these will remain outstanding until fully met. Talbot Court DS0000004780.V275709.R01.S.doc Version 5.1 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 X 3 2 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 X 23 X ENVIRONMENT Standard No Score 24 2 25 X 26 X 27 X 28 X 29 X 30 2 STAFFING Standard No Score 31 X 32 2 33 2 34 X 35 1 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score X 2 X X X LIFESTYLES Standard No Score 11 X 12 2 13 X 14 X 15 X 16 2 17 2 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 2 X X X 3 X 2 X X 1 X Talbot Court DS0000004780.V275709.R01.S.doc Version 5.1 Page 24 Yes 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 YA2 Regulation 14 Requirement A system of reviewing the service users needs assessments must be implemented. (Previous timescale of 31/10/05 partly met) The registered person must demonstrate the home’s capacity to meet the assessed needs (including specialist needs) of individuals admitted to the home.(Previous timescale of 30/11/05 partly met) • Ensure that Service User plans cover all areas of identified need through a process of assessment, and are reviewed at last six monthly. The home should continue to implement a system of Person Centred Planning, or similar, such as Essential Lifestyle Planning. • Attempts should be made to produce care plans in different formats suitable for service users, and DS0000004780.V275709.R01.S.doc Timescale for action 31/03/06 2 YA3 14 31/03/06 3 YA6 15 31/03/06 Talbot Court Version 5.1 Page 25 4 YA7 12,14 5 YA12 12,15,16 6 YA13YA41 16,17 7 YA14 15,16 8 YA16 12,14 evidence that service users/their representatives have been involved in the production (Previous timescale of 30/11/05 partly met) The home must demonstrate how individual choices are made by service users and instances when others make decisions. The home must ensure that structured activity/plans are in place for the service user group, and demonstrate that opportunities for day care and education have been explored (Previous timescale of 30/11/05 partly met). • To ensure that service users are provided with opportunities for social inclusion, participate in the community, and documented evidence is available. • Daily notes should evidence the social activities provided. (Previous timescale of 30/11/05 partly met). The range and availability of leisure activities provided, should through effective care planning and consultation with service users, be increased and records kept of the same. The Manager needs to ensure that all service users activities are monitored and fully evaluated. (Previous timescale of 30/11/05 partly met). The home must evidence and demonstrate that service users rights are respected and routines are flexible to suit the needs of individual service DS0000004780.V275709.R01.S.doc 30/06/06 31/03/06 31/03/06 31/03/06 30/06/06 Talbot Court Version 5.1 Page 26 users. 9 YA17 16 With regard to Meals and menus at the home: • A choice of meal should be offered/recorded for the tea-time meal. • A pictorial menu should be implemented and utilised to assist service users to make an informed choice. • Portion sizes must be consistently documented and ensuring there are no gaps in the recording of foods provided for those on special diets. The home must demonstrate how personal support is provided flexibly and are service users are enabled/encouraged to exercise control over lives. The Registered Manager must evidence an audit trail for the provision of healthcare, including recording service users weight, and the provision of pressure sore and nutritional risk management. (Previous timescale of 30/12/05 partly met). • All of the environmental and premises issues identified in the sections of this report as needing attention must be addressed, (i.e. general maintenance, décor, food safety/kitchen and infection control/laundry room. • A detailed plan of action for each issue with dates for completion should be submitted to the Commission for Social Care Inspection by DS0000004780.V275709.R01.S.doc 31/03/06 10 YA18 12,14 30/06/06 11 YA19 12,13 31/03/06 12 YA24YA30 13, 23 30/06/06 Talbot Court Version 5.1 Page 27 7/2/06. 13 YA31 18 The Registered Manager must 31/03/06 ensure that staff understand their own and other’s roles and responsibilities. Staff must be aware and support the aims and values of the home, and be familiar with the standards of conduct and practice set by the General Social Care Council `Code of Conduct`. (Previous timescale of 30/11/05 partly met). To ensure that vacant carers 30/06/06 posts are actively recruited to and shortfalls in staffing provision are addressed as soon as practically possible. (Previous timescale of 30/11/05 partly met). 30/06/06 • To ensure that induction provided at the home (within 6 weeks of commencement) and foundation training (within 6 months of commencement) is delivered, and is in accordance with guidance issued by `Skills for Care` and includes all safe working practice topics. • To ensure that all new staff are registered on a `Learning Disability Award Framework` accredited training course. (Previous timescale of 30/11/05 partly met). • The Registered Manager must submit an updated staff training and development plan to the Commission for Social Care Inspection, by7/2/06 for all DS0000004780.V275709.R01.S.doc Version 5.1 Page 28 14 YA33 18 15 YA35 18,19 Talbot Court 16 YA39 17 YA42 mandatory and foundation training commensurate with staff duties. This must clearly identify programmed dates of training for completion. 24 • The company must evidence an effective system for quality assurance is in place in which standards and indicators to be achieved are clearly defined and monitored on a continuous basis. • The Registered Manager should involve the service users and staff at Talbot Court in the quality assurance process and explore ways and methods of demonstrating the quality of service is appropriate, and include other stakeholders. (Previous timescale of 30/11/05 partly met). 12,13,17,23 The Registered Manager is required to ensure the health, safety and welfare of service users and staff in relation to safe working practices, (staff training (food hygiene, infection control etc), and associated routines in the home, in addition to deficiencies noted about the premises as detailed in the report. 30/06/06 30/06/06 Talbot Court DS0000004780.V275709.R01.S.doc Version 5.1 Page 29 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 2 3 4 Refer to Standard YA32 YA37 YA39 YA41YA3 Good Practice Recommendations That the home continues to work towards meeting Sector skills workforce targets of 50 of care staff having achieved an NVQ level 2 or above. That the Registered Manager continues working towards the RMA/NVQ IV in Management (to be achieved by 30/9/07) The Registered Manager should review the annual development plan, as recommended in the report. It is recommended that the home is enabled to access and use e-mail and web site facilities to assist with communication and researching current good practice and guidance. Talbot Court DS0000004780.V275709.R01.S.doc Version 5.1 Page 30 Commission for Social Care Inspection Halesowen Record Management Unit Mucklow Office Park, West Point, Ground Floor Mucklow Hill Halesowen West Midlands B62 8DA 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. 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