Inspection on 13/12/05 for Talbot Woods Lodge

This inspection was carried out on 13th 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 no outstanding requirements from the previous inspection report, but made 1 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Talbot Woods Lodge 31/08/06

Talbot Woods Lodge 27/02/06

Talbot Woods Lodge 02/02/05

Talbot Woods Lodge 25/08/04

Talbot Woods Lodge 29/03/04

Similar services:

2 Perhaver Park

The Vicarage

St George`s

5 Seafield Road

Credence House

Radfords

Honeybourne House

32 Beaumont Way

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

CARE HOME ADULTS 18-65 Talbot Woods Lodge 64 Wimborne Road Talbot Woods Bournemouth Dorset BH3 7AR Lead Inspector Heidi Banks Unannounced Inspection 10:30 13 December 2005 th Talbot Woods Lodge DS0000003991.V270635.R01.S.doc Version 5.0 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 Woods Lodge DS0000003991.V270635.R01.S.doc Version 5.0 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 Woods Lodge DS0000003991.V270635.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Talbot Woods Lodge Address 64 Wimborne Road Talbot Woods Bournemouth Dorset BH3 7AR 01202 293390 01202 297817 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 John Colley Mrs Nicola Gail Colley Care Home 14 Category(ies) of Learning disability (14) registration, with number of places Talbot Woods Lodge DS0000003991.V270635.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. One named service user aged 17 years (as known to the NCSC) may be accommodated to receive care. 2nd February 2005 Date of last inspection Brief Description of the Service: Talbot Woods Lodge is a residential care home registered to accommodate a maximum of fourteen adults with a learning disability. The property is in keeping with the neighbourhood and there is ample space for parking at the front of the house. The home has easy access to a bus route which serves the centres of Bournemouth and Winton. Residents have access to a minibus for trips out in the community and are supported to attend health appointments as appropriate by staff. There are thirteen permanent residents at the home at the present time with the remaining one bedroom used to provide respite care for a number of different people with learning disabilities. Bedrooms are single occupancy. Eleven bedrooms are situated upstairs and three are situated downstairs. There are three bathrooms and two toilets for shared use by residents. The home also has a large lounge, dining room and a separate sun lounge / games room. The garden to the rear of the property has been thoughtfully landscaped and provides a further area for use by residents. The home also provides day care for a maximum of five non-residents each day. Talbot Woods Lodge DS0000003991.V270635.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection was unannounced and took place over the course of approximately 8.5 hours on a weekday. The inspection was part of the normal routine of inspecting the service twice a year. The inspector was assisted by the Registered Provider, Mrs Nicola Colley, for most of the inspection but also had the opportunity to talk with two other members of the staff team during the day. There are thirteen permanent residents living at the home at the present time. The age range of the residents is currently between 25 and 67. At the time of the inspection there was one service user accessing the home for respite. On the inspector’s arrival the majority of the service users were not at the premises as they were attending day services elsewhere. There were four service users present at Talbot Woods Lodge accessing their day service provision. The other residents returned to Talbot Woods Lodge from their day services at around 1600 hrs. Information for this report was obtained from discussion with staff, observation of staff interaction with service users, brief conversations with two service users, inspection of service user records and staff records and a guided tour of the premises. What the service does well: Service users’ welfare and independence are promoted by the risk assessment process within the home which details the support needed by service users to lead an ordinary lifestyle. Service users are encouraged to be part of their community, accessing leisure centres, libraries and other amenities in the local area to pursue their interests and develop friendships. Supporting service users with activities is seen as part of the role of Care Assistants working at the home and a range of home-based activities, including hand massage and karaoke, are offered to service users. Service users’ needs, likes and dislikes form the basis of the support that is given to them and staff know where to access this information so that service users are supported in a way that they prefer. Service users are able to access appropriate health care services to ensure that their needs are met including their GP, specialist nursing services, chiropody and audiology. Talbot Woods Lodge DS0000003991.V270635.R01.S.doc Version 5.0 Page 6 There is a commitment to staff training within the home with staff receiving basic and specialist training to meet service users’ needs. Service users benefit from an experienced and well-qualified manager. What has improved since the last inspection? What they could do better: As a result of this inspection one requirement and five recommendations have been made. Recruitment practices were noted not to meet legislative requirements and an immediate requirement has been made to ensure that staff do not commence duties until appropriate information has been obtained including two written references and appropriate checks with the Criminal Records Bureau. This will help ensure the protection of residents. Individual plans for service users should be in format that can be understood by them so that they are aware of the support they will receive and why. Contributors to the Plan, including service users, need to ‘sign up’ to the Plan to indicate their agreement. Bedroom doors are locked when service users are not in them. The majority of service users would need to approach staff for their keys if they wish to gain access to their rooms on their return from the day service. This practice needs to be reviewed regularly, on an individual basis, with the involvement of the service user, their family / advocate and multi-agency team as appropriate to ensure that the independence of service users to access their bedrooms as they wish is promoted. Following a recent adult protection incident where procedures were not followed by staff, the registered provider should ensure that adult protection training is robust enough to ensure that all staff who have completed the training understand the action to be taken if an incident occurs. This will help ensure that service users are fully protected at all times. Although bi-monthly staff meetings are in place, a formal system of individual staff supervision should be implemented to ensure that staff receive the individual support and guidance they need to carry out their work with service users. In the registered provider’s absence from the home, an incident occurred that was not responded to appropriately until the return of the manager from leave two days later. The registered provider should ensure that a member of staff who is given responsibility for the running of the home in the registered Talbot Woods Lodge DS0000003991.V270635.R01.S.doc Version 5.0 Page 7 provider’s absence has the knowledge and skills to do so. This will promote the welfare and protection of service users within the home at all times. 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 Woods Lodge DS0000003991.V270635.R01.S.doc Version 5.0 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 Woods Lodge DS0000003991.V270635.R01.S.doc Version 5.0 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): Not assessed on this occasion. EVIDENCE: Talbot Woods Lodge DS0000003991.V270635.R01.S.doc Version 5.0 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): 6 and 9 Service users may not always know what care and support is provided to them and why as individual Plans are not in formats that are accessible to them. Risk assessments are in place for individual service users and detail the support required by an individual to promote their independence and community participation. EVIDENCE: From a sample of service user records examined it was evident that every service user has an individual care plan (called an ABC Care Plan) which covers aspects of personal and social support required by the individual to meet their needs. Staff working at the home confirmed that they had access to these Plans in the office but also that an individual’s care plan was attached to the inside of their wardrobe and could be referred to during the personal care of a service user. Staff sign to indicate that they have read and understand the care plan for each service user. The ABC Care Plans are currently hand written and not in a format that is accessible to service users. It was noted that in two of the three Care Plans examined the Plan had only been signed by the staff member by whom it was compiled and not all the Plans examined were observed to be dated. Talbot Woods Lodge DS0000003991.V270635.R01.S.doc Version 5.0 Page 11 Work is in progress to develop Essential Lifestyle Plans for every service user living at the home. These will be in a format accessible to service users. There was evidence to support that the registered provider was making contact with significant people in the service user’s life to ensure that the Essential Lifestyle Plan accurately reflects changing needs and personal goals. There was evidence on file to demonstrate that service user reviews take place on a regular basis. It was positive to note that service user participation in the review process is promoted with the home supporting service users to complete a satisfaction questionnaire prior to the review to gain information and feedback about the service that is being provided. Minutes of reviews are kept in service user files but in one file sampled the minutes had not been signed by contributors or dated. Review minutes are not produced in a format accessible to service users. There was evidence on individual service user files to support that community activities are risk assessed and actions to be taken to minimise risk are detailed. The registered provider confirmed that manual handling risk assessments were reviewed on a regular basis for individual service users. Talbot Woods Lodge DS0000003991.V270635.R01.S.doc Version 5.0 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): 13, 14 and 16 Service users are encouraged to access community based activities which offer them a sense of belonging and enable them to pursue their interests and develop friendships. Service users have opportunities to engage in leisure activities within the home that interest them and enable them to occupy their time in a meaningful way. Service users’ rights and responsibilities are generally recognised by the home but the practice of locking all bedroom doors should be reviewed to ensure that the independence of individuals is promoted. EVIDENCE: The majority of service users at Talbot Woods Lodge access day services in the local community. Four service users access day support provided by Talbot Woods Lodge. The registered provider confirmed that there are two service users who occasionally opt to access the day support provided at the home rather than attend their usual day service and this is accommodated where possible to take account of their personal choice. There was evidence that the home maintains good communication with residents’ day services and there Talbot Woods Lodge DS0000003991.V270635.R01.S.doc Version 5.0 Page 13 was evidence that the registered provider liaises with Social Services where there is an unmet need. The registered provider confirmed that the home aims to be communityfocused in the provision of activities. The home has a minibus that service users can use. A range of community-based activities is offered to service users including attendance at a local Special Olympics Club, visits to the pub, library, cinema and leisure centres. At the time of the inspection, service users present during the day were going swimming. There is a programme in place providing evening and weekend activities at the home. The registered provider confirmed that these included hand massage, hair and beauty evenings and karaoke as well as community-based activities. Colourful photographs around the home and in the service user guide show service users engaged in a range of self-help and community activities. It was evident from information discussed at the shift ‘changeover’ that provision of evening activities is recognised as part of the role of the Care Assistant. It was noted that a programme of group activities on display in the hallway was from January – July 2005 and had not been updated to include the second half of the year. Observation of staff interactions with service users and discussion with staff on duty demonstrated that service users’ rights and responsibilities are recognised and service users are treated with respect. Service users have free access to the office and were able to approach the registered provider with any queries they had. During a guided tour of the home, the inspector queried why bedroom doors were locked during the day. The registered provider stated that if bedroom doors were left unlocked at all times there would be a few service users who would gain access to others’ rooms and this would cause distress. The registered provider reported that all service users are issued with a key which they store in the office for safekeeping. Service users will take their key when they wish to gain access to their bedrooms. At weekends there are two service users who generally keep their keys on their person and access their rooms as they wish. The inspector queried whether all service users would be able to ask for their key or access the office if they wanted to go to their bedrooms – the registered provider stated that it was generally apparent from an individual’s body language whether they wanted to go to their bedrooms. Talbot Woods Lodge DS0000003991.V270635.R01.S.doc Version 5.0 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 and 19 Personal support is offered to service users in a way that promotes their privacy, dignity and independence. Service users are supported to access generic and specialist health care services to meet their individual physical and emotional needs. EVIDENCE: Copies of individual Plans were examined and these showed that attention is paid to how individuals prefer to be supported and the level of support that is required by the individual. Discussion with a new member of staff about their role in supporting service users demonstrated an awareness of the need to promote independence and enable service users to do as much as possible for themselves. The member of staff was able to explain how she would obtain information relating to an individual’s needs and preferences, for example, by reading written care plans, asking the service user themselves and through discussion with a more experienced member of staff. The service user records sampled showed that each service user has been issued with a Personal Health Record booklet. A record of health appointments is maintained by staff and showed that service users have been supported to attend their GP, hospital outpatients’ department, chiropody, audiology and specialist nursing services as appropriate in order to maintain good health. Talbot Woods Lodge DS0000003991.V270635.R01.S.doc Version 5.0 Page 15 Individual Plans reflected the needs of service users in relation to diabetes and epilepsy and there was evidence to support that training has been given to staff on specific health issues to promote awareness. Records of service users’ current weight were observed to be up to date. The weight loss of one service user was explored with the registered provider who gave an account of the reasons for the weight loss and how this was being addressed by the home in conjunction with the multi-agency team. Another service user’s weight records showed weight gain – this had been addressed in the individual’s care plan with reference to focusing on healthier options and the need for regular exercise. The registered provider confirmed that information is shared with health care professionals as appropriate. Daily records are maintained for each service user by the home and were noted to be up to date and written in good detail, providing information about each service user’s day, their health, activities and needs. Talbot Woods Lodge DS0000003991.V270635.R01.S.doc Version 5.0 Page 16 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 23 Systems are in place at the home to protect service users from abuse, neglect and self-harm. However, adult protection training should be robust enough to ensure that all staff who have completed the training understand the action to be taken if an incident occurs. This will ensure that the welfare of service users is protected. EVIDENCE: The registered provider stated that the home uses the multi-agency policy and guidelines ‘No Secrets’ as their policy for the protection of vulnerable adults. The home has a ‘Whistleblowing Policy’ which gives examples of potential malpractice and guidance for staff on reporting this. A recent Adult Protection issue arising at the home demonstrated that staff had not responded to an incident effectively at the time of occurrence and not followed procedures in place around the reporting of incidents. This meant that there was a two day delay in the reporting of an incident to appropriate bodies. A new member of staff interviewed by the inspector demonstrated that she was aware of her responsibility to report abuse if witnessed and stated that if she were concerned she would speak to the registered provider. Training certificates in Abuse Awareness were available on file for staff members and the subject seen to be part of an individual’s training plan. Staff training and development meetings occur bi-monthly but it was noted that abuse awareness had not been included in the list of topics covered during 2005. It was particularly encouraging to note that service users are also encouraged to access Abuse Awareness training. Talbot Woods Lodge DS0000003991.V270635.R01.S.doc Version 5.0 Page 17 A copy of the home’s complaints procedure, in symbols format, and contact details for the Commission for Social Care Inspection were on display in the entrance of the home. Talbot Woods Lodge DS0000003991.V270635.R01.S.doc Version 5.0 Page 18 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): Not assessed on this occasion. EVIDENCE: Talbot Woods Lodge DS0000003991.V270635.R01.S.doc Version 5.0 Page 19 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 34, 35 and 36 The home’s recruitment procedures are not sufficiently robust to ensure that service users are fully protected. Staff are able to access relevant training in order to be able to meet the individual and collective needs of service users. There are systems in place to provide support for staff including bi-monthly staff meetings. However there is no formal arrangement for regular individual supervision of staff working within the home to monitor individuals’ performance and provide individual support and guidance around care given to service users. EVIDENCE: Three staff files were examined during this inspection. The first file showed that only one written reference had been obtained for a member of staff who had been employed at the home for two months. The registered provider confirmed that a verbal reference had been taken up but there was no documentation available to evidence this. The registered provider stated that she was awaiting the return of the staff member’s disclosure application from the Criminal Records Bureau (CRB) and confirmed that a POVAFirst check had been completed. However, there was no documentation available on file to demonstrate that a POVAFirst check had Talbot Woods Lodge DS0000003991.V270635.R01.S.doc Version 5.0 Page 20 been carried out. The registered provider confirmed that the member of staff had not been fully supervised at all times during a shift pending receipt of a satisfactory CRB check. The second file examined had no evidence of a CRB check or POVAFirst check. The registered provider stated that a police check had been done in the individual’s country of origin (a copy of this was on file). The registered provider was informed that this was not adequate or in line with current legislative requirements. The third staff file examined had two written references from his most recent employer and a satisfactory CRB disclosure. However, there was no proof of identity held on file. The registered provider expressed concern that two other staff recruited from overseas via an employment agency had certificates of criminal record from their country of origin but did not have CRB or POVAFirst checks. The registered provider was informed that this did not meet current legislative requirements. Training records for three members of staff were examined. These demonstrated that each member of staff has an individual training plan. A typical training plan includes induction training, service user specific training (for example, training in diabetes, epilepsy, effective communication and sensory loss) and training around manual handling, fire prevention, food hygiene, abuse, Breakaway, medication administration and health and safety. Much of the training at the home is delivered via training videos and workbooks. The registered provider confirmed that every three years mandatory training facilitated by an external provider takes place at the home for all staff in moving and handling, infection control, food hygiene, emergency first aid, health and safety and risk assessment. The training videos and workbook packages in these subjects are used as an interim measure for staff who join the team at mid-points during the three year cycle. A member of staff interviewed during the inspection stated that she had found the training offered to her informative and that she was looking forward to undertaking further training in the New Year including NVQ. The registered provider stated her commitment to offering training opportunities to staff and reported that willingness to undertake training is part of the selection criteria in recruiting new staff. The home’s training provision has been accredited by ‘Investors in People’ which the registered provider stated is due for renewal in 2006. The registered provider holds bi-monthly staff meetings at the home which incorporate a training and development element. The 2005 programme included training on oral hygiene, foot hygiene, diabetes, epilepsy, total communication, fire training and sensory loss. Talbot Woods Lodge DS0000003991.V270635.R01.S.doc Version 5.0 Page 21 A member of staff interviewed, who was still on her induction period, reported that she had felt well supported by the registered provider and staff team since commencing employment and had been enabled to work alongside more experienced staff to gain a knowledge of the service user group. She felt that the manager was accessible and stated that she would have no difficulty in approaching either the manager or a senior member of staff for support or advice. The registered provider stated that there was no formal arrangement in place to provide individual supervision for staff. The home holds bi-monthly staff meetings which residents are also invited to attend. The registered provider reported that if staff had any issues they wished to discuss with her on an individual basis they could write their name down on a list at the end of the staff meeting and arrangements would be made for 1:1 supervision on an ad hoc basis. Talbot Woods Lodge DS0000003991.V270635.R01.S.doc Version 5.0 Page 22 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 and 43 The experience and qualifications of the registered provider benefits service users. There needs to be competent and accountable management of the service in place when the registered provider is absent from the home so that the welfare of residents is protected at all times. EVIDENCE: The registered provider is qualified to NVQ 4 level and is experienced in her management role. Following a recent incident where procedures were not followed by staff on duty when the registered provider was absent from the home, measures should be put in place to ensure the safe and effective management of the service in her absence. Talbot Woods Lodge DS0000003991.V270635.R01.S.doc Version 5.0 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score X X X X X Standard No 22 23 Score X 2 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 2 X X 3 X Standard No 24 25 26 27 28 29 30 STAFFING Score X X X X X X X LIFESTYLES Standard No Score 11 X 12 X 13 3 14 3 15 X 16 2 17 Standard No 31 32 33 34 35 36 Score X X X 1 3 2 CONDUCT AND MANAGEMENT OF THE HOME X PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Talbot Woods Lodge Score 3 3 X X Standard No 37 38 39 40 41 42 43 Score 3 X X X X X 2 DS0000003991.V270635.R01.S.doc Version 5.0 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 It is required that the home is in receipt of two written references and satisfactory POVA / Criminal Records Bureau checks before staff commence duties. Staff files must contain information and documents as defined in Schedule 2 of the Care Homes Regulations. Timescale for action 1 YA34 19 14/12/05 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 YA6 Good Practice Recommendations Individual Plans should be available in a format that service users can understand. The involvement of the service user, family members, friends and/or advocates and other agencies in formulating individual Plans should be indicated by them signing up to the plan. Service users’ rights should be recognised by ensuring that restrictions such as the practice of locking bedroom doors are agreed in the individual Plan and Contract with the involvement of the service user, their family / advocate and other agencies as appropriate. DS0000003991.V270635.R01.S.doc Version 5.0 Page 25 1 2 YA16 Talbot Woods Lodge 3 4 YA23 YA36 5 YA43 Adult protection training should be robust enough to ensure that all staff who have completed the training understand the action to be taken if an incident occurs. The registered provider should ensure that all staff receive individual supervision, which is recorded, at least six times a year. The registered provider should ensure that a member of staff who is given responsibility for the running of the home in her absence has the knowledge and skills to do so. Talbot Woods Lodge DS0000003991.V270635.R01.S.doc Version 5.0 Page 26 Commission for Social Care Inspection Poole Office Unit 4 New Fields Business Park Stinsford Road Poole BH17 0NF 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 Talbot Woods Lodge DS0000003991.V270635.R01.S.doc Version 5.0 Page 27 - 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. 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