Inspection on 27/02/06 for Talbot Woods Lodge

This inspection was carried out on 27th February 2006.

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 3 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 13/12/05

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 27 February 2006 09:45 th DS0000003991.V287894.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 DS0000003991.V287894.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. DS0000003991.V287894.R01.S.doc Version 5.1 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 DS0000003991.V287894.R01.S.doc Version 5.1 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. 13th December 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. DS0000003991.V287894.R01.S.doc Version 5.1 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 8.5 hours on a weekday. The lead inspector was accompanied by Christine Main, Pharmacist Inspector, for the first part of the inspection who assessed practices and procedures in the home in relation to medication. The purpose of the inspection was to assess the home’s progress in meeting an immediate requirement made at the last inspection and to assess outcomes for service users against some of the National Minimum Standards. Five recommendations were made at the last inspection in December 2005 but, in order to give the registered provider adequate time to address the issues raised, these outcomes were not inspected on this occasion. The recommendations have therefore been carried forward and will be assessed at the next inspection of the home. The inspector was assisted by the registered provider, Nicola Colley, throughout the visit. 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, a group of residents were leaving the home to attend their day service provision. Five other residents were at the home; one was due to visit her parents later that morning, three residents had medical appointments and one had chosen to attend the home’s day care provision instead of attending her usual day service. Information for this report was obtained from discussion with the registered provider and staff on duty, observation of staff interaction with residents, brief conversations with three residents and inspection of a sample of records including staff personnel files, residents’ files and some documentation relating to medication, health and safety and quality assurance. The inspector received five completed comment cards from service users, one completed comment card from a relative of a service user, two comment cards from health and social care professionals, two from Care Managers and one from a general medical practitioner, information from which is reflected in the report. Thirteen standards out of the twenty-two key standards were assessed at this inspection. What the service does well: The home works closely with Social Services to ensure that the needs of prospective residents are assessed prior to them being admitted to Talbot Woods Lodge. The home has a pre-admission questionnaire which is undertaken with prospective residents as a means of gathering information about their needs and preferences. DS0000003991.V287894.R01.S.doc Version 5.1 Page 6 Residents indicated in comment cards that they are offered suitable activities and those residents spoken to indicated that they are supported to do things that interest them. Residents are supported to maintain contact with members of their families and this is promoted by the home through the arrangement of various events during the year to which residents are able to invite their families and friends. Systems and procedures are in place to promote good practice in relation to hygiene and which help protect residents from infection. Staff are given opportunities to access accredited training that enables them to understand the needs of the service user group and gain formal qualifications in care. The home has a quality assurance process which means that the views of residents and their representatives are sought and that information obtained through this process is used to identify the strengths of the service and the areas that need improvement. What has improved since the last inspection? What they could do better: As a result of this inspection three requirements and four recommendations have been made. The registered provider must ensure that where residents have specific dietary needs or have lost weight, specialist medical advice is sought to ensure that plans put in place are approved and reviewed by a relevant practitioner. This will ensure that the resident’s health care needs are met and monitored appropriately. A requirement has been made around updates to the home’s medication policy and the monitoring of temperatures in refrigerated storage to ensure that practices fully protect residents. The registered provider needs to ensure that servicing of fire systems in the home is carried out at appropriate intervals to ensure that they are fully functioning and therefore, in the event of a fire, promote the safety of residents and staff. DS0000003991.V287894.R01.S.doc Version 5.1 Page 7 Two out of five residents indicated in their comment cards that they would like to be more involved in decision-making within the home. The home should therefore continue to explore ways in which all residents can be included in making choices about what happens in the home. A recommendation has been made in relation to expanding the complaints procedure at the home to include the reporting of concerns. This is to ensure that, where concerns are raised by residents or their visitors, they are logged and the home’s response is documented with reference to the overall outcome. This will help ensure that a person raising a concern knows that it will be given full consideration and that their degree of satisfaction with the outcome is sought and documented. The carpet on the ground floor was noted to rise in certain areas. This should be replaced or refitted to ensure that it provides a level surface and does not present a possible safety hazard to residents and their visitors. It is recommended that fire training and fire drill records are made clearer so that each member of staff has an individual training / drill record. This will enable the registered provider to document that all staff have received the required number of training sessions and participate in an appropriate number of drills. Five further recommendations have been carried forward from the previous inspection of the home in December 2005 to give the registered provider ample time to address the issues raised at that inspection. 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. DS0000003991.V287894.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 DS0000003991.V287894.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): 2 Although there have been no admissions of new residents to the home since 2002, systems are in place to ensure that prospective residents are admitted to the home only after a full assessment of their needs has been carried out. EVIDENCE: There have been no permanent residents admitted to Talbot Woods Lodge since April 2002. The admissions procedure was discussed with the registered provider and the records of one service user examined to evidence this process. The registered provider reported that the home works closely with Care Managers regarding the admission of prospective residents. The home also has a pre-admission questionnaire which enables information about the service user’s daily activities, leisure interests, daily living skills, eating and drinking, main contacts, medication, mobility and general health to be gathered. There was evidence that this questionnaire had been completed for the most recent service user admitted. The registered provider stated that prospective residents are invited to the home for tea visits and overnight visits as part of the admissions process which gives them an opportunity to discuss their needs and aspirations with staff and meet other residents. DS0000003991.V287894.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 Residents are encouraged to be involved in decisions that affect their daily lives which means that they can have some control about the things they choose to do. However, two residents indicated in comment cards that they would like to be more involved in decision-making within the home. EVIDENCE: Discussion with staff and observation of staff interactions with residents showed that they are given opportunities to be involved in decisions about how they spend their day, the food they eat, the clothes they wear, their leisure activities, their personal relationships and holiday plans. The registered provider stated that there is some flexibility for service users who do not wish to attend their day service on occasion to access the home’s day service provision instead. The home does not hold specific service user meetings but service users are invited to attend staff meetings and be involved in discussions about the home. Two residents indicated through comment cards that they would like to be more involved in decision-making within the home. DS0000003991.V287894.R01.S.doc Version 5.1 Page 11 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 15 and 17 Residents can take part in age and peer appropriate activities which means that they have opportunities for fulfilment and achievement according to their individual abilities and needs. The home is supportive of, and sensitive towards, service users’ rights to form personal relationships and maintain links with their families so that they have their own networks of support. The menu offers sufficient flexibility to respond to the preferences of individual residents. Although the home has taken steps to respond to the needs of one individual who has experienced weight loss and has a dietary intolerance, specialist advice around nutrition had not been sought to ensure that his needs are fully met by the service. EVIDENCE: The majority of residents at Talbot Woods Lodge attend day services in the local area. Through the day service some service users are able to access adult education courses that are of interest to them. None of the residents at Talbot Woods Lodge are in paid employment or involved in voluntary work. DS0000003991.V287894.R01.S.doc Version 5.1 Page 12 Residents are encouraged to attend courses such as protecting vulnerable adults training with staff. All five residents who completed comment cards indicated that the home provided them with suitable activities. All residents at Talbot Woods Lodge have contact with members of their family or foster families. The registered provider reported that families are welcomed in the home and at certain times of the year, for example Guy Fawkes’ Night, service users invite their families and friends to come to the home for the bonfire and fireworks display. The home recently hosted a St. Valentine’s disco to which residents were given the opportunity to invite their friends. For service users who do not visit their families at Christmas, families are invited to the home for Christmas lunch. Discussion with one service user indicated that she has a boyfriend. Some residents have good friendships with each other. The registered provider stated that one service user had a bereavement which meant that she had no known living relatives. To respond to this the registered provider stated that she tried to make links with a local advocacy organisation to identify a suitable person, outside of the home, who could befriend her. The resident is reported to have developed a network of support for herself outside of the home since this time. Residents spoken to indicated that they enjoyed their meals at Talbot Woods Lodge. All five residents who completed comment cards indicated that they liked the food provided. Care workers at the home are responsible for preparing meals for service users. The registered provider confirmed that they are involved in making choices about the menu and the menu record for the previous week indicated that there is some flexibility to enable residents who do not like the meal on offer to make a different choice. Observation showed that residents are able to make choices about the content of their packed lunches. Dietary issues relating to one resident with a lactose intolerance whose records showed a loss of weight during last year were discussed. The registered provider reported that staff are serving larger portions to this individual and are liaising with the day service to ensure that they are aware of his needs with regards to nutrition. The resident is reported to have gained a small amount of weight so far this year. The issue has been discussed with the individual’s Care Manager but specialist advice from a general medical practitioner or dietician had not been sought at the time of the inspection. DS0000003991.V287894.R01.S.doc Version 5.1 Page 13 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 20 The home has systems in place for giving residents medication as prescribed but the medicines policy and monitoring of refrigerated storage need improvement to protect residents. EVIDENCE: The home has a medicines policy but some additions were recommended and guidance was provided on this. Medicines were stored securely and different doses of insulin were stored in separate containers that were well labelled for safety. The actual, rather than the maximum and minimum temperatures, of the fridge used to store medicines were monitored and recorded. The records seen were within the accepted range (2-8°C). Staff record medicines received and those provided for residents on leave but records of medicines returned for disposal were not available. Most medicines are administered from Monitored Dosage System (MDS) blister packs and the sample checked agreed with the Medicine Administration Record (MAR) charts. Others are given from original packs and the date of opening them was recorded to provide an audit trail. A check of the remaining quantity of two of these medicines agreed with the records, indicating that they were given as prescribed. The registered provider said that she regularly monitors the records but evidence of monitoring audit trails could be improved. Guidance on this was provided. DS0000003991.V287894.R01.S.doc Version 5.1 Page 14 Some staff had done a safe handling of medicines course and others a course provided by the supplying pharmacy. The home has information about service users’ medications on their records but it would be good practice to have the manufacturers’ patient information leaflets also available for reference. The residents’ general medical practitioners review some medication six monthly and the registered provider stated that others are prompted when indicated on the repeat prescription. Hospital consultants also review medication six monthly or annually and letters confirming this were seen in care files. DS0000003991.V287894.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): 22 The home’s complaints record does not include the raising of concerns and therefore may not provide a full picture of issues that are raised by service users and their relatives / representatives and details of the response by the home. EVIDENCE: A complaints procedure is in place at the home. This has been converted into symbols format to promote understanding among residents. The complaints procedure states that all complaints will be acknowledged within 24 hours and the complainant will be advised of the outcome, in writing, within 28 days. All five residents who completed comment cards indicated that they knew who to speak to if they were unhappy with their care. One relative of a resident who completed a comment card indicated that they were aware of the home’s complaints procedure. Information on the complaints procedure was seen to refer to the National Care Standards Commission and has not been updated to show contact details of the Commission for Social Care Inspection. The registered provider reported that she has not received any complaints about the service since the last inspection. It was discussed that sometimes relatives of service users may raise issues in relation to the care of their relative which, although not formal complaints, may be seen as concerns. The registered provider stated that these are responded to at the time of the issue being raised but are not documented. One relative had stated in a quality assurance questionnaire sent out by the home that the speed of response to issues raised was good but he felt that they were not always given the consideration he believed they should merit. DS0000003991.V287894.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 and 30 Repair of the carpet on the ground floor of the home is needed to ensure that it fits well and does not present a safety hazard to residents or visitors. A policy and procedures are in place to promote good hygiene in the home and protect residents from infection. EVIDENCE: The home is in keeping with properties in the neighbourhood and service users are supported to access their local community by using the home’s vehicle or by public transport. The home presents as clean and spacious. Kitchen fittings are of a non-domestic nature. There is a keypad lock at the entrance of the kitchen. The registered provider has stated that service users access the kitchen under supervision of staff to minimise risks to their safety. It was noted that the carpet in certain areas of the ground floor had risen up. The registered provider stated that this had been caused by a problem with the underlay and she is looking to replace the carpet during the course of the year. The home has an infection control policy. The registered provider stated that aprons and gloves are kept under the sinks in residents’ bedrooms and in the laundry room for use by staff when undertaking personal care tasks. Aprons for use in the kitchen are kept in the kitchen. Household substances identified DS0000003991.V287894.R01.S.doc Version 5.1 Page 17 as substances hazardous to health are stored securely in a locked cupboard in the laundry area. The registered provider discussed the procedures that are in place for disposal of waste. The washing machine has a sluice wash facility. Formal training in infection control is delivered to staff as part of a three year cycle of training. DS0000003991.V287894.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 and 34 Staff have opportunities to access training accredited by the Learning Disability Award Framework (LDAF) and NVQ training which means that they are encouraged to develop competence in their work with residents. Recruitment procedures have been made more robust to ensure that all staff employed by the home are subject to appropriate checks prior to the commencement of their employment. EVIDENCE: Training records indicated that staff are either waiting to start or working towards their NVQ qualifications. Some staff have nursing qualifications from overseas and the registered provider stated that, as such, they are exempt from NVQ qualifications. The registered provider stated that all staff undertake training accredited by the Learning Disability Award Framework (LDAF) as part of their induction training at the home which offers staff an introduction to aspects of supporting people with learning disabilities. In response to an immediate requirement made at the last inspection the registered provider stated that she has taken prompt action to ensure that appropriate checks with the Criminal Records Bureau had been completed for all staff working at Talbot Woods Lodge. A sample of three staff files were inspected. All showed proof of identity, two written references and evidence of an enhanced disclosure from the Criminal Records Bureau. Evidence of work DS0000003991.V287894.R01.S.doc Version 5.1 Page 19 and residence permits were seen to be on file for those requiring this documentation to be employed in the United Kingdom. One individual’s residence permit was seen to be out of date but on request, the home was able to provide evidence of an official letter from the relevant government department which confirmed receipt of an application for extension of the permit prior to its expiry. Telephone advice from the government department concerned was obtained to confirm that this evidence was satisfactory pending receipt of renewal of the residence permit. DS0000003991.V287894.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 39 and 42 Consultation with service users and their families / representatives takes place on a regular basis to promote their involvement in the review and development of the home. Fire alarm servicing had not taken place at an appropriate interval to ensure that the system was fully functional and the safety of residents was fully protected. Records for fire training and drills were not sufficiently clear to readily identify that all staff had participated in the required number of training sessions and drills to ensure their competence and effectiveness in the event of a fire. EVIDENCE: The home’s quality assurance record showed that the registered provider has sent out questionnaires to visitors to Talbot Woods Lodge on an annual basis. Outcomes from questionnaires sent out in April 2005 and January 2006 were seen. Outcomes looked at as part of the questionnaire included quality of care, friendliness of the staff, cleanliness of the home, response to telephone calls, the home’s décor, amenities, food provision and general impressions. In DS0000003991.V287894.R01.S.doc Version 5.1 Page 21 general, responses appeared to have been received from families of residents, and showed ratings as being ‘good’ or ‘excellent’ in all categories. The registered provider confirmed that information from the questionnaires is collated and feedback from the process is sent out to families. The registered provider stated that she ensures that individual comments, which may be raised by individuals as part of this process, are responded to. There was evidence on file that a query about staff training raised by one relative had been responded to in writing. The registered provider stated that consultation with residents takes place informally so that service users’ views on issues such as holidays, activities and menu choices are incorporated into the daily routine of the home. Residents are invited to staff meetings so that they can be involved in discussions about the home and its development. The registered provider stated that some residents are keen to be involved in decision-making within the home and will often advocate for other residents who find it more difficult to express their views. The registered provider stated that she is planning to implement a selfassessment process within the home using a self-audit tool as part of the overall quality assurance process. The home’s fire records were inspected. Records showed that the premises were inspected by Dorset Fire and Rescue Service the previous week and that, at this time, the existing fire precautions were being satisfactorily maintained. Records indicated that weekly fire point checks and monthly checks of emergency lighting and fire extinguishers are undertaken by staff. Servicing of the alarm system and emergency lighting is carried out by a fire safety company but records showed that quarterly servicing of the alarm system had not been carried out between June and December 2005. Records of fire drills and training are maintained, the most recent drill at the home having taken place on 12th February 2006. Fire training at the home takes place every four months at staff meetings and comprises two different training videos. Records are kept of who attended each session but it was difficult to check from the records whether each staff member has undertaken the required number of training sessions and drills to ensure their competent and effective response in the event of a fire. The registered provider stated that she ensures that staff who miss a planned fire training session are given the training at another time. It is therefore recommended that individual fire training records are kept for staff so that it is easier to identify that all staff have participated in the required number of training sessions and drills. Training in moving and handling, first aid, food hygiene and infection control is delivered by an external training provider as part of a three year cycle of training within the home. Evidence that training sessions have been arranged in each subject area during 2006 was seen on the office notice board. DS0000003991.V287894.R01.S.doc Version 5.1 Page 22 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 X 2 3 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 2 23 X ENVIRONMENT Standard No Score 24 2 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 3 35 X 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 3 13 X 14 X 15 3 16 X 17 2 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score X X 2 X X X 3 X X 2 X DS0000003991.V287894.R01.S.doc Version 5.1 Page 23 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 The registered provider must ensure that appropriate specialist advice is sought and implemented for a resident who has lost weight and who also has a dietary intolerance. Records must be kept, in sufficient detail, to record the food that is prepared for him to meet his needs and his actual intake. The registered provider shall make arrangements for the recording, handling, safekeeping, safe administration and disposal of medicines received into the care home including: a) Updating the medicines policy with the recommended additions. b) Monitoring and recording the maximum and minimum temperatures of the refrigerator used to store medicines daily (usual range 2-8°C). The registered provider must ensure that servicing of fire systems and equipment are carried out at appropriate intervals. Timescale for action 1. YA17 12 17(2) 30/04/06 2. YA20 13(2) 30/05/06 3. YA42 23 30/04/06 DS0000003991.V287894.R01.S.doc Version 5.1 Page 24 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 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. This recommendation was made at the previous inspection but was not assessed on this occasion. The home should continue to explore ways of involving residents in decision-making processes within the home so that all residents feel that they are included. 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. This recommendation was made at the previous inspection but was not assessed on this occasion. The complaints process and record at the home should be expanded to include the reporting of concerns by service users and their visitors. 4. YA22 Records should be maintained to detail the home’s response to any issues raised and the overall outcome for the service user or his representative to ensure that they are fully satisfied with the action that has been taken. 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 recommendation was made at the previous inspection but was not assessed on this occasion. The carpet on the ground floor of the home should be replaced or re-fitted to ensure that it is does not rise up in places and does not present a possible safety hazard to residents and their visitors. The registered provider should ensure that all staff receive individual supervision, which is recorded, at least six times a year. DS0000003991.V287894.R01.S.doc Version 5.1 Page 25 1. YA6 2. YA7 3. YA16 5. YA23 6. YA24 7. YA36 8. YA42 9. YA43 This recommendation was made at the previous inspection but was not assessed on this occasion. The registered provider should have a fire training / drill record for each individual member of staff. This should set out the training sessions attended and drills in which they participated to ensure that each staff member participates in the required number of training sessions and drills each 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. This recommendation was made at the previous inspection but was not assessed on this occasion. DS0000003991.V287894.R01.S.doc Version 5.1 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 DS0000003991.V287894.R01.S.doc Version 5.1 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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