Inspection on 17/01/08 for 11 Tarragon Gardens

This inspection was carried out on 17th January 2008.

CSCI found this care home to be providing an Adequate service.

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 4 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

11 Tarragon Gardens 15/01/09

11 Tarragon Gardens 31/08/06

11 Tarragon Gardens 16/03/06

11 Tarragon Gardens 28/09/05

11 Tarragon Gardens 02/02/05

11 Tarragon Gardens 07/07/04

Similar services:

Tanglewood

88 Church Lane

Harmony Care Home

Olivet Christadelphian Care Homes

Sayer House

Beacon Centre For The Blind

60 Olive Lane

Bryndale Avenue, 41 Flats 13, 14 & 18

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

CARE HOME ADULTS 18-65 Tarragon Gardens, 11 Frankley Birmingham West Midlands B31 5HU Lead Inspector Gerard Hammond Key Unannounced Inspection 17th January 2008 09:30 Tarragon Gardens, 11 DS0000017165.V358542.R01.S.doc Version 5.2 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Tarragon Gardens, 11 DS0000017165.V358542.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Tarragon Gardens, 11 DS0000017165.V358542.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Tarragon Gardens, 11 Address Frankley Birmingham West Midlands B31 5HU 0121 411 2133 0121 411 2133 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) RNID Miss Clare Booth Care Home 4 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (4), Sensory impairment (4) of places Tarragon Gardens, 11 DS0000017165.V358542.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. Residents must be aged under 65 years The primary care needs of all service users will be that of Sensory Impairment. 7th February 2003 Date of last inspection Brief Description of the Service: 11 Tarragon Gardens is registered to provide accommodation, care and support for four people with sensory impairment. The service is run by the Royal National Institute for the Deaf and the premises owned by Nehemiah Housing Association. The house is in a modern terrace, with the main accommodation on the ground floor. Above this are two flats, accessed independently via separate front doors either side of the main entrance to number 11. One flat is occupied by a person using the service, and the other is used for staff sleep-in accommodation and by residents for activities and meetings. The accommodation would not be suitable for wheelchair users. In the main house there are three single bedrooms with en-suite shower facilities, an open plan living / dining area, a separate kitchen and also a separate shower room / w.c. The resident’s flat has a bedroom, living room, kitchen (with washer / drier) and bathroom. At the rear of the property is a secure private garden. There is car parking space at the front of the house. The Home is situated in the Frankley area of Birmingham, close to Northfield shopping area. Local amenities such as cinema, bowling alley, gym and restaurants can also be easily accessed at nearby Rubery Great Park. The area is well served by public transport. Information about current fees should be obtained directly from the service provider. Tarragon Gardens, 11 DS0000017165.V358542.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 1 star. This means the people who use this service experience adequate quality outcomes. Information was gathered from a range of sources to inform the judgements made in this report. An Annual Quality Assurance Assessment (AQAA) for the service was completed and returned as required. A visit was made to the home and the inspector saw two of the three residents. It was not possible to seek their views directly on this occasion due to their communication support needs. The Manager and three members of staff were interviewed. A number of records were examined: these included residents’ satisfaction surveys, personal files, care plans, staff records, service reports and safety records. Thanks are due to the residents, Manager and staff for their co-operation and support throughout the inspection process. What the service does well: What has improved since the last inspection? Significant work has been done since the last inspection to meet requirements made and to try and improve the service. Clear efforts have been made to improve people’s personal files by tidying them up and using the same format, so that important information is easier to find. Clearer guidance is now available to staff on exactly when PRN (“as required”) medicines should be given. Staff have had more training, to help them support residents and do their jobs better. A better training and development plan for staff is now in place, so that it is easier to plan and meet future training needs. Some matters Tarragon Gardens, 11 DS0000017165.V358542.R01.S.doc Version 5.2 Page 6 relating to health and safety that needed attention have been dealt with: Fire evacuation drills have been done, the freezer temperature has been monitored regularly, and the COSHH store maintained securely. What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Tarragon Gardens, 11 DS0000017165.V358542.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Tarragon Gardens, 11 DS0000017165.V358542.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1&2 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. People’s needs are assessed, so that it is clear what support is required and what people want. Information is available to help people make up their minds about whether or not the service is right for them, but this should include details of fees, so people know what costs they are responsible for. EVIDENCE: There have been no admissions to the home since the last inspection and there is currently one vacancy. The Manager advised that a referral for this had been received and was being processed. As reported at the time of the last inspection, it is important that prospective new service users get the opportunity to visit and see what the home has to offer before making a decision about placement, following an appropriate assessment of their support needs and wishes. The personal files of the existing residents were sampled and all had current assessments in place. A Statement of Purpose and a Service Users’ Guide are available, providing information about the service and what is provided. It was noted that these do not include information about the amount of fees chargeable. Tarragon Gardens, 11 DS0000017165.V358542.R01.S.doc Version 5.2 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7, 8 & 9 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. People’s care plans have improved, reflecting their needs and personal goals. More work needs to be done to keep these properly under review, so that people get the support they need and achieve their objectives. People are consulted and helped to make choices, but it is still not easy to see how some decisions have been made. Record keeping continues to need improvement so that there is clear evidence that decisions have been made appropriately. EVIDENCE: Residents’ personal files were sample checked. It is clear that good work has been done in tidying files and organising them uniformly, so that information is easier to find than previously. Support plans have been developed and there is evidence of the use of some person-centred approaches. As well as information about people’s personal history and their regular preferred routines, plans contain sections “things I need to learn about”, things I need to be able to do better” and “how I will achieve my goals”. More work needs to Tarragon Gardens, 11 DS0000017165.V358542.R01.S.doc Version 5.2 Page 10 be done in helping people to set realistic, achievable goals that can be measured. These should be evaluated when the plan is reviewed. Care staff complete a monthly summary: this is a good practice that helps to ensure that people’s support needs can be kept under constant review and plans updated as necessary. One person’s file contained minutes of a formal review, but didn’t show who had taken part. Another person’s plan was signed to show that it had been reviewed six months after it had been written, but there was no further record of this (e.g. minutes etc.). Part of the whole rationale for reviewing plans should be to make judgements about whether or not they are working. This should include an evaluation of the goals set, backed by evidence of what has been achieved, where appropriate. The monthly summary report provides an excellent opportunity to “keep on top of this” by maintaining a focus on set targets and looking specifically at what has been done, and it is recommended that these reports are used more constructively to achieve this. It has to be acknowledged that residents stating their goals is one thing, and getting them to take responsibility for their actions in achieving them is something else. Staff report that this is a real problem and that self-motivation is a significant issue for the people who use this service. (See next section Lifestyle also.) That is why it important to set achievable goals and keep full records to support proper evaluation – for example, recording when an activity scheduled in support of an agreed goal is offered but declined. This should provide valuable information about when, why and how goals are being met or not, as the case may be. As previously reported, direct observations provided evidence of residents being given the opportunity to do things around the house and also to go out into the community, but recording of this still needs to be improved. It is hoped that the increase in the use of person-centred approaches will move this forward, but all staff need to understand the importance of good record keeping in showing clearly how decisions have been made. Files sampled had risk assessments in place as previously required, and it was good to note that these were appropriately indexed, making important information more readily available. Tarragon Gardens, 11 DS0000017165.V358542.R01.S.doc Version 5.2 Page 11 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, 15, 16 & 17 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. People have opportunities to do things they want, but poor record keeping makes it difficult to make a properly informed judgement about the quality of their activity opportunities. They are helped to stay in contact with family and friends so that they are able to keep in touch with people important to them. Residents are able to be directly involved in buying and preparing their food, so that they can enjoy their meals and have a balanced diet. EVIDENCE: The last inspection report showed that people were supported to pursue valued activities and access the community on a regular basis. They were attending structured activities at local centres and colleges, and doing tasks designed to foster personal independence and self-help skills such as shopping and cooking. They also went to the cinema and used local pubs, cafes and restaurants and accessed a local club for people who are deaf. Staff reported that this continues to be the case and that people are able to choose what Tarragon Gardens, 11 DS0000017165.V358542.R01.S.doc Version 5.2 Page 12 they want to do on a daily basis. One resident was observed requesting staff support to go out shopping, and she went out for most of the day, returning later in the afternoon. Other residents were offered the opportunity of going out, but declined. A summary of responses to a questionnaire (satisfaction survey undertaken by residents with staff support) showed that two people said their activities were “very good” while the other person said they were “good”. One said, “would like to go out more”. Staff reported that residents agree readily to try different things when asked, but when it comes to actually doing things they frequently refuse. As reported above, self-motivation appears to be a significant issue. Sampling of personal files revealed that daily recording showing the activity opportunities that people enjoy is very limited. It is difficult to make informed judgements about the quality of life that people enjoy without this information. There should be clear links between people’s activities and their agreed personal goals. The information about what people have been able to do, and opportunities offered but declined, is essential when it comes to reviewing their plans and evaluating their goals. All members of staff have a personal responsibility to ensure that daily records are sufficiently detailed to inform this process appropriately. In many cases it is suggested that it should be possible to use the task of writing individuals’ daily diaries as a specific planned activity involving the person directly. This would be much more “person-centred” and could give the residents a sense of ownership and empowerment. People are able to keep in touch with their family members and other people who are important to them. One resident has a particular friendship with someone who used to live at the home, and they visit each other regularly. She called to the house on the day of the inspection visit. The record of meals taken provided evidence of choice, variety and a sufficiently balanced and nutritious diet. Residents are involved in the grocery shopping and are supported each day to make their breakfasts and lunches. Staff usually prepare the main evening meal, and the small size of the home means that different choices can be catered for easily. In response to the satisfaction survey, all three residents said the food was “very good”. Food stocks were examined: these were ample and included fresh fruit and vegetables. Tarragon Gardens, 11 DS0000017165.V358542.R01.S.doc Version 5.2 Page 13 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18,19 & 20 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People are supported in ways that suit them so that their assessed needs are appropriately met. Their physical and healthcare needs are generally met, to help them stay healthy and well, though there may be opportunities to improve this further. Residents get the support they need to make sure they get their medicine in the right amounts and at the right time. EVIDENCE: Direct observations of interactions between residents and staff showed support being given in a respectful manner. Both appear to get on well and seem to be at ease in each other’s company. Staff were observed supporting communication with signing, in accordance with people’s assessed needs. People’s clothing and personal grooming provided further evidence that they receive a good standard of basic personal care and support. One person continues to need particular support with personal hygiene. The en-suite facilities in his bedroom are scheduled for a major refit in the near future and it is hoped that this will make a significant difference to this support. Tarragon Gardens, 11 DS0000017165.V358542.R01.S.doc Version 5.2 Page 14 Sampling of personal files showed that residents are assisted to access primary and specialist healthcare support, including GP, Consultant Psychiatrist, Community Nurse, Optician, Dentist, and Chiropodist. Files also contained charts to show that residents’ weights are monitored regularly. As noted at the time of the last inspection, records contained a section for Health Action Plans. These appear to have remained in the assessment stage and not to have been developed further, as previously recommended. As with general care planning, health action plans should include specific goals that can be measured. The focus should be proactive planning rather than reactive responses to problems as they arise. It is suggested that plans might (for example) show individuals’ target weights and include specific goals for doing regular exercise of each person’s choosing (e.g. walk for 30 minutes 3 times per week). When the plan is reviewed, these can be evaluated and proper judgements made about what is working or what might need changing. Some of these things are already going on (e.g. one person likes to go the gym): these are things to build on. It was suggested that one person who has a clear interest in working with bikes (attending a workshop regularly each week) might be encouraged to develop this by also riding his bike to get the benefits of the exercise, and hopefully a good deal of enjoyment too. Health action planning should be about actively seeking out ways to support people to maintain and to improve their general health and well being, and to do this systematically. The Medication Administration Record (MAR) was examined and had been completed appropriately. The home operates a system of “double signing” for all medication given to residents, so as to minimise the risk of administration errors. The medication file and individuals’ personal records contained information about prescribed medicines, copy prescriptions, sample signatures, protocols for PRN (“as required”) medication and reports each occasion administered. A recent audit by the dispensing Pharmacist found no issues for concern. The medication store was clean and tidy, and secure. Tarragon Gardens, 11 DS0000017165.V358542.R01.S.doc Version 5.2 Page 15 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22 & 23 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are happy to raise any issues they are concerned about, and feel confident that these will be listened to and taken seriously EVIDENCE: An appropriate complaints policy and procedure is in place. All of the residents’ personal files contain a copy, and a record that a staff member has discussed this with them. The complaints file was also examined. Correspondence related to a resident who no longer lives at the home, but showed that issues raised had been dealt with and responded to appropriately. There have been no other complaints received since the last inspection. Previous observations in the home have shown that this group of residents know how to complain, and are comfortable raising any matters of concern. They also have access to an independent advocate specifically appointed to support people with hearing impairment. The person previously fulfilling that role has moved on, and residents are now getting to know her replacement. The written response to the Annual Quality Assurance Assessment shows that all staff have received adult protection training: conversations with staff on duty showed that they were aware of the relevant issues and knew what action to take in the event of discovering or suspecting that residents were being abused. Previous problems have shown that correct procedures are understood and have been followed when required. Tarragon Gardens, 11 DS0000017165.V358542.R01.S.doc Version 5.2 Page 16 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 25, 26, 27, 28 & 30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents live in a house that is homely, comfortable and safe but has some shortfalls: shared spaces are inadequate and options for bathing are limited. The home is generally clean and tidy and acceptable standards of hygiene maintained. EVIDENCE: A tour of the premises was completed. People living in the main house each have a single room with en-suite toilet and shower facilities. The rooms downstairs were seen and were individually styled and decorated, reflecting the needs and wishes of the occupants. Personal possessions and effects were much in evidence. The person living in the upstairs flat has a bedroom, living room, bathroom and kitchen to herself. This was not seen on this occasion, as the resident concerned was out for most of the day. As previously reported, options for communal space elsewhere are somewhat limited, due to the open plan design of the main house. The bedrooms are situated directly off the Tarragon Gardens, 11 DS0000017165.V358542.R01.S.doc Version 5.2 Page 17 lounge / dining room area. There are no other rooms in this part of the house to receive visitors or have a private conversation, other than in the office or individuals’ bedrooms. The other upstairs flat is technically available for residents’ use, but involves going outside the front door in order to access this. Residents have to do this if they want to take a bath, as there are only shower facilities in the main house. This flat is also used by staff on sleep-in duty, and since the last inspection the Manager has established an office up there also. Concerns have also been expressed about the suitability of the neighbourhood for meeting the needs of vulnerable adults, and there have been a number of problems with local youths since the last inspection visit. The Manager reported that the local police have been involved and that matters had improved more recently. A senior manager in the organisation advised that a number of options for relocating the service are still under consideration. Previous inspection reports have referred to the particular difficulties encountered by staff in supporting one resident with his personal hygiene, and the impact this has had on the rest of the house. This has continued to be problematic and it was noted that this person’s en-suite facility has deteriorated significantly, despite the best efforts of the care team to support him appropriately. The Manager advised that funding had been agreed to completely refit this room with more appropriate facilities, but that she had had unexpected problems engaging workmen to take on the job. She said that this had now been resolved and that the upgrade should be completed in the very near future. Since the last inspection the lounge area has been redecorated and the garden has been landscaped and generally improved. Staff continue to try hard and support residents to make the house comfortable and homely: on the day of the inspection visit it was clean and tidy. Tarragon Gardens, 11 DS0000017165.V358542.R01.S.doc Version 5.2 Page 18 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34, 35, & 36 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. A number of improvements are needed in this area to fully ensure that residents are cared for by a properly qualified and well-supported team of staff. EVIDENCE: Four staff files were sample checked: all contained a completed application and two written references. All but one (CH) contained evidence of required checks with the Criminal Records Bureau. Recruitment is dealt with from a central location in this organisation, and the Manager reported that she had requested the necessary documentation from the Head Office following advice that appropriate clearance had been obtained. It is essential that required documentation is available for inspection at all times. The written response to the Annual Quality Assurance Assessment (AQAA) did not show the number of members of the current staff team holding qualifications at NVQ level 2 or above. This was discussed with the Manager who advised that three of the current staff team were actually qualified, and the remainder were due to enrol but that this would not occur before Tarragon Gardens, 11 DS0000017165.V358542.R01.S.doc Version 5.2 Page 19 September 2008. This falls well short of the 50 target required by National Minimum Standards. However, it should be acknowledged that there have been some improvements to staff training since the last inspection. The training plan showed that all staff have completed food hygiene, fire safety and manual handling training during 2007. All staff have also done adult protection, first aid, medication, health and safety, deaf awareness and mental health training, though it was noted that refreshers are due in some cases. Four of the team have qualifications in sign language, and the Manager advised that all others are currently working towards accreditation in CACDP / BSL (British Sign Language). She also said that two members of staff (and herself) had done a course in person-centred planning and that the organisation was now looking to identify staff to take on the role of facilitator, in order to develop this further. The Manager also advised that there are currently two vacant posts on the staff team, one full time (maternity leave) and one part-time (18.75 hours): these are being covered by regular relief staff and by other members of the team doing extra hours, so as to keep the need for agency cover down to a minimum and promote continuity of care. She also reported that staff meetings generally take place each month: minutes were available for five meetings in the past year. All staff had their annual performance appraisal in April 2007. Sampling of staff files showed that formal supervision of staff continues to be below the National Minimum Standard (six times in any twelve-month period, pro-rata for part-time staff). The Manager said that this was due in part to the fact that a senior member of staff with supervisory responsibilities had been on sick leave for several months. Staff interviewed said that they had supervision regularly, and generally felt well supported. Tarragon Gardens, 11 DS0000017165.V358542.R01.S.doc Version 5.2 Page 20 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 38, 39 & 42 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home is being run to an acceptable standard, but there is room for improvement. A new Manager should be recruited to ensure continuity of care for residents. Some more work is needed to show how people’s views are guiding how the service is developed for their benefit. Important checks on equipment in the home must be done at the proper times, to make sure that people living and working there stay safe. EVIDENCE: The Registered Manager holds a recognised nursing qualification (RNMH) and is still working towards gaining the Registered Manager’s Award (RMA). Staff interviewed said that she is approachable and that they felt comfortable raising any matters of concern directly with her. During the course of the inspection Tarragon Gardens, 11 DS0000017165.V358542.R01.S.doc Version 5.2 Page 21 visit, the Manager said that she had given notice and would be leaving shortly to take up a new post. This was subsequently discussed with the Regional Service Manager who said that he was seeking an interim arrangement and that he intends to second an experienced Manager from another home in the organisation to cover while a replacement is recruited. The Manager said that visits on behalf of the Registered Provider required under Regulation 26 (Care Homes Regulations 2001) were generally done each month. Visits are themed around specific National Minimum Standards, so that all the Standards can be covered across a twelve-month cycle. Reports for the preceding year were not all available, and the Manager said that those received did not always arrive in time for action deadlines to be met. Copies of satisfaction surveys completed with residents were seen during the inspection visit. Unfortunately, responses to written surveys completed with the support of the residents’ independent advocate were not received in time for comments to be included in this report. Quality assurance needs continuing development so that clear evidence for the desired outcome for this standard (“Service users are confident their views underpin all self-monitoring, review and development by the home”) can be seen. The introduction of more person-centred approaches and the identification of clear agreed goals for each resident should help in this. Sampling of safety records showed that servicing of fire-fighting equipment is due. It was noted that there were a number of gaps in the record for testing the fire alarm and emergency lighting systems. Two fire drills have been carried out in the past twelve months and there are evacuation plans in place for all residents. The COSHH store was secure. Tarragon Gardens, 11 DS0000017165.V358542.R01.S.doc Version 5.2 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 2 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 3 23 3 ENVIRONMENT Standard No Score 24 3 25 3 26 2 27 2 28 3 29 X 30 3 STAFFING Standard No Score 31 X 32 2 33 3 34 2 35 2 36 2 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 2 3 3 X LIFESTYLES Standard No Score 11 X 12 2 13 2 14 2 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 2 3 2 X X 2 x Tarragon Gardens, 11 DS0000017165.V358542.R01.S.doc Version 5.2 Page 23 Are there any outstanding requirements from the last inspection? YES 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 YA34 Regulation 19Sch 2&4(6) 18(2) Requirement Provide confirmation that CRB clearance has been obtained in respect of staff member CH Ensure that members of staff are formally supervised at least six times in any twelve month period (pro rata for part-time staff) Outstanding since 30/11/06 The Registered Provider must ensure that unannounced monthly visits for the purpose of monitoring service quality in the home are carried out, and written reports of these visits available for inspection in the home. Ensure that essential checks and maintenance of equipment in the home is carried out, to ensure the health and safety of people living and working there. Timescale for action 29/02/08 2 YA36 31/03/08 3. YA39 26 31/03/08 4. YA42 13(4c) 31/03/08 Tarragon Gardens, 11 DS0000017165.V358542.R01.S.doc Version 5.2 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. 1. 2. Refer to Standard YA1 YA6 Good Practice Recommendations Include clear information in the Service Users’ Guide about the amount of fees payable, so that all parties are clear about their responsibilities. Develop the use of person-centred approaches in care planning and management, so that plans include individuals’ agreed, clear and measurable goals. Evaluate goals set, and keep these under review. Make sure that recording of activities is sufficiently detailed to show clear links to individuals’ plans and agreed goals, and including activities offered but declined. Further develop Health Action Plans to build on existing initial assessments: set goals with measurable outcomes. Take action to increase the number of staff holding or working towards qualification at NVQ level 2 or above. 3. 4. 5. YA13 YA19 YA35 Tarragon Gardens, 11 DS0000017165.V358542.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection Worcester Local Office Commission for Social Care Inspection The Coach House John Comyn Drive Perdiswell Park, Droitwich Road Worcester WR3 7NW National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. 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