Inspection on 28/09/05 for 11 Tarragon Gardens

This inspection was carried out on 28th September 2005.

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

The inspector found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 16 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 17/01/08

11 Tarragon Gardens 31/08/06

11 Tarragon Gardens 16/03/06

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 Announced Inspection 28th September 2005 10.30 Tarragon Gardens, 11 DS0000017165.V256761.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 Tarragon Gardens, 11 DS0000017165.V256761.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. Tarragon Gardens, 11 DS0000017165.V256761.R01.S.doc Version 5.0 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 Sensory impairment (4) registration, with number of places Tarragon Gardens, 11 DS0000017165.V256761.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. Residents must be aged under 65 years Date of last inspection 2nd February 2005 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. 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. Tarragon Gardens, 11 DS0000017165.V256761.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. For part of this announced inspection visit, the Inspector was supported by an Interpreter, Andrew Kenny. One resident was out for most of the day: the three remaining were offered the opportunity of an informal interview. Two declined, one accepted. Direct observation and sampling of records (including personal files, care plans and safety records) were used for the purposes of compiling this report. The Registered Manager was not on duty on the day of the visit. The Senior Care Officer leading the shift, and two other staff members were interviewed informally and a tour of the premises completed. Since the inspection visit, a meeting has taken place with the Head of National Specialist Mental Health Services for RNID. It should be acknowledged that 11 Tarragon Gardens forms an integral part of an evolving network of specialist services for people with hearing impairment and mental health support needs. In order to place this report in an appropriate context, it is recommended that further information be sought directly from the Registered Provider, so that proposed and actual developments can be properly understood. What the service does well: The staff team give support in a warm and friendly way, and treat people living in the house with respect. All communication is supported appropriately with signing. Residents are encouraged to be independent, and to do as much for themselves as they are able. Responsible risk taking is also viewed positively, as an integral part of learning and maintaining independence skills. Routines are not rigid, and staff try to be flexible in the ways in which support is given. Residents’ rights are respected. People are supported to attend appointments in order to meet their health needs. Staff encourage residents to follow a healthy lifestyle, promoting a nutritious balanced diet and regular exercise. Individuals are encouraged to take part in activities of their choosing, and to access facilities in the community. Most people are supported appropriately to keep in touch with their families and friends. The staff team tries hard to make the house a welcoming homely place for people to live in and to make the best of the space available. Tarragon Gardens, 11 DS0000017165.V256761.R01.S.doc Version 5.0 Page 6 What has improved since the last inspection? What they could do better: Information about the nature of the service being provided should be made more specific, particularly about how people’s mental health support needs can be met. Care plans need to be developed, so that guidance on how people are supported is detailed and clear. Plans should also specifically address people’s wishes and aspirations and include their goals. Goals should be able to be measured, so that people can tell if they have been achieved or not. Each person’s whole care plan should be reviewed at least every six months. Some thought should be given to the purpose of the activities that people do. Recording of activities should include this, and be more detailed, so that proper judgements can be made about whether activity opportunities are actually meeting individuals’ needs. One resident needs help in maintaining or developing his social network, and another in accepting his responsibilities to keep his room in a hygienic condition. Medication administration recording needs to be accurate and complete at all times. A clear plan should be drawn up to address the shortcomings of the home environment or to relocate the service. Formal staff supervision and some elements of record keeping need to be improved. Tarragon Gardens, 11 DS0000017165.V256761.R01.S.doc Version 5.0 Page 7 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. Tarragon Gardens, 11 DS0000017165.V256761.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 Tarragon Gardens, 11 DS0000017165.V256761.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): 1, 2, 3 Information currently available is not sufficient to enable prospective residents to make an informed judgement about the suitability of this service, or whether it can meet their needs and aspirations. People living in the Home have had an assessment of their support needs, but some information needs more detail. EVIDENCE: The Home’s Statement of Purpose indicates that the service provides “residential care for four young adults who are deaf and have additional mental health needs”. Information on the structure of the organisation providing the service shows that the Project Manager for Tarragon Gardens is directly responsible to RNID Head of National Specialist Mental Health Services. At least two of the current residents are subject to CPA (care programme approach) care management and have regular input from a Community Psychiatric Nurse. At present the Home’s registration category is sensory impairment only, and an application must be made to CSCI so that the registration accurately reflects the nature of the service provided. The Statement of Purpose requires amendment and needs to provide specific information about what “additional mental health needs” actually means, indicating exactly what the service is equipped to deal with. This should include an indication of specialist expertise available within the care team and show training undertaken and qualifications gained by members of staff. Tarragon Gardens, 11 DS0000017165.V256761.R01.S.doc Version 5.0 Page 10 Sample checking of personal records indicated that appropriate assessment information about individuals’ support needs had been collated at the time of admission, and that there is a good format in place for doing this. However, some of the information was not complete, including details of personal skills and help needed in personal care. There was some evidence of efforts to introduce person-centred approaches into this process. The previous inspection report stated that, while residents’ assessed needs generally appear to be met, records do not clearly specify how people are to be supported to ensure that all their needs are met, and this continues to be the case (see also next section: Individual Needs and Choices). Tarragon Gardens, 11 DS0000017165.V256761.R01.S.doc Version 5.0 Page 11 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, 7, 9 Care plans require development to more accurately reflect residents’ changing needs and to include their personal goals. This needs to be done in such a way that targets set can be properly evaluated. Residents are supported to make decisions about their lives, but plans need to show accurately how and / or why individual aspirations are not being met. Responsible risk taking is supported so as to encourage and enhance people’s levels of independence. EVIDENCE: Care plans continue to be in need of further development. This must include specific detail about exactly how support is to be given. Phrases such as “encourage and assist”, “support with cooking” and “raise awareness of the value of money” do not provide sufficient guidance as to how these tasks should be performed. For example “support with cooking” should indicate simple snack preparation or complete meal, help needed to prepare the food, how much assistance needed to use utensils and equipment, any requirements for maintaining hygienic practice and so on. The plan should be informed and supported by appropriate risk assessment. Tarragon Gardens, 11 DS0000017165.V256761.R01.S.doc Version 5.0 Page 12 Care plans should also set goals with measurable outcomes, so that it is clear what is to be achieved and there is a way of deciding whether or not the goal has been met. There is evidence on file of some goal setting, but this needs to be extended and further developed. One person’s plan included “short walks” – the goal for this might be once a day or three times weekly, and for twenty minutes or half an hour. Goals should then be evaluated at review, and amended or re-set as appropriate. Whole care plan reviews should take place at least every six months, with written records kept, showing who takes part and how decisions are made. It is recommended that person-centred approaches are further developed also to support this process more appropriately. Direct observation and sampling of records provided evidence of residents making decisions and choices about what to do from day to day. A conversation with one resident revealed that he is not entirely happy with his placement at Tarragon Gardens and that he does not understand why he has to be there. He is quite clear that he would rather be living in the city from where he came. It was not possible to tell from his records what plans are in place to address his clearly stated wish, or how he has been made aware of the reasons for his current situation. Risk assessments are in place: it is recommended that these be directly crossreferenced to the care plan(s) to which they relate, and vice versa. It is clear from risk assessments completed that responsible risk taking is seen as an integral part of encouraging residents’ individual independence. It was noted that the risk assessment file contained copies of residents’ individual risk assessments: this does not comply with current data protection legislation. It is acceptable to file generic risk assessments in this way, but documents containing personal information about named individuals should only be stored separately on their own records. Tarragon Gardens, 11 DS0000017165.V256761.R01.S.doc Version 5.0 Page 13 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, 13, 15, 16, 17 Residents are able to take part in appropriate activities and access the local community, but recording and evaluation of activities needs to improve. Staff generally support residents to maintain contact with family and friends, but at least one person needs help to maintain or build his social network. Residents’ rights are respected but responsibilities needs to be worked on. the acceptance of accompanying People living in the house have access to a diet that is sufficiently balanced and nutritious. EVIDENCE: The previous inspection report indicated that residents access a range of educational, social and leisure activities, both at home and in the community, in accordance with their wishes. These include local college classes, shops, leisure centres, cinema, restaurants, pubs, bowling, as well as the local clubs for people who are deaf. At home there are games, magazines, DVD / video, Tarragon Gardens, 11 DS0000017165.V256761.R01.S.doc Version 5.0 Page 14 computer, and art and craft materials. The flat used by staff on sleep-in duty is also available during the day for activities. The personal file of one resident had no current record of activities offered, though it was noted that another resident’s file did include such information. It is important that practice is consistent, and that an accurate record is maintained of the activities people undertake. This should include a record of activities offered but refused. The purpose of activities should be explicit and form an integral part of individual care planning. This presents excellent opportunities for goal setting with the person concerned. It may be that an activity is purely recreational, or therapeutic, or educational –or indeed all of these things together. Recording why an activity is undertaken, and then evaluating the success will guide and provide a focus for future planning. Previous records indicate that residents are supported to maintain links with their family and friends, and have access to minicom, fax, videophone and the internet to facilitate this further. Social contact for the resident placed away from his area of origin is limited. Care plans should indicate what steps are being taken to provide opportunities for maintaining former relationships, and for building new ones, so as to prevent social isolation. Daily routines and general practice in the house seek to involve residents in day-to-day tasks and to encourage their independence. Residents were observed preparing lunch and clearing up in the kitchen. There is a longstanding issue about the support one resident requires to maintain his room in an acceptable condition. Supporting residents to make choices and to exercise their rights to do so cannot be entirely divorced from the responsibilities that accompany such freedoms. This is especially true in a communal environment such as residential care, where the actions (or lack of them) inevitably impinge on the freedoms of other people living in the house. An agreement should be reached with the resident concerned about what is an acceptable standard for his room, and what action will be taken should this not be achieved. Food stocks in the house were seen to be adequate, with supplies of fresh fruit and vegetables and salad also available. A system whereby residents take responsibility for filling in a chart indicating what food they have eaten (posted on the kitchen wall) is a good idea in terms of promoting independence and personal responsibility. However, it was noted that there were substantial gaps in the recording. The chart must be filled in correctly if it is to be of any value, or alternative arrangements made, to ensure that an accurate record is maintained of the food people have actually had. One resident reported that he takes part in food shopping for the house, and can choose things he likes. When questioned about the food he gets he said that there were some things he was not allowed to have (“pot noodle”) and that the food in general was “so-so”. Staff advised that he was discouraged from eating certain things because of previous obsessions (i.e. he would only eat one thing) and to Tarragon Gardens, 11 DS0000017165.V256761.R01.S.doc Version 5.0 Page 15 encourage a healthier diet. Residents were observed eating a meal together in a generally relaxed and convivial atmosphere. Tarragon Gardens, 11 DS0000017165.V256761.R01.S.doc Version 5.0 Page 16 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, 19, 20 Residents receive personal support in an appropriate manner, but care plans should be more detailed so that individuals’ preferences and the guidance to staff are clearer. Residents are supported in meeting their physical and emotional health needs, but there is an issue with regard to overall training of the staff team to meet their mental health needs. Residents are protected by general practice in medication administration, but recording needs to be accurate. EVIDENCE: At the time of the last inspection it was noted that there was a lack of clarity in residents’ care plans about how staff should give support to people with their personal care needs. Plans continue to need development in this area (see standard 6 also) as indicated earlier in this report. Daily routines were seen to be very flexible, with individual residents choosing when to get up and what to do during the day. Staff interacted with residents in a warm and friendly manner that was appropriately respectful, and communication was consistently supported with signing. Tarragon Gardens, 11 DS0000017165.V256761.R01.S.doc Version 5.0 Page 17 Records show that residents are registered with a local GP, and are appropriately referred to health professionals and supported to attend relevant appointments, to ensure that general health needs are met. Support is also given by the local community psychiatric nurse service. There was evidence that attempts are made to encourage residents to take exercise and to eat healthily. The Inspector was advised that three members of staff are currently working towards obtaining the Certificate in Community Mental Health Care from The University of Birmingham. There are concerns that the whole care team should be appropriately trained in supporting people with mental health care needs, and this needs to be assessed fully (see Standard 35 also). The accident book was examined. Reports relating to residents are filed on their personal records. It is recommended that the counterfoil stub be numbered, marked with the initials of the person concerned and the date of the accident, to allow reports to be tracked. Staff accident reports should be placed on their personal files. It is further recommended that a prominent note be placed on the accident book to remind staff of the need to make reports to CSCI, as required under Regulation 37 (Care Homes Regulations 2001). The medication administration record (MAR) was examined: one residents’ record appeared to show gaps in recording and it was unclear which month the recording was for. Further investigation revealed that this medication was in fact now discontinued, but the record did not show this. It is essential that MAR sheets are up to date and completed accurately. It was noted that a previous recommendation that protocols for the administration of PRN medication (“as required”) be placed at the front of the MAR for each resident has been met. There is now also an appropriate storage facility for controlled drugs. Tarragon Gardens, 11 DS0000017165.V256761.R01.S.doc Version 5.0 Page 18 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, 23 Residents are aware of their rights to complain, and know who to talk to. General practice afford residents with protection from abuse, neglect and selfharm, but staff training needs to support this need to be assessed. EVIDENCE: It was noted at the previous inspection that an appropriate complaints policy and procedure is in place. This is also available in an accessible format. The inspector was also advised that another new format was being developed. One resident indicated clearly that, if he had any concerns or a problem that he could go and talk to a (named) member of staff. The RNID policy on adult protection has been examined previously and seen to meet requirements. On the day of the inspection the policy was not in place in the appropriate file, with no indication as to where it could be located. Appropriate guidance to staff must be available at all times. It is recommended that the adult protection policy be cross-referenced to local multi-agency guidelines. It was not possible on this occasion to assess whether or not all staff have now received training in adult protection and in physical intervention, as indicated in the last inspection report. Tarragon Gardens, 11 DS0000017165.V256761.R01.S.doc Version 5.0 Page 19 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, 27, 30 The staff team tries hard to make the house homely, comfortable and safe, but this is made difficult by inherent shortcomings of this environment. There is a lack of appropriate shared spaces to supplement residents’ own rooms. The home is generally kept clean and tidy, but there are issues about supporting one resident to keep his room hygienic to an acceptable standard. EVIDENCE: The staff team tries hard to support residents to make the place they live in welcoming, homely, comfortable and safe. Residents in the main house each have single bedrooms with en-suite shower facilities. The person living in the flat has a bedroom, living room, bathroom and kitchen to herself. On the day of the inspection, the house was generally tidy and clean. There have been issues in the past relating to the support one resident needs to maintain his bedroom in an acceptably hygienic condition, and this continues to be the case. (See Standard 6 also) It must be acknowledged however, that this is not for want of trying. The inspector was advised that a new washing machine with a sluice cycle is scheduled for delivery within a week. Tarragon Gardens, 11 DS0000017165.V256761.R01.S.doc Version 5.0 Page 20 Discussions are ongoing within the organisation to relocate this service to more suitable premises. Of particular concern is the lack of shared spaces that can offer residents additional private space (e.g. to receive visitors or to have a conversation with staff) other than their bedrooms. The flat used by staff on sleep-in duty is available to the residents, who sometimes go up there for art and craft and other activities. They also make use of the bathroom, as there are only showers for washing in the main house. However, people have to go out of the house and “go next door” to access this, and this situation is far from ideal. The main living area in the house is very “open plan” in design and the principle thoroughfare to access all other parts of the home. This presents particular problems, for instance in keeping carpets clean. New lounge furniture has been purchased, and the staff have tried to make the best of the available space, but there is only so much that can be done within current confines. Requirements made at the last inspection to replace flooring, purchase a new bed, replace shower curtains and clean carpets have all been met. There is a sizeable enclosed garden to the rear of the property. At the moment there is very little in it and it is merely maintained at an acceptable level. The overall environment would be much improved if this space were developed to make it a more attractive place to be. A ramp and handrail have now been fitted outside the kitchen back door, so as to facilitate access, as required at the last inspection. It was also noted that the paintwork on the front door to the main house is weathered and peeling. This detracts from the overall look of the property and action should now be taken to remedy this. Immediate requirements were also made to remove used ashtrays from the kitchen, and to make arrangements for the extractor fan to be cleaned properly. Tarragon Gardens, 11 DS0000017165.V256761.R01.S.doc Version 5.0 Page 21 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): 35, 36 A staff training and development plan is required to assess accurately whether or not the care team is appropriately trained. It was not possible to tell if staff are being supervised appropriately from information available on the day of the inspection. EVIDENCE: In the manager’ absence, it was not possible to access all the records necessary to assess accurately staff-related issues. As reported earlier, there are concerns about the training received by members of the team to enable them to support residents with mental health care needs. In order to assess this appropriately, an up to date staff training and development assessment and plan is required. This must show clearly all training completed to date for each member of staff. Any gaps in training, including refreshers needed, should be highlighted. The schedule must also show when outstanding training is to be delivered, and by whom. In view of the stated aim of the service, the assessment must show specifically how all of the members of the team have been trained to support people with mental health care needs. The last inspection report showed that staff group meetings were taking place on a regular basis. The records available on the day of the inspection indicated that meetings had taken place regularly until May 2005, but no further records were available from that date. There was a schedule of staff supervision posted Tarragon Gardens, 11 DS0000017165.V256761.R01.S.doc Version 5.0 Page 22 on the office wall, but it was not possible to ascertain from this whether or not staff were having formal supervision meetings in accordance with the requirements of this standard. Tarragon Gardens, 11 DS0000017165.V256761.R01.S.doc Version 5.0 Page 23 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): 41, 42 General practice promotes and protects residents’ health, safety and welfare, but some aspects of record keeping and reporting require attention. EVIDENCE: Two incident reports were seen for which no report required under Regulation 37 (Care Homes Regulations 2001) could be found. It is recommended that the incident book be annotated to draw staff members’ attention to the need to submit such reports to CSCI, as required. Also, copies of reports required under Regulation 26 were not available for the months of January, March, July or August 2005. These visits should take place once a month, and reports made available as required. Safety records were sample checked. The fire alarm and fire-fighting equipment has been serviced. Records of weekly testing have generally been done, but there were some gaps in recording. Fire evacuation drills should take place at least every six months, and records must show who has taken part. Portable appliance testing has been carried out, and the Landlord’s Gas Safety Tarragon Gardens, 11 DS0000017165.V256761.R01.S.doc Version 5.0 Page 24 Certificate is in date. Checks on fridge and freezer temperatures have generally been done. Tarragon Gardens, 11 DS0000017165.V256761.R01.S.doc Version 5.0 Page 25 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 2 2 2 X X Standard No 22 23 Score 3 3 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 2 2 3 X X Standard No 24 25 26 27 28 29 30 STAFFING Score 3 X X X 2 X 2 LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 2 16 2 17 Standard No 31 32 33 34 35 36 Score X X X X 2 2 CONDUCT AND MANAGEMENT OF THE HOME 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Tarragon Gardens, 11 Score 2 2 2 X Standard No 37 38 39 40 41 42 43 Score X X X X 2 3 X DS0000017165.V256761.R01.S.doc Version 5.0 Page 26 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. Standard Regulation Requirement The Statement of Purpose should be amended to provide precise details about the nature of the service being offered. In particular the information concerning available support for people with mental health care needs should be expanded. Assessments of need should be updated to include full information on each individual’s requirements for support. Service information (including the Statement of Purpose and Service User Guide) should contain detailed statements about the capacity of the service to meet the needs of people with mental health issues. Care plans should be developed as indicated in the main body of this report, so as to include the setting of goals with measurable targets. Targets should be evaluated at review and amended or reset as appropriate. Amend the care plan for resident who wishes to return DS0000017165.V256761.R01.S.doc Timescale for action 1 YA1 4 30/11/05 2 YA2 14 (2) 30/11/05 3 YA3 12 & 18(1a-c) 30/11/05 4 YA6 15 31/12/05 5 YA7 12 (2-3) & 15 30/11/05 Page 27 Tarragon Gardens, 11 Version 5.0 6 YA15 7 YA30YA16 8 YA18 9 YA19 10 YA20 11 YA28 12 YA35 13 YA36 to his area of origin to show clearly how his stated wish is being taken into account. The care plan for resident (as in requirement 5 above) needs to show clearly how he is being 12 (2-3) & supported to maintain contact 15 with family and friends, and supported to build / maintain his social networks. Develop the care plan for the resident requiring support to maintain his room, so that it is 13(3)16(2jclear what action will be taken if k) the level of hygiene falls below 12(1a) the agreed standard. The plan should indicate what the agreed standard actually is. (See requirement 4 above also) Develop care plans to ensure 12(4a) that individuals’ preferences, 15(2b) and specific guidance to staff about how support should be given, are clearly stated. Ensure that all members of staff are appropriately and 12 (1) & specifically trained in meeting 18 (1) residents’ mental health care needs. (See requirement 12 below also) Ensure that Medication 13 (2) Administration Records are completed fully and accurately. Provide an action plan indicating proposals to address 23 (2) the issues raised in the main (b,e,h,i,o) body of this report concerning communal / shared spaces in the home. Submit plan to CSCI Submit an up to date training and development plan for all 18 (1c) members of the staff team, as indicated in the main body of this report Ensure that members of staff are formally supervised at least 18 (2) six times in any twelve month period (pro rata for part-time DS0000017165.V256761.R01.S.doc 30/11/05 30/11/05 30/11/05 31/12/05 26/10/05 31/12/05 30/11/05 31/12/05 Tarragon Gardens, 11 Version 5.0 Page 28 staff) Ensure that reports required under Regulations 26 & 37 (Care Homes Regulations 2001) are submitted to CSCI as appropriate Ensure that fire evacuation drills are completed at least every six months. Records should show the names of all those taking part. Ensure that the fire alarm is tested weekly, and that the written record is appropriately maintained. 14 YA41 26 & 37 30/11/05 15 YA42 13 (4) 31/10/05 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 YA19 Good Practice Recommendations Place a prominent note on incident / accident records to remind staff completing reports of the need to meet the requirements of Regulation 37 (Care Homes Regulations 2001) 1 Tarragon Gardens, 11 DS0000017165.V256761.R01.S.doc Version 5.0 Page 29 Commission for Social Care Inspection Birmingham Office 1st Floor Ladywood House 45-46 Stephenson Street Birmingham B2 4UZ National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. 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