Inspection on 31/08/06 for 11 Tarragon Gardens

This inspection was carried out on 31st August 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. 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 17 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 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 31st August & 19th September 2006 09:30 Tarragon Gardens, 11 DS0000017165.V309412.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.V309412.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.V309412.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 F/P 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.V309412.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. 16th March 2006 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. Tarragon Gardens, 11 DS0000017165.V309412.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was carried out using information from a range of sources including feedback from service users, their relatives, advocates and other professionals involved in their support. Information contained in reports from the service provider was also used as well as previous inspection reports. Two visits to the home were made. During these visits personal files including care plans and care records were examined. Safety records, other reports and some staff records were also seen. It was intended to seek service users’ views directly at an informal meeting arranged at the first visit. This was to be facilitated by the residents’ independent advocate. Unfortunately this did not go ahead as planned. The Registered Manager was formally interviewed and several other staff members over the course of the two visits. A tour of the premises was also completed. What the service does well: Prospective residents’ needs are appropriately assessed prior to admission. People’s rights are respected, and staff give support with warmth and friendliness. Efforts are made to ensure that communication is supported appropriately with signing, wherever possible. Residents are encouraged to be independent, to do as much for themselves as individual abilities allow, and to accept personal responsibility for their actions. Responsible risk taking is seen as an integral component of learning and personal development, and the maintenance of independence skills. Staff encourage residents to follow healthy lifestyles, and promote a balanced diet and regular exercise. They are assisted to access primary and specialist healthcare support, according to assessed needs. People are able to pursue valued activities of their own choosing and to access local community facilities. Staff support them to keep in touch with families and friends, in accordance with the wishes of those involved. Appropriate systems are in place for dealing with complaints and addressing concerns which people may raise. Issues relating to adult protection are dealt with in accordance with organisational policies and procedures, and agreed local multi-agency guidelines. Staff work hard to make the house a welcoming and homely place for people to live, and make the best of what is available. Tarragon Gardens, 11 DS0000017165.V309412.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: It is important to ensure that prospective new residents visit and “try out” the service appropriately, before making decisions about placement. Care plans continue to need further development. Setting goals with measurable outcomes should be extended across all identified areas of support need. Records should show clearly how decisions have been made. As previously recommended, the development of person-centred approaches would support progress in care plan improvement. Risk assessments also require further development. There should be clear links between the assessments and the elements of individual care plans to which they relate. Simple indexing and cross-referencing could support this process. It is recommended that the format for risk assessments should be uniform, where possible. Residents’ personal files should be simplified and made more user-friendly. A standard format might support this. Health Action Plans should be further developed: work needs to be done to build on the current initial assessment. Medication records should be reviewed to ensure that protocols are in place for all prescribed PRN (“as required”) medicines. It is further recommended that copies of original prescriptions are maintained, to support monitoring and prevention of prescribing errors. A detailed training and development plan is still required for the staff team. Information in this regard, which has already been supplied, is incomplete. Tarragon Gardens, 11 DS0000017165.V309412.R01.S.doc Version 5.2 Page 7 All required documentation to support a robust system of staff recruitment must be retained in the home and be available for 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. Tarragon Gardens, 11 DS0000017165.V309412.R01.S.doc Version 5.2 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.V309412.R01.S.doc Version 5.2 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, 4 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Prospective residents’ needs are appropriately assessed. Practice with regard to new admissions needs to improve so that prospective residents can be better supported to make decisions about placement. EVIDENCE: There has been one new admission since the time of the last inspection. Sample checking of personal records revealed that a detailed pre-admission assessment had been completed, as required. Records and other information provided by the Manager showed that the new resident only visited the home on one occasion prior to moving in, and that this was for a 3 hour period: clearly this falls short of what is generally accepted good practice. However, it should be acknowledged that there were specific difficulties in arranging this placement, compounded by the distances involved in travelling to visit the home. The Manager also advised that other opportunities to visit were offered but declined on three separate occasions. There were also difficulties in offering overnight stays as the placement had not been vacated. Nonetheless, the importance of operating an appropriate system for admission should not be underestimated. Prospective residents Tarragon Gardens, 11 DS0000017165.V309412.R01.S.doc Version 5.2 Page 10 should not be expected to make decisions about accepting a placement without first having “tried out” what the service offers. Tarragon Gardens, 11 DS0000017165.V309412.R01.S.doc Version 5.2 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, 8, 9 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents’ plans reflect assessed needs and some personal goals, but these need to be kept up to date and further developed. This will ensure that people get the support they need and in the way they want it. People are consulted and supported to make decisions but it is not always easy to see how decisions have been made. Record keeping needs to improve to provide evidence that decisions are made appropriately. Responsible risk taking is encouraged to promote personal independence, but risk assessments need to improve to inform care plans more appropriately. EVIDENCE: Residents’ personal files contain a wealth of detailed information. People using this service have multiple and complex support needs, and the information that needs to be maintained to support their care is, to say the least, substantial. This fact alone presents a significant challenge, in terms of ensuring that information on file is current, accurate and up to date. Good information Tarragon Gardens, 11 DS0000017165.V309412.R01.S.doc Version 5.2 Page 12 management is essential, to ensure that personal records remain effective, “user-friendly” working tools. Previous inspection reports have highlighted the need to develop individual care plans so that they are appropriately detailed, giving clear guidance to staff about exactly how support should be given. Plans should also include individuals’ agreed goals, and these should have outcomes that are clearly measurable. As previously reported, there is evidence that work to achieve these ends is continuing, but files sampled indicated that success is variable. Evidence was seen of care plan reviews, showing who took part, but records did not always show specifically whether or not existing goals had been evaluated. Key workers also complete monthly summary sheets for each person. This is an example of good practice: it is suggested that this could provide an excellent opportunity for setting and reviewing personal goals and keeping them “alive” and current. Conversations with staff indicated that the progress that one resident has made in recent weeks with regard to independence and self-help skills is not now accurately reflected in current care plans. It is important that plans evolve and are kept up to date, in accordance with changes in personal goals and assessed needs. During visits to the home, staff were directly observed supporting residents make decisions about what they wanted to do during the day, and also encouraging them to take responsibility for tasks around the house, including maintaining their own rooms and doing jobs in the kitchen. It is not always easy to see how people have been involved in decision-making, from evidence currently available in personal records. As previously recommended, specific support in the development of person-centred approaches, for both residents and staff, could go a long way towards improving this significantly. It is important that records accurately reflect how decisions have been made. As previously reported, there is evidence on file that responsible risk taking is seen as an integral part of encouraging residents’ individual independence. However, files sampled during this inspection visit indicate that there is some confusion between risk assessments and care plans. There should be clear links between assessments and the plan(s) to which they relate. It was noted that there are a number of different risk assessment formats in use. One person’s file had a form indicating risk assessments had been reviewed, but there were no risk assessments actually on file at the time of inspection. Another person’s risk assessments did not contain judgements about the likelihood of the identified hazards occurring. It is recommended that, where possible, the risk assessment format be standardised. As previously suggested, simple numbering and indexing of plans and risk assessments could improve this aspect of information management. Some consideration should be given to simplifying the current record keeping system. A uniform approach to file organisation would support this. It was noted that one resident currently has five files. Tarragon Gardens, 11 DS0000017165.V309412.R01.S.doc Version 5.2 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 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are able to access appropriate activities of their choosing and to be a part of their local community. They are able to keep in touch with families, friends and loved ones. Staff work hard to respect people’s rights and to encourage them to accept the accompanying responsibilities. Residents are encouraged to eat healthily, and have access to a balanced, nutritious diet. EVIDENCE: Records sampled provided evidence that residents are supported to pursue valued activities and to access the local community on a regular basis. Some attend structured activities at local centres and colleges. Other activities include tasks designed to foster personal independence and self-help skills, including shopping and cooking. People access local cinemas, pubs, cafes and Tarragon Gardens, 11 DS0000017165.V309412.R01.S.doc Version 5.2 Page 14 restaurants, as well as local clubs for people who are deaf. One resident indicated that he thought the activity opportunities available to him are very good, in response to a questionnaire about the service. Records also show that people are supported to keep in touch with their families and friends in accordance with their wishes. They have access to an independent advocate, who is also a member of the deaf community. As reported above, staff try hard to encourage residents to be as independent as personal capabilities allow, and to accept the responsibilities that go with this. Previous reports have mentioned specific problems faced by the care team in respect of supporting one resident to maintain his room to an acceptable standard. While this continues to be a challenge, it was noted that their efforts to encourage him to do what is necessary have met with some success. This was observed directly on the day of the inspection visit. Food stocks were examined: supplies were plentiful and included fresh produce (fruit, vegetables and salad items). A four-week rolling menu cycle is currently in operation, but the size of the home facilitates other choices easily, should these be desired. Sample menus provided evidence that residents have access to a diet that is sufficiently balanced, varied and nutritious. Tarragon Gardens, 11 DS0000017165.V309412.R01.S.doc Version 5.2 Page 15 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 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents’ personal and healthcare needs are met in accordance with their needs and wishes. Development of Health Action Plans could improve this further. General practice in the storage, handling and administration of medication promotes residents’ safety, but some aspects require attention to ensure this. EVIDENCE: Residents enjoy a good standard of basic personal care. Direct observation of interactions between members of staff and residents provided evidence that support is given with respect, and in a warm and friendly manner. During the inspection visits it was noted that communication was appropriately supported with sign language. Residents’ personal grooming and dress provided further evidence of good care and support. The Inspector had sight of questionnaires completed by people involved in residents’ support, who are independent of the care team (these include relatives and other professionals). Comments made included “residents are well cared for and their basic needs are met” and “staff always seem respectful and willing to allow time to talk to me. They always use sign language (I am deaf) and with the residents”. Tarragon Gardens, 11 DS0000017165.V309412.R01.S.doc Version 5.2 Page 16 Personal records provided evidence that residents are assisted to access primary and specialist health care support, including GP, Psychiatrist, Community Nurse, Social worker, and other members of the multi-disciplinary team. Previous reports alluded to the need to develop Health Action Plans, and some work has been done towards this. However, it was noted that current documentation on file is in the format of an initial assessment, and the information contained in these was rather limited. More work needs to be done in this area, to advance assessments through to active planning, including measurable goals. It was noted that additional progress has been made to provide specialist training for staff to meet residents’ mental health needs (see Standard 35 below also). The Medication Administration Record was examined, and completed appropriately. The home currently uses the Lloyds Monitored Dosage System. Medication was securely stored and in date as required, and a suitable facility is available for the storage of controlled drugs, if required. However, it was noted that protocols were not in place for all prescribed PRN (“as required”) medication. This situation must be reviewed, so that guidance is available for all such medication, outlining the circumstances and how it should be administered. Ideally this should be agreed and countersigned by the prescribing doctor. It is also recommended that copies are obtained of original current prescriptions (where these are not already held), to assist in the monitoring and prevention of prescribing errors. Tarragon Gardens, 11 DS0000017165.V309412.R01.S.doc Version 5.2 Page 17 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 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents know that their views are listened to, taken seriously and acted upon. General practice promotes their protection from abuse, neglect and selfharm. EVIDENCE: This service has appropriate policies and procedures in place with regard to complaints and also adult protection issues. Evidence was seen that a recent complaint was independently investigated and the issues that were raised dealt with appropriately. Residents know of their right to complain and are comfortable taking up matters of concern with the Manager or members of the care team. This was observed directly in the course of the inspection visit. A recent allegation concerning adult protection was also taken seriously and referred to the Police and Social services for investigation, in accordance with policy and local multi-agency guidelines. This matter is ongoing, and appropriate action has been taken to prevent re-occurrence and protect the parties concerned. Tarragon Gardens, 11 DS0000017165.V309412.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 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 the environment has some limitations. Communal space is inadequate and options for bathing are limited. The home is kept clean and tidy, and good standards of hygiene are generally maintained. EVIDENCE: A tour of the premises was completed. Residents in the main house each have single bedrooms with en-suite shower facilities. The person living in the upstairs flat has a bedroom, living room, bathroom and kitchen to herself. Previous inspections have highlighted concerns over the lack of options in communal space in the main house. The design of the main living / dining room is very open plan, making it the main thoroughfare to all other rooms in the house. There is no other room to receive visitors or have a conversation with staff, other than the main living room or individuals’ own bedrooms. The other upstairs flat (used by staff on sleep-in duty) is available to residents. It has been used for art and craft and other activities. Residents are also able to make use of the bathroom, as there are only showers in the main house downstairs. As has been pointed out previously, this is far from ideal, as Tarragon Gardens, 11 DS0000017165.V309412.R01.S.doc Version 5.2 Page 19 people have to go out of the house “next door” to access this. One resident’s relative has raised concerns about the external environment of the house, and the suitability of the neighbourhood in particular for meeting the housing needs of vulnerable adults. Plans were being made to relocate this service to more suitable premises, but members of the care team were uncertain about how far these have progressed since the time of the last inspection. The Registered Provider should inform CSCI of the current position with regard to future plans, indicating what action is to be taken to address identified shortfalls. On the day of the second visit, major work to level and landscape the garden was in progress, and this should make a significant improvement to the environment upon completion. In spite of the shortcomings of the current environment, it should be acknowledged that staff work hard to make the house comfortable and safe for the benefit of the people who live there. The home was clean and tidy on both occasions during this inspection, and appropriate standards of hygiene maintained. Tarragon Gardens, 11 DS0000017165.V309412.R01.S.doc Version 5.2 Page 20 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, 34, 36 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. A current training and development plan is still required to assess fully the qualifications, training and competence of the staff to support the people in their care. Complete documentary evidence is not available to support the recruitment of staff, and arrangements for formal supervision are not up to the required standard. Improvements need to be made in all these areas for the benefit of people using the service. EVIDENCE: It was not possible to assess fully the competence, qualifications and training and development needs of the staff team during the inspection visits: this was due in part to the absence of the Manager (due to illness) and the consequent inability of the Inspector to access some staff records. The personal files for two of the most recent recruits to the staff team were sample checked. One had no evidence of a Criminal Records Bureau (CRB) check. There was a completed application on file, but it was noted that there was an unexplained ten-year gap in the employment history, which did not appear to have been checked on the evidence of the accompanying interview Tarragon Gardens, 11 DS0000017165.V309412.R01.S.doc Version 5.2 Page 21 notes. Another staff member’s file did not contain any written references. The files examined were not well organised or appropriately structured. It should be acknowledged that previous inspection reports have found recruitment practice to be generally satisfactory, and it may be that documents have yet to be sent on from the organisation’s central office. However, all documentation required by regulation (Care Homes Regulations 2001) must be retained in the home and be available for inspection. Some information has been provided relating to staff training (“Workforce development plan”) but this does not cover all the issues identified in the last two inspection reports. A full staff training and development plan for the whole staff team is now required, and this should be submitted to CSCI without further delay. The plan must show, for each individual member of staff, details of all relevant training completed and qualifications gained. The plan should clearly identify any gaps in training and indicate when “refreshers” are due. It should also show when outstanding training is to be delivered, and by whom. Information provided already indicates the availability of some courses of training, but shows that, in many instances, places have not yet been booked. It is important that the plan gives an instant overview of the current position of training and development for each person working in the home. It should be possible to see at a glance what training any individual has completed, and what his or her future training needs are. Appropriate consideration should be given to how this information is presented, and the end result should be a valuable working tool: it may be that a spreadsheet format is most useful, as this can be easily updated once it has been set up. Three members of staff have completed their studies towards gaining a Certificate in Community Mental Health and are awaiting final certification. Another three people are due to commence a similar course of study shortly, subject to places being available. Unfortunately, the University of Birmingham is not offering this course this year, so an alternative is being sought. The initiative to continue specialist training for people with mental health support needs is commended. However, it is important that this is supplemented with additional input for other members of the care team, given the specialist nature of the service being provided. This should also be reflected in the training and development plan for the team. The plan should also indicate clearly individual staff members’ stage of training in signing. Feedback from one resident’s social worker says, “I feel most staff have signing skills but for some this is quite basic. I am unsure if it meets the needs of all residents, some of whom have quite limited and idiosyncratic styles of signing”. Training in this area should be demonstrably linked to individual residents’ assessed needs and communication guidelines. (See National Minimum Standard 35.7) As stated above, it was not possible to access all staff records, due to Manager’s absence, so full information relating to staff supervision was not Tarragon Gardens, 11 DS0000017165.V309412.R01.S.doc Version 5.2 Page 22 available. However, evidence gleaned from a schedule displayed on the office wall indicates that formal supervision is still below required standards. The Manager must ensure that staff receive formal supervision at least six times in any twelve-month period (pro rata for part time staff), with written records maintained for each meeting. Tarragon Gardens, 11 DS0000017165.V309412.R01.S.doc Version 5.2 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): 37, 39, 42 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents benefit from living in a home that is generally well run. Appropriate efforts are made to consult with them so that their views might inform service development. General practice promotes the health, safety and welfare of residents, but some issues require attention so as to ensure this. EVIDENCE: The Manager holds a recognised nursing qualification (RNMH) and is working towards the Registered Manager’s Award. She is also waiting to gain a place on the course leading to the Certificate in Community Mental Health referred to earlier in this report. Members of staff indicate that she is approachable and will deal with any issues brought to her attention. Direct observations provide evidence that the staff team generally get on well together and are supportive of each other. Tarragon Gardens, 11 DS0000017165.V309412.R01.S.doc Version 5.2 Page 24 Copies of questionnaires completed by residents (supported by their advocate) relatives and other professionals as part of the service’s quality assurance and monitoring activity were examined. These can be returned to the Manager, or sent to CSCI in accordance with individuals’ wishes. One resident had noted “not happy with agency staff no sign BSL”. As part of the inspection process arrangements were made for an informal residents’ meeting with the Inspector to be facilitated by the independent advocate. It was intended to provide an opportunity for residents to discuss any issues they wished and for the Inspector to seek their views directly. Unfortunately this did not go ahead as planned as on the day allocated the Manager was absent due to illness and the Advocate was out of the area attending another appointment. Previous requirements in respect of reporting under Regulation 26 (Care Homes Regulations 2001) have now been met. Safety records were sample checked. The fire alarm and fire-fighting equipment have been serviced. Tests on the fire alarm and emergency lighting systems have been carried out and written records maintained. It was noted that there were some gaps in recording of the emergency lighting tests. Fire drills have been carried out, but as previously required, records should show the names of all those taking part (residents and staff). Records of testing of the fridge and freezer temperatures were generally complete, though it was noted that there were a couple of gaps in the record for the freezer. Packages of food stored in the fridge were appropriately labelled with the date of opening. It was noted that the main COSHH store was securely maintained, but the cupboard under the sink in the kitchen, which also contains COSHH items was unlocked. Tarragon Gardens, 11 DS0000017165.V309412.R01.S.doc Version 5.2 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 Standard No Score 1 X 2 3 3 X 4 2 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 X 26 X 27 2 28 2 29 X 30 3 STAFFING Standard No Score 31 X 32 2 33 X 34 2 35 2 36 2 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 2 2 2 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 X 3 X 3 X X 3 X Tarragon Gardens, 11 DS0000017165.V309412.R01.S.doc Version 5.2 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. 1. Standard YA4 Regulation 14 Requirement Ensure that prospective residents have had an appropriate introduction to the service before making decisions about placement. Care plans should be further developed as indicated in the main body of this report, so as to include the setting of goals with measurable targets. Plans should be kept up to date in accordance with individuals’ changing circumstances. Ensure that records show clearly how individuals have been involved in making decisions, or where decisions have been made on their behalf. Develop individuals’ risk assessments to show clear links with care plans to which they relate. Risk assessments should include clear identification of hazards, a judgement of the likelihood of occurrence, and control measures to minimise or eradicate the risk. Ensure that all members of DS0000017165.V309412.R01.S.doc Timescale for action 30/11/06 2. YA6 15 30/11/06 3. YA7 YA8 12(2) 30/11/06 4. YA9 13(4c) 30/11/06 5. YA19 12(1) 30/11/06 Page 27 Tarragon Gardens, 11 Version 5.2 18(1) 6. YA20 13(2) 7. YA27 YA28 23(2) 8. YA32 YA35 18(1c) 9. YA34 19 Sch 2&4(6) 10. YA36 18(2) 11. YA42 13(4c) 12. YA42 13(4c) staff are appropriately and specifically trained in meeting residents’ mental health care needs. (See requirement 5 below also) (Partially met) Review medication records and ensure that protocols are in place for all prescribed PRN (“as required”) medicines The Registered Provider should report to CSCI on the current status of plans to address identified environmental shortcomings in this service, or for its relocation, as previously reported. Submit an up to date training and development plan for all members of the staff team, as indicated in the main body of this report. Outstanding since 31/05/06 Ensure that all required documentation (Care Homes Regulations 2001) relating to every member of staff is maintained in the home, and available for inspection. Provide evidence that appropriate CRB clearance has been obtained for all staff working at the home. 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 31/05/06 Ensure that records for fire evacuation drills show the names of all those taking part. Ensure that a complete written record of tests of the emergency lighting system is appropriately maintained. Review the fire risk assessment and ensure that DS0000017165.V309412.R01.S.doc 30/11/06 30/11/06 30/11/06 30/11/06 30/11/06 30/11/06 30/11/06 Tarragon Gardens, 11 Version 5.2 Page 28 13. YA42 13(4c) 14. YA42 13(4c) the requirements of the Fire Officer’s report are dealt with as indicated. Report on action taken to CSCI. (Not assessed) Ensure that the freezer temperature is checked each day, and a written record maintained. Ensure that all COSHH products in use in the home are securely stored at all times. 30/11/06 30/11/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. 3. 4. 5. Refer to Standard YA9 YA19 YA20 YA35 YA41 Good Practice Recommendations Index and cross-reference all risk assessments to the care plan(s) to which they relate. Adopt a standard format for all risk assessments to promote consistency of practice. Further develop Health Action Plans to build on existing initial assessments. Retain copies of current prescriptions to support monitoring and prevention of prescribing errors. Provide training for staff to develop person-centred approaches. Simplify residents’ files so as to make them more userfriendly. Standardise the format for maintaining records. Tarragon Gardens, 11 DS0000017165.V309412.R01.S.doc Version 5.2 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. Extracts may not be used or reproduced without the express permission of CSCI Tarragon Gardens, 11 DS0000017165.V309412.R01.S.doc Version 5.2 Page 30 - 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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