Care Home: Talbot Woods Lodge

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What the care home does well People who are considering using this service have their needs assessed before they move in. Often people have day care at the home before they move in. This means that the manager of the service can be sure that the staff in the home have the skills and experience to meet individual needs. People are supported to make decisions about some aspects of their lives. People who live in the home are supported to take risks as part of developing an independent lifestyle. People who live in the home are able to participate in activities, which interest them. The expert spoke to some of the residents who told her what activities they get involved in. People who live in the home said they are part of the local community. People who live in the service have information about how they live to be supported recorded in their individual plans of care so that staff know exactly how they need care and support. Individual plans of care also identify physical and emotional health needs and the support that each person needs from a person such as a doctor or speech therapist. People who work in the home use a variety of communication methods to ensure that each person living in the home is able to express an opinion or concern. The home`s policy on acting on a complaint or concern is clear and in an accessible format. The home is clean and has infection control procedures and training in place for all staff. The registered manager is very experienced and works hard to ensure that outstanding requirements made by the commission are met. This means that the people who live in the home can be assured that the manager puts their needs at the centre of what they do. What has improved since the last inspection? At the end of the last inspection in August 2006 there were 7 requirements and 11 recommendations. The registered provider has updated the statement of purpose and service user guide to provide more information on the home and the service it provides such as respite and day care. This means that people who are considering moving into the home have all the information they need to make an informed choice. The home keeps a record of the food people eat to demonstrate that they are being offered a healthy choice. This also ensures that they have information for health care professionals if any resident has unexplained weight loss. The medication policy has been reviewed and updated. Improvements in recruitment practice mean that people living in the service are protected. The service has made improvements to the training programme for staff by offering more accredited training. The registered provider has been sending in notification of any occurrences within the home, which affect the people who live there. The service has introduced goals setting for people living in the home, which means individual plans are more personal and meaningful. What the care home could do better: At the end of this inspection there are no requirements and 6 recommendations. The home needs to ensure that records are maintained in a way which is confidential to individual people living in the home. For example, assessments on moving and handling should be kept in individual files not collectively. People living in the home should be supported to use their personal space to see friends if they wish. The registered manager should ensure that they continue to source external training for staff on adult protection. The bathrooms should be upgraded. Staff should continue to work towards National Vocation Qualifications. CARE HOME ADULTS 18-65 Talbot Woods Lodge 64 Wimborne Road Talbot Woods Bournemouth Dorset BH3 7AR Lead Inspector Tracey Cockburn Unannounced Inspection 7th November 2007 11:00 Talbot Woods Lodge DS0000003991.V354145.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 Talbot Woods Lodge DS0000003991.V354145.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. Talbot Woods Lodge DS0000003991.V354145.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Talbot Woods Lodge Address 64 Wimborne Road Talbot Woods Bournemouth Dorset BH3 7AR 01202 293390 01202 297817 Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Mr John Colley Mrs Nicola Gail Colley Care Home 15 Category(ies) of Learning disability (15) registration, with number of places Talbot Woods Lodge DS0000003991.V354145.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 31st August 2006 Brief Description of the Service: Talbot Woods Lodge is a residential care home registered to accommodate a maximum of fifteen adults with a learning disability. The property is in keeping with the neighbourhood and there is ample space for parking at the front of the house. The home has easy access to a bus route, which serves the centres of Bournemouth and Winton. Residents have access to an eight-seat vehicle for trips out in the community and are supported to attend health appointments as appropriate by staff. One bedroom is used to provide respite care for a number of different people with learning disabilities. All bedrooms are single occupancy. Eleven bedrooms are situated on the first and second floors of the home and four are situated downstairs. There are four bathrooms and two toilets for shared use by residents. The home also has a large lounge, dining room and a separate sun lounge / games room. The garden to the rear of the property has been thoughtfully landscaped and provides a further area for use by residents. The home also provides day care for a maximum of five non-residents each day. The basic minimum fee for residents at Talbot Woods Lodge is currently £450 per week. For further information on fees and contracts the office of fair trading website is useful: www.oft.org.uk Talbot Woods Lodge DS0000003991.V354145.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was a key inspection and was undertaken in the middle of the week during the morning and afternoon. As part of the inspection processes an expert by experience was involved and spent time looking round the home, talking with residents and the staff. The expert talked to residents to find out what activities they do. The expert found out how people communicate their wishes, needs and wants. The expert also asked people who use the service what parts of their lives are good and was there anything they would change about the service. The expert spoke to 6 people. Comments and information from the expert’s report are used throughout this report. Survey forms were left for all staff and the people who live in the home as well as relatives. 6 staff returned surveys and 5 people who use the service returned surveys. Comments will be in the main body of the report. The registered provider submitted an annual quality assurance assessment (AQAA) and this has been used in planning the site visit to the service. During the site visit, care documents, policies, procedures and staff files were looked at as well as a tour of the home and discussion with staff. What the service does well: People who are considering using this service have their needs assessed before they move in. Often people have day care at the home before they move in. This means that the manager of the service can be sure that the staff in the home have the skills and experience to meet individual needs. People are supported to make decisions about some aspects of their lives. People who live in the home are supported to take risks as part of developing an independent lifestyle. People who live in the home are able to participate in activities, which interest them. The expert spoke to some of the residents who told her what activities they get involved in. People who live in the home said they are part of the local community. People who live in the service have information about how they live to be supported recorded in their individual plans of care so that staff know exactly how they need care and support. Individual plans of care also identify physical and emotional health needs and the support that each person needs from a person such as a doctor or speech therapist. People who work in the home use a variety of communication methods to ensure that each person living in the home is able to express an opinion or concern. The home’s policy on acting on a complaint or concern is clear and in an accessible format. The home is clean and has infection control procedures and training in place for all staff. Talbot Woods Lodge DS0000003991.V354145.R01.S.doc Version 5.2 Page 6 The registered manager is very experienced and works hard to ensure that outstanding requirements made by the commission are met. This means that the people who live in the home can be assured that the manager puts their needs at the centre of what they do. What has improved since the last inspection? What they could do better: At the end of this inspection there are no requirements and 6 recommendations. The home needs to ensure that records are maintained in a way which is confidential to individual people living in the home. For example, assessments on moving and handling should be kept in individual files not collectively. People living in the home should be supported to use their personal space to see friends if they wish. The registered manager should ensure that they continue to source external training for staff on adult protection. The bathrooms should be upgraded. Staff should continue to work towards National Vocation Qualifications. Talbot Woods Lodge DS0000003991.V354145.R01.S.doc Version 5.2 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. The summary of this inspection report can be made available in other formats on request. Talbot Woods Lodge DS0000003991.V354145.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 Talbot Woods Lodge DS0000003991.V354145.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. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People considering the service are able to make an informed choice based on the information the home provides. People have their needs assessed before they make a decision to move in. This means that the manager knows if the home and staff are able to meet an individual’s needs. EVIDENCE: Since the last inspection the registered provider has submitted an updated service user guide, which contains information on the respite care and day care offered by the service. The home’s Statement of Purpose and Service User Guide were reviewed. This is in an easy-read format and therefore accessible to service users. It was noted that there was no specific mention of the fact that the home operates a day service on the premises or that the home offers respite accommodation on the first floor for one individual. Talbot Woods Lodge DS0000003991.V354145.R01.S.doc Version 5.2 Page 10 The registered provider stated that prospective residents are invited to the home for tea visits and overnight visits as part of the admissions process, which gives them an opportunity to discuss their needs and aspirations with staff and meet other residents. Talbot Woods Lodge DS0000003991.V354145.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. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7, 9, 10 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People have individual plans, which reflect their changing needs and record the decisions they make about their lives as well as the risks they take. Further development of systems for maintaining confidentiality are needed to ensure that the people living in the home can be confident their information is stored correctly. EVIDENCE: The individual plans for two people were reviewed. These were generally comprehensive and contained information on all aspects of activities of daily living including eating and drinking, leisure activities, washing and dressing, elimination, night routine, self-help skills, links to family and bereavement. The individual’s level of independence, nature of assistance needed and choices and decisions that the service user can make were included in the Talbot Woods Lodge DS0000003991.V354145.R01.S.doc Version 5.2 Page 12 plan. There was evidence to demonstrate that service users, their relatives and representatives are encouraged to sign up to their individual plans. All the staff that responded to the questionnaire said they are always given up to date information about the needs of the people they support. At the last inspection there was a recommendation that goal setting is much more specific and achievable. The registered provider has introduced a goals setting sheet which details the goal and how it will be achieved and by when. There was sufficient evidence in two plans to indicate the way in which people communicate in order to make choices and decisions. There was also evidence on file that showed how service users with verbal communication had been encouraged to make choices about outings and activities using promotional leaflets. The experts said in their report: “Not all residents communicate verbally. One resident had a communication book. The book had pictures, symbols and small amount of writing. This resident came up with the idea of the book himself he told me.” The manager explained that the resident who put the communication book together did so with the support of a member of staff using the computer. All the symbols are individual to the person. The experts also said in her report that one resident uses sequence cards and some residents use makaton to communicate. The expert also observed that people living in the home have their own individual ways of getting attention from staff. They use hand gestures or pull staff to where they want to go. A sample of risk assessments were seen for individual service users to identify their level of vulnerability and provide information on action to be taken to minimise risks. Risk assessments covered social activities, household tasks, mobility, eating and drinking, abuse, personal care, self-neglect, aggression and community access. The manual handling assessments for each person living in the home are kept in one file, it would be better if they were within the individual’s personal file which contains all the other information relating to their care. The registered provider has also introduced a slips, trips and falls policy. Talbot Woods Lodge DS0000003991.V354145.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. 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. People are able to participate in activities, which interest them both in and out of the home. Individuals are supported to have relationships with people who are important to them. Further development to enable people to use their private space to see friends could be explored. Improvements mean that the home is better at assessing nutritional risk. EVIDENCE: The people living at Talbot Woods Lodge attend different day services in the community, which enable them to be with their peer group and take part in a range of activities. A programme of activities for the month is on display in the hallway of the home. The home has a vehicle, which can transport up to eight people. Talbot Woods Lodge DS0000003991.V354145.R01.S.doc Version 5.2 Page 14 Discussion with Nicky Colley evidenced that she is aware that effort needs to be made to ensure that all people are enabled to access their community irrespective of their level of disability. The home also organises visits from a massage therapist on a regular basis for seven people who have a severe learning disability. People at Talbot Woods Lodge are reported to have contact with members of their family. It was noted during a tour of the home that the majority of bedrooms continue to be locked by staff at the home while people are not using them. The expert noticed that some people who live in the home have certificates of achievement on display in their bedrooms. The registered provider said that people living in the home are issued with a key, which they store in the office for safekeeping. The expert said in their report: “I talked to 6 people and they told me the activities they were involved in such as jigsaw making, skittles, computer, helping out collecting mugs at the day centre, swimming, singing (karaoke machine) cooking, colouring, drama and tapestry. The residents enjoyed doing these activities and they chose the activity.” The expert observed a member of staff holding a resident’s hand, so wherever the member of staff went the resident also went. The expert did not feel this was acceptable. The home’s food stores had a good range of fresh fruit available to people for inclusion in their lunch boxes. Frozen vegetables were also available and cupboards appeared well stocked to meet the needs of people living in the home. The AQAA submitted by the service included information on activities people participated in both in the home and in the community. Examples included going to Euro Disney, pottery, concerts and the theatre. In the home they also have video nights, fancy dress parties. During the inspection the manager was in the process of arranging Christmas entertainment; a trip to Poulton Park winter wonderland and the theatre. These were ideas, which the residents had come up with themselves. The home has introduced pictures and symbols to help with food choices. The home now employs a full time cook who is currently undertaking an NVQ in domestics and cookery and has completed a nutrition course. The expert said in her report: “Residents are encouraged to participate in kitchen activities and prepare pack lunches.” Talbot Woods Lodge DS0000003991.V354145.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. 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 say they receive care and support in the way they prefer and have their physical and emotional needs met. Improvements to the home’s medication policy mean people are better protected. EVIDENCE: Support plans seen provide sufficient detail to care staff about the individual personal care needs and routines of people living in the service, for example, how they like to be supported with bathing and the help they need to brush their teeth. Risk assessments seen also showed evidence that risks around personal care and self-neglect had been considered. Residents’ records showed evidence of liaison with generic and specialist health care services, for example general medical practitioners, community nurses, dietician, chiropody and physiotherapy. The registered manager explained that they are involved with the sensory integration therapist who has been Talbot Woods Lodge DS0000003991.V354145.R01.S.doc Version 5.2 Page 16 helping the manager and staff work with a number of residents. During staff meetings health care professionals such as a psychologist are invited to meetings to talk to staff about health related issues. Most medicines in the home are administered from Monitored Dosage System (MDS) blister packs and the sample checked during the inspection agreed with the Medication Administration Record (MAR) charts. Since the last inspection there has been a medication error, this was fully documented and a notification sent to the commission. This detailed the action taken at the time. Staff with responsibility for the administration of medication access in-house training and a short training course provided by a pharmacy as well as an external training course. Following a requirement made at the last inspection of the service staff have received further training on how to take an accurate reading of the fridge temperature where the insulin is stored. Talbot Woods Lodge DS0000003991.V354145.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. 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. An accessible complaints policy means that people are able to air their views if they wish and are listened to. Staff need to receive training in safeguarding to understand how to protect people living in the home. EVIDENCE: The home has a complaints procedure which has been converted into an easyread / symbols format. A copy of the procedure is on display in the hallway of the home. All people living in the service are given an orange card, which details the commission’s telephone number should they wish to contact us. The home also undertook a training day called “SAY NO” jointly with Bournemouth forum, which is a local advocacy group. All people living in the home who responded to the survey stated that they knew who to speak to if they were unhappy or wanted to make a complaint. There have been no complaints about the home received by the Commission for Social Care Inspection since the last inspection of the service. The registered manager said that the phone log and concern and complaint register are audited monthly. Talbot Woods Lodge DS0000003991.V354145.R01.S.doc Version 5.2 Page 18 The home has an adult protection procedure, which staff sign to indicate they have read and understood. A copy of the multi-agency policy ‘No Secrets’ is also available for staff reference. Staff meetings are held every two months and the schedule indicates that adult protection is discussed on a regular basis to ensure staff are aware of action they should take in the event that they suspect or witness abuse. Discussion with a member of the staff team indicated that new staff are shown two videos ‘Abuse of adults with learning disabilities’ and ‘No Secrets’. The registered provider stated in the AQAA that all staff undertake external training regarding safeguarding adults. The manager also states that following details of the Cornwall and Merton investigations all staff were given copies of these reports and they were discussed at a staff meeting. Talbot Woods Lodge DS0000003991.V354145.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Refurbishment is ongoing and further work is taking place. The home is clean. EVIDENCE: The home currently provides accommodation for a total of fifteen people, which includes one respite bed. There is a lounge, dining room and sun lounge / activity area on the ground floor. There is a separate laundry room with a washing machine and tumble dryer. The door to the laundry room now has a lock fitted and the exposed pipe work has been lagged. Further work is needed as an exposed pipe runs along the bottom of the step in the laundry room. It was noted that there is another door between the utility area and food store; this was locked. Talbot Woods Lodge DS0000003991.V354145.R01.S.doc Version 5.2 Page 20 The annual quality assurance assessment (AQAA) states that since the last inspection the boiler has been replaced. A new cooker has been purchased, new bedroom furniture has been purchased and chosen by individual residents. A new garden patio has been laid and new flowers have been planted, chosen by the residents. All bedroom doors now have handles. There are still only 2 bedrooms with personalised nameplates on them. The manager explained that this would be completed early in the New Year as the people living in the home wanted a very specific personalised name and the company, which does it, is usually around at Christmas. The building work is complete and now registered with the commission. Bathrooms are not yet refurbished but the manager said this will be happening soon and it is in their AQAA as an improvement over the next 12 months. There are new carpets on the stair and corridors upstairs. The expert noted in her report that: “Residents feel good about their lives because they had their own bedroom, own key; they chose the décor and possessions in there.” The expert also commented that: “Residents appear not to have close personal relationships or friends in their room. Their bedroom is considered a quiet space.” The keys of each bedroom are kept in a key safe in the office, all the people living in the home have access to the key safe and this was observed during the inspection. It was noticed during the tour of the premises that a pane of glass in the window on the landing of the small stairway was cracked. This was pointed out to the registered provider. Household substances identified as substances hazardous to health are stored securely in a locked cupboard in the laundry area. Information supplied in the Annual Quality Assurance Assessment (AQAA) by the registered provider indicates that there is a contract in place for the disposal of soiled waste. The washing machine has a sluice wash facility. New staff are shown a video on infection control in the care home as part of their induction training. The expert also pointed out in their report that the home is over 3 floors and there are a lot of stairs and no lift. The expert was concerned about the future for people living in the home and becoming less mobile. The expert also noted that the tap in the toilet in the entrance hall did not turn off. The expert also thought that the chill out space on the landing was nice. One resident thought that the home “always smells nice.” Talbot Woods Lodge DS0000003991.V354145.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34, 35 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Management need to ensure that staff work towards National Vocational Qualifications. Improvements in training mean staff are receiving the variety of training they need to meet the needs of the people living in the home. Recruitment practice has improved and means that people living in the home are better protected. EVIDENCE: The housekeeper’s job description has been updated and the role is now much clearer. Job descriptions for care workers were seen to be on the 2 files seen. Information supplied in the annual quality assurance assessment indicates that since the last inspection staff have undertaken training in nutrition, breakaway techniques, sensory integration and total communication. The registered provider stated that NVQs are done through a local college of further education. Discussion with the provider indicated that all staff undertake Talbot Woods Lodge DS0000003991.V354145.R01.S.doc Version 5.2 Page 22 training accredited by the Learning Disability Award Framework (LDAF) as part of their induction training at the home. This offers staff an introduction to aspects of supporting people with learning disabilities. The home’s rota indicates that there are generally four care staff on duty at the home between 0800 hrs and 2000 hrs. This excludes the registered provider and the housekeeper. From 2000 hrs there is one waking night duty and one sleep-in duty. Two staff files were examined for evidence of the home’s recruitment process. Both members of staff had commenced in post since the last inspection of the service. Enhanced disclosures from the Criminal Records’ Bureau and PoVA First checks were on record for all staff. All records sampled showed evidence of proof of identity. There were two written references on both the files seen. There was evidence on 1 file that 3 residents were involved in the interview process. There was evidence on care workers’ files that the induction programme for new staff spans four working days. During this time staff undertake a tour of the premises and are given an introduction to policies, procedures and employment issues. Shadowing of more experienced care workers also takes place during this time. At induction staff are introduced to a selection of videos with accompanying workbooks to give them basic knowledge on a range of subjects about supporting people with learning disabilities. One member of staff who responded to the survey said: “My induction was intensive”, they also commented that they had the opportunity to undertake different types of training. During the next 12 months the service is planning for selected staff to undertake total communication co-ordinator training. The registered provider is also planning Mental Capacity Act training for staff. One person who responded to the staff survey thought they could be better at teamwork. Talbot Woods Lodge DS0000003991.V354145.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. 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. Management practice within the home ensures it is well run and has a system of self-monitoring, review and development, which takes into account the views of the people who live there. Practices in the home ensure that the health, safety and welfare are promoted and protected. EVIDENCE: The provider has responded promptly to requirements made at previous inspections and has demonstrated commitment towards meeting the Regulations and National Minimum Standards. The manager is involved in learning hubs and said this offers support in keeping up to date with training and practice issues. Talbot Woods Lodge DS0000003991.V354145.R01.S.doc Version 5.2 Page 24 The home’s quality assurance record showed that the registered provider has sent out questionnaires to visitors to Talbot Woods Lodge on an annual basis. Areas looked at as part of the questionnaire included quality of care, friendliness of the staff, cleanliness of the home, response to telephone calls, the home’s décor, amenities, food provision and general impressions. The registered provider confirmed that information from the questionnaires is collated and feedback from the process is sent out to relatives of service users. The registered provider stated that she ensures that specific comments, which may be raised by individuals as part of this process, are responded to. Records showed evidence that issues raised in surveys had been followed up by the provider. For example, at the previous inspection concern was noted about the use of tinned food such as ravioli. The registered manager removed tinned items from the menu. One person living in the home made it very clear in their questionnaire that they were not happy with this decision and asked for the item to be put back on the menu. This was discussed at the meeting held by the residents. The home’s fire safety records were seen. They contained information on weekly, monthly and quarterly checks; all were up to date. The annual fire check had been completed by Abbey Fire on the 14/09/07. All 16 staff attended fire training on 24/09/07. Fire risk assessment was done on 15/01/07. Water temperatures are checked weekly and portable appliance testing (PAT) testing is also up to date. The home’s accident and injury log was reviewed. This provided a record of all injuries or bruises sustained by service users. Body maps had been used to indicate the area of bruising and following a recommendation at the last inspection there is more detail about the nature or the bruise including colour and size. Following a recommendation at the last inspection the accident book has been updated. The commission has received regulation 37 notices about any accidents or injuries to people living in the home in a timely way. The home has up to date insurance cover. Talbot Woods Lodge DS0000003991.V354145.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 3 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 2 ENVIRONMENT Standard No Score 24 2 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 2 33 X 34 3 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score X 3 3 3 2 LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 2 16 2 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 3 X 3 X X 3 X Talbot Woods Lodge DS0000003991.V354145.R01.S.doc Version 5.2 Page 26 Are there any outstanding requirements from the last inspection? No STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. Standard Regulation Requirement Timescale for action 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 YA10 YA15 Good Practice Recommendations Information such as moving and handling assessments should be kept in the individual’s personal file. The registered provider should consider how they encourage people living in the home to develop personal relationships and use their own rooms to see friends in private if they wish. Residents’ rights should be recognised by ensuring that restrictions such as the practice of locking bedroom doors continue to be reviewed and carefully documented for each individual. All staff should access formal, external training in adult protection from a qualified trainer who has expertise in this field. Refurbishment of bathroom facilities should be considered to ensure that they are in good repair and good decorative order. The registered provider should ensure that they work towards 50 of care staff in the home achieving NVQ 2. DS0000003991.V354145.R01.S.doc Version 5.2 Page 27 3. YA16 4. 5. 6. YA23 YA24 YA32 Talbot Woods Lodge Commission for Social Care Inspection Poole Office Unit 4 New Fields Business Park Stinsford Road Poole BH17 0NF 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. Extracts may not be used or reproduced without the express permission of CSCI Talbot Woods Lodge DS0000003991.V354145.R01.S.doc Version 5.2 Page 28 - 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. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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