Care and Social Services Inspectorate Wales
Care Standards Act 2000
Inspection Report
22 Tal y Wern
Port Talbot
Type of Inspection – Baseline
Dates of inspection – Thursday, 10 September 2015
and 6 October 2015
Date of publication – Wednesday, 4 November 2015
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Summary
About the service
Tal Y Wern is a large detached bungalow which is situated on a housing estate in
Margam, Port Talbot and is registered to provide support and accommodation for four
people who have a learning disability. It is close to a wide range of local services and
amenities within easy access to the M4 motorway.
The registered provider is Community Lives Consortium which is a Swansea based
organisation and primarily offers support to people with a learning disability. Richard
Wilson is the responsible individual and Erith Waters is the registered manager, although
we (Care and Social Services Inspectorate Wales - CSSIW) were informed that Ms.
Waters is no longer the manager. The deputy manager Sarah Phillips is currently acting
manager and will shortly be submitting an application to become registered manager with
CSSIW.
What type of inspection was carried out?
We (CSSIW) visited the home on 10th September 2015 and 7th October for a scheduled
unannounced visit and one announced visit to the provider’s central office in Swansea on
6th October 2015. This is a baseline inspection focussing on all four themes –quality of
life; quality of staffing; quality of leadership and management and quality of the
environment.
The methodology used was:
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Two unannounced visits to Tal y Wern
One announced visit to the registered provider office to examine the two randomly
selected staff files
Examination of records relating to two people receiving care at the home
Examination of two staff files held at Tal Y Wern
Reference to previous inspection report
Discussion with staff and people at Tal Y Wern
Discussion with other professionals – care manager
Tour of the home
What does the service do well?
This inspection identified that there were no significant areas of outstanding practice. The
matters reported here are those which exceed CSSIW’s expectations that conditions of
registration, regulations and national minimum standards are adhered to at all times within
the care provided.
What has improved since the last inspection?
This inspection identified that there were no significant areas of improvement since the last
inspection.
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What needs to be done to improve the service?
There were no issues of non-compliance identified at this inspection.
However, from discussion with the acting manger, the following good practice
recommendations were made:Display current registration certificates at the home, as required in Regulation 28 (1) of the
Care Standards Act 2000. These must be displayed once the new registration has been
processed.
All copies of notifications under Regulation 38 of the Care Home(Wales) Regulations 2002
need to be sent to CSSIW
An audit is undertaken to ensure that all policies are current. We did recommend to the
acting manager that an index of policies with the review date is kept on file as this provides
a clear system of when each policy needs to be reviewed or no changes required.
Since undertaking the inspection visits, the manager has confirmed that the above
recommendations have been put in place.
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Quality Of Life
People using the service can be confident that the staff who support them do so with
patience, sensitivity and kindness. Observations during the inspection visit showed that
interactions between people using the service and the staff who support them were
positive, friendly and affectionate. During interactions there was appropriate humour and
a relaxed and calm atmosphere.
People living at Tal y Wern have a voice and are listened to as there are monthly/bimonthly feedback meetings which are recorded. In addition all the people living at the
home are also supported to complete satisfaction surveys at least annually.
We looked at the records of two people during the inspection and found that the home is
committed to delivering person centred care. The care records provided robust
information regarding how it should be delivered, together with detailed risk
assessments. There was also clear evidence of multi-agency working, with support
being provided by the psychiatrist, speech and language therapist and care manager.
There was also evidence that personal support plans had been reviewed and were
current. In addition the acting manager informed us that daily behaviour charts are
completed and housed on the computer system and this is collated with assistance of the
psychologist and is used in the compilation of behaviour plans.
Two of the people who currently live at the home spend the majority of the week at a day
centre, whilst the other two people are involved in one to one activities with the staff.
One person informed me that she had been on a trip to Swansea and another was keen
to tell me about a previous holiday she had been on. People also frequent the local
cafes etc.
People benefit from a varied diet with good attention to nutrition and hydration, although
from discussion with staff menus are not planned. During the inspection we saw staff
asking people what they would like to have for breakfast and lunch and choices were
offered. The manager also informed us that some of the people living at Tal Y Wern
participate in kitchen activities such as meal preparation/laying the table ready for meals.
People can be confident that medication is administered safely as each person has their
own medication cabinet in their room which is locked. We looked at the medication
administration record (MAR) charts and saw that these were completed appropriately
with no gaps in signing for the medication. There are weekly medication audits and the
manager undertakes a monthly audit. Also there is an annual audit by the pharmacy and
the last one (16/12/2014) did not indicate any issues of concern.
Overall the outcomes for people living at Tal Y Wern are positive as they are being cared
for by competent staff who treated them with courtesy, dignity and respect.
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Quality Of Staffing
Tal y Wern has a small staff team and the staff we observed at the time of inspection
were familiar with the needs of the people living there.
However, the acting manager informed us that currently the staffing levels are
compromised due to staff sickness and staff leaving to pursue other careers. At present
the acting manager is undertaking both a managerial role and also provides hands on
support to the team. We were informed that there will shortly be a deputy manager
joining the team and the provider is actively seeking to recruit staff. Consequently the
current staff team were working extra hours and staff from within the Community Lives
Consortium (CLC) network were being used on a flexible basis. As some of the people
living at the home require the support of two staff in respect of manual handling issues,
this places pressure on the staff when there are limited staff available. The acting
manager informed me that CLC are aware of the issue and are trying to provide support
to the manager and the staff team. Following the inspection visits and prior to this
inspection report being published, the acting manager has informed me that a Deputy
Manager is now in place and there will be a full complement of staff by 31/10/2015.
From examination of two staff files held at the care home, supervision records confirmed
that overall staff receive two monthly supervision and annual appraisals, although the
acting manager advised that there were currently difficulties maintaining this. We spoke
to four members of staff during the inspection visits and received the following positive
comments “Good team support and (I) receive supervision approximately monthly and
have had an annual appraisal. The manager is very good, approachable and organised”.
We discussed the number of qualified staff at the home due to the recent changes, and
currently the home is meeting the required National Minimum Standards (NMS: 23.5)
with 50% of staff holding the required care qualification. The acting manager also
informed us that the majority of staff have also undertaken dementia care training in
order to support people living at the home. From the information we have received, staff
training is current and up to date and the manager is in the process of seeking refresher
training in respect of Deprivation of Liberty Safeguards (DoLs) and staff have received
mental capacity training.
People can feel confident that staff are motivated and positively interact with people at
the home which has a positive impact on their wellbeing.
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Quality Of Leadership and Management
Overall people can be confident that they are receiving support from a service that is
committed to meeting their needs and that of the staff team. From our observations
during the inspection, the acting manager was supporting staff on duty and this resulted
in a calm and friendly atmosphere and care provided to people was unrushed and
appropriate.
The acting manager has been in this post since October 2014, having previously been
the deputy manager from July 2010 and it was clear that she has a wealth of knowledge
regarding the individual needs of the people at the home, and is enthusiastic about her
role as acting manager. She is currently in the process of completing an application to
CSSIW to become registered manager and is updating both the Statement of Purpose
and Service User Guide as part of this application.
From communication with the responsible individual following this inspection, we were
informed that the acting manager has been receiving bi-weekly support from a
designated senior manager within the organisation. The acting manager also
commented that she has “a good staff team and is supported by the organisation”. We
did however, raise our concern with the acting manager about the current staffing levels
and the impact this has on the people living at the home.
However, with the recent appointment of the deputy manager, and increase in staffing
levels at the end of October 2015, this will provide further stability to the staff team, which
will benefit the people living at Tal Y Wern.
Policies are being reviewed to ensure that they are current, although this is work in
progress, as we noted that the Whistleblowing policy was due to be reviewed in July
2015. Whilst good progress is being made in this respect, we would recommend that an
audit is undertaken to ensure that this work is completed when possible. We also
recommended to the acting manager that an index of policies with the review date is kept
on file as this provides a clear system of when each policy needs to be reviewed or no
changes required. These recommendations were positively received.
We discussed the need to display the current registration certificates at the home, as
required in Regulation 28 (1) of the Care Standards Act 2000. We therefore
recommended that these are in place once the new registration has been processed.
People can be confident that there is a robust system in place in respect of managing the
day to day finances of the home, in addition to the individual people’s finances. Each
person has an individual petty cash box with monies that they can access. There is a
clear accounting system in place which evidences the purchases made by people, with
receipts for such.
We also observed that records have been made in respect of incidents/accidents relating
to people at the care home, which provided evidence that the appropriate responsive
action was being taken by the care home. However, following a discussion with the
acting manager, we confirmed that we (CSSIW) have not received copies of Regulation
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38 of the Care Home(Wales) Regulations 2002. Following the inspection, the acting
manager has forwarded these to us at CSSIW and will ensure that such regulations are
completed as required.
People can feel confident that adequate monitoring regarding quality assurance is in
place as the acting manager showed us information that has been collated in readiness
for the quality of care report which is due in January 2016, with feedback being sought
from people living at the home, families, staff and other professionals. Discussions and
regular meetings with the senior manager also contributes to this process.
Overall people can feel confident that the acting manager is committed to supporting the
staff team in order to provide good quality care to the people living at Tal Y Wern.
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Quality Of The Environment
People living in the home can be confident that they are cared for in a clean, comfortable
and relaxed environment in which visitors are made to feel welcome.
The home is in good decorative order and has a spacious kitchen/dining area where
people eat together and there is a separate homely lounge where they can watch
television. We noted the use of pictorial aids in the kitchen area. There is no set menu,
as people are able to choose what they wish to eat, although the home promotes
healthy eating. There is a good sized wet room and toilet in addition to a large
communal bathroom, together with a separate utility room which houses two washing
machines and Control of Substances Hazardous to Health (COSSH) items which are
stored securely in this room.
All the rooms are spacious and have been individually decorated and personalised in
keeping with the people’s wishes. Two of the people living at Tal Y Wern were very keen
and proud to show us their rooms. There is an outside patio area and grassy area with a
small glass house and parking to the front.
Tal Y Wern is owned by Coastal Housing Group and therefore all maintenance work is
undertaken by Coastal. There has been some decoration undertaken and the acting
manager advised that they are awaiting the fitting of a new kitchen.
We saw that there is a current gas safety certificate which was issued in March 2015,
with fire safety checks having taken place in 2015. There is an adequate fire safety
system in place regarding drills and evacuations and no issues have been identified.
Also all staff had received appropriate fire safety training. Records also indicated that
equipment such as the argo hoist was serviced in April 2015 and the manager
undertakes a weekly full equipment check.
People can therefore be reassured that appropriate safety measures are in place to
protect people living at the home, as their personal belongings are secure and their
personal information is properly protected. This is because the entrance door to the
property is locked and entry is via a staff member. There is also a visitor’s book in place
for monitoring those entering and leaving the home. Care and staff records were kept in
lockable cupboards/filing cabinets within the home.
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How we inspect and report on services
We conduct two types of inspection; baseline and focused. Both consider the experience of
people using services.
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Baseline inspections assess whether the registration of a service is justified and
whether the conditions of registration are appropriate. For most services, we carry out
these inspections every three years. Exceptions are registered child minders, out of
school care, sessional care, crèches and open access provision, which are every four
years.
At these inspections we check whether the service has a clear, effective Statement of
Purpose and whether the service delivers on the commitments set out in its Statement
of Purpose. In assessing whether registration is justified inspectors check that the
service can demonstrate a history of compliance with regulations.
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Focused inspections consider the experience of people using services and we will look
at compliance with regulations when poor outcomes for people using services are
identified. We carry out these inspections in between baseline inspections. Focused
inspections will always consider the quality of life of people using services and may look
at other areas.
Baseline and focused inspections may be scheduled or carried out in response to concerns.
Inspectors use a variety of methods to gather information during inspections. These may
include;
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Talking with people who use services and their representatives
Talking to staff and the manager
Looking at documentation
Observation of staff interactions with people and of the environment
Comments made within questionnaires returned from people who use services, staff and
health and social care professionals
We inspect and report our findings under ‘Quality Themes’. Those relevant to each type of
service are referred to within our inspection reports.
Further information about what we do can be found in our leaflet ‘Improving Care and
Social Services in Wales’. You can download this from our website, Improving Care and
Social Services in Wales or ask us to send you a copy by telephoning your local CSSIW
regional office.
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