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Inspection on 13/12/05 for 8 Thorndale Road (Homefield College)

Also see our care home review for 8 Thorndale Road (Homefield College) for more information

This inspection was carried out on 13th December 2005.

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

The inspector found no outstanding requirements from the previous inspection report, but made 3 statutory requirements (actions the home must comply with) as a result of this inspection.

What follows are excerpts from this inspection report. For more information read the full report on the next tab.

What the care home does well

The following are areas identified as good working practices; 1) Good day care provisions provided away from the home 2) Good promotion of residents` choice

What has improved since the last inspection?

The following area was identified as an improvement since the last inspection; 1) Recordings of residents` decision making is in their care records.

What the care home could do better:

The following are identified as areas where they could do better; 1) Review the operational status of the home to ensure that robust procedures are put in place to support staff members who work alone at night. 2) Identify possible risks and carry out risk assessments. 3) Issue contract of residence to residents residing in the home. 4) Record completion dates on residents` care plans.

CARE HOME ADULTS 18-65 8 Thorndale Road (Homefield College) 8 Thorndale Road Thurmaston Leicester LE4 8NQ Lead Inspector Mr Everton Osbourne Unannounced Inspection Tuesday, 13th December 2005 15:30 8 Thorndale Road (Homefield College) DS0000001671.V272647.R01.S.doc Version 5.0 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address 8 Thorndale Road (Homefield College) DS0000001671.V272647.R01.S.doc Version 5.0 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. 8 Thorndale Road (Homefield College) DS0000001671.V272647.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service 8 Thorndale Road (Homefield College) Address 8 Thorndale Road Thurmaston Leicester LE4 8NQ 0116 2925340 01509 815696 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) Homefield College Limited Miss Victoria Margaret Breward Care Home 4 Category(ies) of Learning disability (4) registration, with number of places 8 Thorndale Road (Homefield College) DS0000001671.V272647.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. No one under the age of 16 years may be accommodated in the home. Date of last inspection 19th September 2005 Brief Description of the Service: Number 8 Thorndale Road is a 5 bedroom semi-detached house situated in the village of Thurmaston. The house does not stand out from its neighbours. The home is clean, comfortable and well furnished and accommodates four young people in single rooms, one of which is en suite. The home has a comfortable lounge, kitchen and a lounge/dining room with patio doors leading onto an enclosed garden. The home is one of seven, which are annexed to Homefield College. Students are initially accommodated at the college site, moving to one of the houses when assessment determines the requirement for greater independence, sometimes in a longer term placement. Young people at the college have been placed by the Learning Skills Council. These placements are generally term time only and limited to 2 or 3 years. However, some young people receive continued or additional funding from Social Services Departments and their placements can be for up to fifty-two weeks a year and may progress to become long term. The college (and implicitly the seven houses) provide placements for adults with learning disabilities and those who have autistic spectrum disorder and some challenging behaviours. The college does not provide for students who require nursing care. Four young people are currently accommodated at this home. One is a full time student (52 weeks), one is accommodated for part of the holidays and the other two students are term time only. 8 Thorndale Road (Homefield College) DS0000001671.V272647.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection took three hours and thirty minutes to complete. There are five Recommendations which are still outstanding from the last inspection held on the 19/09/05. Three Requirements were made during this inspection which include one Immediate Requirement. An Immediate Requirement notification was issued concerning keeping residents safe in the kitchen. Observations made indicated that the home is maintained to acceptable standards. One resident and one staff member was spoken with as part of the inspection process. One resident’s care record and the reading of home policies formed part of the inspection process also. What the service does well: What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. 8 Thorndale Road (Homefield College) DS0000001671.V272647.R01.S.doc Version 5.0 Page 6 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 8 Thorndale Road (Homefield College) DS0000001671.V272647.R01.S.doc Version 5.0 Page 7 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 4 and 5 The admission and assessment processes are fair for the protection and care of residents. EVIDENCE: One resident’s assessment inspected indicated that her care needs was assessed before she moved into the home. The document seen contained sufficient information which identified her care needs. No evidence of a Terms and Conditions of residence or contract pertaining to the resident was seen in the care records. It is Recommended that the registered person complete and issue residents with Terms and Conditions of their residency in the home. A Statement of Purpose was not available in the home when requested for inspection. The registered person is required to keep an up to date Statement of Purpose in the home at all times and ensure that it is available for inspection by the Commission for Social Care Inspection (CSCI). The admission process was inspected. One resident’s record seen and conversation held with the resident indicated that prospective residents have trial visits before moving into the home on a permanent basis. 8 Thorndale Road (Homefield College) DS0000001671.V272647.R01.S.doc Version 5.0 Page 8 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 and 10 Residents care plans are robust so that they receive good quality care. EVIDENCE: One resident’s care plan seen contained sufficient information which identified the resident’s care needs. The information contained in the document is robust in giving staff members’ instructions on how to meet the resident’s care needs. No evidence of a completion date for the care plan is recorded on the document. Observations made showed that the document is locked away in a cupboard at all times when not in use. 8 Thorndale Road (Homefield College) DS0000001671.V272647.R01.S.doc Version 5.0 Page 9 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): 11 and 14 Residents have regular contact with family and friends in order to maintain contact with the community. EVIDENCE: Discussion held with one staff member and conversation held with one resident indicated that the resident maintain contact with her family and friends. Evidence of this was seen in the resident’s activities record which show that the resident is continuously engaged in leisure pursuits throughout the week and on weekends. 8 Thorndale Road (Homefield College) DS0000001671.V272647.R01.S.doc Version 5.0 Page 10 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): 20 and 21 The medication process is robust in ensuring that residents receive their medication at times prescribed by their doctors. EVIDENCE: The medication process was inspected. One medication record seen indicated that staff members appear to be administering medication in accordance with doctors’ prescriptions. The medication record was up to date and signed by staff members. Discussion held with one staff member indicated that suitable processes are in place in the event of the death of a resident. Information is provided in the policy for staff members’ guidance. 8 Thorndale Road (Homefield College) DS0000001671.V272647.R01.S.doc Version 5.0 Page 11 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): 23 There is an adult protection procedure in place to respond to suspicion or allegation of abuse for residents’ protection. EVIDENCE: At the time of the inspection one resident inserted a knife into a toaster whilst it was plugged into the electric socket and the socket switched on. The registered person is required to carry out a risk assessment immediately to assess the safety of this resident when in the kitchen. A copy of this risk assessment must be sent to the Commission for Social Care Inspections to show that the risk assessment was carried out. 8 Thorndale Road (Homefield College) DS0000001671.V272647.R01.S.doc Version 5.0 Page 12 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): 26 and 27 The home is maintained to acceptable standards with an emphasis on creating a homely environment. EVIDENCE: Observations made indicated that the home’s fixtures and fittings are maintained to acceptable standards. Conversation held with one resident indicated that she is satisfied with residing in the home. Observations made indicated that there are sufficient numbers of toilet and bathing facilities based on the number of residents residing in the home. 8 Thorndale Road (Homefield College) DS0000001671.V272647.R01.S.doc Version 5.0 Page 13 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): 33 Adequate staffing hours is provided during the day for the care of residents residing in the home. EVIDENCE: The staffing rota seen and observations made showed that sufficient numbers of staff members are on duty during the day. One staff member is on duty during the night with at least one resident who have the potential to display behaviour which could place other residents or the lone-working staff member at risk. Conversation held with one staff member indicated that an on-call staff member is contactable and can be in the home within fifteen minutes of a call being made. It is Recommended that a risk assessment is carried out concerning having one staff member on duty with a resident who have the potential of displaying adverse behaviour which could place other residents and the staff member at risk. 8 Thorndale Road (Homefield College) DS0000001671.V272647.R01.S.doc Version 5.0 Page 14 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): 38, 39, 40, 42 and 43 The management approach to managing the home creates an open and inclusive atmosphere, although one aspect could possibly place residents or staff members at risk. EVIDENCE: Registration documents seen prior to the inspection pertaining to the registered manager indicated that she is suitably experienced and qualified to manage the home. All policies seen during the inspection gives staff members’ guidance and information about safe working practices to be adapted in the home. One resident’s care record seen showed that this resident is prone to behaviour which could place other residents or staff member at risk. No risk assessment was seen concerning having one staff member working during the night with residents who have the potential of displaying very difficult behaviour. All documents and care records inspected were up to date and kept secured in lockable spaces. 8 Thorndale Road (Homefield College) DS0000001671.V272647.R01.S.doc Version 5.0 Page 15 No evidence was seen to indicate that the registered person is carrying out monitoring visits as required. The registered person is required to carry out monitoring visits in accordance with Regulation 26 of the Care Home Regulations 2001. 8 Thorndale Road (Homefield College) DS0000001671.V272647.R01.S.doc Version 5.0 Page 16 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score 2 3 x 3 2 Standard No 22 23 Score x 2 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 3 x x x 3 Standard No 24 25 26 27 28 29 30 STAFFING Score x x 3 3 x x x LIFESTYLES Standard No Score 11 3 12 x 13 x 14 3 15 x 16 x 17 Standard No 31 32 33 34 35 36 Score x x 3 x x x CONDUCT AND MANAGEMENT OF THE HOME x PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score x x 3 3 Standard No 37 38 39 40 41 42 43 Score x 3 2 3 x 2 3 8 Thorndale Road (Homefield College) DS0000001671.V272647.R01.S.doc Version 5.0 Page 17 No Are there any outstanding requirements from the last inspection? 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 YA1 Regulation 4 Requirement Timescale for action 20/12/05 2 YA23 13 3 YA39 26 The registered person shall supply a copy of the Statement of Purpose to the Commission and shall make a copy of it available on request for inspection. The registered person shall 13/12/05 ensure that unnecessary risks to the health or safety of service users are identified and so far as possible eliminated. Where the registered provider is 20/01/06 an individual, but not in day to day charge of the care home, he shall visit the care home in accordance with this regulation. Visits under paragraph (1) or (2) shall take place at least once a month and shall be unannounced and shall prepare a written report on the conduct of the care home and submit a copy to the CSCI. 8 Thorndale Road (Homefield College) DS0000001671.V272647.R01.S.doc Version 5.0 Page 18 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. Refer to Standard YA5 Good Practice Recommendations The home should develop a contractual agreement with each service user detailing the terms and conditions of placement. This Recommendation was also made at the last inspection held on the 19/09/05. The home is recommended within this report to complete a written risk assessment in relation to lone-working, which should be shared with all staff. This Recommendation was also made at the last inspection held on the 19/09/05. The home is recommended within this report to complete a written risk assessment in relation to lone-working, which should be shared with all staff. This Recommendation was also made at the last inspection held on the 19/09/05. The Registered Persons should review the operational status of Thorndale Road in view of the current accommodation of a student who requires accommodation during holiday times. This review will need to take account of the potential staffing implications and must take account of the views of the young people living at the home. The review should consider the appropriateness of the current lone working practice in light of identified support and recording requirements and distance from the college site. This Recommendation was also made at the last inspection held on the 19/09/05. Student care plans should contain a compilation date. This Recommendation was also made at the last inspection held on the 19/09/05. 2. YA42 3. YA33 4. YA33 5. YA6 8 Thorndale Road (Homefield College) DS0000001671.V272647.R01.S.doc Version 5.0 Page 19 Commission for Social Care Inspection Leicester Office The Pavilions, 5 Smith Way Grove Park Enderby Leicester LE19 1SX 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 8 Thorndale Road (Homefield College) DS0000001671.V272647.R01.S.doc Version 5.0 Page 20 - 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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