Inspection on 19/09/05 for 8 Thorndale Road (Homefield College)

This inspection was carried out on 19th September 2005.

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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

8 Thorndale Road (Homefield... 01/07/09

8 Thorndale Road (Homefield... 23/02/07

8 Thorndale Road (Homefield... 13/12/05

8 Thorndale Road (Homefield... 07/12/04

8 Thorndale Road (Homefield... 15/09/04

8 Thorndale Road (Homefield... 18/03/04

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Hillside

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Beech Lodge

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Extracts from inspection reports are licensed from CQC, this page was updated on 08/07/2008.

CARE HOME ADULTS 18-65 8 Thorndale Road Thurmaston Leicester LE4 8NQ Lead Inspector Sharon Treadwell Unannounced Inspection Monday, 19th September 2005 15.30 8 Thorndale Road DS0000001671.V251022.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 DS0000001671.V251022.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 DS0000001671.V251022.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service 8 Thorndale Road Address Thurmaston Leicester LE4 8NQ 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) 0116 2925340 01509 815696 Homefield College Limited Mrs Lynne Lorraine Robinson Care Home 4 Category(ies) of Learning disability (4) registration, with number of places 8 Thorndale Road DS0000001671.V251022.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 7/12/2004 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 DS0000001671.V251022.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection carried out at 3.30pm on a weekday afternoon as students were returning to the home from their educational programmes. Prior to the inspection the inspector had received a completed pre inspection questionnaire from the acting manager and also completed comment cards from four students and from four relatives. The information contained in the questionnaires received prior to the inspection is reflected within this report although these questionnaires were not completed in respect of the four students currently accommodated. All four of those students left Homefield College at the end of the last academic year and the four students currently in residence moved into the home in September 2005. One of the current students is in her third year at Homefield College but this is her first residential year, two students are in their second year at the college and one student is at the beginning of her first year. At the time of this inspection one of the students accommodated was aged under eighteen. The focus of inspections undertaken by the Commission for Social Care Inspection is upon outcomes for service users. The primary method used during this inspection was that of case tracking, which involved selecting two of the young people currently accommodated at the home and tracking the care they received through looking at their records and observation and discussion with young people and staff at the home. This inspection took three and a half hours, during which the inspector spoke with all four of the young people and with the acting manager of the home and two members of staff. All are commended for their warm welcome and for the ease with which they facilitated this inspection. The questionnaires received indicated that the students completing them were happy with their placements and relatives too indicated that they were fully satisfied with the services provided. What the service does well: Young people are well supported and facilitated to access a wide range of education, personal development, employment, leisure and social opportunities. They are additionally encouraged to develop self-care and independence skills in preparation for moving on from Homefield College. Thorndale Road provides a clean, comfortable and homely environment. 8 Thorndale Road DS0000001671.V251022.R01.S.doc Version 5.0 Page 6 During this inspection the students at Thorndale Road were observed to be happy and contented. They spoke positively of their moves to Thorndale Road and spoke very highly of their relationships with the staff. What has improved since the last inspection? What they could do better: Training for staff in the administration of medication is to a good standard but is not currently accredited training. The home has previously been recommended to complete a written risk assessment in relation to the lone working situation and to share its contents with all staff members. This has not been undertaken and this recommendation is re-iterated strongly within this report. The inspector has pointed out during previous inspections that the front sheet of the student’s care plan should contain a date of compilation of the plan and this recommendation is re-iterated within this report. Although student’s files contain evidence of extremely thorough initial assessment by Homefield College, there is no evidence of reasons for or discussion of placement at Thorndale Road or of the involvement of this home’s acting manager in that process. Please contact the provider for advice of actions taken in response to this 8 Thorndale Road DS0000001671.V251022.R01.S.doc Version 5.0 Page 7 inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. 8 Thorndale Road DS0000001671.V251022.R01.S.doc Version 5.0 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection 8 Thorndale Road DS0000001671.V251022.R01.S.doc Version 5.0 Page 9 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 2, 3, 5. An extremely thorough initial assessment is carried out of each student’s individual needs, by Homefield College personnel. Records at the home must evidence how and why the decision is made to transfer a student to Thorndale Road EVIDENCE: The process of initial assessment at the point of admission to the college is an extremely comprehensive one. Admission is after an assessment process involving an interview, an initial assessment day and a two-day residential assessment (evidence of this was seen on one of the files tracked). Subsequently, during the young person’s first term a thorough assessment is undertaken in four main areas of Independent Living, Basic Skills, Vocational Learning and Social and Personal Development. Learning goals are then identified and a comprehensive personal programme compiled. One of the student’s tracked during this inspection was in the process of baseline assessment and staff explained to the inspector the differential daily recording requirements in relation to this student, which is geared towards clearly identifying and evidencing capabilities in a range of areas whilst recording for the other three students is against identified care plan objectives. One of the files examined during this inspection related to a young person who had recently transferred from the main college site. Although this young person’s file contained evidence of a review of the care plan immediately prior 8 Thorndale Road DS0000001671.V251022.R01.S.doc Version 5.0 Page 10 to this transfer, there was no record of the proposed move being discussed or of attendance at this review by any staff from Thorndale Road. The acting manager of this home is currently in the position of not being able to fully evidence the home’s capacity to meet individual needs because there is no record of the reasons for students’ transfers to Thorndale Road or of her involvement in those decisions. No contractual agreements were evidenced on the files tracked during this inspection, either with individual students or with placing authorities. 8 Thorndale Road DS0000001671.V251022.R01.S.doc Version 5.0 Page 11 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7, 8, 9. Care planning for young people accommodated at the home is current and to a high standard. Young people’s individual abilities and support needs are clearly recorded. EVIDENCE: Care planning follows the same format throughout the Homefield provision and is undertaken to a commendably high standard. The Care Plan is drawn up in negotiation with the young person, the family and the placing authority and requires the signature of all parties. The care plans examined during this inspection were not appropriately signed and the acting manager explained that the originals were held on the college site whilst Thorndale Road was provided with copies. The inspector would suggest that consideration be given to reversing this, thus ensuring that a signed copy is available where the young person resides. The inspector has previously recommended the insertion of a compilation date on the front sheet of each student’s care plan. The file examined during this inspection of one of the second year students evidenced that the care plan had been subject to review and, subsequent to the move to Thorndale Road, this care plan had been further updated by the acting manager to reflect progress. 8 Thorndale Road DS0000001671.V251022.R01.S.doc Version 5.0 Page 12 The acting manager was reminded during this inspection to ensure that interim amendments are signed and dated. Care plans examined and young people spoken to evidenced that staff at the home work consistently to develop young people’s self help skills and confidence by encouraging the acquisition of domestic skills, independent travel, access to learning opportunities through college courses, access to a range of leisure activities and efforts to secure appropriate employment experience. A comprehensive individual risk assessment, undertaken as part of the care planning process, ensures that these opportunities are accessed with appropriate support. The home is commended on it’s comprehensive policy on risk taking, which stresses the empowerment of the service user and the requirement for consensual agreement about what constitutes reasonable risk. The acting manager was able to show the inspector a whole range of additional risk assessments, which she has completed relating either to individual students or staff or, in some cases, to all occupants of the home and this is commendable. A house meeting is held weekly at Thorndale Road and the minutes of these meetings, examined during this inspection, evidence the encouragement of young people to express their views. The acting manager is particularly commended for the erection of a chalk board in the kitchen on which young people may note issues for discussion at future meetings. Young people spoke throughout this inspection of their moves to Thorndale Road as being very positive. They spoke of strong relationships with the staff and were observed to relate well with one another and with the staff. One young person found his ‘little daily talks’ with one of the staff ‘helped a lot’. 8 Thorndale Road DS0000001671.V251022.R01.S.doc Version 5.0 Page 13 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, 15, 16, 17. Students are encouraged and facilitated to make full use of community facilities and to participate in a wide range of social, leisure and educational activities. EVIDENCE: During term time each of the student’s accommodated at Thorndale Road follows an individual programme of educational and skill based activities. Some of these programmes are delivered on the Homefield College campus whilst other programmes are accessed through local colleges of further education or are community or home based. One relative commented on the progress her son had made during his placement at this home ‘due to the individual care and programmes he has received’. Evidence was noted on the files tracked of the appropriate involvement of the Connexions service with students and of the appropriate early identification of long term goals in respect of employment and accommodation options. Young people’s files contain behaviour plans in addition to care plans detailing the potential triggers to inappropriate behaviour and suggesting suitable 8 Thorndale Road DS0000001671.V251022.R01.S.doc Version 5.0 Page 14 responses. All students have regular, recorded individual sessions with their nominated key workers to support the achievement of care planning objectives. Young people’s individual programmes were reflective of opportunities to experience a wide range of occupational, educational, leisure and social activities and to develop a range of essential life skills. On the evening of this inspection each of the young people prepared their own tea and a record was retained by staff of food eaten. One young person prepared her menu for the coming week and, as the inspector left two of the young people were going shopping with staff for food items selected. The young people spoke positively to the inspector about recent and planned activities including cinema visits, meals out and a visit to Alton Towers. During the inspection one of the students expressed concern to the inspector about where they would go for the half term holiday in October. The acting manager and staff explained that the reason for this concern was that this home has previously operated term time only because students placed were term time only. The student concerned very clearly told the inspector that they did not want to move from Thorndale Road for the holidays. Staff indicated that another of the young people currently accommodated may also not be going home every holiday. Clearly the accommodation of students on full time placement at Thorndale Road has implications for the provider since the inspector was advised that some members of the staff team are employed on term time only contracts. A review of the home’s operational status will need to address this before the half term holiday in October and decisions made must take account of student’s views. During this inspection the acting manager confirmed that relationships with neighbours were ‘extremely good’. One of the young people was observed during the inspection to be interacting well with an immediate neighbour. 8 Thorndale Road DS0000001671.V251022.R01.S.doc Version 5.0 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. Young people are provided with a very individual service, their specific and very individual health and personal support needs are clearly identified and well met. EVIDENCE: Young people’s care plans clearly address health issues and areas where personal support is needed. None of the students currently accommodated at the home require intimate personal care although staff retain an awareness of the need to monitor and encourage personal hygiene. The files examined contained a full record of all medical appointments and prescribed treatments. A standard pro forma is completed by staff in respect of each medical appointment attended by a young person at the home, which details the reason for the appointment and the action resulting from it. These forms were examined in relation to the young people tracked and were found to comprise a comprehensive record. One of the files tracked evidenced appropriate input from specialist medical professionals. 8 Thorndale Road DS0000001671.V251022.R01.S.doc Version 5.0 Page 16 Each young person has an allocated support worker at the home and individual sessions are held weekly. The records of these evidence that health and personal support issues are regularly discussed with each young person. During the inspection the inspector spoke with the acting manager about the requirement for particular awareness of the home’s additional responsibilities where young people are under the age of eighteen and she undertook to ensure that individual personal sessions with such young people would fully address the issues listed under Standard 19.6. The acting manager is commended on the institution of a ‘women’s group’ at the home which takes place on a weekly basis and addresses a range of health and personal issues. The managers of all of the Homefield houses have undertaken training on the storage and administration of medication with the local pharmacist. The managers cascade this training to care staff in the homes. Whilst the inspector notes that this is good practice, none of the current training is accredited. Medication records were not examined during this inspection. 8 Thorndale Road DS0000001671.V251022.R01.S.doc Version 5.0 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. The homes policies and practices offer effective protection to young people who are supported and encouraged to voice their opinions. EVIDENCE: The home has a comprehensive policy on Abuse, which clearly defines the various types of abuse and also clearly states action required. The home has a separate, equally comprehensive policy on reporting and preventing sexual abuse. This policy clarifies what constitutes sexual abuse and also the principles for the legal determination of inability to consent. The home has made considerable progress during the last year in its development of appropriate Child Protection Procedures. The acting manager of Thorndale Road has undertaken NSPCC training and is now the nominated Child Protection co-ordinator for Homefield College. She has been responsible for the compilation of a written Child Protection policy document and for the delivery of training to other staff. All staff at Thorndale Road have received this training as well as training in the Protection Of Vulnerable Adults. It is crucial to ensure that the Child Protection co-ordinator’s training is regularly updated if she is to deliver training to other staff. At the time of this inspection the Child Protection policy document had just been reviewed and amended. It is recommended that the new version be sent to the local Area Child Protection Committee (ACPC) for confirmation of its appropriateness. The home does not yet have a copy on site of the local ACPC procedures. All the young people are given both guidance and assistance with finance management skills. The nature of support required is appropriately recorded in the care plan. All the young people have bank accounts. 8 Thorndale Road DS0000001671.V251022.R01.S.doc Version 5.0 Page 18 The home has a comprehensive complaints procedure, clearly detailing responsibility within the Homefield College network. No complaints have been received at the home since the previous inspection. 8 Thorndale Road DS0000001671.V251022.R01.S.doc Version 5.0 Page 19 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 25, 28, 29, 30. The home is decorated and furnished to a good standard and service users are provided with well equipped personal and shared space. EVIDENCE: Three of the students showed the inspector their bedrooms. All were highly personalised and young people are encouraged to bring personal belongings. Shared areas of the home were found during the inspection to be clean and comfortable. Young people are encouraged and, where necessary assisted, to deal with their own laundry. Young people, all of whom have only been at Thorndale road since early September, told the inspector that they liked the house very much. The inspector observed that they all appeared very settled and very much ‘at home’ in their ‘new’ surroundings. The home was visited by the Fire Officer in August and the acting manager confirmed that no requirements were identified. Fire fighting equipment is appropriately maintained. A fire drill was undertaken during the inspection when one of the young people activated a smoke 8 Thorndale Road DS0000001671.V251022.R01.S.doc Version 5.0 Page 20 detector whilst cooking. Young people and staff were noted to respond appropriately. 8 Thorndale Road DS0000001671.V251022.R01.S.doc Version 5.0 Page 21 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 33, 35 Young people feel that they have good relationships with the staff team who evidence a commitment to the provision of a high standard of care. EVIDENCE: Within the pre-inspection questionnaire submitted prior to this inspection the manager confirmed that three of the current group of five staff were qualified to NVQ level two or above. The manager is currently studying for the Registered Managers Award. One of the members of staff spoken to during this inspection told the inspector that she was just at the point of completing the LDAF induction/foundation programme and had found it useful and informative. A detailed list of training undertaken by each member of staff at the home during the last twelve months was supplied to the inspector prior to this inspection. Some training is undertaken internally at Homefield College. The list is comprehensive and includes first aid, child protection, fire safety, report writing, autism and aspergers and communication. The inspector was pleased to note that training on ‘preparation for inspection’ was included in the list as well as ‘Post inspection-planning for action’. A copy of the Care Homes Regulations and the National Minimum Standards is retained at the home and the inspector spoke with the acting manager about ways of raising staff awareness of these. 8 Thorndale Road DS0000001671.V251022.R01.S.doc Version 5.0 Page 22 The four students currently accommodated at Thorndale Road have been there only a short time and the acting manager and staff team explained that they were still very much adjusting to living together and to being at Thorndale Road. The inspector was impressed however that the young people appeared comfortable with the staff and spoke positively of relationships with them. Staff meetings, individual support sessions and appraisals are taking place. The inspector has commented under a previous section on the requirement to review the home’s operational status and this review should address staffing numbers. The acting manager told the inspector of the developing focus on getting students into the community and improving their capacity to function independently. This is commendable and involves the encouragement of independent travel. At the time of this inspection, all four young people were being ‘shadowed’ on a daily basis to access public transport to follow their individual programmes. As staff explained, this can be a complex process to organise since students are not all travelling to the same venue. Currently staff are working in excess of their contracted hours to implement this programme as it necessitates more than one member of staff being on duty. Additionally, in respect of young people accommodated at Thorndale Road, there is a high recording requirement, which can be difficult to accommodate whilst supervising four students. Thorndale Road is the furthest distant of all the Homefield houses from the college site making lone working an especially high-risk consideration. A review of operational status should consider the continuing appropriateness of this current practice. 8 Thorndale Road DS0000001671.V251022.R01.S.doc Version 5.0 Page 23 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39, 41, 42. The manager and staff team of this home evidence a commitment to operating it in a manner which best serves the interests of the young people accommodated. EVIDENCE: The home has a fire safety risk assessment, fire fighting equipment is subject to annual service by an approved contractor and records of fire alarm testing and fire drills are appropriately completed. The young people demonstrated to the inspector what they would do if there was a fire at the home. The home has a wide range of Quality Assurance systems to enable appropriate monitoring of service provision. A quality assurance checklist is issued to the acting manager of the home detailing records and practices to be monitored and a weekly report sheet is completed by the acting manager in line with this checklist and submitted to the Homefield Directors. The manager is additionally required to complete a weekly house maintenance report, which is also forwarded to the directors. Young people at the home are regularly 8 Thorndale Road DS0000001671.V251022.R01.S.doc Version 5.0 Page 24 consulted with regard to their views at weekly house meetings, which are recorded. Provider monitoring visits under Regulation 26 of the Care Homes Regulations are taking place and reports of these visits are comprehensive, are available at the home and have been forwarded to the Commission for Social Care Inspection as required under Regulation 26. The visits are not always being made at the required frequency (once a month) Discussions held with the acting manager during this inspection evidenced her commitment to appropriately supporting the staff team at the home. Rotas examined indicate that she is currently working well in excess of her contracted hours to provide the support she considers important whilst still undertaking some twenty-five to thirty hours on the care rota. 8 Thorndale Road DS0000001671.V251022.R01.S.doc Version 5.0 Page 25 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score X 4 2 X 2 Standard No 22 23 Score 3 3 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 3 3 3 4 X Standard No 24 25 26 27 28 29 30 STAFFING Score 3 3 X X 3 3 3 LIFESTYLES Standard No Score 11 X 12 4 13 3 14 3 15 3 16 3 17 Standard No 31 32 33 34 35 36 Score X 3 3 X 3 X CONDUCT AND MANAGEMENT OF THE HOME 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 8 Thorndale Road Score 3 3 X X Standard No 37 38 39 40 41 42 43 Score 3 X 3 X 3 3 X DS0000001671.V251022.R01.S.doc Version 5.0 Page 26 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. 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 Refer to Standard YA39 Good Practice Recommendations The home is recommended to ensure that monitoring visits by the provider are undertaken at a minimum frequency of one per month. The home should develop a contractual agreement with each service user detailing the terms and conditions of placement. 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. The home should obtain a copy of the local Area Child Protection Committee (ACPC) procedures and is recommended to forward its recently ammended policy document to the ACPC for approval. The home is recommended to implement accredited training for all staff responsible for administering medication. DS0000001671.V251022.R01.S.doc Version 5.0 Page 27 2 YA5 3 YA42YA33 4 YA23 5 YA20 8 Thorndale Road 6 YA33YA16 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. Student care plans should contain a compilation date. Student’s records should contain written evidence of the decision making process resulting in admission to Thorndale Road and this decision making process should involve staff from the home. 7 8 YA6 YA3 8 Thorndale Road DS0000001671.V251022.R01.S.doc Version 5.0 Page 28 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 DS0000001671.V251022.R01.S.doc Version 5.0 Page 29 - 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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