Inspection on 16/09/05 for Autism Plus Limited

This inspection was carried out on 16th 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 found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 8 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Autism Plus Limited 22/06/06

Autism Plus Limited 02/03/06

Autism Plus Limited 21/04/05

Autism Plus Limited 16/12/04

Autism Plus Limited 08/07/04

Similar services:

Larch Avenue

Alderson Road 12

Cranworth Close Registered Care Home

The Cornerstone

John Street Nursing Home

Pennine Camphill

Whitwood House

Whitwood Hall

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

CARE HOME ADULTS 18-65 Thorne House Services For Autism St Nicholas Road Thorne Doncaster South Yorkshire DN8 4AG Lead Inspector Janet McBride Unannounced Inspection 16th September 2005 10:20 Thorne House Services For Autism DS0000007974.V250652.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 Thorne House Services For Autism DS0000007974.V250652.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. Thorne House Services For Autism DS0000007974.V250652.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Thorne House Services For Autism Address St Nicholas Road Thorne Doncaster South Yorkshire DN8 4AG 01405 812128 01405 812509 dj@thsa.co.uk 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) Thorne House for Autism *** Post Vacant *** Care Home 33 Category(ies) of Learning disability (33) registration, with number of places Thorne House Services For Autism DS0000007974.V250652.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 21st April 2005 Brief Description of the Service: Thorne house is a care home providing care and accommodation for 33 service users, for Adults with Autism. The organisation is a registered charity, and is run from central offices located at Fieldside Court in the centre of Thorne. The residential service is provided in five properties that are all in easy reach of each other in the town of Thorne. Thorne house is the main unit located in its own grounds. It is divided into five self-contained flats and in total offers places for 18 young adults. Each flat has its own front door and there is a central lobby that visitors to the units can utilise. Along side this is the four satellite homes. Bellwood Crescent and Alexandra Road are in the heart of the community and Rusholme and Hillcrest are on St Nicholas Road both being next door to each other. Each accommodation has single bedrooms and shared communal facilities. Each operating as a domestic household. Staff, are allocated to specific homes and have facilities within for record storage and sleep-in rooms where appropriate. Thorne House Services For Autism DS0000007974.V250652.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was the homes second Unannounced Inspection since April 2005,the Inspection took place on the 16th September 2005 and started at 10:20 and finished at 16:00 hours, a further visit also took place on the 6th October 2005 to check some documentation in staff files. A number of standards were assessed and interviews with members of the management and staff within the homes units, no service users were spoken to on this visit. A number of records were examined and tour of the main house. 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. Thorne House Services For Autism DS0000007974.V250652.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 Thorne House Services For Autism DS0000007974.V250652.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 Potential service users have the information they need to make the choice about moving into the home, and what the service provides and if the home will meet their needs. EVIDENCE: Since the last Inspection the company has updated and completed its statement of purpose and service users guide, this ensures that prospective service users and placing authorities have the information they need to make a choice about living in the home. Thorne House Services For Autism DS0000007974.V250652.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): None of these standards were assessed at this Inspection. EVIDENCE: Thorne House Services For Autism DS0000007974.V250652.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): None of these standards were assessed at this Inspection. EVIDENCE: Thorne House Services For Autism DS0000007974.V250652.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): 19 20 Service users health is monitored and staff can access all NHS health care facilities. Medication practice of secondary dispensing puts service users at risk of receiving incorrect medication. EVIDENCE: Service users health is monitored and staff can access the General Practitioner, if nursing care was needed, this would be sought via GP and District nursing services. Service users also accessed NHS health care facilities such as dentist, optician and any relevant specialists that were necessary. Records are maintained of current medication for all service users, these records were checked and some issues were raised; although the pharmacist as been consulted about secondary dispensing and have prepared weekend medication for some service users going on leave, evidence was found that some staff are placing tablets in containers for staff at day care, or parents when on home leave, to give. Staff and parents do not therefore have information about what they are giving or if it is correct. On examination of MAR sheets some were found to be hand written and were not signed by two members of staff, to verify medication regime. One medication was found to be out of date. Discussion about storage of medication on one of the units causes issues for staff and it will be moved to another area. Thorne House Services For Autism DS0000007974.V250652.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): None of these standards were assessed at this Inspection. EVIDENCE: Thorne House Services For Autism DS0000007974.V250652.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): 24 27 30 Service users live in a homely, comfortable and safe environment, but the bathrooms in all the units and would benefit from some general repairs, and redecorating to make them more homely for service users. EVIDENCE: Tour of the main unit was found to be clean and tidy and well maintained with a minor issue being raised, carpet on the corridor outside one unit requires attention, and each unit now as a refurbishment plan which should ensure that planned maintenance and renewal programme for the fabric and decoration of the premises should take place. All the bathroom and toilets on the units have been identified as needing soap dispenses and hand drying facility, also some of these areas require appropriate covers to windows. Other issues raised in these facilities were; tiles missing, toilet chipped and bath surface very worn. Discussed laundry facilities which remains the same, central laundry based at the main unit, which as been seen on previous visits and found satisfactory. Thorne House Services For Autism DS0000007974.V250652.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): 31 33 36 Staff that are competent and have the skills to deliver the care and support service users. Service users also benefit from staff that is well supported from management. EVIDENCE: Staffing was discussed with both the management and team leaders, staffing remains a problem re; vacant posts, staff on maternity leave and high levels of sickness, however the management are addressing these issues by using agency staff and staff members doing extra shift to ensure that sufficient staff are on duty at all times. Since the last Inspection staff has been provided with copies of the Codes of Practice issued by the General Social Care Council, which are intended to reflect good practice, and describes the standards of professional conduct and practice required of staff. Supervision files were checked which shows that most team leaders has received regular formal supervision sessions, with the exception of a few outstanding, also staff yearly appraisal are outstanding. Thorne House Services For Autism DS0000007974.V250652.R01.S.doc Version 5.0 Page 14 A number of issues have affected staff morale but when interviewing staff and management it was evident that the acting group manager and the chief executive have been communicating with staff on a regular basis, to discuss any issues or concerns raised. Thorne House Services For Autism DS0000007974.V250652.R01.S.doc Version 5.0 Page 15 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 Service users health, safety and welfare are promoted and protected, and records required by regulation and for their protection are maintained and up to date, but with the exception of sending regulation 37 reports to the Commission for Social Care Inspection. EVIDENCE: Since the last Inspection changes within the management structure, the home has a new chief exective, and the group manager has left therefore they have a vacant post, but an acting group manager is in post. Both the chief executive and the acting group manager have met with the Inspector and co-operated with any issues raised. Regulation 26 visit reports have not been sent to the Commission for Social Care Inspection in the past, despite previous requirements made, however these reports are now being received, this provides evidence that the group homes are being monitored. Staff are not sending Regulation 37 incident forms Thorne House Services For Autism DS0000007974.V250652.R01.S.doc Version 5.0 Page 16 on a regular basis, although some have been completed and the acting manager will ensure that all staff are aware of these forms and that they require sending to the Commission for Social Care Inspection. Health and safety was discussed with some members of staff, and examination of fire logbook, records indicate that all appropriate fire tests are carried out on a weekly basis, and evidence was seen that fire alarms and emergency lighting have recently been serviced. Thorne House Services For Autism DS0000007974.V250652.R01.S.doc Version 5.0 Page 17 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 3 X X X X Standard No 22 23 Score X X ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score X X X X X Standard No 24 25 26 27 28 29 30 STAFFING Score 2 X X 2 X X 3 LIFESTYLES Standard No Score 11 X 12 X 13 X 14 X 15 X 16 X 17 Standard No 31 32 33 34 35 36 Score 3 X X X X 2 CONDUCT AND MANAGEMENT OF THE HOME X PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Thorne House Services For Autism Score X 3 2 X Standard No 37 38 39 40 41 42 43 Score 2 X 3 X 2 3 X DS0000007974.V250652.R01.S.doc Version 5.0 Page 18 YES 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 YA20 Regulation 13(2) Requirement Medication; 1) Secondary dispensing by staff must cease and alterative arrangement must be made. 2) MAR sheets that are hand written must have two signatures for verification of medication regime. 3) Medication must be checked to ensure it’s not out of date. Seek alternative storage for medication. Bathrooms and Toilet Facilities; 1) A number of bathrooms have been identified as needing soap dispenses and hand dryers. 2) Windows to have blinds or suitable covers. 3) Replace tiles that were identified as missing. 1. Repair or replace bath that is worn. 2. Repair or replace toilet that is chipped. Corridor carpet on Willow unit requires attention, to ensure safety. DS0000007974.V250652.R01.S.doc Timescale for action 01/11/05 2 3 YA20 YA27 13(2) 23(2)(c) 31/12/05 01/12/05 4 YA27 23(2)(c) 31/12/05 01/11/05 5 YA24 23 Thorne House Services For Autism Version 5.0 Page 19 6 7 8 YA36 YA37 YA41 18 8(1) 37 Staff must receive formal supervision on a regular basis and yearly appraisals. Appointment of manager as soon as possible. Records required by regulation; notifications must be sent to the Commission for Social Care Inspection. 01/12/05 01/01/06 01/11/05 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Thorne House Services For Autism DS0000007974.V250652.R01.S.doc Version 5.0 Page 20 Commission for Social Care Inspection Doncaster Area Office 1st Floor, Barclay Court Heavens Walk Doncaster Carr Doncaster DN4 5HZ 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 Thorne House Services For Autism DS0000007974.V250652.R01.S.doc Version 5.0 Page 21 - 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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