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Inspection on 22/06/06 for Autism Plus Limited

Also see our care home review for Autism Plus Limited for more information

This inspection was carried out on 22nd June 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is (sorry - unknown). 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 5 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 service is well established, and staff are trained to meet the service users needs, good interactions was noticed between staff and service users in various settings, also that staff were able to communicate effectively with service users. Management and staff are working hard to improve standards and ensure that service users are well cared for and protected and that contact with family was supported and maintained. All service users were involved in some form of day care provision, and a range of activities were offered to service users, this was confirmed when speaking to service users, who gave examples e.g.swimming, visits to local gyms and horse riding. Staff interviewed state they supported service users to be able to participate in their choice of activities whenever possible.

What has improved since the last inspection?

The organisation has kept in regular contact with the Commission for Social Care Inspection about the development of the services. Therefore they continue to improve the provision of the service and numerous examples of improvement have been seen on this Inspection. Communication and the cascading of information to staff throughout the service as improved, a number of comments were received during the inspection from staff about improvement within the service and management. Staff interviewed appeared very positive towards the care they provide for service users and their role within the service.

What the care home could do better:

Ensure that the management restructuring is put in place as soon as possible. Address the issues raised in this report and continue with the good practice and build on the good relationships that have been developed between management and staff.

CARE HOME ADULTS 18-65 Thorne House Services For Autism St Nicholas Road Thorne Doncaster South Yorkshire DN8 4AG Lead Inspector Janet McBride Key Unannounced Inspection 22nd June 2006 09:00 Thorne House Services For Autism DS0000007974.V291120.R01.S.doc Version 5.1 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.V291120.R01.S.doc Version 5.1 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.V291120.R01.S.doc Version 5.1 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.V291120.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 2nd March 2006 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 home, 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. Fees range from £1085:41 to £2243:69, as at June 2006, Fees are calculated dependent on needs e.g. 1 to 1 staffing required. The fees cover a number of items e.g. holidays, outings, client training and various therapies, but the fees do not cover toiletries, mobile phones, sweets and some activities e.g. bowling. The central office located at Fieldside Court is the reception area for visitors and they provide lots of information, including the homes last published inspection report for prospective service users and visitors. Thorne House Services For Autism DS0000007974.V291120.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. One Inspector from the Commission for Social Care Inspection carried out this unannounced inspection at Thorne House Services, which started on the 20th of June 2006 and took place over Three days (15 hours). The home is registered for 33 service users, for Adults with Autism. Pre-Inspection work was carried out for example, analysis of notifications and any other relevant documentation. During the Inspection various documentation and records were examined for example, medication records, staff rotas, staff training and also included case tracking of two -service users care plans, which were cross-referenced with other documentation. Prior to the visit ten questionnaires were sent to service users for their views on the service, and six were received back, also six other service users were spoken to throughout the Inspection, some service users comments were limited due to communication skills, therefore discussion with key workers and observation during the Inspection to gather information for this report. This Inspection also included individual interviews with management and members of staff. Tour of all five premises and direct and indirect observation of staff interaction with service users throughout the visit and discussion with staff on duty within these units, eight staff were interviewed so that information could be gathered from as many different individuals as possible that had contact with the service users in their environment. The Inspector would like to thank management, all the staff and service users for their co-operation in the Inspection process, and any issues or concerns that were raised were discussed with the management of the organisation at the end of the Inspection. What the service does well: The service is well established, and staff are trained to meet the service users needs, good interactions was noticed between staff and service users in various settings, also that staff were able to communicate effectively with service users. Management and staff are working hard to improve standards and ensure that service users are well cared for and protected and that contact with family was supported and maintained. All service users were involved in some form of day care provision, and a range of activities were offered to service users, this was confirmed when speaking to Thorne House Services For Autism DS0000007974.V291120.R01.S.doc Version 5.1 Page 6 service users, who gave examples e.g.swimming, visits to local gyms and horse riding. Staff interviewed state they supported service users to be able to participate in their choice of activities whenever possible. 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.V291120.R01.S.doc Version 5.1 Page 7 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.V291120.R01.S.doc Version 5.1 Page 8 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): 1,2,3 Quality in this outcome area for standard is good. This judgement has been made using the written evidence available in care plans and discussions with staff and a visit to the services. Prospective service users have sufficient information about the services, and all are individually assessed prior to admission to the service, to ensure that their needs will be met. EVIDENCE: Prospective service users have information about the services Provided and at the main office there was a lot of information available for visitors and relatives including the most recent Inspection report. Care plans show that all the services users had been assessed before being placed to Thorne services, and that service users are provided with information about the service they will receive in appropriate format. Discussion with staff showed they had good understanding of various assessment tools used, including risk assessments. Evident from training files and observation of interaction between staff and service users that staff had the skills to communicate effectively with individual service users preferred method of communication. Thorne House Services For Autism DS0000007974.V291120.R01.S.doc Version 5.1 Page 9 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): 6,7,9,10 Quality in this outcome area for standard is good. This judgement has been made using the written evidence available in care plans and discussions with staff and a visit to the services. The care plans provide staff with sufficient information to ensure they can meet the needs of residents, and service users are assisted and support by staff to make decisions and choices about all daily living needs. EVIDENCE: Care plans are developed for each individual service user, two of these were case tracked and provided a lot of evidence about the care each individual required, helping staff deliver the appropriate care. Some service users have profound Autism with an inability to imagine and think laterally; also some service users do not have social skills and at times can display unacceptable behaviour’s, therefore staff support service users to make decisions, communicate and behave appropriately at the correct level. Thorne House Services For Autism DS0000007974.V291120.R01.S.doc Version 5.1 Page 10 Other service users had a higher level of ability to express wishes and make choices and service users are encouraged and supported by staff to make decision about everyday tasks. Advocacy services are available and are used on a regular basis. The plans included a pen picture, information on self-help skills and likes and dislikes. Risk assessments were in place and the plan contained approaches and strategies when intervention was required for service users likely to be aggressive or cause harm, each service users has a communication file, which shows limit of communication, what methods are used and what support is needed. Evidence was also seen that the services use speech and language therapy services that advises staff with communication methods to use. Service users are supported in taking risks as part of an independent lifestyle, evidence was seen that these are risk assessed to minimise any identified risks or hazards. Confidentially was discussed with staff members, all aware of information about service users is handled in confidence and that records are kept in secure facilities. Confidentially was discussed with staff members, all aware of information about service users is handled in Thorne House Services For Autism DS0000007974.V291120.R01.S.doc Version 5.1 Page 11 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): 11,12,13,14,15,16,17 Quality in this outcome area for standard is good. This judgement has been made using the written evidence available in care plans and discussions with staff and a visit to the services. The services provide and promote and encourage development of social and practical skills, ensuring they have the opportunity to participate in leisure activities and live as part of the community. EVIDENCE: Through speaking to staff, and some service users and examination of records provided evidence that staff supported service users to have the opportunity to learn and use practical skills, no matter how small a task may seem, some service users participated in household task, with staff support, and where able, and dependent on abilities and preferences, some service users were seen to be making their own packed lunches for day care, and helping to make their own bed. Thorne House Services For Autism DS0000007974.V291120.R01.S.doc Version 5.1 Page 12 Discussions with staff and examination of records evidenced that staff supported service users to participate in the local community, according to assessed needs and within a risk management framework, including development of their employment skills if the individual as that potential. Group homes live within the local community and state they have good relationships within the community. Each service user had a weekly activities chart, which was planned in advance. These were available and show that the majority of planned activities had taken place. The organisation had a fleet of vehicles to facilitate these activities and outings. Parental contact was maintained and supported at an agreed level and in accordance to the needs of the individual service user. Parents were kept informed of the development of their son or daughter; they can go home for overnight, weekend stays or holidays. The majority of service users spend some of their time outside of the home, and have opportunities to mix with other people who have the same disability at disco’s and other events, including holidays and some of these were planned for the following week and service users were happy to tell the Inspector about these and how much they were looking forward to this. Discussions with management and staff evidenced that the routines of the home were flexible to suit the needs of each service user, however some structured routines had been identified for those service users who benefited from these. Staff try to ensure that service users receive a healthy diet, and help service users plan a menu, examination of the records of food provided, evidenced that a varied diet was available to service users and individual likes and dislikes were recorded in service user plans, the organisation are looking at different models nutritional assessment to ensure they use an appropriate assessment that suits service users within the service. Care plans show that service users are weighed on a regular basis and Dieticians would be consulted if concerns were identified Thorne House Services For Autism DS0000007974.V291120.R01.S.doc Version 5.1 Page 13 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): 18,19,20 Quality in this outcome area for standard is good. This judgement has been made using the written evidence available in care plans and records, discussions with staff and a visit to the services. Service users health is monitored and staff can access all NHS health care facilities. Medication policies and procedures are well managed and staff has the necessary skills to administer the medication to residents, ensuring their safety and protection. EVIDENCE: Two service users care plans were case tracked, these were cross-referenced with other documentation for example medication, accident and incident records, and speaking to key workers. Care plans show that Service users health is monitored and staff can access the General Practitioner, if nursing care were needed, this would be sought via GP and District nursing services. The OK health check is going to be introduced this is for assessing and planning health care needs. Thorne House Services For Autism DS0000007974.V291120.R01.S.doc Version 5.1 Page 14 Evidence was seen that service users also accessed NHS health care facilities such as dentist, optician and any relevant specialists that were necessary, for example psychology and speech and language therapist. Records clearly show detailed information of service users personal care needs, daily routines various risk assessments. Key workers spoken to were able to describe care needs of service users, and when they required the input of either GP or district nurses, also aware of any restrictions on privacy, e.g. danger when bathing alone, risk assessments were in place to identify any risks and how they can be managed. Records are maintained of current medication for all service users, records were checked at Hillcrest, Alexandra and Housely mews, all were found satisfactory with good recording systems and BNF available for staff to refer to. Staff that administer medication have completed accredited training courses. Secondary dispensing, as been an issue for some time, but the organisations took a proactive approach to this and worked with the local pharmacist to try and resolve these issues. They developed a method for home leave medicines; with a policy and procedure for staff to follow, they have piloted this on two units and have just completed their first audit which show this is working. One-month supply of medicines is dispensed in a blue wallet all are in blister packs and the wallet is tagged for security. Stock within the wallet is checked when the service users goes on leave and checked back in again when they return all stocks are recorded and signed for then re-tagged. Thorne House Services For Autism DS0000007974.V291120.R01.S.doc Version 5.1 Page 15 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 Quality in this outcome area for standard is good. This judgement has been made by a visit to the services; examination of records and discussions with staff. Service users and relatives are provided with information to enable them to raise concerns or complaints about the services and the care provided, management and staff have a good understanding of Adult Protection and robust polices are in place to protect service users within their care. EVIDENCE: Discussion with management and records checked provided the evidence that complaints are dealt with appropriately, one complaint since the last Inspection, and records show this was investigated, what action was taken and outcome and feedback to complainant. The service is still recording in hard backed book but is looking at developing a more appropriate format. Staff that were spoken to state they were aware of polices and procedures for complaints highlighted by services users or parents. Discussion with a number of who confirmed they were aware of vulnerable adults policy, and able to discuss what the procedure would be taken is if an allegation of abuse was highlighted, and also aware of whistle blowing policy. Before the Inspection report was completed the organisation sent the Commission for Social Care Inspection a draft copy of the revised complaints procedure, this is an appropriate format and looks more professional, each page is numbered this ensures they can not be tampered with, all units with be issued with this new format. Thorne House Services For Autism DS0000007974.V291120.R01.S.doc Version 5.1 Page 16 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): 24,25,26,27,30 Quality in this outcome area is adequate. This judgement has been made using by visiting all sites within the organisation. Service users live in a homely, comfortable and safe environment, but would benefit from some general repairs, and redecorating to make them more homely for service users. EVIDENCE: The organisation has four community houses, in addition to the main house. Each house has its own budget for decoration and refurbishment, however the main house belongs to South Yorkshire Housing Association (SYHA), along with two of the community homes. All sites within the organisation were visited on this Inspection and the majority of the environments seen in the community homes were well maintained, decorated, clean and tidy. Furnishings and fittings provided were in good condition and most sites looked very homely. Some issues were raised in the Main House, radiator covers require attention, and Alexandra kitchen requires upgrading and Rusholme paintwork outside requires attention and the porch at the back of the premises requires attention (SYHA) will be contacted. Thorne House Services For Autism DS0000007974.V291120.R01.S.doc Version 5.1 Page 17 All service users have their own bedrooms, and a number of service users in the community homes were happy to show me their bedrooms, which were very personalised and individual to that person. Bathrooms and toilet facilities were Inspected in all sites, Main house raised a number of issues on the last Inspection; although the organisation as carried out some minor general repairs and made them look more homely, this property belongs to SYHA and are not willing to refurbish bathrooms, but the organisation will continue to carry out some repairs as required. Bellwood bath panel requires attention and Alexandra bath panel needs attention, and some items require fitting e.g. toilet roll holder and towel rail. Refurbishment and development plan for all sites was available, and copy taken for the file. Thorne House Services For Autism DS0000007974.V291120.R01.S.doc Version 5.1 Page 18 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): 31,32,33,34,35,36 Quality in this outcome area is good. This judgement has been made using the available evidence, interviewing management and staff, including a visit to the service. The organisation has improved staffing, via recruited practices, which are very good; this ensures that an effective, competent and qualified staff team who work positively with service users to improve their quality of life. EVIDENCE: The organisation has worked hard at improving staffing, and as recruited a number of staff. Staffing was discussed with both the management and team leaders all of whom state this as improved, and staff seen was aware of their roles and responsibilities. The organisation had appropriate recruitment policies and procedures in place. Four staff files were sampled these were excellent, they were well organised and contained a front sheet checklist to ensure all required information was obtained and kept. Criminal Records Bureau and POVA checks had been completed on all staff. Thorne House Services For Autism DS0000007974.V291120.R01.S.doc Version 5.1 Page 19 Training and development is linked to the services aims and objectives, each member of staff had an individual file, a number of these were examined, also the staffing matrix, which evidenced what training staff, had completed. Staff can access NVQ training, and a number of care staff had achieved NVQ level 2 in care. The organisation is aware of the requirement to have 50 of care staff trained to NVQ level 2. Supervision as improved and evidence was seen in files that staff had received formal supervision on a regular basis, this was confirmed when speaking to staff members, they also confirmed that training and development is discussed at supervision sessions, including any care issue that they raise concerns about. Records show most staff has had their yearly appraisals and lots of comments from staff about how much the management structure as improved including the cascading of information and the support they receive. Team meeting was observed on one of the units, various issues discussed with good communication between the team. Good interaction between staff and service users observed, staff explained in detail the task they were doing giving encouragement all the time. Thorne House Services For Autism DS0000007974.V291120.R01.S.doc Version 5.1 Page 20 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): 37,38,39,40,42 Quality in this outcome area is Good. This judgement has been made using the available evidence, interviewing management and staff, including a visit to the service. The organisation continues to make improvement in the provision of services but they need to put the new management structure in place to ensure they continue to promote consistency within the service. EVIDENCE: Since the last Inspection meeting have taken place between the Commission for Social Care Inspection and Philip Barty (chief executive of the service) to discuss the new management structure they propose, this new management structures need putting in place as soon as possible to promote consistency within the service. Thorne House Services For Autism DS0000007974.V291120.R01.S.doc Version 5.1 Page 21 At the present day-to-day responsibility for the entire group homes and main house continues to be acting group manager Glynis Davidson who as the relevant experience for this role. Since her appointment improvement in staff recruitment, and regular meetings with team leaders and staff to discuss and care and regulation issues. Quality monitoring within the service as improved, Regulation 37 incident forms have been received on a regular basis along with Regulation 26 visit reports. Discussion with staff confirmed they had regular contact with management and attended regular meeting, all of which minutes were available to examine. Parents and relatives are asked for feedback on the service and care provided. Audits are completed on a regular basis on care plans, medication records and premises. Services users rights and best interests are safeguarded by the homes policies and procedures, spot checks were carried out on these, and management confirmed that a number of these requiring reviewing and updating. Health and safety and safe working practice were discussed with management and some members of staff during the Inspection. Examination of some records indicated that all appropriate fire safety is carried out as required. Training file checked shows staff have received training and updates in fire training, moving and handling, health and safety and first aid. Thorne House Services For Autism DS0000007974.V291120.R01.S.doc Version 5.1 Page 22 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 3 2 3 3 3 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 2 25 3 26 3 27 2 28 X 29 X 30 3 STAFFING Standard No Score 31 3 32 2 33 3 34 4 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 3 LIFESTYLES Standard No Score 11 3 12 3 13 3 14 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 2 3 3 2 X 3 X Thorne House Services For Autism DS0000007974.V291120.R01.S.doc Version 5.1 Page 23 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 YA24 Regulation 23(2)((b) Requirement Premises; 1) Main House radiator requires attention. 2) Alexandra kitchen require upgrading. 3) Rusholme paintwork outside requires attention and the porch at the back of the premises requires attention. Bathrooms and Toilet Facilities; 1) Main House upgrades and make as homely as possible. 2) Alexandra bath panel requires attention and items require fitting. 3) Bellwood bath panel require attention. The registered person must ensure that the home achieves a 50 NVQ staff attainment as soon as possible. Management structure; Registration of Responsible Individual and managers for the organisation. Timescale for action 01/09/06 2. YA27 23(2)(c) 01/09/06 3. YA32 18 31/01/07 4. YA37 7 8(1) 01/10/06 Thorne House Services For Autism DS0000007974.V291120.R01.S.doc Version 5.1 Page 24 5. YA40 7 17 The registered person must Review and update all policies and procedures. 01/12/06 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 YA42 Good Practice Recommendations All staff should wear ID badges. Thorne House Services For Autism DS0000007974.V291120.R01.S.doc Version 5.1 Page 25 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.V291120.R01.S.doc Version 5.1 Page 26 - 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. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!