Inspection on 02/05/07 for Inverthorne

This inspection was carried out on 2nd May 2007.

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

The inspector found no outstanding requirements from the previous inspection report, but made 1 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Inverthorne 16/12/08

Inverthorne 12/01/06

Inverthorne 19/07/05

Inverthorne 30/03/05

Inverthorne 14/07/04

Inverthorne 03/02/04

Similar services:

22 Sandown Road

The Highlands

Dilston College Of Further Education

West View House

Prince Bishop Court

Park View (15)

Craigmore House

1 Lanark Close

Extracts from inspection reports are licensed from CQC, this page was updated on 09/07/2008.

CARE HOME ADULTS 18-65 Inverthorne 20 Thornholme Road Sunderland SR2 7QG Lead Inspector Miss Andrea Goodall Key Unannounced Inspection 2nd May 2007 10:00a Inverthorne DS0000015785.V336246.R02.S.doc Version 5.2 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 Inverthorne DS0000015785.V336246.R02.S.doc Version 5.2 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. Inverthorne DS0000015785.V336246.R02.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Inverthorne Address 20 Thornholme Road Sunderland SR2 7QG 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) 0191 5145853 Tyne and Wear Autistic Society Ms Christine Graham Care Home 4 Category(ies) of Learning disability (4) registration, with number of places Inverthorne DS0000015785.V336246.R02.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection Brief Description of the Service: Inverthorne is a care home for 4 younger adults with Autism Spectrum Disorder. It is owned and managed by the Tyne & Wear Autistic Society (TWAS). Inverthorne is a semi-detached family house set on a main road near the City centre of Sunderland. There is a small driveway and garage to the front of the house and a garden to the rear. The home has an open hallway, off which there are a pleasant dining room, large lounge and large kitchen/diner. There is also one bedroom on the ground floor and a toilet. On the first floor there are 3 bedrooms, the bathroom and a games room. There is also a staff sleep-in room which doubles as a small office. The home is indistinguishable from similar surrounding family properties. The home is next door to 2 other small homes operated by TWAS. The same registered manager manages the 3 small homes. The house does not offer accommodation for people with mobility needs, though visitors with such needs could access the ground floor. The home is near to the City centre shops, pubs and sports centres. Residents also have use of a family-sized vehicle for their transport. The weekly fee is £1,522 - £1,803. Inverthorne DS0000015785.V336246.R02.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced visit so the home did not know the inspector was coming. A couple of months before the inspection the manager sent back a questionnaire about the home. The four people who live here filled in picture comment cards about their home with help from staff. Three relatives also sent in comment cards. During the visit the inspector talked with the manager about staff, records, and how the home supports the people who live here. Most parts of the house were looked at, and some people showed the inspector their bedroom. The people who live here have Autism Spectrum Disorder. This makes it very hard for them to say what they think of the service they get at this home. The inspector spent time with residents and staff, and joined them for an evening meal. There have been no complaints or concerns about the home since the last inspection. What the service does well: There is some information about the home in pictures and photographs to help the residents. Staff keep good records about how residents are learning to do things for themselves, such as looking after their own money. People here go out to lots of different activities that they choose. Staff help residents to join in chats about what they would like to do. One relative said about the home, “My daughter seems very happy.” One person said, “The meals are nice. I like to make my own.” There are good choices of meals and people are helped to follow their religious diets. The house is very well decorated and furnished. It is bright, and modern and the people who live here said that they like it. A resident said, “It’s a nice house.” Each person has their own bedroom, which they can use for private time when they are not busy with other activities. The staff have lots of training to make sure that they know how to help people in the right way. People said that they “like” the staff. The staff have lots of training to make sure that they know how to help people in the right way. Inverthorne DS0000015785.V336246.R02.S.doc Version 5.2 Page 6 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. The summary of this inspection report can be made available in other formats on request. Inverthorne DS0000015785.V336246.R02.S.doc Version 5.2 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 Inverthorne DS0000015785.V336246.R02.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 1 and 2. Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. The home provides clear information so prospective residents can make an informed choice about whether to move here. Comprehensive assessment procedures ensure that only those residents whose needs can be met are offered a placement at the home. EVIDENCE: The Service Users Guide includes a brief brochure that is written in plain English, which gives specific information about the house, the service, and the activities. It includes photographs of residents taking part in the daily domestic tasks and relaxing in the house. In this way any prospective new residents would have clear information about the house before they visited to see if it would suit them. Since the last inspection one resident has moved to another new home, and a new resident has come to live at Inverthorne. Inverthorne DS0000015785.V336246.R02.S.doc Version 5.2 Page 9 TWAS has clear written guidelines about referral and assessment to its services. Before they move here, residents’ needs are assessed by social and health care professionals. The prospective resident, their relatives and TWAS staff are also fully included in making a decision about whether the home could meet people’s needs. Three of the young people who live here were already living in other TWAS small homes. The newest resident was already receiving an educational service from the TWAS College. During his assessment he had several visits to the home for meals and went on activities with the other three residents. Inverthorne DS0000015785.V336246.R02.S.doc Version 5.2 Page 10 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. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 and 9. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Clear care planning means that residents are supported towards achieving their goals. People are supported so that they can make their own decisions, and to take acceptable risks as part of an independent lifestyle. EVIDENCE: There are individual care plans for each of the young people living here. These include comprehensive details of each person’s abilities and strengths, as well as their background, cultural/religious beliefs, and a baseline assessment of their support needs. Inverthorne DS0000015785.V336246.R02.S.doc Version 5.2 Page 11 From the assessments, the care plans set out a small number of specific independent living goals (smart targets) for each person in 3 main areas of their lives - domestic, leisure and self- development. These include, for example, learning to manage small amounts of money for a weekly activity; preparing for a bath; and putting clothes away. The plans include detailed instruction to staff about the level of support each person needs with their goals. There are clear daily records about each residents progress and how staff can further support them towards independent living. Residents are often present when staff are completing their care plan records. Due to their Autism most people find it difficult to understand the support plans, but there is a record on each support plans that states when the care plan was verbally explained to each resident and whether the resident can understand their care plan or not. Staff use symbols and pictures when verbally explaining to one resident the steps towards their goals. Staff stated that the care plans do not contain pictures as residents do not understand the wider concept of the care planning process. The people who live here use either speech, gestures or pictures to communicate their likes and dislikes. They are encouraged and enabled to make their own choices and decisions, such as their appearance, menus, leisure activities, and holiday destination. The home has a Participation of Service Users policy that supports residents’ rights to be involved and included in making decisions about the home. Residents have a meeting about every month where they can make suggestions and reach group decisions about the house, for example choosing barbecue equipment for the garden together. Residents are also fully involved in carrying out the household tasks within their home. The people who live here are supported to take acceptable risks as part of an independent lifestyle. There are risk assessment records in place about activities that people carry out that might incur an element of risk, such as using a locked bathroom, rock-climbing and preparing food in the kitchen. In this way staff are clear about the support that people need to minimise any risk to them. It is good practice that these records have been sent to parents and the relevant Social Workers, and are reviewed at least annually. Inverthorne DS0000015785.V336246.R02.S.doc Version 5.2 Page 12 Recently all TWAS small homes have been fitted with a new door security system, which is linked into the homes’ fire alarm systems. This allows the main entrance doors to be locked at all times for security, but the lock releases in the event of the fire alarm system being activated. In this way resident and staff can exit the house in the event of a fire without having to first unlock a door. However this system also means that people cannot access or exit their house without a fob (electronic swipe key). At the time of this visit none of the people who live here had their own fob, and there were no individual risk assessments in place about this restriction. Inverthorne DS0000015785.V336246.R02.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15, 16 and 17. Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Residents can take part in fulfilling, purposeful daytime occupations. Residents can choose from a good range of suitable activities. Residents have good support keep in contact with family members and have many opportunities to meet others at social and leisure events. Residents have clear information about their rights and responsibilities. Residents enjoy nutritious, healthy meals. Inverthorne DS0000015785.V336246.R02.S.doc Version 5.2 Page 14 EVIDENCE: All the residents attend day services provided by Tyne & Wear Autistic Society and one person has an education-funded placement at college. These include vocational courses at the nearby Thornbeck College, such as IT, arts & crafts, and performance arts. Residents also have opportunities to gain practical skills at the TWAS Workshop where they make garden furniture, greetings cards and jewellery, which is sold in the TWAS shop (on a not-for-profit basis). This provides residents with tangible, purposeful outcomes to their daytime occupations. All the residents have their own copy of their weekly schedule so that they can refer to it at any time. The home is a family residence and is indistinguishable from other similar properties in the area. It is a short distance from the city centre so residents have a good range of shops and leisure resources nearby. The people who live here make good use of local facilities in the community including shops, sports centres, pubs, and post office. Residents choose from a wide range of leisure activities that they enjoy in the evenings and at week-ends. These include ice-skating, horse riding, cinema, swimming, sports, concerts, rock climbing and cycling. Residents do have opportunities to meet other people at social settings, such as pubs and disco’s, but the nature of Autism Spectrum Disorder can make it difficult for people to form social relationships. Residents are supported to keep in contact with their relatives by telephone, and some residents have short breaks with their families or are visited by their relatives. Three relatives sent comment cards to the CSCI indicating that they were satisfied with the service provided at Inverthorne. One relative also wrote, “Living so far from the home as we do it is hard to make accurate assessments – but my daughter seems very happy and we have no problem with this placement.” Staff encourage and promote conversations with the residents to help their language and communication skills, but also to involve and include them in discussions about their home. Staff were seen to be respectful and supportive when talking with residents. Residents can choose to use their own bedrooms for privacy when they are not involved in another activity. Inverthorne DS0000015785.V336246.R02.S.doc Version 5.2 Page 15 There are some set routines in the home because people with Autism benefit from structured programmes that helps them make sense of the pattern of their day. It is evident from observations at this and previous inspections that residents have really improved their independent living skills over the time that they have lived here. It was clear that they have also improved their communication skills and their confidence. All residents are involved in grocery shopping at a large supermarket. All prepare meals, snacks and drinks with support from staff. One person said, “The meals are nice. I like to make my own.” Another person pointed to pictures in her communication book to show the different choices she had made for tea. The home has a large family kitchen/diner and a pleasant dining room where residents and staff to dine together. Staff encourage residents to make mealtimes a social occasion where they can talk about their day and discuss their choices of activity for that evening. Meals are nutritious, healthy and suit the age, religious beliefs and preferences of the young people who live here. It is very good practice that the home supported one resident to celebrate Hanukkah. She designed a traditional Jewish menu, and was supported to purchase and prepare all the ingredients and accompaniments such as special candles. She invited the other residents and staff to join her, and photographs of this special night were sent to her relatives. In this way residents’ religious and cultural beliefs are respected and supported. Inverthorne DS0000015785.V336246.R02.S.doc Version 5.2 Page 16 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. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Residents receive the right support to access health care services where necessary so that their health and welfare is well met. EVIDENCE: The four people who live here are young and physically fit. They need support, guidance and verbal prompts to help them to carry out their own personal care. One person needs some physical guidance when shaving. No-one needs support with intimate personal care needs All of the staff are female and this meets the need for gender-appropriate care of the three female residents. It is clear from discussions and from care records that the male resident also prefers female staff support. In this way the home currently meets the individual preferences for support of each of the four residents. Inverthorne DS0000015785.V336246.R02.S.doc Version 5.2 Page 17 It was clear from discussions and from care records that staff have a good understanding of the communication needs of the people who live here and also recognise behavioural changes that could indicate a health care need, for example if a resident was experiencing pain but was unable to verbally express this. The residents are registered with a local GP practice, and have access to community dental, optician and chiropody services as and when required. Residents also have access to specialist health services, for example psychiatry and orthopaedic services. In this way the home ensures that residents health care needs are met by appropriate health care services. At this time all medication is managed by senior staff as none of the residents have been assessed as capable of managing their own medication. All staff have training in safe handling of medication. Care records include comprehensive background information about residents’ medical history and consent forms from GPs about which over-the-counter medications would be suitable or not for each of the people who live here. Medication is delivered to the home by a local pharmacy in suitable containers. Medication is securely stored in a locked, alarmed metal medication cupboard away from residents accommodation. Records of the administration of medication are in place and up to date. Inverthorne DS0000015785.V336246.R02.S.doc Version 5.2 Page 18 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. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23. Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. People have good information so they know how to make a complaint. Staff are trained in safeguarding adults so residents are protected from abuse. EVIDENCE: The home has a Complaints Procedure, which is also in pictorial format, and is periodically explained to the people who live here. Staff ask residents for their comments at Residents’ Meetings. All of the people who live here can express their dissatisfaction with a situation. One resident uses a communication book with a picture of a happy or unhappy face to whether she is satisfied with the service. Relatives have opportunities to contact the home if they are dissatisfied, and can also discuss any concerns at annual reviews. There have been no complaints about this service. Inverthorne DS0000015785.V336246.R02.S.doc Version 5.2 Page 19 All staff receive training in the local vulnerable adult procedures to ensure that residents are protected from abuse. As with all care services for adults in the City of Sunderland, TWAS has adopted the MAPPVA (Multi-Agency Panel for the Protection of Vulnerable Adults) policy and procedures. These are robust procedures for dealing with suspected abuse. All staff are trained in CALM (Calm Aggression-Limitation Management) and new staff will receive this training. This is a method of physical intervention that requires minimal restraint, and is used only to prevent harm to the resident or to others if residents need support to manage their behaviour. This method is approved by the BILD (British Institute of Learning Disabilities) and ensures that all staff can present a consistent, safe approach when supporting a resident in this way. Intervention records were seen to be kept in bound books with numbered pages and clearly detail any triggers and the intervention used to support the resident. These mainly relate to the use of diversion, and time and space for the resident. Inverthorne DS0000015785.V336246.R02.S.doc Version 5.2 Page 20 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. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. People here live in very good quality accommodation that is homely, comfortable, safe and clean. EVIDENCE: Inverthorne provides very good quality accommodation for the four people who live here. It is a family house in a desirable area of the city. The standard of decoration and furnishings are modern, bright and suit the age and lifestyle of the people who live here. The stairway and landing have recently been redecorated by the TWAS decorator. TWAS has its own maintenance team that visits the home on a weekly basis to carry out fire tests and to address any minor repairs. In this way any items can be addressed quickly so the home remains very well maintained. Inverthorne DS0000015785.V336246.R02.S.doc Version 5.2 Page 21 Since the last inspection one resident has moved to a bedroom on the first floor and staff stated that she likes her new bedroom. A new resident has moved into the ground floor bedroom. He said, “I like Inverthorne, it’s a nice house. I like my room.” Two people have keys to their own rooms and they make good use of these to keep their bedroom doors locked when they are out of the house. The other two people have tried to keep their keys several times but staff said that, at this time, they cannot manage them. There are risk assessments in place to show this. Staff support these people to lock their bedroom doors if they are away from the house. Residents are supported by staff to manage the household tasks within the house. Staff support them to manage their own laundry. The washing machine is sited in the kitchen and there are clear risk assessments in place that ensure laundry is not in contact with food preparation surfaces. This is checked every month during health & safety audits of the home. All staff have training in Infection Control and support the people who live here to keep their house very clean and hygienic. Inverthorne DS0000015785.V336246.R02.S.doc Version 5.2 Page 22 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. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34 and 35. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Staff are competent and qualified so residents receive an effective service. TWAS uses robust recruitment practices to ensure that residents are safeguarded from unsuitable staff. EVIDENCE: The staff team is led by the manager and a deputy manager who are also both responsible for two other small homes next door to Inverthorne. There are also two senior support workers, two support workers, and a further support post is vacant at this time. There are at least two staff on duty (including one senior support worker) at the times that the four residents are at home. Staff carry out sleep-in duties so that there is one staff in the house overnight. Inverthorne DS0000015785.V336246.R02.S.doc Version 5.2 Page 23 It was clear from the staff rota that the manager has been covering a number of gaps on the staff rota due to vacant posts, holidays and sick leave across the three homes. Whilst it is acceptable for the manager to cover the occasional gap, recently there have been frequent occasions where the manager has carried out long shifts and sleep-ins. This takes her time away from the many managerial, administrative and supervisory tasks involved in running three small homes. TWAS operates very thorough recruitment and selection procedures. Staff are only employed after satisfactory references and police checks have been received, and this ensures the protection of the people who live here. Residents also have the chance to meet applicant staff during evening activities to see if they have suitable personalities and values to support young people with Autism Spectrum Disorder. A resident said, “I like the staff”. There are clearly good relations between the residents and the staff team. Staff were supportive, encouraging and respectful in their engagement with residents. Three of the four staff have achieved NVQ level 3 and the other is working towards this care qualification. All staff receive Autism Focus training, which is specific training to support them to understand the needs of the people with autism. All new staff will undertake induction/foundation training before starting NVQ training. There is an individual learning plan for each member of staff that identifies any training that they need and a record of all training courses that they have attended. It is evident that TWAS is committed to staff training so that residents receive support from a well-trained, competent staff group. Inverthorne DS0000015785.V336246.R02.S.doc Version 5.2 Page 24 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. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 and 42. Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Residents and staff benefit from a well managed, well organised service. Systems, procedures and practices promote safety and welfare so residents are safe. Inverthorne DS0000015785.V336246.R02.S.doc Version 5.2 Page 25 EVIDENCE: The registered manager has many years experience of working in care settings with children and younger adults with autism, and has been registered as a manager for this and 2 other small homes for the past few years. She has attained a Diploma in Care Management, NVQ level 4, and the Registered Managers Award, all of which are suitable qualifications for a manager of a care home. She is also currently undertaking a certificate in Autism Spectrum Disorder, which demonstrates her commitment to updating her skills and competence in this specialised area of care. There are clear lines of accountability and management support within the TWAS organisation. In this way the residents, and staff, benefit from a well managed service. TWAS has a quality assurance processes in place to review the service, and these includes the views of the residents through their annual reviews and Residents’ Meetings. Pictorial questionnaires are also given to residents from time to time for them to indicate their likes and dislikes about various aspects of the service including staff, other residents, menus, activities, and the house. For example, in the most recent pictorial questionnaire of March 2007, all residents indicated that they particularly “like the staff”. A summary of the collated responses is put in the Service Users Guide for any future prospective residents to see. Also, there are monthly visits to Inverthorne by an external consultant (on behalf of the Provider) who seeks the views of residents and staff, and reports back to the organisation and CSCI on their findings. Staff training records demonstrate that all staff receive statutory training in all health & safety matters, and there are up-to-date records of health & safety checks in the house. All staff receive in-house fire instruction every 3 months, and all residents take part in a monthly fire drill to help them understand what to do in the event of a fire. Inverthorne DS0000015785.V336246.R02.S.doc Version 5.2 Page 26 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 4 3 X 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 4 ENVIRONMENT Standard No Score 24 4 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 X 33 2 34 3 35 4 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 2 X LIFESTYLES Standard No Score 11 X 12 4 13 X 14 4 15 3 16 3 17 4 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 4 3 3 X 3 X 4 X X 3 X Inverthorne DS0000015785.V336246.R02.S.doc Version 5.2 Page 27 NO Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard YA9 Regulation 13(4) Requirement There must be risk assessment in place for each resident whose access into and exit from their house is restricted by the new security door system. This will ensure that residents are individually assessed for their capability to manage their own front door fob. Timescale for action 01/08/07 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 YA33 Good Practice Recommendations TWAS should ensure that the manager is not responsible for covering gaps and shift on the duty rota as this could removes her from her managerial responsibilities, and this could lead to a negative impact on the 3 services that she is responsible for managing. Inverthorne DS0000015785.V336246.R02.S.doc Version 5.2 Page 28 Commission for Social Care Inspection South Shields Area Office 4th Floor St Nicholas Building St Nicholas Street Newcastle Upon Tyne NE1 1NB National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 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 Inverthorne DS0000015785.V336246.R02.S.doc Version 5.2 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. 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!