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Inspection on 10/12/05 for Richmond Close

Also see our care home review for Richmond Close for more information

This inspection was carried out on 10th December 2005.

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

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

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

Thaddeus House offers a high standard of care and service, is extremely well organised, with a committed care management team. Emphasis goes into involving the residents and their families in the process of care, ensuring a highly personal approach to meeting individual needs. Assessment procedures and care planning is of an excellent standard, offering detailed information on each resident`s progress in the meeting of objectives. The staff and residents all contribute to the team approach. Maintenance of good staffing levels, staff training and supervision are well established in safeguarding the interests of residents. Overall the attitude in meeting caring and organisational demands is highly commendable, with forward thinking, involvement and application contributing to an excellent service.

What has improved since the last inspection?

In meeting all the recommendations made, the Home has demonstrated a meaningful commitment to the ethos of continuing improvement of standards.

What the care home could do better:

To maintain the very high standards achieved, constant vigilance is needed.

CARE HOME ADULTS 18-65 Thaddeus House 18/20 Richmond Close The Leys Tamworth Staffordshire B79 7QS Lead Inspector Mr Keith Jones Unannounced Inspection 12th December 2005 09:15 Thaddeus House DS0000005010.V272387.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 Thaddeus House DS0000005010.V272387.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. Thaddeus House DS0000005010.V272387.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Thaddeus House Address 18/20 Richmond Close The Leys Tamworth Staffordshire B79 7QS 01827 311991 01827 66988 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) Walsingham Mrs Patricia MacDonald Care Home 8 Category(ies) of Learning disability (8) registration, with number of places Thaddeus House DS0000005010.V272387.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 20th July 2005 Brief Description of the Service: Thaddeus House is registered to provide care for eight young people with a learning disability who need twenty-four hour support and guidance. The home is located in two semi-detached properties, owned by Focus Housing Association and operated by Walsingham . Each property provides accommodation for four young people and has its own kitchen/ dining and lounge facilities. The two houses have a connecting door and some shared communal areas like activities room and gardens. The home was operated as two family style environments and the service users were encouraged to live an independent lifestyle with support from staff. Thaddeus House DS0000005010.V272387.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection was conducted in a professional and cordial atmosphere with two duty carers. The last inspection report was discussed, and it was noted that there were no requirements made, and recommendations regarding care planning have been dealt with satisfactorily. On the day of inspection there were 8 residents of which 3 were on weekend leave. A tour of the Home allowed free and open access to all areas for inspection. The opportunity was taken to speak with a number of service users with members of staff. Throughout the entire inspection a sense of homeliness and familiar confidence pervaded into all aspects of daily activity expressed by those people met. A review of the administration arrangements confirmed solid practice and effective management. A verbal report was offered at the end of the inspection to both carers and later to the care manager over the telephone. What the service does well: What has improved since the last inspection? In meeting all the recommendations made, the Home has demonstrated a meaningful commitment to the ethos of continuing improvement of standards. Thaddeus House DS0000005010.V272387.R01.S.doc Version 5.0 Page 6 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. Thaddeus House DS0000005010.V272387.R01.S.doc Version 5.0 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 Thaddeus House DS0000005010.V272387.R01.S.doc Version 5.0 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): 1,2,3,4 and 5 Thaddeus House ensures that prospective residents have the necessary information to enable an informed choice to be made. Aims and objectives, terms and conditions are clearly presented in a way to facilitate easy understanding of services and standards of care. The providers ensures that the admission process is a reflection of a joint understanding that residents are aware, and that staff are able to meet expectations to realise a comfortable transition. EVIDENCE: The recently updated care planning process with the Statement of Purpose and guidelines, reflect an expression of philosophy, and have been well established in representing the foundation on which the home operates upon. Case tracking of two resident’s files demonstrated the presentation of a highly personal approach to prospective residents and their relatives on preadmission. A detailed assessment was examined and found to collect a full profile of physical and psychological needs, as well as social, cultural and environmental circumstances. Case tracking also confirmed that a valuable exchange between service users and assessor took place and resources made available. These resources were seen to be an appraisal of staffing skills, equipment and general environment. Thaddeus House DS0000005010.V272387.R01.S.doc Version 5.0 Page 9 Prospective service users and their relatives are able to visit and assess the quality, facilities and suitability of Thaddeus House at any reasonable time, to meet with staff and management. At all times relatives are involved throughout the process. Thaddeus House DS0000005010.V272387.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7,8,9 and 10 Service users are made aware that their assessed and changing needs and personal goals are included within their individual plan of care. There were ample evidence that a ‘partnership of care’ approach focused on positive behaviour, ability and willingness of the individual. Records inspected showed that service users freely make decisions about their life in the home and what they are going to do with their time, based on a detailed risk assessed basis. The philosophy of care, as laid out in the Statement of Purpose, promoting a home environment that will afford service users greater security, choice, independence and a good quality of life. EVIDENCE: Assessments, care plans and risk assessments were examined and found to offer an excellent record of daily living, which were comprehensive, and included a provider assessment; a person centred plan, a health and safety assessment, and a planned intervention, rehabilitation and therapeutic programme. It was noted that each day had a different schedule of events Thaddeus House DS0000005010.V272387.R01.S.doc Version 5.0 Page 11 encouraging therapeutic and social activities geared to meeting service users sense of belonging. Two residents were case tracked with an examination of care records, health records including risk assessments, records of reviews and action plans. Records inspected showed that residents freely make decisions about their life in the home. Altogether the communication ‘package’ offers a comprehensive appraisal of resident’s needs and aspirations. Risk assessments were carried out on an individual basis and reviewed. Those residents spoken with were freely outspoken of the love and attention received, very complementary of the lifestyle offered to them. During the inspection the inspectors were impressed with the lively environment and cheerful banter, it was most encouraging to see how much work had gone into promoting personal awareness and a sense of belonging. Thaddeus House DS0000005010.V272387.R01.S.doc Version 5.0 Page 12 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 and 17 Throughout the inspection residents were seen to be enjoying a high degree of encouragement to express themselves in positive and meaningful ways. Bedrooms were seen to demonstrate that individuality, each different to match personal outcomes. A fully flexible open visiting policy was identified, reflecting the importance placed upon family or friends’ regular contact. Resident’s links with the community are good with individuals being involved in various social and educational opportunities. The residents and staff were seen to be preparing a well-presented lunch. EVIDENCE: The staff reflected upon the policy indicating a flexible routine, established to meet the preferences of service users. The policy was evidenced in admission assessment, care plans examined, and talking to service users, a policy much appreciated and freely expressed. Routine is seen as flexible to acknowledge individuality, yet maintain a focal point for service users to latch on to without Thaddeus House DS0000005010.V272387.R01.S.doc Version 5.0 Page 13 dictating events. Staff were observed to hold a friendly, sympathetic and confident interaction with service users in lounge areas in helping those who required assistance. Service users’ life-styles and interests are recorded in their care plans, discussed with their relatives prior to admission, and documented as far as possible to enhance a position of supported independence. The recording of social activities was seen to be a valuable part of care reporting and planning. The management demonstrated the strength of protecting service user’s rights, which was secured through the robustness of the procedures in place. This was confirmed on examination of records. The tour of the Home demonstrated a high degree of expressed individuality in each of the bedrooms inspected. A varied menu is available for service users, on a residents centred cycle, and represented a wholesome, appealing and varied balanced diet. The preparation is a joint undertaking involving residents and staff. The dining area was very pleasant, offering conducive ambience for a social meal. The kitchen was seen to be clean, well organised and with modern equipment. An effective cleaning schedule was seen to be in operation. Fridges/freezers and food temperature records were seen to be up to date and accurate. The care manager and staff have initiated plans for Christmas festivities, which is keenly anticipated, and are well advanced. Thaddeus House DS0000005010.V272387.R01.S.doc Version 5.0 Page 14 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. Observations of staff indicated that they had a very good understanding of the residents personal, emotional and physical support needs. The medication at this home was well-managed clear and comprehensive arrangements being in place to ensure resident’s medication needs are met. EVIDENCE: It was pleasing to see that the administration of medicines adhere to procedures to maximise protection to service users, the storage was secure. A senior member of staff completed MAR sheets accurately, with accountability recorded throughout the process. The philosophy of promoting individuality and self-determination, as laid out in the Statement of Purpose, continues to be seen to be exercised in many aspects of care. The general atmosphere throughout the home was one of family, confidence, warmth and contentment. Staff were observed in addressing service users in a respectful and dignified way. The service user’s spiritual needs are attended to with respect. Relatives are involved and have free access at all times as desired by the service user. The staff ensure that the service user has the appropriate care and prescribed pain Thaddeus House DS0000005010.V272387.R01.S.doc Version 5.0 Page 15 relief. It was noted that an appraisal of any special preferences or observances is recorded on admission, and is regarded as integral in the assessment process. Thaddeus House DS0000005010.V272387.R01.S.doc Version 5.0 Page 16 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 and 23 Service users individual concerns and complaints were listened to, documented and dealt with sympathetically. All necessary policies and procedures were in place. The management showed satisfactory evidence of a protocol and response to anyone reporting any form of abuse, to ensure effective handling of such an incident. EVIDENCE: The home had a meaningful complaints policy, clearly identifying the CSCI as a resource to approach with a complaint or grievance. A complaints book is maintained which shows a responsible approach in handling complaints appropriately, confirming the level and category of complaint, each being resolved at a local level to mutual satisfaction. Minor complaints being received in-house and resolved to complainant’s satisfaction. Residents’ legal rights are protected by the systems in place in the home to safeguard them, including their contract, the continual assessment of care, planning and policies in place i.e. the complaints procedure. This process was evidenced on examination, and case tracking as previously reported upon. The providers showed satisfactory evidence of a protocol and response to anyone reporting any form of abuse, to ensure effective handling of such an incident. Staff induction and in-house training programmes clarified the responsibilities of all staff in their daily contact with service users, especially their privileged position in protecting service users from abuse, of all natures. Thaddeus House DS0000005010.V272387.R01.S.doc Version 5.0 Page 17 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): 24,25,26,27,28,29 and 30 The home has succeeded in meeting the needs of service users in providing a safe and comfortable environment. Bedrooms were generally well maintained to meet service user’s personal preferences; the outcome is a comfortable and familiar private domain that reflects the service user’s preferences. There is evidence of an awareness of health and safety issues being high on training and supervision priorities. Individual rooms are presented as highly personalised and inviting individual residence. The Home continues to present a clean and pleasant, odour-free atmosphere, much to the credit of staff. EVIDENCE: Thaddeus House is suitable for its stated purpose and meets the needs of individuals living in the home, in providing a safe and comfortable environment. The external state of repair and maintenance is generally very good, offering pleasing patio areas for service users. Car parking is satisfactory although situated in restrictive surroundings. Thaddeus House DS0000005010.V272387.R01.S.doc Version 5.0 Page 18 The overall state of repair and décor is of a very high standard and frequently monitored. Bedrooms were well maintained to meet service user’s personal preferences. Service users are encouraged to bring in their own belongings and furniture, if they wished, in pursuance of promoting independence and individuality. Communal areas were malodour-free, pleasantly furnished with facilities to accommodate social or reflective needs, in a homely setting. Several lounge areas and quiet rooms were much appreciated by residents. The building complied with local fire service, Environmental Health and Health and Safety requirements. The home is close to local amenities and public transport and is in keeping with surrounding properties. There are no outstanding issues with the Fire Officer or Environmental Health. Thaddeus House DS0000005010.V272387.R01.S.doc Version 5.0 Page 19 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 and 36 Staffing levels were seen to be satisfactory, the daily care staffing rota showed adequate balance between skills, qualifications and numbers to provide a good standard of care. The thoroughness of staff selection has a significant effect upon the provision of cares to ensure protection of service users. Records show a very broad spectrum of clinical and allied subjects covered, ensuring that staff fulfil the aims of the home and meet the changing needs of service users. EVIDENCE: An effective staff team supports service users, staff were seen to interact well with the service users, and be mindful of their individual needs and capabilities. The numbers and skill mix of the staff adhered to and exceeded the previously issued Notice of Staffing. Staffing had maintained consistent levels to ensure equilibrium between numbers, skills and qualifications, with a strong presence of long serving experienced staff. Staff on duty were interviewed and found to provide satisfactory evidence of good personnel management, that promoted protection of vulnerable service users. Thaddeus House DS0000005010.V272387.R01.S.doc Version 5.0 Page 20 Discussions indicated a broad spectrum of training on clinical and allied subjects covered, ensuring that staff fulfil the aims of the home and meet the changing needs of service users. Thaddeus House DS0000005010.V272387.R01.S.doc Version 5.0 Page 21 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): 37,38,39,40,41,42 and 43 The staff represent a sound resource of experience and skills, which are reflected in the high standing in which Thaddeus House is held by residents, their relatives and the community alike. The Home has in place a highly effective and motivated care team, sensitive to the needs of each resident, organisational demands and the professional standing of services to people with learning disabilities. Personnel are well trained and appreciated for their professionalism. Policies are meaningful, supported with up to date procedures and skilled application of good practice. Each presents a safe and secure environment in protection of rights, interests, health and safety of the residents. EVIDENCE: The care management have demonstrated competence in running Thaddeus House, in establishing a solid Statement of Purpose and policy portfolio that has been implemented, to achieve a high standard of set aims and objectives. Thaddeus House DS0000005010.V272387.R01.S.doc Version 5.0 Page 22 Staff meetings are held frequently in which staff are encouraged to participate fully in the management and direction within the home. The inspector observed at first hand the confident interrelationship that exist not only between management and staff, but also between staff and residents. There was strong evidence of openness and honesty in speaking with service users, relatives and staff in which day to day events and episodes are freely discussed. Evidence was secured to confirm a quality monitoring system has been introduced, based upon audit of standards, care plans and feed back from service users and relatives. Standards are discussed at staff meetings, daily reports, direct observation and involvement and one to one staff meetings. The procedures manual was randomly examined and found to offer a very comprehensive reference. Fire safety remains high priority for all staff evidenced in routine maintenance checks, regular fire drills and frequent staff training sessions were recognised. Discussion with staff members indicated that supervision sessions and individual training programmes are areas that with continuing improvements, will enhance the desired impact on quality of service. Thaddeus House DS0000005010.V272387.R01.S.doc Version 5.0 Page 23 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 3 3 3 3 Standard No 22 23 Score 3 3 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 4 3 3 3 X Standard No 24 25 26 27 28 29 30 STAFFING Score 3 3 3 3 3 3 3 LIFESTYLES Standard No Score 11 3 12 4 13 4 14 4 15 4 16 4 17 Standard No 31 32 33 34 35 36 Score 3 3 3 3 3 3 CONDUCT AND MANAGEMENT OF THE HOME 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Thaddeus House Score 3 4 3 3 Standard No 37 38 39 40 41 42 43 Score 3 3 3 3 3 3 3 DS0000005010.V272387.R01.S.doc Version 5.0 Page 24 Are there any outstanding requirements from the last inspection? No STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. Standard Regulation Requirement Timescale for action RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Thaddeus House DS0000005010.V272387.R01.S.doc Version 5.0 Page 25 Commission for Social Care Inspection Stafford Office Dyson Court Staffordshire Technology Park Beaconside Stafford ST18 0ES 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 Thaddeus House DS0000005010.V272387.R01.S.doc Version 5.0 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!