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Inspection on 20/07/05 for Richmond Close

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

This inspection was carried out on 20th July 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

What has improved since the last inspection?

What the care home could do better:

CARE HOME ADULTS 18-65 Thaddeus House 18/20 Richmond Close The Leys Tamworth Staffordshire B79 7QS Lead Inspector Kathryn Marks Announced 20 & 21st July 2005 th 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 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 Stationary 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 E51-E09 S5010 Thaddeus V235163 190705 Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Thaddeus House Address 18/20 Richmond Close The Leys Tamworth Staffordshire B79 7QS 01827 311991 Telephone number Fax number Email 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 CRH 8 Category(ies) of LD - 8 registration, with number of places Thaddeus House E51-E09 S5010 Thaddeus V235163 190705 Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: N/A Date of last inspection 16 December 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 Community Homes. 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 E51-E09 S5010 Thaddeus V235163 190705 Stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This Announced inspection was carried out over an early evening visit to see residents on 20th July and one day on the 21st July 2005. During the course of the inspection seven staff were spoken with and made many positive comments about residents busy lifestyle in the home. Residents themselves were observed to be comfortable in the presence of staff and warm relaxed relationships appeared to exist. Residents were in and out of the home at different placements or activities that they said they enjoyed. The Care Manager provided written information regarding staffing, staff training, menu and dietary provision that was observed by the inspector to be in place at the home. On arrival at Thaddeus House residents were busy with staff organising the day. Resident’s accommodation is located on the ground and first floor in a pair of semi-detached houses. Inspector’s observations were that the home was clean and well maintained. Resident’s bedrooms were personalised and reflected the personality of the individual occupying the room. Two residents have just changed bedrooms and houses by mutual consent and both said they were happy with the move. The home had in place a Statement of Purpose and Service Users Guide that provide information to prospective residents and their relatives about the services the home is able to offer. All residents have a full assessment of their needs carried out prior to admission to ensure their needs can be met at Thaddeus House and this is a long-standing group of residents. Arrangements are in place for meeting the health and personal care needs of residents and details are recorded in care records. Observations of the menu identified that there is a choice of well-balanced and nutritious food offered to residents. The home has in place a complaints procedure this is also in pictorial form to promote the understanding of the resident group. The complaints procedure is displayed in the home along with details of how to contact the Commission for Social Care Inspection. Thaddeus House E51-E09 S5010 Thaddeus V235163 190705 Stage 4.doc Version 1.40 Page 6 What the service does well: What has improved since the last inspection? What they could do better: • Care Plans would benefit from a reorganisation perhaps into modular form to ensure all information is in one folder including risk assessments and medical information. A lot of staff time was observed to be spent writing in a variety of different files. “ Could this be better spent with residents”? Residents agreements say and illustrate that the resident will have a key to their bedroom door this is not the case and the agreement should identify this or a key be provided. • 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 E51-E09 S5010 Thaddeus V235163 190705 Stage 4.doc Version 1.40 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 Standards Statutory Requirements Identified During the Inspection Thaddeus House E51-E09 S5010 Thaddeus V235163 190705 Stage 4.doc Version 1.40 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 standard(s) 1,2,5. The home has in place a Statement of Purpose and Service User Guide providing residents and prospective residents/carers/relatives with details of the services the home provides enabling an informed decision about admission to be made. EVIDENCE: Thaddeus House has in place a Statement of Purpose and Service Users guide that gives information to service users and their relatives about the services the home provides. Residents at Thaddeus House are a long-standing group of young people who were all subject to a full and detailed assessment of their needs prior to being admitted to the home. Individuals who are self- funding and without a Care Management Assessment would have a full assessment carried out by the home. All residents have statements/agreements of their terms and conditions of residence at Thaddeus House. Thaddeus House E51-E09 S5010 Thaddeus V235163 190705 Stage 4.doc Version 1.40 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 standard(s) 6,7,9. Care records are in place but would benefit from reorganising into one modular file. Residents were supported to make day-to-day decisions relating to their daily life, enabling them to have some control about matters important to them. Risk assessments were in place with evidence of regular reviews to ensure that the risks identified were kept to a minimum. Thaddeus House E51-E09 S5010 Thaddeus V235163 190705 Stage 4.doc Version 1.40 Page 10 EVIDENCE: Individual Care Plans are in place and have been updated to form the new person centred care plan. Everything that happens in the house is included along with anything the resident wants to do with the key worker. Two residents were case tracked, both spoke with the inspector their bedrooms were visited and records reviewed. Residents are involved in the putting together of the person centred plan. These are communicated to individuals in whatever form they understand, pictorial, verbal, or written form. The care plans are developed following reviews and assessments and cover all aspects of personal, social, and health care needs. Records are maintained in a variety of files and need pulling together so that information is in one place. All Care Plans are reviewed on a monthly basis with the resident; their family or advocate if that is what the resident wishes to happen. Observations were made of residents making decisions about their daily lives including when to get up and retire and how to spend their time. Residents confirmed that they were able to choose leisure activities and that the staff would help them organise specific activities of their choosing. Some liked to play pool others enjoyed painting, jigsaws, and going out. Majority of social activities are community based. Residents chose how to spend their personal allowance although some support was needed. Finances sampled balanced with records maintained. Residents care plans evidenced that risk assessments had been carried out these assessments identified the nature and level of risks and the actions to be taken to minimise the risks. Risk assessments took into account the resident’s lifestyle both within the home and in the community. An appointed member of staff reviews and updates risk assessments on a regular basis. Thaddeus House E51-E09 S5010 Thaddeus V235163 190705 Stage 4.doc Version 1.40 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 standard(s) 12,13,15,16,17. Resident’s links with the community are good with individuals being involved in various social and educational opportunities. Dietary needs of residents are well catered for with a balanced and varied selection of food personal likes and dislikes being taken into account. Thaddeus House E51-E09 S5010 Thaddeus V235163 190705 Stage 4.doc Version 1.40 Page 12 EVIDENCE: Residents attend a variety of day placements to meet their needs various venues are used, Local College, Local Garage, Horse riding, Daybreak, and College at Great Barr, Pottery, Floristry, and Donkey Sanctuary in Sutton Park. All residents had access to a computer at home. Residents said they enjoyed their daytime activities and it was observed that when at home took part in the day-to-day running of Thaddeus House. One resident is currently on holiday in Minorca with his parents. Residents were fully involved in community activities and used local community resources. Individuals regularly used local shops majority unsupported, attend local pubs; local social clubs and regularly went into Tamworth town centre for both shopping and leisure activities. One resident is taking part in Tamworth Carnival supported by a member of staff. Residents access local health care resources and attended health care practices to see individual general practitioners. The deputy manager identified that residents friends and relatives were welcomed into the home with the individual’s agreement. Residents through their access with local community resources had developed relationships with people without disabilities. Staff, were aware of residents rights to develop intimate relationships and were aware of the availability of specialist advice. Individuals were responsible for their own room cleaning being supported by key worker where required to do this. Resident /staff interaction was very positive staff treating residents with dignity and respect at all times. Individuals were offered a varied and nutritional diet that was discussed with them on a daily basis. Thaddeus House E51-E09 S5010 Thaddeus V235163 190705 Stage 4.doc Version 1.40 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 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. Thaddeus House E51-E09 S5010 Thaddeus V235163 190705 Stage 4.doc Version 1.40 Page 14 EVIDENCE: The staff at Thaddeus House were observed to provide sensitive personal support and assistance to individuals living here. No residents require lifting or handling, personal support was provided in private and where possible, intimate care would be given by a person of the same gender. Rising and retiring times are flexible within the realms of attending day placements and confirmed by observations today. Flexible routines were observed to be operating in the home. Where needed advice and guidance are offered to individuals with regard to personal appearance staff promoting positive personal image. All residents attend local health centres and are registered with a general practitioner of their choice. Staff monitor residents health and any problems identified are dealt with promptly. On going risk assessments are carried out and form part of the individual care plan. Six monthly and annual health checks are carried out all residents going out to general practitioner for appointments. The home has in place policies and procedures for the management of medication to inform staff of procedures in the home. Records are maintained of medication received, administered to residents and returned to the pharmacist. Staff had received training in the management of medication from Walsinghams Service Manager. Training in the management of medication is being updated in September and will be ongoing to cover all staff. The pharmacist advises the care manager on medications prescribed and side effects. Thaddeus House E51-E09 S5010 Thaddeus V235163 190705 Stage 4.doc Version 1.40 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 standard(s) 22,23. The home had a satisfactory complaints system in place with some evidence that residents feel that their views are listened to and acted upon. EVIDENCE: Discussions with service users confirmed that they knew how to make a complaint. A copy of the complaints procedure was displayed on the notice board in the kitchen/ diners of both houses. A pictorial form of the complaints procedure is also in place. Residents are safeguarded from abuse via the homes policies, procedures, and staff training. Thaddeus House has a Whistle Blowing policy in place that all staff had received on commencement of employment. Staffs were aware of why at times physical/verbal aggression could be displayed by service users and had systems in place to deal with this. Thaddeus House E51-E09 S5010 Thaddeus V235163 190705 Stage 4.doc Version 1.40 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 standard(s) 24,30. The home was suitable to meet the needs of residents, with adequate communal space, sufficient bathing and shower facilities and single occupancy bedrooms. Thaddeus House E51-E09 S5010 Thaddeus V235163 190705 Stage 4.doc Version 1.40 Page 17 EVIDENCE: Thaddeus House is suitable for its stated purpose and meets the needs of individuals living in the home. It is a pre-existing care home and provides the same living space overall as they provided as at 31March 2002. The premises are comfortable clean and free from offensive odour, providing suitable light heat and ventilation. The home is close to local amenities and public transport and is in keeping with surrounding properties. The deputy manager told the Inspector that there are no outstanding issues with the Fire Officer or Environmental Health. Thaddeus House E51-E09 S5010 Thaddeus V235163 190705 Stage 4.doc Version 1.40 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 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 35 Observations at the time of this inspection were that staffing levels were adequately maintained to ensure that service user needs were appropriately addressed. EVIDENCE: The Deputy Care Manager identified that there is a training programme in place for all designations of staff. New staff received induction and foundation training with Walsingham Homes, training packs being used. All staff had training records and received a minimum of seven days paid training a year staff said they had lots of training opportunities. Training needs assessments for staff are ongoing and training will be provided to meet assessed needs of individual staff. Training and development is linked to the homes aims and objectives of service users. Thaddeus House E51-E09 S5010 Thaddeus V235163 190705 Stage 4.doc Version 1.40 Page 19 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 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 39, 42. All staff demonstrates an awareness of their roles and responsibilities, ensuring that the health, safety, and welfare of residents are observed. Thaddeus House E51-E09 S5010 Thaddeus V235163 190705 Stage 4.doc Version 1.40 Page 20 EVIDENCE: As at previous inspection the home has In House Quality Monitoring systems in place to measure success in meeting the Statement of Purpose of the home. There is an annual development plan for Thaddeus House based on planning, action and reviews with residents being involved and consulted. Documentation identified that yearly development plans had been implemented for each service user, linked to individual personal plans. As at previous inspections the Care Manager/Deputy Manager ensures as far as is reasonably practicable the health safety and welfare of residents and staff. Safe working practices are followed and staff trained in fire safety, first aid, food hygiene, and infection control. Hazardous substances are securely stored and regular servicing of systems and equipment takes place. Risk assessments are carried out for all safe working practices and recorded. All accidents/injuries/reportable incidents are appropriately recorded and reported. Thaddeus House E51-E09 S5010 Thaddeus V235163 190705 Stage 4.doc Version 1.40 Page 21 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 x x 3 Standard No 22 23 ENVIRONMENT Score 3 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 3 3 x 3 x Score Standard No 24 25 26 27 28 29 30 STAFFING Score 3 x x x x x 3 Standard No 11 12 13 14 15 16 17 x 4 4 x 4 4 3 Standard No 31 32 33 34 35 36 Score x x x x 3 x CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Thaddeus House Score 3 4 3 x Standard No 37 38 39 40 41 42 43 Score x x 3 x x 3 x E51-E09 S5010 Thaddeus V235163 190705 Stage 4.doc Version 1.40 Page 22 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 Regulation Requirement Timescale for action RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard 6 Good Practice Recommendations Care records are maintained in a variety of files which appears to involve a lot of staff time searching through different files. The Inspector recommends that care records be formalised into a modular file to bring information together. Thaddeus House E51-E09 S5010 Thaddeus V235163 190705 Stage 4.doc Version 1.40 Page 23 Commission for Social Care Inspection Stafford - 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 E51-E09 S5010 Thaddeus V235163 190705 Stage 4.doc Version 1.40 Page 24 - 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. 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