Inspection on 28/06/05 for Thistledown

This inspection was carried out on 28th June 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.

Other inspections for this house

Thistledown 17/01/07

Thistledown 15/12/05

Thistledown 28/02/05

Thistledown 25/08/04

Thistledown 03/02/04

Similar services:

Hillview Farm

Dalewood Respite Care

Orchard,The

REACH Upton Court Road

Fairways

Treloar College

Kestrel House, St Anne`s Opportunity Centre,

Pinta

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

CARE HOME ADULTS 18-65 Thistledown 33 Beach Road Hayling Island Portsmouth Hampshire Lead Inspector Martin Bayne Unannounced 28.06.05 09.00am & 21.07.05 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. Thistledown H54 S11854 Thistledown V225472 280605 & 210705.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Thistledown Address 33 Beach Road, Hayling Island, Portmouth, Hampshire, PO11 0JB 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) 02392 461282 Mr R Bagoban and Mrs I Bagoban Mr R Bagoban CRH 6 Category(ies) of LD- Learning Disability (6) registration, with number PD- Physical Disability (2) of places Thistledown H54 S11854 Thistledown V225472 280605 & 210705.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: 1- Service users in the categories LD and PD are not admitted under 18 years of age. Date of last inspection 28/2/2005 Brief Description of the Service: Thistledown is a privately owned residential home offering personal care and accommodation for up to six residents with a learning disability. Four of the five residents currently at the home have lived there since 1984, whilst the fifth moved in in 2000. Mr & Mrs Bagoban have owned the home since 1994. Residents have their own bedroom and share communal rooms of a lounge, dining room, kitchen and bathroom. The home is located in a residential area of Hayling Island near to local shops and other facilities. Thistledown H54 S11854 Thistledown V225472 280605 & 210705.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection took place on two dates, 28-6-05 and the evening of 21-7-05. On the day of the unannounced visit of 28-6-05, there were no residents at home as they had gone out to day services. The inspector was invited to attend a barbecue to meet the residents that was being organised by relatives and the owners on the 21-7-05. On the day of 28-6-05, documentation relating to the care of the residents was inspected. The two requirements made on the last visit to the home were followed up and found to have been met. There were no requirements made on this visit to the home. What the service does well: What has improved since the last inspection? What they could do better: Mr Bagoban will continue to look into opportunities for resident to be more involved in the community. Thistledown H54 S11854 Thistledown V225472 280605 & 210705.doc Version 1.30 Page 6 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. Thistledown H54 S11854 Thistledown V225472 280605 & 210705.doc Version 1.30 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 Thistledown H54 S11854 Thistledown V225472 280605 & 210705.doc Version 1.30 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) 2, 3 & 5 Residents’ rights are protected through having a copy of the terms and conditions of residents. Their needs continue to be met at the home. EVIDENCE: There have been no new admissions to the home since 2000. The current residents have a copy of the terms and conditions of residence. Mr Bagoban was aware of the assessment standards should a new person be admitted. He said that great emphasis would centre on compatibility with the people who currently live at the home. From speaking with the residents and the relatives it was clear that the home is meeting the needs of the residents. Thistledown H54 S11854 Thistledown V225472 280605 & 210705.doc Version 1.30 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 Residents’ needs are met, having been assessed, with care plans developed within a framework of risk assessment. EVIDENCE: At the last inspection a requirement was made that each resident has a care plan. A person centred planning approach has been adopted and the plans were appropriate to meet the needs of the residents. Plans detailed health needs, personal goals, care needs and plans for activities and community access. The plans had been reviewed as required by the standards. An annual assessment of needs has also been undertaken as required by the standards. Residents are free to make decisions about their lives and there were no restrictions of freedoms detailed on the care plans. Mr & Mrs Bagoban live on the premises and residents and the Bagobans live as one big family. Residents therefore participate in the day to day running of the home. Thistledown H54 S11854 Thistledown V225472 280605 & 210705.doc Version 1.30 Page 10 At the last inspection a requirement was made that written risk assessments are put in place. At this inspection it was found that these have been developed for activities within and outside the home. Thistledown H54 S11854 Thistledown V225472 280605 & 210705.doc Version 1.30 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) 11, 12,13, 14, 15 & 17 Residents enjoy full and active lives and are supported to maintain family ties. EVIDENCE: The relatives spoke very positively of how residents have become more confident and independent. Four of the residents attend a day service gardening group five days a week, which they said they enjoyed. The other resident has a programme of activities suited to their needs. Residents also have activities in the evenings, such as dancing, numeracy, massage and relaxation. At the weekends residents can go to the pub, on their own should they wish as they are known in the pub. Two of the residents went to Glasgow to compete in the special Olympics, which they greatly enjoyed. The home has a people carrier to take residents on outings. Residents are supported to maintain links with their families and many go to their family homes at weekends. The relatives are very much integrated into Thistledown H54 S11854 Thistledown V225472 280605 & 210705.doc Version 1.30 Page 12 the home having formed a residents support group, who regularly meet to support each other and the home. Residents said that they enjoyed the food at the home. Thistledown H54 S11854 Thistledown V225472 280605 & 210705.doc Version 1.30 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) 19 & 20 Residents’ health needs are attended and medications administered safely. EVIDENCE: All the residents are registered with a local GP practice and residents are supported to attend appointments. Other health care needs such as chiropody, dentistry and eye care are also attended to and recorded. Two of the residents have prescribed medication and require having their medication administered by the staff. The medication is administered by Mr or Mrs Bagoban from the medication cabinet in the staff office. The medication administration records were inspected and found to meet the standard with no gaps within the record. Thistledown H54 S11854 Thistledown V225472 280605 & 210705.doc Version 1.30 Page 14 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) Not inspected on this occasion. EVIDENCE: Thistledown H54 S11854 Thistledown V225472 280605 & 210705.doc Version 1.30 Page 15 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 Residents benefit from a homely environment. EVIDENCE: Mr Bagoban showed the inspector around the home, which was homely and in reasonable decorative order throughout. The home was also found to be clean and well ventilated. At the last inspection it was agreed that the bathroom floor would be repaired. This has not taken place as yet as Mr Bagoban is planning to refurbish the whole of the bathroom. There is large garden to the rear of the home. Thistledown H54 S11854 Thistledown V225472 280605 & 210705.doc Version 1.30 Page 16 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) 33 Residents receive support from staff with whom they have formed a long term relationship. EVIDENCE: The home employs one member of staff who has worked at the home since 1994 and has a good working relationship with all of the residents. A CRB has been undertaken and in respect of this member of staff. Mr Bagoban said that he had arranged training for this staff member in challenging behaviour. Mr & Mrs Bagoban who are both trained nurses in the field of learning disability provide 24 hour support for the rest of the time. The current staffing quotient currently meets the needs of the residents. Thistledown H54 S11854 Thistledown V225472 280605 & 210705.doc Version 1.30 Page 17 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 Active involvement of relatives ensures that the home provides a high standard of care and support to residents. EVIDENCE: Through the very active “Friends of Thistledown”, the relatives support group, there is ongoing feedback on how the service is run. The feedback from relatives was very positive in respect of the care provided in the home. The fire log book was inspected and it was found that tests and inspections of the fire safety system were taking place as required. Thistledown H54 S11854 Thistledown V225472 280605 & 210705.doc Version 1.30 Page 18 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 x 3 3 x 3 Standard No 22 23 ENVIRONMENT Score x x 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 x Standard No 11 12 13 14 15 16 17 3 3 3 3 3 x 3 Standard No 31 32 33 34 35 36 Score x x 3 x x x CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Thistledown Score x 3 3 x Standard No 37 38 39 40 41 42 43 Score x x x x x x x H54 S11854 Thistledown V225472 280605 & 210705.doc Version 1.30 Page 19 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 Good Practice Recommendations Thistledown H54 S11854 Thistledown V225472 280605 & 210705.doc Version 1.30 Page 20 Commission for Social Care Inspection 4th Floor- Overline House Blechynden Terrace Southampton Hampshire 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. 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