Inspection on 30/08/07 for Thistley Lodge

This inspection was carried out on 30th August 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. 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 3 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Thistley Lodge 08/02/06

Thistley Lodge 06/09/05

Thistley Lodge 17/01/05

Thistley Lodge 02/06/04

Similar services:

The Lodge Nursing Home

Bracken House

Sunnycroft

Field Farm House

Edgeview Nursing Home

Church Terrace Nursing & Residential Home

The Forbury

The Maples

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

CARE HOME ADULTS 18-65 Thistley Lodge 40 Warwick New Road Leamington Spa Warwickshire CV32 6AA Lead Inspector Martin Brown Key Unannounced Inspection 30th August 2007 10:00 Thistley Lodge DS0000004412.V337501.R01.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 Thistley Lodge DS0000004412.V337501.R01.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. Thistley Lodge DS0000004412.V337501.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Thistley Lodge Address 40 Warwick New Road Leamington Spa Warwickshire CV32 6AA 01926 435045 01926 435045 thistley@rethink.org www.rethink.org Rethink 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) Mrs Mary Ullah Care Home 8 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (8) of places Thistley Lodge DS0000004412.V337501.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. Thistley Lodge may, within its existing numbers, care for the person named in the application for variation of registration dated 19 May 2006. Date of last inspection 5th October 2006 Brief Description of the Service: Thistley Lodge is a large, detached, three-storey house situated in a residential area of Leamington Spa. It is close to local shops and within walking distance of the town centre and local parks. The home provides services for eight people with enduring mental health problems and there are eight single bedrooms in the property. Although there is no lift in the property, there are two bedrooms and an assisted bathroom on the ground floor suitable for people with physical disabilities. There is a large garden to the rear of the property. Thistley Lodge is staffed 24 hours a day and there is always a registered nurse on duty. The aim of the service is to provide a warm, homely environment, where staff work with service users in a supportive manner in order for the service users to achieve their maximum potential and independence. Thistley Lodge provides a permanent home for service users, although those who want to move on to more independent living are supported to do so. Thistley Lodge is part of the organisation Rethink (formerly the National Schizophrenia Society). The manager stated that the current weekly charge is £419, with additional charges made for toiletries, clothing, leisure activities and hairdressing. A copy of the most recent inspection report is available in the home. Thistley Lodge DS0000004412.V337501.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection that took place between 10am and 4.45pm on a weekday. During that time, staff on duty and all service users were spoken with. The manager was present for some of the time; for the rest of the inspection, a team leader was available. Policies, and procedures and care records were examined, and two service users were ‘case tracked’, that is, their experience of the service provided by the home was looked at in detail. Specific elements of two other service users’ care were also looked at in detail. The recently introduced Annual Quality Assurance assessment was filled in and returned by the management to further inform the inspection, as was accumulated evidence from regulation 37 notices, service user Satisfaction Surveys conducted by the service, and records of ‘Regulation 26’ visits by the registered provider. No complaints or allegations regarding the home had been received by the Commission for Social Care Inspection since the previous inspection. One relative and an advocate were able to be contacted following the inspection and were able to give their perspective on the service. What the service does well: The service continues to provide a spacious, open environment, where service users are supported in a sensitive manner, and where they are able to exercise choice and independence whilst feeling safe and secure. ‘It’s a fantastic place’, ‘staff are very good’ were typical comments in regard of the service by people using it. The overall impression was of a positive, co-operative atmosphere, with relaxed and understanding interactions between staff and service users, and between individual service users, with each being tolerant and supportive of individual needs. The assessment process helps to ensure that the service only admits those whose needs it is likely to successfully meet. Service users continue to benefit from the support of a consistent staff team who are familiar with their needs and how to best meet them. Thistley Lodge DS0000004412.V337501.R01.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. Thistley Lodge DS0000004412.V337501.R01.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 Thistley Lodge DS0000004412.V337501.R01.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): 2 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Prospective service users can continue to be confident that their needs and wishes will be assessed and that a permanent admission will not be confirmed until all parties are satisfied that the service can meet these. EVIDENCE: The home currently has one service user vacancy. The manager was able to give examples of referrals that had not been agreed because it was uncertain that the person’s needs were of a sort that could be satisfactorily met by the home. The manager advised that a prospective service user has now been identified to move into the home, and that initial assessments were underway. The manager confirmed that this includes visits to the home including overnight stays and consultation with the existing service users, and will vary according to individual circumstances. The manager advised that flexibility is required in staff numbers, according to risk assessments, especially during overnight stays, when a prospective service user is being assessed. There is a statement of purpose and service user guide, which provide service users with information relating to the services that are provided in the home. These were available, and it has been noted at previous inspection that these documents are acceptable. Thistley Lodge DS0000004412.V337501.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7,9 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users are supported and encouraged to make decisions about their lives, and are supported to take risks as part of encouraging independence and well-being. Individual care plans reflect changing needs and personal goals. Information in care plans could be laid out in a more user-friendly manner, and more clearly show individual progress, or ‘recovery’. EVIDENCE: A sample of two service users files were examined. Care plan guidelines were seen. These were regularly reviewed, and information in them tallied with current practice and with comments made by staff and by residents about their needs and wishes. Some documents looked at, including those detailing personal wishes and likes, were not dated. When elements of these were discussed with staff and service users it was clear that the information was still current. Staff agreed that all information regarding service users should be dated, to facilitate timely Thistley Lodge DS0000004412.V337501.R01.S.doc Version 5.2 Page 10 reviewing and updating of information. Staff showed a good understanding of individual needs of service users. Service users spoken with said they were able to go out as they pleased; this was observed during the inspection. Where limits were imposed on decisionmaking, such as the main supplies of drinks being locked away, the effect of this was minimised by making available sufficient supplies for immediate needs, and was able to be justified by reference to individual care needs, namely that some service users were at risk of ‘bingeing’ on supplies if they were all openly available. There was no evidence of service users being denied access to drinks. Individual care plans and staff discussions showed how service users were prompted and supported in every day decisions and choices. Staff had a good awareness of residents’ needs, and how to meet them. Risk assessments, and the management of risks, were in place. Some of these were printed, and some hand written. The typed ones were easier to understand. A specific area of individual risk concerning a resident going out for walks was was covered by a detailed care plan, but it took some time to locate this within the relevant file. Staff on duty, and the person concerned, were fully aware and in agreement as to how the risk was managed. The manager and staff were keen to point out the progress that had been made by service users. This view was supported by the advocate, and a relative, and was most notably measured by service users remaining stable for a number of years and avoiding re-admissions to hospitals. This ‘improvement’, or ‘recovery’ was not apparent from reading care plans, and the manager acknowledged that a part of the care plans might usefully show more clearly the positive impact of time spent at Thistley Lodge. Thistley Lodge DS0000004412.V337501.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,15,17 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Service users’ ability to extend and enjoy activities beyond what they are currently able to accomplish unsupported may be hampered by a lack of available staff to support them. Service users enjoy a choice of healthy food suitable to needs and wishes, in ways that foster development, co-operation, and independence. EVIDENCE: Service users go out independently, or are supported by staff to do so when necessary. Service users use local buses, and walk to local shops. Staff and management advised that staff availability to support service users outside the home can sometimes be problematic, and can restrict activities. This was mentioned as a problem by staff, but not by service users. The manager advised that, as far as possible, staffing is deployed to enable activities to take place, and that extra staff can be agreed upon for specific activities to take place. Staffing ratios are normally two staff on duty at any one time during the day. Thistley Lodge DS0000004412.V337501.R01.S.doc Version 5.2 Page 12 One staff spoken with felt that having a mini-bus would help the service support service users being able to go out to a wider variety of activities. Several service users were looking forward to a forthcoming holiday. During the inspection, several service users went out to local shops. One went for a regular walk he enjoys, along a safe, agreed route. One spoke of regular activities outside the home, and another of hobbies and interests, and how these were supported by the service. One person spoken to attends college courses during term time, and was confidently aware of the cooking skills she has developed. Service users also spoke of various family contacts. These were detailed in care plans, alongside other significant contacts. The frequency and type of contact varies depending upon the needs and wishes of the service users and their families. Menus provide a good variety of healthy food. Service users all have involvement in cooking meals on a weekly basis; one person cooks for themselves on a daily basis. The kitchen was well-stocked, service users were positive about food when asked, although most of their interest and positive responses concerned other areas of the service. It was impressive that fruits and herbs from the garden were made use of in cooking. I was told that one service user had gathered plums from the tree in the garden and been helped to make a plum pudding. One service user is a vegetarian; the kitchen and freezer had a good supply of vegetarian substitutes and alternatives. An emphasis on low fat foods was noted in response to the needs of some service users who had been identified as having high cholesterol. Staff advised that there is always a supply of hot drinks and snacks available; the main supplies of such commodities are locked away in line with individual risk assessments where there is a risk of ‘bingeing’ on such supplies. No shortages, or expressed concerns regarding this, were evident during the inspection. Thistley Lodge DS0000004412.V337501.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 18,19,20 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users can be confident that they receive personal, emotional, and health support in ways that they prefer and require. While some shortcomings in the recording of medication were noted, the service has demonstrated it is taking prompt action to deal with these. EVIDENCE: Staff were observed to support the service users in a sensitive way that promotes their privacy and dignity. Throughout the home, there was an easy-going, friendly and mutually supportive atmosphere. Staff were seen to be attentive to individual needs and concerns, and to ensure these were recorded, so that other staff were aware of current issues. Service users were appreciative of staff’s efforts in this respect. ‘The staff are very good’ was one comment from a service user. Records, and discussion with staff and residents demonstrated appropriate involvement of health professionals both on a regular, and on an ‘as required’ basis. Thistley Lodge DS0000004412.V337501.R01.S.doc Version 5.2 Page 14 There is always a trained nurse on duty, who dispenses medication. Most medication is dispensed via ‘blister packs’. This was all seen to be accurate. Medication Administration Record Sheets showed no gaps in recording. However, there was no regular daily stock control of ‘non-blistered’ medication. this meant that any omissions of medications that had been signed for could not be picked up immediately, or possibly ever. Medications are received on a four weekly basis, and should run out at the end of this period. One medication looked at had slightly more of its supply remaining than it should have had, and this fact could not be accounted for – the staff member believed that this small surplus had been carried forward for some time, but could not be sure. The staff member agreed that daily stock control of these medications was needed to ensure that any errors were immediately apparent, and so that any discrepancy in stocks could be accounted for. This action was confirmed by the manager in a telephone conversation the following day. Staff advised that the pharmacy service had previously visited to check and advice on the storage, administration and recording of medications. Records show that this last occurred in 2005. The staff member agreed that a resumption of these visits may be beneficial. One service user had a mild pain reliever recorded as to be given ‘when needed’, but none had been given in recent months, and none was in stock. The manager advised that she would discuss changing this from ‘as required’ medication to a ‘homely remedy’. Several ‘as required’ medications did not detail what the requirement was, but the manager advised that service users were able to articulate their need, and staff then judge the response. This was observed to work well during the inspection when a (relatively new) staff member was observed responding appropriately to a request for some medicine, checking out the cause, and possible alternatives. There were photographs on the wall in the room where medicines are dispensed. The staff member agreed that these may be more useful in the Medication Administration Record Sheets folder, on the individual pages concerned. On individual Medication Administration Record Sheets, the section marked ‘allergies’ was blank. The staff member agreed that this should show ‘none’ if this was the case. Thistley Lodge DS0000004412.V337501.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 22,23 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users can feel confident that their views are listened to and acted upon. The regular access to an advocate helps to ensure that they are protected from abuse, neglect, and self-harm EVIDENCE: An advocate was spoken to, who has had a ‘befriending’ role for many years with people living at Thistley Lodge, and who visits regularly. She spoke positively of the service, says she visits regularly and talks to individual residents. She advised that whilst complaints about the service were relatively frequent years ago, in recent years service users are extremely positive about all aspects of the service. During the inspection, only one related group of concerns was highlighted by a service user. This concerned the state of the carpet in the smoking room, the lack of a fire in the fireplace, and the fact that it was cold in there. No concerns or complaints have been received by us concerning the service. Staff advised that there had been no complaints, and the staff member asked could not locate the complaints log. This staff member was relatively new. The manager later advised that there had been no complaints recently, advised on where the complaints, comments book was located, and would ensure that the staff member was aware of this. There is also a very visible ‘suggestions’ box in the hall. Information concerning the complaints procedure was available. When service users were asked what they would do if they had a complaint, their first response was that they would ‘talk to staff’. If this was not an option, Thistley Lodge DS0000004412.V337501.R01.S.doc Version 5.2 Page 16 they had alternatives, such as relatives, the advocate, or other people that they see, such as health professionals. One person identified a consultant as someone who listened to concerns. Records of residents’ meetings evidenced issues of concern to residents being discussed and addressed. User satisfaction surveys, and ‘one to one’ meetings with key workers also provided opportunities for issues to be raised. Staff have attended relevant Adult Protection courses, and relevant policies and procedures are in place. Staff spoken with were able to discuss abuse issues knowledgeably and explain correct procedures for responding to them. The manager was able to detail satisfactory arrangements for supporting service users in managing their finances, and what safeguards are in place to safeguard them, including ‘spot checking’ of monies and records held on their behalf during unannounced visits by the registered provider. Thistley Lodge DS0000004412.V337501.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 24,30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users benefit from a spacious and homely environment, which is generally maintained in a clean and tidy manner. The smoking area may benefit from some improvement, and in encouraging service users to have an active role in helping ensure this is maintained in a good state. EVIDENCE: The home is spacious, with good-sized bedrooms and a variety of communal spaces. The home was clean and tidy during this unannounced inspection. Service users take responsibility, with prompting and support, for the cleaning and tidying of their rooms. Two bedrooms were seen during the inspection, and these were well-maintained and spacious, and personalised to reflect individual wishes. Service users who showed me their rooms took pride in their clean and well-ordered state; one service user stated that he was in the process of ‘sorting’ his out. Service users had keys for their rooms, locking these when they chose to. Thistley Lodge DS0000004412.V337501.R01.S.doc Version 5.2 Page 18 The kitchen area was spacious and clean, and had benefited from refurbishment. Service users had free access to this, along with all other communal areas. There were a large number of notices on walls around the house. Staff or service users did not see these as detracting from the overall ‘homeliness’ of the home. The sash window in the first floor shower room did not have any ‘limiter’ mechanism of any sort, meaning that it could be fully opened, presenting a potential risk. The manager was advised of this and said she would ensure this was rectified by the ‘handyman’ employed by the service. There is a large garden, which is well-maintained, and provides some seasonal fruits, as well as herbs. There were no unpleasant odours in the home. The laundry was clean and tidy. The previous inspection had noted suitable staff support for service users in laundering clothes, etc. There was no reason to suppose this had changed. The laundry was clean and tidy. There was some spillage noted in one toilet. A service user readily and appropriately mopped this up when asked. A lounge, at the rear of the building, separated by a door from the rest of the building and having a sliding patio door as an additional exit, was now a designated smoking area. This was well-used by service users. One service user asked about a new carpet for this room, as well as new chairs, and a (gas) fire to fill the fireplace. He complained that the heating had not been on at all. The room did not appear cold, and other service users did not mention this as a problem. The manager later advised that the patio door was frequently open to allow for some fresh air, and that this may have led to an impression of coldness, even in summer. There was no smoke extractor. staff agreed that this would be useful in helping to reduce smoke in this room. There were marks on the carpet, these appeared to be residue from smoking, and were in particular areas where smokers generally sat. Thistley Lodge DS0000004412.V337501.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 32,34,35 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Service users would benefit from the availability of more staff at key times to enable them to be supported better in activities outside the home which would help them improve their life skills, and extend their life experiences. There may be a deficit in the understanding of the needs of some service users with autism. EVIDENCE: An examination of staffing rotas showed that the service continues to offer twenty four hour care and support, with one nurse always on duty, to dispense medication and oversee any other medical matters, supported by at least one care staff during the day. At night, there is one nurse on duty. During the day, if one staff accompanies a service user out for whatever reason, then this leaves one staff to support remaining service users, unless an extra staff member has been rostered in specifically for this activity. There is a lone working procedure in place. The manager advised that ‘bank’ staff, who are familiar with the service and the service users, are used, rather than agency staff, to cover any staffing shortfalls. The rota reflected this. Thistley Lodge DS0000004412.V337501.R01.S.doc Version 5.2 Page 20 Staff members spoken to had expressed some concern that the staffing ratio imposed limits on activities for service users, where these activities require staff supervision or support. The manager advised that rotas were designed to try and facilitate such activities. Service users spoken with did not raise concerns that opportunities for activities outside the home were limited. Most appeared content with being able to take unescorted trips to the local shops, although staff advised that staff support would enable them to ‘stretch’ their horizons more, improve their life experiences, their independence skills, and their quality of life. The Annual Quality Assurance Assessment returned by the manager noted, as an area for improvement, “More staff could facilitate more activities, more support with rehabilitation, occupation and developing independence”. Most staff have been at the service for a number of years. The staff file for the most recent recruit was examined, and this showed satisfactory procedures, including evidence of a satisfactory Criminal Records Bureau check. The most recent staff member had an induction checklist, in which all the elements of her induction were noted, and detailed her training, including refresher training on mandatory subjects. Staff spoken to were able to demonstrate their knowledge and competence on such areas as fire safety, food hygiene and awareness of and prevention of abuse. Discussion with staff, and the manager, demonstrated an ongoing commitment to training and the obtaining of National Vocational Qualification level 2, with a satisfactory percentage of staff either with that qualification or in the process of obtaining it. There was a student on placement at the home for a short period. The manager had been advised by the placing agency that this person had satisfactory Criminal Records Bureau clearance, but had no written evidence to this effect. She agreed that this was inadequate. The student readily agreed that a satisfactory Criminal Records Bureau could be brought in, and the manager was able to telephone the following day to say that this had been seen. The manager advised that written confirmation, or a viewing of a Criminal Records Bureau check, would always be sought in future, prior to a student placement commencing. One relative spoken to was full of praise for many of the staff, but felt that, in one or two instances, the understanding of the needs of residents with autism was a little lacking. Thistley Lodge DS0000004412.V337501.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 37,39,42. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users benefit from a well-run home, and from a manager who, although arguably over-stretched recently by other commitments within the service, demonstrated the commitment to addressing any shortfalls promptly. Quality audits need to take account of the tendency of service users to be content with the service as it is. The home continues to promote and maintain the health and safety of the service users and staff. EVIDENCE: Thistley Lodge continues to be run by the same manager, who advised that she has now completed the Registered Manager’s Award. She advised that she Thistley Lodge DS0000004412.V337501.R01.S.doc Version 5.2 Page 22 has been overseeing other homes within the organisation locally, as temporary maternity cover, but that a manager is now in post for these. She acknowledged that the service may have ‘suffered’ from the temporary division of her duties, but was confident she could now address any shortfalls. Copies of service user satisfaction surveys, and records of service users’ meetings were seen. These, along with the prominent suggestion box, and records of one-to-one meetings with key workers, all demonstrated opportunities for service users to air their views concerning the service as well as their individual aims. A tendency for the majority of service users to accept the ‘status quo’ in the service was detected throughout the inspection. With the exception of the person showing dissatisfaction with aspects of the smoking room, service users did not show signs of being unhappy with anything. Therefore there is an obligation on staff, and the service, to advocate for improvements in the service users’ lives. This was seen in the expressed wish for more staff availability to enable service users to enjoy a wider amount of activities outside the home. Service users are also supported by an advocate, who noted in discussion that the level of dissatisfaction amongst service users was a lot higher several years ago, when the service first began. A quality audit was last done in 2005. The manager acknowledged that another was now overdue. Evidence of regular visits by the registered provider or a suitable representative was seen, as well as recent internal satisfaction surveys. Staff showed a good awareness of fire safety procedures. A check on the fire alarm system was undertaken by the contractor during the inspection. The contractor advised that there was an intermittent fault in the light in the warning system, which, although not representing a danger to the safe working of the systems at present, would need addressing, as part of an overhaul or replacing of an aging system. The manager advised that this would be addressed. Dangerous items were safely secured, the home was clean and tidy, and other than the upstairs window requiring a limiter, which the manager advised would be addressed as a priority, no hazards were apparent. Thistley Lodge DS0000004412.V337501.R01.S.doc Version 5.2 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 Standard No Score 1 x 2 3 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 3 ENVIRONMENT Standard No Score 24 2 25 x 26 x 27 x 28 x 29 x 30 3 STAFFING Standard No Score 31 x 32 3 33 x 34 3 35 3 36 x CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 x 3 x LIFESTYLES Standard No Score 11 x 12 3 13 3 14 x 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 2 2 x 3 x 3 x x 2 x Thistley Lodge DS0000004412.V337501.R01.S.doc Version 5.2 Page 24 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 YA20 Regulation 13(2) Requirement The service must ensure that all medications dispensed are stock controlled on a daily basis, to guarantee that service users have received required medication, and that any errors are immediately apparent. A limiter is required on the first floor shower window, to stop it opening to a potentially hazardous degree. Timescale for action 06/09/07 2 YA24 YA42 13(4)(a) 07/09/07 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. 2. Refer to Standard YA6 Good Practice Recommendations All documents concerning residents’ care should be dated, so that the service users can be confident that they reflect current needs. Best practice in administration and recording of medication would be helped by a resumption of regular visits by the DS0000004412.V337501.R01.S.doc Version 5.2 Page 25 YA20 Thistley Lodge 3. 4. 5. YA20 YA20 YA24 6. 7. 8. 9. 10. 11. YA24 YA24 YA35 YA39 YA39 YA42 dispensing pharmacy. The inclusion of service user photographs in individual Medication Administration Record Sheets would help minimise the potential for error. Where Medication Administration Record Sheets include a space to detail allergies, this should be filled in appropriately, to help minimise any potential for error. Alternatives, such as extractor fans, should be sought, for use in the smoking room, to reduce reliance on open windows and doors as a way of ventilating the room, so the room does not become either unduly cold or smokefilled. The service should seek ways to improve and maintain acceptable floor covering in the smoking room, so that service users have a pleasant area to smoke in. The addition of a fire in the fireplace in the lounge would make in more ‘homely’ for service users. The service should ensure all staff have a good awareness of the needs of all service users with autism, by offering further training if necessary. For the service to have an up-to-date view of the quality of its provision, a quality audit is needed to update the one done in 2005. Documents such as Service User Satisfaction surveys , and the ‘lone working’ document should be dated. The fire alarm system should be overhauled/replaced, to ensure the continued maintenance of proper fire safety within the premises. Thistley Lodge DS0000004412.V337501.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Birmingham Office 1st Floor Ladywood House 45-56 Stephenson Street Birmingham B2 4UZ 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 Thistley Lodge DS0000004412.V337501.R01.S.doc Version 5.2 Page 27 - 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. 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