Inspection on 02/05/07 for Thomas House

This inspection was carried out on 2nd May 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is 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 there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 5 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Thomas House 10/10/06

Thomas House 03/11/05

Similar services:

Larch Avenue

Alderson Road 12

Cranworth Close Registered Care Home

Pennine Camphill

Muston Road (70)

Grayling

The Cornerstone

John Street Nursing Home

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

CARE HOME ADULTS 18-65 Thomas House 70 Grove Park Calder Grove Wakefield WF4 3BZ Lead Inspector Tony Railton Key Unannounced Inspection 2nd May 2007 08:00 Thomas House DS0000062919.V338403.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 Thomas House DS0000062919.V338403.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. Thomas House DS0000062919.V338403.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Thomas House Address 70 Grove Park Calder Grove Wakefield WF4 3BZ 01924 283445 01924 263312 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) K and M Care Mrs Maureen Preston Ms Katherine Barrick Care Home 3 Category(ies) of Learning disability (3) registration, with number of places Thomas House DS0000062919.V338403.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category of service only: Care home only - Code PC; To service users of the following gender: Either; Whose primary care needs on admission to the home are within the following category: Learning disability - Code LD The maximum number of service users who can be accommodated is: 3 10th October 2006 2. Date of last inspection Brief Description of the Service: Thomas House is a spacious semi-detached property offering en-suite facilities within the 3 bedrooms, 2 spacious lounges, a large well-equipped kitchen and a garden to the rear of the property. This domestic property is situated in a residential area of Wakefield and the location allows for easy access to public transport and to local community facilities. The operators of Thomas House (K&M Care) have experience of working with adults who have a learning disability and, in particular, those with Autism. The manager/proprietor informed the Commission on 26 February 2007 that the current scale of charges for care at the home are £1400 - £2200 per week. Details about the home are made available to prospective service users and their representatives via the Service User Guide and Statement of Purpose, both of which are available on request from the home. Details of the Commission for Social Care Inspection are included in these documents. Thomas House DS0000062919.V338403.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This visit to the service commenced at 08.00 am and ended at 12 noon. During the visit there was the opportunity to speak to the manager/proprietor and the care coordinator/proprietor. The person who uses the service on a permanent basis was met and their care and support was observed throughout the visit. Two returned CSCI relatives’ surveys were seen along with information provided by the service. Three records of people who use the service were seen and included assessments, care plans, reviews, and daily medical and financial records. The medicine and financial administration systems were checked. The records of one agency worker were seen. Also considered was the providers’ response to the improvement plan requested following the previous inspection visit. What the service does well: What has improved since the last inspection? The manager said that safeguarding training and moving and handling training is been planned for permanent staff. Thomas House DS0000062919.V338403.R01.S.doc Version 5.2 Page 6 Descriptive words are used in the daily records to show and reflect people’s choices and preferences. 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. Thomas House DS0000062919.V338403.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 Thomas House DS0000062919.V338403.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 People living in the home have their personal and healthcare needs assessed. People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to the service. EVIDENCE: The manager said that people using the service have comprehensive assessments of their personal and healthcare needs. The Easy Care Assessments and Integrated Care Management Assessments completed by the Local Authority confirmed this. The manager said that the service does not provide its own assessments. Thomas House DS0000062919.V338403.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, and 9 People using the service need to have their personal care needs written down by the service to tell their staff how they need to be cared for. People who use the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to the service. EVIDENCE: People using the service have some care plans provided by the Local Authority telling others what they need to do to make sure their care needs are met. The Integrated Care Management Programmes confirm this. It was observed that the service does not provide its own care plans telling staff what they should do to meet people’s care needs. The manager said that there are a few care plans that have been reviewed by the multidisciplinary review meetings. The minutes of the service reviews confirmed this. Thomas House DS0000062919.V338403.R01.S.doc Version 5.2 Page 10 People’s care plans should be developed and looked at and checked on a regular basis to make sure the service continues to meet their care and support needs. People’s service reviews show that their relatives, social workers and community nurses are happy with the support and care provided. Thomas House DS0000062919.V338403.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): 12,13,15,16 and 17 People using the service have opportunities for personal development and to enjoy joining in community based leisure activities. They also are offered a wholesome and balanced diet. People who use the service experience good quality outcomes in this area. We made this judgement using a range of evidence, EVIDENCE: The record of activities and daily records show that people using the service are supported and enjoy using ordinary community based leisure services. The manager said that one permanent person using the service enjoys going to the Local Authority day services, horse riding, visiting restaurants and riding in the car. The daily records confirmed this. The daily records use descriptive words to reflect and show people’s choices and preferences with regard to activities and, in particular, choice of menu. Thomas House DS0000062919.V338403.R01.S.doc Version 5.2 Page 12 The menu and daily records show that people are offered a wholesome and balanced diet. Thomas House DS0000062919.V338403.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 and 20 People’s personal and healthcare needs are met, however staff need to have training in the administration of medicines. People who use the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence including this visit. EVIDENCE: The policy and procedures for the administration of medicines are good, however, the manager said that staff are not trained in the administration of medicines. The minutes of the multidisciplinary service review meetings show that people using the service, their relatives and other stakeholders are happy that their personal and healthcare needs are met by the service. One person, who uses the service on a permanent basis, medication was checked and found to be correct, was stored properly, administered correctly, and appropriately recorded. The record of an agency worker who works for the service on a regular basis shows that they have had training in the safe administration of medicines. Thomas House DS0000062919.V338403.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23 The Safeguarding Policies and Procedures are good but staff have not had any Safeguarding Training. People who use the service experience adequate quality in this area. We have made this judgement using a range of evidence including this visit. EVIDENCE: Two returned relatives’ surveys show that they know how to complain about the services provided. Discussion with the manager found that the service has not had any complaints. This was confirmed by previous information provided by the service. The minutes of the service reviews show that people’s relatives and other stakeholders are happy with the quality of care provided. The Safeguarding Policy is good and includes the Wakefield Local Multidisciplinary Safeguarding Procedures. Discussion with the manager and care co-ordinator found that they have not had any safeguarding training or training in how to use physical intervention safely. The assessments of the person using the service permanently show that passive intervention is required to make sure they are safe. The manager said that staff have not had any training on how to use physical intervention properly. Thomas House DS0000062919.V338403.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 24 and 30 People benefit from living in a homely comfortable, clean and safe environment. People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence including this visit. EVIDENCE: A tour of the premises found that all areas of the home are maintained to a good standard and are clean and comfortable. One person who uses the service permanently was observed relaxing in their lounge that is comfortable and homely. The two returned CSCI relatives’ surveys show that they are generally happy with the quality of the environment. The minutes of the five reviews show that other stakeholders such as Social Workers and Community Nurses are happy with the quality of the environment. Thomas House DS0000062919.V338403.R01.S.doc Version 5.2 Page 16 The manager said that a recent visit from the Local Authority contract monitoring officer did not raise any issues. The permanent resident, although without speech, was observed controlling his environment by gestures and actions. Thomas House DS0000062919.V338403.R01.S.doc Version 5.2 Page 17 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32,34, and 35 Permanent staff that know them and how they like to be cared for would better meet people’s care and support needs. Staff that are appropriately trained would better meet people’s needs. People using the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence including this visit. EVIDENCE: Discussion with the manager found that the service is currently using agency workers to care for people in the home. The staff rota confirmed this. The five Multidisciplinary Service Reviews show that people’s relatives, community nurses and social workers are happy with the service and the support it provides. The two returned CSCI relatives’ surveys show that people’s relatives are happy with the care and support provided. To make sure people using the service are safe, information about the agency workers used is given to the manager, and includes police and POVA checks. Thomas House DS0000062919.V338403.R01.S.doc Version 5.2 Page 18 The staff rotas show that there are staff available to care for people using the service, however, some of these are agency workers and not permanent staff who know the people using the service. The manager said that two permanent staff had left and that she is currently recruiting new staff. People using the service would be safer if staff caring for them were appropriately trained, as the manager said that staff have not received training in safeguarding, physical intervention, food hygiene, administration of medicines or moving and handling. Passive physical intervention was observed being used to make sure people using the service remain safe. Thomas House DS0000062919.V338403.R01.S.doc Version 5.2 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 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39, and 42 The staff and care management systems need to improve to make sure people are safe at all times. People using the service experience adequate outcomes in this area. We have made this judgement using a range of evidence including this visit. EVIDENCE: The five service reviews of people using the service show that relatives and other stakeholders are happy with the management and the services provided. The two returned CSCI relatives’ surveys show that people’s relatives are happy with the management and the service provided. The manager said a recent visit from the Local Authority Contract Monitoring Officer did not raise any issues. Thomas House DS0000062919.V338403.R01.S.doc Version 5.2 Page 20 People using the service would benefit from the service having a care management system that includes developing and reviewing people’s care plans. People would also be safer if the service had a staff training and development plan that includes training to make sure that they are looked after correctly and included safeguarding, physical iIntervention, moving and handling and food hygiene training. The manager said that the service has not formally asked for the views of people using the service or their relatives or other stakeholders to see if they are happy with the services provided. The minutes of the five multidisciplinary reviews show that relatives and other stakeholders are generally happy with the services and support offered by the service. Thomas House DS0000062919.V338403.R01.S.doc Version 5.2 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 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 2 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 2 33 x 34 2 35 2 36 x CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 X 2 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 3 2 x 2 X 1 X X 2 x Thomas House DS0000062919.V338403.R01.S.doc Version 5.2 Page 22 Are there any outstanding requirements from the last inspection? Yes 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 YA18 Regulation 15(1) Requirement Timescale for action 16/09/07 2. YA9 13 (4) (c) 3. YA20 YA42 13(2)(6) 4. YA37 18 (1) The service needs to develop care plans telling staff what they must do to meet peoples’ personal care needs. Outstanding Requirement from previous visit. The service needs to develop risk 16/09/07 assessments telling staff what action they must take to make sure people using the service are safe. Outstanding Requirement from the previous visit. To make sure people using the 16/09/07 service are safeguarded and protected staff require Safeguarding training and training in the use of Physical Intervention, Moving and Handling and Food Hygiene and on the Administration of Medicines. The registered person shall 01/07/07 provide an action plan stating how all of these requirements will be met. Thomas House DS0000062919.V338403.R01.S.doc Version 5.2 Page 23 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 3 4 Refer to Standard YA6 YA9 YA35 YA39 Good Practice Recommendations The registered manager should provide care plans that are reviewed on a regular basis. The registered manager should provide risk assessments that are reviewed on a regular basis. The registered manager should make sure that all staff has a training and development plan showing the training received and future planned training. The registered manager should set up a system for quality monitoring and review within the home, which includes seeking the views of relatives and other stakeholders on the quality of the service provided. Thomas House DS0000062919.V338403.R01.S.doc Version 5.2 Page 24 Commission for Social Care Inspection Brighouse Area Team First Floor St Pauls House 23 Park Square Leeds LS1 2ND 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 Thomas House DS0000062919.V338403.R01.S.doc Version 5.2 Page 25 - 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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