Inspection on 10/01/06 for Thorndale

This inspection was carried out on 10th January 2006.

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

Thorndale 12/04/07

Thorndale 13/08/05

Thorndale 10/03/05

Thorndale 25/10/04

Thorndale 30/03/04

Similar services:

22 Sandown Road

The Highlands

Dilston College Of Further Education

West View House

Prince Bishop Court

Park View (15)

Craigmore House

1 Lanark Close

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

CARE HOME ADULTS 18-65 Thorndale 8 Thornhill Park Sunderland SR2 7JZ Lead Inspector Sheila Head Unannounced Inspection 10th January 2006 02:00 Thorndale DS0000015769.V256251.R01.S.doc Version 5.1 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 Thorndale DS0000015769.V256251.R01.S.doc Version 5.1 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. Thorndale DS0000015769.V256251.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Thorndale Address 8 Thornhill Park Sunderland SR2 7JZ 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) 0191 564 2147 0191 567 2902 Tyne and Wear Autistic Society Mrs Jacqueline Fletcher Care Home 6 Category(ies) of Learning disability (6) registration, with number of places Thorndale DS0000015769.V256251.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 13th August 2005 Brief Description of the Service: Thorndale provides personal care and support services for up to six people who have an autistic spectrum disability. Nursing care cannot be provided, and the layout of the building is not suitable for people with a physical disability.The home is a large Victorian semi-detached villa, situated in a very pleasant residential area of Sunderland, within easy reach of a range of amenities. These include a post office, Churches of different denominations, a variety of small shops and public houses. Sunderland City Centre is only a short distance away and this may be reached by public transport, which passes frequently. The property has a garden to the front and a yard to the rear. Limited car parking is available in the rear yard. However visitors can park on the main avenue outside the home. Thorndale DS0000015769.V256251.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection was carried out during an afternoon and early evening as part of the annual inspection process. The inspector toured the building and reviewed a number of records including two care plans, training files and activities programmes. A meal was taken with the six residents at teatime after their return home from college. What the service does well: What has improved since the last inspection? On the day of inspection the front hall was being decorated. The home has already a high standard of fixtures and fittings however a continuous commitment to raise standards continues. There is a new carpet in the lounge. The Registered Manager has successfully completed the Registered Managers Award. The Home consistently provides a high standard of care to the residents. Thorndale DS0000015769.V256251.R01.S.doc Version 5.1 Page 6 What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Thorndale DS0000015769.V256251.R01.S.doc Version 5.1 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 Thorndale DS0000015769.V256251.R01.S.doc Version 5.1 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 2 Comprehensive pre admission assessments are available for each resident. EVIDENCE: The needs of each resident were assessed using a multi disciplinary approach of planning before coming to live in the home so that they and their family knew that their needs could be met. At the moment the home has no vacancies but in the event of a new admission there are systems in place for full assessment of need Thorndale DS0000015769.V256251.R01.S.doc Version 5.1 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 the following standard(s): 6,7 Individual care plans set out the residents needs and involve the resident, their families or advocate. The plans are detailed and cover all aspects of the resident’s lives. The residents are empowered to make their own decisions. EVIDENCE: The content of individual care plans provide detailed information about assessed needs and how the staff will meet those needs. Picture symbols and teach symbols are used to good effect as a communication aid for residents to express their views and needs. Care plans are reviewed monthly in the home with the involvement of the residents. Every term there is a multi disciplinary review that also includes family and advocates and this ensures that agreed plans of care are being met. Residents are encouraged to make their own decisions and choices everyday. During the inspection residents chose the menu for tea, then decided what they were going to do for the rest of the evening. They had a choice of three activities; all were helped to take part in the one of their choice. They decide what they are going to wear and what time they want to go to bed. Risk assessments are in place to make sure the residents are safe in whatever they do. Thorndale DS0000015769.V256251.R01.S.doc Version 5.1 Page 10 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16,17 The daily routines and rules in the house promote independence and choice for each resident that means that they are fully involved in all aspects of the dayto-day running of the home. Meals are nutritious and plentiful which ensures that residents have a good and varied diet. Mealtimes are well organised and orderly so that residents have the necessary support to enjoy their meals. EVIDENCE: At four o’clock the residents returned home from college. The staff numbers allow individual attention to be given to each resident that gives the residents freedom to chose what they do and where they go in the house. The residents have routines such as putting their slippers on once they are home and taking part in household tasks. Each resident takes turns to help with preparing the teatime meal. Teatime was a pleasant experience with all the residents enjoying their tea in a modern clean, spacious dining room. It was quiet with no distractions apart from conversation between staff and residents which was good natured and centred around the activities that were to follow. Good table manners were encouraged and everyone enjoyed their meal that was plentiful and healthy. This is Thorndale DS0000015769.V256251.R01.S.doc Version 5.1 Page 11 supported by the manager seating residents in groups of two so that they can concentrate on their meal and have individual support as required. Thorndale DS0000015769.V256251.R01.S.doc Version 5.1 Page 12 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18 19 Staff are good at supporting the residents to make their own decisions and have choice in the way they live and what they do. There are systems in place to make sure that the health needs of residents are identified. EVIDENCE: Residents are helped by staff to meet their personal care needs in a discreet and caring manner. The residents have their own rooms with their own vanity unit that has a sink, shaver point and storage. Staff were observed helping residents to tend to their own needs in their bedrooms. All staff were courteous and bedroom doors were always closed when the resident was using the washing facilities. Care and support is given to the residents in a sensitive manner by staff who are calmly confident in their approach so that the residents are settled and happy. One resident showed the inspector around their bedroom and were proud to show the new items for their room that they had bought on one of their shopping trips. The residents receive an eye test once a year and have a meeting with a psychiatrist every six months. The home has a small stock of homely remedies that are safely stored and documentation is in place that safeguards its use. The residents have access to their local doctor and have an annual health Thorndale DS0000015769.V256251.R01.S.doc Version 5.1 Page 13 check. If a doctor visits the consultation will take place in the residents own room so that it is private. Thorndale DS0000015769.V256251.R01.S.doc Version 5.1 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 the following standard(s): 22 Residents and their representatives are given information about how to complain and who to when they come to live in the home. They are confident that their concerns will be listened to and will be taken seriously and acted upon. EVIDENCE: Documentation is up to date with no complaints having been recorded since the last inspection. The staff and residents hold regular meetings where the residents by means of pictures and symbols make their views known. The staff sorts out Day to day concerns straight away. During the inspection residents approached staff openly and with confidence. The good relationships held between staff and families encourage an open style culture in the home so that any problems are sorted out immediately. Potential issues are identified early in the process due to excellent communication and a good knowledge of residents and their families Thorndale DS0000015769.V256251.R01.S.doc Version 5.1 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 the following standard(s): 24,30 The home is comfortable, homely and safe. It is clean, well maintained and meets the needs of the residents. EVIDENCE: Staff are proud of the home and strive to improve and maintain the already high standard with involvement from residents and their families so that the residents can live safely surrounded by their own chosen items and furniture. The home has a full time maintenance person as part of the staff team who keeps the home in good working order. There is a repair book that is looked at every day and when a repair or requirement is completed the book is signed and dated. Records are kept up to date and are clear. Safety checks for equipment are documented. Weekly testing of fire alarms is recorded and the residents take part in a surprise fire drill every week. The inspector saw the residents and staff carry out their fire drill safely and quickly on the day of the inspection. Water temperatures are tested throughout the home on a monthly basis but these should be monitored more frequently. Thorndale DS0000015769.V256251.R01.S.doc Version 5.1 Page 16 The communal areas are bright and cheerful with a high standard of furniture and soft furnishings that are also practical and easily maintained. Bedrooms are decorated and furnished to individual taste and reflect their lifestyles. All electrical equipment is tested for safety. Each bedroom has a discreet vanity unit consisting of wash hand basin, electrical shaver point and storage. Bathroom facilities on each floor are shared and are of a good standard. The home has a planned redecoration and maintenance programme. The home is clean and there are no smells. The laundry room is clean and tidy with suitable washing machines and dryers. Staff and residents are active in promoting control of infection with personal hand washing being constantly encouraged and praised. Thorndale DS0000015769.V256251.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 35 Staff are suitably trained to meet the needs of the resident so that the care they give is current and updated and reflects modern practice. EVIDENCE: There is a development and training programme in the home that is clearly documented for each member of staff. All staff have a personal development file that identifies training needs. Required training including first aid, food hygiene and health and safety is all documented and up to date for all staff. As soon as training is completed the next date is entered in the diary to make sure that update training is given within set timescales. All staff have received Protection of Vulnerable Adults training. New starters complete this training within six months of joining the staff. They also work through a full induction programme mentored by the manager or deputy. Staff are trained in interventions using the CALM process. Interventions can only be put into place if the staff member has completed this training and has revision training every six months. Staff spoke about their training and how it was relevant to their job. Staff also commented on the support they received and encouragement from management to complete their training programmes on time. Staff were confident and said the training they received especially the CALM and regular updates helped them to do their job more successfully. The manager has successfully completed the Registered Managers Award. Thorndale DS0000015769.V256251.R01.S.doc Version 5.1 Page 18 The Tyne and Wear Autistic Society encourage staff to complete training with an autism focus as part of their induction programme. Thorndale DS0000015769.V256251.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 39,42 Effective monitoring systems are in place to make sure the home is successful in achieving the aims of the residents. Systems and checks are in place to make sure residents and staff are safe. EVIDENCE: The Care Coordinator monitors the home regularly. Each term a quality audit tool is used to check that aims and objectives in the home for each of the residents are in place and are realistic so they can be achieved. The SMART target process is used. ( Specific, measurable, achievable, realistic and timescale.) This same process is used every month by the manager to ensure that any changes can be put into place quickly. Feedback is sought from families through meetings and questionnaires so that the staff team are aware of concerns or new information that could affect the care of the resident. Residents and staff have regular meetings altogether and Thorndale DS0000015769.V256251.R01.S.doc Version 5.1 Page 20 staff also ask residents individually using picture cards if they are satisfied with the home. All staff are trained in health and safety, fire safety, first aid, food hygiene and infection control so that the residents and staff, through good practice are safe. Certificates are held in personal training portfolios and clear records are kept. Maintenance records are all up to date and risk assessments are in place to identify areas of possible danger. Staff use these assessments and review them monthly to ensure that as far as possible accidents are avoided. The home has a policy for recording accidents that helps staff identify areas of risk so that risks are lessened. Thorndale DS0000015769.V256251.R01.S.doc Version 5.1 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 x ENVIRONMENT Standard No Score 24 3 25 x 26 x 27 x 28 x 29 x 30 3 STAFFING Standard No Score 31 32 33 34 35 36 3 3 x x x LIFESTYLES Standard No Score 11 x 12 x 13 x 14 x 15 x 16 4 17 x x x x 3 x 4 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 DS0000015769.V256251.R01.S.doc Score PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Thorndale Score 3 3 x x x x 3 x x 3 x Version 5.1 Page 22 Are there any outstanding requirements from the last inspection? No STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. Standard Regulation Requirement Timescale for action RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Thorndale DS0000015769.V256251.R01.S.doc Version 5.1 Page 23 Commission for Social Care Inspection South of Tyne Area Office Baltic House Port of Tyne Tyne Dock South Shields NE34 9PT 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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