Inspection on 13/08/05 for Thorndale

This inspection was carried out on 13th August 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 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 3 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Thorndale 12/04/07

Thorndale 10/01/06

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 Sharon McDowell Unannounced Saturday 13 August 2005 at 12.30pm th The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationary Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Thorndale B52 B02 S15769 Thorndale V219741 13 Aug 2005 Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Thorndale Address 8 Thornhill Park Sunderland SR2 7JZ 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) 0191 564 2147 0191 567 2902 Tyne and Wear Autistic Society Mrs Jacqueline Fletcher Care Home 6 Category(ies) of LD Learning Disability (6) registration, with number of places Thorndale B52 B02 S15769 Thorndale V219741 13 Aug 2005 Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: None Date of last inspection 10 March 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 B52 B02 S15769 Thorndale V219741 13 Aug 2005 Stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place on a Saturday morning and lasted four hours. During the inspection a range of documents were viewed including a residents care plan, risk assessments, activities records, staff training records, some company policies and procedures. Two residents were in the Home during the inspection, whilst the others were out on social activities. The Registered Manager was present throughout the inspection supported by one of the Assistant Managers. Lunch was taken with the staff and residents. What the service does well: What has improved since the last inspection? Some aspects of the Homes furnishings have been replaced building on the existing high standard of décor, furnishings and fittings in the Home. Despite some of the challenges that the residents have with their behaviours and the effect this might have on the Home the staff manage to maintain a clean, comfortable and homely environment for the residents to live in. The Registered Manager described improvements to the resident profile, which gives a good picture about the resident’s needs and how staff are to meet those needs. It also gives good insight into what the resident likes, dislikes, and activities they enjoy and general information to let the reader gain an understanding about the person they are reading about. Thorndale B52 B02 S15769 Thorndale V219741 13 Aug 2005 Stage 4.doc Version 1.40 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 B52 B02 S15769 Thorndale V219741 13 Aug 2005 Stage 4.doc Version 1.40 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Standards Statutory Requirements Identified During the Inspection Thorndale B52 B02 S15769 Thorndale V219741 13 Aug 2005 Stage 4.doc Version 1.40 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users’ know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) Nil None of these standards were assessed during this inspection but will be reviewed at the next inspection. EVIDENCE: Thorndale B52 B02 S15769 Thorndale V219741 13 Aug 2005 Stage 4.doc Version 1.40 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate, in all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 9 Risk assessments are in place to support residents to lead independent lifestyle. However they are not always completed in sufficient detail to ensure the risks are clearly identified for staff to be able to implement appropriate action to ensure residents and staff are not placed at harm. EVIDENCE: The Registered Manager explained a revised personal profile that is to be used as part of the residents care plan. The profile covers key areas such as, social and leisure activities, health and safety and home activities. Within this documentation risk assessments are available for areas considered to be a potential risk to the resident, staff or visitors, for example, use of domestic appliances, tools and equipment. Some discussion took place about risk assessments particularly about how to ensure the risk is accurately identified with action implemented to reduce the risk. One risk assessment detailed how a resident would complete tasks in the kitchen and the ‘nature of the risk’ and action to address the risk being described vaguely. Therefore not giving sufficient detail to staff to follow the directions. It did not identify what the risks were in the kitchen, for example, burns from the oven or kettle, cutting oneself on knives, using electrical items. However another adequately identified the risk to a resident who has epilepsy when they used the bathroom Thorndale B52 B02 S15769 Thorndale V219741 13 Aug 2005 Stage 4.doc Version 1.40 Page 10 independently and had appropriate measures in place to reduce risk of harm to the resident without impinging on the resident’s independence and privacy. Thorndale B52 B02 S15769 Thorndale V219741 13 Aug 2005 Stage 4.doc Version 1.40 Page 11 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12,13, 14 & 15 Residents are encouraged and enabled with staff support to lead active lives through a variety of social and recreational opportunities both in the Home and outside the Home. Therefore residents and their families can be assured the residents lead fulfilling lives. Good arrangements are in place to ensure residents are helped to keep in touch with their families. Therefore families and residents can be assured there is support and equipment available to help them contact each other. EVIDENCE: On the day of inspection residents were going out with staff. Two were going shopping, one gentleman saying her was shopping for toiletries and a new pair of slippers, one was going out with another care home and was looking forward to fish and chips and the others were in the house until the afternoon when they were going out to the shops. Each resident has an activity programme for when they are not at college, which includes a range of social and recreational events, such as, going to the library, using a trampoline, going to the dry ski slope, go-karting, swimming and discos. Additional to this the residents go to the local shops, pubs and cafes. Some of the residents have Thorndale B52 B02 S15769 Thorndale V219741 13 Aug 2005 Stage 4.doc Version 1.40 Page 12 been away to Haggerston Castle for a short break with the others going later this summer and the Home has access to season tickets for Sunderland Football Club, which some of the residents enjoy. A video clip was available on the home computer showing some of the residents on go karts on a race track, which they looked like they were enjoying. Some residents are assisted to visit their parents for holidays. In the main the parents will come to the Home to pick them up or if needed the Home can arrange to escort residents to their parents home. Two residents keep in touch with their parents through e-mail and all have access to a telephone to keep in touch with their families. Since the previous inspection the staff have assisted residents to make more home made meals with one resident making a bacon and egg pie as he had requested. There were photographs available to show him making the pie, which he was keen to show off and explain how he had enjoyed making it. On the day of inspection the residents had homemade corned beef pie with beans or peas followed by yoghurt for lunch. They enjoyed a chocolate biscuit with their morning and afternoon drink. Thorndale B52 B02 S15769 Thorndale V219741 13 Aug 2005 Stage 4.doc Version 1.40 Page 13 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 20 Mediation is stored and administered correctly therefore residents are assured they will be given the right medication and their health needs are met. EVIDENCE: None of the current residents takes their own medication independently of staff. Medication is supplied to the Home in blister packs, which helps in checking if the right medication is delivered to the Home and if medication ahs been taken at the right time. All staff responsible for giving out medication have completed a ‘safe handling of medicines’ course. Medication is securely stored in a lockable cabinet. Appropriate policies and procedures are available for the staff to look at for information about storage and administration of medicines. A record is kept of any changes to medication made by the doctor. Thorndale B52 B02 S15769 Thorndale V219741 13 Aug 2005 Stage 4.doc Version 1.40 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) 23 Appropriate measures are in place to protect residents from potential harm and to take the correct action should harm occur. EVIDENCE: Staff have attended training in Protection of Vulnerable Adults with Tyne and Wear Care Alliance. Certificates of training are available in the Home. The Local Authority guidelines are available in the Home for staff to consult in the event of suspected abuse and as reference information. The Registered Provider has practice guidelines available in the Home policy and procedure file, which again directs staff to appropriate information for guidance in the event of abuse occurring in the Home. Thorndale B52 B02 S15769 Thorndale V219741 13 Aug 2005 Stage 4.doc Version 1.40 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) nil These standards were not reviewed at this inspection and will be assessed at the next inspection. EVIDENCE: These standards were not the focus of this inspection however it is noted that some improvements have been made to the Home, such as, a new lounge carpet has been fitted and new round dining tables have been purchased, which allows residents more space at the table. Thorndale B52 B02 S15769 Thorndale V219741 13 Aug 2005 Stage 4.doc Version 1.40 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) nil These standards were not reviewed in full at this inspection and will be assessed at the next inspection. EVIDENCE: On the day of inspection four staff were on duty for six residents, which is an adequate number for the number and needs of the residents accommodated and means they have a good staff to resident ratio. Thorndale B52 B02 S15769 Thorndale V219741 13 Aug 2005 Stage 4.doc Version 1.40 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) nil These standards were not reviewed at this inspection and will be assessed at the next inspection. EVIDENCE: The Registered Provider has recently reviewed the policies and procedures for the Home, which means staff have access to up to date information about how to deal with events and processes in the Home. Thorndale B52 B02 S15769 Thorndale V219741 13 Aug 2005 Stage 4.doc Version 1.40 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 x x x x Standard No 22 23 ENVIRONMENT Score x 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score x x x 2 x Score Standard No 24 25 26 27 28 29 30 STAFFING Score x x x x x x x Standard No 11 12 13 14 15 16 17 x 3 3 3 4 x x Standard No 31 32 33 34 35 36 Score x x x x x x CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Thorndale Score x x 3 x Standard No 37 38 39 40 41 42 43 Score x x x x x x x B52 B02 S15769 Thorndale V219741 13 Aug 2005 Stage 4.doc Version 1.40 Page 19 Yes 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 YA9 Regulation 13(4) Requirement Risk assessments for residents must be completed in sufficient detail to identify the risk and action required to reduce risk. The Registered Person must forward infection control policies to the Commission for Social Care Inspection. The Registered Manager must complete the Registered Manager Award or equvalent by the end of 2005. Timescale for action 31/10/05 2. YA30 13(3) 30/9/05 3. YA37 31/12/05 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 Thorndale B52 B02 S15769 Thorndale V219741 13 Aug 2005 Stage 4.doc Version 1.40 Page 20 Commission for Social Care Inspection Baltic House Port of Tyne South Shields Tyne and Wear 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. Extracts may not be used or reproduced without the express permission of CSCI Thorndale B52 B02 S15769 Thorndale V219741 13 Aug 2005 Stage 4.doc Version 1.40 Page 21 - 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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