Inspection on 11/09/06 for Thornhill Road

This inspection was carried out on 11th September 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

Thornhill Road 13/08/07

Thornhill Road 13/02/06

Thornhill Road 04/10/05

Thornhill Road 20/10/04

Thornhill Road 21/05/04

Similar services:

Larch Avenue

Alderson Road 12

Cranworth Close Registered Care Home

The Cornerstone

John Street Nursing Home

Pennine Camphill

Snydale Care Home

Whitwood House

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

CARE HOME ADULTS 18-65 Thornhill Road 22 & 24 Thornhill Road Rastrick Brighouse West Yorkshire HD6 3AX Lead Inspector Cheryl Stovin Key Unannounced Inspection 11th September 2006 10:00 Thornhill Road DS0000001074.V320721.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 Thornhill Road DS0000001074.V320721.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. Thornhill Road DS0000001074.V320721.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Thornhill Road Address 22 & 24 Thornhill Road Rastrick Brighouse West Yorkshire HD6 3AX 01484 401228 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) jenkinlodge@st-annes.org.uk St Anne`s Community Services Mrs Jillian Northen Care Home 7 Category(ies) of Learning disability (7), Physical disability (7) registration, with number of places Thornhill Road DS0000001074.V320721.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 13th February 2006 Brief Description of the Service: 22 and 24 Thornhill Road is owned and managed by St. Anne’s Shelter and Housing Action and is registered to provide nursing and social care for up to seven adults with a learning disability. The home is situated in a residential area in the Rastrick area of Calderdale, close to local community facilities and public transport links. The property is purpose built and the accommodation is provided on one level and is fully accessible for the service users. All bedrooms are for single occupancy and highly personalised to reflect their occupants interests and tastes. Communal areas are comfortable and furnished and fitted to a good standard. The current weekly charge is £453.90. Additional charges are made for toiletries, clothing and social and recreational activities. Thornhill Road DS0000001074.V320721.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This report refers to an unannounced Key Inspection of Thornhill Road which was undertaken on 11th September 2006 by one inspector. A total of 7 hours was spent on the visit, during which time a full tour of the building was undertaken, records were inspected and staff and service users spoken to. In addition to the visit to the home, when service users were consulted, relatives/visitors were invited as to their opinions of the services and facilities provided within the home by the completion of a comment card. Four replies were received, all of which indicated that they were satisfied with the overall care provided by the home. A pre-inspection questionnaire was accurately completed and returned promptly. In April 2006 the Commission for Social Care Inspection (CSCI) made some changes to the way in which care services are inspected. Care services are now judged against outcome groups. The inspection report is divided into separate sections for each outcome group for example Choice of Home. An overall judgement is made for each outcome group based on the findings of the inspection. The judgements reflect how well the service delivers outcomes to the people using the service. The judgements categories are “excellent”, “good”, “adequate” and “poor”. The judgements are recorded within the main body of this report. More detailed information about these changes is available on our website – www.csci.org.uk What the service does well: All of the residents at Thornhill Road have detailed and holistic individual support plans which ensures that they receive personal and health care support in line with their wishes. A warm and welcoming atmosphere is prevalent within the home. The home is fully equipped with aids and adaptations to promote the residents’ independence and all areas of the home, both internally and externally are accessible for wheel chair users. The establishment continues to deliver a high quality service to the residents of Thornhill Road A wide range of activities are available for the residents to participate in if they choose to do so and regular outings are arranged. The staff team are well trained and highly motivated and committed to providing a high standard of care and attention to the service users. Relationships between staff and residents was observed to be relaxed and friendly with appropriate use of informality and humour. One respondent to the relative/visitor comment card made this additional comment: “The staff are excellent and keep me informed of all changes involving my daughter”. Thornhill Road DS0000001074.V320721.R01.S.doc Version 5.2 Page 6 The home is well maintained throughout and furnished and fitted to a good standard, with individual bedrooms being highly personalised and well equipped. 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. Thornhill Road DS0000001074.V320721.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 Thornhill Road DS0000001074.V320721.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): 2,5, Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users needs are fully assessed and systems are in place to ensure their needs and aspirations are met. EVIDENCE: Service users needs are subject to continuous assessment and review. The organisation uses a person centred planning approach with monthly objectives set. There have been no new admissions to the home since 1993, therefore, it was not possible to assess the admissions procedure. The staff team were able to demonstrate that they have the skills and experience to deliver the care to the service users in a caring and professional manner, and to communicate effectively. Each service user has a licence agreement held on file which details the rights and responsibilities of each party. Intermediate care is not provided within the establishment. Thornhill Road DS0000001074.V320721.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): 6,7,8,9, Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users needs are thoroughly assessed and the home has a good approach to promoting the service users health care. EVIDENCE: All seven of the service users case records were examined and were found to contain detailed information. Person centred planning systems are in place with detailed action plans identifying monthly objectives, and who is responsible for carrying out the action required to meet the objective set. Each service user has an individual plan of care which is reviewed on a monthly basis. Service users likes and dislikes are identified and recorded. A daily record is kept which clearly identifies how the service user has spent their day with outings and activities undertaken recorded, the record is signed and dated. A health action plan is in place for each service user which details any physical and emotional health care needs. Detailed risk assessments are in place which are regularly reviewed. Thornhill Road DS0000001074.V320721.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14,15,16,17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users are encouraged to exercise choice and care is provided in a flexible manner to enable residents to follow their preferred lifestyle. EVIDENCE: Service users are encouraged and enabled to participate in a wide range of community social and recreational activities. Staffing levels are sufficiently high to enable social activities to be undertaken flexibly. Service users interests are assessed and a record is kept of their likes and dislikes. A record is kept of activities undertaken and recent activities have included attending college, swimming, hydrotherapy, pubs and restaurants, cinema and theatres and days out to Knowsley Safari Park and Blackpool. Some service users had recently enjoyed a holiday to Centre Parcs. Thornhill Road DS0000001074.V320721.R01.S.doc Version 5.2 Page 11 Daily routines within the home are flexible and service users are encouraged and enabled to participate, wherever possible, in the day to day running of the home, and service users are very much part of the local community. Each service user is allocated a key worker who actively encourages contact with family and friends, and enables the service user to mark special occasions within their family circle, and to visit members of their family. On the day of the inspection one service user and a member of staff were going out to visit a mill shop with the service users Mum. Visitors are welcomed into the home and all respondents to the relatives/visitors comment cards indicated that the staff welcome them into the home when they visit and that they are kept informed of important matters affecting their relative/friend. The staff were observed to be treating the service users with respect at all times and relationships were observed to be relaxed and friendly with appropriate use of informality and humour. Relationships between fellow residents was also noted to be cordial and relaxed. Service users receive a healthy and varied diet with likes and dislikes recorded. The main meal of the day is served in the evening and meal times were observed to be relaxed and unhurried with assistance given in a sensitive manner. Monday, the day of the inspection, is vegetarian day in the home and the meals served were: lunch a choice of either cheese and tomato omelette or spaghetti on toast, tea Thai green curry or spinach and chick pea couscous, or cheese tomato and basil tortellini with roasted garlic sauce. The home has introduced a five a day fruit and vegetable chart to facilitate healthy eating. Thornhill Road DS0000001074.V320721.R01.S.doc Version 5.2 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. 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 personal and health care support needs are met and support is given in accordance with their wishes. Service users are protected by the medication policies and practices within the home. EVIDENCE: Service users personal and physical and emotional health care support needs are assessed and form part of their plan of care. All personal care is given in private and in accordance with the service users preferences. Service users physical and psychological health care needs are assessed and detailed in their personal care plan. Service users have access to Physiotherapy and Occupational Therapy support on an on-going basis. The home is designed and equipped with aids and equipment to maximise independence and to ensure personal care is carried out safely. Thornhill Road DS0000001074.V320721.R01.S.doc Version 5.2 Page 13 Any medication held at the home is securely and appropriately stored. Medication policies and procedures are in place and medication is only administered by the qualified nursing staff in accordance with Nursing and Midwifery Council (NMC) guidelines. Each service user has a medication profile which details the medication taken, the therapeutic properties and any side effects or contra-indications. Thornhill Road DS0000001074.V320721.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): 22,23 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users views are acted upon. Service users are protected from abuse and neglect. EVIDENCE: The establishment holds a complaints procedure which is included in the service user guide and provides information of the procedure to follow and the correct contact details. All of the respondents to the relatives/visitors comment cards indicated that they were aware of the homes complaints procedure, although none had had the occasion to make a complaint. One respondent made the following comment “Thornhill Road is an excellent placement for my daughter and staff deal with her needs very well, no complaints at all”. The establishment holds a ‘whistle blowing’ procedure which is displayed in the staff room. The procedure details the responsibilities and obligations of the staff to report any instances of bad practices observed or suspected. All of the staff team have received training in the Protection of Vulnerable Adults and all staff spoken to were aware of the procedures to follow. Thornhill Road DS0000001074.V320721.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): 24,25,26,28,29,30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is well maintained, with high standards of cleanliness throughout, providing a pleasant, fully accessible and safe environment for service users EVIDENCE: 22 and 24 Thornhill Road is located in a residential area of Rastick close to community facilities and public transport links. The home is purpose built and comprises of an interconnecting semi detached property, designed over a single floor. The home is fully accessible and provides wheelchair access and adaptations to meet the mobility and personal care needs of service users. The accommodation offers spacious communal areas and a private, landscaped and accessible garden, where service users are able to spend time in the warmer weather. All bedrooms are for single occupancy and highly personalised to reflect the service users interests and hobbies. The home has a programme of routine maintenance, and as some of the decoration in the bedrooms was noted to be showing signs of wear and tear this work is to be prioritised. Thornhill Road DS0000001074.V320721.R01.S.doc Version 5.2 Page 16 The home was observed to be clean and hygienic throughout with infection control measures in place. The laundry facilities comply with regulations. Thornhill Road DS0000001074.V320721.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): 31,32,33,34,35 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The establishment is staffed in sufficient numbers by a well trained and motivated workforce. Service users are protected by the home’s robust recruitment practices. EVIDENCE: From records examined and following observation and discussion during the inspection sufficient staff are deployed to meet the needs of the service users. There is always a Registered Nurse on duty supported by a team of support workers. Rotas seen indicated that there are four members of staff on duty during the day and one waking night staff plus a ‘sleeping in’ during the night. The staff team work flexibly to meet the social and recreational needs of the service users. The staff appeared to work together as a team and relationships with service users was observed to be relaxed and friendly. Staff spoken to during the inspection were able to demonstrate a good understanding of the needs of the service users, and stated that they enjoyed their work, low levels of staff turnover and sickness supported this. All of the respondents to the Thornhill Road DS0000001074.V320721.R01.S.doc Version 5.2 Page 18 relatives/visitors comment cards felt that in their opinion there are always sufficient numbers of staff on duty. Regular staff meetings take place with minutes taken. There is a commitment to training within the organisation and all new staff receive induction training to Skills for Care Council specification. Staff training records were examined which indicated that the following training had recently been undertaken: epilepsy awareness, autistic spectrum disorder, person centred planning, promoting non challenging behaviour, adult protection awareness, team building and fire facilitator training. There is a programme of NVQ training in place and over 50 of the care staff have completed the award. The service users are protected by the establishment’s robust recruitment procedure. Evidence was seen that all staff are subject to the necessary CRB and POVA checks. An application form is completed and two written references are taken up prior to an offer of employment being made. All staff receive job descriptions and statements of terms and conditions. Thornhill Road DS0000001074.V320721.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): 37,38,39,40,42,43 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is well run and managed with the Registered Manager demonstrating a clear sense of leadership. Service users are protected by health and safety procedures and practices. EVIDENCE: The Registered Manager of the home is experienced and competent to run the home. She is a Registered Nurse and holds a recognised management qualification. She is committed to ensuring an open and positive atmosphere is prevalent within the home, and demonstrates a clear sense of leadership. Management and staff work in accordance with the General Social Care Council codes of practice and other legal requirements. Thornhill Road DS0000001074.V320721.R01.S.doc Version 5.2 Page 20 The home adheres to health and safety policies and procedures and all staff receive training in safe working practices, moving and handling, first aid, fire safety and infection control. Monthly health and safety audits are completed, and records seen indicated that these were up to date. The home routinely consults with the service users and their representatives about how the home is run, and a formal quality monitoring system is in place. Thornhill Road DS0000001074.V320721.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 3 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 3 25 3 26 3 27 x 28 3 29 3 30 3 STAFFING Standard No Score 31 3 32 3 33 3 34 3 35 3 36 x CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 3 3 x LIFESTYLES Standard No Score 11 x 12 3 13 3 14 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 x 3 3 3 3 x 3 3 Thornhill Road DS0000001074.V320721.R01.S.doc Version 5.2 Page 22 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. 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 Thornhill Road DS0000001074.V320721.R01.S.doc Version 5.2 Page 23 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. 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