CARE HOME ADULTS 18-65
Thornhill Road 22 & 24 Thornhill Road Rastrick Brighouse West Yorkshire HD6 3AX Lead Inspector
Cheryl Stovin Unannounced Inspection 13th February 2006 14:00 Thornhill Road DS0000001074.V285194.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 Thornhill Road DS0000001074.V285194.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. Thornhill Road DS0000001074.V285194.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION
Name of service Thornhill Road Address 22 & 24 Thornhill Road Rastrick Brighouse West Yorkshire HD6 3AX 01484 401228 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) 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.V285194.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION
Conditions of registration: None Date of last inspection 20th October 2005 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. Thornhill Road DS0000001074.V285194.R01.S.doc Version 5.1 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This unannounced inspection took place on 13th February 2006. Over an inspection year from April until March, care homes have a minimum of two inspections a year. The last inspection was also unannounced and took place on 4th October 2005. What the service does well: 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. Thornhill Road DS0000001074.V285194.R01.S.doc Version 5.1 Page 6 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.V285194.R01.S.doc Version 5.1 Page 7 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): None of these standards were assessed on this occasion. EVIDENCE: Thornhill Road DS0000001074.V285194.R01.S.doc Version 5.1 Page 8 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): 6,7,8 Service users needs are thoroughly assessed and the home has a good approach to promoting the service users health care. EVIDENCE: Service users case records were examined and were found to contain detailed information. 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 and action plans are in place which are regularly reviewed. Thornhill Road DS0000001074.V285194.R01.S.doc Version 5.1 Page 9 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): 11,12,13,15,17 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. The staff team are currently supported by five community support staff from the lower valley support services to ensure that the service users are appropriately supported whilst out in the community. This, however, is shortly to change with an additional 70 hours provided in house to enable leisure activities to take place more flexibly. A mini bus and a people carrier are available for the use of the residents of Thornhill Road. Each service user is allocated a key worker who encourages contact with family and friends, and enables the service user to mark special occasions within their family circle. Varied and nutritious meals are served within the home with a record kept of individual choices taken. The main meal of the day is served in the evening
Thornhill Road DS0000001074.V285194.R01.S.doc Version 5.1 Page 10 and the vegetarian meal being prepared during the inspection appeared attractive and wholesome. Thornhill Road DS0000001074.V285194.R01.S.doc Version 5.1 Page 11 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): 20 The systems for handling and administering medication within the home are robust and safe. EVIDENCE: A local pharmacy supplies the establishment with medication. The medication is booked in and signed for. Any returns are signed and stamped by the pharmacist. The stocks of medication are securely and appropriately stored. The qualified nursing staff are responsible for administering medication in line with NMC guidelines. Stocks of medication reconciled with records held. Thornhill Road DS0000001074.V285194.R01.S.doc Version 5.1 Page 12 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): 22,23 A complaints procedure is in place and service users are protected from abuse. EVIDENCE: The establishment holds and adheres to the corporate St, Anne’s complaints procedure. Staff receive training in the protection of vulnerable adults. Thornhill Road DS0000001074.V285194.R01.S.doc Version 5.1 Page 13 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): 24,25,26,28,29,30 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 individuals interests and hobbies. Thornhill Road DS0000001074.V285194.R01.S.doc Version 5.1 Page 14 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): 32,33,35 The establishment is staffed by a well trained and motivated workforce EVIDENCE: There is always a Registered Nurse on duty who works alongside a team of support workers. The staff team were observed to be meeting the needs of the service users in a sensitive and dignified manner, with appropriate use of informality and humour. There is a commitment to staff training within the home with an on-going programme of NVQ training. At the present time five members of staff hold their NVQ III award and a further four are undertaking their award. All new staff receive appropriate induction training. A wide range of training courses are available for all staff to undertake. Staff spoken to at the time of the inspection demonstrated a thorough knowledge of the service users needs. Thornhill Road DS0000001074.V285194.R01.S.doc Version 5.1 Page 15 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): 37,38,42 The establishment is well run by an effective management team. EVIDENCE: The Registered Manager of the establishment is experienced and qualified to manage the establishment. Health and safety policies and procedures are in place and all staff receive mandatory training in safe working practices. Thornhill Road DS0000001074.V285194.R01.S.doc Version 5.1 Page 16 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 x 3 x 4 x 5 x INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 3 26 3 27 x 28 3 29 3 30 3 STAFFING Standard No Score 31 x 32 3 33 3 34 x 35 3 36 x CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 3 x x LIFESTYLES Standard No Score 11 3 12 3 13 3 14 x 15 3 16 x 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score x x 3 x 3 3 x x x 3 x Thornhill Road DS0000001074.V285194.R01.S.doc Version 5.1 Page 17 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. 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.V285194.R01.S.doc Version 5.1 Page 18 Commission for Social Care Inspection Brighouse Area Office Park View House Woodvale Office Park Woodvale Road Brighouse HD6 4AB National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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