Inspection on 04/12/06 for Thornley Leazes Care

This inspection was carried out on 4th December 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 found no outstanding requirements from the previous inspection report, but made 3 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Thornley Leazes Care 02/12/08

Thornley Leazes Care 30/01/06

Thornley Leazes Care 09/11/05

Thornley Leazes Care 02/03/05

Thornley Leazes Care 28/09/04

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 Thornley Leazes Care Thornley Gate Allendale Hexham Northumberland NE47 9HN Lead Inspector Allan Helmrich Key Unannounced Inspection 4th December 2006 11:15 Thornley Leazes Care DS0000000537.V295621.R02.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 Thornley Leazes Care DS0000000537.V295621.R02.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. Thornley Leazes Care DS0000000537.V295621.R02.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Thornley Leazes Care Address Thornley Gate Allendale Hexham Northumberland NE47 9HN 01434-683769 01434-683769 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) Mrs M L Watson Mr S Watson Mrs L D Charlton Care Home 12 Category(ies) of Learning disability (9), Learning disability over registration, with number 65 years of age (3) of places Thornley Leazes Care DS0000000537.V295621.R02.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 30th January 2006 Brief Description of the Service: Thornley Leazes is converted from a large detached domestic residence set in its own grounds on the outskirts of Allendale. Care and support is provided for twelve service users with a learning disability, three of whom are elderly. Two bedrooms are shared and non have en-suite facilities. There are two communal rooms used as lounge and dining rooms. The home has two bathrooms one of which also has a separate shower cubicle. Outside a summerhouse is used for activities and crafts. This home would not be suitable for anyone with a physical disability as there are short flights of stairs between areas on the ground floor and first floor and there is no lift between the floors. Inspection reports and information about the home are readily available. The weekly charges are £370. Thornley Leazes Care DS0000000537.V295621.R02.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was the home’s annual unannounced key inspection visit. The inspection took place in one day over 4 3/4 hours. Time was spent talking to the manager, staff on duty and several residents. A tour of the premises was made, some of the home’s care records were reviewed and the systems that maintain the residents’ safety. One resident was ‘Case Tracked’. This involved talking to the resident and reviewing the records that are kept in the home to see if the information was accurate. One visitor was available to comment on the service. One of the residents chose to complete a questionnaire provided by The Commission prior to the inspection and one was completed by a visitor. Information was also provided by the home prior to the inspection. Some of this information is used in the production of this report. What the service does well: What has improved since the last inspection? The manager has addressed the four requirements made at the last inspection to improve the home for the residents. Work is still ongoing to introduce a quality assessment system. Some redecoration is taking place and a new bath seat has been fitted to improve the bathroom for residents with reduced mobility. Training for staff is continuing to ensure residents are well cared for. Thornley Leazes Care DS0000000537.V295621.R02.S.doc Version 5.2 Page 6 Care plans continue to be improved and residents are helped by staff to fill in diaries on a daily basis. 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. Thornley Leazes Care DS0000000537.V295621.R02.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 Thornley Leazes Care DS0000000537.V295621.R02.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 2. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. A system is in place to assess the needs of new service users. EVIDENCE: The majority of residents have lived in the home for several years and information about them in their files is comprehensive. One resident recently admitted into the home stated she was comfortable and that the manager and staff are meeting her needs. The assessment of her needs was reviewed and was found to contain some good information obtained by the home and provided by the local authority. Some risk assessments to ensure the safety and wellbeing of the residents and staff team were not in place. Thornley Leazes Care DS0000000537.V295621.R02.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7, 9. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents have good plans in place for daily living. Residents are involved in making lifestyle decisions. Residents are encouraged to be independent. EVIDENCE: Case records have been developed to describe the needs and choices of each resident. The records contain social histories written by staff who clearly know the residents well. Residents have been involved in developing these plans and they are encouraged to write a diary that is used by staff when the files are reviewed. These files are reviewed quarterly, not monthly to ensure any Thornley Leazes Care DS0000000537.V295621.R02.S.doc Version 5.2 Page 10 changes in personal needs are addressed and some of the diary information was too brief to fully describe events the residents are involved in. Three files reviewed contained a good standard of information clearly describing how care is provided. Some of the information was discussed with the manager who agreed that some information was not developed enough to ensure that specific needs are met. Residents are involved in all decisions made in the home and they are involved in meetings when their views are recorded and any actions needed are addressed. The manager also meets separately with each resident specifically to obtain an opinion about the service provided. These conversations are not recorded. Activities residents are involved in have been assessed as appropriate and any risks involved are assessed and minimised. Residents are involved in activities outside the home and the proprietor and staff are available with transport when needed. Residents are encouraged and supported to keep in touch with relatives and friends. Some residents visit their families regularly and have overnight stays and others holiday with members of their family. On the day of inspection a group of residents were going on holiday with staff support. The residents stated that they chose where to go and that they were happy in each other’s company. Thornley Leazes Care DS0000000537.V295621.R02.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15, 16, 17. Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to this service. Residents are supported to live a normal life within the community. A range of healthy meals is provided. EVIDENCE: Residents are very much part of the local community. They regularly use community facilities, visiting nearby shops and other village services. There are regular trips to major shopping centres and meals out in local public houses. Each resident has an activities schedule and a diary records special activities such as; special parties, day trips and other activities. Weekly activities include; day services, outings and shopping. Staff and the proprietor provide transport for residents. Thornley Leazes Care DS0000000537.V295621.R02.S.doc Version 5.2 Page 12 The manager is constantly looking for new activity opportunities for both groups and individuals. Most of the residents have had at least one holiday this year some have been abroad. At the time of the inspection four residents were packed and ready to holiday with each other. Details of each resident’s family contacts and friends are recorded in the individual case records. Some residents have no family support but those that have are assisted to maintain regular contact. The home’s menu is displayed in the kitchen. The meals provided are varied and contain appropriate amounts of fruit and vegetables to keep residents in good health. The food store contained a good quantity of food in small portions to enable staff to meet individual needs if necessary. Every resident spoken to said that they enjoy the meals provided in the home. One resident cooks the main meal once a week for all of the residents. Thornley Leazes Care DS0000000537.V295621.R02.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 at least once during a 12 month period. 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 from evidence gathered both during and before the visit to this service. Good personal and healthcare support is in place for residents. The home’s medication system ensures residents’ needs are met. EVIDENCE: A plan detailing the amount of support each resident needs is in place. The plan identifies each resident’s communication abilities, their likes and dislikes to assist staff in providing good care. Any behavioural issues that need to be addressed are identified, although the records for one person were not to the standard required to ensure the resident is kept safe. The personal support required by each resident is detailed in an individual plan, mobility is assessed and each resident’s dependency is monitored. Periodic health checks are carried out by; dentists, chiropodists and opticians and a record of professionals involved in each residents care is maintained. Thornley Leazes Care DS0000000537.V295621.R02.S.doc Version 5.2 Page 14 The system for administration of medicines was checked and found to be in order. All staff dispense medicines after initial training. Accredited training is in place. Medicines are securely stored and a system is in place to record all medicines in and out of the home. This ensures residents’ needs are met. Thornley Leazes Care DS0000000537.V295621.R02.S.doc Version 5.2 Page 15 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. Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to this service. Residents are safe and protected by trained staff. EVIDENCE: A complaints procedure is provided for residents. Four residents confirmed they would speak to staff if they were unhappy and one resident stated in a questionnaire that she would speak to the manager if she had a complaint. One visitor who completed a questionnaire new about the home’s complaint procedure. Complaint forms are available to anyone in the lobby of the home. The home has not received any complaints since the last inspection but a log is maintained in the home to record any matters of this nature. The manager stated she has spoken to each resident about how to complain but has not produced a format that is easy for residents to understand. A thank you letter received recently from a grateful family is kept in a file for all to see. Staff are trained in abuse awareness and appropriate supportive guidance is available in the home. Thornley Leazes Care DS0000000537.V295621.R02.S.doc Version 5.2 Page 16 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. Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to this service. The home is safe and homely although infection control and privacy could be improved. EVIDENCE: The home is safe and clean. Residents’ bedrooms are individually decorated and furnished. The residents spoken to all stated they liked their rooms and had decorated them to their tastes. A decorator was in the home improving the décor and a new bath seat has been fitted to help residents with reduced mobility. The home is a large stone built house and can suffer from damp in some areas. This was generally addressed with a good standard of hygiene although some slight odours were noted. Thornley Leazes Care DS0000000537.V295621.R02.S.doc Version 5.2 Page 17 Communal washing points did not have liquid soap available to promote good hygiene. Towels are changed daily. The home’s deputy manager is in contact with the community infection control nurse and attends local meetings to obtain best current practice. Some bedrooms and bathrooms on the ground floor could be overlooked from the garden. These rooms had curtains but no net curtains or voiles to obscure the view. Thornley Leazes Care DS0000000537.V295621.R02.S.doc Version 5.2 Page 18 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, 34, 35. Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to this service. Staff are competent and well trained. Appropriate staff recruitment to ensure residents are safe is in place. Staff are supervised and supported in their work. EVIDENCE: A training plan has been produced and staff are provided with regular training to meet the needs of residents. Recent training includes; first aid, health and safety, moving and handling and abuse and aggression. No staff under 21 years old are left in charge of the home. Currently 66 of the staff team has achieved a National Vocational Qualification (NVQ) in care. No new staff have been employed in the home since mid 2004, this gives some stability to the home for the residents. The manager demonstrated that appropriate recruitment takes place. Files reviewed contained the information required to promote safety for the residents. Thornley Leazes Care DS0000000537.V295621.R02.S.doc Version 5.2 Page 19 Staff meet regularly with the manager for support and guidance and a record is kept of these meetings. During the inspection sufficient staff were on duty to meet the needs of the residents. The staff rota confirmed that staffing levels are generally appropriate for residents needs. Thornley Leazes Care DS0000000537.V295621.R02.S.doc Version 5.2 Page 20 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, 39, 42. Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to this service. A competent qualified manager supports residents. A system of selfassessment is in place to promote good care practice. The home is safe for residents. EVIDENCE: The manager has many years experience working with people with a learning disability. She has a Diploma in Management of Care Services and has completed a 2-year course in Psychology. She also has the Registered Managers Award. She is committed to providing good quality care and is currently undertaking an assessment of that quality using a self-assessment tool. Questionnaires Thornley Leazes Care DS0000000537.V295621.R02.S.doc Version 5.2 Page 21 have been completed as part of this assessment and these are still to be analysed. A business plan has been produced and this includes the actions to improve the service. A newsletter has recently been produced to inform residents and their visitors about the home. The home has achieved the Investors in People Award. All of this promotes the quality of the home for the residents. Accidents to residents are not always recorded to identify problems with residents or specific areas of the home that require attention. The home is safe for residents. Requirements made at previous inspections by The Commission and Environmental Health Department have been addressed. Electrical items have been checked to ensure they are safe to use and the water has been tested to ensure it is not contaminated. Thornley Leazes Care DS0000000537.V295621.R02.S.doc Version 5.2 Page 22 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 2 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 2 23 3 ENVIRONMENT Standard No Score 24 2 25 X 26 X 27 X 28 X 29 X 30 2 STAFFING Standard No Score 31 X 32 3 33 X 34 3 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 X 3 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 2 3 3 X 3 X 3 X X 2 X Thornley Leazes Care DS0000000537.V295621.R02.S.doc Version 5.2 Page 23 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. 1. Standard YA2 YA18 Regulation 15 Requirement Ensure that comprehensive information is obtained for new referrals and that all identified issues are addressed to ensure the safety of both residents and staff. Provide privacy to private rooms on the ground floor of the home. Timescale for action 31/12/06 2. YA24 23(2)(e) 31/01/07 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 YA6 Good Practice Recommendations Ensure care plans are reviewed frequently enough to meet the residents’ needs. This would normally be monthly. Ensure diaries filled in by staff on behalf of residents are comprehensive. 2. YA22 Improve the complaints process by producing a pictorial guide or other method best suited to each individual resident. DS0000000537.V295621.R02.S.doc Version 5.2 Page 24 Thornley Leazes Care 3. 4. YA30 YA42 Ensure liquid soap is available at each communal washing point to improve infection control. Record all accident in the home’s log. Events should be followed up and analysed for common issues. Thornley Leazes Care DS0000000537.V295621.R02.S.doc Version 5.2 Page 25 Commission for Social Care Inspection Cramlington Area Office Northumbria House Manor Walks Cramlington Northumberland NE23 6UR 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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