Inspection on 09/11/05 for Thornley Leazes Care

This inspection was carried out on 9th November 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. 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 2 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 04/12/06

Thornley Leazes Care 30/01/06

Thornley Leazes Care 02/03/05

Thornley Leazes Care 28/09/04

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

CARE HOME ADULTS 18-65 The Cave Thornley Gate Allendale, Hexham Northumberland NE47 9HN Lead Inspector Allan Helmrich Unannounced 9 November 2005 11:00 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. The Cave B53-B03 S537 The Cave V239271 091105 Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service The Cave Address Thornley Gate Allendale Hexham Northumberland NE47 9HN 01434 683769 01434 683769 N/A Mrs M L Watson 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) Mrs L D Charlton CRH 12 Category(ies) of LD - Learning Disability (9) registration, with number LD (E) - Learning Disability - Over 65 (3) of places The Cave B53-B03 S537 The Cave V239271 091105 Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: No conditions are applied. Date of last inspection 2 March 2005 Brief Description of the Service: The Cave 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 residents 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 no lift between floors. The Cave B53-B03 S537 The Cave V239271 091105 Stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This is the home’s first annual inspection. The inspection was unannounced and took 3 ½ hours. In that time the manager and both staff on duty were spoken to, a tour of the premises was undertaken and a selection of the records held in the home were reviewed. Three residents were available during the inspection and although their ability to communicate was not good, time was spent in their company to assess the quality of care provided. 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. The Cave B53-B03 S537 The Cave V239271 091105 Stage 4.doc Version 1.40 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 Standards Statutory Requirements Identified During the Inspection The Cave B53-B03 S537 The Cave V239271 091105 Stage 4.doc Version 1.40 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 standard(s) 1, 2. Residents are provided with good information regarding the home and each resident has a full assessment of their needs in place. EVIDENCE: The home has been full since the last referral in 1997. Each resident was provided with a copy of the home’s Statement of Purpose. Four case files reviewed each contained a full assessment of needs that was well written and evaluated recently. The Cave B53-B03 S537 The Cave V239271 091105 Stage 4.doc Version 1.40 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 standard(s) 6, 9. Comprehensive plans are in place detailing the support each resident requires. The residents’ involvement in these plans appears limited. Risk assessments to support residents’ independence are produced. EVIDENCE: Four case records reviewed contained comprehensive information relating to the assessed needs of each resident. At three monthly intervals the key worker reassesses these plans and makes any necessary adjustments. The plans do not appear to be done in consultation with the resident and little use is made of goal plans to enhance fulfilment and meet changing needs. Comprehensive risk assessments are used to promote independence both within and outside of the home. These assessments are regularly reviewed and updated. The Cave B53-B03 S537 The Cave V239271 091105 Stage 4.doc Version 1.40 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 standard(s) 12, 13, 15, 16. No resident is involved with paid or unpaid employment, however they generally have active social lives and take part in community activities. Residents have regular contact with their families and have varying daily routines. EVIDENCE: The case records reviewed identified a resident group that are involved in varied regular activities. The range of activities residents are involved with outside of the home includes; day centre services, outings with an enabler, a drama group, swimming and shopping. Some residents can travel independently and visit the village centre and take part in local events. Holidays taken by residents this year were generally organised individually with family or staff. Residents visited; Spain, Crete, Paris and Scotland. Many residents are close to their families and have regular contact both by visiting and by telephone. Residents use community facilities alone or with the support of staff if required. The Cave B53-B03 S537 The Cave V239271 091105 Stage 4.doc Version 1.40 Page 10 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) 18, 19, 20. Good personal and healthcare support is in place in the home. The frequency of some community support should be reviewed. Staff are supported by good records and community professionals. The home’s medication system is good. EVIDENCE: The residents’ have all lived in the home for several years and have used community services throughout this time. Staff in the home regularly monitor each residents health and all interventions are recorded. Regular appointments to maintain health are in place although the manager was asked to review some appointments related to opticians and dentists. The personal support required by each resident is detailed in an individual plan, mobility is assessed and each residents dependency is monitored. Staff are very experienced and reacted well to one resident who was having an emotional moment. The home has recently changed the medication system. The system for storage and administration was reviewed and was found to comply with current pharmacy guidance. The Cave B53-B03 S537 The Cave V239271 091105 Stage 4.doc Version 1.40 Page 11 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) 22, 23. A complaints procedure is in place in the home. Staff are well trained and aware of issues relating to vulnerable adults. EVIDENCE: The home has a complaints procedure and a log to record any matters of this nature. No complaints have been made to the home since the last inspection. Staff have received training in issues relating to abuse awareness and the protection of vulnerable adults. Appropriate policies and procedures are available to staff in the home. The Cave B53-B03 S537 The Cave V239271 091105 Stage 4.doc Version 1.40 Page 12 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) 24, 30. The home is comfortable, safe and homely. There is a reasonable standard of cleanliness. EVIDENCE: On a tour of the building the home was found to be generally warm and homely. Residents’ bedrooms were individual in style with a general standard of cleanliness. Recently fire authority approved door restrictors have been fitted to some doors to assist movement through the home, some carpets have been replaced and the laundry and foodstore have been improved. The manager was advised that liquid soap and towel dispensers should be available at communal washing points to promote infection control. The manager considers this inappropriate in this home due to the actions of a resident. A risk assessment could be produced to determine the best course of action. A screen was not available for use in shared rooms should privacy be required. The Cave B53-B03 S537 The Cave V239271 091105 Stage 4.doc Version 1.40 Page 13 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) 35. A well-trained staff team supports residents’. EVIDENCE: The majority of the staff team have worked in the home for several years. A training and development plan is in place for each staff member and these show that a good standard of training is in place. Should any new staff be required the home has an induction system that meets the desired standard. The Cave B53-B03 S537 The Cave V239271 091105 Stage 4.doc Version 1.40 Page 14 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) 42. Residents live in a safe home. EVIDENCE: The standard of safety in the home is good. Staff are trained in health and safety. Fire logs are well recorded and staff instruction in fire safety is in place. Electrical items are checked annually and a competent person has assessed the home’s wiring. Water temperatures are safe and fridge temperatures are regularly checked. The water system in the home has not yet been assessed for risks posed by Legionella. The Cave B53-B03 S537 The Cave V239271 091105 Stage 4.doc Version 1.40 Page 15 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 3 3 x x x Standard No 22 23 ENVIRONMENT Score 3 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 2 x x 3 x Score Standard No 24 25 26 27 28 29 30 STAFFING Score 2 x x x x x 2 Standard No 11 12 13 14 15 16 17 x 3 3 x 3 3 x Standard No 31 32 33 34 35 36 Score x x x x 3 x CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 The Cave Score 3 2 3 x Standard No 37 38 39 40 41 42 43 Score x x x x x 2 x B53-B03 S537 The Cave V239271 091105 Stage 4.doc Version 1.40 Page 16 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. 2. 3. Standard YA19 YA24 Regulation 12(1)(a) 12(4)(a) Requirement Ensure that each resident obtains periodic health checks Obtain a screen for use in double rooms to provide privacy if required. Timescale for action 30/11/05 30/11/05 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 YA6 Good Practice Recommendations Demonstrate that residents are involved by their keyworker in assessing their care plans and developing goal plans to meet challenges and promote a better quality of life. Plans should demonstrate the involvement residents have in the direction the home takes and their ability to understand how to make complaints and effect change. Consider the use of soap and towel dispensers at communal washing points. Assess the homes water system for the risks posed by the Legionella virus. 2. 3. 4. YA30 YA42 The Cave B53-B03 S537 The Cave V239271 091105 Stage 4.doc Version 1.40 Page 17 Commission for Social Care Inspection 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. Extracts may not be used or reproduced without the express permission of CSCI The Cave B53-B03 S537 The Cave V239271 091105 Stage 4.doc Version 1.40 Page 18 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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