Inspection on 13/12/05 for Thorntree Way

This inspection was carried out on 13th December 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 no outstanding requirements from the previous inspection report, but made 4 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Thorntree Way 21/11/07

Thorntree Way 08/01/07

Thorntree Way 27/09/05

Thorntree Way 14/01/05

Thorntree Way 17/06/04

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 Thorntree Way 15 Thorntree Way Chase Farm Blyth Northumberland NE24 4LS Lead Inspector Hilary Stewart Unannounced Inspection 13th December 2005 11:40 DS0000000608.V258508.R01.S.doc Version 5.0 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 DS0000000608.V258508.R01.S.doc Version 5.0 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. DS0000000608.V258508.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Thorntree Way Address 15 Thorntree Way Chase Farm Blyth Northumberland NE24 4LS 01670 545569 01670 545569 thorntreemens@ukonline.co.uk ladiesthorntree@ukonline.co.uk Active Care 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) Ms Lana Mash Care Home 9 Category(ies) of Learning disability (7), Learning disability over registration, with number 65 years of age (2) of places DS0000000608.V258508.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. All residents may also have a physical disability Date of last inspection 27th September 2005 Brief Description of the Service: Number 13 and 15 Thorntree Way are two purpose built bungalows situated on a modern housing estate on the outskirts of Blyth. It is the home of 9 people who have a learning disability some have a physical disability as well. The properties are close to the town centre and are situated near to a large supermarket. DS0000000608.V258508.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was unannounced and started at 1140hrs. It took 4 hours. Most of the residents were at home at the time of the inspection. The inspector spoke to six of the residents, two members of staff, one senior member of staff and the manager. Records and the building were examined. What the service does well: What has improved since the last inspection? What they could do better: Staffing levels could be increased. This would enable staff to arrange more activities for the residents in the evenings and at weekends so they can get out more and become more confident in social situations. Consider the installation of electric flush toilets so some residents can maintain their privacy and independence. DS0000000608.V258508.R01.S.doc Version 5.0 Page 6 Storage is not available for items such as wheelchairs and portable hoists so this takes up room in the home. The tiles and floor in the bathroom in number 15 Thorntree Way are still in need of repair. . 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. DS0000000608.V258508.R01.S.doc Version 5.0 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 DS0000000608.V258508.R01.S.doc Version 5.0 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 Each resident who lives at the home has had their needs assessed so staff know how to care for them. EVIDENCE: The manager stated that the needs of each resident were assessed prior to them moving into the home. Evidence was found in the resident’s individual files of them all having a care plan. The manager said that the resident’s needs were being met at the home. DS0000000608.V258508.R01.S.doc Version 5.0 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 and 9. All of the residents have an individual plan that is reviewed regularly. People who live at the home are consulted in a variety of ways about the running of the home so they know they are listened too. Residents are encouraged to take part in a variety of activities so they gain new experiences and gain independence. DS0000000608.V258508.R01.S.doc Version 5.0 Page 10 EVIDENCE: The manager said that each person who lives at the home has an individual plan. This plan is reviewed regularly. Some files were inspected and found to contain information regarding the personal, social support and healthcare needs of the residents. Plans are updated if a residents needs change. One resident keeps their care plan in their room. Staff were observed asking the residents their opinions and speaking to them in a respectful manner. The manager said that residents are supported to be independent whenever possible such as ordering and paying for their own food in a restaurant or taking part in new activities. Some residents have difficulty speaking so staff said they have to use other methods to communicate with them such as watching their facial expressions or body language. This is so they can tell what they like and don’t like. Some of the residents said that they would talk to the staff if they wanted to go out or take part in a particular activity. DS0000000608.V258508.R01.S.doc Version 5.0 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): 15 and 16. The people who live at the home are supported to see their family and friends if they want to. This is so they don’t loose touch with them. Resident’s privacy is respected so they are encouraged to respect the privacy of others. DS0000000608.V258508.R01.S.doc Version 5.0 Page 12 EVIDENCE: The manager said that the residents have contact with their families and friends regularly. Staff at the home get on well with them. The residents can choose to have them visit the home or they will visit them. One resident said that they had been out with their daughter the previous day and had had a ‘great time’ They can invite their friends to social events at the home. At the time of the inspection all of the residents and staff were going to a party at a local pub and some of their friends were joining them. The manager said that staff support and enable the residents to write letters and post cards as well as help to arrange visits and holidays with their relatives and friends. One resident said that they send presents to their family. The manager said that the privacy of residents is respected as much as possible. Staff must ask prior to them entering their rooms and they can see friends and relatives privately. DS0000000608.V258508.R01.S.doc Version 5.0 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 The dignity and privacy of residents is respected to help them feel valued. They are supported to make choices about their appearance so they can show their individuality. EVIDENCE: The manager said that the staff support the residents to make choices about their appearance. Whenever possible they shop for their own clothes. Personal care is carried out in a sensitive way. The home has equipment for the residents to use to help maintain their independence. The manager said that if the toilets at the home had an electric flush this would give some of the residents more independence and privacy. Staff were observed speaking with the residents in a respectful manner. The people who live at the home looked smart and well groomed. Residents said that staff ask to come into their rooms. DS0000000608.V258508.R01.S.doc Version 5.0 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 the following standard(s): Both standards were assessed and found to be met during the previous inspection on the 27-9-05. EVIDENCE: DS0000000608.V258508.R01.S.doc Version 5.0 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 the following standard(s): 24,25,27,28,29 and 30. The home is well maintained and homely in both the communal areas and the residents’ bedrooms but there is a lack of storage space and a need for some repairs to one of the bathrooms. The residents’ rooms suit their needs and promote independence. Privacy is respected in bathing and toilet areas so the residents feel valued. There weren’t any offensive odours present. DS0000000608.V258508.R01.S.doc Version 5.0 Page 16 EVIDENCE: The house has adequate furnishings. Staff described how the residents have made their own rooms individual. One resident showed me their room, which had been personalised to their own taste. Another resident said that they could buy things for their own room when they wanted to. The home has adequate laundry facilities. Policies and procedures relating to the control of infection are in place. The home looks comfortable and is pleasantly decorated. It is clean and well maintained. Storage for wheelchairs and portable hoists is lacking so they have to be left in rooms, which leaves less space for the residents. Adequate storage must be made available. The home has specialist baths in both bathrooms that the staff said work really well. There is also overhead tracking which makes it easier and safer to move residents in and out of the bath. Some of the bathroom tiles are missing and some are cracked. This makes them difficult to clean as well as looking unsightly. The flooring in the bathroom is split which residents and staff could trip over as well as it being difficult to clean. As mentioned earlier residents would have more independence if the toilets automatically flushed. DS0000000608.V258508.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32,33 and 34. Some new staff have been employed at the home so there is a more consistent staff team. Further recruitment is still needed. Staff do not work at the home until they have been vetted so the residents are kept safe. EVIDENCE: The manager said that there is usually at least 3 staff on duty in each house. At the time of the inspection there were enough staff on duty to care for the residents at the home. Some staff thought that more staff were are needed, as they have to work more hours that they should. The manager said that the company is in the process of reviewing the staffing arrangements and recruiting more staff. Two new members of staff have started to work at the home more are still needed. The manager said that five staff have the NVQ 2 in ‘Care’ and 3 have the NVQ 3.One person is working towards the NVQ 4 award. The manager has the Registered Manager award. Staff said that they receive the mandatory training in food hygiene, fire safety and first aid. Staff said that the training was good and helped them with their work. The manager said that all staff are vetted prior to them working at the home. Staff records could not be inspected, as they are not kept at the home but at the company’s central office. DS0000000608.V258508.R01.S.doc Version 5.0 Page 18 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 and 39. . The manager is experienced in running the home so the residents are well cared for. Procedures are in place to promote the health and safety of the residents. They ensure that their best interests and rights are safeguarded. The home needs a quality assurance system to check that it is meeting the needs of the residents. EVIDENCE: The manager said that they have completed training the ‘Registered Managers Award’. They also have all of the necessary qualifications and experience to run the home. The manager also said that it is planned that quality assurance and quality mentoring systems will be operated in the home to seek the views of the residents their families and friends about how the home is meeting their needs. DS0000000608.V258508.R01.S.doc Version 5.0 Page 19 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 3 X X X Standard No 22 23 Score X X ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 3 X X 3 X Standard No 24 25 26 27 28 29 30 STAFFING Score 2 3 X 3 2 X 3 LIFESTYLES Standard No Score 11 X 12 X 13 X 14 X 15 3 16 3 17 Standard No 31 32 33 34 35 36 Score X 3 2 3 X X CONDUCT AND MANAGEMENT OF THE HOME X PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 X X X Standard No 37 38 39 40 41 42 43 Score 3 X 2 X X X X DS0000000608.V258508.R01.S.doc Version 5.0 Page 20 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 YA24 Regulation 23(2) Requirement Timescale for action 01/03/06 2 3 YA28 YA33 33(2) 18 4 YA39 24 Bathroom tiles and the flooring must be repaired or replaced in the main bathroom in number 15 Thorntree Way. (Timescale of 1/12/05 not met). Suitable provision must be made 01/03/06 for storage. (Timescale of 1/12/05 not met). There must be a review of the 01/04/06 current staffing arrangements to ensure that sufficient appropriately qualified and experienced staff are recruited to provide consistent cover of the rota. (Timescale of 1/12/05 not met). The home must have an effective 01/04/06 quality monitoring system based on seeking the views of residents, their families, friends and advocates. DS0000000608.V258508.R01.S.doc Version 5.0 Page 21 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 YA18 Good Practice Recommendations Fit toilets with an electric flush so residents can be more independent and have more privacy. DS0000000608.V258508.R01.S.doc Version 5.0 Page 22 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. Extracts may not be used or reproduced without the express permission of CSCI DS0000000608.V258508.R01.S.doc Version 5.0 Page 23 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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