Inspection on 02/04/07 for Thorpe House

This inspection was carried out on 2nd April 2007.

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

Similar services:

Larch Avenue

Alderson Road 12

Cranworth Close Registered Care Home

The Cornerstone

John Street Nursing Home

Pennine Camphill

Whitwood House

Whitwood Hall

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

CARE HOME ADULTS 18-65 Thorpe House Thorpe House Sawcliffe Hill Dragonby Scunthorpe North Lincolshire DN15 0BQ Lead Inspector Stephen Robertshaw Unannounced Inspection 2nd April 2007 09:00 Thorpe House DS0000066604.V330922.R01.S.doc Version 5.2 Page 1 Thorpe House DS0000066604.V330922.R01.S.doc Version 5.2 Page 2 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 Thorpe House DS0000066604.V330922.R01.S.doc Version 5.2 Page 3 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. Thorpe House DS0000066604.V330922.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Name of service Thorpe House Address 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) Thorpe House Sawcliffe Hill Dragonby Scunthorpe North Lincolshire DN15 0BQ 01724 847788 01724 846688 www.optionsgroup.co.uk Wider Options Ltd Mrs Pauline Hewitt Care Home 9 Category(ies) of Learning disability (9) registration, with number of places Thorpe House DS0000066604.V330922.R01.S.doc Version 5.2 Page 5 SERVICE INFORMATION Conditions of registration: Date of last inspection 14/02/06 Brief Description of the Service: Thorpe House is registered for the care of young people between the ages of 16 and 25 years who have disorders associated with Autistic Syndrome, and other emotional, and behavioural difficulties that are combined with other learning disabilities. Thorpe House is part of the Aalps College North development. The home is situated approximately five miles from the centre of Scunthorpe, and close to the village of Roxby. The accommodation is provided over two floors. It has been converted from an old public house and hotel The home has access to a gym on the site of Roxby House. This includes facilities for indoor games such as basketball, and has a separate weight training area. Also included are changing rooms and shower facilities, to assist the service users in developing their social skills when attending outside venues and sport centres The staff at Thorpe House promote diversional therapies, and provide these facilities as an alternative to hands on approaches when faced with aggressive or threatening behaviours. Thorpe House also provides education to support the service users to develop their social, interactive, and life skills, at the same time as promoting recreational and occupational activities. Previous inspection reports are made available to service suers and visitors in the entrance area of the home. The current fees for the home range between £2155 and £3365 per week. There are no aditional costs incurred to the service users. The fees also include personal allowances for the servie users diatry need and to meet their leisure and holiday requirements. Thorpe House DS0000066604.V330922.R01.S.doc Version 5.2 Page 6 SUMMARY This is an overview of what the inspector found during the inspection. The inspector visited Thorpe House on the 2nd April 2007. The inspection was unannounced and started at 9 in the morning. The inspector was in the home for approximately six and a half hours. The atmosphere was very relaxed and the inspector spoke with four of the eight service users who were living at the home. The manager had returned a pre-inspection questionnaire to the Commission before the site visit took place. This showed who was living at the home, how many staff worked in the home and the services that were provided to the service users. The inspector also spoke with the management of the home and three of the care staff to gather some of the evidence for this report. What the service does well: What has improved since the last inspection? What they could do better: Thorpe House DS0000066604.V330922.R01.S.doc Version 5.2 Page 7 The environment in the home has started to deteriorate and does not appear to be given the quick attention that it once was. This means that the home does not really provide a homely environment at the moment for the service users due to all of the damage that has not been rectified. This also makes it a very uncomfortable working environment for the staff group. 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. Thorpe House DS0000066604.V330922.R01.S.doc Version 5.2 Page 8 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 Thorpe House DS0000066604.V330922.R01.S.doc Version 5.2 Page 9 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): 1,2,3,4 and 5 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. This means that the service users are provided with the opportunity to visit the home before they make a decision to move there on a more permanent basis. EVIDENCE: The home has an appropriate service user guide and statement of purpose that identifies the services that are provided through the home and the training and qualifications of the manager and staff. The Company is currently considering moving some of their managers around the service. This will mean that Thorpe House will need a new statement of purpose when any new manager is in position. The inspector observed the care records for three service users two who are currently living at the home and one who had recently moved on from the home. All of their records included terms and conditions of their residencies at the home. The terms and conditions for the residency at the home included the sixteen principles of care provided through the services at Aalps resources. The terms and conditions had all been signed by the service users or their Thorpe House DS0000066604.V330922.R01.S.doc Version 5.2 Page 10 representatives. A leaflet is also provided to the service users and their carers that explained the fee assessment process for when individuals are admitted in to the home. Care files observed by the inspector showed that the service users had received a comprehensive assessment of their individual needs before they had been admitted in to the home. This included care management assessment of need, psychiatric and psychology assessments and educational statements of needs. The assessment also included information gathered by the home before they had admitted the service users. The home does not accept emergency admissions and this allows more time for the comprehensive assessments of the service users needs to be completed accurately. The assessments included all of the service users personal and healthcare needs. Reports from outside professionals, discussions with service users, direct observation and interviews with staff and observation of their training records supports the evidence that the staff have the necessary skills and knowledge to meet the needs of the service users. This includes specialist training in relation to supporting individual with Autism Spectrum disorders. Before service users are admitted to the home they are provided with a ‘transition’ period. This includes visiting the home for day and overnight visits. On the day of the site visit a prospective service users was visiting the home. He stated that he had been shown the room that he would be moving in to if he chose to live at the home and had been told that the bedroom would be decorated to his personal preferences. The service user said that the staff had been friendly and he was looking forward to moving to Thorpe House. Once the service users are admitted to the home there is a continuous assessment process over a twelve-week period to make sure that the home is suitable to meet their needs. Thorpe House DS0000066604.V330922.R01.S.doc Version 5.2 Page 11 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 and 10 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. This means that the service users are provided with individual choices to meet their individual needs throughout their daily lives at the home. EVIDENCE: The inspector observed the care files for three service users. These all included clear care plans for the service users and detailed how their individual care needs must be met. The care plans had all been evaluated on a monthly basis to make sure that they were still appropriate to the needs of the service users. There was evidence that when appropriate care plans had been finished and new care plans had been developed with the changing needs of the service users. One of the care plans seen by the inspector did not include one of the homes Individual Learning Plans. It was explained to the inspector that this was as Thorpe House DS0000066604.V330922.R01.S.doc Version 5.2 Page 12 they were still in their transition person and the appropriate temporary plans of care were included in the transition documentation. The inspector observed the service users and there was evidence that the service users determine how they fill their time at the home and if they wish to take part in their self development plans or not. The service users also told the inspector that they choose what food they want to eat and what time to get up from and retire to bed. Several of the service user are responsible for managing their own finances however others have care plans to support them with their budgeting skills. The staff clearly records any financial transaction that they are involved in for the individual service users and full receipts were seen to be in place. Where appropriate the service users care plans were supported with clear risk assessments and risk management plans. It appeared that the majority of the risk assessments were appropriate to the needs of the service users, however they had not been regularly evaluated since they had been originally drafted to make sure that they were still appropriate to the needs of the service users. Basic information in relation to individual service users appearances are included in their care plans to give to appropriate authorities if they go missing from the home, or require any medical attention. All of the confidential information held in relation to the service users was stored confidentially and in accordance with the Data Protection Act 1998 and other appropriate legislation. Thorpe House DS0000066604.V330922.R01.S.doc Version 5.2 Page 13 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): 11,12,13,14,15,16 and 17 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. This means that the service users are encouraged and supported to maintain and develop their personal lifestyles at the home. EVIDENCE: The service users are supported and encouraged to develop their social, emotional, communication and independent living skills. Several of the service users are once again in a transition period where they are preparing to leave the home to move on to a more independent lifestyle within a new development based in the local community. All of the service users case files that were observed by the inspector included details of their personal religion and beliefs and the support that they required to meet these needs if they wished to do so. Thorpe House DS0000066604.V330922.R01.S.doc Version 5.2 Page 14 The service users records, discussions with service users and interviews with staff supported the evidence that the service users are assisted to identify appropriate educational and occupational activities for them. This included voluntary work in the local area and attendance at local education facilities. Community links are very good. The service users confirmed to the inspector that they access the local area on a regular basis. They said that this included shopping for their meals, attending places of education and personal interest and attending spots areas in the area including swimming pools and sports centres. The records of the service users daily activities supported that they are involved in these activities. The service users also said that they chose the activities that they wanted to become involved in. Individual service users care plans and assessments identified the activities that they liked to take part in. Service users records showed that they are encouraged to maintain contact with their family and friends. At the time of the site visit the majority of the service users had made arrangements to travel to their families to stay with them over the Easter holiday period. Service users and their families confirmed to the inspector that the home supports the service users to maintain regular contact with them. Care files identify the preferred term of address for the individual service users and the staff were observed keeping to these references during the course of the site visit. The use of public transport is promoted but the home does have access to its own transport for service users that find difficulty using the public transport system. Appropriate insurance was in position for the homes transport. The service users are provided with a weekly budget for their meals and they are supported by the staff to provide a healthy eating option menu. The staff support the service users to go to the local shops and supermarkets to buy the ingredients for the meals. The service users are then given appropriate encouragement to prepare meals for themselves and their peers. Individual care plans included an assessment of service users nutritional needs. The service users confirmed to the inspector that they enjoyed their meals at the home. Thorpe House DS0000066604.V330922.R01.S.doc Version 5.2 Page 15 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 and 21 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. This means that the service users personal and healthcare needs are met at the home. EVIDENCE: Nursing care is not provided in the home, however very clear records are kept of service users healthcare needs and how they are met though visiting professional healthcare workers that are based in the community and this includes local GP services and hospital services.. Service users privacy and dignity are maintained at all times in the home. This evidence was supported through direct observations during the course of the site visit and through discussions with the service users. The service users told the inspector that they are able to pick their own clothes to wear and care plans identified if service users needed support to choice appropriate clothes suit weather and activity conditions. Thorpe House DS0000066604.V330922.R01.S.doc Version 5.2 Page 16 All staff that administer prescribed medication to the service users had received accredited medication training. The staff also receive refresher training in relation to medication and side effects of prescribed medication. The controlled medication at the home was appropriately stored and recorded. All controlled medication was accounted for. Individual service users medication records are supported with a photo to identify the service user with and a record of the side effects that the medication could have on the service user if not taken as prescribed or in a combination with other prescribed medication. The service users individual boxes with their medication in also have a photo of the service user on them to minimise the risk of any service users being given the wrong prescribed medication. None of the service users living at the home were responsible for administering their own medication All of the care files observed by the inspector identified the needs of the service users in the event of their deaths. Thorpe House DS0000066604.V330922.R01.S.doc Version 5.2 Page 17 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 and 23 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. This means that the service users are protected from abusive situation at the home and there is a clear and easy to follow complaints procedure. EVIDENCE: There had been no formal complaints made in the home since the last inspection. Copies of the homes complaints procedures were available on display in the home and are also included in the homes statement of purpose. The service users spoken to by the inspector were able to say that they did not want to complain about anything but if they did they would tell a member of staff. There had been no reports to the local protection of vulnerable adults teams however appropriate policies and procedures were in place to protect the service users form possible abuse. The staff that were interviewed were aware of how to report suspected abuse and said that they had received protection training either through their NVQ’s, with the local authority or through in house training programmes. Thorpe House DS0000066604.V330922.R01.S.doc Version 5.2 Page 18 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): 24,25,26,27,28,29 and 30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. This means that the current environment at the home meets the needs of the service user, however there are some concerns in relation to the deterioration in the homes environment. EVIDENCE: The home and its grounds provide a safe environment for the service users to live in. The outsides of the home including the care park are protected with CCTV cameras. All of the service users have their own individual bedrooms and the inspector observed four of these. All of the rooms had been decorated and furnished to the personal tastes and preferences of the service users. A `prospective service user was visiting the home on the day of the site visit and they were asked how they would like their room to be decorated if they chose to move to Thorpe House DS0000066604.V330922.R01.S.doc Version 5.2 Page 19 Thorpe House. The service user said that he would be happy to move there and that the ‘room is a lot bigger’ than his current room. The majority of the homes bedrooms include en-suite facilities. However the girls wing two of the rooms share a bathroom which includes a bath and a shower unit. This room has been a problem since the home first opened with re-current problems of leaks in to the corridor. The leaks have caused damp on the wall in the corridor and the skirting boards are badly rotten. In the interests of the service users health and safety this problem must be rectified through either determining the cause of the problem and putting it right, or if required re-designing the plumbing for the bathroom to alleviate these ongoing problems. One of the en-suite shower rooms had a badly cracked glass door on the access to the shower unit. The crack was around the handle and could cause serious harm to anyone if the handle was pulled and the door cracked more or broke further. The room was not in use at the time of the site visit. Otherwise the bathroom and toilet facilities in the home are all kept very clean and tidy. Recently due to adverse weather conditions part of the home was flooded. The flooring in the disco/music area was replaced due to water damage. The toilet walls in the visitors are badly marked with damp and are beginning to create an odour. The home has a budget to make any necessary repairs. Staff confirmed to the inspector that if damage occurs in the building it is repaired. However on the day of the inspection there were four windows that were boarded up after being broken over a two-week period. This did not support a homely environment at the home. The home does not have a permanent handyperson in position. They share a team of professionals that are used as a resource by all of the company’s services in the local area. The home does not employ domestic staff. The care staff and service users maintain the environment. If service users carry out any domestic chores this is included in their care plans as part of their personal development, and life skills training. Staff interviews confirmed that they received training and were aware of infection control issues around the home. Laundry facilities are domestic in character and are programmable to disinfection and sluicing standards. Service users are supported through their care plans to take care of their own personal hygiene and laundry needs. The general environment of the home is becoming tardy and would benefit from general redecoration. Thorpe House DS0000066604.V330922.R01.S.doc Version 5.2 Page 20 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 and 36 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. This means that the staff working at the home have the necessary skills and knowledge to meet the needs of the service users. EVIDENCE: The inspector observed the staff personnel and training files for three of the staff that were working at the home. All of the files seen included clearly defined job descriptions and role specification. Interviews with the staff confirmed to the inspector that they understand their own roles and those of their colleagues. There are no volunteers that are employed to work at the home. The staff have positive commitment to NVQ training and nine of the twenty care staff (approx 45 ) have so far completed the award. The majority of the remaining care staff are registered on the NVQ awards and are working towards them. Thorpe House DS0000066604.V330922.R01.S.doc Version 5.2 Page 21 The management of the home have been concentrating on the staffs NVQ training and this has meant that some of the staffs individual mandatory training has not been refreshed as soon as it should have. The manager of the home was aware of this and stated that all of the mandatory training was being reinstated through the company’s training department. The staff all receive specialist training in relation to Autism Spectrum Disorders and challenging behaviours and appropriate numbers of staff are always available at the home. The dependency levels of the individual service users determine the staffing numbers for each shift in the home. This ranges from ½-1 to 1-1 dependent on the individual needs and tasks being undertaken by the service users. Ratios for the residential forum are exceeded due to the high needs of the service users. The recruitment procedures for the home are generally very good and safeguard the service users. However one of the staff personnel files observed by the inspector had only received one reference. The second referee had returned the reference stating that it was not appropriate for them to complete. There was no evidence that an alternative reference was sought. One of the members of staff started working at the home before they had received appropriate security vetting, however there was a clear message included in the file that employment procedures had been improved in the service following this lapse to ensure that this could not happen again. The staff induction is over a minimum of a four-week period, and covers areas specific to the needs of individuals with autism spectrum disorder. Staff supervision records and staff interviews supported the evidence that they receive at least the minimum of six formal recorded supervision periods per year. Additional support is available to the staff though the company’s psychologist. This includes personal support, and support in the development of individual care plans. Service users spoken to by the inspector said that the staff were able to meet their needs, and that they were very helpful to them. Staff supervision records and interviews with management and care staff supported the evidence that al of the staff receive the recommended minimum of six formal supervision periods per year. Thorpe House DS0000066604.V330922.R01.S.doc Version 5.2 Page 22 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): 37,38,39,40,41,42 and 43 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. This means that the management of the home understands the needs of both the service users and the staff groups. EVIDENCE: The manager of the home has completed the Registered Managers Award and is close to completing the NVQ 4 in care. She is also a qualified NVQ work base assessor and a moving and handling assessor. The manager has over twenty years experience in the care field. The current manger is soon to be replaced when she moves on to become the manager for another part of the company’s service. The incoming manager has already completed the registered managers award and the NVQ 4 in care and has experience of managing one of the company’s other residential establishments. Thorpe House DS0000066604.V330922.R01.S.doc Version 5.2 Page 23 The management of the home is very open and positive and the staff and service users confirmed to the inspector that the manager always listens to them. There are regular service user and staff meetings held at the home to support the management in gaining their views on how the service is run and how it should develop. This information supports the homes quality assurance and monitoring system. Questionnaires are sent out on a quarterly basis to service users, their families, outside professionals and care staff working at the home. The returned questionnaires are analysed and the results are published with an action plan. The staff and management at the home maintain all of the records required by regulation. The records were all up to date and were accurately recorded. The records were all stored safely and in accordance with the Data Protection Act 1998. The health and safety requirements of the home were also all up to date. This included current safety certificates for the electrical and gas systems in the home. The homes insurance certificate that was on display was out of date by a couple of days. The manager assured the inspector the home was appropriately insured and the correct certificate for the home insurance would be forwarded from the company’s headquarters to be displayed in the home. All of the necessary fire safety checks are maintained in the home. This included the maintenance of the fire fighting equipment, fire drills, fire doors checks and testing the emergency lighting systems. The home also had a current certificate from the Local Authority for a public entertainment licence. Thorpe House DS0000066604.V330922.R01.S.doc Version 5.2 Page 24 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 3 2 4 3 4 4 4 5 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 4 ENVIRONMENT Standard No Score 24 2 25 4 26 4 27 2 28 3 29 3 30 2 STAFFING Standard No Score 31 4 32 2 33 3 34 3 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 3 2 3 LIFESTYLES Standard No Score 11 4 12 4 13 4 14 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 4 3 3 4 3 3 3 3 3 Thorpe House DS0000066604.V330922.R01.S.doc Version 5.2 Page 25 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 YA24 Regulation 23.2b,c Requirement Timescale for action 30/05/07 2. YA24 23.2b,c 3. YA27 23.2b,c The registered person must ensure that the problem with the leaks in the girl’s shower room are repaired and that the environment in this area is improved. This includes replacing the damaged skirting boards. The broken windows that are 21/04/07 boarded up must be replaced with glass as soon as possible to create an improved environment for both the service users and the staff working in the unit. The registered person must 14/04/07 replace the broken glass door in the shower unit to ensure the health and safety of the service users. 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 YA9 Good Practice Recommendations The registered manager should make sure that all of the DS0000066604.V330922.R01.S.doc Version 5.2 Page 26 Thorpe House 2. 3. 4. YA24 YA24 YA34 5. YA35 service users individual risk assessments are evaluated on a regular basis to make sure that their needs are continuing to be met appropriately. The registered person should improve the general decoration of the home to create a more homely environment. The registered person should repair the damp in the visitor’s area that was caused by the recent adverse weather conditions. The registered person should make sure that all of the personnel files for the staff working at the home include all of the information required by regulation and schedules 2 and 4 The registered person should make sure that all of the care staff working in the home are up to date with all of their mandatory training. Thorpe House DS0000066604.V330922.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Hessle Area Office First Floor, Unit 3 Hesslewood Country Office Park Ferriby Road Hessle HU13 0QF 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. Extracts may not be used or reproduced without the express permission of CSCI Thorpe House DS0000066604.V330922.R01.S.doc Version 5.2 Page 28 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!