Inspection on 09/01/06 for Tilehurst Lodge

This inspection was carried out on 9th January 2006.

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 there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 3 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Tilehurst Lodge 05/11/07

Tilehurst Lodge 30/01/07

Tilehurst Lodge 20/07/05

Tilehurst Lodge 25/01/05

Tilehurst Lodge 22/06/04

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Kestrel House, St Anne`s Opportunity Centre,

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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 Tilehurst Lodge 142 Tilehurst Road Reading Berkshire RG30 2LX Lead Inspector Robert Dawes Unannounced Inspection 9th January 2006 12.20 Tilehurst Lodge DS0000011066.V264126.R01.S.doc Version 5.1 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Tilehurst Lodge DS0000011066.V264126.R01.S.doc Version 5.1 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Tilehurst Lodge DS0000011066.V264126.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Tilehurst Lodge Address 142 Tilehurst Road Reading Berkshire RG30 2LX 0118 967 4675 0118 967 4675 tl142tact@hotmail.co.uk 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) TACT Mr Maurice Allen John Moore Care Home 6 Category(ies) of Learning disability (6) registration, with number of places Tilehurst Lodge DS0000011066.V264126.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 20th July 2005 Brief Description of the Service: Tilehurst Lodge provides 24-hour support for up to 6 men with learning disabilities, some of whom also have mental health issues. The men at Tilehurst Lodge are encouraged to participate in a variety of experiences and opportunities to enable them to lead fulfilled lives, which in most cases includes employment unsupported by staff from the home. These experiences and opportunities are underpinned by The Five Accomplishments to Ordinary Living by John OBrien. The aim at Tilehurst Lodge is to provide a high quality service with comprehensive care planning and risk assessing to reflect individuals needs and preferences. We are committed to working to the highest professional standards on a multi-disciplinary basis to offer real community living. The objective is to provide an environment where people with learning disabilities are able to develop independence and to enjoy the everyday experiences and opportunities that the wider community enjoys and be seen in society as valued individuals. (Extract taken from the homes statement of purpose.) Tilehurst Lodge DS0000011066.V264126.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was a routine unannounced inspection, which was carried out during the day on Tuesday 9th January 2006. The Inspector spoke with one service user, the acting manager and a member of staff. The Inspector also looked at records and observed the interaction between staff and service users. Nine standards were assessed of which seven were met and two nearly met. Three requirements and two recommendations were made. What the service does well: What has improved since the last inspection? The home has continued to be decorated and refurbished. Service users’ behaviour has improved. Several service users have had their medication for mental health problems reduced. Tilehurst Lodge DS0000011066.V264126.R01.S.doc Version 5.1 Page 6 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. Tilehurst Lodge DS0000011066.V264126.R01.S.doc Version 5.1 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 Tilehurst Lodge DS0000011066.V264126.R01.S.doc Version 5.1 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): Number 2. Prospective users’ individual aspirations and needs are assessed. EVIDENCE: An admissions procedure covering the requirements of the standard is in place. A comprehensive pre admission assessed was undertaken on the last service user admitted to the home. Tilehurst Lodge DS0000011066.V264126.R01.S.doc Version 5.1 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): This section was assessed at the previous inspection. EVIDENCE: Tilehurst Lodge DS0000011066.V264126.R01.S.doc Version 5.1 Page 10 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): Numbers 13, 15, 16 and 17. Service users are part of the local community. Service users have appropriate personal, family and sexual relationships. Service users are treated with respect but need to take more responsibility for household and personal care tasks and be subject to a positive rather than a negative behavioural modification system. Service users are offered a healthy diet and enjoy their meals and mealtimes. EVIDENCE: Five service users have paid work in the community. Service users are supported to go out to facilities and activities in the community such as pubs, restaurants, leisure centres, cinemas, social evenings and places of worship. Family and friends are encouraged to visit and keep in contact with the service users. Several service users visit relatives on a regular basis. Two service users have mentors. Two service users in the home have an intimate personal relationship. Health issues have been discussed with them. Staff were observed to be respectful to the service users. A service user said staff treat him with respect. Service users help with housekeeping tasks such as washing up, making drinks, food shopping and personal laundry. The acting Tilehurst Lodge DS0000011066.V264126.R01.S.doc Version 5.1 Page 11 manager said she wants service users to take more responsibility for household and personal care tasks as part of individual personal development programmes. This will enable service users improve the quality of their lives and move towards independent living. The home operates a red/yellow card system as a behavioural modification tool. If a service user receives a red card he is not allowed to go on an outing with staff. Service users are never stopped going out on their own. This system of modifying behaviour is agreed by the service users and recorded in the individual plans. Any sanctions resulting in not going out are recorded. Although this system has resulted in an improvement in service users behaviour the acting manager wants to move from a negative to a positive reinforcement behavioural modification system. She said positive behaviour should be rewarded rather than negative behaviour punished. The inspector supports both the above changes. Service users will gain in confidence and self worth; they will live in a supportive and enabling environment rather than being ‘cared for’; and have the opportunity to work towards living independently. The inspector saw a well-balanced and nutritional menu. Every week service users choose a menu. A choice is available if a service user does not like a particular meal. Several of the service users make their own breakfast. A service user said he enjoyed the meals. Tilehurst Lodge DS0000011066.V264126.R01.S.doc Version 5.1 Page 12 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): This section was assessed at the previous inspection. EVIDENCE: Tilehurst Lodge DS0000011066.V264126.R01.S.doc Version 5.1 Page 13 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): This section was assessed at the previous inspection. EVIDENCE: Tilehurst Lodge DS0000011066.V264126.R01.S.doc Version 5.1 Page 14 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): Numbers 24 and 30. Service users live in a homely, comfortable and safe environment. The home was clean and hygienic. EVIDENCE: The home is spacious, comfortable and well maintained. Decoration and refurbishment to various parts of the home has taken place over the last year. A refurbishment and maintenance programme is in place. The home was clean and hygienic. Tilehurst Lodge DS0000011066.V264126.R01.S.doc Version 5.1 Page 15 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): This section was assessed at the previous inspection. EVIDENCE: Tilehurst Lodge DS0000011066.V264126.R01.S.doc Version 5.1 Page 16 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): Numbers 37 and 39. Service users need to have a registered manager in place to run the home. An effective quality assurance and quality monitoring system, based on seeking the views of service users, needs to be in place to measure success in achieving the aims and objectives of the home. EVIDENCE: The registered manager has been on long-term sick leave since the end of November 2004. The acting manager has undertaken her responsibilities competently and conscientiously but a registered manager must now be in place to give authority to the running of the home and the changes that have to take place. An annual development plan is produced but views of the service users, family, friends and outside professionals are not sought in a systematic way to inform this plan, i.e. through satisfaction questionnaires. A responsible individual does not visit the home at least once a month to assess the standard of care provided in the home. Regular inspections of the premises are made. Tilehurst Lodge DS0000011066.V264126.R01.S.doc Version 5.1 Page 17 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 3 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 X 23 X ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 X 33 X 34 X 35 X 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score X X X X X LIFESTYLES Standard No Score 11 X 12 X 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score X X X X 2 X 2 X X X X Tilehurst Lodge DS0000011066.V264126.R01.S.doc Version 5.1 Page 18 Yes Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. 2 Standard YA37 YA39 Regulation 8 24 Requirement The home must have a registered manager in place to run the home. The registered person must establish and maintain a system for reviewing and improving the quality of care provided at the home. The registered person must ensure a responsible individual visits the home at least once a month to assess the standard of care provided in the home. (This requirement is outstanding from the last inspection). Timescale for action 28/02/06 31/03/06 3 YA39 26 28/02/06 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 2 Refer to Standard YA16 YA16 Good Practice Recommendations Encourage and enable service users to develop their independent living skills. Introduce a positive rather than a negative behavioural modification system. DS0000011066.V264126.R01.S.doc Version 5.1 Page 19 Tilehurst Lodge Commission for Social Care Inspection Berkshire Office 2nd Floor 1015 Arlington Business Park Theale, Berks RG7 4SA 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 Tilehurst Lodge DS0000011066.V264126.R01.S.doc Version 5.1 Page 20 - 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. 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