Care Home: Thorpe View Short Breaks Service

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What the care home does well Information that is given to people about the service is produced in an easy read format using pictures and also in DVD format, which gives people a good understanding about the rules about how the service runs and their rights. This is valued by people and helps them make an informed decision about using the service, "The promotional literature is first class. We were given a conducted tour of the facility, which was most helpful and reassuring". Detailed assessments that identify people`s needs and preferences and how they like to live their lives are very informative and help staff to make sure people are safe, well cared for and healthy. The service also works closely with other professionals to make sure they can meet the sometimes complex and challenging support needs of people. All new staff have completed a full induction and receive appropriate training to help them meet the different needs of the people who use the service. The manager works closely with the staff team and encourages and supports personal development in their role, staff said they felt they "get good support and supervision and the manager is very approachable".Specialist personal and healthcare needs are written down, which support and guide staff in providing a consistent service and maintain a person`s safety and welfare. People get good support from staff to manage their medication. The service has a positive approach to risk taking with clear policies and protocols in place to guide staff and ensure people`s independence and choice are promoted at all times. They have a high level of choice and control in their lives, which is good practice and something that is valued by the people who use the service. The manager and staff team provide a service that respects the rights and best interests of people at all times. As one person described it "The carers listen to me and help me with things I cannot do for myself". This was also confirmed by relatives who said, "They treat our son as an individual and respect his needs and wishes", and "Staff are excellent, friendly and very well motivated". The environment is well maintained and decorated and furnished to a good standard with appropriate aids and adaptations in place to support and encourage people`s independence around the home. All the records examined during this visit were securely stored. The organisations policies and procedures we examined were suitable for purpose and provided good guidance for staff. They were reviewed and updated on a regular basis or as changes occurred. The service is well managed with staff and guests feeling well supported and able to contribute to the running of the home. What has improved since the last inspection? The service is newly registered so this is the first key inspection. What the care home could do better: It is recommended the service develop epilepsy management plans for all the people with epilepsy who use the service, to ensure their independence is promoted and their safety is maintained. The service should consider how they could actively involve guests in the staff selection process. The manager should ensure all staff are aware of COSHH procedures and all substances are securely stored at all times to maintain the safety of people using the service. CARE HOME ADULTS 18-65 Thorpe View Short Breaks Service Thorpe View Thorpe Avenue Morecambe LA4 6NG Lead Inspector Jenny Donnelly Unannounced Inspection 28th July 2008 10:30 Thorpe View Short Breaks Service DS0000071301.V365070.R01.S.doc Version 5.2 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Thorpe View Short Breaks Service DS0000071301.V365070.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Thorpe View Short Breaks Service DS0000071301.V365070.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Thorpe View Short Breaks Service Address Thorpe View Thorpe Avenue Morecambe LA4 6NG 01772 534355 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) Social Services Directorate Mrs Joanne Wendy Tolson Care Home 6 Category(ies) of Learning disability (6) registration, with number of places Thorpe View Short Breaks Service DS0000071301.V365070.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following categories of service only. Care home only - code PC, to people of the following gender:- Either. Whose primary care needs on admission to the home are within the following categories: Learning disability - Code LD The maximum number of people who can be accommodated is: 6 Date of last inspection New Service Brief Description of the Service: Thorpe View is a short break service operated by Lancashire County Councils Community Services Directorate. It provides residential short breaks to adults with Learning Disabilities some of who may also have a physical disability. The short break can range from one night to two weeks. The service operates 365 days per year. The house is single storey and has been purpose built and is fully accessible. There is a reception area that leads to an open plan kitchen/dining room with lounge. There is a second lounge, which is used as a quiet area and a conservatory that has patio doors leading onto a pleasant patio and garden. There are four short break bedrooms, which are single occupancy and have ensuite shower and toilet facilities. In addition there are two shared bathrooms one with an overhead tracking hoist and assisted bath. Suitable aids and adaptations are in place around the home to promote people’s independence. The home can only be accessed using the Council’s voucher system so all referrals are made via a Social Work team after an assessment by the Social Worker. The cost of the service is £9.94 per night and people can stay between one and fourteen nights. Thorpe View Short Breaks Service DS0000071301.V365070.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 2 star. This means the people who use this service experience good quality outcomes. This inspection visit took place over one day. We (Commission for Social Care Inspection, CSCI) spent time with people staying in the home and talking to them about their experiences. We also met with the staff on duty and looked at records relating to the running of the service and how people like to be supported to live their lives. We also sent out surveys as part of this inspection to get feedback from people who have used the service, staff and other professionals involved with the home. Before the visit the manager completed an Annual Quality Assurance Assessment, which provided information about all aspects of the running of the service. This included a self-assessment against the National Minimum Standards (NMS) recording what the home does well, what has improved and plans for the future. It also included information about policies and procedures, health and safety and information about the people living and working there. People who use the service are referred to as guests. What the service does well: Information that is given to people about the service is produced in an easy read format using pictures and also in DVD format, which gives people a good understanding about the rules about how the service runs and their rights. This is valued by people and helps them make an informed decision about using the service, “The promotional literature is first class. We were given a conducted tour of the facility, which was most helpful and reassuring”. Detailed assessments that identify people’s needs and preferences and how they like to live their lives are very informative and help staff to make sure people are safe, well cared for and healthy. The service also works closely with other professionals to make sure they can meet the sometimes complex and challenging support needs of people. All new staff have completed a full induction and receive appropriate training to help them meet the different needs of the people who use the service. The manager works closely with the staff team and encourages and supports personal development in their role, staff said they felt they “get good support and supervision and the manager is very approachable”. Thorpe View Short Breaks Service DS0000071301.V365070.R01.S.doc Version 5.2 Page 6 Specialist personal and healthcare needs are written down, which support and guide staff in providing a consistent service and maintain a person’s safety and welfare. People get good support from staff to manage their medication. The service has a positive approach to risk taking with clear policies and protocols in place to guide staff and ensure people’s independence and choice are promoted at all times. They have a high level of choice and control in their lives, which is good practice and something that is valued by the people who use the service. The manager and staff team provide a service that respects the rights and best interests of people at all times. As one person described it “The carers listen to me and help me with things I cannot do for myself”. This was also confirmed by relatives who said, “They treat our son as an individual and respect his needs and wishes”, and “Staff are excellent, friendly and very well motivated”. The environment is well maintained and decorated and furnished to a good standard with appropriate aids and adaptations in place to support and encourage people’s independence around the home. All the records examined during this visit were securely stored. The organisations policies and procedures we examined were suitable for purpose and provided good guidance for staff. They were reviewed and updated on a regular basis or as changes occurred. The service is well managed with staff and guests feeling well supported and able to contribute to the running of the home. What has improved since the last inspection? What they could do better: It is recommended the service develop epilepsy management plans for all the people with epilepsy who use the service, to ensure their independence is promoted and their safety is maintained. The service should consider how they could actively involve guests in the staff selection process. The manager should ensure all staff are aware of COSHH procedures and all substances are securely stored at all times to maintain the safety of people using the service. Thorpe View Short Breaks Service DS0000071301.V365070.R01.S.doc Version 5.2 Page 7 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 View Short Breaks Service DS0000071301.V365070.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 View Short Breaks Service DS0000071301.V365070.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): 2, 3, 4, 5. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. A thorough assessment process ensures people’s needs are assessed and the home is able to provide a personalised service that meets their individual needs and preferences. EVIDENCE: The service can only be accessed using the Council’s voucher scheme therefore all referrals come to the home after a Social Work assessment has been completed. When the referral is made the manager contacts the person or their family/representative to arrange an initial visit to the home. This is the start of a two part assessment process. Part one of the assessment will gather information about the person’s individual needs and preferences and other essential information that staff would need to know to ensure a person’s wellbeing and safety during a stay. If at the end of the visit the person feels they want to use the service they are invited back for two further visits when they will have a meal with other people using the service. If these visits are successful an overnight stay is planned as a trial visit. This enables the person to make an informed decision about planning a stay and also enables the service to complete the assessment process. Thorpe View Short Breaks Service DS0000071301.V365070.R01.S.doc Version 5.2 Page 10 During this assessment process risk assessments are completed regarding any identified hazards and control measures agreed with individuals ensuring they are promoting people’s independence. Part two of the assessment process is more person centred and focuses on other areas of a person’s life such as relationships, likes and dislikes, what makes them happy or sad and leisure pursuits. This part of the assessment is an ongoing process that develops as staff get to know people and develop a better understanding of them. The service works closely with a number of other agencies to ensure they are able to meet the specialist needs of their guests. This has included the development of strategies and risk assessments to support people and specialist training to give the staff the skills and knowledge in line with current good practice. Contracts are issued to people on an annual basis that clarifies the number of nights people are eligible for during the year. In addition people are given an informative brochure including the terms and conditions of their stay, which they are asked to sign. An easy read version of the brochure that uses photographs has also been produced for guests making it more accessible to them. Thorpe View Short Breaks Service DS0000071301.V365070.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, 10. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The service ensures people’s individual needs and choices are respected and appropriate levels of support provided. EVIDENCE: As the service is newly established the care plan systems are not yet fully developed. Detailed assessments are in place for all the people who use the service, which provide staff with valuable information that enables them to respond to individuals in a consistent way. Due to the nature of the short stay service it will take time to develop person centred care plans with everyone. The manager has agreed a pro forma for the care plan, which is being introduced. Supporting people to lead an independent lifestyle and make choices in their lives is an ongoing challenge for the service. The detailed assessment is invaluable to staff in helping them to understand what is important to the person and the choices they are able to make in their lives. We spent time Thorpe View Short Breaks Service DS0000071301.V365070.R01.S.doc Version 5.2 Page 12 with service users and staff during this visit and observed good practice in the way people were supported with decision making. A pictorial menu is used to decide on meals. Another example was a person being offered a selection of fruit enabling them to gesture at the fruit they wanted, as they are not able to vocalise their preference. Staff spoken to were aware of their role and responsibility in taking on an ‘enabling’ role and respecting people’s rights to make choices and decisions about their lives. Responses to surveys sent out as part of this key inspection confirmed people’s views. • • “The carers listen to me and help me with the things I cannot do for myself”. “They treat our son as an individual and respect his needs and wishes”. Each person using the service is allocated a key worker from the staff team who will spend time getting to know the person and take a lead role with the manager in coordinating their care package to make sure it supports and promotes his or her independence. Consultation takes place with guests before, during and after their stay to capture their views and opinions about all aspects of the service. Individual risk assessments are completed for each person staying in the home to ensure they are kept safe at all times. These included personal risk assessments as well as general risk assessments relating to the environment or other factors. One person had a very detailed epilepsy management plan that ensures their independence was promoted whilst keeping them safe. It is recommended these be developed for all the people with epilepsy who use the service. All the records examined were securely stored either electronically or in paper copy in the manager’s office. People who use the service and staff have access to relevant information and are aware of the need for confidentiality. Thorpe View Short Breaks Service DS0000071301.V365070.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, 17. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People are supported to pursue their interests and lead a fulfilling lifestyle of their choosing. EVIDENCE: The second part of the assessment process gathers information relating to people’s interests and hobbies and how they like to spend their time. It was evident from our discussions with the manager and staff that they provide a good range of activities both in the home environment and in the local community. A “what’s on” notice board has been developed that provides information about activities and events in the local community, with staff supporting people to keep this updated by gathering information and leaflets from the tourist information centre. Some people use the short break service as a holiday and may just want to relax whilst others continue with their usual routines such as attending the Thorpe View Short Breaks Service DS0000071301.V365070.R01.S.doc Version 5.2 Page 14 local day service, work or college. It is during the assessment process a person’s preferences will be agreed with them. The layout of the home enables people to have quiet time alone or to enjoy the company of others in the main lounge. The home has a range of in house activities it can offer to people such as DVDs, tabletop activities and a karaoke, which one person was enjoying during this visit. Alternatively they can “do their own thing” one person in their survey response said that “staff supported them to go swimming” another said, “activities are governed by staff availability but they do their best to offer variety and stimulation”. The manager described how the service is planning to have use of an accessible vehicle for use in the evenings and weekends. The kitchen is open plan and is accessible to all the people who use the service. Meals and mealtimes are very flexible and are planned on an individual basis around the person’s preferences and cultural needs. Drinks and snacks are readily available and staff support people to prepare their meals, including shopping for the provisions. Food preferences are identified in the assessment including likes and dislikes and any special dietary requirements. A pictorial menu has been developed to help people make informed choices about the food they prefer. Thorpe View Short Breaks Service DS0000071301.V365070.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. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Personal and healthcare needs are well documented ensuring individual and specialist needs are being met. EVIDENCE: Through the assessment process individual’s personal support needs are agreed with them or their family member or representative. This provides staff with detailed guidance about all aspects of a person’s personal and healthcare support they require. Aids and adaptations are in place around the home in addition to people having their own equipment that they may bring with them. The home works closely with other professionals to ensure they have the appropriate support and guidance. Healthcare needs are well documented at the assessment stage including contact details for a person’s GP and any other health professionals involved with them. Prior to a visit commencing all health and medical details are confirmed in case there have been any changes since their last visit. Staff have completed relevant training to support them in their role such as Epilepsy Thorpe View Short Breaks Service DS0000071301.V365070.R01.S.doc Version 5.2 Page 16 management, the safe handling of medication, assisted feeding and tracheotomy care. The service does not store any medication other than the medication that people bring with them for their short break. This is recorded when entering and leaving the home. Lists of medication are agreed with people when they are contacted prior to their break commencing with Medical Record sheets (MAR charts) completed to record the medication and when and how it should be administered. We examined the medication held in the home against the records and found these top be up to date and accurate. All medication records are double signed if there are two staff on duty. All staff responsible for the administration of medication have received suitable training to ensure they are competent. Thorpe View Short Breaks Service DS0000071301.V365070.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, 23. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Sound policies and procedures are in place that keep people safe and ensure their views are heard. EVIDENCE: The home has a suitable complaints policy and procedure, which is issued to all the people, who stay in the home. A complaints and compliments pack is held in each room. There have been no formal complaints recorded but some issues were raised on the feedback sheet people are asked to complete at the end of their stay. These were addressed immediately by the manager to the satisfaction of the person concerned. There were also several compliments about the quality of the service recorded. Within 24 hours of someone completing a short break the manager contacts them or their representative to check out if they have any issues or concerns with the service provided. All staff receive induction training including Safeguarding adults. In addition the local Council provide training in this area. Suitable policies and procedures are in place to guide and support good practice and staff are made aware of the home’s policies and procedures relating to Safeguarding including the Whistle blowing policy. Thorpe View Short Breaks Service DS0000071301.V365070.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, 30. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Thorpe View provides a safe and comfortable home with suitable equipment and furnishings for people to enjoy their stay. EVIDENCE: Thorpe View is a purpose built facility and is all on one level and fully accessible. It has been decorated and furnished to a high standard and provides a safe and homely living environment to people on short breaks. There were no obvious hazards noted and the home was clean and hygienic throughout. The home is registered for six people with the home divided into two distinct units, a four bed short break facility and a two bed emergency placement unit. Currently only the four short break beds are in use, whilst staff are being recruited to support people in the two emergency beds. These units are self contained and separated by a keypad lock on the dividing door. The two bed Thorpe View Short Breaks Service DS0000071301.V365070.R01.S.doc Version 5.2 Page 19 unit has a lounge/kitchen dining room, with access to the patio and gardens and two bedrooms. In the four bed unit there is an open plan lounge and kitchen/dining area with a conservatory attached which leads onto a secure garden and patio area to the rear and side of the home. There is also a separate lounge and reception area that provides comfortable and private space for people to relax or meet friends. All the rooms are ensuite with toilet and shower and there are two shared bathrooms one with overhead tracking hoist and assisted bath. The front door is secured on a keypad during the daytime and all the people who use the facility have a key for their rooms. The home has suitable aids and adaptations to encourage and support people’s independence around the home, with people able to bring in their own equipment if necessary. Thorpe View Short Breaks Service DS0000071301.V365070.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, 36. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Thorpe View has a committed and well trained staff team who provide a consistent and responsive service that meets individual needs. EVIDENCE: All new staff are issued with a clear job description and complete a thorough induction to the home. This includes being issued with a code of conduct and relevant policies and procedures to guide their practice. Key workers are identified who take a lead role with a particular service user, which gives them a better understanding about the persons needs and preferences. Staff are encouraged and supported by the service to complete relevant NVQ qualifications and through the induction and ongoing training and personal development are given the skills and knowledge necessary for the role they take on. The manager works closely with the staff team and other professionals such as Physiotherapists, Occupational Therapy and Speech and Language Therapist to ensure people’s needs are being assessed and responded to appropriately. Thorpe View Short Breaks Service DS0000071301.V365070.R01.S.doc Version 5.2 Page 21 The manager monitors the staffing levels in the home to ensure they are sufficient to enable staff to provide a personalised and flexible service. As it is a new service and only the four short break beds are operational the home is still recruiting new staff. Based on feedback from people who have used the service and their families there has been a high level of satisfaction with the support provided by the staff team, with the following comments being typical. • • • “The staff treat me well”. “Staff are excellent, friendly and very well motivated”. “Staff were excellent”. We examined staff files, which included relevant information as required by the National Minimum Standards (NMS). The service has robust recruitment procedures in place that ensure all necessary checks and references are in place. The manager records all training and development activity ensuring staff are receiving relevant training for their role. Based on our discussions with staff and feedback in the staff surveys training has been given a high priority with staff completing an in depth induction training programme including core subjects and specialist areas specific to individual guests such as PEG feeding and Tracheotomy care. Staff made the following comments about the training. • • • “This was the best induction training I have received”. “We all received specialist training to help us care for one of our guests”. “The training has been very good and really helpful to me”. The manager provides regular formal supervision for the staff team but it was evident from our discussions with staff informal support and guidance is also provided, with staff feeling “valued in their role”. “The manager is easy to talk to and we can discuss any issues any time”, “we work well as a team and get good support”, “we have good management who guide the staff team” were typical responses we received. Thorpe View Short Breaks Service DS0000071301.V365070.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, 41, 42. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The manager provides clear direction and leadership ensuring the service is operating efficiently and effectively in the best interests of the people who use it. EVIDENCE: The manager has relevant experience and is suitably trained for her role. She provides a clear sense of direction and leadership to the staff team who feel “valued” in their role. There was a mutual respect evident between the manager and staff with several of them commenting on how “they work well as a team”. The service has been designed and planned around the needs and preferences of the guests who use the service and their views are shaping future developments. The service recently purchased Karaoke equipment and Thorpe View Short Breaks Service DS0000071301.V365070.R01.S.doc Version 5.2 Page 23 sports equipment at the request of people who have used the facility, which is a good example of how responsive the service is to people’s needs. Within 24 hours of a person’s short break the service contact them or their representative by phone to check out if they have any concerns or feedback about their stay. In addition to this guests also have the opportunity to complete the compliments/complaints form that is left in their room. The service is in the process of developing this further with a more detailed survey/questionnaire to be completed at the end of a visit. Feedback we received from people who have used the service confirmed that people’s views are sought and acted upon as the following comments reflect. • • • “The staff took heed of what we told them about what our son likes to do, and did do their very best to accommodate him”. “They treat our son as an individual and respect his needs and wishes”. “The carers listen to me and help me with things I cannot do for myself”. The policies and procedures examined during this visit were detailed and in line with current good practice and legislation providing staff with clear guidance in relation to their responsibilities. There are good systems in place to maintain the health and safety of the environment and the people who use the service and work there. A good range of risk assessments were in place for the guests who stay there as well as general risk assessments relating to the environment and equipment. The manager and staff complete routine checks to identify any hazards and take remedial action. Toilet cleaner, which is a COSHH substance, was left in the staff sleep in room toilet, although it is not easily accessible to people who use the service, all COSHH substances must be securely stored at all times. The cleaning fluid was removed immediately by the manager who will ensure staff are made aware of COSHH procedures. Each bedroom has a safe deposit box or alternatively the service will support people with their finances if requested, this is agreed with them at the start of their break. All transactions staff are involved with are recorded and receipts retained. Thorpe View Short Breaks Service DS0000071301.V365070.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 X 2 3 3 3 4 3 5 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 3 26 3 27 3 28 3 29 3 30 3 STAFFING Standard No Score 31 3 32 3 33 3 34 3 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 3 2 3 LIFESTYLES Standard No Score 11 3 12 3 13 3 14 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 3 3 3 X 3 2 X Thorpe View Short Breaks Service DS0000071301.V365070.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. Standard Regulation Requirement Timescale for action 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 3 Refer to Standard YA9 YA34 YA42 Good Practice Recommendations It is recommended epilepsy management plans are developed for all the people with epilepsy who use the service. The service should consider how they could actively involve guests in the staff selection process. The manager should ensure all staff are aware of COSHH procedures and all substances are securely stored at all times. Thorpe View Short Breaks Service DS0000071301.V365070.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Lancashire Area Office Unit 1 Tustin Court Portway Preston PR2 2YQ 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 View Short Breaks Service DS0000071301.V365070.R01.S.doc Version 5.2 Page 27 - 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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