Inspection on 20/12/05 for Thackley Grange

This inspection was carried out on 20th December 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Thackley Grange 24/07/07

Thackley Grange 26/07/06

Thackley Grange 31/08/05

Thackley Grange 14/02/05

Thackley Grange 07/09/04

Similar services:

Whiteley House

Tyndale Avenue

2-10 Norfolk Road

Bennfield House Nursing Home

Eastfield Residential Home

Sign Health

Springwood

Fairburn Mews

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

CARE HOMES FOR OLDER PEOPLE Thackley Grange Boothroyd Drive Town Lane Idle Bradford West Yorkshire BD10 8LN Lead Inspector Sean Cassidy Unannounced Inspection 20th December 2005 09:30 X10015.doc Version 1.40 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 Thackley Grange DS0000033578.V272127.R01.S.doc Version 5.0 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. 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. Thackley Grange DS0000033578.V272127.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Thackley Grange Address Boothroyd Drive Town Lane Idle Bradford West Yorkshire BD10 8LN 01274 613937 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) City of Bradford Metropolitan District Council Department of Social Services Mr Anthony Charles Regan Care Home 34 Category(ies) of Dementia - over 65 years of age (2), Mental registration, with number Disorder, excluding learning disability or of places dementia - over 65 years of age (32) Thackley Grange DS0000033578.V272127.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 31st August 2005 Brief Description of the Service: Thackley Grange is a Bradford Local Authority run purpose built property including a day care centre, it accommodates up to 36 older people, 26 of whom have a functional mental illness, the remaining 10 are respite and short stay beds offering care to older people with functional mental illness and mild to moderate dementia. The home is managed over two floors and is a short walk away from a range of shops including a post office, grocery store, cafés, and pubs. The home is easily accessed by public transport and the main bus routes for Shipley, Leeds, and Bradford pass close by. There is a good-sized car park to the front and side of the building. The home has extensive gardens including an enclosed area. Thackley Grange DS0000033578.V272127.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection. The inspector spent the day speaking to residents, relatives and staff. Documentation relating to the care of the residents was also looked at, this included care plans, risk assessments, daily records and policies. What the service does well: What has improved since the last inspection? The home now ensures that they obtain an assessment for residents before they move into the home. More specialist training relevant to the carers needs is provided to staff. Residents’ weights are recorded regularly. Adult protection training is being provided to all staff. Thackley Grange DS0000033578.V272127.R01.S.doc Version 5.0 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. Thackley Grange DS0000033578.V272127.R01.S.doc Version 5.0 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Thackley Grange DS0000033578.V272127.R01.S.doc Version 5.0 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1,3,4. The home does not have the necessary information available to assist residents in making an informed choice about moving in. Residents are not aware of the Service User Guide and do not know how to get one. The Service User Guide does not contain the necessary information. The home obtains an assessment of each resident prior to moving in. Residents and relatives were confident that the home would be able to meet their needs. EVIDENCE: The person in charge was not familiar with the new Statement of Purpose or the Service User Guide. The documents presented did not include the required information. Service users and relatives spoken to on the day could not identify what the Service User Guide was and were unsure whether they had received one from the home. Thackley Grange DS0000033578.V272127.R01.S.doc Version 5.0 Page 9 The care files showed that the home had obtained assessments on the two most recent admissions prior to a bed being offered. Service users and relatives spoken to felt that the staff seemed to know what they were doing and they worked very hard. All those spoken to were confident that the home could meet their needs. Thackley Grange DS0000033578.V272127.R01.S.doc Version 5.0 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9. More work is needed to ensure the identified care needs of the residents are appropriately planned for and met. Not all the health care needs of the residents are being met. The medication process adopted by the home assists residents to self medicate where possible. EVIDENCE: The care plans for three residents showed a small improvement has been made with planning care. The resident assessments highlighted areas where there were care needs but no care plans were found to assist carers provide for those needs. Examples of this were, mobility needs, nutritional needs and personal care needs. Service users or their representatives are not involved with the care planning. Care plans are not consistently signed or dated and are not reviewed regularly Residents said that staff were helpful in meeting their personal needs. “They encourage me to do as much as I can for myself.” Care files contained records Thackley Grange DS0000033578.V272127.R01.S.doc Version 5.0 Page 11 to show residents have access to other health professionals such as GPs Dentists and Chiropodists. Regular weights of residents were carried out. The care files showed no evidence that residents are appropriately risk assessed in areas of nutrition, falls and pressure areas. No evidence was found to show residents psychological health is monitored regularly. The medication records were examined and were in good order. The home has a good medication policy. All residents files showed that they had been appropriately assessed for the ability to self medicate. Thackley Grange DS0000033578.V272127.R01.S.doc Version 5.0 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 14 The home tries to ensure residents are involved with all issues regarding choice to control their own lives. EVIDENCE: Residents spoken gave some positive feedback about the choices they receive in the home. “ I can see my visitors when I want. The staff are very helpful in that way.” “ I was encouraged to take as many possessions as I wanted into the home.” One service user was unaware that there were resident meetings to discuss home issues. She was not aware of what was planned from an activity point of view. “I haven’t been told what activities are planned for the home. I would like to know as I would like to attend if possible” All rooms inspected contained many personal possessions belonging to residents. Advocate information is displayed in a number of areas within the home. Mail is provided to residents unopened. Thackley Grange DS0000033578.V272127.R01.S.doc Version 5.0 Page 13 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16,18. Residents and relatives spoken to expressed confidence in the home dealing with a complaint if it arose. Service users are being protected by the adult protection procedures adopted by the home. EVIDENCE: The complaints procedure was examined and contained the necessary information needed to ensure a complaint could be properly made. Although those spoken to said that they did not know the complaint procedure they said if they had a complaint they would take it to the person in charge. No complaints had been recorded since the last inspection. An adult protection investigation is ongoing and it is hoped an outcome will be available in the very near future. There is an ongoing programme of adult protection training being provided to all staff. Those that have already undergone the training were very positive about it. Thackley Grange DS0000033578.V272127.R01.S.doc Version 5.0 Page 14 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19,26. The home environment is safe and well maintained. It is suitable for the stated purpose. The residents and relatives confirmed that the home is kept very clean, pleasant and hygienic. EVIDENCE: The home is accessible and well maintained. The décor throughout is of a good standard and this was recognised by the residents and relatives spoken to. One resident said, “ I couldn’t have asked for a better place. It is very comfortable and warm. Nearly as good as my own home.” The home should be commended on the cleanliness and tidiness. All service users spoken to thought that the domestic staff worked very hard and did a good job. One resident said, “ The home is very clean and tidy and the young ladies work very hard to keep it that way.” The home was free from offensive Thackley Grange DS0000033578.V272127.R01.S.doc Version 5.0 Page 15 odours on the day of inspection. Policies are in place for controlling infection and staff receive updated COSHH information. The washing machines have disinfecting programmes and all soiled materials are placed in soluble bags for washing. Thackley Grange DS0000033578.V272127.R01.S.doc Version 5.0 Page 16 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27,29,30. Both staff and residents expressed concerns regarding the number of staff on duty. Residents are not in safe hands at all times. The standard of training provided to carers helps carers to be competent when carrying out their roles. EVIDENCE: Service users spoken to felt that the main problem with the home was that the staff were always busy and didn’t really have a lot of time to sit and chat with them. This was observed during the course of the day. Staff spoken to said that they were short staffed and a recent recruitment campaign had not been able to bring them up to the numbers they should have. This was highlighted with the person in charge. It was identified that the home was not providing the correct amount of staff on shifts. On regular occasions staff from one unit are taken to help out on another, leaving one unit inadequately staffed. The inspector has highlighted this previously, but this poor practice continues. Two staff members said that they could only give the bare minimum of care and they did not have the time to give the extra personal care that they wanted to and the residents needed. The staff are now attending training relevant to the specialist area of care provided by the home. The home have now attained the recommended 50 of staff being trained to NVQ level 2 standard. One new member of staff confirmed that she has commenced a relevant induction that she was presently working through. Thackley Grange DS0000033578.V272127.R01.S.doc Version 5.0 Page 17 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. 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 and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31,33,35,36 The home does not have a registered manager in position at the moment. The evidence seen shows that the home attempts to run the home in the best interests of the residents. Service users with large amounts of savings are not benefiting from potential interest due to the way their money is managed by the home. Staff are not being appropriately supervised or appraised by the management of the home. EVIDENCE: The registered manager on the homes certificate has been removed from his post and replaced by another person. The Commission has not received notification with regards to this move and therefore cannot give information Thackley Grange DS0000033578.V272127.R01.S.doc Version 5.0 Page 18 about the person managing this home at the present time. Verification has been sought but has not yet been provided at the date this report has been written. Residents and relatives spoken to were unsure as to what has happened to the previous registered manager and they are unaware of his replacement. Staff are also unsure as to the management of the home at present. They expressed concerns about the lack of leadership and management of the home. The person in charge was able to provide evidence to show the home attempts to obtain the views of the residents and their representatives regarding the running of the home. This information is displayed on the notice board downstairs. It is recommended that this information be better displayed throughout the home as opposed to just in the downstairs corridor. The records kept for service users monies were examined. These showed service users who have savings with Bradford Social Services do not receive interest for the first £500. The Commission is in discussions with Bradford Social Services at present to try and resolve this matter. Although it does not comply with the guidance published by the Commission for Social Care Inspection it is hoped that a satisfactory outcome will soon be obtained for residents. Staff supervision continues to be an area that requires more input. The person in charge agreed that the home is not providing suitable supervision or appraisal to the staff working at the home. Thackley Grange DS0000033578.V272127.R01.S.doc Version 5.0 Page 19 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People 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 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 2 x 3 3 x x HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 3 10 x 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 x 13 x 14 3 15 x COMPLAINTS AND PROTECTION Standard No Score 16 3 17 x 18 3 3 x x x x x x 4 STAFFING Standard No Score 27 2 28 x 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 x 3 x 2 3 x x Thackley Grange DS0000033578.V272127.R01.S.doc Version 5.0 Page 20 Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP1 Regulation 5 Requirement The registered person must provide a Service User Guide for current and prospective residents. (The previous timescale of 30/11/05 was not met.) The care plans must be drawn up with the involvement of the resident or a representative. (The previous timescale of 30/11/05 was not met.) The residents care plan must be kept under review, at least once a month. (The previous timescale of 30/11/05 was not met.) Falls risk assessments must be written and reviewed to ensure unnecessary risks to the resident are identified and so far as possible removed. (The previous timescale of 30/11/05 was not met.) The staffing numbers and skill mix of staff must be appropriate to the assessed needs of the service users. (The previous timescale of 30/11/05 was not met.) DS0000033578.V272127.R01.S.doc Timescale for action 28/02/06 2. OP7 15 28/02/06 3. OP7 15 28/02/06 4. OP7 13 28/02/06 5. OP27 18 31/03/06 Thackley Grange Version 5.0 Page 21 6. OP35 20 7. OP36 18 8 OP31 39 The registered provider must demonstrate how each individual service user will receive any interest applicable to their individual savings. (The previous timescale of 30/11/05 was not met.) The registered person must ensure that the carers are appropriately supervised. (The previous timescale of 30/11/05 was not met.) The registered person must inform the commission when a person registered to manage the care home changes. 28/02/06 31/03/06 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. Refer to Standard Good Practice Recommendations Thackley Grange DS0000033578.V272127.R01.S.doc Version 5.0 Page 22 Commission for Social Care Inspection Aire House Town Street Rodley Leeds LS13 1HP 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 Thackley Grange DS0000033578.V272127.R01.S.doc Version 5.0 Page 23 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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!