Inspection on 24/07/07 for Thackley Grange

This inspection was carried out on 24th July 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 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 26/07/06

Thackley Grange 20/12/05

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 Ashley Fawthrop Key Unannounced Inspection 10:00 24th July 2007 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.V336360.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 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.V336360.R01.S.doc Version 5.2 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 vacant post 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.V336360.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 26th July 2006 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 34 older people with mental disorder including dementia on a permanent and short stay basis. There is an attached day centre with 10 places for people with 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. The home has a range of bathroom and toilet facilities for independent and assisted use There is a good-sized car park to the front and side of the building. The home has extensive gardens including an enclosed area. Information provided by the home in respect of fees says that residents pay according to their financial assessment. To the 24th July 2007 the fees range from £94.43 a week (low rate) to £159.95 (medium rate) and £435.68 (highest rate). The last inspection report is available in reception. Thackley Grange DS0000033578.V336360.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced visit finished in one day I would like to thank everyone who took the time to talk to me and express his or her views. Before the visit, accumulated information about the home was reviewed. This included looking at the number of reported accidents and incidents, adult protection issues, reports from other agencies, i.e., the Environmental Health Officer, and correspondence following the last inspection. This information was used to plan this inspection visit. I case tracked four people’s care plans. Case tracking is the method used to assess whether people who use services receive good quality care that meets their individual needs. Where appropriate, issues relating to the cultural and diverse needs of residents and staff were considered. Using this method I assessed all twenty-one key standards from the Care Homes for Older People National Minimum Standards, plus other standards relevant to the visit. I spoke with identified people who live at the home and relevant members of the staff team who provide support to them. Documentation relating to these people was looked at. Where possible, contact was also made with external professionals to obtain their opinions about the quality of services provided at the home. What the service does well: People said that they did have the opportunity to visit the home before moving in. That staff were friendly and always respectful and polite. Others said that they were able to organise their own days. If you want to do activities you could, if you choose not to then you do not have to. People can be involved in group activities or individual hobbies. For those people who have lost the ability to concentrate on activities, staff speak with them individually and reminisce. Thackley Grange DS0000033578.V336360.R01.S.doc Version 5.2 Page 6 People said that the staff are always kind and caring. One person said that they could go to their room whenever they wished and had lots of person al possessions that made it homely. Personal care assistance is always given in private. Staff showed genuine concern for people and discussed openly how they help people make difficult decision about their future. There continue to be regular staff meetings and meetings with people who live at the home so that they can express their views about the service. What has improved since the last inspection? What they could do better: When a person’s well being changes which could alter the plan of care, this should be written in the care plan. The results and any action that has been taken after a quality audit, should be made available to people who live in the home. This is evidence that the manager and staff take the views of people seriously. Please contact the provider for advice of actions taken in response to this Thackley Grange DS0000033578.V336360.R01.S.doc Version 5.2 Page 7 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. Thackley Grange DS0000033578.V336360.R01.S.doc Version 5.2 Page 8 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.V336360.R01.S.doc Version 5.2 Page 9 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. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 3 and 6 People using the service experienced good quality outcomes. This judgement has been made using available evidence including a visit to this service. People do have the information they need to make an informed choice about the home they are assessed and have the opportunity to visit before they move in. EVIDENCE: Since the last inspection the statement of purpose has been updated and has plenty of information about the services the home offers. The home cares for people with mental disorders including dementia and it is made clear that this is their specialist area. This is good practice because it make sure that people have up-to-date information about what services the home can offer and allows people to make an informed decision about whether the home can meet their needs. Thackley Grange DS0000033578.V336360.R01.S.doc Version 5.2 Page 10 People are aware of the Service User Guide and its contents. This has been completed since the last inspection. All people are assessed before they move into the home, these are done by people trained and experienced in the care of people with mental disorders. People said that they did have the opportunity to visit the home before moving in. This is good practice as it gives staff the opportunity to see assess people in the home and it gives the person wanting to move in to the home a chance to meet people. The home does not provide intermediate care. Thackley Grange DS0000033578.V336360.R01.S.doc Version 5.2 Page 11 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. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10 People using the service experienced good. quality outcomes. This judgement has been made using available evidence including a visit to this service. The recording of information has been improved since the last inspection. The physical, mental and social needs are met and the medication system is safe. EVIDENCE: The care plans of four people were case tracked. There was good information about people’s past histories. This is good practice as it gives staff an opportunity learn about their past experiences and what is important to them. There was good evidence of the involvement of health professionals. Where risks had been seen, assessments had been done to make sure the risk is at a minimum and staff are aware of it. This is good practice as it is evidence that people do take acceptable risks. Thackley Grange DS0000033578.V336360.R01.S.doc Version 5.2 Page 12 The care plans that were seen were up to date and aimed to meet the differing needs of the people they were written for. Medication records were looked at. There was an up to date list of approved signatures for cross-referencing and all staff assisting with medication have had training The medication administration records sheets had no gaps. This is an improvement since the last inspection. Medicines are stored in locked cabinets and are given to people by staff that have been trained. This is good practice as it reduces the risk of mistakes. People said that staff were friendly and always respectful and polite. Personal care assistance is always given in private. Dignity and modesty are respected. Staff always knock before entering bedrooms. Thackley Grange DS0000033578.V336360.R01.S.doc Version 5.2 Page 13 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15 People using the service experienced good. quality outcomes. This judgement has been made using available evidence including a visit to this service. People’s social lives are seen as important, activities are meaningful and meet the diverse needs of people. EVIDENCE: The home employs an activity coordinator who has done specific training relating to creative crafts. Socialisation is part of care planning where individual hobbies and pastimes are written. This is good practice because activities can be planned to meet people’s individual and diverse needs. People said that they were able to organise their own days. If you want to do activities you could, if you choose not to then you do not have to. People can be involved in group activities or individual hobbies. For those people who have lost the ability to concentrate on activities, staff speak with Thackley Grange DS0000033578.V336360.R01.S.doc Version 5.2 Page 14 them individually and reminisce. This is good practice as it is evidence that everyone’s social needs are addressed. I sat and watched staff talking with people conversations included day to day events, how people enjoyed their holidays or what was on the telly. This is evidence that the staff find people important and are interested in them and helps to create a homely atmosphere. The daily menu is on display in the dining room this is written each day and was up to date on the day of the visit. This is good practice because out of date information could cause distress for people who suffer memory loss. The individual needs of people from other countries were evident in the care plans the staff had recorded important information relating to religion, problems with communications or diet. This is good practice as the home recognises the cultural and dietary needs of people. The service has improved since the last inspection and more is done individual activities on a day-to-day basis after with people who live in the home. People said that the staff are always kind and caring. Thackley Grange DS0000033578.V336360.R01.S.doc Version 5.2 Page 15 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. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 People using the service experienced good. quality outcomes. This judgement has been made using available evidence including a visit to this service. People are protected by the complaints procedures and the policies and staff training relating to the protection of vulnerable people. EVIDENCE: There have been no complaints since the last inspection. The complaints policy is displayed on notice boards around the home. People said that they were confident that staff would deal with their concerns. The training records show that staff are receiving training in the protection of vulnerable adults. There is information on display on how to report suspected abuse. This is good practice as it explains who is responsible for taking action so staff can act quickly. Thackley Grange DS0000033578.V336360.R01.S.doc Version 5.2 Page 16 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. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 22, 24 and 26 People using the service experienced good. quality outcomes. This judgement has been made using available evidence including a visit to this service. People live in a clean comfortable well maintained home that meets their diverse and individual needs. EVIDENCE: All areas of the home were clean tidy and free from odours. Bedrooms were individually decorated and showed good signs of personalisation. One person said that they could go to their room whenever they wished and had lots of personal possessions that made it homely. On walking around the building peoples room were furnished to a good standard people have the opportunity to bring in their own possessions from home. Thackley Grange DS0000033578.V336360.R01.S.doc Version 5.2 Page 17 This is good practice as is gives people a sense of ownership and individuality. The home is cleaned by staff that are employed to clean, there was equipment and cleaning materials available. The home has an infection control policy. This is good practice as it helps staff lower the risk of infection. Thackley Grange DS0000033578.V336360.R01.S.doc Version 5.2 Page 18 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. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30 People using the service experienced good. quality outcomes. This judgement has been made using available evidence including a visit to this service. Staff are experienced and trained to a good level and the recruitment policy is robust so protects people from potential abuse. EVIDENCE: On the day of the inspection some staff had received the results of their training in medications and were pleased with the results. Staff said they had plenty of opportunity to go on training courses and said it was good because they had the skills to care for people with mental disorders. The training records reflected this and there was evidence that training was on going. Staff showed genuine concern for people and discussed openly how they help people make difficult decision about their future. Staff were seen talking to each other in so that the best course of action could be taken. This is good practice it is evidence that the staff have the skills and confidence to help people through difficult times. Thackley Grange DS0000033578.V336360.R01.S.doc Version 5.2 Page 19 The recruitment and selection of staff is done with the input of the local authorities Human Recourses section. People complete application forms and references are taken up. All staff have criminal records checks before they start to work at the home. This is good practice as it protects people from potential abusers. Staff said that there is good access to courses and they can ask for training in supervision. Thackley Grange DS0000033578.V336360.R01.S.doc Version 5.2 Page 20 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. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 and 38 People using the service experienced good quality outcomes. This judgement has been made using available evidence including a visit to this service. The home is managed by people with the skills to manage well and it is run in the best interests of the people who live there. Staff are supervised and the home has a safe environment. EVIDENCE: The manager has been in post for over a year and since the last inspection has registered the Commission as a manager. She has worked hard with the staff team to improve the recording of and the delivery of care in the home. Thackley Grange DS0000033578.V336360.R01.S.doc Version 5.2 Page 21 There continue to be regular staff meetings and meetings with people who live at the home so that they can express their views about the service. The home has an independent quality visitor who talks to people and provides monthly feedback. The local authority conducts an annual survey and people’s views are passed on to the home. The home should make sure that the outcomes of such consultations are shared with people who live in the home and their relatives. I recommended adding a section about quality in their newsletter do this. This would be good practice is it is evidence that the home acts on the suggestions of people who live there and find their views important. Senior officers continue to supervise a small group of staff. Records of dates are maintained on the computer and on a wall chart. The pre-inspection information and records seen at the home show that there are comprehensive health and safety polices and procedures. Statutory checks continue to be maintained and appropriate risk assessments are in place for the environment and hazardous substances in the home. Thackley Grange DS0000033578.V336360.R01.S.doc Version 5.2 Page 22 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 3 3 3 X X 3 HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 3 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 4 14 4 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X 3 X 3 X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 4 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 3 Thackley Grange DS0000033578.V336360.R01.S.doc Version 5.2 Page 23 Are there any outstanding requirements from the last inspection? No 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 Refer to Standard OP9 Good Practice Recommendations Where people have seen changes in people’s behaviour have been seen due to medication, this should be written in the care plan not on the medication sheet. Any results and action taken following the quality audit should be made available to people who live in the home. 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