Inspection on 26/07/06 for Thackley Grange

This inspection was carried out on 26th July 2006.

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

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Thackley Grange 24/07/07

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 Sughra Nazir Unannounced Inspection 26th July 2006 10:00 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.V294756.R02.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.V294756.R02.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 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.V294756.R02.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 20th December 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 34 older people, 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 goodsized 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. 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.V294756.R02.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The Commission for Social Care Inspection (CSCI) will be inspecting homes at a frequency determined by how the home has been quality rated. The inspection process has now become a cycle of activity rather than a series of one-off events. Information is gathered from a variety of sources, one being a site visit. All regulated services will have at least one key inspection between April 2006 and June 2007. This is a major evaluation of the quality of a service and any risk it might present. It focuses on the outcomes for people using it. All the core National Minimum Standards are assessed and this forms the evidence of the outcomes experienced by residents. On occasions it may be necessary to carry out additional site visits, some visits may focus on a specific area and are known as random inspections. This was the first inspection of this home for the 2006 to 2007 period. Due to the number and nature of requirements outstanding from previous inspections this home was rated as adequate. The visit to the home was carried out by one inspector who took 7 hours to gather information by looking at files and speaking to the residents, visitors and staff before giving the senior care staff member detailed feedback. The inspection coincided with a quality visitors’ visit to the home and their report dated 4th September 2006 is referenced in the report. Prior to the inspection visit, a pre-inspection questionnaire was sent out to the manager for completion. This was returned and the information has been used to inform the visit. In addition survey cards were left at the home for completion by residents and relatives. Eight surveys have been received from residents and comments made by service users in the surveys and during the inspection are included in the report. The last survey was received on 24th August 2006. After the site visit surveys were sent to local GPs, one was returned and the respondent was positive in their responses to questions asked. No specific comments were made. The people who live at the home are called both residents and service users so both terms are used in the report. Thackley Grange DS0000033578.V294756.R02.S.doc Version 5.2 Page 6 What the service does well: What has improved since the last inspection? 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 Thackley Grange DS0000033578.V294756.R02.S.doc Version 5.2 Page 7 contacting your local CSCI office. Thackley Grange DS0000033578.V294756.R02.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.V294756.R02.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1,3 and 6 The quality in this outcome area is poor. This judgement has been based on available evidence including a visit to this service. Residents do not have the information they need to make an informed choice about the home. EVIDENCE: The Statement of purpose needs revising to make sure that residents have upto-date information about management and staffing arrangements in the home. Residents are not aware of the Service User Guide or its contents. The manager said that this document was at draft stage. Short stay residents have been admitted to the home without an up to date assessment. This was brought to the attention of the manager. The home does not provide intermediate care. Thackley Grange DS0000033578.V294756.R02.S.doc Version 5.2 Page 10 Thackley Grange DS0000033578.V294756.R02.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9 and 10 The quality in this outcome area is adequate. This judgement has been based on available evidence including a visit to this service. Documentation needs improving to ensure service users needs are being met. EVIDENCE: Staff have spent some time transferring care plans into a new format. There was good evidence of the involvement of health professionals. A number of care plans were looked at and at least two files did not have recorded reviews of care plans since April. There was no evidence of involving residents and/or their relatives in drawing up care plans. Two service user files for short stay residents were reviewed. Documentation for one resident who had had a number of previous stays was very limited. There was a document with brief details but no information was recorded on how to meet this resident’s needs. There were no moving and handling or other assessments in place. This is poor practice. 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 Thackley Grange DS0000033578.V294756.R02.S.doc Version 5.2 Page 12 had some training. The medication administration records (MAR ) sheets had some gaps where there was no recording to confirm whether or not the person had taken their medication. This is unsafe practice and was brought to the attention of the manager. Service users 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.V294756.R02.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14 and 15 The quality in this outcome area is adequate. This judgement has been based on available evidence including a visit to this service. Service user’s experience and feedback about activities is mixed EVIDENCE: On the day of the visit there were no structured activities taking place. Residents were sitting in the smokers lounge or upstairs lounges making conversation or sitting quietly. A small group of service users talked about the activities in the home. They said they had played dominoes in the garden and looked forward to quizzes that take place in the evening. One service user in their survey said the “craft coordinator is sometimes covering other areas in the establishment which creates boredom for residents.” Another one said that activities are sometimes good “ the activities are good when available.”` One resident said she used to go to the theatre and would like to do this. One of the notices displayed in the corridor was for a play and this resident said she Thackley Grange DS0000033578.V294756.R02.S.doc Version 5.2 Page 14 hadn’t seen it as she spends time either in the lounge or her room. Information about activities might be better displayed or discussed with residents. The notices seen also publicised clothes sales at the home. The manager said that exchange visits were planned with other homes. In particular a visit was being planned to a home where there are a large number of residents from an Eastern European background. This would introduce staff and residents to new experiences. There had been a world cup barbeque at the home with food reflecting other countries. There are visits from the local church and the Salvation Army. One resident commented positively about the memorial service planned for a resident who had passed away. The service should do more individual activities on a day-to-day basis after consulting residents on their needs wishes and preferences. Residents said that they had newspapers and magazines delivered and could have mobile phones if the chose. This helped to keep in touch with people outside the home. One resident said she usually goes to bed at 11pm and can choose what time she gets up. The home has 5 water coolers and jugs of pop are positioned in most lounges. There were jugs of water in most bedrooms. This is good practice and ensures that fluid intake is maintained in hot weather. The inspector saw lunch being served in the main dining room upstairs and in the short stay wing. The home made good use of fans to keep the dining room cool. Staff sat alongside residents and there was more conversation in the less formal short stay dining room. The manager said that new dining tables and serving tureens had been ordered. This would encourage residents to serve themselves and promote more interaction at mealtimes. Nearly all the residents had the set meal for the day, a couple of residents had bananas with their custard instead of the set pudding. Staff said that residents are told about the menu for the day and can ask for an alternative. Residents said that they had enjoyed the meal and that it was well-cooked. One resident said that they sometimes like the food at the home. They said “ tea in the afternoon is always sandwiches not much variety for people with other dietary requirements.” Thackley Grange DS0000033578.V294756.R02.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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 The quality in this outcome area is adequate. This judgement has been based on available evidence including a visit to this service. Service users are confident that any concerns will be dealt with, staff need more training to make sure that they keep service users safe. EVIDENCE: . The complaints policy is displayed on notice boards around the home. Three service users confirmed that they were confident talking to staff or the manager about any concerns. Staff were asked about adult protection training, one out of the three said she had not had training on adult protection. This should be addressed so that all staff are aware of their responsibilities. Thackley Grange DS0000033578.V294756.R02.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19 and 26 The quality in this outcome area is good. This judgement has been based on available evidence including a visit to this service. Service users live in a clean environment. EVIDENCE: All areas of the home were clean tidy and free from odours. Bedrooms were individually decorated and showed good signs of personalisation. One service user said they were “very happy with the environment ”. Another said that the home was usually clean but sometimes other residents didn’t flush the toilet. One resident in the short stay wing said that she found the commode chair uncomfortable to sit on and there was no other chair in her bedroom. This matter was raised with the manager. Thackley Grange DS0000033578.V294756.R02.S.doc Version 5.2 Page 17 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, 28, 29 and 30 The quality in this outcome area is poor. This judgement has been based on available evidence including a visit to this service. Staffing levels are perceived as poor by staff and residents. EVIDENCE: All eight service user surveys returned said that staff were usually or sometimes available when needed. One said “clients are left for long periods of time without any staff checking on them.” Another resident said, “basic care is provided however the little extra care needed is lacking.” Staff said that more staff were needed so they could have more time to talk to and stimulate service users. The quality visitor comments that one staff member spoken to said she felt “a bit stressed while on duty with agency staff, and spent most of her time telling them where things were, rather than doing what she should have been doing” The situation is improving with plans underway to recruit to the additional hours agreed by the organisation. A number of staff files were looked at there was no up-to-date recruitment information. Many of the staff had been appointed by previous managers and documents were not in place. Thackley Grange DS0000033578.V294756.R02.S.doc Version 5.2 Page 18 Whilst reviewing the staff files and in conversations with staff it became apparent that a number of families were amongst those employed at the home. Two staff members said that this had caused problems and conflict within the home. New applications for employment will be considered on merit. More than 50 of the staff team have a qualification at NVQ (National Vocational Qualification) level 2 or equivalent. Staff said that there is good access to courses and they can ask for training in supervision. Thackley Grange DS0000033578.V294756.R02.S.doc Version 5.2 Page 19 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, 33 and 38 The quality in this outcome area is adequate. This judgement has been based on available evidence including a visit to this service. Management arrangements are improving. EVIDENCE: The manager was appointed earlier this year and this has created some stability and reduced anxiety at the home. She has not yet submitted a full application to the Commission for registration. This means that the service is operating without a registered manager. There are regular staff meetings and meetings for residents for them to express their views about the service. The home has an independent quality visitor who talks to staff and residents and provides monthly feedback. The local authority conducts an annual survey and service users’ views are passed on to the home. The home must ensure that the outcomes of such Thackley Grange DS0000033578.V294756.R02.S.doc Version 5.2 Page 20 consultations are shared with other stakeholders including relatives and the Commission. Supervision has improved and senior officers now all supervise a small group of staff. Records of dates are maintained on the computer and on a wallchart. There has been some concern that the use of a “one pot” system for handling residents’ monies means that individuals cannot see how much interest they are getting on their own savings. The system is used in other local authority homes. The manager said that there are plans to obtain individual statements for residents that would show what each person earned in terms of interest. The pre-inspection questionnaire and records seen at the home show that there are comprehensive health and safety polices and procedures. Statutory checks are being maintained and appropriate risk assessments are in place for the environment and hazardous substances in the home. Thackley Grange DS0000033578.V294756.R02.S.doc Version 5.2 Page 21 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 3 2 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 3 X X X X X X 3 STAFFING Standard No Score 27 2 28 3 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 3 X 2 X X 3 Thackley Grange DS0000033578.V294756.R02.S.doc Version 5.2 Page 22 Are there any outstanding requirements from the last inspection? Yes 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 4,5 and 6 Requirement The manager must provide a Service User Guide and up-todate Statement of Purpose for current and prospective residents. The manager must make sure that new residents including those on short stays are only admitted with an up to date and comprehensive assessment. The manager must make sure that all service users have an up-to-date care plan that is regularly reviewed. The care plans must be drawn up with the involvement of the resident or a representative. (The previous timescales of 30/11/05 and 28/02/06 were not met.) Falls risk assessments and moving and handling 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 and DS0000033578.V294756.R02.S.doc Timescale for action 31/10/06 2 OP3 14 30/11/06 3. OP7 15 31/12/06 4 OP7 15 31/12/06 Thackley Grange Version 5.2 Page 23 5 OP9 13 6 OP12 14 7 OP18 13 8 OP27 18 28/02/05 were not met.) All medication records must be fully completed in accordance with Royal Pharmaceutical society guidelines. The registered person must ensure that residents have access to a range of activities that meet their needs and interests. The manager must make sure that all staff including domestic staff receive training on Adult protection. 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.) The manager must make sure that staff files contain a completed application form references and evidence of CRB. The manager must make application to the Commission for registration. The registered person must demonstrate how each individual service user will receive any interest applicable to their savings. (The previous timescales of 30/11/05 and 28/02/06 were not met.) 30/09/06 31/10/06 31/12/06 31/12/06 9 OP29 19 30/11/06 10. 11 OP31 OP35 39 20 31/10/06 31/12/06 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.V294756.R02.S.doc Version 5.2 Page 24 Thackley Grange DS0000033578.V294756.R02.S.doc Version 5.2 Page 25 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.V294756.R02.S.doc Version 5.2 Page 26 - 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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