Inspection on 31/08/05 for Thackley Grange

This inspection was carried out on 31st August 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Poor. 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 26/07/06

Thackley Grange 20/12/05

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 BD10 8LN Lead Inspector Sean Cassidy Unannounced 31 August 2005 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 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 20050831 S33578 Thackley Grange V235048 Stage 4 J52.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Thackley Grange Address Boothroyd Drive Town Lane Idle BD10 8LN Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 01274 613937 City of Bradford Metropolitan District Council Mr A Regan Care home 34 Category(ies) of Dementia - over 65 (2) registration, with number Mental Disorder -over 65 (32) of places Thackley Grange 20050831 S33578 Thackley Grange V235048 Stage 4 J52.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: None Date of last inspection 19 January 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, café’s, 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 20050831 S33578 Thackley Grange V235048 Stage 4 J52.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection carried out by one inspector and lasted a full day. The purpose of the inspection was to make sure the home was operating and being managed to a satisfactory standard. The inspector spoke to several service users and members of staff. A number of documents were examined which included care plans, risk assessments, staff files and other records. What the service does well: What has improved since the last inspection? The home now has a Statement of Purpose that will very soon be made available to all. Improvements have been made with the recruitment procedure and employees’ records are kept in the home. All the necessary documentation required before employment could be commenced was obtained. Thackley Grange 20050831 S33578 Thackley Grange V235048 Stage 4 J52.doc Version 1.40 Page 6 The home has now got a staff group in place that has been trained to NVQ level 2 or above. 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 20050831 S33578 Thackley Grange V235048 Stage 4 J52.doc Version 1.40 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 Standards Statutory Requirements Identified During the Inspection Thackley Grange 20050831 S33578 Thackley Grange V235048 Stage 4 J52.doc Version 1.40 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 standard(s) 1,3,4,5. The Statement of purpose and Service User Guide must be available to residents so that they have more information to make an informed choice about where to live. The home does not ensure that residents receive an appropriate contract or a Statement of Terms and Conditions at the point of entry The system for assessing residents moving into the home needs to be reviewed as they do not ensure that their care needs can be met prior to moving into the home. Staff need to be provided with more specialist training in the areas relevant to residents. The records showed that there is a slight improvement but more must be provided. Prospective residents are offered trial visits whenever possible. EVIDENCE: The manager was able to produce an updated Service User Guide and Statement of Purpose that covered all the areas contained in the standard. These documents have only recently been developed and have not yet been Thackley Grange 20050831 S33578 Thackley Grange V235048 Stage 4 J52.doc Version 1.40 Page 9 made available to the residents. This was confirmed through conversations held. The manager agreed that each resident would receive a copy of the Service User Guide very soon. The contracts used by the home for those who self fund do not contain all the necessary information and a Statement of Terms and Conditions is not provided to all at the point of moving into the home. Some resident files inspected showed that the home does not properly assess residents before moving in. Some files had no evidence that an assessment took place. One resident that had moved to another home returned three months later without being reassessed. The home used the original documentation without reviewing it. Residents who move from the short stay unit to the long stay unit are not reassessed to show their changing needs. Residents spoken to felt that the staff group that cared for them appeared to be well trained to do their job. The training records showed an improvement in providing staff with specialist training in areas relevant to the resident group. Trial visits are offered by the home and this is highlighted in the Statement of Purpose. Some residents stated that they did have the opportunity to come and stay prior to moving in. Thackley Grange 20050831 S33578 Thackley Grange V235048 Stage 4 J52.doc Version 1.40 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 standard(s) 7,8,10. The care planning system of the home does not ensure the residents care needs are being met and they are being appropriately protected. Residents feel that their privacy and dignity is respected at all times. EVIDENCE: The resident care files inspected do not ensure that all the care needs were being identified and planned for. The document, which the home uses as a care plan, does not give clear detail of the action that needs to be taken by care staff to ensure all aspects of care are met. These documents appear to be used as an assessment tool and do not involve the resident even though it clearly states that it must. Care plans that should have been in place were not. Examples of this are; no care plan for identified poor mobility; no care plan for someone that needed assistance with hygiene; no care plan for a resident assessed as having poor nutritional status; no care plan for a resident who was reviewed by a GP as possibly having Gastroenteritis; regular checks of residents weight not carried out. The risk assessments used by the home do not properly protect residents, as they are not reviewed correctly. The falls risk assessments seen did not reflect the status of a resident. For example, one Thackley Grange 20050831 S33578 Thackley Grange V235048 Stage 4 J52.doc Version 1.40 Page 11 resident who had fallen and broken an ankle had not had the risk assessment reviewed after the incident and it stated they were a low risk of falling. Residents care plans are not reviewed and do not reflect their changing needs. It is very hard to get a clear and accurate picture of the care package, as a resident may not have anything written about them in the daily records for over two weeks or more. One service user in the short stay unit had been admitted four days earlier and had no plans of care in place or risk assessments. Residents spoken to spoke very highly of the staff and said they worked hard and respected their privacy and dignity at all times. “Nothing is too much for them.” They have a key to their own doors and they also have a locked drawer in their room to keep valuables if they wished. Staff were seen to knock on resident’s doors before entering. Thackley Grange 20050831 S33578 Thackley Grange V235048 Stage 4 J52.doc Version 1.40 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 standard(s) 12,13,15 Residents are provided with a variety of activities, which they enjoy getting involved with. Regular contact with relatives and friends is promoted and enabled by the home. Residents appeared very happy with the quality and provision of meals. EVIDENCE: Residents spoken to were very happy with the facilities and social activities offered by the home. An activities co coordinator has recently been employed. Each resident had a care plan in place and a record was made of what each individual was involved in. Two residents said that they were able to leave the home and go out for meals as a group when they wished. Planned days out are provided which many of them enjoyed. One resident said, “I have no regrets moving in here as it is like home from home.” They were happy with the access they had to the outside community and stated that there were no restrictions on their relatives visiting them at the home. The food was sampled by the inspector and was presentable and tasty. The residents spoken to felt the quality of the food provided within the home was good. The cook was aware of their likes and dislikes and they were regularly asked if there was anything they would like to see added to the menu. Thackley Grange 20050831 S33578 Thackley Grange V235048 Stage 4 J52.doc Version 1.40 Page 13 Residents said they were offered snacks after their tea in the evening, which they enjoyed, and they also said fresh fruit was regularly provided. Thackley Grange 20050831 S33578 Thackley Grange V235048 Stage 4 J52.doc Version 1.40 Page 14 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 standard(s) 18 The home needs to ensure residents are more thoroughly protected from incidents of abuse. EVIDENCE: A number of incidents were identified during the inspection that highlighted problems with ensuring residents were protected from abuse. One incident recorded that a male resident had been found in a female residents room when she was in a state of undress and also quite distressed. This incident was reported to the person in charge and the manager was also aware. No further action was taken and the local Adult Protection unit was not informed or consulted regarding advice. The home did not carry out any risk assessments for the residents and there was no other record made of it in the care plans. There have also been a number of incidents in the home when residents have been very aggressive and putting other residents at risk. There were no risk assessments found in the files to assist staff in dealing with these situations. The manager was asked to report the first matter to the Adult protection unit. Some staff have received Adult Abuse training. One member of staff felt that she was not comfortable dealing with aggressive incidents as she did not have any training. The home do have an ongoing programme to provide Adult Abuse training but it may need to review the content of the course. Thackley Grange 20050831 S33578 Thackley Grange V235048 Stage 4 J52.doc Version 1.40 Page 15 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 standard(s) None of the above standards were inspected on this visit. EVIDENCE: Thackley Grange 20050831 S33578 Thackley Grange V235048 Stage 4 J52.doc Version 1.40 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27,28,29,30 Both staff and residents expressed concerns regarding the numbers of staff on duty. The recommended numbers of staff working in the home trained to NVQ Level and above has been reached. The recruitment procedure adopted by the home helps to protect service users. The training of staff should be audited as some feel they receive appropriate training that makes them feel confident whilst others do not. EVIDENCE: Feedback from the manager and staff on both levels highlighted that staffing levels are not adequate and that shifts can be very busy. Some residents spoken to also indicate that they felt staffing levels were minimal. “ The staff are lovely and kind but they always seem to be rushing around and busy.” Staff stated that it was common to work below the normal levels, as there was an issue with getting staff to fill the shifts. Care records of two employees recently started were inspected. These were found to contain all the necessary information needed before they could start work. The training records were examined and it was identified that new staff receive a robust induction when they commence work. Some staff spoken to felt the organisation encouraged them with identifying their training needs and providing for them, two staff felt this was not the case. Thackley Grange 20050831 S33578 Thackley Grange V235048 Stage 4 J52.doc Version 1.40 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 35,36,37,38. Service users are not receiving the full amount of interest on their savings that they would receive if their savings were held in a bank or building society. They are therefore losing out financially. More regular supervision is needed to ensure staff feel supported and guided. The systems for ensuring good communication records in the home must be reviewed to ensure service users are appropriately protected. The standards of health and safety of service users and staff are below standard. EVIDENCE: Thackley Grange 20050831 S33578 Thackley Grange V235048 Stage 4 J52.doc Version 1.40 Page 18 The records of service users monies were examined. Mainly, service users or relatives are responsible for managing individual finances. Bradford Social Services is the corporate appointee those service users who need assistance with finances. Service users who have savings with Bradford social services do not receive any interest for the first £500; this does not comply with the care homes regulations or guidance published by the Commission for Social Care Inspection. Individual statements have recently started being issued to service users but this is still very infrequent. The manager should soon be able to access this information and print the relevant details, which will therefore resolve this issue. All transactions are recorded and receipted; service users sign for monies received. Staff supervision has not been taking place and some staff spoken to expressed feelings that they did not feel supported by the senior team. The records kept by the home relating to residents are not in good order. It is extremely difficult to try and understand what the care needs for each individual are. Information that should be recorded in the daily records is recorded in another book for all residents. Daily records of care are not recorded and therefore lead to confusion, as was the case when I attempted to get information on residents during the inspection. The mandatory training records for staff showed that not all staff have received the correct training. The manager is not reporting accidents to the Commission when a resident sustains a serious injury. One resident fell in the garden and sustained a head injury, which resulted in that person vomiting. This is a side affect of concussion yet no observations were carried out or action taken to refer this person for further medical attention. Many risk assessments relating to falls were not reviewed and did not reflect the resident’s needs. Risk assessments were not completed for residents who were known to display violent and aggressive behaviour. Thackley Grange 20050831 S33578 Thackley Grange V235048 Stage 4 J52.doc Version 1.40 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score 2 2 1 2 3 x HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 x 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 x 15 3 COMPLAINTS AND PROTECTION x x x x x x x x STAFFING Standard No Score 27 2 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score x x 1 x x x x 2 2 2 1 Thackley Grange 20050831 S33578 Thackley Grange V235048 Stage 4 J52.doc Version 1.40 Page 20 yes Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard 1 Regulation 5 Requirement The registered person must provide a Servive User Guide for current and prospective residents. The registered person must ensure that prospective residents are assessed prior to moving in. This also refers to the movement of residents from the short stay unit to the long stay unit. The registered person must ensure that the home promotes and makes proper provision for the health and welfare of residents. This refers to the need for more specialist training in the specialist area of Mental Health. The residents plan of care must be drawn up following a comprehensive assessment and provide the basis of the care to be delivered. The care plans must be drawn up with the involvement of the resident or a represntative. The residents care plan must be kept under review, at least once a month. Falls risk assessments must be written and reviewed to ensure unnecessary risks to the resident 20050831 S33578 Thackley Grange V235048 Stage 4 J52.doc Timescale for action 30 November 2005 30 November 2005 2. 3 14 3. 4 12 30 November 2005 4. 7 15 30 November 2005 30 November 2005 30 November 2005 30 November 2005 Page 21 5. 6. 7. 7 7 7 15 15 13 Thackley Grange Version 1.40 8. 8 14 9. 18 12 10. 27 18 11. 35 20 12. 13. 14. 36 37 38 18 17 12 15. 2 5 are identified and so far as possible removed. Residents weights must be regulary checked and appropriate action taken when identified. the registered person must ensure that the residents are safeguarded from abuse whenever possible. The saffing numbers and skill mix of staff must be approprite to the assessed needs of the service users. The registered provider must demonstrate how each individual service user will receive any interest applicable to their individual savings. the registered person must ensure that the carers are appropriately supervised. Individual records kept on a resident must be secure and in good order. The registered person must ensure that the care home is conducted to make proper provision for the health and welfare of the residents. The registered provider must ensure residents receive a written contract and Terms and conditions at the point of moving into the home. 30 November 2005 Immediate 30 November 2005 30 November 2005 30 November 2005 30 November 2005 30 November 2003 30 November 2005 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. Refer to Standard Good Practice Recommendations Thackley Grange 20050831 S33578 Thackley Grange V235048 Stage 4 J52.doc Version 1.40 Page 22 Commission for Social Care Inspection Aire House Town Street Rodley 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 20050831 S33578 Thackley Grange V235048 Stage 4 J52.doc Version 1.40 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. 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