CARE HOME ADULTS 18-65
Thingwall Hall Nursing Home Thingwall Hall Drive Broadgreen Liverpool Merseyside L14 7NZ Lead Inspector
Miss Orla Murphy Unannounced Inspection 10:00 26 & 27 October 2005
th th Thingwall Hall Nursing Home DS0000005473.V266457.R01.S.doc Version 5.0 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 Thingwall Hall Nursing Home DS0000005473.V266457.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 Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Thingwall Hall Nursing Home DS0000005473.V266457.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION
Name of service Thingwall Hall Nursing Home Address Thingwall Hall Drive Broadgreen Liverpool Merseyside L14 7NZ 0151 228 4439 0151 254 1951 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) Brothers of Charity Mr Steven Wright Care Home 40 Category(ies) of Learning disability (40) registration, with number of places Thingwall Hall Nursing Home DS0000005473.V266457.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION
Conditions of registration: 1. 2. Service users to include up to 40 LD Maximum no registered 40, of which up to a maximum of 26 PC (Personal Care) and up to a maximum of 14 N (Nursing) 15th November 2004 Date of last inspection Brief Description of the Service: The service consists of 6 separate houses (bungalows) in the grounds of Thingwall Hall. The main hall is now the administrative centre for the organisation. There are 4 houses that provide personal care only and 2, which provide personal care with nursing. The service is run by a voluntary organisation, The Brothers of Charity. The site is quite large, set in its own grounds & set back from a side & main road. The bungalows are located throughout the grounds but accessible, being a short walk from each other. There is access to public transport and Liverpool is easily accessible. Parking is available in the main car park. There are shops/leisure facilities locally & a wider range a short bus ride from the area. Thingwall Hall Nursing Home DS0000005473.V266457.R01.S.doc Version 5.0 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. The Inspection was unannounced and neither residents nor staff knew the Inspector was coming. Given the number of residents and separate houses, the inspection was carried out over 2 days. The last inspection report was examined and 4 requirements needed to be followed up on this visit. The Inspection was the first in the home’s required visits, which are 2 inspection visits per year. 15 residents and 6 staff were spoken to at the inspection. Four residents were “case tracked”. Case tracking means that the Inspector concentrates on the care given and experiences of one or more residents, to get an idea of what is like to live there and how that person’s needs are being met. Case tracking also shows the inspector where needs aren’t being met. A variety of records (care plans, medical notes, complaints records, assessments, reviews, medication sheets, meeting minutes, menus, timetables, risk assessments and significant events) were examined. What the service does well: What has improved since the last inspection?
Complaints information has now been included in the Service User Guide and each bungalow holds its own complaint record. The furniture identified in one bungalow at the last inspection has been replaced. Thingwall Hall Nursing Home DS0000005473.V266457.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. Thingwall Hall Nursing Home DS0000005473.V266457.R01.S.doc Version 5.0 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS
Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Thingwall Hall Nursing Home DS0000005473.V266457.R01.S.doc Version 5.0 Page 8 Choice of Home
The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 2 Residents are fully assessed to identify the care & support they need. EVIDENCE: Most of the current residents have lived at the bungalows & in the service for a number of years. Current procedure is a gradual process of moving in which was discussed with and confirmed by assessments & staff. Assessments of all four residents case tracked were detailed and informative. These assessments were updated where changes occurred and Essential lifestyle Plans (ELP’s) addressed the needs in the assessment. The residents spoken to stated they were satisfied living in the homes. Thingwall Hall Nursing Home DS0000005473.V266457.R01.S.doc Version 5.0 Page 9 Individual Needs and Choices
The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7 & 9. Residents all have Essential Lifestyle Plans, which records their needs and wishes. Residents are encouraged and supported to make decisions about their lives in some ways, but not fully. Risks are assessed in relation to some areas, but are applied too widely. They are not specific & measurable. EVIDENCE: The 2 of the 4 residents case tracked said they felt staff met their needs. A visitor of another resident (who could not discuss their needs) also felt their relative’s needs were met. Observations of residents who could not verbally communicate and records seen in the nursing bungalows showed that these residents were involved in their day to day lives and enabled to be as independent as possible. All Essential Lifestyle Plans seen were very positive and identify the specific work needed to help a resident succeed. These Plans give lots of information about each residents goals, likes/dislikes, things they are good at, things they need help with, what makes them angry or sad and what makes them happy. It tells staff, from the resident’s point of view, how best to care for them and help them. Daily records were detailed and linked to the Essential plans.
Thingwall Hall Nursing Home DS0000005473.V266457.R01.S.doc Version 5.0 Page 10 However, observations in the residential bungalows did not reflect that certain aspects of the values of the Essential Plans, such as confidentiality of an individual, respect, privacy & choice were carried out in practise in particular situations. This has been discussed with the Manager and must be addressed. Inappropriate language/information was also found in daily records. This must cease. Residents have a forum where chosen representatives discuss the service & any issues they may have. This is positive & minutes seen were good. However, on a more basic level within the residential bungalows, it was evident choice & having a say in day to day issues were lacking at times. Essential Lifestyle Plans recorded a commitment to residents being as independent as possible, developing skills in this area. However, in practise it appears this is controlled, perhaps because of safety concerns, such as access to the kitchen/laundry equipment. Such blanket control however is not in line with promoting independence and valuing people. Where individual residents cannot use the kitchen, normal crockery or other equipment they must be risk assessed in relation to this, but most residents must be allowed degrees of opportunity to access their home, playing a role within it, with supervision where required. Thingwall Hall Nursing Home DS0000005473.V266457.R01.S.doc Version 5.0 Page 11 Lifestyle
The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 16 & 17. Resident’s access to activities has improved and developed. Resident’s rights and responsibilities are promoted on an organisational level but are in need of development on a day-to-day basis. Residents are offered a healthy diet but are generally not involved in skills relating to this. EVIDENCE: Activities are an area that has continued to progress, has been developed and greatly improved. The organisation employs specific activities co-ordinators to plans activities for residents. The four residents case tracked had various timetables of activities & pursuits to meet their needs and wishes. One stated, “ I do a course and its really good”. Other residents are involved in horticultural & other work experience roles developed by the organisation. However, it was evident that residents must be more involved in their home, choosing drinks, care routines, cooking and laundry decisions on a day-to-day basis. Where completely unsafe for them to do so, this must be risk assessed. Plastic plates/cups/glasses are not what most people would use on a daily basis inside a home and must only be used, for individuals (as opposed to groups) in situations where the risk assessed is deemed too great. One
Thingwall Hall Nursing Home DS0000005473.V266457.R01.S.doc Version 5.0 Page 12 resident case tracked said when asked “ I never cook, I don’t know how to”. “The staff cook for us”. Resident’s likes/dislikes and allergies in relation to food were all recorded in Essential lifestyle Plans. Menus seen were varied, nutritious & satisfactory. Most kitchen areas in the bungalows were inaccessible to residents, either being closed or residents not allowed to enter. Thingwall Hall Nursing Home DS0000005473.V266457.R01.S.doc Version 5.0 Page 13 Personal and Healthcare Support
The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19 & 20. Residents physical and emotional needs identified are met. The administration & recording of medication is satisfactory. EVIDENCE: All residents had detailed information regarding their physical, emotional & medical needs, both within their Lifestyle Plans and their assessments. Records were in place for all healthcare appointments and their outcome. Treatment was also recorded. The medication administration was examined for the 4 residents case tracked and 3 other residents in the bungalows that provided nursing. These were all satisfactory and up to date. The policy & procedure in relation to medicines was clearly directive. Thingwall Hall Nursing Home DS0000005473.V266457.R01.S.doc Version 5.0 Page 14 Concerns, Complaints and Protection
The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22. The complaints procedure is in each bungalow and accessible to residents. EVIDENCE: The complaints procedure is now detailed in the Service User Guide. Each bungalow holds its own complaints record. The visitor spoken to on the first day of the inspection was satisfied that they could approach the Manager/staff if they had any concerns or complaints. She also felt these would be listened to & acted upon. 2 of the residents case tracked and 2 other residents were aware of what a complaint concern was, and said they would tell staff if unhappy. Thingwall Hall Nursing Home DS0000005473.V266457.R01.S.doc Version 5.0 Page 15 Environment
The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24 Some houses require redecoration/refurbishment. EVIDENCE: All 6 properties were seen over the 2-day inspection. 2 houses, Woodlands & 4 Willow Close were decorated & fitted to a high standard. This reflected that the other properties were not as homely or comfortable and this needs to be addressed. Residents should have an equal standard of accommodation. Thingwall Hall Nursing Home DS0000005473.V266457.R01.S.doc Version 5.0 Page 16 Staffing
The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32 Staff are well trained but need to reflect in parts and apply values of training into practise. EVIDENCE: Staffing numbers changed by agreement in the last few months. This should be reviewed regularly to ensure it is effective and meeting resident’s needs. Some observations made over the two days highlighted inconsistencies in training received & practise observed during the inspection. As described in previous standards, staff must put into practise the values and commitments in Essential lifestyle Plans by encouraging independence, promoting equality & choice, preserving privacy/dignity and retaining confidentiality for residents on a day-to-day basis. Thingwall Hall Nursing Home DS0000005473.V266457.R01.S.doc Version 5.0 Page 17 Conduct and Management of the Home
The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 39 Quality monitoring systems are not in place. EVIDENCE: Regulation 26 visits by the provider should be carried out monthly. These visits are to ensure the provider is aware of the practises and condition of the service and can address any concerns or issues. These must be resumed immediately as they play an important role in monitoring the quality & progress of the service, buildings, staff & residents. Monthly reports must be sent to CSCI. An annual audit of the service, including views of residents, their carers/relatives and others must be carried out. This audit & its outcomes/action must be published for residents & carers/relatives and also sent to CSCI. Thingwall Hall Nursing Home DS0000005473.V266457.R01.S.doc Version 5.0 Page 18 SCORING OF OUTCOMES
This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from:
4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable
CHOICE OF HOME CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score X 3 X X X Standard No 22 23 Score 3 X ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 2 2 X 1 X Standard No 24 25 26 27 28 29 30
STAFFING Score 2 X X X X X X LIFESTYLES Standard No Score 11 X 12 3 13 X 14 X 15 X 16 1 17 Standard No 31 32 33 34 35 36 Score X 2 X X X X CONDUCT AND MANAGEMENT OF THE HOME 2 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21
Thingwall Hall Nursing Home Score X 2 3 X Standard No 37 38 39 40 41 42 43 Score X X 1 X X X X DS0000005473.V266457.R01.S.doc Version 5.0 Page 19 Are there any outstanding requirements from the last inspection? NO Thingwall Hall Nursing Home DS0000005473.V266457.R01.S.doc Version 5.0 Page 20 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 YA6 Regulation 12 Requirement The values promoted in residents ELP’s must be evident in practise. Residents who cannot use normal crockery for safety reasons must have a risk assessment relating to this. Normal crockery must be in place except where assessed as unsafe for individual residents. Residents must be enabled to be involved in daily living activities within the bungalows. Staff must respect resident’s confidentiality in records and in discussions. All bungalows must be decorated & fitted equally, to a homely and comfortable standard. The staffing changes agreed recently should be reviewed for effectiveness. An annual audit of the quality of the service, incorporating residents/carers views must be carried out & results published for residents & CSCI. The provider must carry out monthly, unannounced visits, in line with this regulation, and forward a report to CSCI detailing the findings. Timescale for action 01/02/06 2 YA9 13 21/12/05 3 4 5 6 7 YA16 YA16 YA10 YA24 YA33 12 12 12 23 18 21/12/05 21/01/06 21/01/06 21/04/06 21/02/06 8 YA39 26 21/02/06 9 YA39 26 21/12/05 Thingwall Hall Nursing Home DS0000005473.V266457.R01.S.doc Version 5.0 Page 21 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 Thingwall Hall Nursing Home DS0000005473.V266457.R01.S.doc Version 5.0 Page 22 Commission for Social Care Inspection Knowsley Local Office 2nd Floor, South Wing Burlington House Crosby Road North Liverpool L22 0LG National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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